MINNESOTA
JULY 2020
PHYSICIAN
THE INDEPENDENT MEDICAL BUSINESS JOURNAL
Volume XXXIV, No. 04
The seeds of a revolution Telehealth and COVID-19 BY BILL SONTERRE AND REID M. HAASE, MHIM
T
he implementation and use of telehealth have undergone rapid and massive changes as a result of the COVID-19 public health emergency. In the initial month of the pandemic, the United States saw a whopping 4,300% increase in claims for telehealth encounters. The nation’s March yearover-year (2019/2020) figure jumped an astounding 8,336% in April. (See https://tinyurl.com/mp-telestats for statistics sorted by date or region.)
Institutional racism in medicine
Minnesota also saw sharp increases. Stratis Health’s Virtual Health/Telehealth Sharing Group, which includes health system telehealth directors from 16 urban and rural health systems, practices, and associations, documented a 1,000-fold increase in the use of telehealth in Minnesota in the first month after the coronavirus outbreak. Prior to the outbreak, nine Minnesota health systems reported a collective 1,149 telehealth visits per day. As of April 24, the health systems reported conducting 15,480 telehealth visits per day. That total included 7,612 telephone visits and 7,868 video visits.
The seeds of a revolution to page 144
It’s time for changes BY CHARLES E. CRUTCHFIELD III, MD, ET AL.
I
nstitutional or systemic racism is defined as “the distribution of resources, power, and opportunity in our society to benefit white people and the exclusion of people of color.” Present-day racism is built on a long history of racially distributed resources. It’s a system that comes with a broad range of policies that keep it in place and is present in every element of society, including health care. To elucidate and address many of these issues, members of the Minnesota Association of African-American Physicians (MAAAP) have contributed their perspectives to this Institutional racism in medicine to page 104
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NNESOTA’S MI
JULY 2020
|
REQUEST FOR NOMINATION
Volume XXXIV, Number 4
COVER FEATURES Institutional racism in medicine It’s time for changes
By Charles E. Crutchfield III, MD, et al.
H
The seeds of a revolution Telehealth and COVID19 By Bill Sonterre and Reid M. Haase, MHIM
DEPARTMENTS CAPSULES .................................................................................. 4 MEDICUS.................................................................................... 7 INTERVIEW .................................................................................. 8
L RS EA IN F L L T H U E N T I AA D E C A R E LE
Publication Date: November 2020
Nominate the 100 Most Influential Health Care Leaders In our November 2020 edition, Minnesota Physician will profile 100 of our state’s most influential health care leaders. In a format featuring photos, bios, and quotes, we will highlight the men and women most responsible for making Minnesota a global model for health care delivery.
Serving older adults and caregivers
These individuals will represent every aspect of the industry: physicians,
Dawn Simonson Metropolitan Area Agency on Aging
business executives, political leaders, policy analysts, etc.
CARDIOLOGY............................................................................. 16
you know anyone within your organization you feel should be considered,
We invite you, our readers, to participate in this recognition process. If please fill out the form below and mail it or submit online (www.mppub.
Women’s heart health disparities
com/top100.html) or via e-mail (comments@mppub.com) prior to
Gender-specific factors
September 25. We welcome your input and participation in making this
By Courtney Jordan Baechler, MD BEHAVIORAL HEALTH................................................................. 18
list as comprehensive and meaningful as possible.
The P Factor A new framework for assessing mental health By Brent Nelson, MD
HEALTH CARE POLICY................................................................. 20 The 2020 legislative wrapup
I would like to nominate the following individual(s): Nominee’s name (please include all advanced degrees):
Pandemic impacts deliberations
Nominee’s title:
By Tom Hanson, JD, and John Reich
Nominee’s affiliation:
ONCOLOGY............................................................................... 22 Chronic lymphocytic leukemia
Brief description of the nominee’s work and influence:
Updates in management By Sandeep Jain, MBBS, MRCP, FRCP
DERMATOLOGY.......................................................................... 26 Cutaneous manifestations of COVID-19 Keeping the differential diagnosis open By Phillip Keith, MD
Nominator information (strictly confidential):
Name: Phone #:
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EDITOR___________________________________________________________Richard Ericson, rericson@mppub.com ART DIRECTOR______________________________________________________ Scotty Town, stown@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email comments@mppub.com; phone 612.728.8600;. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.
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MINNESOTA PHYSICIAN JULY 2020
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CAPSULES
Racism is a public health crisis, says Hennepin County resolution The Hennepin County Board of Commissioners voted July 1 in favor of a resolution declaring racism as a public health crisis. The board’s resolution was prompted by several recent events, including the Memorial Day murder of George Floyd and the worldwide protests that followed. Since 2017, the board has reviewed data that clearly shows disparities in education, jobs, income, housing, justice, transportation, and health for people of color living in Hennepin County. These disparities have lifelong impacts, leading to higher disease rates, including a disproportionately higher burden of COVID-19 infection rates and fatalities. “Ultimately this resolution is about the health and well-being of Hennepin County residents who
have borne the brunt of racial discrimination and racial inequity through various different systems,” said Commissioner Angela Conley, who introduced the resolution with Commissioner Irene Fernando. She urged her colleagues to stop “treating symptoms of disparities— such as poverty—and step back to see all the connections that got people there. It’s critical that the county adopt a lens of health to examine policies and practices to ensure we are not overtly engaging in racist behavior.” The full resolution is available online at https://tinyurl.com/ mp-hc-resolution.
HealthPartners closes seven clinics In response to the COVID-19 pandemic and a shift to telehealth services, HealthPartners is permanently closing seven clinics and a drug and alcohol treatment program.
The move follows temporary closures of HealthPartners sites prompted by stay-at-home orders, reluctance by some patients to visit clinics, and the previous ban on elective procedures. The seven permanently closed clinics are Park Nicollet Cottage Grove; Highland Park in St. Paul; Riverside in Minneapolis; Stillwater Medical Group in Mahtomedi; Westfields HealthStation in New Richmond, Wis.; Regions Maplewood Behavioral Health Clinic; and HealthPartners’ Central Minnesota Clinic. In addition, HealthPartners is closing Regions Alcohol and Drug Abuse Program in St. Paul. Some clinical services will be consolidated at other HealthPartners sites, and former patients of the closed clinics will have access to expanded telehealth services. Some jobs likely will be eliminated, but most workers will shift to other locations.
Zero-copay, zerodeductible plan unveiled Health benefits company Gravie recently announced a new zero-deductible, zero-copay health plan that employers can offer to their workers. “Gravie Comfort” offers 100% coverage on most common health care services, including preventive care, primary care, specialist visits, labs and imaging, generic prescriptions, online care, and more at a cost comparable to most traditional group health plans. For less frequently used services, such as hospitalization and specialty drugs, the plan allows employees to choose an out-ofpocket expense limit. The employer-sponsored plan offers full coverage for most services on day one, with access to a broad, national network. It will be available to enrollees for the upcoming 2021 plan year.
MEDICAL MALPRACTICE ATTORNEYS
Angela Nelson
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Ryan Ellis
Marissa Linden
Jennifer Waterworth
CAPSULES
Marek Ciolko, CEO of Gravie, said the plan was designed to address concerns over continuing reductions in coverage under employer-provided plans, as well as increasing out-ofpocket costs, narrowing choice of providers, and administrative obstacles. Ciolko noted that employee health care often represents employers’ second highest expense category. Gravie’s defined contribution approach allows employers to set and stick to a benefits budget that works for their business, and employees are free to choose the out-of-pocket maximum that works for them. To learn more, visit www.gravie. com/gravie-comfort/.
Physician groups stress value of vaccinations The Minnesota Medical Association (MMA), the Minnesota Chapter of the American Academy of Pediatrics (MNAAP), and the Minnesota Academy of Family Physicians (MAFP) have launched Practice Good Health, a unified effort encouraging Minnesota families to proactively care for their physical and emotional well-being, especially during the pandemic. The program promotes vaccinations, provides patient information, and supports physicians. Vaccinations in Minnesota and across the country have drastically decreased due to COVID-19 and fears associated with seeking health care at a physician’s office or other medical clinics. It is estimated that from 70–80% of Minnesota’s children have experienced delayed physician visits, important vaccinations, chronic health care, and routine treatment of everyday illnesses because parents are concerned about bringing their children to the clinic for fear of exposure to the virus. Under current state law, children must be vaccinated to attend public school in Minnesota. However, Minnesota is one of about 15 states that allow
parents to exempt their children from immunization requirements based on their personal beliefs. Statewide, about 2% of children are exempted from immunization requirements. These children are concentrated in certain areas of Minnesota. For example, about 10% of kindergartners in Wadena County have not received their MMR vaccine. Two pieces of legislation that would eliminate the personal belief exemption for vaccine requirements and fund a grant program that supports community outreach and education about the importance of vaccines have been introduced in recent sessions, but neither has been signed into law.
Wastewater testing strategy may help trace spread of COVID-19 A new testing strategy involving samples from wastewater treatment facilities may soon complement state-funded testing measures to monitor COVID-19 prevalence across Minnesota. Developed by two researchers at the Duluth campus of the University of Minnesota Medical School—assistant professors Glenn Simmons Jr., PhD, and Richard Melvin, PhD—the testing strategy is intended to help state leaders and health care professionals trace the spread of COVID-19 and overcome limitations imposed by current population testing strategies. “We know that there are a good number of infected people who are not actually symptomatic, so they may not qualify for diagnostic testing because they don’t present symptoms, but they are still infectious,” Simmons said. “We are looking at a way of getting a population-level understanding of how much infection exists within the community. And by doing that, we’ll then be able to monitor how well our state’s mitigation and treatment efforts are really working.”
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CAPSULES
After exploring past studies and literature about coronaviruses, particularly the strains causing the MERS and SARS outbreaks, Simmons recognized similarities, including symptoms of gastrointestinal distress that could lead to infection in other parts of the body. The researchers formed an agreement with the Minnesota Environmental Science and Economic Review Board, which represents more than 50 Minnesota wastewater treatment facilities. He and Dr. Melvin will test wastewater using a PCR (polymerase-chain reaction) process to detect COVID-19 genetic material, ultimately gathering numerical data about the virus’ presence and expansion in various Minnesota communities. Data will be gathered through fall 2020. Simmons said findings could support under-resourced areas in Minnesota, and could potentially eliminate some aspects of health
disparities. He also noted that some people who may be symptomatic are uncomfortable getting tested due to discrimination and bias or lack of trust or access to health care.
Grant supports mental health programs Wilderness Health has received a $771,767 grant from the Health Resources and Services Administration (HRSA) to support the development of a telehealth program across its 10-member health system network, focusing initially on mental health services. The grant funds will be used to develop telehealth capacity and infrastructure, including the addition of a dedicated program manager, equipment, and training resources. Successful implementation will facilitate increased access to care. In-person mental health services can involve wait times of several months.
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Telehealth can reduce that timeframe and allow patients in remote areas to avoid traveling long distances. It can also benefit primary care providers by pairing them with specialists for treatment consultations as well as medication management assistance. “The network has been working on improving access to mental health resources in our region for several years and had identified expansion of telehealth capacity as a crucial need in our strategic plan,” said Cassandra Beardsley, executive director at Wilderness Health. Members of Wilderness Health include Bigfork Valley Hospital; Community Memorial Hospital, Cloquet; Cook Hospital; Ely Bloomenson Hospital; Fairview Range Hospital, Hibbing; Grand Itasca, Grand Rapids; Lake View, Two Harbors; North Shore Health, Grand Marais; Rainy Lake Medical Center, International Falls; and St. Luke’s, Duluth.
