Des Moines University Clinic

Hologic’s Discovery A™ system with dual X-ray bone densitometry technology provides “significantly more information” and does so more accurately than the 10-year-old equipment it replaced, says Jean Schuster, radiology manager.

The new system enables the clinic’s certified DXA technologists to assess bone health, including structural geometry of the hip and existence of vertebral fractures. This information allows providers to diagnose and monitor patients with such fractures and osteoporosis.

“By detecting low bone density and vertebral fractures, the patient can begin treatment and avoid further complications,” Schuster says. “It’s exciting to be able to provide that information.”

Identical to the unit featured on NBC’s “The Biggest Loser,” the equipment will aid researchers exploring bone density, nutrition and exercise. It accurately measures fat mass, lean mass and total body mass for the entire skeleton as well as individual parts of the body.

The Hologic DXA unit can accommodate patients ranging from infants to adults up to 450 pounds. An additional bonus for patients and staff: The equipment generates information painlessly, non-invasively and quickly. “The longest scan takes 60 seconds,” Schuster notes.

Learn more about Des Moines University Clinic’s Radiology department.

Elizabeth Trausch, D.P.T. DMU Clinic

Wetting one’s pants after sneezing. Discomfort while sitting. Painful intercourse. Millions of women are believed to suffer these and other pelvic floor disorders along with the physical, emotional and social nightmares they create. Many suffer silently, too embarrassed to discuss these issues even with their physicians.

DMU’s Physical Therapy Clinic can offer solutions, however. Its specially trained staff use manual techniques along with computer technology, called EMG biofeedback, to evaluate and measure length, tone and strength in the pelvic floor muscles. This technology helps the therapist analyze the problem and propose treatment.

“If the pelvic floor muscles are weak or uncoordinated, a woman can have incontinence issues and/or pain. There may be trigger points and tightness in these muscles, just like any other muscle in the body,” says Elizabeth “Libby” Trausch, D.P.T.’08, a DMU Clinic therapist trained to treat patients using EMG biofeedback. “Women with pelvic floor muscle disorders may experience frequent urination or leaks, which may cause them to avoid social settings. They may experience pain during intercourse, a poorly localized ache between the legs, feel like they’re sitting on a golf ball or even experience low back pain that does not seem to be improving with other interventions. Resolving those issues can make a big difference in women’s lives.”

Pelvic floor disorders, as well as pelvic organ prolapse, are caused by several factors, including pregnancy and vaginal delivery or C-section, injury, pelvic surgeries and resulting scar tissue, heavy lifting, obesity and heredity. Pelvic organ prolapse is a condition in which female pelvic organs protrude downward into the vaginal area, causing pressure and pain.

EMG biofeedback provides an immediate visual representation of contractions in pelvic floor muscles, indicating their strength, endurance or lack thereof. That feedback augments other findings and assists the therapist and patient in identifying solutions.

“Patients can see how much or how little their physical efforts contract their muscles,” Trausch says. “It’s wonderful motivation for them to work harder on specific exercises that can address the problem. A study has indicated that 40 percent of women perform Kegel exercises incorrectly, so physical therapy intervention can be a tremendous help in identifying the correct muscles and using them effectively.”

Trausch also works with patients to “retrain” their bladders with diaries, exercise, diet and nutrition, giving them greater control and longer periods between trips to the bathroom.
“We work with patients in a physical therapy environment that analyzes their posture, strength, core and hips as well as pelvic issues,” she says. “We combine education with private, gentle, effective care.

“I’m excited about how we can help patients in this way,” she adds. “A woman may have been dealing with incontinence, discomfort and pain, never realizing something could be done. We can help.”

Winter 2010 Annual Report

• DMU’s well-rounded wellness program goes platinum
• Great needs fuel passion for physical therapy
• An era of accomplishments
• New positions, new opportunities
• Scholarships inspire students
• DMU Clinic takes care of community
• Sim Center snapshot
• Inspiring tomorrow’s health care providers, scientists

In the University’s Homeless Camp Outreach, students learn to help people “where they are” – and gain compassion in the process.

“Who’s going to the new camps? Who’s going to the levee?”

“There should be plenty of batteries in your bags.”

On a sunny Sunday morning, 14 DMU students and friends assemble in the Academic Center parking lot, chatting amiably while D.O. student Katie Melton’s dachshund mix zips around excitedly. They divvy up coffee urns, Styrofoam cups and a dozen bags and backpacks filled with socks, winter caps, blankets, batteries, cat food and other items.

“HCO has been a weekly reminder to think beyond oneself,” says first-year liaison Nathan Palmolea, D.O.’13. “By simply increasing awareness of social justice issues, I believe we can make significant progress in solving them.”

Thus equipped, members of DMU’s Homeless Camp Outreach (HCO) pile into cars and set out to visit people in Des Moines’ homeless camps.

“I call it global health in our own backyard,” says Sharon Mueller, M.A., family medicine faculty member and HCO adviser.

