ALSO INSIDE: Writing Contest Winners

Reasons Why 7 Doctors Write Why We Need the Arts in Medicine

MINNESOTA MEDICAL ASSOCIATION JULY 2011 MINNESOTA MEDICAL ASSOCIATION

17 22 JULY 2011 TABLE OF CONTENTS

COVER STORY Medical Imaging 14 Winners of our photo 47 contest p.30 PULSE

14 A Life in Pictures | By Suzy Frisch Taking photos is the best medicine for pediatric surgeon Roberta 37 Sonnino.

FEATURE 16 The Body Electric | By Kim Kiser Medical students create an online showcase for their creative works.

Medical Musings 17 Visual Cues | By Carmen Peota A Minneapolis Institute of Arts program aids people with memory Results of our eighth annual writing contest loss.

Student Winners 18 A New Leaf | By Lisa Harden Rehab patients express themselves through clay. 38 Unspoken Words | By Erica Warnock

40 The River | By Aaron Crosby 20 Study Break | By Kim Kiser Medical students use Art of Medicine awards to explore Physician Winner their creative side.

43 Hospice | By William Shores, M.D. 22 Uniform Design | By Carmen Peota Scrubs become high fashion. Physician Honorable Mention

44 Bethany, House of God PERSPECTIVE | By Jamie Santilli, M.D. 45 I Believe, You Believe 47 Seven Reasons Why Doctors Write | By Tony Miksanek, M.D. | By Marilyn Aschoff Mellor, M.D. Physicians write for the same reasons that nonphysicians do, 46 Infertility 628.2 | By Carrie Link, M.D. plus some special ones.

8 | Minnesota Medicine • July 2011 MMA NEWS

minnesota MEDICINE 25 State Launches Time Out Campaign 2011 MMA Officers Owner and Publisher President Minnesota Medical Association Patricia J. Lindholm, M.D. Editor in Chief 26 Meet a Member: Therese Zink, M.D., M.P.H. President-Elect Charles R. Meyer, M.D. Lyle J. Swenson, M.D. Editors Chair, Board of Trustees Carmen Peota 27 Legislative Limbo David C. Thorson, M.D. Kim Kiser Secretary/Treasurer MMA Communications David E. Westgard, M.D. Director 28 MMA in Action: Recent Ways MMA Members and Speaker of the House Terry Ruane Mark Liebow, M.D. MMA News writer Staff Have Worked for Physicians Vice Speaker of the House Scott Smith Robert Moravec, M.D. Graphic Designers Past President Janna Netland Lover 29 New BCBS Contract Review Now Online Benjamin H. Whitten, M.D. Michael Start MMA Chief Executive Publications Assistant Officer Kristin Drews Robert K. Meiches, M.D. Advisory Committee Zubin Agarwal MMA Board of Trustees Maria Carrow Northwest District Donald L. Deye, M.D. Robert A. Koshnick Jr., M.D. Mark Eggen, M.D. Northeast District Barbara Elliott, Ph.D. COMMENTARY Jon S. Hallberg, M.D. Michael P. Heck, M.D. Neal Holtan, M.D. Paul B. Sanford, M.D. Peter J. Kernahan, M.D. 49 Why We Need the Arts in Medicine North Central District Robert K. Meiches, M.D. Wade T. Swenson, M.D., M.P.H. | By Gary Christenson, M.D. Gregory Plotnikoff, M.D. Patrick J. Zook, M.D. Martin Stillman, M.D., J.D. Studies show that incorporating the arts can save money, improve the Twin Cities District Barbara P. Yawn, M.D. Michael B. Ainslie, M.D. Anjali Wilcox patient experience—and do a lot more. Beth A. Baker, M.D., M.P.H. Therese Zink, M.D., M.P.H. Carl E. Burkland, M.D. Benjamin W. Chaska, M.D. Copyright & Post Office CLINICAL & HEALTH AFFAIRS V. Stuart Cox III, M.D. Entry Donald M. Jacobs, M.D. Minnesota Medicine (ISSN Roger G. Kathol, M.D. 0026-556X) is published each 52 Tularemia in Two South Dakota Children Charles G. Terzian, M.D. month by the Minnesota Medical David C. Thorson, M.D. Association, 1300 Godward Street | By Nadia A. Sam-Agudu, M.D., DTM&H Southwest District NE, Suite 2500, Minneapolis, Cindy Firkins Smith, M.D. MN 55413. Copyright 2011. Keith L. Stelter, M.D. Permission to reproduce editorial Southeast District material in this magazine must David C. Agerter, M.D. be obtained from Minnesota ALSO INSIDE Daniel E. Maddox, M.D. Medicine. Periodicals postage Gabriel F. Sciallis, M.D. paid at Minneapolis, Minnesota, and at additional mailing offices. 10 ...... Editor’s Note Douglas L. Wood, M.D. At-Large POSTMASTER, send address Fatima R. Jiwa, M.B. ChB. changes to Minnesota Medicine, Resident 1300 Godward Street, Ste 2500, 12 ...... Letters Minneapolis, MN 55413. Maya Babu, M.D. Student Subscriptions 24 ...... Viewpoint Carolyn T. Bramante Annual subscription - $45 (U.S.), $80 (all international) 51 ...... Index of Advertisers AMA Delegates Missing Issues and Back Raymond G. Christensen, M.D. Issues Kenneth W. Crabb, M.D. 55 ...... Employment Opportunities Missing issues will be replaced for Stephen F. Darrow, M.D. paid subscribers at no additional Anthony C. Jaspers, M.D. charge if notification is received Sally J. Trippel, M.D., M.P.H. 60 ...... End Notes within six months of the publica- John M. Van Etta, M.D. tion date. Replacement of any issues more than six months old AMA Alternate Delegates will be charged the appropriate John P. Abenstein, M.D., M.S.E.E. single back issue price. Single back Blanton Bessinger, M.D., M.B.A. issues of Minnesota Medicine can Minnesota Medicine is intended to serve as a To Submit an Article Maya Babu, M.D. be purchased for $25 (U.S.) and Contact Carmen Peota at David L. Estrin, M.D. $30 (Canada, Mexico, and other credible forum for presenting information [email protected]. Paul C. Matson, M.D. international). Send a copy of your and ideas affecting Minnesota physicians and Benjamin H. Whitten, M.D. mailing label and orders to Kristin The editors reserve the Drews, 1300 Godward Street, Ste their practices. The content of articles and right to reject editorial, 2500, Minneapolis, MN 55413 or MMA Alliance fax it to 612/378-3875. scientific, or advertising Co-presidents the opinions expressed in Minnesota Medicine material submitted for Candy Adams publication in Minnesota Dianne Fenyk do not represent the official policy of the Medicine. The views expressed in this journal do Minnesota Medical Association unless this is not necessarily represent Contact Us specified. The publication of an advertisement those of the Minnesota Minnesota Medicine, 1300 To Advertise Medical Association, its Godward Street, Ste 2500, Contact Jocelyn Cox at does not imply MMA endorsement or editors, or any of its con- Minneapolis, MN 55413. Phone: 612/623-2880 or jcox@ stituents. 612/378-1875 or 800/DIAL MMA mnmed.org. sponsorship. Email: [email protected] Web: minnesotamedicine.com

July 2011 • Minnesota Medicine | 9 editor’s note| 10 Medicine•July |Minnesota 2011 kindling enough and storiesare predicaments Our patients’ artistic fire. for endless

Photo by Scott Walker alone withtheir thoughts,theywaitforthe tains. Apart from humaninteractionand the isolationofNew Mexico moun- instructor, writer BobShacochis, fleeto vista. Some, likemyformerBennington surrounded by hisbooksandaCapeCod day totheirnook,likeJohn Updike did, for thebreakthrough. Some retire each Many waitdays,weeks, or years artists ing ordisgorgeinthree-hour torrents. streams thatcome unbiddeneachmorn- kee to Wright’s studiosat Taliesin. house’s purchaser totravel from Milwau- ing Water, inthethree hoursittookthe sketches forhismostfamoushouse,Fall- floodofgenius, Wrightlegendary drew the page through theleadofhispencil.In one table, pouringthefire ofhisideasontothe Wright went straightfrom bedtodrafting his 92years. For mostmorningsofhislife, spark, whichstayed aglow tothelastof constant inFLW’s lifewashiscreative Through acclaimandacrimony, theone preceding triumph.doldrums artistic fairs, failedmarriages,andprofessional life wasaroller coasteroftorridlove af- tion andturnedarchitectural heads. Guggenheim Museum explodedconven- as Tokyo’s Imperial Hotel andManhattan’s Radical yet lyrical, Wright’s creations such Burns’ ofthearchitect’s documentary life. immersion intoFLW by watchingKen Wright’s followers. We completedour sin resort withcabinsdesignedby oneof wife andIhappenedtostayata Wiscon- on thewives ofFrank Lloyd Wright, my I T.C. Boyle’s novel brain. While Iwashalfwaythrough ’ve gotFrank Lloyd Wright onthe For most,creative ideasaren’t endless Tumultuous anderratic, Wright’s Seeking theSpark The Women , based of amatchless,soaringcreative vision. branches toward thesky, rising asasymbol for years, afully-grown elmstretched its as of thehousethatserved Wright’s studio camouflaged front doors.In themiddle hidden recesses, outsized fireplaces, and tion. Wright housesare fullof surprises, seem modern60years aftertheirconstruc- tries andhorizontal linesthatmadethem homes, dramatichouseswitharched en- walked toschoolpastFrank Lloyd Wright paying attentionandfindingtheirmuse. nesota physiciansandmedicalstudentsare nesota Medicine fire.endless artistic Andthismonth’s ments andstoriesare kindlingenoughfor if we payattention,ourpatients’ predica- shot unlesswatchedorlistenedfor. But muses canbehiddenoutofsightorear- hush oftheexamroom. In thesevenues, through thecrisisatbedside,orin job, inthebustleofoperatingroom, They mustfindtheirinspirationonthe or sitforhoursinfront ofgreat paintings. oftimetofleethemountains luxury or photographfrequently don’t have the process. artistic muses are ethereal-but-real forces inthe Small flamesinthetinderbox ofcreativity, hours intheLouvre whiletheycompose. Bach whiletheywrite.Still otherssitfor sunset whiletheypaint.Others listento the creativity stirring.Some watchthe a gentleshove torouse thejuicesandget internal musetospeak. Charles R.Meyer, M.D., editorinchief, can be reached [email protected] Growing upinRiver Forest, Illinois, I Physicians whowrite,paint,perform, For themuseneedshelp, someartists, isproof againthatMin- Min- letters |

ited by the National Transportation Safety Board, which is the nation’s watchdog così fan tutte agency over all mass transit. Sept. 24 – Oct. 2, 2011 The article lists a number of sources including the FAA website on traveling silent night safely with kids, which makes the point WORLD PREMIERE Nov. 12 – 20, 2011 that all children are safer in the event of unexpected turbulence and rough landings if they are in their own seats in approved werther Jan. 28 – Feb. 5, 2012 Ten who answered the call for help. child restraints.

ALSO INSIDE: The biggest problem is a practi- Things to Know about 7 Flying with Kids cal one: until recently, the only child re- lucia di Radiation and Air Travel straints approved for kids were regular car lammermoor Medical Conditions in Pilots seats, which are huge, clumsy, and not ap- Mar. 3 – 11, 2012 propriate for long security lines, crowded spaces, narrow aisles, etc. But there is an MINNESOTA MEDICAL ASSOCIATION JUNE 2011 “airplane-only” child restraint, the CARES madame child aviation restraint, which has been butterfly If Only They Had Known Her FAA-certified for all phases of flight. It is Apr. 14 – 22, 2012 I am writing this with tears in my eyes. for kids 22 to 44 pounds from 1 to 5 years One of the stories in your article “Is There of age, weighs one pound, and can be car- a Doctor on Board?” (June, p. 25) deals ried in a pocket. (To learn more, check out with our business manager. She died en www.kidsflysafe.com.) route to Florida in January with her sister The FAA and the airlines should be and daughters present. ashamed of themselves for not providing She was and will always be one of an equivalent level of safety to the young- the people I have most admired. She was est travelers who, unlike their elders, can- a multi-cancer survivor who never had a not brace in the event of severe turbulance. bad day. She truly was an inspiration to many of us and the heart and soul of our Louise Stoll, Ph.D. Managing Director practice. We are still trying to recover from Kids Fly Safe, LLC this loss. It was interesting for us to hear Burlington, Vermont the physicians’ perspective, but I only wish they had known what a truly special per- son she was. WHAT’S ON Stephen T. Hustead, D.O., FACC Photo by Steve McHugh. Photo by Steve Metropolitan Cardiology Consultants Minneapolis YOUR MIND?

Kids Need Restraints Health care reform? An article you’ve I read your advice to parents about fly- read in a recent issue? A problem in your ing with young children (“Children and practice? Airplanes: Are We Having Fun Yet?” June, Send your thoughts to Letters at p. 33) and am appalled that the author Minnesota Medicine, mnopera.org was ambivalent about whether all children 1300 Godward Street NE, Suite 2500, should be in their own airplane seats ap- Minneapolis, MN 55413 612-333-6669 propriately restrained and that he bought or [email protected]. The 2011 – 2012 season into the FAA’s spurious claim that if parents is sponsored by: had to purchase a ticket for their young- est kids, more would drive not fly—and there would be more children injured as WE WANT TO HEAR SEE 3 OPERAS a result. FOR AS LITTLE AS $50 Both of these ideas have been discred- FROM YOU!

