Summer Institute for Medical Students

I’m privileged to serve as faculty for another year of Hazelden Betty Ford’s Summer Institute for Medical Students (SIMS). Here are my PowerPoints and some additional resources.

Many thanks to Kari Caldwell for involving me in SIMS and also the Professionals in Residence (PIR) program!


Postscript [07/30/2021]. I’ve long advised medical students and residents to acquire some psychotherapy skills, regardless of their eventual specialty. Motivational interviewing (MI) and cognitive behavioral therapy (CBT) are relatively easy to learn and have broad clinical utility.

Some MI resources include:

  • Miller WR, Rollnick S. Motivational Interviewing, 3d ed. New York: Guilford Press, 2013 [classic textbook]
  • Sim MG, Wain T, Khong E. Influencing behaviour change in general practice. Part 1—brief intervention and motivational interviewing. Aust Fam Physician 2009;38(11):885-888 (PMID: 19893835; and here)
  • Sim MG, Wain T, Khong E. Influencing behaviour change in general practice. Part 2—motivational interviewing approaches. Aust Fam Physician 2009;38(12):986-989 (PMID: 20369152; and here)
  • Hall K, Gibbie T, Lubman DI. Motivational interviewing techniques—facilitating behaviour change in the general practice setting. Aust Fam Physician 2012;41(9):660-667 (PMID: 22962639; and here)
  • Searight HR. Counseling patients in primary care: evidence-based strategies. Am Fam Physician 2018;98(12):719-728 (PMID: 30525356)

In terms of CBT, I highly recommend the professional trainings at the Albert Ellis Institute, starting with the primary certificate practicum. Some other resources include:

  • DiGiuseppe RA, Doyle KA, Dryden W, Backx W. A Practitioner’s Guide to Rational Emotive Behavior Therapy, 3d ed. Oxford: Oxford University Press, 2014 [classic textbook]
  • Harden M. Cognitive behaviour therapy—incorporating therapy into general practice. Aust Fam Physician 2012;41(9):668-671 (PMID: 22962640; and here)
  • Stuart MR, Lieberman JA. The Fifteen Minute Hour, 6th ed. Boca Raton: CRC Press, 2019 [please see, in particular, Chapter 4]
  • Frenz DA. Another Arrow for Your Quiver: REBT for SUD. Minneapolis: David A. Frenz, M.D., 2018 [PowerPoint presentation]

Some Thoughts About Thinking

I recently did a corporate “lunch and learn” on metacognition, which is our singular ability to think about our thoughts (as far as I can tell, my dog has no such capacity). This would appear abstract and likely impractical but it is actually the key to mental health.

I’m happy to work at the level of things and thoughts. The former generally involves practical solutions (problem solving) while the latter consists of philosophical solutions (e.g., cognitive behavioral therapy). But I’m much more interested in the thinker—that’s where the ultimate solution lies.

The “thinker” in this context is consciousness or awareness, which is always present but seldom appreciated. As Rupert Spira counsels, “Allow the experience of being aware to come into the foreground of experience, and let thoughts, images, feelings, sensations and perceptions recede into the background. Simply notice the experience of being aware. The peace and happiness for which all people long reside there.” Elsewhere, he advises, “Be knowingly the presence of awareness.”

You can find my PowerPoint here or by clicking on the image above. ✸


P.S. If this sounds like mindfulness, it might be. Mindfulness has become one of those everyday words that now lacks meaning, or at least a shared understanding. For an interesting perspective, please see Stephan Bodian’s Beyond Mindfulness:

“For all its wonderful benefits, the practice of mindfulness has another downside: it tends to maintain the subject–object split, the gap between the one who’s being mindful, the act of being mindful, and the object of mindful attention. In other words, no matter how mindful you become, there’s always a you that has to practice being mindful of an object separate from you. As a result, mindfulness perpetuates the very sense of separation it’s designed to overcome.”

Chasing Your Tail

Years ago, in one of my former lives, Scott Hinrichs, HealthEast’s vice president for mission, bioethics and spiritual care, tapped me to speak at its annual President’s Prayer Breakfast. I’m not sure that the audience walked away with much, however, the event was a tremendous gift to me. Absent the commitment, I doubt that I would have reflected on my spiritual journey.

