Physician Recruiting - Minnesota Town Innovates to Recruit Doctors

Asks Humorist Garrison Keillor for Help

Prelude: International Falls ,Minnesota, reputed to be the coldest town in the U.S., is short on doctors. Its 7 person clinic needs a surgeon and three family physicians. So local leaders turned to Garrison Keillor, Minnesota’s icon of humor, to rustle up a few good doctors, He responed on “A Prairie Home Companion,” listened to by 4.3 million listeners on 580 public radio stations, by composing and singing a doctor recruiting ballad. You can listen to it duluthclinic.org. Here are snippets from Garrison Keillor’s Song on International Falls’ Efforts to Lure Doctors. So far 15 doctors have responded to the call for help.

They’re looking for doctors, in International Falls.

Up on the Northern Border, where the loon calls.

They don’t need a psychiatrist, they’re basically all right.

They Need fishhooks removed, and treatment for frostbite.

It’s not a luxury resort with miles of sand beaches,

It’s more known for blizzards, wood ticks, and leeches.

It gets cold in winter so you cannot feel your face.

But for the right kind of person, it could be the perfect place.

Here’s is my limerick commenting on Garrison’s noteworthy effort..

There once was a humorist named Garrison Keillor,

A real fine feeler, not known as a wheeler dealer healer,

Garrison wrote and sang a song calling for physicians,

Who might want to practice and fish under cold conditions.

Among physician recruiters he became a scene stealer


Reference

Damon Adams, “Radio Icon Sings Praises of Minn. Town to Lure Doctors, “American Medical News, June 11, 2007

Clinical Innovations - Health Care at the Work-Site as a Major Innovation

Another Way for Resolving The Clash of Cultures between Managers and Professionals and Reducing Costs

“As a manager of professionals, how often in your career have you had to confront attempts by your professional associates or subordinates to challenge your authority? As a professional, how much longer can you put up with managers who interfere with your right to work autonomously?"

Joseph A. Raelin, The Clash of Cultures: Managers and Professionals, Harvard Business School Press, 1986

One of this blog’s purposes is to acquaint readers with powerful new innovative trends – those with “legs” strong enough to transform health care. In recent years, those trends have included consumer-driven care with its step-children – HSAs, high deductible health plans, retail clinics, and now a new kid on the block – work-site health care.

In one way or another, most major developments in health care have two purposes,

•To resolve conflicts between managers of corporations and independent physicians in order to contain costs, expand access, and improve care. Those conflicts led to the managed care movement – with HMOs serving as intermediaries to bring doctors to heel. Because of rebellions by patients and doctors, managed care largely failed.

•To find organizational models that would achieve these same ends. To date, the most effective models have been physician-led private and academic multispecialty groups and integrated hospital-based health systems with administrators (often physician leaders) and salaried physicians working in tandem.

For the most part, these developments have failed to resolve the authority and cost issues at the workplace. Corporations are hemorrhaging from health benefit costs -- and are desperately seeking solutions – solutions to protect employees’ health, retain employee loyalty, and save costs.

This is where CHD Meridian Health care, a medical management company enters the picture. It proclaims it is a champion of “employer-sponsored care.“ Meridian is a Nashville- based medical management company whose services are designed to provide cost-effective medical outcomes for large employers and their employee, retiree, and dependent populations. CHD Meridian is a managed care and managed cost provider.

The company designs, builds, staffs, and manages employer-sponsored health care work sites offering health care services directly to a company's covered population. Information systems within these sites communicate with existing pharmacy benefit management (PBM) vendors, as well as monitor employees, retirees, and their dependents. CHD Meridian currently provides employer-dedicated services at the worksite to 225 clients.

These services feature work site clinics conducted by salaried primary care physicians and nurses. Employees have direct access to care for workplace illnesses or injuries, chronic disease programs, occupational medicine care, generic drug prescriptions, lab work, physical therapy services – mostly free of charge or at markedly reduced rates. Clients include GE, Toyota, and other Fortune 1000 companies. Savings to date amount to about 20 to 25 percent of benefits costs.