UCare wins top workplace honors UCare, an independent, nonprofit health plan, has been named one of the Top 150 Workplaces in Minnesota by the Star Tribune. Top Workplaces recognizes companies in Minnesota based on employee opinions measuring engagement, organizational health, and satisfaction. The analysis includes responses from over 76,000 employees at Minnesota public, private, and nonprofit organizations. Rankings are based on survey information collected by Energage, an independent company specializing in employee engagement and retention. UCare is ranked 23rd on the large company list, and is one of only a small number of companies to be named a Top 150 Workplace all 11 years of the program.
MEDICUS
Abdurrahman Hamadah, MD, has joined St. Luke’s Nephrology Associates in Duluth. Dr. Hamadah is board-certified in internal medicine and in nephrology, and is also certified by the American Society of Diagnostic and Interventional Nephrology. He completed his internal medicine residency and a nephrology fellowship at Mayo Clinic in Rochester. Rachel Hardeman, Phd, MPH, associate professor at the University of Minnesota’s School of Public health, has been named the inaugural chair of the Blue Cross and Blue Shield of Minnesota Foundation’s Endowed Professorship of Health and Racial Equity. The professorship was created with a $500,000 grant from the Blue Cross Foundation to the University of Minnesota to establish an endowed chair focused on health insurance research and course work.
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Rahul Koranne, MD, has been appointed by DHS Commissioner Jodi Harpstead to the Comprehensive Health Association Board of Directors, which governs programs to provide basic health insurance coverage to Minnesotans unable to obtain coverage through the open market. Dr. Koranne is president and CEO of the Minnesota Hospital Association. Santo M. Cruz, JD, is now senior vice president and general counsel for CentraCare, where he will lead the health system’s legal and compliance functions and report to President and Chief Executive Officer Ken Holmen, MD. Mr. Cruz previously served as CentraCare’s associate general counsel and vice president of community and government relations. Prior to joining CentraCare, he was deputy commissioner of DHS. Matthew Prekker, MD, medical director of Hennepin Healthcare’s Extracorporeal Membrane Oxygenation (ECMO) Program, and his colleagues have received the Award for Excellence in Life Support–Platinum Level, the highest designation level given by the Extracorporeal Life Support Organization (ELSO). The award recognizes programs worldwide that distinguish themselves by having exceptional personnel, procedures, and systems in place to support critically ill patients with ECMO.
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MINNESOTA PHYSICIAN JULY 2020
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INTERVIEW
Serving older adults and caregivers Dawn Simonson Metropolitan Area Agency on Aging Please describe how the Metropolitan Area Agency on Aging (MAAA) was started.
Please tell us about the Live Well at Home program.
MAAA began in 1973 as a program of the Metropolitan Council in response to the Older Americans Act (OAA). The federal government created the OAA to address the nutritional and social needs of older adults that began to emerge with extended longevity. We became an independent nonprofit in 1994.
Live Well at Home is a funding program of the Minnesota Department of Human Services (DHS) to encourage expansion of services to support older adults living in the community and their family caregivers. We help organizations in the Twin Cities prepare their proposals to align with the objectives of DHS.
Please tell us about the Older Americans Act and how it informs your policies.
What does the Juniper program do and how can physicians become involved?
The Act was created in 1965 by Congress, the same year as Medicare. The two programs provide funding streams and policies to deliver social services and health care across the nation. Along with Social Security, the OAA and Medicare are our nation’s compact with older citizens for health and security in old age. OAA services and programs are aimed at helping older adults live independently in their homes and communities. This orientation has helped to spur a strong network of provider organizations that make it possible to be safe and cared for at home rather than in an institutional setting—which matches peoples’ desires and is the most cost-effective way to live.
Juniper offers classes across the state to help older adults take an active role in maintaining good health—something we all desire. We collaborate with the other six AAAs in Minnesota, 130-plus health care and community organizations, and health plans to deliver classes that help people manage chronic conditions, get fit, and prevent falls. People who take the classes report eating healthier, increasing physical activity, working more effectively with their health care professionals, and feeling better. They also form ties to other older adults and learn about community services that can boost their well-being. The classes are beneficial for people with diabetes, high blood pressure, heart disease, COPD, arthritis, depression, fall risk, and other health conditions.
Our mission has expanded. We help people optimize health and well-being as they age, focusing on low-income older adults and those who face social inequities. Our work complements clinical health care, addressing the 80-plus percent of health that happens outside the clinic. We provide home-delivered meals, transportation, care management, chore services, evidence-based health promotion programs, and caregiver support through a network of service providers. We also provide consultations on Medicare, housing, and financial support and act as consultants to other organizations, helping them seek funds and design services. How has the Minnesota Elder Care and Vulnerable Adult Protection Act impacted your work?
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“...”
How has your mission changed over time?
We “...” connect patients with services and programs that will help them maintain and follow treatment protocols. We report suspected abuse and neglect as directed under the provisions of this Act when we learn of it through our interactions with older adults and others. This reporting occurs primarily in our service as the state of Minnesota’s partner in providing Senior LinkAge Line services. Our staff—most of whom are social workers and human services professionals—are ultimately concerned with the health and safety of the older adults we serve. What can you tell us about how MAAA works with state agencies serving older Minnesotans?
The Minnesota Board on Aging gives our nonprofit organization the designation of “Area Agency on Aging.” We partner with them to administer OAA and state funding. They guide MAAA’s Area Agency on Aging work and hold us accountable for the public funds we manage. We also work with the Minnesota Department of Health (MDH) to bring evidence-based healthy aging programs to people across Minnesota.
In response to the COVID-19 pandemic, we now offer Juniper classes using HIPAAsecure video conferencing. People are changing their routines, are at increased risk for isolation, and many are skipping their regular medical appointments for fear of contracting the coronavirus. Chronic conditions can easily get out of control in this situation. Participants have found that online classes work well. In some cases, attendance has been higher and more consistent than with our in-person classes. People love that classes such as a Tai Ji Quan: Moving for Better Balance or Living Well with Diabetes are now available online for everyone, anywhere in the state. One participant in the Living Well with Chronic Pain class told the instructor how grateful he was that he could attend virtually.
We know that people are more likely to participate in a Juniper class if their physician recommends it. Physicians can help by referring patients to classes through our portal at yourjuniper.org or by giving their patients our web address (https://metroaging.org) or toll-free phone number (855-215-2174). Most classes are free or low cost, and some health plans also cover the cost. A second way to get involved is to consider becoming an advisor to Juniper. We welcome input from physicians. Physicians serving older patients may not be aware of how your work can help their patients stay healthy. Please share some ways of improving this communication.
We’d love to have physicians think about us as their partner in keeping people healthy. Through our networks, we connect patients with services and programs that will help them maintain and follow treatment protocols. We are happy to provide information tailored for physicians, including webinars, short in-person presentations, and written materials, both for provider and patient use.
What are some of the biggest challenges to your work related to COVID-19?
As an administrator of federal funds, including over $6 million in the Families First Coronavirus Response Act and CARES Act funds, we need to stay tuned to the most pressing needs of older adults and their family caregivers and be highly responsive. It’s our job to maximize the investment of these resources for the greatest impact. We are seeing increased need for home-delivered meals, caregiver support, and alleviating isolation. We project that we will double the OAA dollars we provide to community partners this year for homedelivered meals compared to last year, and we do not expect the demand to diminish any time soon. When Adult Day Centers were ordered closed by the Governor in late March, we saw a spike in demand for caregiver services as family caregivers were called upon to provide full-time care. Our partners have stepped up to meet the changing needs, often by designing and delivering new services such as telephone reassurance or by expanding existing services. We have seen powerful new partnerships form,
such as one between Metro Meals on Wheels and Afro Deli. Together they provided over 12,000 halal home-delivered meals during April, an option that was previously not available. What final thoughts you would like to share with our readers?
Research published by Health Affairs in April 2020 attests that when health care providers partner with AAAs, older adults have improved health outcomes and reduced percapita health care spending. MAAA has the interest and capacity to engage in partnerships with physicians to address the health-related social needs of older adults. We’ve learned your language, meet requirements for data security as a HIPAA-covered entity, and can bring resources to the table that respect both data and what’s important to older adults. Connect with us to innovate together to improve the health of your patients and our communities. Dawn Simonson is the executive director of the Metropolitan Area Agency on Aging, a nonprofit that serves both older adults and caregivers.
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3Institutional racism in medicine from cover article, including a handful of personal experiences. These world-class professionals join me in this commentary to address what remains America’s single biggest unsolved challenge.
was a document with implications for African-Americans, leading to the closing of historically Black medical schools, leaving just two in the nation. African-Americans were excluded from the institution of medicine, leaving Blacks vulnerable to institutional abuses in health that facilitated distrust and disenfranchisement.
The lack of trust among Blacks for the American health system was substantiated over Before the Civil War, very few Blacks graduated time by unscrupulous research, such as the use from American medical schools—perhaps fewer of cervical cancer cells from Henrietta Lacks than two dozen. Most Black doctors at that time without permission after her death; the Tuskegee learned through apprenticeship. Despite their Blacks were forced to form their Study, where Black men were told they were being scarcity, the benefits of Black doctors treating own medical organizations. treated for syphilis, but actually, they were not, so Black patients were already evident, both in terms the researches could document the natural course of Black doctors better understanding medical and destruction of the disease; Dr. J. Marion issues prevalent among Black Americans and in Sims, a 19th-century physician, who conducted their being more receptive to treating members of brutal gynecologic surgery on enslaved Back the Black community. women without anesthesia to “perfect his surgical After the war, opportunities began developing techniques”; and many other projects that have for Black students, almost exclusively male, to attend medical school. treated Black Americans disrespectfully and even inhumanely. Established in 1867, the Howard University College of Medicine was the While the 14th Amendment presumably established racial equality first all-Black medical school. By 1910, a survey of medical schools known in 1868, it did not address discrimination, segregation, or many of the as “The Flexner Report” identified over 150 medical schools nationwide, fundamental seeds of racism. For instance, White medical schools had no including Black-only medical schools. directive to accept Black students, and few did. The Flexner Report was intended to standardize medical education and In 1896, the Supreme Court’s Plessy v. Ferguson decision upheld the racist increase physicians’ quality in the United States. Despite good intentions, it concept of “separate but equal.” Segregation of public schools was not found unconstitutional for another half-century in the 1954 Brown v. Board of Education decision that itself took over 15 years to take full effect. These past actions on society established institutional racism in every sector, and health care was not immune.
A historical perspective
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Blacks were forced to form their own medical organizations, such as the National Medical Association, when prevented from joining White organizations, namely the American Medical Association. The cover of the first journal of the National Medical Association, in 1909, clearly stated: “Conceived in no spirit of racial exclusiveness, fostering no ethnic antagonism, but born of the exigencies of the American environment.” Even today, the challenges that influence whether Black students matriculate or apply to a medical school program remain multifaceted. They include financial cost, bias and stereotypes, imagery and career attractiveness, and underperforming precursor schools. Statistical trends confirm our nation’s inability to attract and sustain a diverse physician workforce. When the Flexner Report was released in 1910, Black doctors’ proportion to the Black population in the United States was 2.5%. In 2019 it was 5.0%. The most current data at the University of Minnesota Medical School for 2020 shows 3% Black enrollment.
From institutional to personal—Dr. Zeke McKinney For health care workers, discrimination is still prevalent. One thing in particular that remains a problem is placing Black or underrepresented professionals in positions of authority. While it is appreciated and admirable for employers to address issues of diversity and inclusion, it sends an inverted message when the time and energy required to manifest these intentions is not allocated. Unfortunately, this same degree of obtuseness can exist in terms of understanding the context in which underrepresented minorities can experience discrimination with respect to their workplace performance.
