2001septoct

The AcademicHealth CenterDelivering onthe Promises

Sep

t/O

cto

ber

2001

The AcademicHealth CenterDelivering onthe Promises

HMS E

thics

Guide

lines

��

��

�� !

� �� !��"��#�$��#�� %��&�� "��&��%# �� !��

� ��"�#��#�$�#�� "��"��#��"�� '��#��%#��%��#��#�$��#�� (�#$��

"��#$$� �� %��"��&��'

��

��

��# ��)#*� #��(#��

��#!��+��"�$��#�#�#��)#,$#

��()��"��

��(��#�� #�$��-��#��*��#��$��*"��-#��#�� (# ��.��"�'�#�$��

*��(��#��"��#��/�� #��/��# ��-��#��"��#��/�� #��/��# ��)#,$#��"��#��/�� #��/��#

��)��$#��0�

��

��

��

��

V O L U M E 3 , N O . 5 S E P T E M B E R / O C T O B E R 2 0 0 1

CO N TE N TSPhysician Co-editor Thomas B. Dunkel, M.D.Physician Co-editor Richard J. Morris, M.D.Managing Editor Nancy K. BauerAssistant Editor Doreen M. HinesHMS CEO Jack G. DavisRMS CEO Roger K. JohnsonProduction Manager Sheila A. HatcherAdvertising Representative Betsy PierreCover Design by Susan Reed

MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Hennepin and Ramsey MedicalSocieties, 3433 Broadway Street NE, BroadwayPlace East, Suite 325, Minneapolis, MN 55413-1761. Periodical postage paid at Minneapolis,Minnesota. Postmaster: Send address changes toMetroDoctors, Hennepin and Ramsey MedicalSocieties, 3433 Broadway Street NE, BroadwayPlace East, Suite 325, Minneapolis, MN 55413-1761.

To promote their objectives and services, theHennepin and Ramsey Medical Societies printinformation in MetroDoctors regarding activitiesand interests of the societies. Responsibility is notassumed for opinions expressed or implied insigned articles, and because of the freedom givento contributors, opinions may not necessarilyreflect the official position of HMS or RMS.

Send letters and other materials for considerationto MetroDoctors, Hennepin and Ramsey MedicalSocieties, 3433 Broadway Street NE, BroadwayPlace East, Suite 325, Minneapolis, MN 55413-1761. E-mail: [email protected].

For advertising rates and space reservations,contact: Betsy Pierre, 2318 Eastwood Circle,Monticello, MN 55362;phone: (763) 295-5420;fax: (763) 295-2550;e-mail: [email protected].

MetroDoctors reserves the right to reject anyarticle or advertising copy not in accordance witheditorial policy.

Non-members may subscribe to MetroDoctors at acost of $15 per year or $3 per issue, if extra copiesare available.

2 LETTERS

3 PHYSICIAN’S SOAP BOXHas the AMA Taken its Third Strike?

4 PHYSICIAN’S SOAP BOXThe Failure of Integration

6 COLLEA GUE INTERVIEWNorman Westhoff, M.D.

10 FEATURENew Funding and New Expectations for the Academic Health Center

14 Changes to Health Provider Contract Law in 2001

16 Celebrate Women in Medicine Month

17 Index to Advertisers

18 Highlights of the Code of Medical Ethics of the AMA

20 HMS/RMS Winter Medical Conference

21 Medical School Seeks to Increase Presence in “Silicon Valley of India”

22 MN PERSPECTIVEPublic Health Fared Well in Legislative Session

23 October 11 is Declared Turn off the Violence Day

RAMSEY MEDICAL SOCIETY

24 President’s Message

25 RMS Alliance/In Memoriam

HENNEPIN MEDICAL SOCIETY

26 Chair’s Report

27 HMS Alliance

28 Ethical Accountability Guidelines for Physiciansin our Changing Healthcare Environment

On the cover: The Academic HealthCenter’s new funding brings with itnew expectations for positive outcomesfor the state. See article on page 10.

MetroDoctorsDoctors

MetroDoctors The Journal of the Hennepin and Ramsey Medical Societies September/October 2001 1

2 September/October 2001 MetroDoctors The Journal of the Hennepin and Ramsey Medical Societies

L E T T E R S

Letter to the Editor:

The article in MetroDoctors July/August 2001concerning living conditions in Iraq was mostinteresting. According to a July 16, 2001feature on National Public Radio by MichaelRubin who spent nine months teaching in theKurdish sector of Iraq, living conditions aremuch different there. The Kurds are alsounder the same constraint of UN sanctions asthe rest of Iraq, yet all of the money from thesale of oil is directed to its intended purpose,humanitarian support of the populace.

According to Mr. Rubin, the Kurds haveample resources for children, medical servicesand the general economy is thriving. If theIraqis do not understand why the UN forcesbombed them, the Kurds certainly do not

understand why the Iraqis used poisonous gason them.

New weapons and uniforms are evidentin the Iraq military, yet children starve.Should Saddam decide to direct the fundsfrom UN sanctioned oil sales to the childrenand needy in his own nation, little of thesuffering Dr. Ott was shown by his Iraqigovernment sponsors would be present.

When Dr. Ott was shown the AlAmeriyah bombing site which the U.S. hadtargeted through faulty intelligence and thefact that the Iraqi government put civilians ina previously designated strategic site, did hisIraqi guides also tell of the systematic Iraqimurder, rape and pillage in Kuwait? That wasnot an error, but a planned and programmaticactivity carried out over several months by theIraqi military. To a physician, loss of life istragic, yet anyone familiar with those eventsof a decade ago would have little difficultydifferentiating between the two.

Providing medical assistance andhumanitarian aid to those in need, regardlessof location or political situation is commend-able. Placing blame for the tragic depravationsin Iraq on UN sanctions which can providefor the needs of the civilian population, butdo not allow Saddam to rebuild weapons ofmass destruction, is both incorrect and naive.The Iraqi government has the resources tochange the situation if it chooses to do so. ✦

J. W. Ogilvie, M.D.

Editor:

If one were to criticize Gene Ott’s Soapbox(July/August 2001) description of the healthproblem of Iraq, that person would beconsidered calloused, insensitive and heartless.Gene’s description of the health and medicalproblems of ordinary Iraqi people is indeedheart-rending. Unfortunately, Gene’sexposition suffers from two importantconsiderations. First, and probably of lesserimportance, is his involvement with organiza-tions and people with tunnel vision. RamseyClark and the Association of Friendship,Peace and Solidarity have never been friendsof our foreign policy. Their views arenotoriously naïve, and if acted upon, wouldonly serve to encourage other despots androgue nations.

Far more important is Gene’s strikingomission. Nowhere in his writing is there anymention of the role of Saddam Hussein andhis government in the etiology of Iraq’s healthproblems. If Iraqi leadership had anyresemblance to the surrounding Arabic states,the Iraqi people might be healthy and wealthy.Saddam’s unyielding despotism and tyranny isthe root cause of the Iraqi problems Genedescribes. He is the leader who had tens ofthousands of Iraqis killed in Hamas years ago,their only crime being political opposition.Saddam sent diced pieces of a member of hisleadership to the man’s wife, simply becausehe dared ask a question about Saddam’sactions.

Indeed, the health problems of the Iraqipeople would vanish with a change inleadership. The problems are not a directresult of our foreign policy. They are directlyrelated to the awful leadership of thatunfortunate country. Gene would be moreconvincing if he presented a more balancedpicture. ✦

Sincerely yours,Seymour Handler, M.D.

MetroDoctors welcomesletters to the editor. Send yours to:

Nancy K. Bauer, Managing EditorMetroDoctorsHennepin & Ramsey Medical SocietiesBroadway Place East, Suite 3253433 Broadway St. NEMinneapolis, MN 55413-1761

Fax: (612) 623-2888E-mail: [email protected]


A

Has the AMATaken its Third Strike?

ANOTHER TURNOVER IN CHIEF EXECUTIVE OFFICERS hasoccurred at our AMA. It seems this is becoming a recurring dream…oris it a nightmare? The person hired to take the AMA out of its sinkingspiral of misdirection and missed opportunities has been fired by theboard that restructured its governance and promised a “new AMA” onlythree years ago.

Ratcliff J. “Andy” Anderson, M.D., was brought in from outsidethe AMA leadership ladders to right a sick organization after it initiateda soul-selling endorsement agreement with the Sunbeam Corporation.The deal was allegedly completed by its CEO, John Seward, M.D.,without the Board of Trustees’ involvement. In its drive to create non-dues revenue, the AMA appeared to violate its own Code of Ethics andthe leadership had to be reminded by its rank-and-file members andoutside observers that selling its AMA brand to a corporate bidder wasviewed as bad business and a breach of itsmission—dedicated to the health of America.Seward lost his job, but the board membersescaped.

So now we are treated to another debacle.The AMA legal counsel completes a real estatedeal on behalf of the AMA that his boss, AMAEVP/CEO Andy Anderson, M.D., considered agive-away. Anderson relieves the generalcounsel, the counsel whines to his friends onthe Board of Trustees, the board reinstates himand lets him resign with a golden parachute.The CEO says, “Wait a minute. I have acontract to manage the AMA staff, and youhave circumvented my authority. Besides that,you have compounded the economic losses.”No internal resolution could be developedbetween the board, its chair, and the emascu-lated CEO. What happens? A public fight. Asuit of the AMA Board of Trustees and its chairby the only person it is authorized to hire, itsEVP/CEO. Everyone in the country who hasany interest in the AMA learns that itsgovernance body overstepped its authority, dida back-door deal with an employee, andrevealed its faulty operations and mismanage-

ment. As a result, every physician, AMA member or not, is brushedwith the taint of corruption in the profession.

Two strikes, Sunbeam and Anderson. But if one looks back a fewmore years, there was another EVP/CEO, James Sammons, M.D., whoafter the 1987 stock market crash, tried to ensure members of his seniorstaff with unauthorized retirement benefits. Another public airing ofbad management and corrupted practices that sunk another EVP/CEOand put egg on our collective faces.

These recurrent public crises seem to indicate physicians cannotgovern and physicians cannot manage. Physicians can neither get theiract together to collectively improve the lives of their patients, norenhance their profession. We have talked about getting adequate healthcare to all Americans for decades, but we are worse off today than 20years ago. The gap between the haves and have-nots is wider. Disparitiesin health status between populations in America is a national tragedyand disgrace. Yet where is the AMA? Still working on the narrow issueof patient’s rights in order to get back at powerful insurance companiesand showing the world it cannot manage its organizational affairs.

I believe healthy organizations are honest, create an environmentof open communication, exhibit respect in all its actions, and buildtrust with its members, employees, and customers. How do we gradeour AMA today? Is our AMA failing? Is it fading? It seems to takeanother strike every few years. Can you do it three times and survive? ✦

A. Stuart Hanson, M.D., served as a delegate to the AMA for 12 yearsand was chair of the Minnesota Delegation.

B Y A . S T U A R T H A N S O N , M . D .

P H Y S I C I A N ' S S O A P B O X


WWE ARE WITNESSING A SAD END TO A NOBLE DREAM and theenormous efforts of many dedicated professionals and communityvolunteers over the last eight years, as Allina spins off Medica anddisintegrates into separate organizations. The significance of theseevents should not be under-estimated. Health care organizations acrossthe country have looked to the vertically integrated Allina model as apossible solution to the intractable and growing crisis caused by ourinsatiable appetite for an increasing menu of important health careservices and the contentious issue of how and who should pay for thoseitems.

The timing of the announcement, virtually simultaneous with thecall for the breakup of Allina by the Attorney General amid charges ofwasted money and administrative mismanagement, might seem to lendcredibility to the accuracy of the charges, but, in fact, the decision is theculmination of a thorough strategic re-evaluation process by the AllinaBoard over the last eight months. The facts will show, I believe, thatadministrative expenses have played an insignificant role in this healthcare cost crisis, and that the Allina Board has been diligent andresponsible in sorting through the many complexities of attempting toprovide care for patients with dollars that fall far short of patients’expectations. A disintegration requires a new Board and a redefinitionfor Medica of the proper constructive role it can play in providinghealth care for the state, but if we assume that we have by that act fixedthe problem, we will be making an enormous mistake.

We are at an important fork in the road. It is important tounderstand what went wrong. As we analyze what happened, we mustset aside our prejudices, preconceived notions, and short-term politicalagendas. Does co-operation and collaboration ultimately implycollusion? Are the rights of patients best served by tension or co-operation between payers and providers? How much are we willing topay in functional duplication to maintain that tension? If we misdiag-nose the real reasons for the failure of integration, we may attempt to fixthe wrong problem. Then, there is a very real risk of taking a giant stepbackwards, setting a fix to the problem even farther into the future.

Recall the environment during which Allina was formed. It wasthe time of the Clinton health care reform, and the state legislature hadpassed plans for integrated service networks that would provide seamless

health care for the citizens of the state. Big was not a bad word then. Itseemed to make good economic and intuitive sense to organize thehealth care system to provide a seamless experience whereby theprocesses of registration, clinical information transfer, clinical care plansand after care, and payment processes would be transparent andautomatic for the patient coursing through the system. Cost savings,then as now, had to justify every decision. The cost savings projected forthe process of integration were based on the elimination of duplicativefunctions through the system and by promoting or requiring standard-ized, proven approaches to medical problems.

Each party to the merger—the hospitals of Healthspan, Medica,and allied physicians had historically fantasized that the others held thekeys to their financial destinies and improved, consistent patient care—and that given the opportunity, one or the other could do a moreefficient job of cutting out and/or controlling the costs in the system.The health plan needed to gain greater control over the ability tocontrol costs in the hospital and in physicians’ offices. The strategy wasto partner with physicians in exchange for a transfer of risk to physi-cians so that each would be likely to manage costs as efficiently aspossible wherever that care occurred. The hospitals wanted increasedcontrol over their revenues and an increased market share of patientswith which to spread their large fixed costs. With a secure large patientbase and a full house provided by a channeling feature of a health plan,the cost per patient would diminish and the savings would make theplan more competitive or provide needed capital for expanding medicalcapabilities and technology. Physicians wanted to minimize intrusiveoutside interference with their practice operations and medical decisionsfrom the health plan and to be financially recognized for their labor-intensive efforts in the hospitals to streamline processes of care.

Uniting and justifying each of these specific interests was thesincere belief of each that patients would be the ultimate, unequivocalbeneficiaries. Medical care would be organized and efficient withpredictable and consistent quality based on proven literature basedmedical practice. It was to be win-win-win-win for all the partiesinvolved.

That clearly has not been the result. What happened to derail theseworthy intentions?

Unfortunately, first of all, no one part of the system had the pot ofgold about which the others had fantasized. Then, in addition, the valuethat each had anticipated from the others never materialized.