It takes an employment base of about 1700 employees to make these clinics work. Employee coalitions can also avail themselves of these services. This approach reduces acute care expenses, takes care of low risk problems, and helps retain employees. Furthermore, it gives employers tight control of costs, partly because doctors are working on salary have no incentives to provide excess services.
Employer-sponsored health care was pioneered to enable large employers, mid-sized employers, and consortia to directly contract for primary care and pharmacy benefits - and to realize significant savings - without disrupting existing managed care or pharmacy benefit management plans.

Direct contracting reduces costs while improving access and quality of care. CHD Meridian was the first employer-sponsored health care provider to achieve accreditation by the Accreditation Association of Ambulatory Healthcare (AAAHC).

Will work-site health clinics resolve the nation’s health cost and access crisis? Of course not, but these clinics show convenient, lower-cost, consumer-oriented care can effectively be delivered where employers work. And, along with retail clinics, they’re an example of innovative organizational restructuring, outside the usual ambulatory health care settings.

Clinical Innovations - Internet Health Markets – Too Disruptive an Innovation?

Are Virtual Visits and Virtual Markets Too Wild a Dream?

This blog emerges out of two visions,

• One is that of Barry Diller, the Hollywood mogul who has become a television/Internet billionaire (he was the nation’s most highly paid CEO last year, taking home $470 million). His vision was that people would buy goods and exchange information “interactively” through remote, animated, and intensely human encounters on the television and Internet screens.

• The second is that of David Brailer, MD, the former national health information coordinator for the Bush Administration, who resigned last year, and who has now founded, with $700 million in support from Calpers, Health Evolution Partners. This venture firm’s mission is to cut costs, mostly through remote technologies that keep people out of institutions. One of Brailer’s visions is to fund Internet Health Markets, which, among other things, might set up competitive markets to read chest X-rays.

Are these two visions, one from a commercial media mogul and the other from a doctor and economist, too radical – too wild a dream – for cutting costs? Would they call for to wrenching a change in current patient-doctor relationships?

Maybe.

Certainly the visions, fully deployed, would radically change the nature of our health system, which is based on hands-on personal encounters between patients and doctors in private settings in medical offices, clinics, and hospital rooms. Keep in mind, however, that changes wrought by this visions, would be evolutionary not revolutionary.

And so far, legal and regulatory barriers, based on privacy, licensure, reimbursement, turf, and relationship considerations have impeded these visions. Telemedicine, after all, has been around for 20 years, and despite its established cost-cutting powers, has yet to take the medical world by storm.

It’s not that the technologies are not there. Already, American radiologists are outsourcing imaging interpretation to radiologists in India, Australia, and other countries. The same is true of interpretation of complex cardiac rhythm strips. Barriers to outsourcing routine X-rays are likely to fall too.

And remote exams of patients using audio-visual technologies are common in the telemedicine world – and in institutions like Mayo are often used to elicit a second opinion within that institution. Furthermore, audiovisual examinations by doctors and nurses of home-bound patients is established in the chronic disease management industry and has been shown to dramatically cut hospital admissions and emergency room visits.

Which leads to another vision. Why not virtual interactive patient visits – using audio-visual interactivity coupled with measurements of vital signs, blood constituents, blood gases, body mass indices, and information from the patients’ personal health record?

The obstacles remain formidable – radical restructuring of the patient-doctor relationship, medical legal issues, and who shall pay and how. These obstacles are not insurmountable if costs continue to rise, if wireless technologies combining imaging, text, and sound continue to evolve, if medical licensure authorities change their policies, if medical legal threats abate, and if the payment system for physicians is altered to make it reasonable for them to participate.

Clinical Innovations - Disruptive Innovations for Diabetes

No Miracles Among Friends

I see the Robert Wood Johnson Foundation is staging an international competition to identify the top “disruptive innovations” in the health care world.

You can find the rules for entry by googling “Robert Wood Johnson, disruptive innovation.” The competition closes on July 8, when the top 12 finalists will be selected. I congratulate the foundation on their effort, and I wish them luck.

Disruptive innovations are likely to be the backbone of improving health care – especially for addressing the epidemic of obesity and diabetes, now so prevalent in the Western World.

Disruptive innovations are innovations that make any product or service more convenient, less expensive, quicker to use, more effective, and more accessible to users. In health care, it’s important to point out that most disruptive innovations are not miracles – like open-heart surgery or multiple organ transplants, or in the case of diabetes, pancreatic transplants or bone marrow transplants to cure juvenile diabetes.

Two stories come to mind to make the point.