12 | Minnesota Medicine • July 2011 pulse |

„ Photography A Life in Pictures Taking photos is the best medicine for pediatric surgeon Roberta Sonnino. | BY SUZY FRISCH

f the thousands of phy is my mental sanity. If I’m pictures Roberta stressed, tired, frustrated, or OSonnino, M.D., has have something on my mind, taken over the years, one in the first thing I do is grab my particular illustrates for her the camera. The world we live in is powerful connection between very regulated. Surgery is very her photography and her ca- regulated—you have to do reer in pediatric surgery: It’s things a certain way. This al- of a premature baby, swaddled lows my creative side to come in blue surgical towels, rest- out.” ing her tiny hand in the large And while giving Sonnino hand of the chief surgical resi- an outlet, photography also dent. To Sonnino, the image has served her professionally. of their hands together exudes It’s provided her with another compassion, healing, and the way to forge bonds with her fragility of life. “That picture patients and their families. became the emblem for me,” says Sonnino, who captured Sharp Shooter the moment in 1990 when she Born into a family of photog- was an assistant professor of raphers, Sonnino began snap- surgery and pediatrics at Rain- ping photos around the age of bow Babies and Children’s 3 with her father’s camera. She Hospital in Cleveland. spent most of her childhood in Now a professor of pediat- her parents’ native Italy, and ric surgery and associate dean often Venice and the Dolomite coat, Sonnino started shooting opened the door for conversa- for faculty affairs at the Uni- Alps served as stunning back- pictures of her patients and tions you might not have had versity of Minnesota Medical drops in her pictures. Her skill other babies in the neonatal with families and their kids.” School, Sonnino also is a pro- became apparent early, and intensive care unit (ICU). She noticed a greater sense of fessional photographer whose by the time she was in high At first, the photos were trust and sensed families were work has been exhibited across school, her classmates were just for her personal use and more comfortable asking ques- the country and published in paying for her pictures. for teaching purposes. But tions about their child’s care books, magazines, journals, She didn’t combine pho- over time, she started printing without worrying that they and online. “Being a photog- tography with medicine until copies for the parents of her were wasting her time. rapher is a big part of who I medical school, when the chair patients. And that’s when her She began to see her patients am, and it was a big part of my of her department at the Uni- practice—and her relationship differently, too. They were no practice,” she says. versity of Padova asked Son- with her patients—changed. longer “the appendectomy in Sonnino began shooting nino to take clinical photos “I think it allowed me to Room 2,” she says. “They were photos to relieve stress during during his operations. connect with my patients and the cute kid who had an ap- the early days of her medical Eventually, photography de- their families on a completely pendectomy in Room 2.” career. She says it still helps veloped into an important part different level,” she says. “I Eventually, Sonnino started her unwind, although she re- of Sonnino’s practice. About wasn’t just a doctor or surgeon photographing infants in the tired from clinical practice nine years ago, when digital telling them what’s right or neonatal ICU weekly. She in 2004. “The best way I can photography made it easy to wrong with their kid. There would create albums that summarize it is that photogra- slip a small camera into her lab was a human connection that documented the first months

14 | Minnesota Medicine • July 2011 | pulse Photo by Steve Wewerka Steve Photo by Photos courtesy Roberto Sonino Photos courtesy Roberto

Roberta Sonnino, associate dean for faculty affairs at the University of Minnesota Top: Sonnino began taking photos in the neonatal ICU about a decade ago. This one Medical School, is an advocate for having an avocation. Hers is photography. Here appeared in the book Journey to Authenticity--Voices of Chief Residents. she is with a favorite photograph—of the hand of a premature infant resting inside Bottom: This image of a newborn sleeping with her head cradled in her mother’s the hand of a resident. palm, which Sonnino calls “Sleeping Beauty,” appeared on the cover of Academic Medicine in January. of these fragile babies’ lives out pictures to my patients, I born, terminally ill, or die in families in a different way.” and give them to the families thought the reaction was over early infancy. Since she began Although mostly self-taught, right before the infants were the top. But my staff told me working with the organization Sonnino has completed a cor- discharged. most of my patients didn’t in 2006, she has taken pic- respondence course through Taking pictures was often have an 8-by-10 of their child, tures for about 50 families. “It the New York Institute of the farthest thing from the and I had given them some- makes a humongous difference Photography and participated minds of the parents, who thing they thought they would in families’ grieving process in several photography work- were so intently focused on never have.” and their ability to heal. The shops over the years. Earlier caring for their children. families were never going to this year, she passed the Profes- Some didn’t own a camera or Photos for Grieving take their babies home. Now sional Photographers of Amer- couldn’t afford to pay a pho- Parents they have these pictures they ica exam and is on her way tographer. “People don’t think Sonnino also volunteers for can cherish,” Sonnino says. to becoming a Certified Pro- to bring cameras in, or in life Now I Lay Me Down to Sleep, “You also get a huge sense of fessional Photographer. She and death situations they feel a nonprofit that provides free satisfaction. I no longer take often pores over photography it’s inappropriate,” Sonnino professional photographs to care of the kids, so it allows me books and magazines, gaining says. “When I started handing families whose babies are still- to do something to help these inspiration from Ansel Adams,

July 2011 • Minnesota Medicine | 15 pulse |

Galen Rowell, Anne Geddes, and Sandy Puc’, the co-founder of Now I Lay Me Down to Sleep. Sonnino’s favorite subjects are children, but she also enjoys shooting flowers, bugs, and coral reefs as well as sunsets, under- water sea life, aerial pictures of land, and reflections on water. Her photograph of the silhouette of an airplane against a yellow field at sunset graces the cover of the book Ghost Plane by Ste- phen Grey. The television show “Extreme Makeover” turned her “Cloud Nine,” an aerial shot of clouds hovering over the land, into a tile floor for a client’s bedroom. Numerous galleries have held shows that included Sonnino’s work. Locally, her photos have been displayed at the University of Minnesota’s Amplatz Children’s Hospital and Hennepin County Medical Center. Her images have also appeared in shows spon- sored by Blue Cross and Blue Shield of Nebraska, the University of Kansas Medical Center’s Child Development Unit, and the March of Dimes. In addition, they are displayed on her website, www.hiresphotos.com. In 2007, Sonnino was commissioned to take pictures for Journey to Authenticity: Voices of Chief Residents, „ Student Blog a coffee table-type book published by the Accreditation Council for Graduate Medical Education. Sonnino traveled around the The Body Electric country taking portraits for that book, which won several awards. Medical students create an online showcase for their creative works. | BY KIM KISER Advocate for an Avocation Sonnino’s office at the U boasts just a few of her photos, includ- ing a poster-sized shot of an arena in Verona, Italy, at night and a very day, across the entire globe, millions of physicians begin close-up of two cats’ faces. She plans to ramp up her photography Emillions of stories with, Patient presents with—medicine’s business, marketing her services and seeking medical photogra- Once upon a time. Indeed, every hospital visit is itself a collision phy or portraiture jobs after she retires. of stories, those of patients, and families, and workers, and science. For now, though, Sonnino is trying to teach her peers about Those words come from the editor’s introductory note in the importance of having outside interests. (In addition to pho- “The Body Electric,” an online forum for University of Min- tography, she also enjoys alpine skiing, biking, hiking, scuba div- nesota Medical School students (http://ilovethebodyelectric. ing, and listening to classical music—especially opera.) She often blogspot.com/). The blog was created this past January by speaks to faculty groups about maintaining balance in life. She Aaron Crosby and Neil Siekman, both of whom recently fin- also talks one-on-one with physicians who feel the need to get ished their first year. re-energized about their work—a sign of burnout, she says. “I At the time, Siekman was finishing up a screenplay he have seen people who don’t have anything they can retire to be- and a friend had been writing. He discovered Crosby was also cause they didn’t plan it,” she says. “I have photography on my interested in creative writing, and together, they decided to CV because I want to be a role model to faculty for having a plan create a place where they and other students could share their when I retire.” works. In her next chapter as a professional photographer, Sonnino Since Siekman and Crosby got word of the blog out by plans to continue documenting the lives of her former patients. email and on Facebook, a number of students have posted She says the relationships she’s formed with many of her charges their essays, poems, photos, and musical recordings. Some and their families following surgery continue today. When Son- are related to medicine. For example, one student shared a nino travels for meetings or conferences, she often reconnects poem she wrote that compared love with Staphylococcus aureus with them. “I like to take pictures of what they look like now,” infection. she says. “That’s fun, and the families won’t let you go.” Siekman says they hope to make the forum more interac- Recently, she met and photographed a former patient, tive and encourage members of the incoming class to contrib- whose first photos she took after he had half a lung removed as ute as well. a newborn; today, at 21 he is studying bassoon at The Julliard “Medicine is one of the most humanistic of all profes- School. “What surprises me is that he has the lung capacity to sions,” Crosby says. “You can’t just be studying science and play the bassoon professionally,” she says, noting that her photos applying it to other people. You have to explore your own deliver “a very positive message.” „ humanity.” „

16 | Minnesota Medicine • July 2011 | pulse

caption here Photo courtesy Minneapolis Institute of Arts of Photo courtesy Minneapolis Institute A docent at the Minneapolis Institute of Arts discusses a painting with adults who have memory loss and the volunteers accompanying them.

Last year, when Starks stumbled on „ Art and Memory Loss a description of the Discover Your Story tours, a Minneapolis Institute of Arts Visual Cues (MIA) program in which specially trained A Minneapolis Institute of Arts program aids people with memory loss. docents lead discussions about selected pieces of art, she signed on as a volunteer. | BY CARMEN PEOTA The tours are designed to help people with memory loss reflect and reminisce as they edical student Jamie Starks also saw something else: how people with compare their own stories with those told has witnessed firsthand how dementia changed when they were ex- in the works of art. Starks, who recently Mquickly the scope of a per- posed to art and music and took trips into began her third year of medical school, es- son’s life can shrink because of cognitive the community. corts people on the tours.  decline. She saw her grand- mother, who was diagnosed with dementia with Lewy bod- ies several years ago, go from Medical students Kim Spronk and Jamie Starks want the wider medical community to know being active and independent that the Minneapolis Institute of Arts’ Discover Your Story program is a resource for anyone. to being withdrawn and de- “We’d like to get the word out to providers that if they have patients who have memory loss pressed as she found herself or dementia and need an outing or intellectual stimulation, we’d encourage them to tell able to do less and less. Starks their patients about this program,” Spronk says. had seen similar effects when she worked at an adult day- Tours take place on the second Friday and Saturday of each month and can be scheduled care center during her under- for any time the museum is open. All tours are free, but preregistration is required. To re- graduate years in Madison, serve a space, call 612/870-3140. For further information, go to www.artsmia.org/index. Wisconsin. But there, Starks php?section_id=26.

July 2011 • Minnesota Medicine | 17 pulse |

Starks says people who come in withdrawn and reserved opened up during the tours. “You get them in front of art, and you ask them ques- tions about the art and experiences from their life and if it reminds them of anything,” she says. “It’s really quite remarkable to see them awaken and see how happy and engaged they become.” Starks thinks that’s in part because of the way the leaders engage tour par- ticipants. “You can see them respond to being treated like there isn’t something wrong with them. They get to escape from being someone with a disease for at least an hour, be normal adults, be intellectually stimulated, and interact with their peers.” Starks was so impressed with the program that in the fall of 2010 she recruited classmate Kim Spronk to go on a tour. “I only had to go once to see that it was a great program and some- thing that I definitely wanted to be involved in,” Spronk says. Now both women are recruiting their peers at the medical school to volunteer with the program. Spronk points out that volunteer- „ The Healing Tree Project ing benefits the students in addition to the people they’re trying to help. A New Leaf “There’s really a lot to be learned about Patients express themselves through clay. | BY LISA HARDEN how to effectively engage with some- one who has dementia,” she says. It’s a skill Starks thinks will be increasingly important for doctors in the future, ardiac and respiratory problems with the Northern Clay Center. as the population ages. And that’s one may have stolen Mary Lanpher’s “I wanted to do something with art reason she and Spronk are trying to get Cability to walk on her own and that celebrates the human spirit,” says Bob more medical students involved. breathe without an oxygen tank, but they Payton, a therapeutic recreation specialist But both say the best part of vol- haven’t robbed her of her creativity. at Bethesda who is coordinating the part- unteering is watching the way people Lanpher is among 100 patients and nership. “This is a fun project that takes respond to their experience in the mu- their family members at Bethesda Hospi- patients’ minds off their pain and lifts seum. “Sometimes it happens the mo- tal in St. Paul working with an artist from their spirits.” ment they walk in the door,” Spronk the Northern Clay Center to create a life- Working in small groups, patients says, noting that they begin to look sized Healing Tree that will be displayed and family members are making clay up and around immediately because on a lobby wall after it is finished in the leaves that express their feelings about ill- the museum itself is beautiful. “We see fall. ness and the healing process. Sentiments them come alive.” „ The initiative is part of Bethesda’s that adorn individual leaves include “It’s a healing arts program, which uses both the journey,” “He’s not finished with me yet,” performing and visual arts to help patients “Thanks for taking care of my husband,” who are recovering from injury or living and Lanpher’s “Health, what a gift.” with neurological conditions. The Heal- Participants include inpatients from ing Tree is a first-of-its kind collaboration the hospital’s complex medical care, re-

18 | Minnesota Medicine • July 2011 | pulse

George Hoyt works on a tile that will become part of the Healing Tree. spiratory care, traumatic brain injury, and medical behavior units, as well members of the stroke, spinal cord, and memory care support groups and patients with Parkinson disease. Artist Lucy Yogerst is designing the Healing Tree’s trunk, which will represent the hospital’s values—life, compassion, respect, and community. “Creativity is ev- erywhere,” she says. “Watching this come together is really something.” One participant, George Hoyt, who struggles to speak, had a twinkle in his Lover eyes that spoke volumes as he painted a leaf alongside his wife and two grand- daughters. “It’s not about the end product but the process,” says Erin McGee, one of two Netland Janna Photos by From left: Kathy El-Kandelgy, Bethesda staff member Erin McGee, Kay Gross, and Betty Hoyt and her therapeutic recreation specialists helping granddaughter, Hannah Lehman, take part in a group session led by an artist from the Northern Clay Center. with the Healing Tree project. “The ex- citing part is watching people who think they have limitations discover that art is something they can do.” „

July 2011 • Minnesota Medicine | 19 pulse |

„ Fisch Awards Study Break Medical students use Art of Medicine awards to explore their creative side. | BY KIM KISER

ince 2007, more than 40 Univer- sity of Minnesota medical students Shave received Fisch Art of Medicine Student Awards. Named for Robert Fisch, M.D., an emeritus professor of pediatrics who is also an artist, the monetary awards encourage students to explore the arts and humanities—fields not typically empha- sized in medical school curricula. “It’s an opportunity to be more than a laborer of a certain profession,” Fisch explains. Students have used the awards to take classes or pursue an interest. Some have gone on to produce radio documentaries, record their music, or travel beyond Min- nesota’s borders to perform or study with a master of their art. This year, 10 students received

awards. They were honored at a ceremony Arts Studio Aerial Photo courtesy Xelias in April at the Mill City Clinic in Minne- Aerial artist and medical student Laura Waller performs on the Spanish web during Art-a-Whirl, an annual art crawl apolis. Here are the stories of three. in northeast Minneapolis.