Risk transfer was a non-starter. Medical capabilities have increased

The Failure of Integration

B Y R O N A L D J . P E T E R S O N , M . D .F o r m e r A l l i n a B o a r d M e m b e r

P H Y S I C I A N ' S S O A P B O X


steadily over the last eight years. New expensive medications, newtechnologies, new imaging techniques, and new long-term strategies forcontrolling and preventing chronic disease make the prediction ofmedical costs virtually impossible for a health plan which must price aproduct some 12-18 months before it is offered to customers. Sophisti-cated medical practices wanted no part of assuming such an unpredict-able economic risk themselves that would put their interests in conflictwith that of their patients at a risk of personal bankruptcy.

Promoting a “channeling” feature in the health plan presented animpossible paradox for both the hospitals and Medica. An integratedsystem works at its most efficient state when all the medical care stayswithin a given system. The hospitals sought for some way to promotethe use of the hospital system preferentially to make that value equationwork. Yet choice—of physicians and hospitals—has always been thehallmark and most attractive feature ofMedica Choice. By de-emphasizingchoice, one did so at the peril of thehealth of the Plan. The health plan faced aslightly different set of issues. In order tomake a channeling product viable, itneeded to be priced at a discountsufficient to neutralize the very attractivenature of Medica Choice. The size of thatdiscount was so high that virtually theonly providers who were members of theproduct were owned assets of the system.

The mechanics of the merger alsowere much more difficult than anyoneimagined. Recall again that the mergers ofthe hospitals—Abbott-Northwestern,United, and Unity-Mercy intoHealthspan had really happened in nameand concept only when Medica was addedto the mix. The work of forging thediffering hospitals and their staffs whohad competing strategic interests andviews of the world into a single unit had not as yet happened whenHealthspan and Medica joined to form Allina. The grunt-work detailsof standardizing information technology, standardizing care andadministrative policies, and the allocation of financial resources involveconsiderable pain and tension under the best of circumstances.Unfortunately, the nation-wide combination of exploding medicaldemands and diminishing government funding magnified thesetensions explosively as competition for a diminishing pool of invest-ment capital from a marginal balance sheet bottom line became moreintense and bitter. Medica, which has struggled unsuccessfully for thehearts of physicians since the bitter days of Richard Burke, and hencealso Allina, became the focus of that bitterness as the individualaspirations and strategic needs of hospitals and hospital programscollided with and were subordinated to wider corporate priorities.

The Allina Board has for the last eight months been sortingthrough these realities. It painfully came to the conclusion on July 17that all would best be served by dividing once more into separate

entities pursuing their own strategic goals. It turned out that thestrategic goals of Medica and Allina and the Attorney General’sdemands were for widely different reasons one and the same. Nonethe-less, the health system still remains fragmented and disconnected. Thereis an overpowering imperative, in order to achieve health care improve-ment, to co-ordinate clinical and demographic information, and tostandardize and validate differing approaches to medical problems, bothto improve the quality of that care and to maximize the efficiency of thesystem. Allina was not that vehicle. Perhaps that co-ordination needs tobe even broader—across the entire community of insurers, hospitalsand health systems. That discussion needs to occur now. The rootproblems remain.

A new Medica Board faces a set of almost impossible tasks. Wemust have realistic goals and expectations. Unfortunately, significant

cost savings should not be one of them.Changing the board does not alter a starkset of realities. The cost increases inmedicine of the last five or six years havebeen driven by new pharmaceuticals, newapproaches to disease and new capabilities.Physicians have not had a meaningfulincrease in reimbursement in five or sixyears despite the steady increase in practiceexpenses and a very tight labor market fromwhich to draw employees. Much of thework of medicine, answering phonemessages and questions, refilling andmonitoring medications, and providingadvice for minor problems by phone is notreimbursed at all. Shrinking marginsdespite increasing workloads and ever-longer days threaten the stability of theentire health care work force, includingboth doctors and hospital nurses. For thehospitals four or five years of minimal“profits,” which in a non-profit world

provide the funding for investing in new capabilities and technology,have created a backlog of pent-up capital demand to deliver on thepromises of new medical capabilities we all demand and expect. Thenew Board will face a very contentious set of negotiations almostimmediately.

Broader long term strategic issues of society-wide importance loomonce that immediate hurdle is successfully negotiated. Should care bemanaged or not? If so, by whom? Who should set the priorities formedical care delivery in a society where we each feel our individualrights and interests are paramount? If we follow our instincts and wishto put each individual patient in charge, what device do we use to fundour individual needs and choices, provide catastrophic insurancecoverage, and keep it affordable at the same time? The demographictime bomb that ticks for the Social Security system ticks as well for thehealth care system. Will it still be there when we all need it? ✦

Who should set thepriorities for medical

care delivery in asociety where we each

feel our individualrights and interests

are paramount?


AQ

Norman Westhoff, M.D.

Editor’s Note: This interview was conducted by Penny Chally, HMS/RMS Alliance member.

Norman Westhoff, M.D. is an occupational health physician inRoseville, who, in the fall of 2000, led a group of health professionalsfrom the Twin Cities to Dmitrov, Russia. The trip was at the invitationof the Department of Health in the Dmitrov Raion, and the RussianFarm Community Project, based in Edina. In addition to Dr. Westhoff,members of the delegation included: Dr. Cecil and Penny Chally,Wayne and Beverly Erickson, J. Michael Gonzalez-Campoy, M.D., Ph.D.,Mark Harris, Dr. Austin and Mary Indritz, Carol Mason, and RobertTitzler, M.D.

What was the purpose of your 1998 and 1999 trips, priorto escorting the delegation, to Dmitrov, Russia?

It was to get acquainted with some of the healthcare professionals in thearea and to do a needs assessment. I was invited to do this because of tiesthat the Russian Farm Community Project (RFCP) had developed withthe local administration in Dmitrov. RFCP has had a fair amount of suc-cess with their agricultural programs in the Dmitrov Raion over the pasteight years and Governor Gavrilov asked Ralph Hofstad of RFCP to sendprofessionals in the fields of health, medicine and social work, for thepurpose of consultation with their local counterparts in Dmitrov.

My first and second trips to Dmitrov, in1998 and 1999, were withDoug Aretz, the administrator of St. Benedicts Senior Health Care in St.Cloud. I visited a number of healthcare facilities in Dmitrov while Dougvisited a number of social care facilities.

What were the results of these trips?

Doug and I made a commitment to continue a dialog with Dmitrovhealthcare and social care professionals, as well as to help with some physicalneeds such as hospital beds and other durable equipment. In addition, wewould try to send some donated medicines and vaccines. We have sincedelivered five cargo containers of donated equipment and supplies toDmitrov, with more shipments in the works.

In the fall of 2000, I led a group of physicians and health profession-als from the Twin Cities to Dmitrov, upon the request of officials from theDmitrov Raion Department of Health who extended an invitation toRFCP for such a delegation to visit healthcare and social care facilities inthe region.

What was it during your first visit that really made youbecome further involved with this healthcare project inDmitrov?

When I went with Doug in 1998, I had no idea what to expect. I thoughtit might be an exotic educational activity to see how the Russians deliv-ered healthcare. A combination of factors made me become interested infurther involvement: their wonderful hospitality to their American guestsand, obviously, their great need for help — not only for supplies andequipment, but also for help to effect some reform in the way healthcareis delivered.

Even though the Communist system fell apart 10 years ago, the ad-ministration of the healthcare programs is still quite bureaucratic and cen-tralized. That’s not all bad when you have a system with so many short-ages, since they do need to allocate their resources carefully, but it doestend to slow down innovative ideas and initiatives. Yet, at the same time,the administrators and physicians are quite open to learn about whatAmerican physicians have to offer.

So, what has happened since those first visits?

At the end of each trip, a good four to six hours have been spent betweenthe Dmitrov healthcare administration and physicians and the Americanhealthcare participants in panel discussions and exchanges, as well as set-ting priorities for further actions on programs and development.

Besides the container shipments, we have also hand delivered a num-ber of intravenous drugs, antibiotics, chemotherapy and pediatric immu-nizations. We were able to get these donated from pharmaceutical compa-nies. However, that is just a drop in the bucket compared to the vast need.

Now we are trying to focus on empowering the physicians and pa-tients to take more responsibility for the delivery of healthcare. As anexample, Dr. Bob Titzler, one of the physicians from the fall 2000 delega-tion, went back to Russia this past April and spent a month with thedoctors in the health department working out treatment guidelines for

C O L L E A G U E I N T E R V I E W


chest pain, diabetes outpatient care, and pediatric immunizations. Theidea of treatment guidelines, while commonplace here in America, is brandnew to them.

Penny Chally, with the help of Marina Ostenny and others, had pa-tient-oriented materials translated, or found already translated materials,which have been sent on to Dmitrov. Patient-geared information relatedto coronary care, diabetes, and other diseases fulfills another great need.

In September, a group of ten Russian physicians and social serviceprofessionals will be arriving for a 14-day visit in the Twin Cities.

How did this trip come about?

As far back as my first visit in 1998, we, as a group of Americans andRussians, have talked about the possibility of a trip to the Twin Cities.Several Russian specialists have been to meetings in Western Europe, how-ever, none of them have been to America. The biggest impediment totheir coming here was the expense. Russian doctors, nurses, and feldshers(nurse practitioners) are paid very little compared to American standards.This, in part, has to do with tax revenues that are too low, and, in part,with healthcare being seen as a luxury rather than a necessity.

In any case, they cannot pay for an airline ticket to the United States.The Russian 2000 delegation pledged to bring a Russian contingent herein the year 2001. Now it is going to happen and the Russian delegation isgoing to arrive September 18. For the dream of bringing them here andshowing them some of the facilities and how our systems work, it is nec-

essary to enlist the support and develop mechanisms to find donationsfrom those here who would welcome the opportunity to support thisimportant piece of building bridges between Dmitrov and Minnesota.

The Russian delegation is made up of 10 people; six of them arephysicians, three are clinicians and three are administrators. We feel it isequally important that administrator-physicians come here because thereare many things we are going to show them that are related to systems andorganization. If there are to be any changes of that sort in Russia, it wouldhave to be seen as important and, often, it would have to start at the top.

Where are some of the places and areas that they will visitwhen they are here this fall?

All details are not yet final at the time of this interview; however, they willbe spending a fair amount of time at several hospitals and clinics in theTwin Cities and some in St. Cloud. There is a primary interest in heartdisease prevention and treatment, as that is by far the greatest cause ofpremature death in Russia, about three times what it is in the UnitedStates. Among other areas of interest are diabetes management and pedi-atric preventative care.

In the area of social services, especially the care of the elderly, theywill visit some transitional care units in St. Cloud. They will see whathandicapped accessibility involves, including vans for transportation ofhandicapped persons, which is virtually unknown in Russia. They will

RMS Membership Advantages forPhysicians and their Practices

For more information call 612-362-3704.Products and Services Offered to RMS Members by RCMS, Inc.

➢ Office Supplies – US Office Products • 651-639-470025-40% discount on a full-range of office supplies and office furniture. Free delivery. www.gop.usop.com

➢ Collection Services – Allied Interstate, Inc. & First Contact, Inc. • (800) 447-2934A medical collections agency with over 25 years of experience. www.alliedinterstate.com

➢ Auto Leasing – Boulevard Leasing, Inc. • 612-781-8449Competitive rates and flexible lease terms on the car of your choice.

➢ Confidential Data and Material Destruction – Document Destruction Service • 612-898-3030Discounts up to 27% for on-site shredding, destruction, disposal/recycling of all sensitive documents.

➢ RMS Gold or Platinum – MBNA America • (800) 847-7378 ext. 5000Credit up to $100,000 for Platinum and $25,000 for Gold cards.

(Continued on page 8)


Maplewood Office1560 Beam Ave.Maplewood, MN 55109(651) 770-0110

Woodbury Office7616 Currell Blvd., #115Woodbury, MN 55125(651) 578-2700

St. Paul - Downtown101 E. 5th St., #2106St. Paul, MN 55101(651) 291-9166

Midway Office720 Central Medical Bldg.St. Paul, MN 55104(651) 645-3628

DERMATOLORY CONULTANTS, P.A.

David W. Anderson, M.D.Lori R. Arnesen, M.D.Jennifer A. Biglow, M.D.Daryl A. Brockberg, M.D.Charles E. Crutchfield III, M.D.Humberto Gallego, M.D.

are pleased to announcethe association of

in the practice of Dermatology

MALINEE SAXENA, M.D.

Pierre M. George, M.D.Noel A. Hauge, M.D.Dennis M. Leahy, M.D.Jane B. Moore, M.D.Harold G. Ravits, M.D.Jerry W. Stanke, M.D.

Eagan OfficeSuite 2201185 Town Centre Dr.Eagan, MN 55123(651) 251-3300

was born in Romford,England and lived in Indiaand Canada. She went tohigh school in Brookings,South Dakota. Shegraduated with a B.A. inphysiology and childpsychology from theUniversity of Minnesota.

Her medical degree wasobtained in 1997 from the University of MinnesotaMedical School. She then went on to complete herTransitional Internship at Hennepin CountyMedical Center in 1998.

Dr. Saxena has completed her Dermatologyresidency at the University of Minnesota whereshe served as Chief Resident in 2000-2001.

Jeff.

also visit a variety of other social service locations, including those dealingwith HIV/AIDS, in St. Paul and Minneapolis.

At the invitation of the Omaha Medical Society, some of the delega-tion will be going to Omaha, Nebraska for a few days to see healthcareservices in that area.

What can physicians, and others within Minnesota, do to helpdefray the costs of the Russian visit to Minnesota? Also, whatopportunities would they have to visit with the Russian group?

There are several opportunities to visit with our Russian friends. The firstis at the Minnesota Medical Association Annual Meeting in St. Cloud.The physicians have been invited as guests of the MMA to give them aview of the workings of a physician organization, something they do nothave in Russia. There will be a place at the meeting where contributionscan be made to help fund the visit.

There are also two other opportunities to visit with the Russiandelegation. One is a dinner at the Moscow on the Hill restaurant in St.Paul on Sunday, September 23, 6:00 p.m. The other is a boat cruise onLake Minnetonka on Saturday afternoon, September 29, noon to 3:00 p.m.A letter with details about these events will have been sent out by the timeof the printing of this article. However, if any member does not have theletter and wishes to come to one or both events, please call the RMS office

at 612/362-3704 for further details. We would like to have a great response!The reason for the need for fundraisers is that RFCP needed a loan

to finance the roundtrip airfare. In addition, we need to raise money forexpenses during their stay here. Members of the Russia 2000 delegationwill be providing bed and breakfasts, transportation and time throughoutthe entire week.