•During he early days of the first century, faithful disciples roamed the land preaching and winning converts. One day, St. Peter and St. Paul arrived at an inn in Jerusalem, weary and footsore. They called for wine and refreshed themselves, then fell into an argument as to who should pay. To settle the dispute, they threw dice. Paul shook the box and threw a four and a five. Peter followed and threw two sevens. Paul gave him a long look, and said sadly,”Peter, old man, no miracles among friends, please.”

•The other tale involves three surgeons boasting about their best operations at the height of the Cold War... The English surgeon said, “I once performed brain surgery on a deaf mute and restored him to full hearing and speaking.” The American said, “I did a spinal cord transplant on a quadriplegic and restored him to full movement.” The Russian said,” I removed a man’s tonsils “The English and American surgeons, astonished, asked,”What’s so miraculous about that?” “Because, “explained the Russian, “In my country, people are afraid of opening their mouths, and I have to remove them by coming from a different direction.”

Diabetes is like that. You have to approach it from different directions – high tech and high touch, prevention and maintenance. Many high tech approaches, which are essential disruptive innovations – insulin, inhaled insulin, insulin-pumps, monitoring devices, other drugs, and transplants – have been tried and work for many but often fail to stem the tide of complications.

For most doctors, controlling diabetes demands attention to preventive details and instructing patients ( To get the attention of his patients, Stanley Feld, MD, an endocrinologist in Dallas, had his diabetic patients sign a contract saying they would either abide by his rules or not be his patients. He also issued patients T-shirts bearing the words: “In Control!”).

For doctors, prevention entails,

•Precise blood glucose control

•Inspecting the bottom of patient’s feet – something many obese diabetics can’t do for themselves.

•Assessing loss of sensation in feet and lower limbs.

•Monitoring blood pressure.

•Checking blood lipids, blood creatiine and creatine clearance, and urinary albumin.

•Protecting the kidney with new drugs.


•Making sure patients take oral diabetic agents and insulin correctly.

•Instructing patients on proper diets and having a nutritionist or dietician re-enforce their message.

•Encouraging patients to lose weight and exercise (obesity is considered a precursor to most adult diabetes).

•Managing complications – blindness (the leading cause of adult blindness), heart disease and stroked (causes 65% of deaths among diabetes), kidney disease (accounts for 44% of case of kidney failure), and amputation (more than 60% of lower-limb amputations occur in diabetics).

Among diabetics and their physician friends, there are few miracles, because old habits are hard to break, and treatment regimens are hard to follow. But there are disruptive innovations on the horizon. Until these disruptions mature and take hold, the physicians’ best bet for controlling the vascular catastrophes associated with diabetes is strict adherence to best practice guidelines and rapt attention to clinical details.

Physician Recruting - A Book Review: Everything You Ever Wanted To Know About Physician Recruiting but Were Afraid to Ask

Merritt, Hawkins, & Associates Guide to Physician Recruiting, April 2007, 155 pages, $89 + $12.95 for shipping, 800-967-7790

Every once in a while a book comes down the pike that is worth every cent you pay for it, even though the price may seem high at first glance.

Merritt, Hawkins, & Associates Guide to Physician Recruiting is such a book. It contains information for recruiting doctors you won’t find in such compact form anywhere else. It is based on the Merritt, Hawkins, & Associates 20 years of experience in the recruiting field and on its numerous surveys of young physicians.

This is a no nonsense book. It contains facts on the physician shortage, what doctors want, where they want to settle, what they expect in terms of salaries and benefits, what salaries and benefits are being offered, why foreign medical school graduates are essential to the health care system, what the split is between females and males in various specialties, why locum teens have become an important commodity, what you have to pay doctors for emergency room coverage, how you can persuade doctors to join your group or hospitals, and a cogent introduction on who doctors think and why doctors are different than most other professionals. In short, this book contains everything you might possibly want to know about recruiting doctors.

The book is about physician search as a sequential process, as a kind of physician search safari. It answers these questions: Where do you look when you seek a physician? Will it be hard to find the right physician? Who else is looking? What are the legalities involved? What’s your game plan? Who’s on your safari team? What kind of pay and benefits should you offer? What resources do you need? The book is not only valuable for the hunter, but for the hunted. If you’re a physician being recruited, you will find more information here than anywhere else I know.