Underrepresented individuals may be seen as “oppositional” in workplace interactions when speaking up, even when they do so appropriately. The latitude offered others—such as not being disciplined when frequently late—may not be offered to minority employees.
she did not know how to “control” me. While the administration never told me directly what had happened, a union representative informed me of the incident. She was never again my supervisor, and although temporarily relocated to a different office, she was suddenly back working in the same building as me without notice. After years of dealing with constant harassment, the message communicated was loud and clear: my feelings and experience were not valued.
Even outside of workplace performance, social interactions for underrepresented individuals that intersect with workplace culture can be challenging. For example, there is a common practice of workplace teams going out for “happy hour” meetings. This can result in excluding those with religious beliefs that include Discrimination remains abstaining from alcohol.
a prevalent problem.
Additionally, many underrepresented professionals (including myself ) almost always dress extremely professionally, always wearing a tie or dress shoes. I had experienced several independent instances where workplace colleagues saw me outside of work, when I was dressed in street clothes, and heard “Wow! I didn’t recognize you; you look like a thug (or hood or gangster).”
Lastly, a common challenge remains in how Blacks and other underrepresented populations fear or hesitate to engage institutional structures. This hesitation also exists in the area of bringing about those concerns to leadership when they arise.
A double-edged sword?—Dr. Dionne Hart My home is Chicago, one of the most segregated cities in the world, so I have personal experience with racism. Yet I honestly believed racism would not be overt in health care.
I continue to explain to well-meaning White colleagues that racism still exists, is systemic, and impacts them. I have grown tired of justifying my experience as a Black woman, as a mother of two Black men, and as a professional. There is no current or future cultural competency course that will change someone’s heart—and we need to change hearts.
A systemic issue—Dr. Charles Crutchfield As a senior medical student, I did a surgical rotation at a southern institution with a large hospital. On one occasion, I assisted on a parathyroidectomy, and as I was leaving the operating room, one of the nurses came up to me abruptly. She wagged her finger in anger and said, “This is the last time I’m going to tell you this. Pay attention to the corners!”
Institutional racism in medicine to page 124
That changed when my brother Michael died of complications from an aortic dissection. After collapsing at work, Michael waited for hours in an emergency department with classic signs. After an excruciating wait, he was sent home by providers who determined he likely had a kidney stone. While preparing for a follow-up primary care appointment, Michael died from cardiac tamponade. When his heart stopped, he fell with only a towel around him as if he’d just stepped out of the shower. Michaels’ death led to me leave Chicago to train at the Mayo Clinic. I committed myself to becoming one of the best physicians, one who would never make such a serious misdiagnosis as the one that led to my brother’s untimely death. Although my overall experience as a resident was outstanding, there were dark moments. For example, I would be mistaken for the interpreter or directed to leave a patient’s room because visitors were not permitted after hours. I had also been told by a colleague that they felt threatened when I shared a critical statistic about an African American woman whose case was left out of a presentation. As an attending physician with authority, I have encountered other experiences that were not mere professional slights, but “blows to the gut” that made me feel helpless and hopeless. On my first day on call as an attending physician, a nurse told me she was so happy I was on staff and “tickled pink” that I spoke English. I learned to live with such microaggressions to avoid retaliation until things got out of hand. My supervisor threw objects at me during rounds, regularly yelled at me, and reportedly called me an n-word b**** in my absence, telling others MINNESOTA PHYSICIAN JULY 2020
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3Institutional racism in medicine from page 11 I had no idea what she was talking about, and I was utterly dumbfounded. At the end of the case, the surgeon said everything had gone very well, telling me, “Thank you for your help. Nice job.” I wondered, “Why would a nurse criticize me when the surgeon did not?” Did parathyroidectomy involve “corners” that I didn’t do correctly? Returning to the main locker room, I passed two more operating rooms, one with a janitorial crew of two African American men and two Hispanic men, all wearing surgical scrub suits. One of them was methodically mopping the corners. It hit me like a brick: my skin color led the nurse to assume I could not have been part of the surgical team. I became so enraged that my face felt as if it was on fire. I went to find her to let her know that I was a medical student and part of the surgical team. Thankfully, I did not find her, as I would have said something that would have gotten me in big trouble.
attending surgeon and I waited for drying towels. He was given a towel, but I was asked why I was just standing there and instructed that the garbage was in the corner. On another occasion, a woman at a restaurant assumed I attended community college. When I said I did not, she told me that it was never too late to get an excellent education. I chose not to clarify that I was already a medical doctor.
We need to change hearts.
Racism is a culture shock—Dr. Inell Rosario Throughout my education, classroom professors often had a difficult time distinguishing me from another Black female student, even though we had no significant resemblance. I also did not expect the continuing parade of racially offensive encounters I would face over time, even as a medical student. For instance, after scrubbing for a case during my residency, the
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I also painfully recall going for a second opinion to a local facility with my mother-in-law, who had been recently diagnosed with mantle cell lymphoma. The physician walked in, saw five family members, read an erroneous note on my motherin-law’s chart indicating she did not speak English, and said, “Oh no, not another one to slow down my day.” I reassured him that we all spoke English and would translate for her. That was the only time I ever threw out the “I’m a doctor” card, but it made no difference. He never apologized or changed his attitude toward us.
Because of my upbringing and faith, these incidents have not rocked my self-confidence or made me bitter. Even amid current racial unrest, I’m confident we will move forward. There are many good people of all races, and we need to create the narrative. Character, capability, and chemistry have no color. Overall I see myself as a doctor who also happens to be a Black woman. I want to treat patients of all ethnicities and see their differences only in a manner that allows me to connect with them to provide patientcentered care. I will continue to do my part in educating my colleagues so that we enable all physicians to take care of all patients irrespective of color.
Where are the black health care executives?—Dr. Tamiko Foster It is not for lack of capable and qualified individuals that so few African Americans hold positions as executives and on boards of health insurance companies, health systems, and hospitals. An unwelcoming and dismissive culture contributes to qualified professionals from underrepresented populations often hesitating to bring concerns to management or seek leadership positions within dysfunctional institutional structures. A culture that fails to address these systemic issues—which could be done in many simple ways—only perpetuates them. I remember it as if it were yesterday: “This is Dr. Morgan. She is my boss now.” These were the words of the company’s former chief medical officer, a White male who introduced me to the group of health care C-Suite executives I would be working with. His stern introduction appeared to be some sort of rite of passage.
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As I took my seat at the table of White men, most at least 20 years my senior, the voices of welcome were drowned out by the daunting realization of loneliness that accompanies leadership as an African American. The reality of seeing and realizing how few people who looked like me in these leadership spaces was inevitable. Disparities in health care leadership and governance opportunities have been attributed mainly to racial discrimination and bias. While African Americans and other non-Whites have increasingly gained a seat at the table in diversity and inclusion positions, their presence in top leadership positions
in health care organizations, such as the C-suite, boards of directors, and senior management, is lacking. For the few who do attain such positions, their voices are often silent due to fear of an unjust backlash that comes from failing to conform. They have the title without the power and the pressure to work twice as hard to be respected. I had the painful experience of backlash from a trusted mentor after a promotion. The promotion was not worth the daily microaggressions and attempts at sabotage, but I stood strong. Others have been passed up for promotions, commonly described in the minority community as the classic case of “training and doing the work for the inexperienced White male colleague who received the promotion.” White privilege acts as a pass that grants those who are part of an informal network unique opportunities but leaves others feeling left out.
through actions that are intentional, measurable, sustainable, and reflect the institution’s visions, mission, and guiding principles.
Changes to make a real change
To make real change the actions must be intentional, measurable, sustainable, and embedded in the institution’s visions, mission, and guiding principles. We must require health care corporate leaders and executives, as well as those in academia, to take a deep look and dive on why and how to implement systemic change. We must construct health care systems and medical school policies, My skin color led the nurse to practice from an anti-racism lens, and implement assume I could not have been accountable action. Some areas to address first include: part of the surgical team.
During my career, several African American leaders have shared their stories of being labeled as “unsociable,” “unfriendly,” or “overly sensitive” when their participation in a system that has been socialized as being right is questioned. It’s a heavy burden to feel that your performance is judged at a microscopic level based on your skin color. This is what White privilege and racism in the workplace looks like. It’s disheartening to see organizational charts full of faces in leadership who don’t look like you. Recruitment and retention for African Americans and other non-Whites in these positions need to be strengthened. This happens best through policies put in place and enforced rather than being left to chance. Like many, I felt confident in my ability to do the job when given the opportunity and the resources to succeed. Sadly, this opportunity is not granted for most due to the color of their skin.
Requiring Predominantly White Institutions (PWI) to recruit, matriculate, hire, and retain Black students, staff, and faculty and create safe spaces for Black individuals to be supported and thrive in these environments. Providing opportunities to mentor Blacks and offer role models. Investing in pipeline programs. Teaching about health disparities within the medical school curriculum. Preparing all students to work in diverse health care systems and communities. Teaching future physicians on how to be culturally competent and anti-racist. Institutional racism in medicine to page 344
An unprecedented moment?—Dr. David Hamlar and Mary Tate Black men were counted as two-thirds of an American citizen under the Constitution. The Civil War nearly destroyed the Union. We endured the Jim Crow era, countless lynchings, and riots in the 1960s and the 1990s— and we continue to see racial inequality and disparities in all facets of American life. None of these events was considered “unprecedented,” so why is this moment any different?
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We continue to struggle to enroll underrepresented students in our medical schools, to demand equal access to medical care through programs such as the Affordable Care Act, and to seek funding for clinics and hospitals in communities of color that are patient-centered and culturally sensitive. Despite all of the barriers, Minnesotans of color have managed to find a way to survive, but at the cost of nation-leading health disparities. By any other name, this is systemic racism, which has led recently to street protests involving all demographics. Black people are underrepresented in the composition of CEOs of area hospitals, Fortune 500 companies, the state government, and within the police departments themselves. By holding them all accountable in this moment of recognition, admitting that systemic racism exists, and working toward the engagement of White America, we can make a real effort to change. As a start, we must 1) construct health care systems and medical school policies, practices, and procedures from an anti-racism lens and implement accountable policies, practices, and procedures; and 2) make real change
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3The seeds of a revolution from cover To support Medicare beneficiaries receiving telehealth services, the federal government in March announced expanded coverage. The Centers for Medicare and Medicaid Services (CMS) issued Medicare 1135 waivers intended to provide regulatory flexibility for providers and enhanced utilization by patients—but those waivers may not continue after the pandemic.
Key elements of the waiver Under its 1135 waiver—the section of the Social Security Act that enables waivers during public health emergencies—CMS chose to enact the following key components: • Expanded list of eligible telehealth practitioners that includes all those eligible to bill Medicare for professional services (includes physical therapy, occupational therapy, clinical social workers, etc.) • Originating site of telehealth visit can be patient home or residence • Expanded geography allowed for all telehealth visits including both rural and urban settings • Use of expanded list of 80+ telehealth available procedural codes • Payment parity for audio-only telephone visits • Use of Place of Service (POS) billing code where patient would have been seen • Provider licensure flexibility to practice in every state (subject to state licensure rules)
• Audio-only virtual communications allowed for certain services • Use of non-HIPAA compliant technology platforms • Allowing critical access hospitals (CAH) and rural health clinics (RHC) to be originating sites This massive, unexpected experiment in the use of technologies, processes, and role adaptations—sparked by the pandemic—removed barriers and accomplished in a few short months what otherwise would likely have taken years.