She and D.O. students Sikander Khan, Rachel Agneberg and Michelle Heaton stop at Krueger’s Amoco on Southwest Ninth Street to fill their coffee urn. Suzie, the cashier, greets them and rings up the coffee, three individual cups of coffee and two bags of day-old doughnuts. The total charge: $3.88.

“The owners know the students are doing this for a good cause,” she smiles.

The group continues south and pulls into an empty warehouse parking lot. Coffee and bags in hand, they mount the levee along the Raccoon River. Nested along the riverbank below lies a camp of tents, tarps, clotheslines, coolers and furniture.

“Hello! Can we come down?” Mueller calls out.

“Sure, good morning!” is the friendly reply.

Mueller and DMU student Sikander Khan, left, admire their cat, Sunset. “Most homeless people haven’t done anything bad or wrong; they just ran out of luck,” Mueller says. “Any of us could be in the same boat.”

Many homeless, many reasons
According to the Iowa Institute for Community Alliances, 17,476 Iowans were homeless in 2008, tracked by a statewide information system used by most homeless agencies in the state. More than 6,100 were in Des Moines. Nearly 3,000 more in the city received services – such as in shelters or transitional housing – to avoid homelessness.

“There are so many different types of people who are homeless – families, individuals, the chronically homeless, in shelters off and on, the newly homeless,” says Deirdre Henriquez, program manager of the advocacy team at Primary Health Care Inc. (PHC), a federally funded community health center that offers and helps coordinate services for the homeless.

A number suffer addictions, mental illness, physical disabilities or family problems. The economic downturn and lack of jobs also contribute. Some are second- or third-generation poor or homeless.

“There are as many reasons people are homeless as there are homeless people,” says Joe Stevens of Joppa Outreach, a nonprofit organization that began helping Des Moines’ homeless in 2008. “That’s why we work to end homelessness, one person at a time.”

“Listening to life”
As a first-year D.O. student, Winston Willis often took study breaks “biking in strange places.” He remembers an especially beautiful day when, basking in his ride, he noticed a person “tucked up under the girders” of a freeway overpass.

Willis couldn’t ignore the situation. A former smoke jumper for the U.S. Forest Service, he’d spent his months off volunteering at nursing homes and juvenile detention centers. “I wanted to put myself in positions to meet people and see the world through their eyes,” he says. “It’s listening to life – how you’re going to meet others in your heart.”

It’s also key to a medical career, he says. “Compassion, humility, teamwork and dedication are all part of being professional,” he notes.

Mary teases her husband, Rick, about the birth date they share, Valentine’s Day. They became homeless in October after Rick’s employer, Regency Homes – once Iowa’s largest developer – went bankrupt. They preferred their small tent over the bedbug-infested apartment where they previously lived, but Mary’s medical needs, stemming from surgery she had in 2008 for a brain tumor, make their situation especially difficult. “We can’t stay here,” Rick says.

In fall 2008, Winston donned a backpack of bottled water and socks and set out to meet homeless campers and survey their interest in visiting with medical students. Classmate Charles “Jace” Taylor joined him. They soon discovered they had more to give than the basics of clothing, food and fuel.

“The thing we hadn’t anticipated was the personal relationships we could have with the people we met,” says Willis, D.O.’11, now in an internal medicine rotation at Des Moines’ Mercy Medical Center. “The snowball was officially rolling down the hill.”

Willis is preparing a poster presentation for the annual meeting of the American Association of Colleges of Osteopathic Medicine (AACOM) in April on how the outreach developed and its “utility as a tool for validating the humanity of the campers and fostering professionalism in our students.”

“As simplistic as it is, my goal is to change the world. And we’ve already done that by changing people’s minds,” Willis says. “We have students saying, ‘I never knew I could just talk to them.’ They will take that to their practice.”

From December 2008 to early December 2009, 71 individuals – mostly DMU students, with some employees and friends – had provided more than 1,050 volunteer hours in homeless outreach, 1,005 of those in the camps. HCO is now a university-recognized special-interest group, receiving modest funding and staff support in coordinating bulk purchases and donations.

“It keeps you really rounded if you work with people different from you,” says Christina Donat, D.O.’12, HCO vice president. “If you can’t understand their situations, you can’t understand your patients. You have to see each person and meet them where they are.”

The students’ views aren’t naïve or romantic. They know some homeless people abuse alcohol and drugs, are dangerous to themselves or others, fail to take their medications or simply make bad choices.

“It can be a weekly challenge,” says HCO President Sikander Khan, D.O.’12. “For example, one [homeless] woman was pregnant, it was cold and she was walking around barefoot. And sharps were all over the ground! But you have to step back and not judge.”

A kind greeting, a warm blanket, a pack of batteries – small things make a big difference to homeless individuals.