Finally, the book brims with information you may not have known:
Did you know?

•There will be a projected shortage of 200,000 doctors by 2020

•The five major causes for physician turnover once you have recruiting them

•The return of investment and efficiency gains of physicians who invest in specialty
hospitals

•The base salaries/guarantees being offered to physicians

•The average incomes generated by physicians by specialty for hospitals

•The physicians and types of physicians required per 100,000 population

•Overhead as a percent of income in practices.

•The percent of residents who are female in various specialties

•The number of international medical graduates by specialty

•The percent and size of hospitals recruiting doctors

•Salaries being offered as indicated in various compensation surveys

•The IRS/HHS/Stark recruiting regulations.

I thought not. You will find this and other hard-to-find nuggets of information between this little volume’s covers. If you’re looking for just the right doctors for just the right price for just the right reasons, buy this book, read it, absorb it, pass it around.

Heart Disease - HeartMath – Why Understanding The Mathematics of Heart Rhythms Helps Reduce and Correct Stress

Measuring and Minimizing Stress And
Reducing Deaths From Coronary Artery Disease

In conclusion, our analyses suggest that approximately half the recent decrease in deaths from coronary artery disease in the United States may be attributable to reductions in major risk factors and approximately half to evidence-based medical therapies. Future strategies for preventing and treating coronary heart disease should therefore be comprehensive, maximizing the coverage of effective treatments and actively promoting population-based prevention by reducing risk factors.

Earl S. Ford, MD, MPH, “Explaining the Decrease in U.S. Deaths from Coronary Disease, 1980-2000, New England Journal of Medicine, June 7. 2007

This week I met Dr. Bruce Wilson, a cardiologist who practices in Milwaukee. Bruce is an academic cardiologist, founder of a specialty heart hospital, and medical director of HeartMath, LLC., a 15 year old company dedicated to studying, measuring, and reducing stress as a factor in causing and aggravating coronary artery disease.

Stress isn’t always mentioned as a cause of coronary artery disease, but Bruce has no doubt it’s perhaps the major underlying factor in the high-strung fast-paced U.S. society.

What are the usual risk factors mentioned as causing coronary artery disease?

According to an article in this week’s New England Journal of Medicine, multiple factors led to and contributing to 62% fewer deaths in men and 49% fewer deaths in women from coronary disease in the U.S from 1980 to 2000.

About 44% of these changes were attributed to reduction of these risk factors:

•Decrease in total cholesterol concentration, 24%

•Systolic blood pressure, 20%

•Smoking prevalence, 12%

•Physical inactivity, 5%

These reductions of risk were partially offset by increases in,

•Body mass index, 8%

•Prevalence of diabetes, 10%

About 47% of the decreased deaths were attributed to these treatments,

•Preventive treatments after myocardial infarction (bypass and revascularization), 11%

•Initial treatments for myocardial infarction and unstable angina, 10%

•Treatment for heart failure, 9%

•Revascularization for unstable angina, 5%

•Other therapies, 12%

The New England Journal article didn’t mention stress as an important risk factor, perhaps because stress is subjective and difficult to measure, i.e., isn’t quantifiable. Yet some experts like Wilson maintain daily stress may be a more important, overarching, contributing background cause than all other risk factors combined.

This is where Dr. Wilson enters the picture. He believes stress may be as important a risk factor to consider as an elevated cholesterol and LDL cholesterol, a low HDL cholesterol, increased weight, elevated blood pressure, and decreased physical activity combined. . His ideas, and those of HeathMath, are being implemented and tested at a number of major academic cardiovascular centers.

HeartMath LLC is a performance company providing a range of services, products, and technologies to boost performance, productivity, health, and well-being while dramatically reducing stress.

The name HeartMath derives from the fact that the company is based on the mathematics of heart rhythms and how these rhythms “entrain” other body organ systems, including the brain, during periods of stress, which in Western society, preoccupies us during most of our waking moments.

One of HealthMath’s products is EmWave, a small 2.2 ounce handheld device people can carry with them in their pocket or purse to relieve stress and restore tranquility and “coherence” in their thinking, performance, and brain function.

Founded in 1991 as a non-profit research organization by Doc Childre, HeartMath has earned global recognition for its research-based techniques and proprietary technology to transform the stress of change and uncertainty, and to bring coherence and renewed energy to the workplace, and the home.