The future of waivers In June, Stratis Health conducted a new survey of Minnesota health systems to prioritize components of the Medicare 1135 waiver that should be continued. Results in ranked order, along with benefits cited by respondents: Maintain the expanded list of eligible telehealth practitioners that includes all those eligible to bill Medicare for professional services (includes physical therapy, occupational therapy, clinical social workers, and others). Benefit: broader set of practitioners can bill Medicare for telehealth. Originating site of telehealth visit can be patient home or residence. Benefit: Ability to do telehealth visits in patient homes/residences. Expanded geography allowed for all telehealth visits including rural and urban settings. Benefit: opens up urban settings for telehealth visits. Use of expanded list of 80+ telehealth available procedural codes. Benefit: broader set of services and access allowed for telehealth visits. Payment parity for audio-only telephone visits. Benefit: supports cases where telephone is the only option for remote visits. Use of place of service (POS) billing code where patient would have been seen. Benefit: improves telehealth reimbursement for providers. Provider licensure flexibility to practice in every state (subject to state licensure rules). Benefit: broader access to specialists across states. Audio-only virtual communications allowed for certain services. Benefit: supports cases where audio is the only available method for remote visits. Use of non-HIPAA compliant technology platforms. Benefit: allows for more options for patients/families to connect to providers.
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Allowing CAHs and RHCs as originating sites. Benefit: broader access to telehealth in rural communities. Survey respondents also suggested including pharmacies as eligible telehealth clinicians and allowing FQHCs and RHCs as eligible originating sites. These items had not been included in the Medicare 1135 waiver. The results of the Stratis Health survey have been shared broadly across Minnesota, including with legislators, health care associations, the Minnesota Department of Health, Minnesota Department of Human Services, and health systems. Survey results were serendipitously underscored by a 3-page letter sent to the Senate and House of Representatives minority and majority leaders supporting permanent enactment of telehealth waivers and exceptions. This national letter was signed by 340 organizations including EMR vendors, health care associations, and integrated networks, as well as to payor organizations.
Legislation The bipartisan Enhancing Preparedness through Telehealth Act—proposed by Minnesota Sen. Tina Smith and three other senators—requires an
inventory of telehealth readiness to anticipate and prepare for future needs (https://tinyurl.com/mp-legislation-01). The legislation recognizes that there are many lessons learned from the use of telehealth during the current pandemic, and seeks to put in place a five-year reporting cycle (conducted by the Department of Health and Human Services) to inform readiness steps for any future public health emergency. The recurring report will: Conduct an inventory of telehealth initiatives in existence, including their capacity to handle increased volume during the response to a public health emergency; Identify methods to expand and interconnect regional health information networks and state and regional broadband networks; Evaluate ways to prepare for, monitor, respond rapidly to, or manage the events of a public health emergency through the enhanced use of telehealth technologies; Promote greater coordination among existing federal interagency telehealth and health information technology initiatives; and Make recommendations related to updates on the use of telehealth in public health emergencies in federal and state public health preparedness plans and any actions taken to implement such recommendations (https:// tinyurl.com/mp-legislation-02).
Other lessons In response to COVID-19, health care organizations responded quickly with adapted workflows to make the sudden shift from in-person encounters to telehealth visits. The urgency of the pandemic did not allow for typical planning cycles, budgeting, or systematic implementation steps. Rapid implementation was essential. Some organizations that had telehealth
Suggested links Great Plains Telehealth Resource and Assistance Center: gptrac.org/ Long-Term Care Telehealth Toolkit: tinyurl.com/mp-tele-02 National Consortium of Telehealth Resource Center Covid-19 Toolkit: tinyurl.com/mp-tele-03 Rural Telehealth Toolkit: tinyurl.com/mp-tele-04 Telehealth Toolkit for General Practitioners: tinyurl.com/mp-tele-05 Telehealth Toolkit for End-Stage Renal Disease Providers: tinyurl.com/mp-tele-06 President Trump expands telehealth benefits: tinyurl.com/mp-tele-07 Medicare—telemedicine fact sheet: tinyurl.com/mp-tele-08
programs quickly scaled them up, while others new to telehealth had to learn and adapt to new ways of delivering patient care remotely. Many organizations have now shifted from this hurried response to one of more deliberate planning, role redefinition, and longer-term visioning for the best use of telehealth tools. Health systems are now determining which patients are likely to benefit the most from long-term telehealth services. With provider and patient satisfaction high, telehealth options are likely to reshape health care long after the pandemic passes. Before COVID-19 hit and the Medicare waivers were announced, Minnesota health systems identified their top challenges: educating staff and physicians on telehealth workflows; scaling up issues related to equipment availability and deployment; understanding coding/billing to obtain appropriate reimbursement; and facilitating/supporting telehealth encounters with patients.
Join the dialog We recommend that you contact your state senator’s or representative’s offices to advocate or provide input on telehealth policy. To learn more, interested physicians can contact Sue Severson at Stratis Health. Bill Sonterre, strategic account executive at Stratis Health, is a senior health information technology leader and business consultant.
Reid M. Haase, MHIM, is program manager and health IT consultant at Stratis Health.
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Medicare telehealth FAQ’s: tinyurl.com/mp-tele-09 HRSA Telehealth Toolkit: tinyurl.com/mp-tele-10 CMS Medicare Telehealth Services: tinyurl.com/mp-tele-11 Center for Connected Health Care Policy: www.cchpca.org/ Rural Telehealth Research Center: tinyurl.com/mp-tele-12 NQF tele-behavioral health guide: tinyurl.com/mp-tele-13b
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CARDIOLOGY
Women’s heart health disparities Gender-specific factors BY COURTNEY JORDAN BAECHLER, MD
E
very year, more women die of heart disease than from all forms of cancer, Alzheimer’s disease, and chronic lower respiratory disease combined. While heart disease is the leading cause of death for both women and men, regardless of race and ethnicity, women represent more than half of all cardiovascular-related deaths. Sixty-four percent of these women have had no previous symptoms. Unfortunately, the statistics speak for themselves. One woman dies every 80 seconds from cardiovascular disease. The reasons for these discrepancies may include reproductive factors, including those related to pregnancy and childbirth; disparities in the treatment of women; elevated plaque levels; acute and chronic conditions; responses to extreme stress; and psychosocial factors. Additional research is critical.
What the numbers say Let’s break it down and see how we got here and what we can do to change outcomes. We know that our risk of heart disease starts early. Reproductive factors, including early menarche, early menopause, and miscarriage, are associated with an increased risk for coronary artery disease. We also know
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that high blood pressure during pregnancy, pre-eclampsia, and gestational diabetes increase the risk of developing heart disease later in life. Additionally, while men are more likely to be classified as overweight, statistics show that women are more likely to be classified as obese or extremely obese. Unfortunately, these risks start to develop during reproductive years, when weight gain often starts for women, and during multiple pregnancies. Many women do not return to pre-pregnancy weight. We also see gaps in care as these risk factors develop during times focused on reproductive health care, when women may encounter less focus on lifelong, chronic disease mitigation. For many women, their obstetrician and gynecologist (ob-gyn) becomes their primary care physician.
Prevention We have a lot of work to do in the area of preventive care. In a study of more than 20,000 women who had a calcium score assessment, women who had a significant level of calcified plaque had a 75% higher mortality than men who had a similar level of plaque. Studies also show that women are less likely to be advised on their cardiovascular risk by physicians. Women are also less likely than men to be placed on lipidlowering treatments. Diabetes is a significant risk factor for heart disease, but women with diabetes fare considerably worse than men. Women with diabetes are more likely to develop congestive heart failure, coronary heart disease, myocardial infarction, and ultimate death from coronary heart disease, than men with diabetes. We might hope that it gets better with acute presentations, but that is not the case. Men and women with symptoms of heart attacks present differently. While the most common presentation for both genders is chest pain, women are more likely than men to present with fewer common symptoms, including shortness of breath, jaw pain, back pain, and nausea and/or vomiting. Unfortunately, when women do present to the hospital, they are less likely to receive guideline-directed care or evidence-based medicine. If they present with chest pain, they are less likely to get a cardiac catheterization than men. Women are 2–3 times less likely to receive implantable cardiac defibrillators than men and 1.5 times less likely to be referred to cardiac rehabilitation than men. Finally, women are 25% more likely to die after a heart attack than men.
Specific conditions
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A few areas of study warrant additional attention. One of these is a condition called Myocardial Infarction with Non-obstructive Coronary Artery Disease (MINOCA). Angiograms appear normal in nearly half of women who have experienced a heart attack. Many women who come in experiencing symptoms of heart attacks and troponin elevations, and are taken for cardiac catheterization, are found to have no clear culprit for the heart attack. The large arteries appear clear of significant plaque (defined as <50% stenosis). The role that microvascular arteries may play is a
For nearly 50 years, medical research has honed and crafted the art of detecting and treating cardiovascular disease, drastically reducing the mortality rate of a cardiac event. However, the studies that produced these medical advances primarily included men. Until recently, there had been Another area is Spontaneous Coronary Artery Dissection (SCAD), an little effort to ensure that women made up roughly acute condition that occurs when a tear forms in half of all research participants. Even then, the one of the coronary arteries. There are typically data that was collected for women was combined no pre-disposing risk factors for this condition, with the men’s research data, missing the unique which occurs primary in women in their thirties characteristics of the women participants. As a and forties. As SCAD causes slow blood flow, or One woman dies result, women’s cardiovascular research lags that ultimately complete blockage of blood flow, it can every 80 seconds from of men by up to 35 years. cause heart attacks, arrhythmias, or even sudden cardiovascular disease. death. An awareness of SCAD is critical for Responding to the need clinicians, emergency medicine technicians, and The Minneapolis Heart Institute Foundation’s patients because of the uniqueness in presenting Penny Anderson Women’s Cardiovascular patients, and in their subsequent treatment. SCAD Center focuses on understanding heart disease is more common in women. It has some association in women—preventing it, treating it, and with recent childbirth (during the first few weeks after delivery), and is more optimizing patient care. Our active research and databases started in common in patients with fibromuscular dysplasia, inherited connective the areas highlighted above, including SCAD, Takotsubo’s, and STEMI tissue diseases, and in those with severe hypertension and illegal drug use. (ST-segment elevation myocardial infarction). Additionally, we are actively growing area of study, particularly in women’s heart disease. It may require more aggressive treatment to improve outcomes and decrease the risk of developing more aggressive heart disease later.
Takotsubo syndrome, or stress-induced cardiomyopathy—sometimes referred to as broken heart syndrome—is another area to highlight for women’s heart disease. Takotsubo is an acute and reversible form of heart failure that occurs at a much higher rate in women. It is usually triggered by an extremely stressful event. Patients present with symptoms of a heart attack. It is common to see EKG changes, troponin elevations, and wall motion abnormalities on echocardiogram. When the patient is taken for cardiac catheterization, the coronary arteries appear normal, but the echocardiogram continues to show a decrease in left ventricular function with a classic Takotsubo pattern. Upon further history, it is usually found that these patients had a stressful event prior to their clinical presentation. Ongoing research shows that these events can reoccur for patients with high rates of both morbidity and mortality. Further understanding of those who are most likely to be affected by this condition and minimizing the risk is an area of active study.
enrolling women in the WARRIOR study (Women’s Ischemia Trial to Reduce Events in Non-Obstructive CAD) to determine whether intensive medical treatment to modify risk factors and vascular function in patients with coronary arteries showing no flow limit obstruction but, with cardiac Women’s heart health disparities to page 324
Behavioral health Overall mental health also contributes to women’s heart health. Thirtytwo percent of all coronary artery disease is thought to be secondary to psychosocial factors such as depression, stress, anxiety, and social isolation. Each year, one in five women has a mental health challenge, and depression is two times more common in women. Women are twice as likely to experience post-traumatic stress disorder and are two times as likely to experience generalized anxiety disorder. Income disparities can contribute to this risk. Women earn less than their male colleagues. In fact, women who work full-time are paid about 25% less than their male counterparts. Finally, 65% of women are the primary caregiver (either for their own children, their parents, or both). While genetics are always important to understanding health differences between men and women, the human genome project showed that between all genders and races, we are 99% similar. It begs the question to examine societal structures on the various pressures on women throughout life, as well as the way we access care—when, where, and how—our access to insurance, and our ability to partake in research.