One final question, what future steps do you see for theTwin Cities-Dmitrov project?

The hope is that the physicians, administrators and social care workerswill be excited and take home new ideas and, in addition, feel more em-powered to carry through with these ideas and make them a reality.

I would anticipate that there would be another visit to Russia in2002 by more American physicians to continue with the sharing of ideasand understanding of each other’s healthcare systems. If our readers havean interest in participating, you are invited to contact me at 763/785-7731 for more information.

In addition, we also have an ongoing commitment to send whatmedical equipment and supplies that we can to Dmitrov, as well as trans-lated patient and physician education materials. While the needs are tre-mendous, I believe the people of goodwill here in the Twin Cities can, andwill, help to make a difference for those in Dmitrov. ✦

Interview conducted by Penny Chally, HMSA, RMSA, MMAA and memberof the Russian 2000 delegation.

Colleague Interview(Continued from page 7)

DR. MALINEE SAXENA

She currently resides in St. Paul with her husband


F E A T U R E S T O R Y

T

Academic Health Center

New Funding —

New Expectations

B Y F R A N K B . C E R R A , M . D .

THIS PAST LEGISLATIVE SESSION PROVIDED a pointed discussion around the valueand benefit of higher education. The argument centered on two key questions: Whobenefits most from a college education—the individual or society? And then, who shouldfund the benefits of a college education—the public or the individual? In Minnesota andacross our nation, the discussion surrounding appropriate levels of public funding forhigher education will continue to draw attention to the very real value of education—tothe individual and to the societies who benefit from an educated populace.

This past legislative session, however, there was agreement in Minnesota on the im-portance of public funding for one area of higher education—health professional educa-tion at the University of Minnesota’s Academic Health Center. In a historic and unprec-edented move, the Minnesota Legislature directed the next two tobacco settlement pay-ments to an endowment for education within the Academic Health Center. Minnesotawill benefit from this significant public investment in the education of health profession-als. These are the doctors, nurses, pharmacists, public health professionals, dentists, andveterinarians who care for Minnesota.

New Endowment Based on Strategic VisionIt’s clear that this new funding comes with new expectations—expectations of positiveoutcomes for the state. It’s called accountability. What Minnesotans are saying is that theywant to understand what they’re getting for their public investment in educating newhealth professionals. They want to know that these professionals are committed to im-proving the health of our communities, conducting cutting-edge research to discover anddeliver new treatments and cures and equipping our graduates with the knowledge andskills to help strengthen the economic vitality of our health industries.

The Academic Health Center also heard that message loud and clear during a com-prehensive planning and strategic visioning process completed more than a year ago bythe faculty of the AHC. Supported by the Board of Regents, faculty engaged staff, stu-dents and the community in a process to lead health professional education, research andoutreach/service in a new direction that reconnects with communities, produces newkinds of health professionals, and revitalizes the discovery mission—all in an environmentof greater accountability. At the outset it was clear that meeting the expectations of Min-nesotans required a new covenant with Minnesota to guide health education, research

It’s clear that

this new funding

comes with new

expectations ...

of positive

outcomes for the

state. It’s called

accountability.



and outreach. The resulting plan—endorsed by the Board of Regents in July 2000—isnow used as the basis for transforming the work taking place within the schools of theAHC.

A key ingredient of the covenant was finding a new, sustainable source of funding.Anyone involved in health care today knows that traditional resources no longer providethe support necessary to fund education. In fact, the significant issues surrounding fund-ing of health professional education—and medical education in particular—are not newin this state. As a leader in the development of managed care, Minnesota experienced theimpact of reduced reimbursement rates earlier than most. The financial issues inherent ina teaching hospital led to the sale of University Hospital and a partnership with FairviewHealth Services four years ago—a move that was recently reported by a distinguishedexternal review panel to be the right decision at the right time. In an effort to provideefficient and quality patient care, the 18 individual university physician practices havenow become one practice plan, University of Minnesota Physicians, or UMP, providing amore coherent entry point for patients and community physicians seeking the hope ofscientific breakthroughs for their patients.

By its very nature, however, education of health professionals is inefficient. The oldmantra of “see one, do one, teach one” means that, at some point, you have to turn overthe stethoscope and scalpel. Today’s health care marketplace is positioned for higher effi-ciency and greater productivity—the antithesis of quality one-on-one professional educa-tion. It simply takes time to transfer knowledge and skill from one generation to the nextfor professions as hands-on as ours.

Yet it’s absolutely necessary for our students to train alongside community profes-sionals throughout the state and to understand health care delivery within hospitals, clin-ics, schools and community centers. The cost of that type of mentorship is funded bydecreasing sources of dollars—ranging from reduced Medicare/Medicaid payments toreductions in reimbursement rates spurred originally by managed care.

Faculty within the Medical School, in particular, are caught in a strange paradox—asacademic physicians, research is a key component of their role. In addition, care of pa-tients, through UMP, places an increased demand on time—as it does for all practicingphysicians. We see more patients to maintain the same level of practice income. Whencombined, the time that’s squeezed is that for the important work of educating students.

Today’s health

care marketplace

is positioned for

higher efficiency

and greater

productivity —

the antithesis of

quality one-on-

one professional

education.


Academic Health Center

(Continued from page 11)

How ironic that the core reason for theexistence of a medical school—educa-tion—is the one area that has not been di-rectly compensated. This endowment willallow us to change that fundamental gapfor this institution.

Making the Case Involveda Lot of HelpTwo years ago, there were a number ofvoices stating that the Academic HealthCenter—and in particular the University’sMedical School—were in trouble. Changesin academic medicine had led to the de-parture of more than 80 faculty membersand the sale of University Hospital. Medi-cal School morale issues affected the other

five disciplines. Yet we did not successfullymake the case for immediate help.

One of the key differences this yearwas the broad community consensus foradequate funding for the AHC and theplacement of the Medical School front andcenter on the University’s agenda. Leadersfrom the AHC and individual schools metwith leaders in business and industry, healthcare leaders, and community members. Wetraveled throughout the state to hear doc-tors, public health professionals, nurses,pharmacists, patients, and others tell uswhat was needed from our large public re-search university. And we had an opportu-nity to explain what would happen to en-rollments in medicine, nursing, pharmacy,and other schools without a new, sustain-able source of funding. These combinedvoices of community and business leaderswere absolutely key.

Also important was the voice of Presi-dent Mark Yudof. He spoke of the Medi-cal School’s needs from the date the Legis-lature began its session, also emphasizingthe needs of Minnesota for expanded en-rollments in nursing, dentistry, pharmacy,and other health professions.

Faculty members from each of thehealth professional schools met with indi-vidual legislators to explain the problem—and to advocate for their peers and col-leagues. The Medical School even set up abuddy program, pairing faculty with theirown legislator. More than 40 organizations,including most medical societies and spe-cialty associations, endorsed the University’srequest on behalf of the AHC.

It’s clear that those concerted voicesled to the establishment of the new AHCendowment, which will, among otherthings, fund the core budget of the Medi-cal School and help rebuild lost physician-scientist faculty. Unfortunately, the Univer-sity overall did not share the same success.We’re very aware that our future strengthis tied to the strength of this University—nationally, there is no such thing as a strong

Dermatology, Gastroenterology,General Surgery, Internal

Medicine, & Neurology

BBBBBRAINERDRAINERDRAINERDRAINERDRAINERD M M M M MEDICALEDICALEDICALEDICALEDICAL C C C C CENTERENTERENTERENTERENTER, P, P, P, P, P.A..A..A..A..A.• 42 Physician independent multi-specialty group• Located in a primary service area of 50,000 people• Almost 100% fee-for-service• Excellent fringe benefits• Competitive compensation• Exceptional services available at 162 bed local

hospital, St. Joseph’s Medical Center

BBBBBRAINERDRAINERDRAINERDRAINERDRAINERD, M, M, M, M, MINNESOINNESOINNESOINNESOINNESOTTTTTAAAAA• Surrounded by the premier lakes of Minnesota• Located in central Minnesota less than 2 1/2 hours

from the Twin Cities, Duluth, and Fargo• Large, very progressive school district• Great community for families

CCCCCALLALLALLALLALL COLLECTCOLLECTCOLLECTCOLLECTCOLLECT TTTTTOOOOO A A A A ADMINISTRADMINISTRADMINISTRADMINISTRADMINISTRATTTTTOROROROROR:::::Curt Nielsen(218) 828-7105 or (218) 829-49012024 South 6th StreetBrainerd, MN 56401

There are immediate openings at BrThere are immediate openings at BrThere are immediate openings at BrThere are immediate openings at BrThere are immediate openings at BrainerdainerdainerdainerdainerdMedical Center fMedical Center fMedical Center fMedical Center fMedical Center for the for the for the for the for the folloolloolloolloollowing specialties:wing specialties:wing specialties:wing specialties:wing specialties:DerDerDerDerDermatologymatologymatologymatologymatology, Gastroenterology, Gastroenterology, Gastroenterology, Gastroenterology, Gastroenterology, Gener, Gener, Gener, Gener, GeneralalalalalSurgerSurgerSurgerSurgerSurgeryyyyy, Inter, Inter, Inter, Inter, Internal Medicinenal Medicinenal Medicinenal Medicinenal Medicine, and Neurology, and Neurology, and Neurology, and Neurology, and Neurology.....

bmc@brbmc@brbmc@brbmc@brbmc@brainerd.netainerd.netainerd.netainerd.netainerd.netwwwwwwwwwwwwwww.br.br.br.br.brainerdmedicalcenterainerdmedicalcenterainerdmedicalcenterainerdmedicalcenterainerdmedicalcenter.com.com.com.com.com


Medical School that’s not part of a strongUniversity—so we’re now adjusting ourtimelines as we share the costs of the un-der-funding of core University services.

New Covenant of TrustMinnesotans should be proud of the sizeand significance of this new endowed in-vestment in health professional education.Funded with the remaining two tobaccosettlement payments in January 2002 andJanuary 2003, the endowment is projectedto reach nearly $374 million when fullyfunded in 2004. It is expected to generate$5.6 million next year, about $14.1 mil-lion in 2003 and up to $17 million annu-ally thereafter.

In the next two years, the endowmentwill be used to fund the Medical School’score educational programs, hire new phy-sician scientists in strategic areas, and ex-pand our nursing, pharmacy, and ruraldentistry programs. We see the endowmentas a covenant of trust with the people ofMinnesota. In fact, endowment funds willbe committed to accomplishing exactlywhat we have promised through the sevenelements of our strategic vision for the AHC.

First and foremost, we are committedto creating and preparing the new healthprofessionals for Minnesota. That meanseducating health professionals who under-stand how to promote the health of the in-creasingly diverse communities and cul-tures of this state, and who can work in ateam with professionals from other disci-plines. It is frequently humbling for me torecognize that the students who begin studythis fall will exit our schools within four toeight years into a professional landscape Ican’t begin to predict. Yet we do know thatthe new professionals must be able to use abroad range of integrative, preventive, andevidence-based tools. They must be ableto understand and use information systems.And for the benefit of the people of thisstate, they must provide leadership withinthe health and care delivery community.

Next, we are committed to sustainingthe vitality and excellence of Minnesota’shealth research. If we are to be on the lead-ing edge of health research, we need to in-vest in our programs and reward excellence.We are actively rebuilding our research ca-pacity. NIH awards are up, and our newMolecular and Cellular Biology Buildingwill open next year.

The third promise of our vision is toexpedite the dissemination and applicationof new knowledge of health and deliveryof health care in Minnesota. That’s an areawhere we clearly need improvement. Fac-ulty within our schools and colleges regu-larly publish the outcomes of their re-search—yet we haven’t always shared ourknowledge with the communities who’vetaught us so much. We also need to do abetter job of translating our work into us-able applications to benefit Minnesota’shealth. However, we are working to developthree community sites for the educationand training of our students as part of oureffort to move more of education into thecommunity.

Next, we are committed to develop-ing new models of health promotion andcare for Minnesota, and we’re well-posi-tioned to do this as we have six health dis-ciplines within the AHC, not to mentionthe range of disciplines afforded by theUniversity as a whole. We are working withstate leaders through the National Instituteof Health Policy in redefining health pro-fessional education and the state’s healthcare workforce needs. Health promotionwill require more collaboration with pub-lic health, more significant communicationskills training, nontraditional approaches,and a better understanding of anthropol-ogy and behavior. Actually, we can learnfrom our community colleagues in thisarea, including the Institute for ClinicalSystems Improvement’s work in evidence-based medicine.

A key promise of our vision involvesthe critical need to reduce health dispari-

ties in Minnesota and to address the needsof the state’s diverse populations. Over theyears, we’ve regularly patted ourselves onthe collective back when Minnesota isranked in the top of surveys on health sta-tus. After all, we educate a majority of thehealth professionals for the state, so we mustplay a role, goes the thinking. If thatpremise is true, then we share in the re-sponsibility for meeting the needs of thosewho don’t speak English and those whoseculture views health differently than ours.

Another expectation of our vision in-volves the commitment to using informa-tion technology to educate, conduct re-search, and provide service to individualsand communities in Minnesota. The prac-tice of medicine today requires a familiar-ity with Internet resources merely to keepup with patients. We must teach our stu-dents—and the people who rely on them—the tools of life-long learning. And we mustdo so, not just because it’s the right thingto do, but also because health care knowl-edge today has an approximate lifespan of18 months.

The final element of our vision in-volves the largest community commit-ment—that of building a culture of ser-vice and accountability to Minnesota.There is no other way for us, in the Aca-demic Health Center, to effectively meetthe state’s needs for the right kind of healthprofessional workforce without establish-ing stronger on-going relationships with thepeople we serve. That means continuingthe work we began prior to, and during,the legislative session—of truly listening,talking and learning from the clinics andhospitals where our graduates work, to thebusinesses who fund health care for theiremployees, and to the people of Minne-sota who have invested in us. ✦

Frank B. Cerra, M.D. is the Senior Vice Presi-dent for Health Sciences at the University ofMinnesota.


I

Changes to Health ProviderContract Law in 2001

IMPORTANT CHANGES CAME ABOUT asa result of the collaboration, planning and jointlobbying of the Fair Contracting Coalition rep-resenting Hennepin Medical Society, RamseyMedical Society, Minnesota Medical GroupManagement Association, Minnesota Chiro-practic Association, American Physical Therapy-MN Chapter, Minnesota Spinal Cord InjuryAssociation, and Minnesota Medical Associa-tion. The unprecedented results build on theprohibition on contract stacking won previously,leaving important work for the future such as aprohibition on managed care/no-fault (this yearpassed unanimously by the Senate), eliminationof contract stacking everywhere; opening theblack box of reimbursement allowables andwithhold formulas; eliminating silent networksand fee shopping; preventing unilateral re-cod-ing of claims and recoupments; and eliminat-ing unreasonable delays in credentialing andcontracting; etc. With the success attained inthe 2001 legislative session, the Coalition is grow-ing and dedicated to creating a fair contractingenvironment that will benefit providers andconsumers by improving the accountability ofhealth plan performance as it impacts the qualityand accessibility of health services in Minnesota.