Out, but not down
At the levee camp, Sharon Mueller exchanges a bear hug with Jim, a tall, trim ex-Marine with a broad smile and jovial sense of humor. He accepts coffee from the students and shows them how he’s winterized his tent, by sandwiching a blanket between it and a tarp on top.

Michelle, who shares a tent 20 yards away with her two American bulldogs, strolls up for coffee and conversation. A homeless woman on her own, she contemplates the pale blue sky. She’s waiting for the day to warm up, so she can wash her hair in a bucket.

“I’m so glad it’s a nice day,” she says, returning to her tent. At that moment, the Weather Channel reports the temperature as “42 degrees, feels like 36.”

Mueller asks Jim if he needs anything special. “I lost my sunglasses,” he says. The group laughs as he tries on Mueller’s rhinestone-edged pair.

Jim’s expression darkens, though, as he talks about being downsized in November 2008 from a job he’d loved for six years. Unable to pay rent, he moved to the river last March.

“I grew up middle class – I’d never been homeless before,” he says. “I don’t want to be here this winter. I’ve applied for jobs. When I applied at Taco Bell, the manager just looked at me. I know the minute I turned around, that application went into the trash.

“It’s hard to walk in and put your best foot forward when you look and smell like a river rat,” he adds.

Leveraging resources
While Iowa’s harsh winters make tenting year-round a hardship, Des Moines has a positive reputation among some homeless for its “strong base of caring, compassionate agencies” that work together to help, says PHC’s Henriquez. PHC, Joppa Outreach and other social service agencies formed the

Street Outreach Coalition to coordinate and leverage resources and services, from shelter options to food stamps to medical care. HCO is a new member of that team.

“The DMU students have done a wonderful, wonderful job,” Henriquez says. “I’m so impressed by their passion and efforts. It’s so important – we want medical personnel to be aware of issues of the homeless.”

HCO members don’t provide medical care to homeless people, but they help refer them to available services and help in other ways. Rachel Agneberg and Michelle Heaton have accompanied their friend Bob – a self-described “urban survivalist” – to his physical therapy and psychiatric appointments. The two second-year D.O. students met him through the University’s Chronic Care Program, which has given them insight on both the medical profession and homelessness.

“Bob has been homeless so many years, his medical records are with doctors in different states. We’ve seen what his doctors have to do to continue his care,” Agneberg says.

When his physical therapist recommended he use a $40 TENS machine to help reduce his back pain, the two women pitched in to pay for it. “Bob and his wife live on less than $150 a month, which puts that $40 in perspective,” Agneberg says. “He was so grateful.”

During a cold snap last fall, Agneberg, worried about Bob, sent an e-mail message around to her classmates to ask for any help they could give. “I got about 30 jackets, boots, shoes, blankets, backpacks,” she says. “The community of this school is so giving.”

She notes, though, that she and her classmates get more than they give in their friendships with homeless people.

“Even with his health and other problems, Bob has a great outlook on life. He’s opened my eyes to looking at a patient as a person, not a stereotype,” she says. “It’s made me so grateful for everything I have and that’s been given to me.”

HCO adviser and DMU faculty member Sharon Mueller greets Jim and Alyssa, who camp on the Raccoon River levee.

Parting thoughts
As Mueller and the three students finish their visits to the levee camps, Khan reviews notes he’s recorded on his iPhone on each person’s needs: size 10 pants for Mary, compression hose for Rick, Ibuprofen for Dave, film for a Minolta camera Bob found in the trash. They smile at the Christmas decorations adorning Al’s “cabin,” made of recycled lumber and other materials.

They comment on the growing chill. The once blue sky is now cloud-covered; the temperature is just shy of the day’s high 45 degrees. They think about Michelle, washing her hair in a bucket.

Most of all, the students think about their friends. Despite the great challenges homeless people face, Agneberg tells other students to participate in outreach efforts with “an open mind and an open heart.”

“If you want to learn, understand medicine, you’ll take away the education of a lifetime,” she says. “You will grow not only as a physician, but also as a person.”

Learn how you can help in your community, or support DMU’s Homeless Camp Outreach by contacting Sharon Mueller.

Fitness force: Wellness director Joy Schiller shows off DMU’s platinum well workplace award and its wellness staff-Shelby Herrick, Nicole Frangopol and Shannon Kalsem, M.H.A.’03.

Like many, Samina Akbar, Ph.D., had struggled with her weight for years. She’d tried various diets, lost weight and gained it back. In her first year at DMU, the assistant professor of microbiology and immunology felt too busy to exercise.

But Akbar also knew of her parents’ history of high blood pressure. She wanted to be healthy for her husband and their two children. And then she read a heartfelt essay by student Richard Rapp, D.O.’11, about his determination to win his own battle to lose weight.

“Something clicked for me this time,” says Akbar, who now exercises at least five days a week. She reviews notes and prepares lectures while using one of the Wellness Center’s elliptical machines. She’s cut her daily caloric intake to less than 1,000 – according to the American Cancer Society, the average American consumes more than 2,600 – and joined DMU’s Weight Watchers program. She’s shed 40 pounds.