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BEHAVIORAL HEALTH
The P Factor A new framework for assessing mental health BY BRENT NELSON, MD
F
inding ways for accurate and consistent diagnosis in mental health has been sought since the emergence of self-awareness. For millennia we have struggled to understand who we are and how our internal experience matches with the reality of the external world. We work to describe the complexity of this experience so others can relate, understand, and interact. At times, our internal state or interactions with the external world do not match our expectations, which becomes distressing. This can lead to dysphoria and to cycles and behaviors we consider abnormal. We seek out care in the hope of understanding and intervention, with the goal of improved feelings and a return to health. This is the practice of psychiatry and medicine in general.
History The practice of medicine has evolved over thousands of years, driven by a welldefined process of description, measurement, diagnosis, and intervention. Over time, science has sought to establish systems to standardize the description of disease and identify potential solutions or treatments. This is especially true regarding the subjective nature of the dysphoria described above. Chinese
historical records dating back to 1100 BCE show motivation for the classification of mental health problems. These records included detailed observations of behaviors and emotions, grouping them into categories for study and treatment. The ancient Greeks attempted to explain possible causes of notable afflictions with the goal of testing ways of healing them. Kraepelin, Bleuler, and Freud all crafted theories around symptom clusters and drives. These explanations were guided by our early, and sometimes erroneous, understanding of neurology and the brain. These pioneers were left feeling an incomplete understanding of the system and knew there were still many missing pieces of the puzzle.
The DSM and its limitations In 1952, the American Psychiatric Association developed the Diagnostic and Statistical Manual of Mental Disorders (DSM). This groundbreaking manual harkened back to the work done in 1100 BCE to offer a taxonomy of symptoms grouped into diagnoses. The goal was to provide a common language for describing various mental health presentations in order to provide specificity for clinical care and future scientific discovery. While highly successful in clinical care, it was well-known that, despite the DSM’s taxonomy and descriptions of multiple symptoms, the manual does not necessarily reflect groupings of underlying neuropathophysiology. A simple example: not all sadness is vegetative depression, just as not all chest pain is myocardial infarction. Studies of the DSM also reported significant overlap between different diagnoses, leading to ambiguity and potential misidentification of an illness, as well as to subsequent misapplication of a treatment. A study by Newmann et al. in the Journal of Abnormal Psychology proposed a “rule of 50%,” which states that half of individuals who meet diagnostic criteria for one disorder also meet criteria for a second disorder. For example, anti-NMDA receptor encephalitis was classically diagnosed as schizophrenia, but now, due to advanced diagnostic techniques, is recognized as an auto-immune disorder that manifests as psychosis. Another example is the childhood spectrum of disorders called PANDAS, which were often labeled as obsessive-compulsive disorder but are now are also thought to be related to strep infections and a possible autoimmune connection. While the symptoms of both of these disorders are consistent with the DSM’s descriptions, underlying etiology is developing clarity in some of the “OCD” disorders and not others, likely because they are different disorders, even though the symptoms are similar.
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Providers clearly recognized a need for more precision in not only our language, but also our understanding of underlying physiology.
Comparisons to medicine Historically, the successful practice of medicine has been dependent on the sophistication of the tools available. In some areas of medicine, problems can be described and measured easily due to their macroscopic nature. This allows for development of a reliable mechanistic understanding, which then leads to a clear rubric of steps required to address the problem. Other areas are based on microscopic findings. These topics are less visible initially, but as high-resolution
microscopic tools have become available, medicine has once again developed understanding and suggested a rubric for these otherwise hidden problems. While improvements in microstructure tools have provided immense discovery, scientists have also found disease to be more than just structural disruption. There are often processes functioning out of homeostasis. While these disruptions are still physical in nature, often chemical, the issue frequently arises from a change in the steady state of the system. These are measured via tests of levels, markers, and even genetic interactions. Psychiatry and neurology are among a group of specialties where the substrate of study is both physical and functional, but also dependent on something else. Physical issues such as brain injuries are visible at the macroscopic level and variations in dopamine receptors related to psychosis are visible at the microscopic level. Sympathetic overdrive, as seen in posttraumatic stress disorder, is a disruption of functional homeostasis between sympathetic and parasympathetic nervous systems and can be seen at the homeostatic functional level, visible through changes in heart rate variability. These are all reliably measurable but also do not entirely explain the outcomes we observe. Something is still missing from our understanding.
Research Domain Criteria Recognizing the need for translational study, The National Institute of Mental Health announced in 2009 a new research framework, called Research Domain Criteria (RDoC), intended to change the way mental health was studied and understood. RDoC integrates many levels of study (genomics, circuits, behavior, self-report) to ground the understanding of mental health across various dimensions. The goal is not to serve as a diagnostic guide or to replace current systems of diagnosis, but to provide a framework that can benefit diagnosis and intervention through a solid, translational, mechanistic footing. While initially controversial, RDoC has now been in place for over 10 years and is beginning to provide recognizable benefits to the field. Many The P Factor to page 304
The “g” and “p” factors Modern science continues to search for definition of this missing piece. One area of study focuses on large-grained observational constructs. This is most notable in the study of general intelligence, or g factor. General measures of intelligence were developed to provide practitioners with a less-subjective measure of general cognitive brain function. This is used to predict when individuals may have a harder time navigating the world in areas such as education, work, and independence. This inspired a series of papers on a construct called the p factor. The intent of this factor was to provide a less-subjective assessment of the liability/sensitivity one may have to stressors over time. Caspi described this construct via conduct disorder in the Journal of Clinical Psychological Science, stating that “the propensity to persistent conduct disorder symptoms from adolescence to midlife is indicative of General Psychopathology rather than specific to an Externalizing style.” The authors suggest that, while individuals may have many other factors or behavioral patterns that determine one’s way of interacting with the world, there is a common factor that will determine whether they are at higher risk for future psychopathology and other diagnoses.
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The difficult part of the p factor is that it doesn’t really diagnose— more than anything else, it provides a likelihood for suffering. This lack of diagnosis is what makes it a bit provocative. It’s more a unifying factor for emotional sensitivity and for potential distress. On the positive side, it may predict when a normally effective set of “brain tools”—e.g., proclivities for managing situations in certain ways—prove to be ineffective under stress. In addition, the p factor suggests that all “disorders” are connected in a common way: if there is one, then there are often others.
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Both the g factor and the p factor have been met with much skepticism. Many suggest that they are far too large-grained to be practical and lack predictive guidance. Others report that they are subject to tremendous biases in areas such as culture, education, and experience. The clear conclusion of many of the studies is that psychiatry needs additional tools to address the gap left by considering only the physical or functional aspects of the human nervous system. Assessment and understanding of how the nervous system functions at an informational level is vital to a more complete understanding of both the diagnosis and treatment of these complex and debilitating disorders.
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HEALTH CARE POLICY
The 2020 legislative wrapup Pandemic impacts deliberations BY TOM HANSON, JD, AND JOHN REICH
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s the 2020 Minnesota legislative session gaveled in on Feb. 11, it was largely expected to be a quiet term. A balanced, two-year budget had passed the year before, the economy was humming, and, with an anticipated $1.3 billion surplus, there was no must-pass legislation. Passage of a bonding bill for infrastructure projects across the state was expected to be the highlight of the session. The Democratic majority in the House indicated interest in spending the budget surplus on affordable housing and homelessness issues, while the Republican-controlled Senate had hoped to use some of the budget surplus for tax relief. However, with Minnesota remaining the only splitparty Legislature in the country and all 201 legislative seats up for election in the fall, many expected agreement would prove elusive on any controversial issues, as each caucus would push its own priorities and see no reason to compromise mere months prior to an important nationwide election. Suffice it to say, the legislative session did not go as expected. By March 17, exactly five weeks into the session, a new reality set in due to extraordinary measures undertaken by the Legislature in response to the COVID-19 pandemic. The House and Senate both met briefly to pass a $20 million
OB & GYN CARE
COVID-19 response package, followed seven days later with an additional $200 million COVID-19 response package. After those bills passed, the Legislature began an unprecedented extended recess until April 14. From March 17 to April 14, the Legislature met just twice, each day passing a single COVID-19 response bill. The first of these bills was more comprehensive in nature, including various funding and policy provisions, while the second established a rebuttable presumption that those who work in certain occupations and contracted COVID-19 had acquired it on the job, and were therefore eligible for workers’ compensation. The Legislature eventually resumed relatively normal functions after moving to a virtual environment. Committee meetings via Zoom videoconferencing became the norm, and new rules were passed to allow for legislators to participate in floor sessions from various remote locations. As a result, both the House and Senate engaged in regularly scheduled committee meetings, and each met in floor session several times a week. The issues moved beyond only dealing with the COVID-19 response, and bills began advancing through the new, much slower, process. Eventually, nearly 50 bills were passed and signed into law in the last month of the regular session. The Legislature adjourned the 2020 regular session on the constitutionally required date of May 18. Concurrently, Gov. Tim Walz declared a peacetime emergency on March 13, which afforded him broad authority under state law to address the COVID-19 pandemic through executive order. Each peacetime emergency declaration is in effect for 30 days and can be renewed as many times deemed necessary by the Governor. Subsequently, Gov. Walz has continually renewed the peacetime emergency, issuing more than 75 Executive Orders, which is an unprecedented number.
including advanced maternal age.
management of peri-menopause
Certified nurse midwifery.
Center for Urinary and Pelvic Health, including urodynamics.
The peacetime emergency declaration added a wrinkle to the Governor’s relationship with the Legislature during the legislative interim. In a normal year, House and Senate members would all be back in their districts campaigning. However, state law requires that if the Governor issues, or in this case renews, a peacetime emergency and the Legislature is not in session, then the Governor must call a Special Session to allow the Legislature to review the Governor’s actions. Under state law, the Legislature may vote to terminate the peacetime emergency but does not have to approve it.
well-woman screenings and in-office procedures
Nutrition and wellness
Legislation of interest
Gynecologic surgeries,
Infertility evaluation and
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Menopause Clinic, including
consultations. treatment.