It is common knowledge that meditation, happiness, calmness, lack of anxiety, reduced stress on the job or in a marriage or other relationship may prevent coronary disease or enhance healing after a coronary event.

Over the last 15 years HeartMath, LLC, has devoted itself to reducing stress as a cause of coronary disease. It has advanced the idea and developed technologies to measuring stress levels by recording the heart rate variability through an electrocardiogram or a analysis of pulse rhythms as recorded on a portal device worn on the wrist or ear.

Cardiovascular recordings, in short, are a measure of one’s emotional state or “intellectual coherence.” By thinking of positive things like appreciation, love, or happiness, one can change the heart rate variability. This change, an increase in variability, in turn, emotionally and physiologically reduces stress. One can see this change reflected in a visible “freeze frame” on a handheld device known as the EmWave.

Wilson and his associates believe one can use this portable device to measure and decrease stress, improve intellectual performance on the job, prevent coronary disease, and promote healing. Dr. Wilson has written a book The HeartMath Approach to Managing Hypertension and is in demand as a speaker on how HeartMath’s technologies can be used to reduce stress and minimize the risk of coronary artery disease.

I don’t pretend to be an expert on such matters as heart rate variability as the body’s master guidance system controlling stress, or on stress a major cause of coronary artery disease. But for your edification and to introduce you to the language of heart rate variability, I submit this excerpt from an article by two HealthMath advocates.

New Tool for Stress Reduction, Rehabilitation, and Performance Enhancement

Rollin McCraty, Ph.D. and Dana Tomasino, B.A.

An Introduction to Heart Rate Variability Feedback

Heart rate variability feedback is an exciting new technology that has broad-based applications in stress reduction, rehabilitation, and performance enhancement.
This article focuses on heart rhythm coherence feedback training, which has proven to facilitate rapid, profound, and enduring improvements in a wide variety of conditions.

An important reason this technology is effective in so many and diverse applications is that it facilitates the maintenance of a physiologically efficient and highly regenerative inner state, characterized by reduced nervous system chaos and increased synchronization and harmony in system-wide dynamics.

This psychophysiological mode, termed physiological coherence, is conducive to healing and rehabilitation, emotional stability, and optimal performance.
This article provides an introduction to heart rate variability feedback, explores its advantages, and discusses the use of heart rhythm coherence feedback to promote the physiological coherence mode.

A new heart rhythm coherence monitoring and feedback system known as the Freeze-Framer is introduced, and examples of the effective use of this technology to reduce stress and promote positive emotional states and coherence in a wide range of wellness and performance enhancement applications are presented.

Significance and Measurement of Heart Rate Variability

Heart Rate Variability (HRV) is a measure of the naturally occurring beat-to-beat changes in heart rate. The analysis of HRV, or heart rhythms, is a powerful, noninvasive measure of neurocardiac function that reflects heart –brain interactions and autonomic nervous system dynamics.

HRV can be derived either from the electrocardiogram (ECG), using electrodes placed on the chest, or from pulse wave recordings, using a plethysmographic optical sensor placed at the fingertip or earlobe.

ECG recordings have the advantage of producing fewer movement-related artifacts. However, pulse wave recording devices also provide data suitable for most applications, and, as they require no electrode hook-up, are more easily adaptable for use in a much wider variety of settings (see below).

Advantages of HRV Feedback

A promising advancement in biofeedback technology is the recent development of HRV feedback systems. In relation to other types of biofeedback, HRV feedback offers several unique advantages. First, HRV feedback reflects the activity of both the sympathetic and parasympathetic branches of the autonomic nervous system and the synchronization between them, and thus provides a window into the dynamics of the system as a whole.

Compared to EEG feedback, HRV feedback is also considerably simpler and more straightforward to learn and use, which facilitates rapid improvement. Further, because the instrumentation utilizes only a simple pulse sensor requiring no electrode hook-up, it is extremely versatile and can be used easily and effectively as an educational tool not only in clinical settings but also in the home, in the workplace, in schools, or even while traveling.

Its cost-effectiveness also makes it accessible to a greater number of people and in a wide range of applications. In relation to other biofeedback modalities, HRV feedback is also more reflective of changes in emotional/ psychological state, and thus is particularly powerful in applications where reducing stress and increasing emotional stability are critical.