Downtown Minneapolis is bleak right now. The towers have been empty since the shelter-in-place order was issued last winter. Many buildings are boarded up due to property damage from rioting. Sirens are constantly going off because of the sharp increase in crime. Street vagrancy is prevalent outside of my office building.
The world is upside down, however, this abandoned church reminds me every morning to continue healing the sick. ✸
I’m helping one of my employers with a four-week “meditation challenge.” It grew out of a recent lunch and learn for employees that included some material on mindfulness. The more the merrier, so I’m sharing this with my entire social network.
Here’s the challenge: Meditate three times per day, generally in the morning when you wake up; sometime in the afternoon; and again in the evening right before you go to bed. Start with 5-minute sessions, increasing the duration week-by-week as follows:
Week 1: 5 minutes, 3 times per day
Week 2: 10 minutes, 3 times per day
Week 3: 15 minutes, 3 times per day
Week 4: 20 minutes, 3 times per day
In terms of technique:
Assume any comfortable position. I personally like a semi-supine position (see below)
Set a timer (e.g., on your phone) with a soft alarm
Close your eyes
Direct your attention to your breath. This might be your nose, chest or belly
Follow your breath in and out. Some people use simple mental mantras for each in-breath and out-breath. Examples are: in-out, deep-slow and calm-ease
Internal and external distractions will occur. Just let thoughts, emotions and sensations pass without judgment. Return to your breath, using a mantra, if needed. On the flip side, don’t worry if you feel sleepy or even doze off. Allow that to pass without judgment, too.
And that’s it!
Please let me know how you feel during and after the challenge.
I’ve been closely following media reports about Zoom security — for example, unauthorized people “zoombombing” (infiltrating) meetings. Although some of the identified security concerns are real, experts note that Zoom has been responsive and rapidly implemented fixes. And I have yet to see a story specific to Zoom for Healthcare, the paid, HIPAA-compliant plan. At this point, I don’t think that we need to throw out the proverbial baby with the bathwater
I’ve been doing telehealth for a few years. Now everyone wants in due to the coronavirus pandemic. My partner, John Sutherland, Ph.D., and I have been furiously spinning up mental health and addiction clinicians at Allina Health. We transitioned at least 75 providers this week and more will soon follow.
This post will provide some practical advice for those new to telehealth. It comes straight from the trainings that John and I have delivered in recent days.
Keep it Simple 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!). Make sure you get a Business Associate Agreement to achieve HIPAA compliance (although a safe harbor [waiver] exists during the current public health emergency).
Be Professional I remind providers that they are health professionals, not creepy basement YouTubers. The following are small touches that make a big difference
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)
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
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
In one of my lives (I have a few), I serve as the medical director for a commercial health plan. My duties involve developing policies and reviewing claims. It’s the greatest job on earth if you love evidence-based medicine (which I do!). And it connects perfectly to another life: teaching EBM at the University of Minnesota, which I’ve been doing since 2004.
I’m pleased to return to St. Joseph’s Hospital, my former employer and postgraduate alma mater, on August 20th to discuss health insurance with the family residents.
This post contains my key teaching points and didactic materials.
Suggested Thought Process
Is the health care service a covered benefit? (cf. benefit plan)
Does the carrier have a policy concerning the health care service?
In the absence of a specific policy, is the health care service medically necessary?
Does the member (patient) and/or evidence meet criteria?
At a very high level, benefits are determined by the member’s benefit plan. Eligible services are subject to the plan’s terms, as often summarized in medical policies. Excluded services are not eligible for coverage and cannot be funded by the plan (doing so would violate a contact with the plan’s owner).
I’m pleased to be partnering with Allina Health’s hospitalists on education and order set creation. The latter includes a presentation at their annual CME conference, offered on a repeating basis on April 5th, April 10th, April 26th and May 2nd.
Hospitalists frequently care for patients following overdoses and other opioid-related misadventures—trauma, endocarditis, and so on. Buprenorphine is a very nifty widget in these circumstances.
Another common scenario is acute pain management for patients who take buprenorphine in the community. Pain control is neither hard nor complicated, so long as you follow a few simple rules.
Special thanks to Drs. Saul Singh and David Beddow for their partnership on this.
How much alcohol is too much? For years, we’ve been using numbers from the National Institute on Alcohol Abuse and Alcoholism (NIAAA). It defines low-risk drinking as:
Women No more than 3 drinks per day; and No more than 7 drinks per week
Men No more than 4 drinks per day; and No more than 14 drinks per week
where 1 drink = 14 grams of absolute or “pure” alcohol. This corresponds to 12 ounces of beer, 5 ounces of table wine or 1.5 ounces of distilled spirits (e.g., vodka).
All that is about to change. A new study involving about 600,000 people found that drinking targets should be a lot lower—probably no more than 100 grams of alcohol per week. This corresponds to just 7 standard drinks.
The study found that people who consume more than 100 grams of alcohol per week had a higher risk of dying. They also had more heart attacks, strokes and other cardiovascular diseases.
Here’s the flip side: drinking less appears to add years to your life. For example, 40-year-olds increase their life expectancy by at least 1 year when they reduce alcohol intake from NIAAA’s current upper limits to no more than 100 grams per week.
I’ve loaded these data into my longest running PowerPoint slide deck (Slides 14–16) and am encouraging my students to change the advice they give to patients. Please pitch in and start spreading the word!
I’m honored to be the keynote speaker at the Minnesota Academy of Family Physicians’ Spring Refresher. Here’s a fairly final version of my PowerPoint.
The bulk of my presentation will be devoted to the systematic management of major depressive disorder. The STAR*D Study, which has only become more relevant over time, will provide the overall framework.
I’ll also be discussing suicide assessment and how to monitor various psychotropic medications.
I attended Hazelden Betty Ford’s Professionals in Residence (PIR) program in 2002. I started the week thinking I was going to be a family physician—I was a resident at the time—but was hooked on addiction (bad pun intended) by the end of the experience. And so began my odyssey to an eventual career in addiction medicine.
I returned to PIR as faculty in 2009 and have been teaching for the program ever since. I lecture on Screening, Brief Intervention & Referral to Treatment (SBIRT—not to be confused with Ernie and Bert!).
My slide set has evolved considerably over the years. This blog post contains the latest and arguably greatest.
I’ve been treating opioid addiction with buprenorphine (Suboxone, Zubsolv, Bunavail) since 2005. Here’s a conference presentation that covers some perennial questions that I receive from primary care providers. I’m happy to bring the slide deck to you for a live training.