“For the first time in my life, I’ve wanted to exercise,” she says. “I’ve definitely noticed the difference. When I’d come up the stairs, I used to be out of breath. Now I can go up the stairs while talking to people.”

Akbar is among hundreds of DMU employees, students, spouses and alumni who regularly use the University’s 25,000 square-foot Wellness Center, sweat through its fitness classes or intramural sports, and get personal consultations from its four full-time staff.

Employees also can earn money for working out, getting preventive health care and participating in other health-related activities through DMU’s Wellness Pays program; in fiscal year 2009, employees earned nearly $35,900 in these incentives.

For its comprehensive wellness offerings and operating plans, in August DMU became the nation’s first university or college to earn the highest recognition granted by the Wellness Councils of America (WELCOA )

“That gave us a real sense of accomplishment,” says wellness director Joy Schiller, M.S. “With DMU as a health sciences university, it’s imperative we be a role model for other organizations.”

Achieving platinum status was a 20- year process, says Schiller, who became DMU’s first wellness program director in 1989. At the time, the campus workout area was the gym of St. Joseph Academy, the former Catholic girls’ school that the College of Osteopathic Medicine – now DMU – took over in 1972.

“The showers by the gym were constructed for young girls, so they hit at about navel level for some adults,” recalls lanky biochemistry and nutrition Chair David Spreadbury, Ph.D. He was on the committee that recommended Schiller’s hiring. “That makes this recognition all that much sweeter for those of us who lived through it.”

DMU is an Olympian among wellness programs now. In WELCOA ’s seven benchmarks, it scored 179.6 out of 180 possible points. One reason DMU earned platinum status is that it links worksite health promotion objectives with business outcomes. One tool in that effort is the annual comprehensive health questionnaire, or “personal wellness profile” (PWP), offered free to employees. Individual results help each participant see where his/her health behaviors should change; aggregated results, tracked year to year, guide wellness staff in designing programs.

Those results show that the University saves money through better employee health: Fiscal year 2009 was the third consecutive year that health care premiums did not rise for DMU employees. Also that year, the number of employees with just one or no major health risk factors – the “healthiest” category – rose 9.4 percent, to 117 PWP participants.

“The PWP is so important in helping us assess and address employees’ health risk factors,” Schiller says.

Equally important is the positive support of DMU’s wellness staff.

“A huge credit for my success goes to the wellness staff,” Akbar notes. “I have never seen such a great group of non-judgmental people. I owe them big thanks.”

How well is your workplace?
The Wellness Councils of America, which serves more than 3,200 member organizations nationwide, uses seven benchmarks to evaluate the wellness of a workplace:

• Strong CEO-level leadership and support
• A cohesive wellness team
• Data collection to drive health efforts
• An operating plan that defines what the wellness program expects to accomplish
• Appropriate health promotion interventions based on collected data
• A supportive environment
• Ongoing, consistent evaluation of outcome

Physicians typically dash from one patient or procedure to another through long exausting days. Jeannie Pflum, D.O.’97, an obstetrics and gynecology doctor in Santa Rosa, CA, is no exception.

When they’re able to pull free for a while, most doctors like to slow down. Here, Pflum is an exception.

A speed demon since she was old enough to commandeer two wheels or strap on a pair of skis, Pflum gets her heart pumping while off-duty by pushing super souped-up cars and motorcycles to their limits on table-flat dried lakebeds.

She’s the second woman to be clocked at over 300 miles per hour in a car, but the only woman to reach that speed in a car and also set a speed record on a motorcycle. In October, Pflum established a new record by donning an armor-plated leather suit, hunkering down behind the handlebar of a 1,000cc motorcycle in the desert near El Mirage and accelerating to 186.4 miles per hour.

“It was fun!” said the doctor, who’s 44, the mother of two and stepmother to two more. “It definitely makes my blood pressure go up.”

She joined a super-select club of drivers in October 2002 when she hit 302.179 mph in a torpedo of a car built by family friend Seth Hammond of Santa Barbara, a big name in the costly, adrenaline-rich sport of chasing land speed records.

Pflum will tell you it is an absolute rush to go more than 300 mph in a car, maybe even more of one to accelerate to nearly 200 mph on a motorcycle. But the main reason she treks to the torrid Bonneville Salt Flats and El Mirage to push wheeled vehicles to speeds typically known only by contraptions with wings?

It’s to spend quality time with her dad.

“People ask me, ‘Why do you do this?’ It’s because my father started me,” Pflum said. “It’s a really cool father-daughter thing.”

Breaking speed records is Jeannie Pflum's idea of fun - and a great way to spend time with her dad, Lee Gustafson. Above, Pflum and friend Seth Hammond prepare Gustafson for a race.

Her dad is Lee Gustafson, a retired boat-store owner in San Luis Obispo County, CA. All his life, Gustafson has loved to build engines.