Minnesota Session 2001Chapter 170The Minnesota Legislature enacted chapter 170in the 2001 session. Chapter 170 provides threeareas of benefit to health care providers that willalso help consumers: 1) Passive contracting limi-tations; 2) Mandatory disclosure of contractchanges; these provisions became effective Au-gust 1, 2001; and 3) Provider options to de-cline and later participate in new categories of

medical service. The consumers benefit by amoratorium on managed care in auto medicalhealth benefits. The Participation and Morato-rium provisions were effective with theGovernor’s signature on May 25, 2001.

The Fair Contracting Coalition introducedthis legislation to improve the relationships be-tween physicians and other health care provid-ers and health plans in Minnesota. Fairness inhealth care provider contracts is an area of sig-nificant concern for all members of the Coali-tion. The Coalition also believes that consum-ers would not receive “all appropriate medicalcare” as called for in the 1974 No-Fault auto

insurance statute if managed care plans limitedconsumers in the choice of providers and healthservices authorized for payment.

(1) Passive Contracting LimitsPreviously, health plans were allowed to “pas-sively contract,” that is, propose amendmentsto provider agreements with no need for theprovider to respond, thus allowing new amend-ments to be automatically added by default.

Under the new chapter 170, effective Au-gust 1, 2001, a provider must be given a noticein writing of an offer to participate in a newcategory of insurance under an existing provider

The Minnesota Medical Association has announced the launch of the new “HassleFactor Surveillance System” in an attempt to resolve some of the administrativeproblems that pull physicians away from patient care.

The Hassle Factor initiative responds to physician reports that glitches withthird-party payers, including payment delays, drug formulary changes, and poorcustomer service, increase their job stress and decrease the time that they are avail-able to patients.

The Hassle Factor system will be used to track, analyze, and develop inter-ventions for burdensome administrative problems.

Copies of the Hassle Factor Log were mailed to physicians last May and canbe found on the MMA Web site at http://www.mnmed.org/survey/HasselFactor/HassleFactor_survey.htm.

For more information on the MMA Hassle Factor Surveillance System, con-tact Janet Silversmith at (612) 362-3763 or [email protected]. ✦

MMA Initiative AddressesPhysician Hassles with Payers

B Y R I C D A V E N P O R TD a v e n p o r t & A s s o c i a t e s


SHARING A SINGLE FOCUS

®

HEALTHEAST® WOUND CARE IS NOW LOCATED AT THE HEALTHEAST® VASCULAR CENTER

As a disease management center, we offer an integrated program of diagnostics, treatment,

follow-up, disease prevention and education focused on vascular patients.

Partner with us to ensure your patients receive the best care possible.

651/232-2550www.healtheast.org/vascular

Gallery Professional Building, Suite 60017 W. Exchange St., St. Paul, MN 55102

agreement. The provider has 60 days from thepostmarked date of the contract offer to con-sider participation. If the provider has not affir-matively signed the amendment and returnedit indicating they want to participate, the healthplan is prohibited from automatically addingthem to the network for this new category ofinsurance. The effect of this amendment is togive the provider 60 days to review the implica-tions of the proposed terms or relationship, andavoid being automatically put into a new cat-egory of service by default under a short or un-defined timeline.

(2) Mandatory Disclosure ofContract ChangesThe second area of protection for providers givenby Chapter 170 is disclosure of contract terms.Changes to existing contracts must be disclosedto the provider. Changes that affect the financialreimbursement or alter contract policies andprocedures governing the relationship betweenthe health plan and the provider must bedisclosed prior to the effective date of suchchanges. With this amendment, effective August1, 2001 in Minnesota law, all health planprovider contracts, whether for medical services,workman’s compensation products, or automedical coverages must have terms disclosedprior to the effective date. No longer canunilateral changes be made to provideragreements with notice given after the fact. Formany health plans this is a major change in theirmethod of contracting. We advise members towatch for changes in contracts that appear tobe retroactive from the date you first becameaware of the proposed change. Changes madewithout giving prior notice to the provider arenow illegal.

(3) Option to Participate LaterAfter Initially DecliningThe third area of protection with Chapter 170is the right to participate at a later date in a cat-egory of insurance previously offered where theprovider initially declined participation. Shoulda provider decline to participate in the first of-fer of a new category of insurance they have theright to reapply in two years and bi-annuallythereafter. Thus, no longer do providers needbe concerned about being permanently “shut-out” of a new product if they initially declineparticipation.

While the option to participate and themoratorium are scheduled to sunset or expireby June 30, 2002, the Coalition will work nextsession to make these permanent protections inlaw for providers and consumers. These changesimprove the opportunity for providers to reviewproposed changes to their provider agreementsand also work with health plans to improveterms based on reasonable opportunities to re-view and communicate prior to contract par-ticipation deadlines. ✦

The information provided in this article is not asubstitute for legal advice. Providers interested indetermining the specific application of this lawto their practices or in negotiating the terms ofprovider agreements should discuss the matter withtheir own attorneys, accountants and consultants.

Ric Davenport is a consultant with Davenport& Associates, (952) 471-0462.


Celebrate Women inMedicine Month

EEVERY YEAR THE FEDERATION of medi-cine, led by the American Medical Association,designates September as Women in MedicineMonth. This year’s theme—Leaders Making aDifference—celebrates the contributions ofwomen physicians who are working hand inhand with their male colleagues to advance theprofession and improve the health status of theircommunities.

We’ve come a long way since 1915 whenwomen represented 5 percent of the practicingphysicians and the American Medical Associa-tion reluctantly seated its first woman delegate.That same year, the American Medical Women’sAssociation was founded to foster professionalvisibility and improve the standing of womenin medicine.1 It would be another five years be-fore women received the right to vote in theUnited States.

Throughout the mid 20th century, womenphysicians continued to struggle for represen-tation in their profession. Even during the WorldWars, when doctors were in high demand,women were either barred from service or of-fered limited positions in the military. By thelate 1960s, women in all walks of life began toquestion their place in society. With the growthof the feminist movement came an increasedinterest in the professions, including the prac-tice of medicine.

By the last decade of the 20th century, closeto 45 percent of entering medical students werewomen. Women now make up 23 percent ofall practicing physicians in the U.S. and in somespecialties (OB-GYN, Pediatrics, Psychiatry)they are at parity or majority. Women physi-cians are, by and large, a young group—65 per-

cent are under the age of 45 years.2 They lagbehind their male colleagues in salary and aca-demic rank, but there are positive signs of growthand acceptance in many areas. In the state ofMinnesota, women are well represented in theMinnesota Medical Association, making up 22percent of their membership, and 24 percent ofthe Minnesota physicians belonging to the AMAare women.3

So, how do we interpret the gains ofwomen in the field of medicine? Has it been apositive experience? Will the momentum con-tinue or will we see a backlash as occurred afterthe Flexner report of 1904 when 50 percent of

women’s medical schools closed within fiveyears?

Certainly, there have been many changesin our society over the past 100 years. Womenreceive an education equal to men, and are heldto the same high standards of practice. Advancesin science and technology have brought us suchbreakthroughs as antibiotics, organ transplan-tation, elimination of many communicable dis-eases, and more. Computers and informationtechnology have put vast stores of knowledge atthe fingertips of anyone with an Internet con-nection. Our culture has advanced and em-braced the concept of basic human rights for all

Minnesota Women PhysiciansPresent

George Dow, Managing Consultant“What Do I Want to Be, Now that I’ve Grown Up?”

Joel Greenwald, M.D., Financial Advisor“Case Studies in Financial Planning —

What you Need to Know for Retirement”

To Register, call Robyn at (612) 362-3736

featuring:

Saturday, September 159:00 a.m. - 1:00 p.m.

& new members welcome luncheon

A Career & Financial Summit for Women Physicians

Calhoun Beach Club

B Y A N N E W . T O W E Y, M . D .O p h t h a l m o l o g i s t , L a k e v i e w C l i n i c


races, genders, creeds, and other minoritygroups. Men are justifiably proud of their wives’and daughters’ accomplishments. Women arenow free to pursue their goals, both education-ally and professionally.

So, how have women changed the face ofmedicine? I think that women have brought asense of compassion, an innate ability to com-municate, and a willingness to partner with theirpatients, which has humanized the face of medi-cine. From the early days of the women’s move-ment when women demanded the right to knowand participate in areas of reproductive healthand childbirth, women have been advocates foradvances in wellness, long before it became fash-ionable to do so. I believe that women have alsohelped their male colleagues to achieve a morehumane lifestyle by showing that however dif-ficult, it is still possible to balance a family anda practice. Many courageous women refused totake “no” for an answer when told that “Girlscan’t be doctors,” or “You can’t get married andstill practice medicine,” to “Don’t you dare getpregnant on my residency service.” They grace-fully, but forcefully, showed the way to othersfollowing in their footsteps.

Where do we go from here? The theme ofthis year’s women in medicine month is leader-ship. Leadership seems to be like the weather,everyone talks about it, but not much is done.As physicians, we are already leaders whetherwe know it or not. Our patients look to us toset a good example and to give good advice. Justa few simple activities can yield tremendous re-sults and be rewarding as well.

How can you get involved? Join Minne-sota Women Physicians. This organizationstarted as an outgrowth of Alpha Epislon Iota, asorority for women medical students present formany years at the University of Minnesota. Ev-ery year Minnesota Women Physicians hosts aseries of informative workshops, lectures, andopportunities for networking for women in andaround the Twin Cities. Each summer a picnicto welcome incoming female medical studentsis hosted by Minnesota Women Physicians atthe home of Karin Tansek, M.D. The next event,scheduled for September 15, is a half-day semi-nar on “Financial Planning and Mid-CareerOptions.” A membership directory serves as avaluable resource for women physicians in thearea.

Volunteer to attend a function of Hennepin

or Ramsey Medical Societies. In addition to gov-ernance opportunities, there are social eventssuch as the recent Minneapolis Institute of Arts“Star Wars” Exhibit, and the upcoming Mos-cow-on-the-Hill dinner party or LakeMinnetonka Boat Cruise to meet and interactwith physicians from Russia.

Volunteer to be a delegate to the Minne-sota Medical Association’s Annual meeting andHouse of Delegates. This is a wonderful oppor-tunity to meet some of the leaders of our medi-cal community. They want to meet YOU too!You will have an opportunity to learn aboutpolicy issues and even draft your own resolu-tions. The MMA’s committee on Women Phy-sicians has sponsored a number of such resolu-tions including providing access to contracep-tives, a ban on guns in school, protection fromnoisy toys, which can permanently damage hear-ing. As past chair of this committee, I have hada chance to meet many fine individuals whowould never have otherwise crossed my path.

Join the Women Physicians’ Congress ofthe American Medical Association. This con-gress focuses on addressing women’s health andprofessional issues of special interest to womenphysicians. A one-year trial membership is free.Membership information is available on-line atwww.ama-assn.org/wps. In March 2002, theWomen Physicians’ Congress will sponsor aprogram on women’s leadership issues and morein Los Angeles, California.4

It is important for women physicians toget involved in organized medicine at all levels.The family of medicine needs us to carry for-ward the great legacy of good health and equalaccess to health care in the 21st century. Othermembers of our society rightly look to physi-cians for advice and value our opinions. Let’sgive them something to admire. ✦

References:1. More, ES “The American Medical Women’s Asso-ciation and the Role of the Woman Physician 1915-1990”. JAMWA 1990:45(5): 165-1802. JAMA, September 6, 2000-Vol. 284, No. 9, 1114-11203. Minnesota Medical Association, Minneapolis, MN,membership services4. American Medical Association, Women PhysicianSection at: www.ama-assn.org/wps

Sept./Oct.Index to Advertisers

Brainerd Medical Center ....................... 12

Dermatology Consultants ....................... 8

Financial Network .................................. 3

HealthEast Vascular Center ................... 15

Hennepin Cty. Medical Center CME ... 19

HMS/RMS Winter CME ..................... 20

Midwest Medical Insurance Co. .............. 9

RCMS Inc. ............................................. 7

Red Pine Realty .................................... 17

U.S. Office Products ..... Inside Back Cover

U of M CME............. Outside Back Cover

Walser Auto ................. Inside Front Cover

Weber Law Office ................................... 2

This property features six nicelyappointed homes and cabins in apark-like setting on 12 acres, with1500 feet of unique Lake Superiorshoreline. This one-of-a-kind shorelinehas all that Lake Superior has to offer:water on three sides of some units, abay, rocky cove, ledge rock points,and a cliff-top overlook. This is anoutstanding property with everythingfor your family and guests. Theproperty is zoned commercial so itcould be run as rentals, too. It doesn’tget any better than this. Priced to sell.$820,000.

Mike Raymond, RealtorP.O. Box 938

Grand Marais, MN 55604e-mail: [email protected]

800/387-3585 / 218/387/9599www.RedPineRealty.com

Spectacular Lake Superior Setting


SSECTION E-2.00: OPINIONS ONSOCIAL POLICY ISSUESIn the previous issue of MetroDoctors, we exam-ined the historical evolution and overall struc-ture of the AMA’s Code of Medical Ethics, alongwith the first of 10 sections. In this article, weturn to the section of the Code that encom-passes the wide array of Opinions that are re-lated to “social policy.”

Social Policy and the RevisedPrinciples of Medical EthicsTo begin with, it should be noted that the origi-nal Code devoted an entire section to the rela-tionship between physician and society. Theimportance of this relationship has been re-tained, not only through the provisions that areincluded in the section on “Social Policy Issues,”but also in the Principles of Medical Ethics. Thepreamble specifically refers to physician’s respon-sibility to society. Principle III, which remainsunchanged from the 1980 version, elaboratesupon this obligation by calling upon physiciansto seek changes in laws that are contrary to thebest interests of the patient. Principle VII em-phasizes that a physician as a citizen of a com-munity holds a special social responsibility toparticipate in activities contributing to its im-provement. According to the June 2001 revi-sion of this Principle, this extends to a responsi-bility to participate in activities that promotethe betterment of public health. Finally, Prin-ciple IX, which has been added through the2001 revision of the Principles, addresses thevery basic social need for access to medical care.

Topics Addressed Under“Social Policy”This section of the Code contains the largest

number of Opinions, which cover a large arrayof topics that are central to medical ethics. How-ever, the majority of Opinions can be categorizedunder a few broad topics, including reproductiveissues, genetics, organ transplantation, research,end-of-life care, and allocation of resources.