Laura Waller sity of Puget Sound in Tacoma, Washing- Along with calluses, rope burns, and When Laura Waller needed a break from ton, Waller came home to St. Louis Park sore muscles, she has gained support from studying for her board exams this spring, and spent a year and a half working and a community of encouraging coaches and she would drive to a converted warehouse earning a core certificate in public health classmates. “Together, we celebrate ev- in northeast Minneapolis, climb a rope, before starting medical school. During eryone’s individual triumphs,” she says, hang upside down, and practice drops, that time, she signed up for a three-week explaining that the class was made up of twirls, and other acrobatics. introductory class at Xelias. “I had a job, I people ages 18 to 60, some of whom had An aerial artist, she has studied and had time, I had money to spend and a car never done anything athletic. performed at Xelias Aerial Arts Studio for to get me there,” she says. Since starting with Xelias, Waller has the past two and a half years. Waller, who But after the first class, she almost done six performances, the most recent is starting her third year of medical school, quit. “It was a 90-minute class, and I one being at Art-a-Whirl, an art crawl in competed in gymnastics in high school. “I couldn’t move afterward. I didn’t go the northeast Minneapolis. As far as apparati, loved it, but part of me wanted to do aerial second week but then reluctantly went she prefers working on tissu, which in- arts, and it never happened,” she says. back the third week. I thought, ‘Do I re- volves climbing a length of fabric, wrap- After finishing college at the Univer- ally want to do this?’” she says. ping herself in it, and doing dramatic

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dent, the St. Louis Park native had a chance to see Luciano Pavarotti and An- drea Bochelli perform. “Seeing them live made me want to sing,” he recalls. Laube hadn’t sung before. And when a friend gave him voice lessons for his birthday, he discovered it wasn’t like being part of a concert band. “It was so emotional,” he recalls. But he found he wasn’t comfort- able singing in front of anyone. Laube applied for a Fisch award to continue with voice lessons. After return- ing from South Africa, he began working with an instructor at the MacPhail Cen- ter for Music in Minneapolis, exploring different types of music and working on singing in front of an audience. “I had seen ‘The King’s Speech’ right before my recital, and I knew exactly what the guy Photo courtesy University of Minnesota The Fisch Art of Medicine awardees with champions of the arts Jon Hallberg, M.D., and Robert Fisch, M.D. was dealing with,” he says. “He had an im- Pictured from left to right are Jon Hallberg, Justin G.R. Laube, Laura Waller, Ari Nahum, Tou Lee Xiong, Amy Wen- pediment. I was censored.” tland, Robert Fisch, Elizabeth Jacobson, Kyle Sanders, Kirsten Kesseboehmer, and Russell Johnson. For Laube, who will be doing his residency in internal medicine at UCLA Justin Laube in Westwood, California, and hopes to “It’s an hour Wearing a dark suit coat and white shirt, continue with his music there, performing fourth-year medical student Justin Laube at the awards ceremony was the culmina- and a half, stepped in front of the audience at the tion of months of work, practice, and self- Fisch award ceremony, rose to every inch discovery. where there’s of his height, and in a rich tenor began “Singing relaxed me,” he told the au- to sing “La donna è mobile” from Verdi’s dience that night. “I learned to go from Rigoletto—a piece that he says shows his no dwelling range. Laube then transitioned to the South African National Anthem, which on medical weaves in lyrics in five languages—Zulu, The 2010-11 Fisch Xhosa, Afrikaans, Sotho, and English. Art of Medicine school.” The anthem has special meaning for Laube, who has family in the country. He Award Recipients —Laura Waller spent four months there last year, during Elizabeth Jacobson, ceramics which he worked in Zithulele Hospital on drops, and Spanish web, which involves the Wild Coast. There, he noticed how Russell Johnson, drumming climbing a cloth-covered rope slipping her much a part of life music was. “There was Kirsten Kesseboehmer, drawing ankle or wrist in a loop at the top, and per- singing everywhere,” he recalls. “When Justin G.R. Laube, voice forming acrobatic moves while spinning. people would be waiting to be seen in the Waller used her Fisch award to pay clinic, they would start singing to pass the Ari Nahum, piano for classes and a costume she wore in a re- time.” Kyle Sanders, dance cent show. Several of her medical student Laube, who started playing the trum- Laura Waller, aerial arts friends have watched her perform, and pet in the fifth grade and was a member of one even decided to try aerial arts herself. a concert band at the University of Wis- Amy Wentland, ceramics “With circus, it’s an hour and a half consin, Madison, had given up playing Tou Lee Xiong, painting where there’s no dwelling on medical music during medical school. “But every Erica Obara, piano school, which I think is really great,” she moment of studying, I was listening to says. “Circus really requires that you be music,” he says. there in the moment.” Then, as a second-year medical stu-

July 2011 • Minnesota Medicine | 21 pulse |

being a type A thinker to ing her third year of medical being more right-brained and school, used her Fisch award intuitive.” to take a 12-week life-drawing class at the Minneapolis Col- Kirsten Kesseboehmer lege of Art and Design. Kirsten Kesseboehmer has Taking the course meant straddled the arts and sci- leaving medical school behind ences throughout her life. for four hours every Thurs- During high school in White day night—something Kesse- Bear Lake, she thought about boehmer found energizing and going into medicine but also enlightening. “My instructor considered studying art. Dur- had done medical illustrating, ing her undergraduate years at and she was interested in the the University of Wisconsin, brain and using the left and Madison, she took premed right brain. We talked a lot courses but majored in Eng- about that. She would explain lish. “I wasn’t sure I would be to me how a lot of drawing was successful in premed classes, a left-brain activity, which was and I enjoyed English, so it interesting to me. I thought it was a great diversion,” she re- was more of the other. But I calls. realized you have to use your Other than doing a little whole brain for everything,” photography, art fell by the she says. “And it reminded me wayside until she took part to use as much of my brain as in an exchange program at possible—to be both concrete the University of Technology and creative—when solving Medical student Keri Bergerson on the runway in a dress by Kayla Styczinski. in Vienna, Austria, between problems in medicine.” undergraduate and medical Kesseboehmer came out of school. Originally intending the class with a portfolio of „ Fashion to finish a double major in Conte´ crayon drawings and biology there, Kesseboehmer prints, a number of which Uniform Design took some classes, then put ac- were displayed at the Mill Scrubs become high fashion. | BY CARMEN PEOTA ademics on hold. “I decided I City Clinic for the awards would try living in Vienna and ceremony. She has since not going to school,” she says. participated in several life- he everyday uniform of surgeons was the focus of a unique She got a job and spent her drawing coops in the Twin Tfashion show held at the University of Minnesota’s Rapson free time sitting in a plaza near Cities, where artists come to- Hall in April. The event, called “Scrubbed Into Fashion,” show- a church, painting. “I would gether to sketch. She hopes to cased the creative talents of six undergraduate clothing designers, sit next to an old accordion take a life-sculpting class and each of whom made one couture and one ready-to-wear garment player and would be painting also has been thinking about using scrubs, and the modeling ability of medical students, who and people would come by setting up a life-drawing class strutted down the runway in those creations. The event was a and talk to both of us,” she for medical students taking fundraiser for Smile Network International, a nonprofit that says. “It made me realize how anatomy. “It’s very important brings teams of volunteer doctors to impoverished countries to much I missed doing my art.” to have a humanitarian ap- repair the cleft lips and palates of children. When she started tak- proach in medicine and not Medical student Ralph Radke came up with the idea for doing ing anatomy class in medical just look at the patient as a the fashion show/fundraiser last summer after his plan for going school, she would trace the bunch of neurotransmitters,” on a medical mission fell through. Radke, who is just beginning muscles of the cadaver with a she says. “You need to look at his fourth year, had wanted to go with a plastic surgery team to scalpel and imagine recreating the person as a human being Guatemala. “I was thinking, how can I do something now rather the contours with a pencil on and how they fit into their en- than waiting until I’m a doctor?” he says. paper. vironment.” „ A fan of the television show “Project Runway,” Radke thought Kesseboehmer, who is start- it would be fun to mix fashion and medicine and see what hap-

22 | Minnesota Medicine • July 2011 | pulse

Left: Medical students Julie Nebo- rak (left) and Elizabeth Jacobson in dresses by Jennifer Krava, who told the judges she was inspired in part by the symbol of the caduceus. Upper right: Medical student models Nicole Boettcher (left) and Keri Berger- son (right) with designer Kayla Styczin- ski as she explains her design approach to the judges. Lower right: Medical student model Jo Barta wearing a dress by Jennifer Voth, who won the Scrubbed Into Fash- ion design competition.

wearing clothing that looked like anything but scrubs. One garment had hand- painted neon-colored designs inspired by African prints. An- other had exposed metallic zip- pers to reflect the look of surgi- cal tools. One of the designers had cut 11 pairs of scrubs into strips, washed them so they frayed, dyed them black, then sewed them into ragged vests and shawls. The clothing was judged by

Photos courtesy of Minneapolis2night three local fashion-industry experts. Winner Jennifer Voth pened. When he discovered told the crowd she took her in- that the local organization What could be done spiration from the anatomy of Smile Network International the human heart. She had dyed was doing just the kind of work with the plainest of tan scrubs red and purple and he wanted to support, the con- screen-printed shapes similar cept for the event emerged. He to the chambers of the heart pitched the idea to the medi- garments? on her form-fitting dresses. cal school’s student council, of Clever touches included using which he’s a member, as well A Night of Glam Edina fashion designer who drawstrings from the pants to as to an undergraduate fashion The night of the event, about appeared on season six of create straps for the dresses and and business group, and the 500 fashionistas, many of “Project Runway,” served as sewing matching gloves. Smile Network’s board of di- whom were medical school the emcee and showed off his “I thought everyone did rectors. All agreed to help out. alumni, students, and faculty, own collection of scrubs-in- an amazing job,” Radke says. They enlisted a slate of gathered in the atrium of Rap- spired clothing using profes- “They put a lot of time into it sponsors including the univer- son Hall, where a portable sional models. Then, the med- and had really well-thought- sity’s Medical Alumni Society runway complete with colored ical students hit the runway. out garments.” and put out a challenge to de- spotlights was set up and a DJ Like the professional mod- Three months after the event, sign students: What could be played electronic rock music. els, the students first struck Radke, who was all smiles him- done with the plainest of gar- Attendees munched on hors a pose with shoulders back, self that night, is still amazed ments? Radke sent an email d’oeuvres, collected “swag pelvis thrust forward, and a at the success of the fashion to his fellow medical students bags” and sunglasses provided sober expression on their faces, show—it raised $10,000 for asking for volunteer models. by sponsors, bid on silent auc- then took commanding strides the Smile Network. “I would Eventually, six designers set to tion items, and watched the down the catwalk—the stu- love to see it go on and on,” he work making clothing for the show. dents had been coached by a says. “For sure, we’re going to medical students. Christopher Straub, an volunteer on how to model— try to do another year.” „

July 2011 • Minnesota Medicine | 23 viewpoint |

An All or Nothing Career? fter reading a thought- busy clinic practice, an inpatient service, provoking and controversial op-ed and saw obstetrical patients who delivered Ain the New York Times, “Don’t at all hours (mostly at night, it seemed). Quit this Day Job,” by Dr. Karen S. Sibert, My children had the good sense to I decided to share it on Facebook. Wow, choose careers other than medicine. When did I ever generate discussion. The premise they were in grade school, they frankly

Photo by Steve Wewerka Steve Photo by of the article is that working “part time” stated that they did not want to work the Patricia J. Lindholm, M.D. (less than 60 hours per week) is a disservice long hours their mother was working. MMA President to society because tax dollars subsidize part That style of practice left me feeling of medical school and postgraduate educa- burned out. Fifteen years into my career, tion. “I think it’s fine if journalists or chefs I began wondering if I could go the dis- Fifteen years or lawyers choose to work part time or quit tance. I entered lotteries and sweepstakes, their jobs altogether,” Sibert writes. “But hoping to win enough to retire early. I fan- it’s different for doctors. Someone needs tasized about being a full-time gardener into my career, I to take care of the patients.” She argues (my favorite hobby). In my practice, we that with the projected physician short- had no experience with part-time practice began wondering age, only those who commit to full-time or job sharing. practice (more than 80 hours per week) It took a crisis in the form of suicidal if I could go the should be admitted to medical school. She ideation for me to come to my senses, get is especially harsh with women physicians, help, and restructure my life. I know now whom she says are “less productive” than that I made the right decision to cut back distance. their male counterparts. on some work hours and responsibilities. Perhaps this article hit home for me I’m a better doctor to my patients because because I was trained during the same of that; but still, I feel some shame about era as Dr. Sibert. I fully bought into the admitting that I could not live up to my “macho” model of medical practice. I image of the ideal, heroic doctor. missed weddings, recitals, and reunions Must medicine be an all-or-nothing because I did not feel free as a student or career as Dr. Sibert implies? Must we give resident to ask for any special favors. I be- our lives completely to our profession, or came the mother of three lovely children can we have a life and a practice? during my training years but tried hard to I suspect that the physician shortage not let being a parent affect my ability to will worsen if we tell prospective medical work because I did not want to appear to students that they must choose between be a slacker or to inconvenience my fel- medicine and self-care, family, or the low residents. When my children were still other soul-feeding activities that make life quite young, I started a practice and was joyful. on call nearly seven days a week. I had a

24 | Minnesota Medicine • July 2011 | mma news

Kali has two new lungs. State And parents who finally feel like Launches they’re not holding Time Out their breath. Campaign

he Minnesota Safe Surgery Coalition’s campaign to elimi- Tnate wrong-site, wrong-procedure, and wrong-patient events within three years is gaining momentum. More than 100 health care providers thus far have pledged to join the Minnesota Time Out Campaign, a statewide effort to eliminate mistakes by conducting a time out for every patient, during every pro- cedure, every time, and in every health care setting. The MMA

© Aleksandr Lobanov - Fotolia.com Aleksandr Lobanov © has promoted the campaign and is a member of the Safe Surgery Coalition. The Time Out campaign asks physicians, frontline staff, and administrators to hold each other accountable for conducting ef- fective time outs for patients undergoing invasive procedures. It is a response to the increasing number of wrong-site events that have occurred in Minnesota health care facilities. Between Octo- ber 2009 and October 2010, 31 wrong-site events were reported in the state. Many of those were attributed to the lack of an effec- tive time-out process; in a number of cases, there was no process in place. During a time out, all activity stops, and a designated staff person verifies the patient’s name, the procedure, and the loca- tion of the procedure while referring to source documents. A staff person other than the one performing the procedure then locates She was born at 22 weeks, and by age and verbally confirms that he or she can see the site mark and one needed a double lung transplant. states where it is located. The person performing the procedure +HUSDUHQWVZHUHWROGWRFKRRVHEHWZHHQVXUJHU\ then repeats that information. “We cannot be successful without the commitment of every DQGKRVSLFH7KH\FKRVHXV$QGEHFDXVHQRRQH physician and Minnesota health care organization that conducts HOVHRIIHUVRXUGHSWKRI SHGLDWULFVSHFLDOWLHV³ZLWK surgical and other invasive procedures. It is crucial that we work RXURQVLWHVWDIIRI LQIXVLRQQXUVHVDQGUHVSLUDWRU\ together to make sure the Minnesota Time Out steps are followed WKHUDSLVWVWRGLHWLWLDQVDQGSKDUPDFLVWVWRD everywhere and all the time. Without this level of consistency and PHGLFDOGLUHFWRUDQGSULYDWHGXW\QXUVHV³.DOL rigor across the state, we will not achieve our goal,” says Robert LVWKULYLQJ Meiches, M.D., MMA CEO. The Minnesota Time Out campaign was officially launched 0HHW.DOLDQGOHDUQPRUHDW June 15. MeetTheMiracle.com “We got a really great response from the provider commu- nity, and a number of specialty societies signed on,” says Rebecca Schierman, MMA manager of quality improvement. For more information about the Minnesota Time Out cam- paign, contact Schierman at [email protected]. click