Outside of the efforts to address the COVID-19 pandemic, health care policy was not a big focus during the 2020 legislative session. As we discussed in Minnesota Physician after the 2019 session closed, there were major policy and funding changes included in the 2019-2020 budget. As a result, the 2020 session was largely focused on policy. Highlights of legislation that passed this year:
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JULY 2020 MINNESOTA PHYSICIAN
H.F. 3398 (Morrison)/S.F. (Rosen): Prior authorization. The Legislature modified the utilization review and prior authorization requirements used by Minnesota’s health insurance companies to medically manage health
requiring drug makers to turn over insulin at little or no cost or face fines care benefits. Among other provisions, the revised law shortens deadlines for represents a violation of the Fifth and Fourteenth amendments to the both standard review authorizing decisions and expedited review decisions; Constitution. Gov. Walz stated that the law would remain in force pending states that utilization review organizations will not be able to revoke or what is likely to be a protracted court battle. change a prior authorization, absent evidence of fraud, misinformation, or conflicts with state or federal law; requires H.F. 3028 (Morrison)/S.F. 2939 (Nelson): the review to be done by a physician within the Criminal background check fee. This bill strikes same or similar specialty; mandates a continuity the $32 health board fee covering a criminal of care of 60 days if the individual changes health background check related to physician licensing plans; and requires annual posting on the health fees, makes technical changes to the governing Five weeks into the session, plans’ public website of the number of prior statute, and makes similar changes to other a new reality set in … authorizations that were authorized or denied. occupational boards.
the COVID-19 pandemic.
H.F. 3100 (Howard)/S.F. 3164 (Jensen): Insulin pricing. Minnesota’s Alec Smith Emergency Insulin Act creates an emergency supply of insulin for 30 days for diabetics who cannot afford the medication. It also sets up a longer-term program for those under certain income limits and for those who don’t have insurance (or have insurance with large co-pays). The legislation requires manufacturers to supply the drug, either by resupplying pharmacists or sending insulin directly to patients, and imposes fines on companies that fail to participate. Those fines increase as non-participation continues—$200,000 per month for six months, increasing to $400,000 per month for the next six months. After a year of non-participation, fines go to $600,000 a month. The Pharmaceutical Research and Manufacturers of America (PhRMA) has filed a lawsuit in federal court charging that
S.F. 4458 (Howe)/H.F. 4537 (Wolgamott): Worker’s compensation claims. This bill creates a rebuttable presumption that an employee who contracts COVID-19 is presumed to have an occupational disease arising out of and in the course of employment. Eligible employees include police officers; firefighters; nurses or health care workers; corrections officers or security counselors employed by the state or a public body at a corrections facility; EMTs; health care providers, nurses, or assistive employees employed in a health care, home care, or long-term care setting with direct COVID-19 patient care or ancillary work in COVID-19 patient units; and child care workers required to provide child care to first responders and other health care workers. The The 2020 legislative wrapup to page 254
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ONCOLOGY
Chronic lymphocytic leukemia Updates in management BY SANDEEP JAIN, MBBS, MRCP, FRCP
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hronic lymphocytic leukemia (CLL) is characterized by an accumulation of small, mature lymphocytes in the blood, bone marrow, and lymphoid tissues. It is only distinguishable from small lymphocytic lymphoma (SLL) by the presence of leukemic cells in peripheral blood. CLL is the most prevalent leukemia in adults. According to the National Cancer Institute, an estimated 20,700 people were diagnosed with CLL in the United States in 2019. It is more prevalent in men than women and the median age of diagnosis is 70 years.
Diagnosis
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Common presentation is an asymptomatic adult who is found to have elevated absolute lymphocyte count on a blood test done for other indications. Manifestations of CLL include lymphadenopathy, organomegaly, diseaserelated cytopenia, and constitutional symptoms including fatigue, low-grade fever, unexplained weight loss, and night sweats. The diagnosis of CLL requires the presence of >5 X 109 clonal B lymphocytes, sustained for at least three months. The leukemic cells are characteristically small, mature lymphocytes
Other tests routinely performed include serum chemistry, serum immunoglobulins, and direct antiglobulin test. Fluorescence in situ hybridization (FISH) can be performed on peripheral blood lymphocytes, which is helpful in determining prognosis. Most common chromosomal aberrations include del(13q), trisomy 12, del(11q), and del(17p). Presence of isolated del(13q) is associated with a favorable prognosis. Patients with leukemic cells which carry del(17p) and del(11q) are associated with adverse outcomes. IGHV unmutated status is associated with early need to start treatment.
Staging and indications for treatment There are two widely accepted staging systems for CLL: Rai and Binet. Both are simple, inexpensive, and rely solely on physical examination and standard laboratory tests. Several trials comparing immediate versus deferred chemotherapy have established that there is no survival benefit from early treatment for indolent CLL, and it is universally accepted practice to defer start of treatment until patients become symptomatic, as defined by the International Workshop on Chronic Lymphocytic Leukemia.
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with a narrow border of cytoplasm and a dense nucleus lacking discernible nucleoli. Smudge cells are commonly seen on peripheral smear. Diagnosis is confirmed by flow cytometry of peripheral blood. Bone marrow examination is not routinely performed in clinical practice, but may be required in clinical trials or to evaluate unexplained cytopenia. CLL cells co-express the surface antigen CD5 together with the B cell antigens CD19, CD20, and CD23. Consultation with a hematopathologist is recommended whenever possible.
JULY 2020 MINNESOTA PHYSICIAN
Factors affecting first-line treatment selection Multiple effective options are available when a decision is made to start treatment. Remarkable progress has been made in the last few years in the targeted therapy for CLL. Current treatment options include chemoimmunotherapy (CIT), a combination of chemotherapeutic agents with monoclonal antibody for CD20 such as rituximab or obintuzumab, Bruton tyrosine kinase inhibitors (BTKi) such as ibrutinib, acalabrutinib, and B-cell lymphoma-2 inhibitors (BCL-2i) such as venetoclax, or a combination of the above. Important considerations include age, comorbidities, del(17p) status, cardiac history, concomitant medications, renal function, financial considerations, and logistical access. For younger patients with no significant comorbidities and del(17p) wild-type status, the options include CIT, BTKi, and BCL-2i. The most effective CIT is FCR, a combination of fludarabine, cyclophosphamide, and rituximab. The median progression-free survival (PFS) with FCR is 55 months, however >90% patients with IGHV unmutated are expected to progress on follow-up. CIT such as FCR employs genotoxic therapy with an associated 3% to 5% risk of secondary hematologic malignancies such as myelodysplastic syndrome and acute myeloid leukemia. Both BTKi and BCL-2i-based therapies have superior PFS compared to CIT. The expected five years PFS for first-line BTKi ibrutinib-based therapy is 70%. The expected two years PFS for BCL2-i venetoclax-based 1-year fixed dose
Monitoring of response is done using careful physical, blood, and bone marrow examination. Partial response is defined as >50% decrease in the absolute lymphocyte count, and >50% decrease in the size of lymph nodes and organomegaly. Complete response is defined as resolution of all For elderly patients or patients with significant comorbidities, improved PFS lymphadenopathy, hepatomegaly, splenomegaly, but not overall survival has been demonstrated with and normal lymphocyte count with Hgb >11.0 both BTKi and BCL-2i-based therapies over CIT. and platelets >100 along with normal bone marrow BTKi are associated with increased risk examination. Patients who achieve complete of atrial fibrillation and bleeding. They are response should be evaluated for Minimal Residual contraindicated in patients on anticoagulation. Disease (MRD) using multicolor flow cytometry CLL is the most prevalent BTKi-like ibrutinib is chronic therapy and can be or next-generation sequencing. Prospective clinical leukemia in adults. expensive in the long run. Patients with del(17p) trials have shown that patients who achieve MRD, or TP53 are resistant to CIT and need treatment negativity defined as blood and bone marrow with with either BTKi or BCL-2i in which response <1 CLL cell in 10,000 leukocyte, have improved rate is similar in patients with del(17p) versus clinical outcomes. wild type. BTKi therapy is also associated with Selecting treatments for relapsed CLL increased risk for infections, including invasive Patients previously treated with CIT can be treated with either BTKi or fungal infections, and patients receiving therapy with BTKi should be BCL-2i with similar considerations. Patients who appear to have progressed carefully monitored for infections. on BTKi should have careful evaluation to rule out other medical conditions BCL-2i therapy is associated with significant risk of tumor lysis contributing to the presentation, such as an infection. Patients should also be syndrome (TLS). In the CLL14 regimen, allopurinol was started and the evaluated for the possibility of Richter’s transformation, a rare complication first course of treatment was with obinutuzumab alone. Obintuzumab where CLL suddenly transforms in a significantly more aggressive form effectively decreased WBC count and reduced risk of TLS. Venetoclax of large cell lymphoma. When true progression on BTKi is confirmed, is introduced with the second course and a ramp-up is done as per the first line treatment is 88%. Thus, both BTKi and BCL-2i-based therapies offer superior efficacy and avoid genotoxicity. BCL-2i-based therapy is also attractive as it offers fixed-duration therapy.
prescribing information. With these precautions, the risk of TLS is low. There is significant risk of neutropenia with venetoclax-based regimen.
Chronic lymphocytic leukemia to page 244
V Alzheimer’s is now an approved condition V
HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS
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MINNESOTA PHYSICIAN JULY 2020
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3Chronic lymphocytic leukemia from page 23 overall prognosis is poor. FISH and cytogenetic should be repeated, and BTK should be evaluated for mutations. BTKi should be continued while other treatment options are being considered, due to significant rebound effects. CIT is unlikely to be effective in this population. Treatment options include BCL-2i-based therapy, Phosphoinositide 3 kinase inhibitors (PI3K i), hematopoietic stem cell transplant, and clinical trials. Recent studies have shown that BCL-2i-based therapies can produce durable responses in patients with BTKi refractory disease and should be the preferred option. Patients who are refractory under both BTKi and BCL-2i therapy should be evaluated for clinical trial of newer therapies and/or hematopoietic stem cell transplant.
Supportive care and management of complications Cytopenia can be seen in CLL related to therapy such as chemotherapy or drugs such as BCL-2i, which can cause neutropenia. Growth factors such as granulocyte colony stimulating factor (G-CSF) are effective and should be used in accordance with guidelines from the American Society of Clinical Oncology. Cytopenias can be autoimmune in nature. There is an established relationship between CLL and autoimmune thrombocytopenia and autoimmune hemolytic anemia. These should be distinguished from cytopenias due to excessive bone marrow infiltration with CLL cells. In difficult cases, bone marrow biopsy is helpful in distinguishing autoimmune cytopenias from bone marrow dysfunction. CLL is characterized by intrinsic immune dysfunction, which can be aggravated by the therapy for CLL. Infections are a frequent complication
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JULY 2020 MINNESOTA PHYSICIAN
during management of CLL patients. Patients should be encouraged to complete routine vaccinations, as vaccinations achieve a reasonable rate of seroconversion and protection in immunocompromised cancer patients. Live vaccinations are contraindicated. Hypogammaglobulinemia is another well recognized complication of CLL. IVIG therapy has been shown to reduce the rate of recurrent infections, but is expensive and needs recurrent IV infusions. Therapy decisions should be individualized and reserved for patients with severe hypogammaglobulinemia and recurrent infections.
Conclusions Recent advances have substantially improved the outcomes for CLL patients. Genetic tests have prognostic significance and, more importantly, help guide therapy and prevent patients from receiving toxic therapy, which has less chance of being effective. Monitoring for MRD can help patients with prognostic information and improve the design of clinical trials as MRD negativity is a surrogate for improved clinical outcomes. Multiple novel targeted therapies such as BTKi and BCL-2i are now available with impressive efficacy and better toxicity profile compared to CIT. Sandeep Jain, MBBS, MRCP, FRCP, is board-certified in medical oncology, hematology, and internal medicine. His areas of special interest include myeloma, lymphoma, and lung cancer. Dr. Jain practices at Minnesota Oncologyâ&#x20AC;&#x2122;s Burnsville clinic.
3The 2020 legislative wrapup from page 21 employees contracting COVID-19 must provide positive test results, or, if a test is not available, must be diagnosed and documented by the employee’s licensed physician, licensed physician’s assistant, or licensed advanced practice registered nurse. A copy of the test or written documentation by the employee’s health care provider must be provided to the employer or insurer.
