Dean's Message:
Rural health care: A look back, a look ahead

The first 25 years of the Duluth School of Medicine has taught us much about rural health and educating and supplying physicians for underserved rural communities. The School has enjoyed remarkable success, consistently leading the nation in the percent of students who choose family practice careers (over 50 percent) and in those who settle in small rural communities (over 40 percent). The next 25 years, however, will require ever more innovative strategies to prepare students for the benefits and challenges of a rural practice, and for meeting health care needs of the communities in which they will serve.

We have learned that selection of applicants is the critical factor in graduating future rural practitioners. Over 75 percent of our students have spent more than half of their first 18 years of life in a small rural community of 20,000 or less. This “imprinting” makes them three times as likely to choose family practice careers and set up practices in small rural towns. Once selected, however, students with potential interest in rural practice must have that interest nourished, by a curriculum that not only gives them a strong general academic background, but also provides the specific training necessary to prepare them for a rural practice. The small class size in Duluth, together with the close interaction with peers and with the faculty, permits students to make the transition from student to student-physician in a “holding environment” that encourages professional development from a small town perspective.

In addition to careful selection strategies and curricular design, educational activities in rural communities are mandatory if we are to reassure students that medicine can, indeed, be practiced in a small town without fear of isolation or providing less than the highest quality care. These clinical experiences must move from being solely disciplined-based to include interdisciplinary team-based experiences to prepare students to practice in the new health care delivery system. This realization led to the development of the Rural Health School, a joint effort of health professions schools and colleges at the University and throughout the state, which uses the principles outlined above to create interdisciplinary rural educational sites. At these sites medical students from the Rural Physician Associate Program (RPAP), nurse practitioner students, physician assistant students, and pharmacy students work together to learn better ways to address patients with complex needs as well as community health problems.

The future will also require interventions that will yield better outcomes for rural communities. For example, an NCI-funded project directed by clinical faculty member Tom Elliott is isolating better ways to detect and treat cancer through clinics in 21 rural communities. Like other defined populations, rural communities have unique health care needs that are just beginning to be understood.

The future will also require all students to learn better ways to provide culturally sensitive health care to diverse populations. This will include even greater emphasis on educating American Indians, among other minority groups, if we are to have a substantial impact on the serious health problems facing these underserved populations.

The school begins its next 25 years with the same commitment to serving the health care needs of rural communities that it made in 1972. This mission, sustained by adherence to academic excellence in education, research, and service/outreach, will enable the school to maintain its national leadership in rural medicine for the next 25 years.

Ronald D. Franks,
Dean, UMD School of Medicine

It’s official. As of July 1, 430 full-time faculty physicians formerly represented by 18 department practice plans began marketing as the new integrated practice organization, University of Minnesota Physicians (UMP). Clinical faculty voted to unify their plans last year in order to streamline clinical practice operations and compete more effectively in the health care marketplace.

Since last July, a board has been elected to guide the transition, a mission and values have been adopted, executive director Lisa Jetland has been hired, and key issues such as human resources, financing, billing, contracting, and marketing have been addressed. As of July 1, UMP is managing contracting and billing services provided by University of Minnesota Clinical Associates. UMP will soon oversee financial reporting as well.

“This month we will introduce UMP in the market through communications to key audiences, such as third-party payers, purchasers, and referral providers. ” Jetland says. A broader campaign to promote UMP to the media and general public is planned for fall.

Between now and January 1, 1998 efforts will focus on folding individual practice plan activities into UMP. This will begin with extensive communications to faculty and staff explaining what the transition to UMP will mean to them, Jetland added, including details about employment and benefits. By September, management will begin dissolving the 18 separate legal entities that now support clinical practices and transfer those operations to UMP. By January 1, 1998, UMP will be functioning as an integrated practice plan for all University clinical practice, according to Jetland. Practice group operations will continue as divisions called clinical service units (CSUs). Department chairs or their designees will be CSU managers.

UMP is a nonprofit organization directed by a board and administrator. The UMP board comprises 12 elected members representing specialty, surgical, hospital-based, and primary care areas. The Medical School dean is an ex officio member; non-voting directors are the executive director, a representative from Fairview-University Medical Center, and the chair of the Medical School’s clinical sciences council. The new organization is legally separate from but affiliated with the U as well as Fairview-University Medical Center.