July 2011 • Minnesota Medicine | 25 mma news |

„ Meet a Member Therese Zink, M.D., M.P.H. Through the MMA Foundation, writer and educator Therese Zink has published a collection of Minnesota medical students’ essays and poems. | BY LISA HARDEN

riting is more than a pastime for Becoming a Doctor: Reflections by Minne- Wfamily physician Therese Zink, sota Medical Students will be given to first- M.D., M.P.H., who recently edited two year medical students at the University of collections of enlightening stories and Minnesota and Mayo for the next four poems by physicians and medical students. years, as well as medical school faculty. Wewerka Steve Photo by Therese Zink on her farm near Zumbrota. Zink writes Zink, whose works have been pub- The book also will be sold at Uni- creatively in order to process her experiences as a lished in Family Medicine, Academic Medi- versity of Minnesota bookstores. Proceeds doctor, which she says helps her be a better family physician. She’s encouraging medical students at the cine, the Journal of American Medical As- will benefit the Fisch Art of Medicine Stu- University of Minnesota to do the same. sociation, Minnesota Medicine, and several dent Awards and the Vince and Mary Kay anthologies, says that writing helps phy- Hunt Global Health Fund. “When you practice medicine for a sicians work through what they witness. “The students’ stories remind us of while, you take that privilege for granted. “It’s important as doctors to process what the incredible privilege we have as doctors When you see the students’ writing and you see. It makes you a better physician.” to walk side by side with patients in the their sense of awe, it makes you realize Zink is helping the next generation best and worst of times,” Zink says. “The what a privilege it is.” „ become better physicians through writing. students are just learning to assume the As a faculty member in the Rural Physi- mantle of that privilege. cian Associate Program at the University of Minnesota, she reads posts on a discussion board by students on rural rotations. In 2007, she realized that those chron- Therese Zink at a Glance icles of rural practice begged for a larger Specialty: Family medicine audience. She solicited stories and poems from doctors and other health profession- Medical School: Ohio State University, 1985; M.P.H., University of Minne- als along with some medical students to sota, 1992 include in The Country Doctor Revisited: Residency: St. Paul Ramsey Medical Center (now Regions Hospital) Family A 21st Century Reader, published by Kent Medicine Residency, 1985-1988 State University Press in 2010. The realis- Practice: Family physician at Fairview Zumbrota Clinic; associate director of tic depiction of rural medicine—no Mar- research and evaluation for the Rural Physician Associate Program, director of cus Welby here—received rave reviews Global Family Medicine, and professor of family and community medicine at from the medical community and is being the University of Minnesota used by the Society of Teachers of Family Medicine to prompt discussions between MMA Involvement: Minnesota Medicine advisory committee member; editor rural physicians and medical students of Becoming a Doctor: Reflections by Minnesota Medical Students, which will about the realities of rural practice. be distributed to all first-year Minnesota medical students beginning in 2011 In her latest project, Zink has collab- and funded by the MMA Foundation orated with the MMA Foundation to pub- Hobbies: Writing, cross-country skiing, horseback riding, biking, running, lish a collection of 20 stories and poems gardening from medical students at the University of Minnesota and Mayo Medical School.

26 | Minnesota Medicine • July 2011 | mma news

Legislative Limbo Meet 0HHW.DOLDQGOHDUQPRUHDW

he 2011 legislative session ended without a budget deal and significantly fewer new Tlaws than usual. Here’s a look at some of the bills important to physicians that the MMA weighed in on this year.

Bills That Passed Bills That Didn’t Pass COMMUNITY PARAMEDICS • Legisla- NEWBORN SCREENING REGISTRY tion was signed into law that creates a REPEAL • S.F. 1017 would have modi- new level of provider called “community fied the state’s newborn screening law to paramedics.” They’ll practice under the prohibit the Department of Health from authority of an ambulance medical di- keeping any blood samples for more than The rector and work with a patient’s personal 24 months. This would have put the test- physician and health care home to help ing labs out of compliance with federal with care coordination. The law directs laws and would have ended the state’s the commissioner of human services to newborn screening registry. The bill convene a work group to determine the was originally included in the omnibus types of services community paramedics Health and Human Services budget bill will be allowed to bill for and to evaluate but was removed because of opposition. Miracle how they could coordinate services with The MMA opposed this proposal. health care homes. The MMA supported MINOR CONSENT REPEAL • Bills were this legislation. introduced in both legislative bodies that CONCUSSION AWARENESS IN YOUNG would have repealed a provision in Min- ATHLETES • A new law requires all coaches nesota law that allows minors to receive or officials to remove athletes who are sus- care for mental health, chemical depen- pected of having a concussion from com- dency, and reproductive health issues petition until the athlete has been assessed without a parent’s consent. This law has by a practitioner who is trained and expe- been on the books in Minnesota since rienced in evaluating and managing con- 1974. The Senate bill, S.F. 1017, received cussions. It also requires coaches and of- a hearing in the Judiciary Committee ficials from school and association athletic but did not go any further. The MMA programs to receive annual training on opposed the repeal effort. concussions based on information from FREEDOM TO BREATHE EXEMPTIONS the U.S. Centers for Disease Control and • H.F. 188 would have exempted bars .com Prevention. The MMA supported this from the state’s clean indoor-air require- legislation. ments and would have allowed smoking ANATOMICAL GIFT PROMOTION in bars that are separated from restaurants ACCOUNT • People renewing their driver’s by walls or doors. The bill never received license or car tabs will be able to donate $2 a hearing in either body. The MMA op- to an anatomical gift account, which will posed the exemptions. fund nonprofit organizations working to SEAT BELT PRIMARY OFFENSE • The increase the number of organ, tissue, and House approved a floor amendment to eye donors. The MMA supported this a judicial policy bill that would have re- legislation. pealed Minnesota’s primary offense law for failure to wear a safety belt. If passed, it would have prohibited law enforcement officials from stopping and ticketing a driver solely for failing to wear a seat belt. The Senate never adopted the amend- ment, so the repeal failed. The MMA op- posed this amendment.

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July 2011 • Minnesota Medicine | 27 mma news |

MMA in Action Some of the recent ways MMA staff and members have worked for physicians in Minnesota.

„ The MMA, „ Janet Silversmith, MMA director of vention. On June 2, members of the group in conjunction health policy, conducted an educational met with leaders of the Office of Native with the Min- session about state and federal health care American Health to discuss disparities in nesota Academy reform implementation at Fairview Ridges care and health outcomes. of Family Physi- Hospital on June 17. cians Foundation, „ MMA managers of physician outreach held interpreter „ Eric Dick, Mandy Rubenstein and Dennis Gerhard- services train- MMA manager stein represented the MMA at the Uni- ing for medical of legislative af- versity of Minnesota’s Graduate Medical Dionne Hart, M.D. students May 18 fairs, attended a Education orientation sessions June 17 at the University of Minnesota Medical June 16 meeting and July 1. School’s Duluth campus and for physi- of health care cians May 25 at Affiliated Community lobbyists from Medical Center (ACMC) headquarters in around the state Willmar. Dionne Hart, M.D., chair of the to discuss the MMA Minority and Cross Cultural Af- possible con- Eric Dick fairs Committee, co-presented the mate- sequences for rial at ACMC, which serves a large num- providers and patients of a state govern- ber of patients who speak limited English ment shutdown. Participants represented in communities throughout southwestern hospitals and medical clinics, dental clin- Minnesota. MMA member Ruth Westra, ics, services for the disabled and seniors, D.O., chair of the department of family mental health clinics, and medical trans- Dennis Gerhardstein Mandy Rubenstein medicine and community health at the port services. medical school in Duluth, led the session „ Ten MMA in Duluth. „ Karolyn members were Stirewalt, J.D., part of the Min- „ MMA Trustee Roger Kathol, M.D., MMA policy nesota delegation and MMA member Terrence Cahill, counsel, rep- to the AMA an- M.D., represented the MMA at a provider resented the nual meeting June forum on May 25 convened by the Min- MMA at a 18-22 in Chicago. nesota Department of Health to discuss meeting of the Also attending what information and data should be in- ARRA Porta- were MMA Board Maya Babu, M.D. cluded in an insurance exchange. bility Grant Chair Dave Thor-

Karolyn Stirewalt Task Force to son, M.D., and MMA President-Elect develop an Lyle Swensen, M.D. Seven other Minne- expedited regional process for phy- sota physicians attended the meeting as sicians who are seeking cross- well, representing their national specialty border licensing. The task force is com- societies. In addition, 10 Minnesota medi- posed of staff members from regional state cal students attended the AMA Medical medical boards and medical societies in Student Section meeting, and seven resi- Wisconsin, Illinois, Indiana, Iowa, Kansas, dents attended the AMA-Resident Fellow Missouri, Minnesota, Missouri, and South Section General Assembly. MMA member

Roger Kathol, M.D. Terrence Cahill, M.D. Dakota. Steven Darrow, M.D., was elected AMA- RFS Speaker of the House. MMA mem- „ Britta Orr, J.D., MMA health policy ber Maya Babu, M.D., was elected RFS analyst, is part of a Minnesota Cancer delegate. MMA member Jon Van Etta, Alliance work group that is developing a M.D., an internist at St. Luke’s Internal policy agenda with regard to cancer pre- Medicine Associates in Duluth, ran for

28 | Minnesota Medicine • July 2011 | mma news

but was not elected to the AMA Board of Trustees. BCBS Contract Revieww

„ Dave Renner, C ONTRACT REVIEW OF 2011 B Now Online CBS AW AR E PROV MMA director of IDER SE RVICE AG REEMENT n this docume mary of the nt, we provi changes de a sum- C made of prior years’ state and federal he MMA has released its summary of I ross and B to the lue Blue amendments (BCBS Shield of Mi on th ) 2011 A nne e MMA web are available A ware P sota site greeme rovider mnmed at: h insuran nt (Agre Service .org/Ke ttp://www. ce or sim that emen tabid/2205/Default.aspxyIssues/Le (II.P.) ilar t this su t). Pleas galA ypes of mmary i e note dvocac provisio a compr s not intend y/ ns. legislation, pro- changes in the Blue Cross and Blue Shieldld ehensiv ed to e lega be not a substitute l analy Either The sis, and party m defini advice. for legal it is Ag ay ele tion of “R T If and accounting reemen ct to ter Charg eg you are t w mina es” w ular ing the interested ithout ca te the as amen Billed specific in written notice use by no eve ded to application determin- to provid nt will Re say tha men mination will the other party ing be hi gular B t in t to you of this gher ille vided a legislative of Minnesota 2011 Aware Provider Servicece r pract Agree- become effective 130. The ter- than the d Charge contac ice you w after Health charg s t your ow ill nee the recei Services provided toes afor th or n attor d to (VIII. B. 1.) pt of the wr days e same consulta ney, ac itten patient, nt. Blu countant noti to the extent allowed by private pay that e Cross ce. ble this is a has indi law.” standar cated (II. S.) Note: applica- and it will d provider Chan tract Although generally not contr ges and was appr the update to physi- Agreement. Providers are required to acceptt provider act Agreement clarifica oved con- alter tio The by negotiations. it based ns in th MM state r on are as follows: e 201 A remai egulator 1 thi ns con s, s defini cerne T Definitions tion in t d abou here are flict with hat it appe t man the requirements ars to c changes y clarif S on- in the ication tatute § of Minnesota 2011 Agreement. s and 62A.64 cians at Lake- the terms of the agreement to be a part of the our members to The de ers a (1) an fini re d (2 1 review We urge tion of encoura ) . Pro them carefully. wa “Concu le ged to c vid- s expand rrent Re gal counse onsult ed to inc view” l and with th This A Subscr lude provision Blue C eir greeme iber’s ca review to ross about when nt will re of b of the ensure this accepted and become e outpati oth inp compliance. ffective ent Hea atient a It will signed by merly lth Servi nd The definition view Hospital in Blue Cross network auto Blue , it was ces. (II matica . D. lly Cross. limited ) Fo of terms renew sion” only to “inpatient r- (RVUs) is “Relative commenci for one-y . admis- new Value subs ng on ear . RVUs Units” equent July 1 nents: have three renewa for each work ex compo- ment l term. The an pense, pra incorpo The Ag definit d malp ctice rates ree- ion of “ ractice expens your or the prov Respo Primary Co term expense. e Stillwater on June Among the changes are the addition of iginal s isions nsibilit ve ined by They a ig y” ren ned Agr of co is new rage the reso re de- ewal am eement verage and in to provide the urce cost endme and al under cludes all services s nee nts to d l Con Blue Cro ded ate. Reviews tracts t ss Sub which is hat are n scriber based on 1. Minnesota ant to any ot seco Statute coordination ndary p Section ursu- Dave Renner HEALTH 62A.64 of INSURANCE; states benefits, 15. Eric Dick pro- a new provision on quality care delivery, a An agr PROHIBITED in pertinent auto eement between AGREEMENTS. part: 1. prohibit, an or grant insurer and the payment the insurer a health specified an option care provider 2. require, in to pr may or grant the contract; ohibit, the not: insur the insur provider er or payor er an from at a option contracting lower price; to require, with vided an update at reduction in the amount of advance notice the pr other insurers ovider to accept or payors a lower to pr payment ovide services in the event at a lower the pr price ovider agrees than to pr ovide services to any Olmsted Medical Center on June 23. (from 90 to 45 days) providers will be given other when changes are made to the agreement, „ Dave Thorson, M.D., and Janet Sil- and a requirement that providers make information available to versmith were among a dozen Minnesota subscribers about advance directives. health care leaders who met with Medi- Each year, the MMA teams up with the Twin Cities Medical Society care and Medicaid Services Administra- and the Minnesota Medical Group Management Association to provide this tor Donald Berwick, M.D., June 21, to review for members. Physicians who want to know more about how the spe- discuss new Medicare accountable care cifics of this agreement apply to their practice should contact their attorney, organization rules. accountant, or consultant. The full report is available online at www.mnmed.org/contract.