The first Opinion of the section, also oneof the oldest of the section, pertains to repro-ductive rights but also to physicians’ autonomyand freedom of practice within limits set by thelaw. Opinion 2.01 specifically states that Prin-ciples of Medical Ethics do not prohibit physi-cians from performing abortions. This is a clearillustration of how the AMA’s Code stands apartfrom the Hippocratic tradition, although inother instances, it builds upon that traditionmore closely, for example in safeguarding con-fidentiality.

Other Opinions related to reproductionaddress issues related to artificial insemination,in vitro fertilization, and surrogate motherhood,and consider various procedures related to em-bryos and fetal tissues. Some of these Opinionsoverlap with genetic issues, such as genetic test-ing, counseling and therapy, culminating withan Opinion on human cloning.

At the other end of the biological spectrumstand all the Opinions related to end-of-life care,including advance directives, the withholdingor withdrawing of life-saving treatment, as wellas euthanasia and physician-assisted suicide. Inregard to both of these activities, the Code statesclearly that they are fundamentally incompat-ible with the physician’s role as healer.

Other Opinions in this section addressmany of the ethical questions that often areraised in the context of end of life, such as futil-ity and quality of life. Many ethicists havepointed to the difficulty of building consensus

when using such terms, since they rely on highlysubjective determinations. In this regard, theOpinion on futility in end of life care (Opinion2.037) proposes a procedural approach at re-solving disputes that can occur between physi-cians and patients, or more likely their surro-gate decision-makers, when treatment decisionsare made for those who are terminally-ill.

Section 2.00 of the Code also addressesmatters related to organ transplantation, a rela-tively recent development in medicine that hasraised fundamental ethical questions in regardto individuals’ absolute control over their bod-ies and all of its parts, and the possibility to useorgans or other tissues to save the lives of otherindividuals. In fact, issues related to organ trans-plantation present a vivid illustration of con-cepts fundamental to contemporary medicalethics, namely the principle of patient au-tonomy and the concept of utilitarianism,which often is referred to when arguing for amaximization of social goods, even at the ex-pense of individual rights.

Thus, the current system of organ procure-ment requires that an individual specificallyconsents to the donation of his or her organs.In the absence of such consent, organs are notremoved, and the lives of patients waiting fororgans remain in jeopardy. In contrast, if it wereacceptable to society to maximize resources suchas organs, and to ensure that patients in need ofthem had a high chance of receiving timely trans-plants, organ donation could be mandatory in-stead of voluntary, with arguably little harm tothe dead donors.

A similar tension between protecting therights of individuals and maximizing social util-ity exists in the context of biomedical research,whereby new scientific knowledge can be gainedthat will benefit all of society and future gen-erations of patients. Yet, current ethical stan-dards, as captured in Opinion 2.07 on clinical

Highlights of the Code of Medical Ethics ofthe American Medical Association

B Y F R A N K A . R I D D I C K , J R . , M . D .A N D K A R I N E M O R I N , L . L . M .


investigation and other related Opinions, en-sure that the design of clinical research proto-cols be rigorously evaluated so to assure that thedata produced will be scientifically valid and sig-nificant and that those who participate in re-search do so voluntarily. This fundamental re-quirement of human participation in researchhas given rise to the doctrine of informed con-sent. In fact, one of the earliest references to thenotion of consent appeared in the Code in rela-tion to human experimentation, in parallel tothe development of the Nuremberg Code. And,despite the fact that these issues have been de-bated for several decades, controversy surround-ing clinical trials continue to arise, as addressedin recent ethics policies developed by CEJA,including one on “sham” surgery (Opinion2.076, “Surgical ‘Placebo’ Controls”) and a Re-port on international research adopted last June(CEJA Report 2 – A-01, Ethical Considerationin International Research).

A small number of Opinions included inthis section of the Code serve to reinforce thatthe role of physicians is defined in terms of theirrelationship to patients in need of medical careand not in terms of other social goods or stateinterests. Particularly, Opinion 2.06 prohibitsphysicians’ participation in capital punishment,even though executions are lawful in many statesand at the federal level. However, this shouldnot mean that physicians are not sometimescalled upon by society to play a role in protect-ing society’s interests, such as intervening in casesof abuse or neglect (Opinion 2.02, (Abuse ofChildren, Elderly Persons, and Others at Risk)or in cases of risks to the public (Opinions 2.23,“HIV Testing” and 2.24, “Impaired Drivers andTheir Physicians”).

Together, these and all the other Opinionsin section 2.00 of the Code that were not high-lighted in this discussion, present ethical guid-ance that physicians can rely on when dealingwith the many aspects of medical practice thatare influenced by social attitudes and norms,and that conversely help shape changes withinsociety. Physicians, therefore, may view the prac-tice of medicine as a unique dialogue with society.

The full content of the AMA’s Code ofMedical Ethics is accessible online at www.ama-assn.org/go/ceja. ✦

Frank A. Riddick, Jr., M.D. is Chair, Councilon Ethical and Judicial Affairs. Karine Morin,L.L.M. serves as Secretary, Council on Ethicaland Judicial Affairs.

The mission of Hennepin County Medical Center’s CME program is to provide organized, planned education activities

to help physicians improve the delivery of medical care.

For more information, please call HCMC Continuing Medical Education

at (612) 347-2075. Fax (612) 904-4210. Toll Free 888-263-4262.

www.hcmc.org

SEPTEMBER 200121 Contemporary Issues in Dialysis

Midway Sheraton, St. Paul

OCTOBER 20014-5 Annual Forensic Science Seminar

Pillsbury Auditorium, HCMC

19-20 Society for Acupuncture Research Annual SymposiumPillsbury Auditorium, HCMC

25-26 Advanced Life Support in ObstetricsPillsbury Auditorium, HCMC

27 Annual Mpls. Medical Research Foundation Event: Focus on Pediatrics

NOVEMBER 200129 – DEC.1 Annual Orthopaedic and

Trauma SeminarMinneapolis Convention Center

DECEMBER 200114 10th Annual Family Practice Update

Ramada Inn, Bloomington

M A R K Y O U R C A L E N D A R


I

Medical School Seeks to IncreasePresence in “Silicon Valley of India”

IF KUMAR BELANI and international educa-tion leaders at the University of Minnesota gettheir wish, the Medical School will have a stron-ger presence in Bangalore, India, in the near fu-ture. For starters, this would mean increasingthe number of medical students doing clinicalwork in Bangalore, and developing faculty ex-changes to collaborate on research in specificdiseases.

At the recommendation of Belani, who isspearheading the project, he and a contingentof medical school leaders traveled to the city in1999 to explore its potential for clinical workand research. As a Bangalore native and gradu-ate of the city’s renowned St. John’s MedicalCollege, Belani knew the city’s untapped re-sources.

“I knew Bangalore was the perfect placefor the Medical School to make strides in glo-balizing medical education and research to ben-efit patient care,” said Belani.

Disease, including heart disease and rheu-matic fever, is rampant in Bangalore, linkedlikely to the country’s extreme poverty. Morethan 400 million or 40 percent of the country’sone billion people now live in substandard con-ditions. Tuberculosis is India’s number onehealth problem, and the incidence of HIV/AIDS is increasing. It is also going largely un-treated.

This widespread disease has spurred the es-tablishment of world-class heart hospitals andother medical facilities in the city, includingHOSMAT Hospital, the Manipal Heart Foun-dation and Manipal Pediatric Heart Hospital.“Bangalore has an excellent medical infrastruc-ture in place, in which students and faculty canlearn and make a real contribution,” said PhilPeterson, infectious disease specialist and co-director of the Medical School’s office for inter-national education and research programs.

The opportu-nities for researchthere are also excel-lent, and includeprospects for fund-ing from NIH andother sources. A re-search collaborationon HIV/AIDS is al-ready underway,headed by infec-tious disease andpublic health spe-cialist Alan Lifson.Similar collaborations are in the offing.

Three University of Minnesota medicalstudents have completed clinical rotations inBangalore since 1999, when exchange agree-ments were signed with St. John’s, HOSMAT,and Manipal Hospitals. Several more studentsare exploring this option.

“The student learning opportunities inBangalore are tremendous,” said medical schooleducation dean Greg Vercellotti. “The qualityof the facilities is excellent and the chance to doclinical work and research in this part of theworld provides our students with an invaluableeducation.”

Last year, Mary Ollapally, dean of St. John’sMedical College, visited the medical school toexplore increased student and faculty exchangeswith Bangalore. To date, funding has preventedBangalore students from completing clinical ro-tations here.

Known as the Silicon Valley of India, themedical school is looking forward to the daywhen the technology companies located in Ban-galore will become involved in medical researchin priority areas. “The fact that the city is soadvanced technologically, and that it is Englishspeaking, are great advantages,” said Peterson.

These and other factors make Bangalore adesirable place for students and faculty every-where. Several medical schools, includingHarvard and Johns Hopkins, have entered thecompetition to establish a presence. “We’d beopen to working with other medical schools aswell as the talented physicians in Bangalore,”said Peterson. “All of us can learn from theirdedication and third force humanitarianism.”

Bangalore has potential for public health,nursing and veterinary medicine as well. Uni-versity Senior Vice President for Health SciencesFrank Cerra is interested in establishing pro-grams in these areas. “Students and profession-als in all the health sciences can learn and makecontributions in this important arena,” he said.

Part of the University’s capital campaignhas been earmarked to fund international medi-cal education and research projects like the Ban-galore exchange. If funding allows, an advanceteam will head to Bangalore again this fall,headed by Cerra and Dean Michael. There, theywill finalize expansion of the University’s pres-ence in Bangalore. All those concerned in bothcountries have only to benefit. ✦

University of Minnesota faculty with faculty from St. John’s MedicalCollege that visited Bangalore in December 2000 to conduct the firstInternational Medical Update.


T

Public Health Fared Well inLegislative Session

M N P E R S P E C T I V E

THE HEALTH OF THE PUBLIC generallyfared well during this past legislative session. I’mpleased that in response to the Governor’s pro-posals, more health initiatives were passed thissession than had been the case for a number ofyears. We, in public health, very much appreci-ate the support and involvement of physiciansand others in passing and implementing theseand other initiatives to improve the health ofour communities.

The Children’s Health Insurance Expan-sion initiative, in the Department of HumanServices budget, provides funding to ensure con-tinuous health care coverage for 20,000 low-income kids who either don’t have coverage now,or fall in and out of coverage due to the com-plexity of eligibility rules. This represents thefirst major step in years toward insuring all kidsin our state.

One of our biggest victories in the Depart-ment of Health budget was the initiative toeliminate racial and ethnic disparities, which waspassed with most of the funding that we requested($13.9 million over the biennium and ongoing).

This legislation gives us added resourcesto address long-standing health disparitiesamong American Indians, populations of color,and immigrants and refugees. Virtually acrossthe board (and notably at all income levels), thesepopulations have worse health outcomes thantheir white counterparts here, and often worsethan the same populations in other states. OurOffice of Minority and Multicultural Healthpublished a report a few years ago, and an up-date more recently, which outlines some grimstatistics and offers recommendations on howto improve them. This legislation focuses par-ticularly on immunizations, infant mortality,

HIV/AIDS and sexually transmitted diseases,breast and cervical cancer screening, cardiovas-cular disease, diabetes, and unintentional inju-ries and violence.

The Minnesota Department of Health’sOffice of Minority and Multicultural Health canhelp practices assess their “cultural competency”to ensure that medical treatment and patienteducation are understood and used by all theirpatients.

$2.2 million for the biennium was fundedto provide grants to communities for suicideeducation and outreach. Depression is a signifi-cant cause of suicide. More outreach and edu-cation, complemented by increasing recognitionof depression in the primary care setting, shouldresult in more people seeking advice from theirhealth care providers about depression.

Our Emerging Health Threats initiative re-ceived $3.6 million, about 75 percent of whatwe’d proposed. It helps to stabilize funding andadd capacity for the MDH Public Health Labo-ratory, which has been funded by a combina-tion of dwindling federal grants and fee revenuesintended for other purposes.

The Medical Education Endowment Ex-pansion, begun in 1999, will receive an addi-tional $374 million in principal, (yielding a to-tal of approximately 17 million per year in in-vestment income). This dedicates all of the state’sremaining one-time tobacco settlement proceedsfor the University of Minnesota AcademicHealth Center to expand medical education inMinnesota.

The state Poison Control System received$2.7 million, which fully funds its operation forthis biennium. However, the Legislature still hasdeclined to guarantee base funding for future years.This system provides the public and health careproviders statewide with information and treat-ment advice about poisonings and toxic exposures.

MDH received $2.65 million to supportinitiatives recommended by the Long Term CareTask Force to support planning grants, construc-tion projects and additional options forMinnesota’s long-term care system. Physiciansare well aware that the population is aging, andthat we need a variety of care settings and ap-proaches to meet those needs.

For the first time, there will be direct statefunding for community clinics ($4 million peryear), and a doubling of current funding for ruralhospital capital improvement grants (to $5 mil-lion per year). In addition, a new intergovern-mental transfer will generate additional federalfunding to help offset the disproportionate costsof charity care born by Hennepin County Medi-cal Center and Regions Hospital. Direct publicfunding should help to eliminate some of thecost shifting on to private payers to support allof these important safety net providers.

While the Governor’s proposal for a com-prehensive teen pregnancy prevention effort wasnot adopted, a number of Youth Health Im-provement activities were funded, includingyouth risk behavior programs and expansion ofpublic health nurse home visiting services.

All told, there were more health policy is-sues on the table this year than we’ve seen inawhile. And given the number of issues still tobe addressed to keep high quality health careavailable and affordable in our state, we shouldexpect that trend to continue.✦

Jan Malcolm was appointed Minnesota Commis-sioner of Health by Governor Jesse Ventura in Janu-ary 1999. The Minnesota Department of Healthis the state’s lead public health agency, responsiblefor protecting, maintaining and improving thehealth of all Minnesotans.

B Y J A N M A L C O L MM i n n e s o t a C o m m i s s i o n e r o f H e a l t h


IIMAGINE A DAY WITHOUT VIOLENCE.No need to inquire about a patient’s bruises.No bandages to cover batterings.No surgeries to cut out bullets.No stitches to pull together knife wounds.No sexual assault evidence exams.No disrespect among colleagues in the workplace.And for those of us who are parents, no worries that our child might beamong the next victims.

That’s the goal of the Turn Off the Violence campaign. October 11has been proclaimed Turn Off the Violence Day this year. On that day theTurn Off the Violence Coalition — which brings together the voices ofmedical professionals, educators, law enforcement, social service agencies,clergy, and parents — asks people to start with the simple step of turningoff violent media.