The regents approved a new private practice policy in June that acknowledges the new practice organization and gives the AHC senior vice president and Medical School dean more responsibility for clinical practice oversight.

–Peggy Rinard

The greatest accomplishment of public health may be that people take its many contributions for granted, says Anne Barry, Minnesota Department of Health commissioner. But changing times call for a change of course for the profession, she told School of Public Health graduates at June 13 commencement ceremonies.

“We need to avoid isolating ourselves in our own little professional or organizational boxes,” said Barry, herself a graduate of the school. The traditional tools of the trade may not be sufficient to achieve further gains in public health – or to even maintain past accomplishments, she said.

The war against infectious diseases, for example, illustrates the need to remain flexible in the face of change. Fifteen years ago infectious diseases such as diphtheria, typhus, tuberculosis, and polio were under control. But then came HIV, E coli, hanta virus, cryptosporidium, new food-borne illnesses, antibiotic-resistant diseases, and the resurgence of TB. “Infectious disease is back on the agenda – in a big way,” Barry said.

Today’s public health practitioners face increasingly diverse communities, an aging population, and significant institutional changes that affect the way they conduct the business of public health. Health care reform and the growth of managed care have also “begun to redraw the traditional division of labor between health care and public health,” she said. Health care providers are now taking more responsibility for activities historically associated with public health – preventive care and health education, for example. Public health, in turn, has “returned to the basics and begun to redefine itself,” focusing on the core functions of assessing needs, planning and developing policy, and assuring that basic public health needs are met.

While these core functions represent leadership opportunities for public health, they leave key tasks to others and underscore the importance of building partnerships to meet public health goals, Barry said.

“If we are to successfully forge partnerships with other organizations and institutions in the community, we must learn to share leadership and responsibility within our own respective agencies and organizations,” she said. And because public health touches on nearly every aspect of human existence, “we have potential partners in almost every nook and cranny of society,” she said. “We need to exploit the possibilities that lie in that fact.”

Barry’s own agency, the Minnesota Department of Health, is in the midst of an experiment in creating shared leadership. All employees of the agency “need to know that their views and concerns will be heard and respected, that their views really will be taken into account in making decisions and setting policy, and that they will not be penalized for expressing themselves,” she said.

“We need to recognize that – when we make connections across traditional institutional or professional boundaries – the whole really does exceed the sum of the parts,” she explained. “We can no longer safely afford to stay within our own narrow areas of specialization. We need a larger vision – one that transcends traditional professional and institutional boundaries and offers a more flexible approach to a rapidly changing public health agenda.”

Guest speakers at other AHC graduations included Harold Slavkin, director of the National Institute of Dental Research, (College of Dentistry); David Hilfiker, medical director of Joseph’s House, a care center for homeless AIDS patients in Washington, D.C., (Medical School); Senior Vice President Frank Cerra (College of Pharmacy); Graduate Chand Khanna (College of Veterinary Medicine); and Susan Jeska (School of Nursing).

–Gayle Bonneville

Turtle Derby

Instructional technology grants awarded

Instructional technology grants totaling $50,000 have been awarded to seven faculty projects by Health Sciences Learning Resources, Acting Director Stuart Speedie has announced.

The grant program was designed to improve AHC instruction and student orientation through use of computer-based information technology. Technologies include computer-assisted instruction, distance education via interactive television, web-based courses, computer-based course support, and simulations and modeling. Winners also receive services provided by Biomedical Graphics.

Winners are:
Computer-assisted tutorials for small animal imaging
Victor Cox, veterinary pathobiology; Dan Feeney, Patrick Redig, and Patricia Walter, small animal clinical sciences.

Conversion of a CD-ROM program in veterinary microanatomy to authorware and preparation of a library of the digitized and labeled images
Caroline Czarnecki, veterinary pathobiology.

Pediatric dentistry education for the year 2000 and beyond
Pamela Erickson and Gayathri Sambasivan, division of pediatric dentistry, preventive sciences department.