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July 2011 • Minnesota Medicine | 29 cover story |

MEDICAL IMAGING winners of our photo contest

t. Paul photographer Steve Wewerka, who served as one of the judges for our photography contest and regularly takes photos for Minnesota Medicine as Swell as national publications, says that taking a good photograph is a com- bination of finding an interesting subject and bringing your own artistry to it. For him, that means looking high and low at the subject to find a new perspective that will make the shot fresh. As a challenge to himself, Wewerka began doing just that last January when he launched a year-long project called “Wandering I,” in which he takes a photograph a day using the camera in his iPhone. “I use a minimal amount of equipment,” he says, “which forces me to have to use all of my artistic and visual skills to create compelling, unique, fresh imagery.” Those photos can be viewed on his website www.wewerkaphoto.com and on Facebook, where he posts a photo a day on his Wandering I page. Fresh, unique imagery is what Wewerka was looking for when he helped pick the winners of our first annual photography contest. Last May, we challenged medi- st cal students and physicians to “Give Us Your Best Shots.” They responded by sub- 1 place mitting 47 photographs. In addition to publishing the winning photos, we’re also sharing what the John Valesano, photographers said about their images as well as Wewerka’s comments about what medical student, University of made the winning photos so compelling. Minnesota Canal Park, Duluth This was taken March 23, the day after an incredibly windy storm blew spray from Lake Superior on the trees and the street lights all night. Nothing says “Duluth, Minnesota” like a street lamp covered in frozen water from Lake Superior.

Steve Wewerka says three things stood out about John Valesano’s first-place photo of the ice-encrusted street lamp: “The fact that it was unique subject mat- ter, the fact that the photographer broke that golden rule of always having the sun behind you and did it successfully, and the fact that he added in the human ele- ment really made that a successful pic- ture.” He notes that including the child in the shot gives the image “a quirky feel.”

30 | Minnesota Medicine • July 2011 cover story |

2nd place Ann Vogt, medical student, University of Minnesota A butterfly caught in the water, Mabira Forest, Uganda I was initially startled by something moving in the usually calm water. Then I realized it was a butterfly flapping its wings, trying to free itself and at the same time distorting the image of every- thing around it.

Second-place winner Ann Vogt’s photo was “absolutely all about color,” Wewerka says. But he also liked the fact that the butterfly is slightly off-center. “It wasn’t this perfect bulls-eye picture of a butterfly on the water,” he says. He also noted that the ripples in the water suggest “great movement” and make the photograph seem three-dimensional.

32 | Minnesota Medicine • July 2011 | cover story

rd Wewerka says third-place winner Sean O’Brien’s photo is all 3 place about composition. He notes that a number of elements sug- gest scale and distance. “There’s the canoe on the shoulders Sean O’Brien, of the people going into the water. It’s angled just right so that medical student, University of Minnesota it leads you into the picture. And it’s almost pointing exactly at Getting back to the water after a rain-filled portage, the other canoe that’s out in the lake.” He also says the ripples Boundary Waters Canoe Area in the water near the person carrying the canoe give the photo- The scene was stunning. The photo captures some of the beauty graph “a decisive moment” feel. of Minnesota.

July 2011 • Minnesota Medicine | 33 cover story | Honorable Mentions

Rachel Steckelberg, medical student, Mayo Medical School The Pagoda, Patterson Park, Baltimore, What inspired her to capture the image: The lighting at the time of day I took the shot, and the unique architecture of the structure.

Amanda Weinmann, medical student, University of Minnesota The Sentinel and Three Patriarchs, Zion National Park, Utah I decided to treat myself to a vacation at the Grand Canyon and Zion. I am trying to learn photography but only had a small point-and-shoot, and this landscape gave me the idea to practice “stitching.” This photo is really 15 small photos made into one. I was able to capture the Virgin River and all of the Three Patriarchs, something I could not otherwise have achieved with my small camera.

34 | Minnesota Medicine • July 2011 | feature © panco - Fotolia.com Medical Musings Results of our eighth annual writing contest Photography by Steve Wewerka

his year, 31 brave physicians and medical students entered their manuscripts in our annual writing contest. Our judges selected William Shores’ poem “Hos- Tpice” as the winning entry in the physician category. Honorable mentions in the physician category went to Marilyn Aschoff Mellor’s poem “I Believe, You Believe,” Jamie Santilli’s “Bethany, House of God,” and Carrie Link’s “Infertility 628.2.” In our student category, we named two winners: “Unspoken Words” by Erica Warnock and “The River” by Aaron Crosby. Thank you to all who entered. And congratulations to our winners.

July 2011 • Minnesota Medicine | 37 feature |

Erica Warnock’s “Unspoken Words” is about the crossroads of two worlds—that of being a patient „ student winner and that of being a physician. Erica Warnock University of Minnesota

rica Warnock has a perspective on medicine that few other medical students Warnock couldn’t stop thinking have. Having dealt with her own chronic health problems, she knows what it’s about the young woman. “There was the Elike to be a patient. “I feel like I’m trapped between two worlds having had so weird dynamic of realizing I’m now on the many experiences as a patient and trying to learn to be a doctor,” she says. professional side and not knowing exactly Writing, she says, helps her process what she is experiencing and feeling. “It’s thera- how to approach her, what to say, and peutic.” Growing up in Pittsburgh, she wanted to be a writer. But when she started then about what I wanted to say to her.” experiencing migraines in middle school, her interests turned to medicine. She studied She wrote her winning poem “Unspoken communication sciences and disorders and psychology at Northwestern University in Words” soon after that encounter. Evanston, Illinois, before starting medical school last fall at the University of Minnesota. Warnock says she doesn’t usually Last spring, as part of the “Essentials of Clinical Medicine” class, she began spend- write poetry but felt this story could better ing half a day a week in the hospital, taking histories and performing physical exams. be told as a poem. “I wanted to frame it One of her patients brought her to the crossroads of being a patient and being a physi- as an exchange between her and I, which cian. “A lot of the things she was saying felt like words that could easily have come out seemed to fit the format of a poem better.” of my mouth or have come out of my mouth at some point,” Warnock says. “I felt like there were so many parts of her story I could relate to: having to deal with side effects of medications, having anxiety, feeling tired of being tested, having to figure out how to live her life now that she has this diagnosis.”

38 | Minnesota Medicine • July 2011 | feature

Unspoken Words | By Erica Warnock

What do you know about suffering? What do you know about fear? About living with sickness as a constant companion? About all of the worries that come with being sick? You are innocent and inexperienced Last night I had a heart pounding, A carefree child Thoughts racing Your only understanding of pain Body sweating Is what is written in textbooks Panic attack You know nothing about disease. You know nothing about being afraid. Illness makes no distinction It is terrifying to face the unknown All are vulnerable prey when it attacks Like a child plagued by recurrent nightmares We fool ourselves into thinking Only it is more likely your fears will come true Healthy habits will protect us Than that you will discover a monster hiding under the bed Or the invincibility of youth will intercede What will they find? What will you do? But the cloak of disease has enveloped me Potential answers fill you with dread As surely as it has surrounded you. And worst-case scenarios displace all other thoughts. What do you know about medications? What do you know about uncertainty? About the problems that arise when the same drugs that help you About constantly questioning what the future holds? Post a flashing neon welcome sign on your forehead Being too afraid that a bad day is on the horizon Inviting infections to invade To enjoy the good days Turn your lungs into the perfect lair for bugs Having life controlled by your bowel habits Bacteria and viruses and all types of nastiness My world has changed so much in three short years You know nothing about side effects. You know nothing about ambiguity. It is a never-ending balancing act I’ve already scoped out this unit Like walking on a tightrope in a circus For the nearest bathroom, just in case All it takes is the tiniest nudge Three years ago I wouldn’t have needed to Or a strong wind But now I know symptoms always lurk in the shadows To push things in the wrong direction I try to appreciate the good days as a blessing Then the side effects become worse than the disease itself But sometimes they just make the bad days And you must cope with the consequences. Seem that much worse by comparison. What do you know about being a patient? What do you know about how to reassure me? About the procedures that never end? About how to empathize with patients? Scan, scope, culture, repeat … and repeat again You nod your head They search deep within Say you’re sorry Examining your innermost parts Claim to understand Yet answers remain elusive Do you really? You know nothing about tests. You know nothing about what I’m going through. Sometimes you feel reduced to a specimen to be studied I wish I could take off my white coat You wonder if you are a person anymore Sit beside you and confess everything Or just a body to probe and scope Tell you that I know plenty of things about illness An empty vessel full of isolated organs Never covered in our curriculum Your diagnosis becomes an intellectual challenge Because I’m living through it too. Dependent on your body but not on you Tell you I know how difficult your life has become And test after test tells them nothing. Sometimes I think being a patient is harder Than learning to be a doctor.

July 2011 • Minnesota Medicine | 39 The River | By Aaron Crosby

ell, I should probably be “Wheaded back up to the Cities.” This is always one of the hardest things for me to say at this place, my grandfather’s house. Growing up, I

Aaron Crosby has been writing stories since he was a child. spent many happy days here—eating „ student winner raspberries and getting scratches all over my body from crawling around Aaron Crosby in the brush on top of his hill. When University of Minnesota I started college, my visits became shorter and less frequent. Boundless, aron Crosby comes from a family has made it a point to carve out time to shapeless, and indefinable as time is, of storytellers. As a child, he fre- do so as a medical student (he helped start it became parceled into three-month Aquently spent part of his summers an online literary journal for students in portions, which were subdivided into with his mother’s family in southeastern his class). “It’s nice to flex a creative mus- unrelenting exam periods. Still, at the Minnesota. He remembers sitting around cle after studying science all the time,” he completion of any one of those peri- the kitchen table listening to his aunts, un- says. He also made time to visit his grand- ods, I would hop in the car with my cles, cousins, and grandparents tell stories. father, the subject of his winning essay, family and ride down the Mississippi “That’s part of where my love of stories “The River.” to see Grampa. comes from,” he says. Crosby’s story is an amalgamation Now, the races I run are much Crosby, who just finished his first year of two trips he made to Minnesota City longer indeed. As a medical student, of medical school at the University of Min- this past year to visit his grandfather and they have stretched from scholarly nesota, started writing his own stories as a to hear his stories about life as a towboat 5Ks to marathons, and there is only child. “When I was born, my parents got pilot on the Mississippi River. “Every time the prospect of them getting lon- me a subscription to National Geographic. I go down there, he gets out this binder ger. Correspondingly, I only journey I would flip through the articles and look of newspaper clippings from when he down to see him a few times each at the pictures and try to write my own worked on the river,” Crosby says. “He has year. The visits are different now, too. books and draw pictures to go with them. pictures of boats he was on or of him on No longer do I visit for a week at a I realized after a while that my pictures boats. He picks a couple each time to tell time and spend the days exploring the were horrible, but the stories were fun to us about.” countryside and watching baseball. write, so I stuck with that.” Crosby says his ultimate goal is to Instead, I come for a day to chat and In high school in Shakopee, Minne- record some of his grandfather’s stories to maybe watch a Western. sota, Crosby thought he wanted to be a keep them in the family. “That was one This is why I hate myself so history professor; but he changed his mind of my inspirations for this piece,” he says. deeply when I have to initiate the after writing his senior thesis on avian in- During his break from medical school leaving part of the visit. His house fluenza. He decided instead to major in this summer, Crosby says he hopes to do is empty now. My grandmother, his microbiology at the University of Minne- more writing. He also plans to start the horses, and lastly his dog have all sota. summer with a visit to his grandfather, to departed his halls for more heavenly Although he admits he didn’t have hear and capture more of his stories of life ones, and he now goes to bed and much time for writing as an undergrad, he on the river. wakes up each morning alone. As I

40 | Minnesota Medicine • July 2011 | feature

begin to put on my heavy winter coat, I pilot. That is why my mother calls him fore I even take off coat or set down my feel as if I’m abandoning him. “Captain.” He has always been—and will bag. I will seek to save every loose scrap “Oh, hold on just a second, boy. I got always be—mythical to me, large and in- of time I can for studying upcoming exam something for ya,” he says with a cackle. vincible. At an age when most have lost material. I scare myself briefly by consider- Despite the fact that there is always a vein their fight with mortality and those who ing laminating my notes so that I can use of sadness laying in every departure, he haven’t require the doting attention of a them in the shower. When exams are over, brightens at the prospect of having some- nursing home staff, he still rises before the I will surely take days to catch up with thing to give me. I pray it’s food. sun to hurl hunks of firewood into the fur- my girlfriend, and there will be reunions “Here ya go. This here is a pot roast. nace that heats his home. He is not a lion, with parents and nights of laughter with Good stuff. You put that on a dinner roll or a wolf, or a steadfast rock—all titles that friends. with a bunch of barbecue sauce, and boy, have been ascribed to men of greatness. And during all of this, the River will you got yourself a sammich. Say, boy, you He is the River. He is steady, and power- continue to flow silently on. need some rolls?” ful, and calm. He proceeds from his origin In clinic, I spend hours questioning “No, no Grampa.” I laugh and then to his ending with purpose and force and patients about their history, their family’s ask, “Aren’t you not supposed to be eat- requires the assistance of no man to do so. history, their moods and fears. Yet, placed ing stuff like this, though? Aunt said we Which is what I fret over most, I sup- before my own grandfather, I have not should watch what we bring you. She wor- pose. Every time I snap my seat belt into been able find the words to plainly ask ries about you.” place and look out the window to wave such things. “She wants me to eat cardboard is goodbye, I try to drink in the River. He My seat at the library is ringed by what she wants. You don’t worry about always stands there, just inside the gate, to stacks of books, each filled with the toil it. Just eat this, it’ll make you strong like give me one last farewell gesture. Some- of an individual’s lifetime of dedication bull.” times, if I look closely, I think that I can to scientific inquiry flattened onto sheets I smile and nod and accept the Ziploc see a hint of moisture in his eyes, a tinge of and bound fast with paste. They hold the bag full of leftover beef, a tender gift in redness belying the sadness beneath. tales of our society’s greatest discoveries every sense of the word. I look from the I know that there is more he would and serve as a timeless catalog and history saltless mass, a consequence of Grampa’s like to tell me. I wonder if he knows that of thought. There’s no permanent record DASH diet, and open my mouth to say I prize his stories. His memories are like of the River, however, who can only pour something clever, but my wit fails me. grains of sand in an hour glass that cannot into me his thoughts. I must be his pages “Thanks, Grampa.” agree on which should be allowed to fall and binding. “Say hi to that little sister of yours if first. They must be prompted by some- On this day, as we reach the end of his you see her,” he says. He follows me out thing—a photograph of an old building, yard, I fill myself with resolution. I pause of the house that he literally built with his a drive down a back road, a pitcher who at the gate and turn around. “Grampa, own two hands and into the yard, passing throws a knuckleball. wait,” I say. “Before I go, could you tell his gardens and countless bird feeders. Every time I leave, I think that both me a story?” It’s a sight that I’ve never gotten used of us expects it to be the last time we will Caught off guard, he is silent a mo- to—his tall, ursine figure hunched, his see each other. Standing here today, I want ment before asking, “Well, sure. What feet shuffling on the uneven sidewalk as to grab him and demand he tell me every- about?” he works to avoid tripping. Those feet thing, but I cannot think of how to begin. I already have an answer. confidently strode across the rolling decks When I get home, I know I will “The River.” of many riverboats. They were first the feet walk in the door and make my way to the of a crewman, then a mate, and finally a kitchen to start my coffee percolating be-

July 2011 • Minnesota Medicine | 41 feature |

William Shores has wanted to write about the patient who was his inspiration for his poem “Hospice” for years.