“He tells me a story about taking an engine apart on his bed, and his grandmother wanting to kill him,” his daughter said.

For decades, Gustafson has built engines for Seth Hammond, who for fun creates some of the fastest cars in the world.

Hammond and Gustafson both set records in the long, tubular Lakester-class car (think of a Cub Scout’s Pinewood Derby racer).

Jeannie Pflum grew up hanging out with Hammond and her dad as they built crazy-fast cars and accompanying them to the Bonneville Salt Flats to see what they could do. As a young woman she left

Southern California to pursue a career in medicine – she studied at the medical school that would become Des Moines University, then served her residency at the University of Vermont and joined the Sutter Medical Group of the Redwoods. She’s an ob-gyn specializing in minimally invasive gynecological surgery.

But she never stopped trekking to the desert whenever possible to spend time with her dad and to share in his love of cars built solely to go fast.

“It’s a father and daughter, ‘I’m going to go hang out with my dad’ sort of thing,” she said.

In 1999, she decided to do more than watch. She asked to drive the Lakester on a speed run. Her father and Hammond, whose wife, Tanis, began driving in 1986 and broke several records, saw no reason to deny Pflum. Though it’s inherently dangerous to drive a car more than 200 mph, the Hammond-Gustafson team holds that a trained, properly suited and belted driver in a well-built car is less likely to be hurt on the lakebed than on the highway drive home.

Pflum is astride the cycle on which she exceeded 190 mph.

These days Pflum is focused on reaching 200 mph on a Honda 1000cc motorcycle modified and owned by another colleague of Hammond and her father, Jamie Wagner of Torrance, CA. She figures the 186.4-mph record she set in October on a 1.3-mile course at El Mirage was a good step. One of the best parts of that run: Her dad didn’t think he’d be able to make it there, but he arrived just in time to see her go.

Speed-demon Pflum sets another record
After this article was published on Nov. 2, Jeannie Pflum set a new record on a Class 1000cc production motorcycle, owned and built by Jamie Wagner, of 190.198 miles per hour. She set the record Nov. 14 on the El Mirage dry lakebed in the Southern California desert.

The Southern California Timing Association (SCTA) is the sanctioning body for the Bonneville Speed Week events in August and the El Mirage dry lakes events held once per month, May through November. To compete at the lakebed, the owner and rider must be members of a participatory club. Pflum is a member of the Gear Grinders out of Southern California.

Created by the College of Podiatric Medicine and Surgery (CPMS) and Iowa Health System, the three-year residency program – through Iowa Methodist Medical Center – is one of only three in Iowa and the only one in Des Moines. The residency was established through the combined efforts of Eric Barp, D.P.M.’01, FACFAS, and Linda Bratkiewicz, D.P.M.’91, FACFAS, both podiatric physicians with Iowa Health and the CPMS administration. Bratkiewicz was appointed director of the program early in its development.

“This residency encompasses every aspect of foot and ankle reconstructive surgery. Residents will complete several rotations in internal medicine, pathology, rheumatology, general and vascular surgery, behavioral medicine and other areas,” Bratkiewicz says. “That’s important, because we’re part of a large medical group. It really benefits the resident as well as patients to have that team approach.”

The residency offers a high number of and wide variety in surgical cases, she adds. Another advantage is the strong support of the directors and staff of Iowa Methodist’s five other residency programs.

“They bent over backward to support it,” Bratkiewicz says. “A lot of programs don’t have that camaraderie or financial commitment. All our residents are paid the same salary and benefits, and more than most podiatric medical residencies.”

The residency received provisional approval from the Council on Podiatric Medical Education (CPME) in October. The program is partially funded by a grant from the Iowa Osteopathic Education and Research Fund for its first three years.

Roger Drown, D.P.M.’09, the program’s first resident, says he “took a gamble” by pursuing it when it was applying for CPME approval. But he knew he’d benefit from working with Bratkiewicz and Barp; he and his wife, Lisa, and their five children also wanted to stay in Des Moines. He’s come to appreciate the “great enthusiasm for teaching” among the physicians and staff he works with.

“Iowa Health takes very good care of their students and residents,” he says. “I think this will be one of those programs that students will seek, because of the people involved, the hospital it’s affiliated with and the community it’s in.”

“It’s true what they say – the first time you see a total solar eclipse, your first question is, ‘When is the next one?’” she says.

Over the past decade, Prescher has viewed five total solar eclipses, when the moon completely blocks the sun’s bright surface. This “totality” lasts only a few minutes, but Prescher says it’s worth every second.

On one level, a total eclipse makes visible parts of the sun not normally visible to the human eye, such as its corona and prominences. But viewing the phenomenon goes beyond the visual treat, Prescher says.

“It’s very emotional. It’s hard to put into words how you feel when you’re standing at the edge of a lake or in the African desert and suddenly the moon takes this Pac-Man bite out of the sun,” she says. “It’s fascinating.”