Many Americans are horrified and baffled by real life crime and vio-lence and yet sit down every evening to watch violent videos, listen toviolent music, play violent video games, go to violent movies, and watchtelevision shows that make violence and disrespect look ordinary, macho,heroic, and even humorous. And for too many people, violence is becom-ing the ordinary way of resolving conflict, releasing emotions, and dem-onstrating power.

Among those who have concluded that there is a direct causal linkbetween media violence and violent behavior are the American Academyof Pediatrics, American Medical Association, American Psychological As-sociation, National Institute of Mental Health, National Institute on Mediaand the Family, U.S. Centers for Disease Control, and the U.S. SurgeonGeneral’s Office.

Kids in violent families or violent neighborhoods may be most atrisk. Media violence is one form of violence we can all turn off.

But that’s just the beginning! Turn Off the Violence is also workingto educate people about anger management and nonviolent conflict reso-lution. Among the free resources downloadable from their website are anEducators’ Guide and a Community Action Guide, both filled with prac-tical, concrete ideas about how each of us can help turn off violence in ourhomes, workplaces, schools, and communities.

In 1994 the Minnesota Medical Association recognized Turn Offthe Violence “for work that has significantly benefited victims of violenceand for efforts to end violence in the state of Minnesota.”

For more information about the Turn Off the Violence campaign andcoalition membership, visit their website at www.turnofftheviolence.orgor contact Sheila Miller, Executive Director, Turn Off the Violence, P.O.Box 27321, Minneapolis, MN 55427, (763) 529-6227.

Excerpts from Turn Off the Violence reproducible handouts.At home...1. Turn off violent entertainment and do something fun, safe, and

healthy.2. If you’ve already chosen to turn off violent entertainment, turn it

back on and see what America’s children are being exposed to.3. Write at least one letter to a television advertiser, video game com-

pany or music company. Turn Off the Violence offers sets of post-cards you can use to voice your opinions.

If you have kids...1. Teach your kids to love reading. (Language skills help them express

anger without violence.)2. Demonstrate respect.3. Demonstrate nonviolent conflict resolution.4. Talk about your values.5. Listen.6. Set boundaries.

At work...1. Consider how you resolve conflict and react to stress. Do you ever

use words that shame, humiliate, intimidate? Do you hold in youranger and take it out later on others? Managing anger is a disciplinethat takes practice.

2. Lead by inspiration rather than intimidation.3. Sponsor a Turn Off the Violence event for employees and their fami-

lies, or the community.

Today you can be part of the solution by turning off the violence. ✦

Footnote: Turn Off the Violence began in Minnesota in 1991 but had laindormant in recent years after a change in leadership. The Hennepin MedicalSociety, an original member of the Turn Off the Violence coalition, is pleasedto announce that the campaign is back under the wings of its founders and anenthusiastic board of directors and they’re soaring with a renewed sense ofenergy.

October 11 is DeclaredTurn off the Violence Day

B Y S H E I L A M I L L E RC o - f o u n d e r , T u r n o f f t h e V i o l e n c e

PRESIDEN T ’S MESSAGER O B E R T C . M O R A V E C , M . D .

RMS-Officers

President Robert C. Moravec, M.D.

President-Elect Peter H. Kelly, M.D.

Past President John R. Gates, M.D.

Secretary Jamie D. Santilli, M.D.

Treasurer Peter J. Daly, M.D.

RMS-Board Members

Kimberly A. Anderson, M.D., Specialty Director

Victor S. Cox, M.D., Specialty Director

Charles E. Crutchfield, III, M.D., At-Large Director

Kelley C. du Ford, Medical Student

Thomas B. Dunkel, M.D., MMA Trustee

Michael Gonzalez-Campoy, M.D., At-Large Director

James J. Jordan, M.D., Specialty Director

Kathryn M. Klingberg, M.D., Resident Physician

Charlene E. McEvoy, M.D., At-Large Director

Ragnvald Mjanger, M.D., Specialty Director

Kenneth E. Nollet, M.D., Ph.D., At-Large Director

Thomas F. Rolewicz, M.D., Specialty Director

Paul M. Spilseth, M.D., At-Large Director

Lyle J. Swenson, M.D., MMA Trustee

Charles G. Terzian, M.D., Specialty Director

Jon V. Thomas, M.D., At-Large Director

David C. Thorson, M.D., Specialty Director

Russell C. Welch, M.D., At-Large Director

RMS-Ex-Officio Board Members &Council Chairs

Brent R. Asplin, M.D., AMA Young Physician SectionBlanton Bessinger, M.D., MMA PresidentKenneth W. Crabb, M.D., AMA Alternate DelegatePaul J. Dyrdal, M.D., Sr. Physicians Assoc. PresidentStephen P. England, M.D., Community Health

Council Chair*Michael Gonzalez-Campoy, M.D., Education

Resource Council ChairEleanor Goodall, Alliance PresidentFrank J. Indihar, M.D., AMA DelegateWilliam E. Jacott, M.D., U of MN RepresentativeMatthew D. Layman, M.D., AMA Delegate for

American Society of AnesthesiologistsMelanie Sullivan, Clinic Administrator*Lyle J. Swenson, M.D., Public Policy Council Chair*Russell C. Welch, M.D., Communications

Council Chair

*Also elected RMS Board Member

RMS-Executive Staff

Roger K. Johnson, CAE, Chief Executive OfficerDoreen M. Hines, Membership & Web Site CoordinatorSue Schettle, Director of Marketing & Member Services


R

From Where I Sit…“Patient Communication andDisclosure as Patient Safety Tools”

RECENTLY THE MINNESOTA MedicalAssociation convened its Patient Safety TaskForce to help address physician specific issuesin the patient safety arena. This task force willhelp provide a voice from the physician’s per-spective in dialogues with Minnesota groups thatare addressing patient safety issues and will helpidentify strategic methods for improving patientsafety in the clinic practice setting. It is expectedto make specific recommendations to the MMABoard of Trustees regarding policies specific topatient safety.

A key issue to be addressed initially by thetask force is that of disclosure. Disclosure is de-fined as the communication of information re-garding the results of a diagnostic test, medicaltreatment or surgical interventions. Disclosurein the face of an adverse patient outcome in-volves the honest and factual description of theoccurrence as well as the possible implicationsof the event on the patient’s health and well-being. Disclosure is not meant to be an admis-sion of guilt or liability or finger pointing toquickly allay the blame somewhere else. Dis-closure should be timely, purposeful and disci-plined.

Disclosure also means a commitment bythe physician to follow through with thepatient’s family and to stay involved and be avail-able to discuss questions with the patients andtheir family. A key determinate in many mal-practice suits is the lack of response by the phy-sicians involved in an adverse event. Many pa-tients sue their physicians and hospitals just tofind out what happened and answer questionsthat could (should) have been answered shortlyafter the event. Disclosure helps enable the emo-tional healing that should occur following anadverse event. Many times the emotional heal-ing is just as important as the physical healingfollowing an illness or injury. Failure to discloseand openly communicate with the patient andfamily following an adverse event has the po-tential to become malignant with buildup ofresentment and anger.

Communication is an important safety

tool. It is a skill set that should be actively culti-vated and developed. For many of us, it mayrequire professional training or assistance toovercome some of our bad habits. But, com-munication is a fundamental component of thephysician-patient relationship and one in whichwe should be setting the standard. It cannot betaken for granted. The substitution of a desig-nee to speak on a physician’s behalf can have itsown unintended consequences. The designeesmay not have the background to adequatelydiscuss the events and outcome at hand. Moreimportantly, it can give the impression that thephysician did something wrong and has some-thing to hide. Communication and disclosurego hand in hand.

Documentation of such discussions is alsocritical to its success as a patient safety tool. Thedocumentation should identify who was presentduring the discussions as well as what was dis-cussed and also should try to document thequestions that were answered. Remember, a keymessage to patients and families is that an ad-verse event is multi-factorial in a complex sys-tem and a significant amount of investigationand review must be completed as part of theevent review process. Physicians should avoidjousting and finger-pointing when discussingerrors.

So what can you do right now to improvecommunication and disclosure? I would sug-gest the following steps:• Work with your clinic staff and office

managers to develop a policy around dis-closure and patient communication in theevent of an adverse outcome.

• Critically evaluate your own patientcommunication skills (be honest) andlook for opportunities to enhance your



Ra

ms

ey

Me

dic

al S

oc

ie

ty

W

RMS AL L IAN CE N EW S

Brenda AndrewsonCo-PresidentWHO? WHAT?

The Ramsey Medical Society Alliance has beena force in our medical community for almost 80years and, yet, I am continually amazed at howmany people do not know who we are or whatwe do. Clearly there is a need to better promoteourselves within our community. The morepeople understand what it is that we do, the morepeople will be interested in participating and join-ing us in our mission to promote educationaland charitable endeavors, which improve healthand quality of life within our community. TheAlliance has many valuable projects of which weshould all be proud.

This past March, we raised almost $20,000with the RMS Foundation to support Spare KeyFoundation in their mission to help families withcritically ill children. Those of you who haveheard Patsy Keech from Spare Key speak aboutthe difficulties that these families endure knowthat there is seldom a dry eye in the house by thetime she is finished.

This past April, our Body Language HealthFair once again educated St. Paul third gradersabout healthy, life-long habits. Volunteers, fromour Alliance and the community, staffed boothsincluding physical fitness, nutrition, mentalhealth and self-esteem, a mock hospital room,our skeletal system, a HiTECH Heart as well asa presentation by The Extinguisher (The AMA’santi-smoking superhero). The gratitude expressedby these young students and their teachers wasreward enough, but we also got to see several ofour members dress up as The Extinguisher in ahigh tech body suit complete with muscles. Talkabout the rewards of volunteerism!

Our annual Holiday Auction not only pro-vides us with the opportunity to get together withfriends for a relaxing, fun-filled evening, but alsoraises funds for our various philanthropicprojects. This past year those included the Ameri-can Cancer Society, Caring Hearts for the Home-less, Festival of Trees, First Steps, Growing Home,Model Cities, Sexual Violence Center, WigsWithout Worry and the AMA Foundation. Wechoose our projects based on what our membersare interested and involved in. We choose to serveour community, but we also want to support you.

Our Alliance is not just about health edu-cation and fundraising. We also provide supportto our physicians, our families and each other.We’ve hosted programs about mid-life careerchanges, the stresses of the medical marriage andhow to have an impact on the legislative process.We have a variety of interest groups such as abook club, two bridge groups, an investment cluband a trusted friends group. For many of us, thebest benefit of belonging to the Alliance is thestrong network of friends who truly care for oneanother.

So, how do we go about promoting our-selves? I think each and every one of us needs totake on the task of letting others in the medicalcommunity know what we do. If each of usmakes a point of telling at least one potentialmember about the great things we do and en-courages that physician spouse to attend a meet-ing or program, we will see results. We all knowphysician spouses who are not yet members ofthe Alliance. Perhaps some of them are the hus-bands/wives of your spouse’s partners, yourfriends or your neighbors. The next time you seethem, why not tell them about what we do? Youdon’t need to become a telephone solicitor, justtell them about the parts of the Alliance that youmost enjoy and invite them to give us a try byattending a meeting or program.

Some of you may feel uncomfortable try-ing to “sell” the Alliance to your friends and ac-quaintances. Hey, I’m a charter member of theMinnesota Shy Club myself, but we all have totake part in this membership effort. Our Sep-tember meeting is designed to make this easy forall of us. On September 19, join us for lunchand a discussion about the RMS Alliance, whowe are and what we do. We encourage each ofyou to invite a potential member to join us. Andif a luncheon meeting doesn’t fit with your sched-ule, join us for a wine tasting with spouses onOctober 4. The Ramsey Medical Society Alli-ance has given so much to our community andto each of us personally. We owe it to ourselves,and to our Alliance, to keep it strong and grow-ing. ✦

In MemoriamSUBBAYAMMA ATLURU, M.D. died July13 at the age of 49. She graduated fromGuntar Medical College, India in 1980 andcompleted her internship and residency at theUniversity of Minnesota in 1993. Dr. Atluruwas board certified in Family Practice andpracticed at North Suburban FamilyPhysicians in Shoreview. She joined RMS in1993. ✦

skills by participating in communicationworkshops. Remember that 20 to 25 per-cent of patients will switch physicians solelybecause of communication issues!

• Get involved in your health care systemto review and lobby for good disclosurepolicies. Ask to see a copy of the policyfrom your administrator or patient safetycommittee representative.

• Involve your patients in a discussionabout their safety within the healthcaredelivery system. Encourage them to askquestions of the healthcare team. Give yourpatients tips to improve their well-beingduring hospitalization. Ask patients toverify the site of surgery prior to enteringin the hospital.

• If you are involved in an adverse event,ask your healthcare system administrationleaders to involve you in the discussionswith the patient and family and take anactive role in their healing process that isneeded following an adverse event. (Hos-pital policies may already require that phy-sicians lead the discussion with patients andfamilies).To shy away from our responsibility for

communication is to abdicate a key componentof the doctor-patient relationship. This is a criti-cal issue that will help define our overall successin improving patient safety. ✦

President’s Message(Continued from page 24)


NHMS-Officers

Chair Virginia R. Lupo, M.D.

President David L. Swanson, M.D.

President-Elect T. Michael Tedford, M.D.

Secretary Richard M. Gebhart, M.D.

Treasurer Michael B. Ainslie, M.D.

Immediate Past Chair David L. Estrin, M.D.

HMS-Board Members

Michael Belzer, M.D.

Carl E. Burkland, M.D.

Jeffrey Christensen, M.D.

William Conroy, M.D.

Paul A. Kettler, M.D.

James P. LaRoy, M.D.

Kathy Larson, Alliance PresidentRonald D. Osborn, D.O.

Joseph F. Rinowski, M.D.

David F. Ruebeck, M.D.

Richard D. Schmidt, M.D.

Leah Schrupp, Medical StudentMarc F. Swiontkowski M.D.

D. Clark Tungseth, M.D.

Joan M. Williams, M.D.

HMS-Ex-Officio Board Members

Barbara H. Subak M.D., Senior Physicians AssociationLee H. Beecher, M.D., MMA-TrusteeKaren K. Dickson, M.D., MMA-TrusteeJohn W. Larsen, M.D., MMA-TrusteeRobert K. Meiches, M.D., MMA-TrusteeHenry T. Smith, M.D., MMA-TrusteeDavid W. Allen, Jr., MMGMA Rep.

HMS-Executive Staff

Jack G. Davis, Chief Executive OfficerNancy K. Bauer, Associate Director

CHAIR ’S REPO RTV I R G I N I A R . L U P O , M . D .