„ physician winner William Shores, M.D.

illiam Shores, M.D., didn’t set out to become a poet. About a decade ago, “picked at it” before sending it to Min- the semi-retired family physician discovered by accident he liked to write. nesota Medicine. “This was a story I’ve WThen the lead physician at the Mayo Clinic Health System’s St. Peter Clinic, told before at hospice meetings—just not he was looking for a way to share his ideas and values about work with his colleagues. in this language. Those were close to her He tried what he calls a “Walmart-type” morning meeting, but staff were too busy to at- exact words: She would like to help but tend. So Shores began putting his thoughts into words and sending email missives he la- will have to wait until next week. She was beled “A Good Monday Morning.” “I would write this paragraph, which was sometimes an amazing woman.” whimsical and sometimes serious,” he says. “Always there was a little message hidden it.” Shores says writing now provides him Shores found he enjoyed the process of writing and began experimenting. He even- with the opportunity to re-examine expe- tually decided he liked poetry. “You can get a story told in a small amount of words,” he riences he’s had over his 33-year career. “I says. “It feels natural to do that.” get [the story] down on paper and look Now 63, Shores serves as medical director for the Benedictine Living Communities at it from different angles,” he says, not- and Good Samaritan Nursing Home in St. Peter and has more time for wordsmithing. ing that all physicians meet many amaz- He’s joined a writing group that meets once a month. Members critique each other’s ing people and encounter many moving work. And he’s taken to carrying around a little notebook, in which he jots down ideas, events over the course of a career. analogies, and phrases during the day. “I write those down and then plug them in when “That’s the thing,” he says. “Some of I sit down to write,” he says, which is usually first thing in the morning. these stories are coming back now that I His poem “Hospice” was inspired by a real patient who died about 25 years ago. have more time.” He’s wanted to write about her for years. In March, he crafted a rough draft and then

42 | Minnesota Medicine • July 2011 | feature

Hospice | By William Shores, M.D. She was dying, of course. The signs were there for all to see. The tumor stood proudly in the crosshairs of the once mighty Cyclotron as it blazed With all the effect of a toy ray gun. The metastases laughed as they drank to the dregs the poison cocktail, Unfazed … then gave the hangover to the hostess Leaving her tired and sick, but not without her smile. Never without her smile. She was dying, of course. We all knew it. But who could tell her? Not her husband. Their lives now one with their toddler boy Conceived in defiance of the Intruder two years ago And now nestled next to her on the sofa. Not her oncologist. He wasn’t immune to her smile And was drawn into the vortex of her love and acceptance. Do not confuse this with blind denial … you can’t fully smile with your eyes closed. “Sue, we have this group in town,” I began, trying to ease into the hospice spiel. “They volunteer to be with … people … who are … very sick.” “Oh doctor,” she stopped me. “That sounds wonderful!” Her curly haired child cuddled closer as she smiled and finished, “But I’m too tired right now. Maybe I can help out next week … when I’m stronger.” She was living, of course.

July 2011 • Minnesota Medicine | 43 feature |

„ physician honorable mention

Bethany, House of God | By Jamie Santilli, M.D. My Heavenly Angel, Sweet daughter Bethany Touches my cheek Awakens my sleep y daughter Bethany was born in 1984 at 28 weeks gestation weigh- Each serene night ing just over 2 pounds. At the time she was born, I was in medical At two twenty two Mschool. My husband and I named her Bethany, which has two mean- ings: “house of poverty,” very appropriate for medical students with incredible Her wings Grace my face educational debt, and “house of God,” which may have contributed by divine With love’s embrace intervention to her long life considering all of her medical problems. She was not Attempts to erase able to speak or walk because of cerebral palsy and experienced many other health Worry on my face problems caused by her prematurity. She communicated through electronic aug- At two twenty two mentative systems and was educated in the Burnsville public schools by many amazing teachers, professionals, and attendants. She enjoyed each day to its fullest, A Premature Gift from God smiling and giggling much of the time. She died unexpectedly in her sleep in the I could not save her middle of the night at age 19, one week prior to starting her senior year in high In life or death school. I only did my best For several years after her death, every night I would wake up at 2:22 a.m., To shield her from fate look at my clock radio, think of my darling daughter in a much better place, not restricted by her earthly body that failed her. I would wake in the morning I feel a breeze refreshed, ready for another day with residents, medical students, and patients un- Caress my earthly face aware of the transformative depth of my understanding of personal loss and the A tear rolls power of resilience and purpose. To the pillowcase As a physician, we know life is a death sentence, yet in the United States, I open my eyes many fear even the topic of death. I realize now that my experience of the grieving The clock reveals process as a surviving parent has been eye-opening and life-renewing, and it has en- Two twenty two hanced my ability to understand the emotions of others experiencing grief and loss. My daughter was a blessing and in so many ways enriched my life, encourag- Each morning I awake to race ing me to live each day to the fullest and giving me hope for a life beyond this To care for the human race earthly existence. Renewed by my Angel Jamie Santilli is a family physician and medical educator at the University of Minnesota Eternal Hope and Grace Medical School. She practices at University of Minnesota Physicians’ Primary Care At two twenty two Center in Minneapolis.

Perhaps in a name Her fate was sealed My darling Bethany Your path revealed Your last breath …Taken At two twenty two

Eternal life No Earthly strife Enriches my life Remembered at night At two twenty two.

44 | Minnesota Medicine • July 2011 | feature

„ physician honorable mention I Believe, You Believe

| By Marilyn Aschoff Mellor, M.D.

Like an unsecured sail in the face of a gathering storm she lies propped up panting softly, skin sallow against bleached hospital sheets. Leukemic and rock-bottom anemic this child of Jehovah’s Witnesses needs blood to survive.

Her jaw set father write because I love to write. There are times when certain pa- refuses transfusions. tients leave a strong impression on me, and I find them showing Her mother, drinking tears, I up in my poetry. This was such an incident. It made me step disappears from the dialogue. back and consider that what I believe is but one small perspective in His words, my words swirl the grand scheme of life. The poem is still new and continues to be with all of us aware of prevailing winds. a work in progress. Marilyn Aschoff Mellor practices in the emergency department at Would they could feel the breath of God Children’s Hospitals and Clinics of Minnesota in St Paul. She is a past in the court order for treatment. Medical Musings winner.

July 2011 • Minnesota Medicine | 45 feature |

„ physician honorable mention

Infertility 628.2 | By Carrie Link, M.D.

The budding and flowering of spring is here. Rooting hormone will quicken them The rains have come and cleansed my land of sadness As well as water and so much fertilizer. Nourished me Add the warmth and comfort of nurturing sunshine With possibility And time. And yet another opportunity, Allow the seeds to sprout beneath the earth that’s mine Bringing guarded hope for this next season. Where I hold them and wait to check them for 10 more days.

Seeds are purchased carefully When that anticipated tenth day comes, we will look With too much thought, too much preparation. For the telltale shoot, the tiny flourishing bud They’ve been collected And again we’ll wait, Inspected Tensely anticipate Carefully chosen, selected, some rejected A natural disaster that would devastate For the fruits of these labors will be a labor itself. Me and this precious potential progeny.

We abandoned the natural planting Flooding maybe, a cascade of sanguinous debris. That simple commune with nature. Or an infestation makes the soil hostile to growth. We adopted science to help us germinate, Or tornadoes twirl around my long stalks and tangle them Propagate, Condemned So the shoots take root, in a complex chemical reaction that I can To be cut, with surgical precision, from my abdomen illustrate, Which could never be planted again. But not fully understand. Only 40 percent of the crop will even survive that first stage. We must re-examine the growths under the microscope And then will the crop bear fruit? With a close and attentive eye Will it be a peaberry, the unusual coffee bean twin For those buds must be appropriately grown, Growing within To be Sown. Or a lone pineapple fruit that when The sterile collection, then judicious planting of our own Harvested will be the height of sweetness? Selected seeds into an impeccably fertile ground.

write poems in an attempt does not. For this particular tient’s side of the curtain, this to consolidate my emo- poem, I was struck by the emo- poem just happened. It’s my I tions around my role see- tional challenges of patients at reflection about working with ing patients and to record my either end of the reproductive patients around the issue of memories of certain encoun- spectrum—those wanting to fertility as well as my personal ters. be pregnant but who are not, experience with it. Poetry conveys the profound and those finding out about an Carrie Link is a member of experience of working with unintended pregnancy. When the family medicine faculty at patients in a way that simply it became my turn to experi- Smiley’s Clinic in Minneapolis. journaling about an encounter ence medicine from the pa-

46 | Minnesota Medicine • July 2011 | perspective 7 Reasons Why Doctors Write

Physicians write for the same reasons that nonphysicians do, plus some special ones.

By Tony Miksanek, M.D.

s a profession, physicians are a remarkable group of writ- ers. What doctors lack in good penmanship is more than Acompensated for by their skill in penning stories and poems. Their literary accomplishments are even more impressive given a lack of formal training in the art of writing. Only a few physician-authors have MFA degrees. Most medical students do not major in English or literature while in college. Doctors be- come talented writers the old-fashioned way. They practice. They also teach themselves via voracious reading with attention to style and technique. They occasionally attend writing workshops. It helps that doctors are immersed in stories. If the business of medicine is taking care of patients, then the currency used in the transaction are the narratives of illness told by patients and received by physicians. Doctors spend a good chunk of their professional lives listening to stories. It’s only natural that doctors would retell versions of these tales or craft their own new ones. All the elements of a story are readily available to any doc- tor: plot, protagonist, antagonist, setting, dialogue, and theme. Physicians witness struggle—disease, death, and suffering—all the time. Writers call it conflict. Physicians regularly observe cures, acts of heroism, and even miracles. Writers refer to it as de- nouement. Doctor-writers have oodles of experience to tap from. They have a rich pipeline of poignant images, unforgettable lan- guage, colorful characters, and vexing irony in any single day. In addition, physicians get plenty of practice writing and editing

July 2011 • Minnesota Medicine | 47 © abraxi, sabri deniz kizil - Fotolia.com perspective |

Doctors spend a by writing in clever and vivid ways. Humor and compas- sion provoke memorable moments in literature. A perfect example is The House of God by Samuel Shem. good chunk of their 4. Joy—Writing is fun. Okay, maybe not always—rewrites, ed- iting, and the evil “writers’ block.” At some level (the spark professional lives that begins the project or reading the finished manuscript), there is euphoria. Would you settle for glee? listening to stories. 5. Honor—Writing allows physicians an opportunity to me- morialize patients and colleagues. These literary works fea- ture a fictionalized version of a character or an amalgamation It’s only natural that of a few people. Creative writing can immortalize someone. P.S. Doctor-narrators also reap literary longevity. doctors would retell 6. Atonement—Doctors make mistakes. They sometimes be- have badly. They have regrets. Stories and poems can be part versions of these tales. of their penance. Think “Brute” by Richard Selzer. 7. Notoriety—Let’s not lie to ourselves. Who among us would not want to be a rich and famous author? I don’t know any office notes, consultations, and histories and physicals. doctors who would turn down a Pulitzer Prize, National There is an elite roster of physician-writers for readers to Book Award, or an appearance on “The Oprah Winfrey drool over. Anton Chekhov, John Keats, Arthur Conan Doyle, Show.” Good luck with that. MM William Carlos Williams, A.J. Cronin, W. Somerset Maugham, Tony Miksanek is a family physician in Benton, Illinois, and author of and Mikhail Bulgakov are a few names that immediately come to two collections of short stories, Raining Stethoscopes and Murmurs. mind. There are also many recognizable physician-writers includ- He regularly writes book reviews for the Journal of the American ing Michael Crichton, Robin Cook, and Frank Slaughter who Medical Association. may not get the love (critical acclaim) but certainly get the money (commercial success). There is a sizeable but unquantifiable group Reprinted with permission from the Literature, Arts, and Medicine blog at of practicing physicians who engage in creative writing without New York University School of Medicine. fanfare. These doctors take their writing seriously whether they consider it a hobby, diversion, or passion. I estimate that as many as 4 to 7 percent of all practicing physicians in the United States are currently working on a poem, story, or novel. With hectic, unpredictable, and stressful jobs, why do doc- Call for Papers tors want to write? Given the demands and responsibilities associ- ated with a career in medicine, why do so many physicians make Minnesota Medicine publishes submissions from medical time to write? The short answer is that doctors write for many of students, practicing physicians, researchers, and experts the same reasons that nonphysicians do: They feel compelled to from other fields. We welcome contributions of letters, write. They have something to say. They love words and language. commentaries, perspectives, articles about clinical articles, They are excited by the process and gratified by the result. They and original research. We’re currently seeking submissions are inspired. related to these topics: Here are seven special reasons (ranked from most important to least important) why doctors write: Hospitals - Articles due July 20 1. Therapy—Physician heal thyself. Nothing promotes healing like writing a poem or short story or even a single glorious Drugs - Articles due August 20 sentence. Writing helps a doctor get things off their chest in a much more productive way than yelling at a nurse, ranting Ears, Noses, Throats - Articles due September 20 at a patient, or being grouchy at home. Poems and stories written as a form of therapy are easy to spot. They have a Communication - Articles due October 20 confessional quality. 2. Exploration—Doctoring is hard. Creative writing is an op- Send your manuscripts to [email protected]. For more portunity for physicians to make sense of what they do. information, go to www.minnesotamedicine.com or call Stories written for the purpose of searching sometimes have Carmen Peota at 612/362-3724. themes that focus on medical ethics and boundary issues. 3. Sharing—Doctors can pass along knowledge and experience

48 | Minnesota Medicine • July 2011 | commentary

Why We Need the Arts in Medicine Studies show that incorporating the arts can save money, improve the patient experience—and do a lot more.