Prescher discovered the hobby after she and her daughter moved from Omaha, NE, to San Diego. Wanting to meet people, she began studying astronomy at the Reuben H. Fleet Science Center and Space Theater. In 1999, she learned about a travel opportunity to Romania to view a total eclipse of the sun. She saved up for her and Audrey to go.

“I was addicted,” she admits. In July, Prescher traveled to Yichang, in the Hebei Province of China, to view the longest total eclipse of this century, during which the moon completely covered the sun for six minutes and 39 seconds at a point over the Pacific Ocean. This year, she and Doug plan to view an eclipse near Tahiti.

“People may wonder why I would travel halfway around the world to see a few minutes of totality,” she admits. But her enthusiasm makes sense given the trips themselves, which have included Africa’s Victoria Falls, Egypt’s Great Sphinx, China’s Great Wall and a seven-day cruise down the Yangtze River.

Interacting with local residents and fellow eclipse-chasers is a bonus, too. Total eclipses occur approximately once every 18 months but in a given location only once every 300 to 400 years, creating a unique individual and group experience.

“In Egypt, 20,000 people were gathered at our site to view the eclipse,” she recalls. “At the last minute we had to move because the Egyptian president decided that was where he wanted to view it. But we still enjoyed great viewing from the mesa we were on.”

Kelly Prescher’s “eclipse canon”
Location                                  Date                            Length of totality

Bucharest, Romania             Aug. 11, 1999             2 minutes, 23 seconds

Zambia, Africa                     June 21, 2001             4 minutes, 57 seconds

Solum, Egypt                      March 29, 2006          4 minutes, 7 seconds

Novosibirsk, Siberia            Aug. 1, 2008               2 minutes, 27 seconds

Yichang, China                  July 22, 2009               5 minutes, 25 seconds

Shedding light on solar eclipses
According to NASA, the moon is about 400 times closer to the earth than the sun, while the sun is about 400 times larger than the moon. That creates the illusion on earth that the two orbs are the same size, enabling the moon to completely block the big star’s light when their paths cross, casting the moon’s shadow on earth and creating a total solar eclipse.

A partial solar eclipse occurs when the sun and moon are not completely in line. An annular eclipse occurs when the two orbs are exactly in line, but the moon’s apparent size is smaller than the sun’s. That makes the sun appear as a very bright ring, or annulus, around the moon.

The path of totality is the track of the moon’s shadow across earth’s surface, typically about 10,000 miles long but only 100 miles or so wide. That path is where eclipse-chasers want to be.

With the sun’s surface visually blocked, viewers can see its less-bright corona, a halo-like plasma “atmosphere” that extends millions of miles into space. Also visible are the sun’s prominences, the whip- and loop-shaped features that extend outward. Because the direct light of the sun is blocked, some brighter stars and planets are visible, too.

Eclipse-chasers like Kelly Prescher closely study the NASA eclipse website for information on weather trends, paths of totality and best viewing locations.

This scene, while humorous, illustrates how an incomplete or evasive response is counterproductive and highlights the consequences when health care professionals are not prepared to meet their legal, regulatory and ethical obligations to disclose adverse events.

When things do not turn out as planned during a patient encounter, regardless of fault, most physicians and other health care providers want to show compassion and disclose what happened.¹ Significant anecdotal experience – such as the examples at www.sorryworks.net/disclosepolicy.phtml – demonstrates that full disclosure combined with apology in these situations results in reduced lawsuits, payouts and costs while improving patient satisfaction and quality. Yet it is estimated that only one in four errors is disclosed to affected patients.² Escalating lawsuits and jury verdicts, the high cost and limited access to professional liability insurance, and fear of shame and damage to professional reputations have left providers in denial and struggling with how to respond. These fears are intensified by a sense that insurers, attorneys and other advisers are pressuring them to remain silent to avoid premature admissions of liability in subsequent adversarial proceedings.

Health care disclosure lawsuits are generally analyzed using a paradigm of informed consent and autonomy. Judges have routinely held that physicians have a fiduciary responsibility to disclose adverse events to patients and may invoke civil liability when failure to timely disclose negatively affects a patient.

Lucian L. Leape, M.D., professor of health policy at Harvard University, asserts, “Full disclosure is the right thing to do. It is not an option; it is an ethical imperative…Patients are entitled to a full and compassionate explanation when things go wrong.”³ This position is consistent with the ethical principles of veracity, beneficence and patient autonomy.