Internet self-assessment in pharmacology: a model for web-based medical education
Leonard Lichtblau, pharmacology; Joseph Konstan, computer sciences.

An interactive computer atlas of hematology morphology
Karen Lofsness, medical technology division, laboratory medicine and pathology.

Internet-based integration of select pharmacotherapy courses
Robert Straka, John Rotschafer, David Guay, College of Pharmacy.

Computerized teaching materials for professional curriculum
A.M. Trent, associate dean of academic affairs, College of Veterinary Medicine; James Waddell, clinical and population sciences; P. Jane Armstrong, small animal clinical sciences; Victor Cox, veterinary pathobiology, Michelle Mero-Reidel, veterinary biomedical graphics.

Filling openings more quickly and addressing concerns about compensation, labor relations, and professional development are among the priorities of the AHC’s human resources office, which is offering new and improved services.

One immediate change is that as of July 1, recruitment for academic and civil services jobs is being handled through the AHC Human Resources Office rather than through central administration. Director Jeanette Louden expects the change to cut the average amount of time to fill a position by about a month. Recruitment focus will be on difficult to fill positions. The change will also allow Louden and her staff to help AHC schools and colleges design positions and identify internal candidates. Although civil service and bargaining unit applications will be screened in AHC human resources, for the time being candidates will still apply through the U’s main office in the Donhowe building. Louden also plans to hire human resource specialists who will focus on compensation, labor relations, and employee training and development. The switch from generalists to specialists is designed to improve the quality of services provided to AHC schools and colleges.

Other priorities for the first year are to work with unions to improve labor and management relations in the AHC; create employee orientation materials and development opportunities for faculty and staff; and streamline human resources processes.

If you have questions or concerns about human resources issues, send them to Louden at loude002@maroon.tc.umn.edu or call 624-7957. The HR office is now located on 5th floor of Boynton. Faculty and staff are also invited to serve on a planning committee to improve HR services.

Ronald Franks, Dean of the Duluth School of Medicine, has accepted a new position as dean of the James H. Quillen College of Medicine and vice president of health sciences at Eastern Tennessee State University in Johnson City, Tennessee beginning September 1, 1997. Franks has been Dean of the School of Medicine since 1988. He was instrumental in developing the Rural Health School, which teams up students in medicine, nursing, pharmacy, and public health at a clinical site in a rural town. An interim dean will be appointed and a national search will be conducted for his replacement.

The Minnesota Medical Foundation Golf Classic will be held Aug. 25 at Rolling Green Country Club in Medina. Last year’s tournament raised more than $70,000 for medical research and scholarships at the U’s Minneapolis and Duluth medical schools. Space is limited and the past few classics have been sellouts. Call 625-6136 to register.

The 1997 Patrick J. Manning Animal Research Awards went to Albert Nakano, a graduate student in cell biology and neuroanatomy, and Hau Tran, a laboratory technician in the Research Animal Resources Department. Nakano was selected for his work with the group FACTS (Focus on Animals’ Contributions to Science) and Brain Awareness Week as well as extensive use of tissue culture as an alternative to animals. Hau Tran’s qualifications include his exceptional care for animals during his ten years at the U. Awards were presented on May 21 at the annual appreciation luncheon for staff and students who work with animals. Manning, who died in 1994, was director of Research Animal Resources.

Cancer Center faculty were invited to apply for $20,000 "brainstorm" grants for interdisciplinary research projects at the center’s June meeting. Director John Kersey also announced the appointment of Tucker LeBien, lab medicine and pathology, as Cancer Center deputy director, and David Rothenberger, colon and rectal surgery, as associate director for clinical research and programs. Both appointments were effective July 1. On June 1, the Cancer Center submitted a proposal for an institutional support grant to the National Cancer Institute. Ninety-eight faculty were represented in the grant application. Cancer Center members receive nearly $20 million a year from the NCI, ranking the U 17 out of the top-funded 20 institutions. The grant application centered on five Cancer Center program areas: prevention and etiology, genetics, cell biology and metastasis, immunology, and transplant biology and therapy; and six shared resources: analytical chemistry and biomarkers, data collection and support services, flow cytometry, peptide synthesis and design, tissue procurement, and biostatistics.