The PowerPoint has generally aged well. I’m not sure that I would add much today—except, perhaps this Lars Kenseth cartoon, which I saw over the weekend, and some stuff from Stephan Bodian’s Beyond Mindfulness. By all means laugh, but then puzzle for a few minutes over the deeper meaning.

What’s that part of you that’s been there all along?

Lars Kenseth. Originally published in Wired on Wednesday, March 4th, 2020.


Postscript. I didn’t immediately realize that today marks the 10th anniversary of my presentation. More than coincidence? ✸

Self-Care During a Pandemic

Update [10/12/2020]: Here’s the recording of the session. Enjoy!

Remember airplanes? In the event of an emergency, flight attendants advise us to adjust our own oxygen masks before helping others. I’ve always found that an apt metaphor for anyone in the healing arts.

Delta Air Lines, Inc.

Tomorrow I’m presenting on self-care during a pandemic (but it could be any personal or shared crisis really). Not self-care for our patients and clients—but self-care for ourselves. The main message concerns the relationship that we have toward time and the present, although there will some other stuff sprinkled in as well.

Many thanks to the University of Minnesota’s Center for Practice Transformation for hosting the event. It’s not too late to sign up and the price is right (free)! ✸

Doubleheader

The Twins were eliminated by the Astros yesterday, however, it’s still baseball season! In that spirit, I’m “pitching” a split doubleheader today in two different ballparks through the wonders of Zoom.

The first presentation is for the Minnesota Sheriff’s Association at its Correction Care Division’s Annual Conference. The subject is identification and management of substance withdrawal syndromes (I’m the medical director for two county jails).

CentraCare Health; St. Cloud, Minn.

The second outing is for CentraCare Health at its Opioid and Controlled Substances Prescribing Training. I’m the middle reliever in a line-up that includes Drs. Michael Massey (pain medicine) and Lynn McFarling (medical informatics). The two-hour event is designed to fulfill Minnesota’s new(ish) legislative mandate for provider education. My contribution deals with unhealthy substance use with special attention to patients with chronic pain syndromes.

CentraCare Health; St. Cloud, Minn.

Just click on the above images or hyperlinked text to access my PowerPoints. ✸

Wild West of Waivers

Thank you for joining us for today’s legal/regulatory webinar related to the Covid-19 pandemic. This post contains links to the various resources that we discussed. Additional resources will be added after the event based on your questions

Disclosures
The webinar represents a partnership between Allina Health (David Frenz’s employer) and the Center for Practice Transformation. Please review Dr. Frenz’s disclosures, especially that bit about seeking counsel from experienced health lawyers like our panelists, Teresa Knoedler and Kit Friedemann


in partnership with

Questions to Ask Yourself

  1. Is the health care service permitted by law? (if yes, then go to #2)
  2. Is the health care service permitted by the patient’s health plan? (if yes, then go to #3)
  3. What is the claims submission process? For example, what CPT code and place of service code (Item Number 24B in the 1500 Health Insurance Claim Form) should be submitted for payment?


Introduction
High-level Explainer by Kit Friedemann, J.D.

Emergency Declarations
Federal
Minnesota
#StayHomeMN

HIPAA Enforcement
Office of Civil Rights resource page
Telehealth and Telemedicine Tool Kit

Medicare
Expansion of telehealth with 1135 waiver
CMS Interim Final Rule
MLN Booklet — Telehealth Services [requirements prior to Covid-19]
Medicare Coverage of Substance Abuse Services [prior to Covid-19]

Minnesota Department of Human Services
Waivers and modifications
MHCP Provider Manual

42 CFR Part 2
Substance Abuse and Mental Health Services Administration (SAMHSA)
Relationship to HIPAA enforcement discretion

Ryan Haight Act
Use of Telemedicine While Providing Medication Assisted Treatment (MAT)
Drug Enforcement Administration (DEA) Covid-19 Information Page

Predicting Suicide & Violence

I delivered this live webinar for the University of Minnesota’s Center for Practice Transformation way back on September 14th, 2018. I’m egregiously slow in posting, however, better late than never? ✸

Covid-19 Telehealth Training

Thank you for joining us for today’s telehealth training. This post contains links to the various resources that I discussed via screen share

Disclosures
The webinar represents a partnership between Allina Health (my employer) and the Center for Practice Transformation. Please review my disclosures, especially that bit about seeking counsel from an experienced health lawyer. I’m a medical doctor, not a juris doctor


in partnership with

Platform/Vendor Selection
I use a number of telehealth platforms including Vidyo, Epic Warp Drive and Zoom for Healthcare. I recommend Zoom for Healthcare if you need to get up fast and don’t have an IT department supporting you. It’s literally purchase and practice. Patients just need the Zoom app, which is device and operating system agnostic (and free!)