Professional codes of ethics also call for disclosure as part of the patient relationship. For example, American Medical Association Ethical Opinion 8.12 – Patient Information states:

Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician’s mistake or judgment. In these situations, the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred. Only through full disclosure is a patient able to make informed decisions regarding future medical care…

Concern regarding legal liability which might result following truthful disclosure should not affect the physician’s honesty with a patient.⁴

Government agencies and health care organizations have followed industry trends toward transparency, including disclosure. For example, the Joint Commission on Accreditation of Health Care Organizations requires accredited hospitals to develop a policy on disclosure of unanticipated outcomes.⁵ Its Patient Safety Standard RI.1.2.2 provides that “Patients, and when appropriate, their families are to be informed about the outcomes of care, including unanticipated outcomes.” The Patient Safety and Quality Improvement Act (PSQIA) of 2005 established a confidential system for providers to voluntarily report adverse events without fear of litigation.⁶ Starting in October 2008, the Center for Medicare and Medicaid Services (CMS), many states and some private insurers halted payments to hospitals for additional care resulting from “reasonably preventable” errors called “never events.”⁷ Sixty-three percent of Leapfrog hospitals adopted that group’s “never event disclosure policy,” which requires an apology to the patient, a root cause analysis and public reporting.⁸

According to the American Society for Healthcare Risk Management, 35 states have laws making a professional’s statements of apology, sorrow or regret following an adverse outcome non-admissible. The theory behind these “I’m sorry” or “apology” statutes is that “if patients were treated with openness and sympathy—and offered prompt compensation—when doctors make mistakes instead of showing the detachment doctors frequently feel required to project to protect themselves from malpractice suits, they would be less likely to sue and, if there were less patients suing, there would be a corresponding decline in malpractice insurance costs.”⁹

Unfortunately, the vast majority of these state apology statues protect only the portion of discussions related to apology and regret and not broader disclosure—the primary basis for liability. Attempts to set a federal standard protecting disclosure conversations have not been successful.¹⁰ Thus, even with apology statutes, patient disclosure conversations can be used against a provider in most jurisdictions.

Important considerations for developing and implementing a disclosure protocol

1. Disclosure is an ongoing process that does not mean there was an error or require an admission of fault.
Adverse outcomes can occur even when the applicable standard of care has been met. In most cases, a root cause analysis and investigation must be conducted before discussing the cause. Disclosure is not designed to assign fault but to enable care providers to discuss medically relevant information with patients so they are fully informed about their care. Therefore, providers should have an initial disclosure discussion with patients regarding what is known; actively investigate the cause; keep patients informed as information becomes available; and resolve the situation when it is appropriate. Documentation of these steps should be maintained in the patient record. For more information on the “I’m Sorry Works Disclosure Process,” see www.sorryworks.com.

2. Advanced planning, written protocols and training for adverse outcomes are crucial.
Well thought-out protocols should be developed and reviewed throughout health care organizations to ensure that the response after an adverse outcome is timely, orderly, compassionate and appropriate. These comprehensive written policies should address who will talk to the patient, when and where conversations should take place, and the scope of disclosure. They may also address complex matters such as conflicts of interest, compliance investigations and media inquiries. Professional liability insurers should be consulted and contracts reviewed to ensure there is not a contractual basis to later deny coverage or cancel a contract because a disclosure conversation is later interpreted to be an admission of liability or failure to cooperate with defense counsel.

Timely and effective communication with patients and families is important. A study in the September Journal of General Internal Medicine found that disclosure and apology increased physician ratings but did not guarantee patients would not bring suit. Rather, the patient’s perception of what was said was more important than the act of apologizing and disclosing itself in deciding whether or not to sue.¹¹ This is an important point, since many providers have not been trained and lack skills to effectively present bad news to patients who are upset, frustrated and disappointed (Leape, 2009). Therefore, administrators, providers and staff would benefit from didactic training (including practice disclosure conversations) to prepare for how to apologize and disclose without subjecting the facility to undue liability. Many training resources exist.

Train to explain without blame
There are barriers to disclosure when there has been an adverse medical outcome. However, providers are ethically and legally required to discuss medically relevant information to ensure patients are fully informed about their care, regardless of the impact on the provider. Legal protections for disclosure, such as apology statutes, are beneficial but are generally limited in scope.

Ultimately, the provider and health care facility should complete an ethical, legal and risk management disclosure analysis to promote communication that timely and sympathetically provides patients with medical information without assigning blame. They should then commit to a well thought-out and carefully crafted disclosure policy, didactic training and implementation process.

Assistant Professor Denise Hill teaches courses at DMU on health law and ethics, public health law and ethics, advocacy and conflict resolution. She practices law as an of counsel attorney with Whitfield & Eddy law firm. A trained mediator, Hill is president of the Iowa Society of Health Care Attorneys and serves on several health care and public policy boards.

Resources
www.thedoctors.com/KnowledgeCenter/PatientSafety/DisclosureResources/CON_ID_001054: includes a helpful adverse outcome flow chart, a series of disclosure scenarios and links to training videos.

www.ashrm.org/ashrm/education/resources/files/apology_statutes.pdf: listing of state apology statutes.

www.acpe.org/ACPEHome/Toolkit/apology.aspx: provides a listing of online resources on apology and disclosure.

www.oregon.gov/OPSC/docs/CUAO-Guidelines-KP.pdf: Kaiser Permanente offers effective guidelines for communicating unanticipated adverse outcomes.