Learn more These bills will be compiled at the website of the state’s Office of the Revisor of Statutes (www.revisor.mn.gov). To learn more about an individual House or Senate bill, or to track bills that may carry forward during the 2021 session, visit www.leg. state.mn.us/leg/legis.
Tom Hanson, JD, an attorney with Winthrop & Committee meetings via S.F. 1098 (Rosen)/H.F. 1246 (Morrison): Weinstine, represents clients before the Legislature Zoom videoconferencing Prescription Drug Price Transparency Act. This and regulatory bodies. Prior to joining the firm, he became the norm. legislation requires drug manufacturers to submit worked for the Republican Caucus in the Minnesota certain pricing data to the Minnesota Department House of Representatives for eight years and served of Health (MDH) and requires MDH to publicly for eight years in Gov. Pawlenty’s administration, post certain data. Specifically, a manufacturer of including four years as the Commissioner of a brand name drug whose price increases by 10% Minnesota Management and Budget. or more in a 12-month period or 16% or more in a 24-month period, and/ or a generic drug whose price increases by 50% or more in a 12-month period, must submit information related to the increase, including the John Reich, director of government relations at Winthrop & Weinstine, has net yearly increase over the introductory price, total sales revenue for the extensive experience in lobbying and strategy management. Prior to joining the drug during the previous 12-month period, the manufacturer’s net profit firm, he worked for the DFL Caucus in the Minnesota House of Representatives attributable to the drug during the previous 12-month period, and other for five years and served for four years in Gov. Dayton’s administration. pricing information. A drug manufacturer that does not comply may be subject to a civil penalty not to exceed $10,000 per day. Lastly, MDH must issue an annual report to the Legislature on implementation.
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MINNESOTA PHYSICIAN JULY 2020
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DERMATOLOGY
Cutaneous manifestations of COVID-19 Keeping the differential diagnosis open BY PHILLIP KEITH, MD
C
utaneous manifestations of Coronavirus Disease 2019 (COVID-19) are being reported more frequently as the global pandemic unfolds. COVID-19 has been reported to have dermatologic manifestations including morbilliform exanthems, urticaria, livedoid and vesicular eruptions, and pernio-like changes in 0.2–20% of patients. The skin may also be affected in children with multisystem inflammatory syndrome (MIS-C). The latest case series of 716 patients with associated cutaneous eruptions associated with COVID-19—based on an international registry of 31 countries and reported by Freeman et al. in the Journal of the American Academy of Dermatology (JAAD)—found associated cutaneous features in 171 COVID-19 lab-confirmed cases. The following frequency of morphologies were reported: 22% morbilliform eruptions, 18% perniolike changes, 16% urticarial, 13% macular erythema, 11% vesicular, 9.9% papulosquamous, and 6.4% retiform purpura. Cutaneous eruptions typically occurred after other COVID-19 symptoms such as cough, headache, sore throat, and fever in 64% of patients, and simultaneously with these symptoms in 15% of patients.
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JULY 2020 MINNESOTA PHYSICIAN
The morphology of skin lesions may be a helpful marker to predict COVID-19 severity.
The emergence of COVID Toes COVID Toes have emerged as a possible sign of a current or prior COVID-19 infection in younger patients that present with chilblain-like eruptions. Also known as pernio, chilblains is an inflammatory condition that commonly occurs on acral surfaces such as the feet and hands, typically after cold exposure, and especially in winter climates. Cutaneous signs include erythematous or violaceous macules or patches that may evolve into vesicles or bullae. This eruption can be asymptomatic but is often associated with a burning quality. When case reports from Europe were noted in patients developing these lesions despite ambient mild temperatures, clinicians and public health officials became concerned that pernio-like eruptions may be associated with COVID-19. Preliminary evidence suggests the pathophysiology of pernio-like lesions associated with COVID-19 is secondary to the immune system’s response to viral infection. The immune system increases interferon to fight the viral infection, which subsequently inflames blood vessels in acral areas. The histopathology from these cases does not show evidence of an occlusive vasculopathy. Early data from the international registry cited in JAAD reported clinical features, timing, COVID-19 severity, and outcomes in 318 patients with pernio-like skin lesions. The median age of patients was 25 years, and 45% had other COVID-19 symptoms (fever, cough, headache, and sore throat). Feet-only features were present in 84% of cases, handsonly in 5.1% of cases, and a combination was present in 10% of patients. Overall, patients with pernio-like changes have milder cases of COVID19, since only 16% of patients were hospitalized, as reported in the most recent publication from the international registry. Lesions lasted for approximately 14 days. No known patients with pernio-like lesions presented with stroke. These lesions can be asymptomatic but are more likely to be painful or have a burning quality similar to idiopathic chilblains. This condition can be treated with high-potency topical steroids, low-dose aspirin, nifedipine, and hydroxychloroquine, depending on disease severity. The timing in which cutaneous symptoms presented is an important takeaway from the registry. Pernio-like lesions occurred before COVID-19 symptoms in 13% of patients, at the same time in 15%, and after COVID-19 symptoms in 54%. COVID-19 testing among patients in this series was highly variable. Seventy-two percent of registry cases were in suspected cases without confirmatory testing and approximately 19% of patients who received testing (PCR or antibody serology) tested negative. This group suggests that pernio-like eruptions should be considered a COVID-19 testing criteria that should prompt PCR and antibody testing. Patients and their physicians should also consider whether or not selfisolation is necessary. It is important that clinicians keep the differential diagnosis open when evaluating patients with pernio-like lesions on the extremities because other diseases can cause similar cutaneous changes (e.g., infections, vasculitis, and thrombosis.)
Cutaneous manifestations that may be associated with COVID-19
• Oral cavity changes, including erythematous lips, lip fissuring, or strawberry tongue.
Eruptions associated with vesicular, urticarial, morbilliform, and macular • Polymorphic rash that can be maculopapular, targetoid or erythema are most common on the trunk and extremities and be pruritic. erythema multiforme-like rash, or widespread scarlatiniform The recent international registry data reported erythema affecting the extremities and that 22–45% of patients with these morphologies perianal area. required hospitalization. Patients with a • Bilateral non-purulent conjunctivitis. morbilliform exanthem morphology are more likely • Erythematous hands and feet with to have pruritus and involvement of the trunk and desquamation. extremities. This morphology was detected after Many [MIS-C] patients require • Unilateral cervical adenopathy that is 1.5 other COVID-19 symptoms in 76% of patients. hospitalization in intensive care. centimeters in size. Drugs and other viruses can also cause • The clinical features noted above do not morbilliform eruptions and urticaria, so it is need to be present at the same time to important to keep culprits other than COVID-19 make the diagnosis. in the differential diagnosis. Vesicular eruptions were reported in 15% of patients before the onset of other COVID-19 symptoms in a Spanish case series published in the British Journal of Dermatology. Vesicular eruptions can also be seen in other dermatologic conditions such as erythema multiforme; eczema herpeticum; eczema coxsackium; and hand, foot, and mouth disease. However, an acute, widespread vesicular eruption that resembles varicella in a younger patient should prompt the clinician to consider COVID-19 as a possible underlying cause. Papulosquamous eruptions have been reported and may resemble pityriasis rosea with scaly oval-shaped papules and plaques on the trunk and extremities. These eruptions can be treated with topical steroids and antihistamines. Livedoid changes with retiform purpura have also been reported in COVID-19 patients. These changes, along with acral cyanosis, indicate vasculopathy, with commonly affected areas including the extremities and buttocks. These skin changes differ from pernio-like lesions and are more commonly found in older critically ill patients. This is typically a late finding after other COVID-19 symptoms have presented. Every patient was hospitalized, and 82% had acute respiratory distress syndrome in the recent JAAD case series.
Toxic shock syndrome, often caused by Staphylococcus aureus or Streptococcus pyogenes, typically presents with fever, chills, myalgias, hypotension, nausea, vomiting, and widespread erythema that may desquamate. In a New England Journal of Medicine report involving children with MIS-C from 26 states, Feldstein et al. reported that cutaneous involvement was found in 76% of patients, and Kawasaki disease-like features in 40% of their patients in their study involving children with MIS-C. In that same report, coronary artery Cutaneous manifestations of COVID-19 to page 284
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Kids and MIS-C Multisystem Inflammatory Syndrome in Children (MIS-C) can present with features of Kawasaki disease and/or Toxic Shock Syndrome. Kawasaki disease may be triggered by an infectious pathogen, but its underlying cause has not been identified. It typically affects children under the age of five and is more common in patients of Asian descent. The CDC has outlined the features of MIS-C to include: • Fever for more than 24 hours. • Laboratory evidence of inflammation. • Evidence of multisystemic involvement (more than two systems, including cardiac, renal, respiratory, hematological, gastrointestinal, dermatological, and neurological).
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3Cutaneous manifestations of COVID-19 from page 27 aneurysms were found in 8% of patients. Patients with Kawasaki diseaselike symptoms were more likely to be younger than five years old in this case series. Another case series published by Dufort et al. in the New England Journal of Medicine involving children with MIS-C from New York State reported 60% of those patients had rashes. Thirty-six percent of those patients had Kawasaki disease-like features. Similar to the prior case series, younger patients were more likely to exhibit Kawaski disease-like features (48% of children 0–5 years old, 43% 6–12 years old, and 12% 13–20 years old presented with Kawasaki disease-like features, respectively). Dermatologic features were the most common presenting sign of MIS-C in this group. Symptoms of MIS-C are highly variable, and early recognition of this condition is important since many patients require hospitalization in intensive care. Thirteen non-fatal cases of MIS-C (average age 5) were reported in Minnesota by the state health department on July 1, 2020. However, only eight patients required intensive care. Treatment options for MIS-C include intravenous immunoglobulin, systemic steroids, anticoagulation therapy, anakinra, tocilizumab, and siltuximab.
Assessment of cutaneous manifestations of COVID-19 The heterogeneous cutaneous manifestations of COVID-19 can be challenging to assess. Pernio-like lesions may be a more specific cutaneous
sign of this disease compared to eruptions with other morphologies. It is very important that new onset pernio-like eruptions prompt physicians to consider PCR and serology testing, as well as quarantining. Children with cutaneous signs of MIS-C who have other symptoms for this disorder should be referred to the hospital for immediate evaluation. It’s important to note that the severity of COVID-19 appears to be higher in patients who have associated urticarial, vesicular, and morbilliform eruptions, compared to those with pernio-like eruptions. In fact, patients with retiform purpura have the highest associated severity of COVID-19.
Referrals Due to the complexity of cutaneous manifestations in COVID-19, primary care doctors should not hesitate to refer patients to dermatologists for evaluation of possible COVID-associated eruptions. Telemedicine visits can be helpful for patients who have other systemic symptoms of illness and pose an infectious risk to others. This technology can also be utilized for patients in rural areas who may lack access to a boardcertified dermatologist. Phillip Keith, MD, is a board-certified dermatologist, a fellow of the American Academy of Dermatology, and a member of the Minnesota Dermatological Society. He is a physician at Dermatology Consultants and practices in St. Paul and Vadnais Heights.
Moving online creating a healthier Minnesota Juniper offers evidence-based programs that help prevent escalation of disease, reduce hospital admissions, lower health care costs and improve independence. Our nationally recognized locally delivered programs concentrate on fall prevention, managing and preventing diabetes, managing other chronic conditions and pain.