Solo practitioners and small groups are able to purchase Zoom for Healthcare licenses on a onesie-twosie basis though resellers like LuxSci, which brings the cost down

Make sure you get a Business Associate Agreement to achieve HIPAA compliance (although a safe harbor [waiver] exists during the current public health emergency; please see below)

Scheduling
Use security features. These include meeting passwords and waiting room features [Update: Please see new post for an illustrated explainer]

Conducting Sessions
Socialize individuals and groups to expectations including

  • Physical safety, e.g., no sessions while driving
  • Privacy, especially in shared spaces. Think: Headsets or earbuds on both ends
  • Minimizing environmental distractions (sound, light, motion)
  • Deferring personal activities to personal time: smoking, vaping, eating, toileting, et cetera
  • Video on (especially for groups); audio toggled on/off

Looking & Sounding Professional
Try at all times to exceed the standards of creepy basement YouTubers. The following are small touches that make a big difference

  • Use good lighting. Cheap solutions are readily available on Amazon
  • Place your camera at eye level. Options include putting your laptop on a few reams of paper
  • Use a headset microphone. I like Sennheiser gaming headsets with noise-cancelling microphones
  • Select a bland background. If none is readily available, blow in a virtual background
  • Minimize environmental distractions. Under the current circumstances, that might include your kids and dog
  • Look into your camera often. That’s where your patient is, not elsewhere on your screen (even if that’s where they appear to be)
  • Keep your camera clean (and keyboard, too — wink, wink!). Optical wipes are available through Target and other retailers

Documentation
Payment for telehealth requires that certain elements appear in your visit documentation. The following is the header of my charting templates, where *** are elements that are populated for each encounter

  • Date of Service: ***
  • Start Time: ***
  • End Time: ***
  • Type of Service: Evaluation and management (E/M)
  • Type of Encounter: Telehealth [or: Virtual health]
  • Mode of Transmission: Secure, synchronous, real-time audio and video communication via Vidyo [or: Zoom for Healthcare, et cetera]
  • Originating Site: *** [patient location — city and state]
  • Distant Site: Minneapolis, Minn.
  • Basis for Service: Virtual health, in my judgment, is an appropriate and effective means for providing this service secondary to the current COVID-19 pandemic and the need for social distancing. I have previously seen the patient for traditional in-office care and consider their mental status, including the absence of imminent danger, amenable to virtual care [the final sentence can be edited or deleted]

Collecting Clinical Data
I love scales, measures and patient self-rating forms. The same instruments that I administer in my office can also be administered via telehealth through

I’m also okay with home drug testing provided the panel includes sample validity assays and GC/MS confirmations

Notable Waivers & Exceptions
All sorts of regulatory waivers and exceptions have been granted because of the Covid-19 pandemic. Those most relevant to mental health and addiction include

Good luck!


Update: Here’s a link to a recording of the webinar.

Free Telehealth Training

Allina Health is pleased to be partnering with the University of Minnesota’s Center for Practice Transformation on a free telehealth training this Friday, April 3rd, at 12 p.m. The webinar is an adaptation of trainings that John Sutherland, Ph.D., and I have been conducting at Allina in response to the Covid-19 pandemic.

I will cover a broad range of topics including the logistics of conducting a telehealth encounter. I will also address regulatory issues such as documentation requirements, exceptions to the Ryan Haight Act, deferred enforcement of HIPAA and waivers and modifications granted by the Minnesota Department of Human Services.

Please consider Zoom for Healthcare if you haven’t already landed on a telehealth platform. It is device and operating system agnostic, and many patients are already using it for other reasons (e.g., distance learning for their children). Solo practitioners and small groups are able to purchase licenses on a onesie-twosie basis though resellers like LuxSci, which brings the cost down.

Many thanks to Julie Rohovit, Ph.D., Joe Curtis and the whole gang at the Center for Practice Transformation for spinning up this webinar on very short notice. ✸

ECHO Wrap-Up

I appreciated the opportunity to discuss telehealth during today’s Project ECHO webinar. Here are some of the resources that I mentioned

Please contact me if you have any questions. ✸