Until recently, drug development has focused on how medicinal compounds affect organs and systems. But advances in molecular biology and computer-aided design are enabling scientists to zoom in on the critical juncture between a biological target and a drug molecule. That ability is allowing scientists to make molecular structural changes that improve effectiveness.

“It’s like using a small, carefully aimed bullet rather a shotgun approach to treat a disease,” explains College of Pharmacy Dean Marilyn Speedie.

For patients, the new approach means drugs that are more effective and have fewer toxic side effects. While only a few molecular drugs are being used clinically, HIV protease inhibitors for example, the approach appears to herald the future for pharmaceuticals. Ultimately, it’s likely that drugs for every kind of disease will be formulated this way.

For anyone involved in drug development, from academic health centers to pharmaceutical companies, it means a whole new range of research and clinical possibilities and an expanded cast of scientific characters.

Designing a targeted, molecular drug begins with understanding the disease at a molecular level and identifying a target, such as a receptor, enzyme, or gene that isn’t working as it should and needs to be fixed. The next step is to visualize the biological target using technology such as X-ray crystallography, nuclear magnetic resonance spectroscopy, or computerized molecular modeling. Based on the geometric shape and charge distribution of the molecular components, a scientist chooses a chemical molecule that will interlock or bind with the target to correct the problem. Then he or she tinkers with the “lead” molecule until it fits the receptor or other biomolecule, much like a locksmith shapes a key to make it fit and open a specific lock. Some drugs are designed to fit the lock, but not turn or activate the mechanism, blocking the function of the receptor or enzyme. Much of the talent needed to support this approach can be found among the College’s own medicinal chemistry faculty, who have been working in the molecular design arena for a number of years. In fact, the growth of the discipline has paralleled the advances in molecular biology and technology that make rational molecular drug design possible. United by a common foundation in chemistry and an interest in molecular recognition, faculty specialize in different aspects of drug design such as synthesis, bioactivity, structural biology and modeling. Interestingly, medicinal chemistry faculty do not actually focus on producing drugs. Rather, they work several steps ahead of industry to develop concepts and tools that other researchers and drug companies can apply, explains Professor Philip Portoghese.

“The reason we are leaders in exploring new concepts in drug design is that we don’t focus on products,” Portoghese says.

But sometimes their research does result in a new drug. An example is carbovir, an AIDS compound created by Professor Robert Vince several years ago and licensed to Glaxo Wellcome for development. The compound, slightly altered and under a new name, was shown to be highly effective in recent clinical trials. Like AZT, it inhibits the reverse transcriptase enzyme that HIV uses to replicate itself inside immune cells. But carbovir has some structural differences that appear to make it less toxic and 20 to 50 times more potent than AZT. More of the drug gets through digestion into the bloodstream, and carbovir stops replication of the virus earlier in its replication cycle. The drug is expected to be on the market next year.

One of the group’s strengths is opioid receptors. Portoghese, who leads this effort, synthesizes chemical compounds to match the geometric shape of these receptors. Found throughout the body as well as in the brain, opioid receptors mediate pain relief and play a role in immunity and other functions. While he focuses on the nature of these receptors and their linkage with chemical molecules, Portoghese has patented a number of his synthetic compounds because of their ability to relieve pain, suppress immunity during organ transplantation, treat alcoholism, and suppress appetite. Most recently, he produced a type of opioid that relieves pain at peripheral sites but can’t get into the brain. Consequently, it doesn’t have side effects that cause addiction. Portoghese works closely with assistant professor David Ferguson, a computational chemist who uses the computer to create 3-D graphic models of very complex organic and chemical molecules. “Being able to visualize the structure of opioid receptors on a computer screen is like a dream come true, Portoghese says. “I never expected to see this during my career. Now, we have both halves of the puzzle. Before, we were working in the dark.”

“The computer is an important tool because it allows you to build, simulate, and visualize molecules made up of thousands of atoms, a task that wasn’t possible 10 years ago. You can’t construct a protein molecule made up of thousands of atoms any other way,” Ferguson explains. Computer models have begun to take some of the guess work out of designing drugs, he adds. “We can see how a drug binds to a receptor in a cell and come up with strategies for more potent therapies.”