Footnotes
1 American Society for Healthcare Risk Management (April 2001): Perspective on disclosure of unanticipated outcome information.

2 Fein S.P., Hilborne L.H., Spiritus E.M., et al. (2007): The many faces of error disclosure: a common set of elements and a definition. J Gen InternMed. 22(6), 755-761.

3 Leape, L. L.: Full disclosure and apology – an idea whose time has come.

4 Given that professional codes of ethics can be incorporated by reference into state licensing boards’ administrative rules, failure to disclose adverse events is a basis for professional discipline in some states. American Medical Association (2008): Code of Medical Ethics: Current Opinions with Annotations, 2008-2009.

5 The Joint Commission on Health Care Accreditation, Patient Safety Standard RI.1.2.2.

6 Patient Safety and Quality Improvement Act of 2005. Public Law 109-041. S 544, 109th U.S. Congress, 2005.

7 Centers for Medicare & Medicaid Services.

8 The Leapfrog Group.

9 Chicago Sun Times editorial (Feb. 25, 2005): Doc’s humble apology could be saving grace.

10 Clinton, H.R., & Obama, B., 2006: Making patient safety the centerpiece of medical liability reform. New England Journal of Medicine. 354 (21), 2205-2208.

11 Adams, D. (Sept. 22, 2009): Apologizing for medical errors may not stop you from being sued.

Using tents allowed DMU alumnus Pat Crocker and his colleagues to treat an influx of H1N1 flu patients efficiently and effectively.

Pat Crocker and his crew got creative in coping with an H1N1 flu surge last fall.

Most medical centers expected the H1N1 flu virus would increase their patient counts this year, but last fall Pat Crocker, D.O.’80, and his colleagues found themselves in an especially hot spot for the flu and in the media.

“Austin turned out to be one of the early epicenters of H1N1,” says Crocker, emergency medical director at Dell Children’s Medical Center of Central Texas. “We started seeing flu patients in early September and got up to 400 a day, 70 percent with the flu or influenza-type illnesses.”

Fortunately, Crocker and the Dell team were ready. They expanded their “surge capacity” plan made after the terrorist attacks on Sept. 11, 2001, and used during Hurricanes Katrina and Rita. The plan mapped out a pandemic care area that provided immediate, delayed and overnight care capacity, with pre-packaged and palleted supplies ready for rapid deployment. The plan also featured three Western Shelter tents, erected on the medical center’s parking lot, that could be assembled in two hours and provided a weather-secure environment.

How did patients feel about being treated in a tent?

“They were really happy,” Crocker says. “They would drive up and see a swarm of patients and think they would have a long wait, but it was very efficient. From intake to dismissal, a patient would be in and out typically under 30 minutes. And the kids and families thought the tents were kind of cool.”

The tents relieved the load on the medical center’s emergency room and kept the highly contagious from other patients, he says. The well-organized process likely kept people from getting sicker, too.

“Before the tents were up, 8 to 10 percent of our patients were leaving the hospital without being seen” because they didn’t want to wait, he notes. “That fell to less than 1 percent after the tents were erected.”

The tents also drew a surge in media attention. ABC’s “Good Morning America” and CBS’s “The Early Show” both broadcast from Dell, and almost 80 other television and radio stations covered the hospital.

“Our 15 seconds of fame lasted a little too long,” Crocker laughs.

Dell and its parent organization, Seton Family of Hospitals, used the social media website Twitter as well as tents to tackle the flu surge. Crocker and a fellow emergency medical physician, Tate Ehrlinger, posted daily and sometimes hourly reports – “tweets” – about H1N1, physician recommendations and other helpful tips (www.twitter.com/setonh1n1).

While the number of flu patients at Dell has declined to about 200 per day, Crocker and his colleagues continue to watch for signs of the H1N1 making an antigenic shift. That occurs when two or more different strains of a virus or different viruses form a new subtype that could be more virulent or resistant to the vaccination.

“I think we were really lucky that we didn’t see that. Most patients seemed like they had a bad cold,” Crocker says. “In the months ahead, we will see if the H1N1 virus recombines with the bird flu or other virus.”

He’s also concerned by the virus’s high incidence among people under age 18, and the fact it’s “clearly active” in summer months. “That’s really unusual for the flu,” he says. “You have to wonder what’s in the future – seeing the flu year-round?”

Worried whether your child has the flu?

Pat Crocker, D.O.’80, chief of emergency medicine at Dell Children’s Medical Center in Austin, TX, advises parents to call or see a doctor if a child has flu-like symptoms and
• is younger than a year old
• is more ill than you would expect
• has a fever for more than three days
• is lethargic and symptoms do not improve after taking Tylenol
• has an existing chronic illness or some other risk factor.

He advises a trip to the emergency room if symptoms include shortness of breath, chest pain, trouble breathing, persistent vomiting, seizures or confusion.

Source: www.seton.net/about_seton/fluh1n1_information