By Gary Christenson, M.D.

e need the mu- viously for children when they needed 1. Studying the arts makes medical sician stat!” an injection. However, the immediacy students into better doctors. the physician of this demand wasn’t so typical. After Medical students must master an array called out. A all, stat requests are usually reserved for of clinical skills in addition to an increas- “Wyoung boy with severe spasticity was blood work, medications, X-rays, and ingly complex knowledge base. They are scheduled to receive a series of painful transportation to the operating room. expected to hone their observational, lis- injections of botulinum toxin. The doc- Dobbs’ story is just one example of how tening, and critical thinking skills while tor knew that getting the boy to coop- the arts are becoming a regular part of expanding their capacity to empathize erate was always a challenge. He had a daily medical practice. And it shows how with the patient. To accomplish the history of bolting around the room, physicians are coming to see their clini- latter goal, most medical schools have making it difficult and time-consuming cal value. added some element of the humanities for the staff to do their work. The doc- Although some might be inclined to to their curricula. A number of schools tor had learned from experience that dismiss the arts as a triviality, luxury, or have students read literature written by music could be used to relieve a child’s unjustified expense in a time of concern physicians and patients that portrays fear and anxiety, be a distraction from over rising health care costs, research is the experience of illness and treatment pain, provide comfort, and increase the showing that use of the arts in health from dual vantage points. In our state, likelihood that the child would be coop- care can be cost-effective. For example, a storytelling and theater have been used erative during a medical procedure. And recent study done at Tallahassee Memo- to teach students how to effectively take music therapy had helped this patient in rial HealthCare demonstrated that using a medical history. Last year, for example, the past. music therapy when preparing children Mayo Medical School and the Mayo Upon hearing the request, Sarah for CT scans significantly reduced use Clinic Center for Humanities and Medi- Dobbs, artistic director for the Centre of sedative medications, associated over- cine partnered with the Guthrie Theater for the Arts at Toronto’s Holland Bloor- night stays, and nurse time, and resulted to offer the one-week selective “Telling view Kids Rehabilitation Hospital, re- in a cost savings of $567 per procedure.1 the Patient’s Story,” which drew upon cruited one of her music therapists and It also decreased the need for repeat CTs improvisation and storytelling to teach hurried to the treatment room with because of poor-quality scans. When ex- students to take and report patients’ a drum, djembe, shakers, and guitar. trapolating those numbers to all pediat- medical history. Their plan was to engage the child by ric CT scans done in the United States, Other programs encourage medical drumming and singing together while researchers estimated a potential savings students to relate their own experiences the physician and nurse completed the of $2.25 billion per year.2 Such findings through story or the visual arts. For ex- procedure. It worked. support the business case for adopting ample, first-year medical students at the Dobbs told me this story as I was on arts programming in health care facili- University of Massachusetts participate my way to tour the new Laguna Honda ties and practices. But there are other in One Breath Apart, an arts-based re- Hospital in San Francisco during the reasons why physicians, educators, and flective module that has been incorpo- April meeting of the Society for the Arts health care administrators should be- rated into their anatomy class. A collec- in Healthcare. Dobbs explained that come advocates for incorporating the tion of drawings and writings generated using live music had been requested pre- arts in medicine. by the students has been published by

July 2011 • Minnesota Medicine | 49 commentary | the curriculum’s director, Sandra Bertman oped by Kairos Dance Theater in Minne- much more responsive to the message, Ph.D., in a book of the same name.3 apolis is offered at Park Nicollet’s Struthers “Dance makes the heart grow stronger” Harvard Medical School has found Parkinson’s Center as well as other local than to “Exercise makes the heart grow that training medical students in the visual long-term care facilities, adult day-care stronger.”14 Dance is one of the best ways arts can help them develop their clinical centers, and senior community centers. to improve health on a number of levels. observational skills. Students who partici- This evidence-based program strives to In addition to its physical benefits, dance pated in formal training consisting of art engage elderly patients and their fam- enhances social engagement, which is im- observation exercises, didactics that inte- ily members and caregivers in movement portant to overall health and well-being, grate fine arts concepts with physical di- through dance improvisation and story and it’s one of the best activities for delay- agnosis topics, and a life-drawing session developed out of participants’ own mem- ing the cognitive decline associated with demonstrated better visual diagnostic skills ories. “Dance” is broadly defined, and it Alzheimer’s disease.15 when viewing photographs of dermato- includes rhythmic movement to music for In addition, the arts can be used to logical lesions than students who only re- those confined to a wheelchair. A study by promote public health. A great example of ceived conventional training.4 researchers in the University of Minneso- this was Sidewalks Saving Lives, a collab- The arts also can convey lessons in ta’s department of kinesiology found that orative project of the University of Minne- ways traditional lectures cannot. It isn’t most of the participants at a local senior sota’s Center for Urban and Regional Af- surprising that the top-rated lecture by center said the activities helped them stay fairs, Kwanzaa Community Church, and first-year medical students on the Univer- healthy by improving flexibility, coordina- Juxtaposition Arts in north Minneapolis, sity of Minnesota’s Twin Cities campus for tion, balance, and endurance. They also in which community members worked seven consecutive years was a reading of agreed that the shared reminiscence and with artists during 2008 and 2009 to paint physician and playwright David Feldshuh’s discussion improved their memory and sidewalks with educational messages about Miss Evers Boys by Guthrie Theater actors. social skills.7 HIV/AIDS and the importance of being The play, about the Tuskegee syphilis ex- In addition, music and song have tested. periments, illustrates ethical issues related been used as an alternative means of com- to informed consent and human experi- munication for those recovering from 4. The arts can improve the patient mentation. post-stroke aphasias,8 and a number of experience. programs have patients in various set- Until recently, the design of modern 2. The arts have therapeutic benefits. tings create art to increase their sense of health care environments has been primar- When I attended medical school in the control, distract them from pain, decrease ily based on efficiency, prevention of infec- early 1980s, physical therapy and occu- their stress level and blood pressure, and tion, accommodation of new technology, pational therapy were the only adjunct provide them an outlet for emotional ex- and cost savings. However, a body of re- modalities recommended for helping pa- ploration and expression.9 Storytelling has search has shown that patients tend to be tients recover from disease or surgery. At been noted to improve the quality of life less stressed, less anxious, require less pain the time, we knew little about art therapy, for cancer patients,10 increase lung func- medication, and ready for discharge earlier music therapy, dance and movement ther- tion associated with asthma,11 and reduce when their environment includes views of apy, expressive arts therapy, drama therapy, symptoms and doctor visits.12 One report the natural world.16,17 poetry therapy, and a host of other ap- noted that regularly playing the Australia The effects of various forms of visual proaches that use one or more arts modal- didgeridoo decreased apneic episodes for art are being studied so that hospitals se- ity to promote healing. Although many of patients with obstructive sleep apnea.13 lect the most healing images for patient these therapies originally were intended to For these reasons, physicians should con- rooms.18 Although preliminary studies improve the emotional health of patients, sider the arts among their prescriptive suggested that representational art de- we are discovering they have other thera- options and advocate for increased avail- picting landscapes is the most welcomed peutic benefits. ability of arts programming within their and healing choice,19 others have ques- Museums such as the Museum of institutions. tioned whether this view is too limiting.20 Modern Art in New York and the Min- Considering the subjective nature of art neapolis Institute of Arts have programs 3. The arts can help prevent disease. appreciation, many hospitals including for patients with Alzheimer’s disease and Physicians often find it frustrating to talk Bethesda Hospital in St. Paul allow pa- memory loss that use visual and cogni- to patients about getting regular exercise. tients to choose art pieces that will grace tive stimuli to evoke memories. Dance has They can suggest that patients do more to the walls of their room during their stay. been shown to improve the mobility of pa- increase their activity level, but patients The new University of Minnesota Amplatz tients with conditions such as fibromyalgia frequently don’t adhere to that advice. Children’s Hospital even allows children and Parkinson disease.5,6 However, a campaign to decrease heart to choose the color of the lighting in their The Dancing Heart program devel- disease in England found that people were room.

50 | Minnesota Medicine • July 2011 | commentary

Boynton Health Service and president of the Bedside visits by musicians and artists Society for the Arts in Healthcare. Index of Advertisers also distract children from pain and help them explore their feelings about their ACUTE CARE, INC. | www.acutecare.com REFERENCES illness. Mayo Clinic’s Art at the Bedside AFFILIATED COMMUNITY MEDICAL CENTER | Program engages professional artists to 1. DeLoach Walworth D. Procedural-support music www.acmc.com therapy in the healthcare setting: A cost-effective- AMA LITIGATION CENTER work with patients to create art using wa- ness analysis. J Ped Nursing. 2005;20(4):276-84. | tercolors, colored pencils, and clay, as well 2. Wood B. CT scans and radiation exposure. AAP www.ama-assn.org/go/litigationcenter Grand Rounds. 2008;19:28-9. CUYUNA REGIONAL MEDICAL CENTER as authors and poets to guide patients in 3. Bertman S. One Breath Apart: Facing Dissection. | www.cuyunamed.org journaling and writing poetry and mem- Baywood Publishing Co., New York:2009. 4. Dolev J, Friedlander L, Braverman I. Use of DAVIS REAL ESTATE SERVICES GROUP | oirs. Likewise, musicians play in Mayo’s fine art to enhance visual diagnostic skills. JAMA. www.davisrealestatemn.com patient and family lounges as well as in 2001;286(9):1020-1. 5. Bojner-Horwitz E, Theorell T, Anderberg U. Dance/ EMERGENCY PRACTICE ASSOCIATES | hospital rooms. movement therapy and changes in stress-relat- ed hormones: a study of fibromyalgia patients epamidwest.com with video interpretation. Arts Psychother. 2003; FAIRVIEW HEALTH SYSTEM | 5. The arts can promote physician 30(5):255-64. fairview.org/physicians 6. Hackney M, Kantorovich S, Levin R, Earhart G. well-being. Effects of tango on functional mobility in Parkinson’s FAIRVIEW - AMPLATZ CHILDREN’S HOSPITAL | The arts have soothing, reflective, and re- disease: a preliminary study. J Neurolog Phys Ther. uofmchildrenshospital.org 2007:31(4):173-9. storative powers that can counteract the 7. Tabourne C, Lee Y. Study of Kairos Dance Theatre’s HCMC - BEST OF HENNEPIN MEDICAL CONFER- stresses associated with medical school Dancing Heart Program. University of Minnesota, ENCE | www.hcmc.org/bestofhennepin Department of Kinesiology, 2005-2006. or practice. Although many physicians 8. Schlaug G, Norton A, Marchina S, Zipse L, Wan HEALTHPARTNERS MEDICAL GROUP - URGENT CY. From singing to speaking: facilitating recovery CARE | healthpartners.com were involved in the arts before entering from nonfluent aphasia. Future Neurol. 2010;5(5): medical school, they put those activities 657-65. LAKE REGION HEALTHCARE | www.lrhc.org 9. State of the Field Committee State of the on hold during their training. University field report: Arts in healthcare 2009. Washington, LAKE REGION HEALTHCARE - HOSPITALIST | of Minnesota medical students have an DC: Society for the Arts in Healthcare. 2009; www.lrhc.org p. 19. Available at: www.thesah.org/doc/reports/ LAKEWOOD HEALTH SYSTEM opportunity to keep those interests alive ArtsInHealthcare.pdf. Accessed June 13, 2011. | through the Robert O. Fisch Art of Medi- 10. Morgan N, Graves K, Poggi E, Cheson B. lakewoodhealthsystem.com Implementing a expressive writing study in a cancer MANKATO CLINIC cine program. The program, named for clinic. Oncologist. 2008;13(2):196-204. | www.mankato-clinic.com the well-known local artist, writer, and 11. Bray M, Theodore L, Patwa S, Margiano S, Alric J, Peck H. Written emotional expression as an inter- retired pediatrician, provides students MAPLE GROVE SURGICAL SPECIALISTS | vention for asthma. Schs. 2003;40(2):193-207. www.mgssmn.com with a small financial award to pursue and 12. Pennebaker J. Writing about emotional events: From past to future. In Lepore SJ, Smyth JM (Eds.) MERCK - DULERA | dulera.com develop their interests and skills in such The writing cure: How expressive writing promotes diverse areas as painting, drawing, sing- health and emotional well-being. Washington, DC: MERCY HEALTH NETWORK | American Psychological Association. 2002:281-91. www.mercynorthiowa.com ing, clowning, photography, and playing 13. Puhan M, Suarez A, Lo Cascio C, Zahn A, Braendii O. Didgeridoo playing as alternative treat- MILLE LACS HEALTH SYSTEM | an instrument as a way to find relief from ment for obstructive sleep apnoea syndrome: ran- www.mlhealth.org the rigors of medical study. domized controlled trial. BMJ. 2006;332(7536): 266-70. MMIC | www.mmicgroup.com For many of us practicing physicians, 14. White M. Arts development in community MMIC HEALTH IT | pursuing the arts can help us rebalance health: a social tonic. Radcliffe, Oxford, UK. 2009:24. 15. Verghese J, Lipton R, Katz M, Hall C, Derby C, www.MMICHealthIT.com our busy lives. Art provides not only an Kuslansky G, et al. Leisure activities and the risk MN OPERA | mnopera.org opportunity to explore and express our of dementia in the elderly. New Engl J Med. 2003; 348(25):2508-16. OLMSTED MEDICAL CENTER | feelings but a respite from the heavy re- 16. Ulrich R. View through a window may influ- www.olmstedmedicalcenter.org sponsibilities inherent in our profession. It ence recovery from surgery. Science.1984; 224(4647):420-1. OMS SPECIALISTS | also provides us with a chance to develop 17. Ulrich R, Simons R, Losito B, Fiorito E, Miles www.omsspecialists.com our creative potential. M, Zelson M. Stress recovery during exposure to natural and urban environments. J Environ Psych. PEDIATRIC HOME SERVICE | Given the growing evidence of how 1991;11:201-30. www.meetthemiracle.com 18. Ridenour A, Goldman K, Goodwin L. the arts can improve clinical skills, pro- Architecturally Integrated Art Program: Case Study RTW | www.rtwi.com mote healing and prevent disease, increase of Rady Children’s Hospital. Presented at the Society for the Arts in Healthcare 22nd annual conference in SANFORD HEALTH - ORTHOPAEDIC AD | patient satisfaction, and help us find bal- Burlingame, California, April 15, 2011. www.sanfordhealth.org ance in our own lives, physicians should 19. Ulrich R, Lunden O, Eltinge J. Effects of expo- sure to nature and abstract pictures on patients SANFORD HEALTH | www.sanfordhealth.org be advocates for the arts in general and, recovering from open heart surgery. J Soc VA MEDICAL CENTER - ST. CLOUD | more specifically, in medical education Psychophysiological Res. 1993;30, suppl 1, S7. 20. Nanda U, Hathorn K. Nature vs. abstract art in www.stcloud.va.gov and practice. MM healthcare: What we know, what we don’t know WAPITI MEDICAL GROUP - ER | & what we really should find out. Presented at www.erstaff.com Gary Christenson is director of the mental the Society for the Arts in Healthcare 22nd annual conference in Burlingame, California, April 14, 2011. health clinic at the University of Minnesota’s WAPITI MEDICAL GROUP - HOSPITALIST | www.connecthealthinc.com