“Drug development begins with drug design,” Speedie says. “Once an active molecule is identified, it needs to get to its target within the body in an active form. This is particularly challenging for proteins, peptides and other products of biotechnology. Other research groups within the College of Pharmacy provide expertise in drug delivery, disposition, and optimal clinical use.”

Medicinal chemistry faculty already have a number of collaborations across the AHC as well as with drug companies and faculty across the nation. They work closely with the Medical School’s pharmacology department, for example, where scientists test the activity of compounds.

One way to further promote drug design and development at the University of Minnesota would be through an AHC-wide center. Such a center could provide opportunities for scientists involved in different aspects of drug design and development to meet and work together, expose clinical researchers to drug design, and foster new connections with industry.

It’s not likely that the AHC will ever move drugs through the entire pipeline from concept to marketplace the way a pharmaceutical company does, but Speedie hopes to “catalyze” interaction within the AHC and to support more interaction with industry.

“I think that bringing specialties together could generate a synergy that would enable researchers to expand their goals and carry drug development further at the University,” she says.

–Peggy Rinard

The Health Sciences Orchestra will perform a special concert at 4 p.m. on Thursday, July 3, at Fairview-University Medical Center in the University campus hospital lobby. A crew from CBS will videotape the concert for a segment of “Ordinary/Extraordinary” scheduled to air later this summer. Beatrice Robinson, assistant professor in the human sexuality program, was quoted in the July issue of Shape magazine for her participation in a program for overweight women with low self-esteem. Susan Wolf, associate professor of law and medicine, argued that it is wrong to seek a ban on cloning in a June 19 Star Tribune opinion piece. “We have to balance the promise of research and the potential benefits against the need for regulation and caution. We have to do better than a ban,” she wrote. KARE-TV portrayed the story of a North Carolina family whose son is at Fairview-University Medical Center for a blood and marrow transplant to treat severe aplastic anemia. Charlie Peters, associate professor of pediatrics, was interviewed for the June 18 piece. In a June 15 Star Tribune article Frank Cerra, senior vice president for health sciences, outlined the dramatic effect proposed federal Medicare cuts would have on medical education. “If this becomes law, we will lose over half of our [graduate medical training] budget in two years,” Cerra said. Jesse Goodman, associate professor of medicine, offered suggestions on how to detect and treat Lyme Disease June 13 on WCCO-TV. Henry Buchwald, professor of surgery, spoke about the pros and cons of weight-loss surgery for severely obese patients in a June 12 Star Tribune article. Maria Hordinsky, associate professor of dermatology, appeared on WCCO-TV on June 2 to discuss treatment options for female hair loss.

–Teri Charest

Hon Cheung Lee, Distinguished McKnight Professor, department of physiology, received an honorary degree in medicine and surgery from the University of Genova in June. Minnesota Medical Foundation presented five Distinguished Teaching Awards to clinical faculty and six to resident faculty at the foundation’s spring reception. Clinical faculty include Jerome Abrams, surgery; Joel Jahraus, family practice and community health; and Wesley Miller, Claus Pierach, and M. Thomas Stillman, medicine. Resident faculty recipients were Richard Battafarano, surgery; Stuart Bloom, internal medicine; Matthew Clayton, surgery; Anna Koniaris, obstetrics and gynecology; Neeraj Kumar, neurology; and Frank Moga, surgery. Third- and fourth-year medical students selected the winners. Joseph Keenan and William Manahan, family practice and community health, are recipients of Minnesota Physician 1997 Community Caregivers awards. Angela Thomas-Brown and John Northwood received Leonard P. Burke. Memorial Awards for community service contributions during residency training. Frank DiGangi, professor emeritus of pharmacy, received the second annual Lawrence C. and Delores M. Weaver medal at the College of Pharmacy graduation. Don Uden and Robert Straka were named the College of Pharmacy’s teachers of the year. Carl Osborne, professor of veterinary medicine, received the Didactic Teaching Award and the Norden Distinguished Teaching Award at CVM’s annual spring awards banquet.