In March all of our community-based courses were canceled due to COVID-19. With a network of 160 statewide partner programs, and over 850 certified program leaders we can help your patients overcome the challenges of self-isolation and take charge of their health. We are pleased to offer these programs in an online setting that can now be accessed in the safety of your patients homes. The live, online courses are facilitated by trained and certified leaders in HIPAA-secure, easy to use video conferencing settings.
Refer your patients to Juniper directly or start a program through your clinic or in your community.
For more information please visit: www.yourjuniper.org or call 1-888-215-2174
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Innovations for Aging, LLC, a nonprofit subsidiary of Metropolitan Area Agency on Aging, is the managing partner for Juniper,
JULY 2020 MINNESOTA PHYSICIAN providing management information systems, coordination, member services and support to our partner organizations.
Orthopaedic Specialists New Location: Woodbury, MN 215 Radio Drive Suite 100 Woodbury, MN 55125
shrinerstwincities.org ï&#x201A;&#x; 612-596-6105 MINNESOTA PHYSICIAN JULY 2020
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3The P Factor from page 19 and new techniques that the next generation of diagnosis and intervention interesting data sets have been generated and findings produced, yielding will be sought. The models become more human-like each day and provide insight into symptoms, diagnosis, and intervention. Yet we still lack a us with easier ways to test theories and play out possible scenarios. We can complete path from presentation to mechanism produce probabilities of outcomes that increasingly to intervention to health. RDoC is a complicated predict future states accurately. We once again feel framework that has produced a tremendous as if we have discovered a missing piece, if not the amount of data. We continue to struggle with missing piece. the sheer complexity of the data, our complex Half of individuals who Summing up nervous system, its actions, and interactions meet diagnostic criteria It is an exciting time for neuroscience research between multiple nervous systems, which we for one disorder also meet and mental health treatment in general, given the call human behavior. Not only is this complexity criteria for a second disorder. new understanding being gathered each day. It difficult to navigate scientifically, but it also often is important for us to remember the history of produces far too much data to be practical for a where we have been and how the mystery of the clinical environment. brain has driven us. Given the new computing Neuroinformatics power we can access, we are not only provided Navigating data and translation into understanding and practical clinical with new understanding but also profound responsibility, as groups such tooling for diagnosis and treatment is the next frontier. This is a new field the AI for Good Foundation remind us. Ultimately it is our drive to called neuroinformatics. The raw computing power that has become recently understand ourselves and our relationship with the world that will provide available provides us with the capability to analyze and understand data us with answers and the ability to provide hope and relief from suffering. at a level not previously available. Computational neuroscience, large data sets, and machine learning give us insights into how thought is produced Brent Nelson, MD, an adult interventional psychiatrist, is Chief Medical and factors that relate, and even cause, large-scale changes in thought and Information Officer at PrairieCare Medical Group and a consultant at the
behavior. There are now new ways to model and measure the information flow through complex nervous system components. It is through these models
Center for Neurotherapeutics.
Carris Health
is the perfect match
Carris Health is a multi-specialty health network located in west central and southwest Minnesota and is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. CURRENT OPPORTUNITIES AVAILABLE FOR BE/BC PHYSICIANS IN THE FOLLOWING SPECIALTIES: • • • • • •
Anesthesiology Dermatology ENT Family Medicine Gastroenterology General Surgery
• • • • • •
Hospitalist Internal Medicine Nephrology Neurology OB/GYN Oncology
Loan repayment assistance available.
FOR MORE INFORMATION: Dr. Leah Schammel, Carris Health Physician
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Shana Zahrbock, Physician Recruitment Shana.Zahrbock@carrishealth.com (320) 231-6353 | carrishealth.com
• • • •
Orthopedic Surgery Psychiatry Psychology Pulmonary/ Critical Care • Rheumatology • Urology
Family Medicine & Emergency Medicine Physicians
Great Opportunities
• • • • •
with a Mankato Clinic Career
Immediate Openings Casual weekend or evening shift coverage Set your own hours Competitive rates Paid Malpractice
Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:
Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com
763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com
Apply online at www.mankatoclinic.com
SHARE YOUR INSPIRATION.
On the U.S. Army health care team, you will enjoy the satisfaction of providing quality care to Soldiers and their families, in a setting with innovative technologies, robust resources and a dedicated, supportive team.
Helping physicians communicate with physicians for over 30 years. MINNESOTA
AUGUST 2018
PHYSICIAN
THE INDEPENDENT MEDICAL BUSINESS JOURNAL
Volume XXXII, No. 05
CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD
U
niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.
Physician/employer direct contracting
CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144
Advertising in Minnesota Physician is, by far, the most cost-effective method of getting your message in front of the over 17,000 doctors licensed to practice in Minnesota. Among the many ways we can help your practice: •
Exploring new potential BY MICK HANNAFIN
Learn more at healthcare.goarmy.com/nz72
W
ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.
•
Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk, Physician/employer direct contracting to page 124
•
Share new diagnostic and therapeutic advances Develop and enhance referral networks Recruit a new physician associate
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3Women’s heart health disparities from page 17 symptoms, will reduce the patient’s likelihood of dying, having a heart attack, stroke/TIA, or being hospitalized. Perhaps most importantly, we are examining why women are not participating in research more equally. To fully understand why we don’t have equal representation, even in 2020, takes a qualitative and quantitative approach to better understand where bias might occur. We also need to ensure that we are offering an approach that includes all voices and reaches women where it’s easiest for them to participate in research with the trust, time, and outcomes they deserve.
Overall mental health also contributes to women’s heart health.
We have recognized the importance of strong partnerships between obstetricians and cardiologists in the development of our Cardiopregnancy Program to ensure the best outcomes for moms and babies. However, we recognize that, in addition to recognizing high cardiovascular risk during pregnancy, we also need to further establish protocols that address ongoing strategies for lifelong risk mitigation prior to conception and for the many years afterwards. Part of this strategy will require additional prevention strategies and protocols that close these gaps in the years when many women get care only from their ob-gyn. There is an opportunity to partner in more aggressive ways with our primary care doctors and ob-gyns to ensure we have
“The Hub helped me get back on Social Security so that I could pay my bills while I continue to work on my health.”
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optimal prevention strategies, as well as cardiovascular disease recognition, similar to what men receive. Additionally, with the recognition that 80% of health occurs outside of our clinical walls, we are uniquely positioned to better partner with community organizations where our female patients live, work, and play to best prevent these outcomes and ensure we have truly met their needs.
A personal perspective This is an exciting time to do more than analyze the data and to truly create action plans that close these gaps. To be successful, it’s going to take all of us working in partnership in innovative, disruptive ways to create a movement that closes these gaps forever.
Courtney Jordan Baechler, MD, is a board-certified internist and cardiologist, focusing on the prevention of heart disease and behavioral change that supports overall well-being. Dr. Jordan Baechler serves as medical director of the emerging science centers at the Minneapolis Heart Institute Foundation, focusing on the women’s science center and the prevention center. Her previous roles include an appointment as assistant commissioner for the Minnesota Department of Health.
Resources, tools, solutions. With Disability Hub MN, you can put an essential resource directly in your patients’ hands. From explaining health coverage options to submitting medical benefit applications, Hub experts are uniquely positioned to support people with disabilities.
A Place To Be Your Best.
YOU’D MAKE A REALLY GOOD DOCTOR IF YOU WEREN’T BEING AN OFFICE MANAGER.
Dr. Julie Benson, MN Academy Family Physician of the Year
POSITIONS AVAILABLE:
OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic) • Independent/growing system • Located in the heart of lakes country, Staples, MN • Critical access hospital with 5 primary clinics and a senior living facility • 15 family medicine physicians and 16 advanced practice clinicians • Competitive salary, benefits, and sign-on bonus available For more information, contact TSgt James Simpkins 402-292-1815 x102 james.simpkins.1@us.af.mil or visit airforce.com
Contact Michael Paul at 218.894.8633, or michaelpaul@lakewoodhealthsystem.com
©2013 Paid for by the U.S. Air Force. All rights reserved.
Practice Opportunities throughout Greater Minnesota: Our nation faces an unprecedented number of individuals who having served their country now receive health care benefits through the VA system. We offer an opportunity for you to serve those who have served their country providing community based health care in modern facilities with access to world-leading research and research opportunities. We provide outstanding benefits with less stress and burnout than many large system policies create. We allow you to do what you do, best – care for patients.
Minneapolis VA Health Care System Metro based opportunities include: • Chief of General Internal Medicine • Chief of Cardiology • Cardiologist • Internal Medicine/Family Practice • Gastroenterologist • Psychiatrist
Ely VA Clinic
Hibbing VA Clinic
• Tele-ICU (Las Vegas, NV)
Current opportunities include:
Current opportunities include:
• Nephrologist
Internal Medicine/Family Practice
Internal Medicine/Family Practice
US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.
Possible Education Loan Repayment • Competitive Salary • Excellent Benefits • Professional Liability Insurance with Tail Coverage
For more information on current opportunities, contact: Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964 One Veterans Drive, Minneapolis, MN 55417
•
www.minneapolis.va.gov MINNESOTA PHYSICIAN JULY 2020
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3Institutional racism in medicine from page 13
The following health care professionals contributed to this article:
Requiring institutional leaders and others within the academic setting to take an in-depth look and dive into why and how to implement systemic change.
Charles E. Crutchfield III, MD, Clinical Professor of Dermatology, University
Many additional changes are needed. This article has focused on issues faced by Black physicians, but structural racism extends from here into population health through a number of avenues that include government policy, community access, and reimbursement. These issues are as complex and deeply embedded as the ones we have discussed and we will explore them further in a follow-up article next month.
Association of African-American Physicians, and Medical Director at
In closing The term “institutional racism” was first coined in 1967 by Stokely Carmichael and Charles V. Hamilton in “Black Power: The Politics of Liberation.” They wrote that while individual racism is often identifiable because of its overt nature, institutional racism is less perceptible because of its “less overt, far more subtle” nature. Institutional racism is a form of racism embedded as normal practice within society. It leads to discrimination in criminal justice, employment, political power, and education. It is present in health care where we are all taught Primum non nocere (“First do no harm). Addressing the issues discussed in this article will help foster a new generation of Black physicians and health care industry leaders. We are committed to that new generation and the people they serve of all races having a better, more equitable future than experienced today or by any generation before.
of Minnesota Medical School, Immediate Past President of the Minnesota Crutchfield Dermatology.
Tamiko Foster, MD, MPH, Corporate Medical Director at Centene Corporation. David Hamlar MD, DDS, Assistant Professor in the Department of Otolaryngology, Head and Neck Surgery, at the University of Minnesota.
Dionne Hart, MD, President of the Minnesota Association of AfricanAmerican Physicians.
Zeke J. McKinney, MD, MHI, MPH, FACOEM, Faculty Physician, HealthPartners Occupational, and Environmental Medicine Residency.
Inell Rosario, MD, Otolaryngologist with Andros ENT & Sleep Center. Mary Tate, Director of Minority Affairs and Diversity at the University of Minnesota Medical School.
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URGENT RESOURCES FOR URGENT TIMES. In a pandemic, speed and access to information and resources are vital. Knowledge saves time, and you need all the time you can get to save lives. Introducing the COVID-19 Resource Center. Right here, right now, for you. On our website, you’ll find the latest information and resources for important topics like: • Telemedicine: including best practices and plain language consent forms • Links to infectious disease prevention guidance • Education and resources for healthcare providers on the front lines
You can access Coverys’ industry-leading Risk Management & Patient Safety services, videos, and staff training at coverys.com. All in one place, for our policyholders as well as for all healthcare providers. Thank you. For all that you are doing. You are our heroes, and we are here if you need us.
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Holly Boyer, MD
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