July 2011 • Minnesota Medicine | 51 clinical & health affairs |

Tularemia in Two South Dakota Children

By Nadia A. Sam-Agudu, M.D., DTM&H

„ Tularemia may be relatively rare in the United States, but physicians must be able the patient was hospitalized for further to recognize it in order to treat it in its earliest stages. They also need to understand management. Her Lyme disease titer was that most antibiotics are not effective against the disease. This article presents two rechecked on admission and was again cases of tularemia infection among school-aged children in South Dakota who were negative. On physical exam, she had im- successfully treated with IV gentamicin and oral antibiotic combinations. pressive cervical adenopathy (Figure 1a) on her right side that was semifluctuant eported cases of tularemia lived on a reservation in northeastern and mildly tender to palpation. The tick are relatively rare in the South Dakota. About four weeks prior attachment site on the patient’s scalp was United States. However, to hospital admission, she experienced now ulcerated (Figure 1b). Pediatric in- the risk of infection is pres- intermittent fevers that lasted about one fectious disease and otorhinolaryngology Rent in almost every state. States in the week. A deer tick (Ixodes scapularis) was consults were obtained. Given the pa- South Central region have the highest found on her right parietal scalp one day tient’s history and presentation, physical rates; those in the Midwest are not as af- after the fevers started. A large papule exam, previous laboratory results, and fected. Occasional outbreaks occur, and had developed at the site of tick attach- lack of response to antibiotics, tulare- bioterrorism is an ongoing concern. Ul- ment. During the first week of illness, mia was suspected. Her chest X-ray was ceroglandular disease is the most com- she developed mild cervical lymphade- normal, as was tuberculosis skin testing. mon presentation of tularemia infec- nopathy on the right side. She did not Lymph node aspiration was performed tion. Clinicians should know that most have any myalgias, arthralgias, or rash. by the otorhinolaryngologist; gram stain antibiotics used in empiric treatment of During initial evaluation on Day 3 and cultures were negative. The micro- lymphadenopathy in children are not ef- of her illness, her complete blood count biology laboratory personnel had been fective against tularemia. A high index of (CBC) was unremarkable. Lyme dis- alerted to the possibility of tularemia. suspicion and early diagnosis and treat- ease was suspected, and she was treated A peripherally inserted central catheter ment are key to combating the infection. empirically with 14 days of amoxicil- (PICC) was placed, and IV gentamicin This article reports on tularemia infec- lin. However, subsequent Lyme disease was initiated, pending results of Fran- tion in two school-aged children from titers were negative. At her postamoxi- cisella tularensis serology. The patient’s the same area in South Dakota who pre- cillin evaluation, the fevers had resolved, F. tularensis titers were markedly elevated sented with strikingly similar symptoms but the right cervical lymphadenopathy at 1:5,120 (>1:160 is positive). Barton- within days of each other. had worsened. The tick attachment site ella henselae serology was negative. The on her scalp was larger and more ery- patient was discharged from the hospi- Case 1 thematous. She was given five days of tal after two days. She received a 10-day A previously healthy 5-year-old Native azithromycin to treat cellulitis and/or course of gentamicin, with an additional American girl was referred by a local cat-scratch disease (Bartonella henselae 10 days of oral doxycycline for a satisfac- physician for further management of sig- infection). There was no improvement, tory response and resolution. nificant right cervical lymphadenopathy. and the cervical adenopathy progressed The patient had not responded to stan- even further. There was no spontaneous Case 2 dard empiric antibiotic therapy, and the suppuration. Exactly two weeks after the first patient adenopathy had actually progressed dur- After four weeks of illness and no was admitted, the same physician re- ing the antibiotic treatments. The girl response to amoxicillin or azithromycin, ferred yet another patient for manage-

52 | Minnesota Medicine • July 2011 | clinical & health affairs

Figure 1a Figure 1b she had an enlarged left tonsil (Figure 2b). Francisella tularensis titers were elevated at 1: 2,560. Patient No. 2 received 17 days of IV gentamicin and 10 days of oral cip- rofloxacin before her symptoms resolved. At about a year post-treatment, there have been no reported relapses in either child, nor have there been any known pe- diatric tularemia cases from that particu- lar reservation since these children were The patient in Case 1 had impressive cervical adenop- The site of the tick attachment, which became evaluated. athy on her right side. ulcerated. Discussion Tularemia (also known as rabbit fever, Figure 2a Figure 2b deer-fly fever, or meat-cutter’s disease) has become a relatively rare diagnosis in the United States. The annual number of re- ported cases ranged from 300 to 900 from the 1950s through the mid 1960s; since 1985, the number has averaged between 100 and 200.1 However, the risk for infec- tion continues to be present almost every- where in the country; tularemia has been reported in every state except Hawaii.1 The patient in Case 2 had cervical adenopathy on her The patient also had an enlarged left tonsil. left side. States in the South Central United States such as Arkansas and Missouri have the highest rates of endemic tularemia. States ment of a similar-looking left cervical weeks into her illness), the odynophagia in the Midwest generally have much lower adenopathy. Given the first patient’s di- and fever had resolved, but she had de- reported rates. Of note, South Dakota was agnosis, the physician already suspected veloped tender left cervical adenopathy. A in the top five states for reported tulare- tularemia prior to the transfer. Patient “bug bite” associated with tenderness and mia cases from 1990 to 2000, and from No. 2 was a previously healthy 6-year-old swelling was discovered on her left occipi- 2000 to 2008.1,2 When compared with girl, also Native American, who lived on tal scalp. No tick was found. She was pre- other Midwestern states, South Dakota the same reservation as Patient No. 1. The scribed oral cefdinir for bacterial cellulitis (population 819,000) had 62 cases of tu- children were not related, nor were they and cervical adenitis. laremia from 2000 to 2008, Minnesota acquainted with one another. Neither had The left cervical adenopathy pro- (population 5.3 million) had seven cases, traveled significantly, been swimming in gressed during and after the cefdinir and North Dakota (population 676,000) lakes or rivers, or been in contact with do- course. She did not report any myalgias, reported nine cases.2,3 Earlier tularemia mestic or wild animals prior to the onset arthralgias, or rash. She was re-evaluated outbreaks have been reported in South of symptoms. in the clinic on the day prior to admission Dakota, all on Native American reserva- The second patient’s symptoms for progressive left cervical adenopathy. tions; the most recent was an outbreak in- started within three days of those of Pa- Her CBC was unremarkable. Erythrocyte volving nearly 30 cases in 1984.4 tient No. 1. By the time the former was sedimentation rate was 51mm/hour. Lyme Tularemia typically presents as an admitted, she had been ill for almost six disease and Epstein-Barr virus titers were acute febrile illness, with or without ob- weeks. She also had fevers during the first negative. Given the similarity of her symp- vious physical findings. It may present as week of illness. toms to those of Patient No. 1, F. tularensis ulceroglandular or typhoidal disease, with The girl was initially evaluated for titers were sent, and she was transferred to or without pneumonia. Patients with ul- large tonsils and odynophagia, and was our institution for PICC line placement ceroglandular tularemia may present with prescribed amoxicillin for acute tonsillitis, and initiation of gentamicin therapy. Her a tender maculopapular lesion at the bite/ even though rapid group A streptoccocal chest X-ray on admission was negative, contact site that ultimately ulcerates. They testing on a pharyngeal swab had been as was her tuberculosis skin test. The pa- also may have impressive regional adenop- negative. tient’s exam findings were similar to those athy. As with our two cases, the majority On postamoxicillin evaluation (two of Patient No. 1 (Figure 2a); additionally, of patients (approximately 75%) present

July 2011 • Minnesota Medicine | 53 clinical & health affairs | with ulceroglandular disease.5 Typhoidal and Prevention’s surveillance reports;1,2 an unacceptable number of cases may be tularemia occurs in about 25% of patients; in the Arkansas study, almost 75% of missed if clinicians are not aware of the it manifests with high fever, splenomegaly, the children were younger than 6 years almost universal risk in the United States. hepatomegaly, and enteritis. of age.8 Clinicians caring for children in For clinicians who identify a case of There have been outbreaks of tulare- every state should be aware of the risk of tularemia, evidence-based data on treat- mia in various parts of the United States tularemia and consider this diagnosis, es- ment of pediatric patients will likely re- and around the world, especially in Eu- pecially when a child presents with fever, duce complications and result in the best rope. Patients may contract tularemia as adenopathy, or skin lesions that do not outcomes for those patients. Some of the a result of bites from or contact with ro- respond to standard empiric antibiotics. greatest gains may be made in providing dents and lagomorphs, cats, contaminated Physicians should be especially attuned to evidence for clinicians who may otherwise meat/water, deer flies, ticks, and mosqui- the possibility of tularemia in subacute or limit doxycycline and ciprofloxacin ther- toes.5 Tularemia is highly infectious; a sin- chronic cases of unexplained adenopathy apy in children who may need prolonged gle organism is enough to establish clini- in children. The presence or evidence of treatment. Rigorous, multicenter clinical cal disease.5 Inhaled F. tularensis organisms an ulcerated arthropod, insect, or animal studies on the efficacy and toxicity of tu- may cause pneumonia, which has up to bite in an area that is drained by, or proxi- laremia treatment options and combina- 50% mortality. As such, its potential as an mal to, affected lymph nodes is strongly tions would be extremely useful to pedi- agent of bioterrorism is of great concern. suggestive of tularemia. atric providers treating patients with the In these two patients, the presenta- The toxicities, age limitations, and infection. MM tion was somewhat similar to that of stan- lack of Food and Drug Administration At the time of writing, Nadia Sam-Agudu dard bacterial cervical lymphadenitis, al- approval for routine use of tetracyclines was a clinical assistant professor of beit more impressive. The children were ill and fluoroquinolones in young children pediatrics at the University of North Dakota for four to six weeks before tularemia was may cause some providers to hesitate School of Medicine and Health Sciences suspected and worked up. Fortunately, prescribing these medications. However, in Grand Forks, and a pediatric infectious they presented with relatively benign dis- once tularemia is suspected or confirmed, diseases specialist with Sanford Children’s ease, and recovered without sequelae. appropriate initial therapy with gentami- Hospital and Clinic in Fargo. She is currently the technical advisor, pediatrics, for the Standard recommended treatment cin should be initiated. If oral therapy is Institute of Human Virology in Nigeria and an for tularemia is parenteral streptomycin or deemed appropriate for continuation of adjunct assistant professor of pediatrics at gentamicin for at least 10 days.6 Gentami- therapy or if aminoglycosides are contra- the University of Minnesota Medical School. cin has been successfully used in children.7 indicated for a patient, oral ciprofloxacin

Oral agents such as ciprofloxacin and dox- or doxycycline should immediately be pre- REFERENCES ycycline are recommended as alternatives6; scribed for the appropriate duration6; the 1. Centers for Disease Control and Prevention. however, few clinical studies have investi- threshold for prolonged treatment should Tularemia—United States, 1990-2000. MMWR gated their efficacy in and ability to be tol- be relatively low in order to ensure suc- Morb Mortal Wkly Rep. 2002;51(9):181-4. 2. Centers for Disease Control and Prevention. erated by children. Snowden and Stovall cessful treatment and complete resolution. Reported tularemia cases by state-United States, 2000-2008. December 21, 2009.; Available at: www. recently published a retrospective review The second patient, for example, required cdc.gov/tularemia/surveillance/Tul_CasesbyState. of 30 pediatric tularemia cases in Arkansas a longer course of gentamicin, perhaps be- html. Accessed April 4, 2011. 8 3. U.S. Census Bureau. 2010 Resident Population. that occurred between 1996 and 2006. cause of the duration of illness (six weeks) Available at: www.census.gov/. Accessed April 4, The authors noted that children who were before receiving appropriate treatment. 2011. 4. Centers for Disease Control. Outbreak of tick- treated with oral antibiotics alone or with However, both children tolerated oral an- borne tularemia—South Dakota. MMWR Morb shorter courses (d seven days) of initial tibiotics quite well, and did not experience Mortal Wkly Rep. 1984;33(42):601-2. 5. Nigrovic LE, Wingerter SL. Tularemia. Infect Dis gentamicin therapy were more likely to any relapses. Clin North Am. 2008;22(3):489-504, ix. relapse or require prolonged therapy. When compared with Snowden and 6. Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as a biological weapon: medical and public Most of the antibiotics used in em- Stovall’s review (which reported an average health management. JAMA. 2001;285(21):2763-73. piric treatment of routine infections in of three inpatient cases a year in Arkansas, 7. Cross JT Jr., Schutze GE, Jacobs RF. Treatment of tularemia with gentamicin in pediatric patients. children do not affect tularemia, and the a highly endemic state), the diagnosis of Pediatr Infect Dis J. 1995;14(2):151-2. 8. Snowden J, Stovall S. Tularemia: Retrospective diagnosis is typically confirmed by sero- two pediatric cases of tularemia within review of 10 years’ experience in Arkansas. Clin logical tests. Therefore, only when a cli- two weeks of each other in the Midwest Pediatr (Phila). 2011;50(1):64-8. Epub 2010 Sept. 13. nician specifically considers tularemia can suggests that the incidence of tularemia the correct diagnosis be made and proper may be higher than reported. Cases may treatment initiated. present in clusters, perhaps based on tick Children younger than 10 years of populations and/or greater seasonal expo- age account for a significant number of sure to ticks. Therefore, as much as tu- cases in the Centers for Disease Control laremia is relatively rare in the Midwest,

54 | Minnesota Medicine • July 2011 end notes |

„ Snapshot This photo was taken in a rural Maasai village in Tanza- nia that was situated outside the bounds of available health care. Jeremiah Eisenschenk, M.D., then a University of Minnesota medical student, and a fellow student had just completed a health as- sessment on the family, who lived in the inkajijik (Maasai for home) when the mother whispered in Maasai, “Wait, there is one more,” and placed her 3-week-old daugh- ter in his arms. Jennifer Poole, M.D., snapped the photo with Eisenschenk’s camera before they proceeded with the ex- amination. Eisenschenk calls the photo “Arms of Hope.”

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