NOW THAT I’VE HAD my 25th medical schoolclass reunion, I realize I’ve been around longenough to appreciate the fact that there are pen-dulums in medicine and that they are activelyswinging. They have a slow periodicity, possi-bly measured in decades, but they do swing. Iwas struck most obviously by this recently as Isee the controversy in my field surrounding vagi-nal birth after C-section. In 1981, I rememberthe sense of walking into uncharted, but well-reasoned, territory when we let the first fewwomen with one previous C-section undergo aclosely monitored trial of labor, and they suc-ceeded beautifully. The difference in post-de-livery morbidity and hospital stay almost madeus giddy, after the routine of scheduling five toseven repeat sections a week. We were seeingthe 99 percent success rate then, not the 1 per-cent severe complication rate. Now, though, asa specialty, we’re looking much more at the 1percent devastating uterine rupture rate, com-plete with fetal neurologic morbidity and in-fectious hemorrhagic complications in themother. And so we are quickly turning backtowards repeat C-sections, probably until theproblems inherent in operating for the fifth timeon a patient rise again to our collective con-sciousness.

Similarly, I speculate on whether therearen’t other pendulums out there, that may notbe recognized because we may not be in oneplace long enough to observe them. For instance,we’ve all heard anecdotes about residents in thefirst half of the 1900s, in which residents al-most paid for their own training rather thanbeing paid for it. As teaching hospitals lost fund-ing for postgraduate medical training in the lastdecade, the notion of requiring payment fromprospective residents, in exchange for their be-ing given access to patients and a place within alearning environment, has seemed not com-pletely improbable on occasion. Another pen-dulum could be swinging.

The recent increase in membership in or-ganized medicine within the Twin Cities is an-other ebb and flow phenomenon that has been

very welcomed by existing members of theHennepin and Ramsey Medical Societies. I liketo think it is due to awareness by physicians ofthe need to join together to speak with one voiceas a profession committed to taking care ofpeople and not just a pendulum swing, but Ican’t be certain of that.

The current turmoil in medical cost reim-bursement that we have seen so dramaticallyplayed out in the Twin Cities in the last monthin the Allina/Medica tsunami restructuringmakes me wonder if there may be a pendulumgoing toward the direction of fee-for-service re-imbursement that we thought we’d left behinda couple of decades ago.

Some of these reflections beg the questionof the other under-appreciated importance ofcorporate memory in our medical institutions.For without such memory, our institutions arebound to be periodically as barren as the north-ern Minnesota forests leveled by the fires of acouple of years ago. When an old tree or twofall, the rest of the forest structure remains andcan regenerate around the framework stillpresent. But when an entire forest is wiped out,from the old growth hardwoods to the weeds,new growth is completely dependent on whatblows into the area or is deposited by visitingbirds. I strongly argue that as baby boomers startto approach retirement years and deplete theranks of practicing physicians in massive num-bers, and that as institutions try to restructurein the interests of re-defining their core missions,that we not throw out all the old trees — thosewho would provide a framework for new treesto fill in and eventually grow to full stature. Notall clocks are quartz; some have pendulums anda periodicity that we can only define after morethan half the cycle has been completed. ✦


He

nn

ep

in

Me

dic

al S

oc

ie

ty

T

HMS AL L IAN CE N EW S

THE HENNEPIN MEDICAL ALLIANCE isan educational and charitable volunteer organi-zation, working in partnership with others, topromote the health and well-being of its mem-bers and the community through education,advocacy and service.

How does HMSA fulfill thismission statement?How do we impact educational and charitablepriorities in our community?• Body Works 2002, April 8-12 at Lutheran

Brotherhood Auditorium, will be our 19thannual health fair for Minneapolis publicschool third graders. We have over 100volunteers to present this successful healthproject that educates and motivates chil-dren to work at staying healthy.

• Provide materials to STOP America’s Vio-lence Everywhere (SAVE). This topic is alsoone of the Body Works areas.

• September 2000 was the first “SteppingStones Gala” in celebration of the first 90years of the HMSA (the oldest medical al-liance in the country). This event raisedmore than $12,000 for three teen clinics.We hope to be involved in another galafundraising event next year.

• HIV/AIDS education folders have beendistributed to more than 200,000 middleschool students. This project, under theable leadership of Diane Gayes and DianneFenyk, has provided information foldersto adolescents with an accompanying cur-riculum guide for teachers. We believe thisis an effective model for the primary pre-vention of STDs and HIV/AIDS withinthe targeted middle school population.These materials have been distributedthroughout Minnesota and several otherstates plus in Tanzania, Kenya and Russia.

Who are the others with whomwe work in partnership?• Since all the above activities involve fund-

ing, we are grateful to The Minnesota

Medical Association, Hennepin MedicalSociety, Hennepin Medical Foundationand our own HMSA membership for sup-port.

• We have also benefited from other countyalliances for HIV/AIDS funding.

• Through the HMSA Philanthropic Fundwe have also contributed to the AmericanMedical Association Foundation to ben-efit the University of Minnesota MedicalSchool and the Medical Student AssistanceFund and the Medical School ExcellenceFund.

• We lend our support to U of M medicalstudent and resident partners organizationsand plan to work on SAVE projects withthem.

• We have a tradition of an annual plannedevent with Ramsey Medical Society Alli-ance and look forward to more joint in-volvement in the future.

How does HMSA promote thehealth and well-being of itsmembers?• By providing volunteer service opportuni-

ties to our community we feel we help en-rich and add balance to our members’ lives.

• We also value the old and new friendshipsand social activities this organization pro-vides. We start off each September withour Opening Event, a relaxed mid-daygathering of members for lunch and so-cializing. This year, Dr. Gary and BarbaraHanovich have graciously opened theirhome to us for this occasion to be heldFriday, September 14.

• Another fall tradition is the joint meetingof Hennepin Medical Society Alliance andRamsey Medical Society Alliance. This yearis HMSA’s turn to host this gathering. Wehave arranged a backstage tour Friday,October 26 at the Guthrie Theater fol-lowed by a lobby lunch and speaker to dis-cuss the past and future Guthrie with us.This should be a delightful and informa-

tive day with the new facility plans under-way for the theater. We are fortunate tohave this world-class theater available andaffordable for our enjoyment for the past38 years.

Here are words from Guthrie Artistic DirectorJoe Dowling to get us ready for our visit:

A Place of MagicWelcome to the Guthrie Theater! The Guthrieis a place of magic. Visiting our backstage givesyou a glimpse of the magic in the making. Athriving and lively artistic community is basedin this building, where extraordinary actors, ar-tisans and artists work.

The process is complex and challenging,and it’s all aimed at serving our audience by pre-senting the very best of the world’s theatricalliterature to the very best of our abilities.

There’s nothing like the Guthrie. Every-thing you see on our stage is built to create theworld of the play, where talented actors bringthe words of the best playwrights to life for you.Enjoy your visit and come back soon.

Alliance members of both Ramsey andHennepin are encouraged to plan to come tothis event and invite your friends to join you.Watch your mail for further information.

We welcome any physician spouse (maleor female) to visit our activities and considerjoining HMSA. For more information pleasecall Kathy Larson (952) 925-4476. ✦

K A T H Y L A R S O N


BackgroundSince 1997, the Hennepin Medical Society’s Ad Hoc Ethics Task Force,co-chaired by Drs. Barbara LeTourneau and Burton Schwartz, has workedwith Karen Gervais, Ph.D., Director of the Minnesota Center for HealthCare Ethics, to respond to concerns of the Society’s members about chal-lenges to the physician-patient relationship in our changing health careenvironment and society. Chief among these concerns were the indepen-dence of physician clinical judgment, and the ability of physicians to beeffective patient advocates.

Initially, the Task Force discussed case studies to help it define ethicalguidelines for physicians. Commentaries based on Task Force discussionsof several cases were published in the HMS Bulletin throughout 1997-99.Then, in September of 1999, the Task Force began a formal process toarticulate ethical accountability guidelines for physicians.

In August, 2000, the HMS Board discussed and made recommen-dations concerning the resulting Task Force document, Ethical Account-ability Guidelines for Physicians in our Changing Healthcare Environment.Then, at its March 22, 2001 meeting, the HMS Board unanimously passedthe motion that “each HMS member consider and voluntarily adopt theseguidelines as an ethical framework for practice.”

We are pleased to present the fruits of our labor on the pages thatfollow. Member responses to the Guidelines is welcome. Please addressyour responses to Jack Davis at [email protected] or Barbara LeTourneau,M.D., at [email protected].

IntroductionHealth care is a vital human service, not a commodity. Health care ser-vices are delivered through a unique human relationship, one patient at atime. While the complexity of modern health care necessitates a teamapproach to care delivery, the physician-patient relationship remains thecenterpiece of each patient’s encounter with the health care system. In anenvironment characterized by “perverse financial incentives, fierce marketcompetition, and the erosion of patients’ trust,” the professionalism of thephysician, and thus the integrity of the physician-patient relationship, isincreasingly challenged and questioned.1 Marketplace rules and govern-mental regulations are insufficient bases for the preservation and protec-tion of this crucial relationship. Ultimately, the professionalism of thephysician is its critical safeguard.

The Ad Hoc Ethics Committee of the Hennepin Medical Societyhas elaborated ethical guidelines for core domains of physician responsi-bility in the physician-patient relationship. These domains include:

(1) Fiduciary obligations(2) Medical decision making obligations(3) Obligations due to patient vulnerability(4) Obligations to deliver culturally responsive health care(5) Obligations to protect patient confidentiality(6) Obligations to monitor personal standards2

The Committee’s guidelines for ethical accountability in each of thesedomains flow from its understanding of the physician-patient relation-ship as a fiduciary relationship. The largest obligation of the physician isto serve as the fiduciary of the patient’s best interest insofar as the patientrequires medically appropriate health care services to avoid harm and toreceive benefit. In the pursuit of this fiduciary relationship, the physicianmust strive to be attentive to, and respectful of, the values and beliefs ofthe patient. The physician’s complex role as trustee of the individual patient’swelfare is unique and irreplaceable.

The guidelines are intended to capture the crucial dimensions ofphysician accountability in the physician-patient relationship.

(1) FIDUCIARY OBLIGATIONS

The historic calling associated with the physician is a fiduciary one: thephysician is to promote the best interest of the patient. To act in the patient’sbest interest is to provide medically appropriate care that, in the physician’sprofessional judgment, will:• remove or prevent harm to the patient, and• benefit the patient.General Fiduciary Guideline:As the patient’s fiduciary, the physician has an ethical responsibility toalways act in the patient’s best interest (i.e., provide medically appropriatecare that the physician believes will remove or prevent harm to the patientand benefit the patient).

(a) CONFLICTS OF INTEREST:Conflicts of interest and conflicts of obligation have great potential tocompromise the physician’s pursuit of the patient’s best interest in our

Ethical Accountability Guidelines for Physiciansin our Changing Healthcare Environment


current health care environment. A conflict of interest may arise betweenphysicians’ self-interest and physician’s fiduciary obligations. A conflict ofobligation exists when the physician is positioned as a double agent: as anagent of the patient and as an agent of a third party with potentially com-peting interests.Guidelines:• The physician has an ethical responsibility to act in the patient’s best

interest in preference to self-interest.• The physician has an ethical responsibility to clearly recommend and

explain, and advocate coverage for, the diagnostic/therapeutic optionconsistent with the patient’s best interest and the patient’s informedchoice.

• The physician has an ethical responsibility to analyze and personallyclarify what kinds and degree of risk-sharing arrangement, and/orcontractual terms might compromise their pursuit of the patient’sbest interest.

• The physician has an ethical responsibility to disclose conflicts of in-terest to patients with patient informed consent whenever appropri-ate.

• The physician has an ethical responsibility to seek ongoing educationabout conflicts of interest.

(b) CONFLICTS OF OBLIGATION:Some argue that the physician has a duty to both patient and society.While this is certainly in some senses true, some argue that societal inter-ests concerning health care resources expenditure should be factored intothe physician’s recommendations concerning individual patient care op-tions.

The Committee categorically rejects this view. While a physician hasan ethical responsibility to practice cost-effective medicine, the physician’sfiduciary role in relation to the patient becomes unrecognizable if thephysician engages in rationing access to health care services on a patient-by-patient basis. To be fair, rationing must be a population-based policy-making activity, the results of which must be applied evenhandedly (i.e.,similarly situated persons should be treated similarly) across a population.Even then, policy-making is a value-laden, highly controversial activity.Physicians should seek to contribute their special expertise to such policydecisions, and at times may be called upon to implement resource alloca-tion decisions at patients’ bedsides.

To the extent that the physician considers a resource allocation policydetrimental to the best interests of the category of patients affected by it,the physician should advocate for the interests of patients and oppose theallocation policy. The ethical principles of avoiding foreseeable harm, pro-moting foreseeable benefit, and equity, should guide the physician in act-ing to influence resource allocation policies.

But the physician should not confuse this policy-influencing rolewith his/her fundamental role as patient fiduciary. To the extent that thepublic believes physicians engage in bedside rationing in order to servesocietal interests apart from individual patients’ best interests, to that ex-tent the public rightfully ceases to trust physicians as their fiduciaries.

Guidelines:• The physician should not engage in bedside rationing in relation to

individual patients.• To the extent that the physician considers a resource allocation policy

unduly or unfairly detrimental to the best interests of the patientsaffected by it, the physician has an ethical responsibility to opposethat allocation policy.

(c) DENIALS OF COVERAGE AND LACK OF COVERAGE

FOR MEDICALLY NECESSARY SERVICES:As the patient’s fiduciary, the physician is an advocate for the patient’s bestinterests so far as access to needed health services is concerned. In ourcurrent health care arrangement, access to coverage and access to servicescannot be separated. Therefore, as the patient’s fiduciary, the physicianhas an additional ethical responsibility of advocacy under certain circum-stances. If the patient is denied coverage for a prescribed service, the phy-sician has an ethical responsibility of advocacy for coverage proportionateto the physician’s belief that the treatment is medically necessary to avoidharm and/or provide benefit.

The ability of a patient to pay for health care services should not be abarrier to getting necessary care. In former times, it was accepted that thephysician had a duty to provide pro-bono care. Changes in the organiza-tion of health care, specifically the embeddedness of the physician’s prac-tice in a clinic, group practice, and health plan, effectively constrain thecapacity of the physician to do pro-bono work. The impacts of pro-bonowork fall not only on the individual physician, but on the clinic, healthplan, and arguably, the enrolled population of patients as well. The clinicand health plan should define a safe haven for limited pro-bono work onthe physician’s part, and the physician should determine the strength ofthe obligation to provide pro-bono services on a case-by-case basis in lightof the ethical responsibility to prevent avoidable harm. Physicians shouldactively encourage their health care organizations and their professionalorganizations to undertake and support initiatives that will improve ac-cess to health care to all in our society.Guidelines:• The physician has an ethical responsibility to advocate for coverage

of medical services in proportion to the physician’s judgment that theservices are in the patient’s best interest.

• The physician has an ethical responsibility to provide pro-bono ser-vices guided by the duty to prevent avoidable harm, consistent withduties to clinic, health plan, and enrolled population.

• The physician has an ethical responsibility to encourage health careorganizations to define a safe haven for limited pro-bono work.

• The physician has an ethical responsibility to encourage health careorganizations and professional associations to promote improvementsin access to health care for all.

• Physicians have an ethical responsibility, individually and collectively,to advocate for payers’ coverage of medical services, which meet stan-dards of community practice, research efficacy, and serve the patient’sbest interest.



(d) EQUITY:Physicians are frequently required to justify their recommendations forpatient treatment with reference to practice guidelines. Coverage policies,decisions about what will be covered for a population, are the basis forcoverage in individual cases. Such guidelines and policies may, from aphysician’s perspective, be ill grounded. In such cases, the physician hasan ethical obligation to advocate for change.

Alternatively, in the case of an individual patient, such guidelinesand policies may be hostile to an individual patient’s best interests, eventhough generally consonant with patients’ collective best interests. Thephysician has an ethical responsibility to advocate on the patient’s behalfin such cases. A patient may be an outlier with respect to a practice guide-line, such that equity may require the physician to advocate for the pa-tient as an exception. While similar cases should be treated similarly, dis-similar cases may warrant dissimilar treatment. Likewise, there is an im-portant distinction between a coverage policy and an individual coveragedecision. Equity may require the physician to advocate for the patient asan exception to a coverage policy as well, on the ground that the failure toprovide coverage can be expected to have a more devastating impact onthis patient’s best interest than in the standard case.Guidelines:• If the physician considers a practice guideline or a resource allocation

policy detrimental to the best interests of the patients affected by it,the physician has an ethical responsibility to advocate for the interestsof patients and oppose or seek to modify the practice guideline orallocation policy.

• The physician has an ethical responsibility to advocate that the pa-tient be treated as an exception to a practice guideline, proportion-ately to the physician’s judgment that the practice guideline is hostileto the best interest of the individual patient.

• The physician has an ethical responsibility to advocate that the pa-tient receive coverage, proportionately to the physician’s judgment thata coverage policy is hostile to the best interest of the individual patient.

(2) MEDICAL DECISION-MAKING OBLIGATIONS

The physician has central responsibility for the quality of patient/surro-gate medical decision-making. Consistent with the rights of patients to befully informed of their health status and to be enabled to make informedchoices concerning their health care options, the physician has an ethicalresponsibility to seek a therapeutic relationship with a patient, in whichthe physician’s knowledge, skill, and concern for the patient, and thepatient’s values concerning health care options, meaningfully partner.Guidelines:Autonomous patient/surrogate health care decisions:• The physician’s interactions with the patient as decision maker must

be informed by the ideal of patient autonomy.• The physician has an ethical responsibility to determine patient com-

petency to understand health circumstances and treatment options,and patient capacity to apply personal beliefs and values to make ahealth care decision.

• The physician has an ethical responsibility to provide the patientwith sufficient understandable information so that the patient caneffectively apply personal beliefs and values to make a health caredecision.

• The physician has an ethical responsibility to disclose all medicallynecessary and appropriate treatment options a reasonable personwould wish to know, regardless of coverage.

• The physician has an ethical responsibility to explain, in relation toeach option, associated risks and benefits and their likelihood, qual-ity of life implications, and other information pertinent to the indi-vidual patient’s choice.

• The physician has an ethical responsibility to recommend and ex-plain the rationale for the treatment option the physician considerswould be most likely to avoid harm and promote benefit.

Conflicts between patient and physician:• When patient decision-making is seriously at odds with the physician’s

best interests assessment of the patient’s options, the physician has anethical responsibility to understand the source of the patient’s deci-sion and address it appropriately.

• The patient may be incompetent to make a decision and so the phy-sician has an ethical responsibility to seek a qualified surrogate;

• The patient may be in need of further information and so the physi-cian must provide it; or

• The patient may be making a decision from a different value or be-lief perspective than the physician (for example, on the basis of cul-tural or religious assumptions, beliefs, and values), and so the physi-cian has an ethical responsibility to understand, address, and respectthe patient’s decision.

Conflicts between patient and others:• The physician has an ethical responsibility to advocate for the patient

when family members or other decision-makers make decisions con-trary to the autonomously expressed wishes of the patient.

• The physician has an ethical responsibility to advocate for the patientwhen surrogates make decisions the physician considers inconsistentwith the best interest of the patient.

• The physician has an ethical responsibility to seek assistance in timelyconflict resolution through ethics consultation or other appropriateresources.

(3) OBLIGATIONS DUE TO PATIENTVULNERABILITY

Vulnerability is a matter of both kind and degree, and is present in allphysician-patient interactions. Physicians have special responsibilities toaddress the multiple sources of patient vulnerability. Some vulnerabilityconcerns apply to all patients. For example, physicians must both under-stand the potential harm to patients from, and avoid, boundary viola-tions.

Other obligations arise out of the specific characteristics and circum-stances of the patient. A patient may be especially vulnerable for one of

Ethical Accountability Guidelines(Continued from page 29)


many reasons: for example, they may be in the midst of a health carecrisis; they may have just received bad news; they may be in a weakenedstate, confused, or in pain; they may be unaccustomed to health caresettings, separated from loved ones and customary support persons, try-ing to understand western health care options in terms of diverse culturalor religious beliefs, or facing a frightening diagnostic or treatment event;and/or they may be potential patient candidates for research.Guidelines:• The physician has an ethical responsibility to be trained in the types

of boundary violations that undermine the therapeutic relationshipand avoid them.

• The physician has an ethical responsibility to determine the patient’sindividual vulnerabilities and adjust his/her practice style to addressthose vulnerabilities, seeking specialized help whenever necessary.

• The physician who would recruit patients into research has an ethi-cal responsibility to:(i) Be trained in research methods and in the ethics of the respect

and protection of human research subjects;(ii) Engage in research with patients only with prior IRB review

and approval;(iii) Have reason to think the potential risks associated with research

participation are reasonable in relation to potential benefits forthe patient;

(iv) Disclose the conflicts of interest present for the physician, i.e.,the specific respects, financial or otherwise, in which the physi-cian stands to benefit if the patient decides to participate;

(v) Assure that patients understand the change in role that willoccur from physician/patient to researcher/patient; and

(vi) Meaningfully assure the patient that a decision not to partici-pate in research will in no way compromise their relationshipwith their physician or the quality of their care.

(4) OBLIGATIONS TO DELIVER CULTURALLYRESPONSIVE HEALTH CARE

Persons of non-mainstream cultures often bring unique perspectives tohealth care decision-making that challenge physicians’ explanatory, advi-sory, and relational capacities. The physician has special obligations inrelation to such patients, in order to fulfill the conditions of the fiduciaryrelationship. In addition, because health care organizations and institu-tions have so much influence over the provision of care, physicians shouldadvocate for changes that will lead to better service of culturally diversepatients and families.Guidelines:• The physician has an ethical responsibility to endeavor to under-

stand and respect the patient’s culturally-based beliefs and values asthey relate to health care decision-making.

• The physician has an ethical responsibility to seek the assistance ofcultural intermediaries who work within the health care system tofacilitate communication and decision-making when it is needed.

• The physician has an ethical responsibility to communicate, in un-derstandable terms, the patient’s options, and the risks and benefitsassociated with each.

• The physician has an ethical responsibility to make a treatment rec-ommendation, along with a rationale respectful of the communica-tion customs, beliefs, and values of the patient, at the same time thathe/she conveys the respects in which he/she sees the option to be mostconsistent with the patient’s best interest from a western health careperspective.

• The physician has an ethical responsibility to endeavor to make cer-tain that the patient’s decision reflects the patient’s perspective andvalues.

• While the physician has an ethical responsibility to refuse to engagein any actions he/she considers harmful, the physician should attemptto accommodate non-harmful cultural practices, as he/she attemptsto promote the patient’s best interest as the physician sees it.

• The physician has an ethical responsibility to bear in mind that everypatient has a right to refuse unwanted treatment, even when, from awestern medical perspective, such refusal is likely to result in avoid-able harm.

• The physician has an ethical responsibility to advocate for institu-tional practices consistent with culturally responsive health care.

(5) OBLIGATIONS TO PROTECT PATIENTCONFIDENTIALITY

The duty to protect the patient’s confidentiality is virtually an absoluteduty. Only anticipated harm to others justifies the physician’s abrogationof this ethical responsibility. Consistent with the role of the physician asfiduciary, the medical record must be a private record between patient andphysician, unavailable for non-medical purposes. The physician has anethical responsibility to keep an accurate medical history – only in thisway can a patient’s long term health history be understood and the crucialissue of continuity of care be managed. Except with the authorization ofthe patient (or his/his representative) or as permitted or required by law,physicians must resist uses of the patient history for insurance, employ-ment, or other non-medical purposes. Any use of the patient’s record forresearch purposes must be disclosed and consented to by the patient. Inthe case of minors, physicians are responsible for knowing and followingstate laws related to informing the parents or guardians of minor patientsabout treatment obtained or needed by the minor. The minor has a rightto know in advance whether the physician has a legal obligation to dis-close certain medical information to a parent or guardian.Guidelines:• The physician has an ethical responsibility to be familiar with and

adhere to the standards of confidentiality surrounding a patient’s medi-cal record, unless the patient is a threat to the welfare of others.

• The physician has an ethical responsibility to keep an accurate pa-tient medical history.

• Except with the authorization of the patient (or his/her representa-tive) or as permitted or required by law, physicians must resist uses ofthe patient history for insurance, employment, or other non-medicalpurposes.

• Patient consent must be sought and obtained for the use of patientinformation for research purposes.



• If the law requires disclosure of a minor patient’s medical informa-tion to a parent or guardian, the physician should inform the adoles-cent of this in advance.

(6) OBLIGATIONS TO MONITOR PERSONALSTANDARDS

The level of physician training and expertise, as well as the physician’spersonal moral convictions, behaviors, conditions, or illnesses may be per-tinent to the physician’s capacity to act as the patient’s fiduciary and toassure patient protection. Physicians should disclose their level of trainingand expertise to patients, and they should submit to mechanisms to pro-tect patients where matters of personal behaviors, conditions, or illnessesare a source of concern.Guidelines:Patient protection:• The physician has an ethical responsibility to disclose to patients their

level of training and expertise.• The physician has an ethical responsibility to participate in screening

for competence.• The physician has an ethical responsibility to participate in screening

and treatment for compromising behaviors, habits, and illness.

(a) PHYSICIAN’S MORAL CONVICTIONS:Another aspect of physician’s personal standards, in contrast to thephysician’s professional standards, is the physician’s personal moral beliefsand values. These may sometimes conflict with legitimate treatment choiceson the part of patients. Thus, the physician might conscientiously refuseto participate in a particular intervention. The goal of medical decision-making is that a patient will make a knowledgeable treatment choice byapplying his or her beliefs and values to the information concerning treat-ment options the physician has thoroughly and thoughtfully provided,along with the physician’s own recommendation of one of those options.When a physician’s personal moral standards become the basis for thatrecommendation, the fiduciary quality of the physician-patient interac-tion is lost.Guidelines:• The physician has an ethical responsibility to disclose personal moral

convictions to the patient when those convictions would lead to aphysician’s conscientious refusal to provide the patient a lawful treat-ment option.

• If the physician refuses to provide a patient’s lawful treatment choiceon personal moral grounds, the physician has an ethical responsibil-ity to support the patient in pursuing the patient’s choice of treatmentby referring to an appropriate physician.

(b) PHYSICIAN’S PROFESSIONAL STANDARDS:Personal standards differ from professional standards. When a physician’sprofessional standards are the basis of a conflict with a patient or surrogatetreatment request, what are the physician’s duties?

Guidelines:• If professional treatment standards agree, and there is conflict be-

tween physician and patient concerning treatment, the physician hasan ethical responsibility to provide a full rationale for the physician’sprofessional objections to the patient’s/surrogate’s request, and refuseto provide the treatment requested. Only if the patient/surrogate re-quests a referral should the physician refer.

• If professional treatment standards differ, and there is conflict be-tween physician and patient concerning treatment, the physicianshould refer the patient for further consultation.

(c) CONFLICT-RESOLUTION:• In general, the physician has an ethical responsibility to seek to avoid

conflict through thorough, clear, and respectful communication.• In the event of conflict, the physician has an ethical responsibility to

seek timely ethics consultation or other approaches to conflict resolu-tion, and inform patients/surrogates that such options are availableto them as well.

ConclusionThe above discussion and ethical accountability guidelines reflect the de-liberations and conclusions of the Ad Hoc Ethics Committee of theHennepin Medical Society. The ethical principles from which these ethi-cal accountability guidelines derive are the central principles of bioethicsestablished over the past 35 years. These principles are: autonomy,nonmaleficence, beneficence, and justice. The guidelines fill in a fiduciaryconception of the physician’s role in today’s health care system: They restmost significantly on the physician’s obligation to ascertain and promotethe patient’s best interests, attentive to and respectful of patient values andbeliefs. It is this specific understanding of the physician’s obligation topromote the patient’s best interests that is the ethical touchstone of eachof the ethical accountability guidelines contained in this document. ✦

1) Wynia, MK, Latham, SR, Kao, AC, “Medical Professionalism in Society,” NEJM1999;341:21

2) The Committee was guided by the delineation of domains of physician ethicalaccountability in Emanuel, LL, “A Professional Response to Demands for Ac-countability: Practical Recommendations Regarding Ethical Aspects of PatientCare,” Ann Intern Med 1996;124:240-249

This document is intended only to serve as an ethical guide for physicians. It isnot intended to establish or define clinical or legal standards of care or to be astatement of the law of Minnesota.

Ethical Accountability Guidelines(Continued from page 31)

NOW

Gary PietruszewskiAccount Executive

[email protected] Old Highway 8 NW Tel: 651-639-4757 New Brighton, MN55112 Fax: 651-639-4747

Now, you can save

more than 50% on the

Super Paramount

LIST PRICE$545.00

You Pay Only$270.00

The Super Paramount (#7578) by office Masterwas rated one of the most affordable series ofadjustable chairs.

Features:�Pneumatic Lift�Tilting Backrest�Tilting Seat�Sliding Seat�Swivel/Rocking Tilt�Adjustable Lumbar�Basic Plus Fabric (most colors available)�KR-21 Height Adjustable Arms

Please allow upto 2 weeks for delivery. Prices do not includedelivery or setup charges.

2001septoct

Documents