Interview

Forging a New Future

Zeke McKinney, MD, MHI, MPH

One of your three board certifications comes from the emerging field of Clinical Informatics. What can you tell us about this subspecialty?

People conflate the field of informatics with technology, and really it’s not a requirement. The field of informatics is all about how we manage information from the simplest level of how we just collect data so we can do something with it, all the way up to how we use that data to actually change the practice of what we do, whether it’s in medicine or any other domain. Some simple examples of informatics solutions that have nothing to do with technology are when we’re working on the wards in the hospital, people are paging you and you’re getting a lot of things coming at you all the time. Somebody might just keep data on a piece of paper or use a checklist. That’s a very simple informatics solution that has nothing to do with technology. Look at managing information in the library. The Dewey Decimal System, that’s an informatics solution. Again, it has nothing to do with technology at all. Now, the intersection of technology is the fact that technology makes it very easy for us to manage information. So as a consequence, technology and informatics go hand-in-hand. The field of clinical informatics is really the overlap of clinical care delivery, information technology and how all those things go together.

Health systems don’t really understand what it means for someone to be a clinical informatician and how they might want to use that. People who are clinicians and also informaticists are having a hard time finding a job where they can do both of those things at once. Every clinician is about halfway to be an informaticist because if you ask any doctor, nurse or PA “Tell me 10 ways in which your clinic could be more efficient”, they could tell you those 10 things instantly. Then you ask them the next question. How would we fix those things? The people who give you a blank stare are probably not your informaticians or informaticists but the people who know how to answer that question probably are.

With all kinds of health care businesses creating positions like “director of digital transformation,” please discuss the intersection of digital transformation with clinical informatics and why it is important for physicians to take leadership positions in this area.

Digital transformation is a little bit of a vague term. Generally, it means adopting more advanced technology to improve practices, and of course that intersects strongly with clinical informatics about how we use information in such a way to be efficient, effective and deliver better care optimally. It’s how we integrate more of what people are doing even outside of the clinical space. Everybody and their mom has a smartwatch or a Fitbit or some kind of wearable, and we’re still trying to figure out how to use personal health records to fix the problem of the silos of information exchange between health systems. Somebody who’s in a role of digital transformation or clinical informatics is going to think about that kind of stuff. That’s exactly where you need people with medical training because physicians understand clinical care, they understand the complexities of the data, they understand what all that data means. Using people who are only trained in information technology or databases, or who are only trained in quality improvement or statistics will not lead to the best outcomes. Trying to tell clinicians what to do is going to fail. We are better able to engage clinicians by having someone who speaks their language and knows what’s happening when they see a patient in the clinic. We need to help physicians understand why electronic health records may or may not be able to do what they want them to do or maybe that what they’re asking for isn’t even the thing that they think they want.

Please tell us about the current relationship between preventive medicine and occupational medicine.

I’d say they’re sister fields. The American Board of Preventive Medicine has three primary specialties. One is called general preventive medicine and public health, there’s occupational medicine and then there’s aerospace medicine. All of them have the orientation of prevention, but I don’t know that occupational medicine came from preventive medicine only because occupational medicine has its own thing. The father of occupational medicine is Bernardino Ramazzini who was an Italian physician in the 1600s who focused on people who, in doing their jobs, were exposed to the hazards that caused serious health conditions. But you can take it all the way back to Hippocrates who also looked at hazardous work-related exposures, for example miners getting lung diseases. Occupational medicine started board certifying in 1955, as perspective emergency medicine first board certified around 1980. Most of allopathic medicine, as much as we want it to be preventive, is really not. It’s, you’re sick today, you show up today, we kick you out and we see you next time. Preventive medicine specialties are thinking about the root cause, and how we not only treat this one patient, but how we treat everybody at a system level in terms of the factors of public health and social determinants of health that actually impact everybody. 

We’re kind of neurotic as a country as it pertains to public health.

Occupational medicine has always presented certain ethical dilemmas. What can you tell us abut these concerns?

That’s a real thing and real mythology at the same time. There are corporate medical directors, who are occupational medicine physicians to this very day. That’s probably the job many people in my field aspire to get on because it’s a pretty mellow job and pays really well. However there is a conflict of interest when a company is paying you and telling you, “We have to meet quotas X, Y, and Z, and you got to get people back to work”. There have been issues in the past with some occupational physicians, not necessarily being as focused on what is best for the patient and more on what is best for the company. However, if you think about it philosophically, all of that is wrong, because really the approach should be that we are sitting as stewards between an employer and an employee. Everyone should in theory have the same goal that a person gets better. An employer is also often providing insurance. Their insurance rates are higher if people aren’t healthy and are getting injured. Unfortunately, sometimes you have people who are overly focused on the bottom line for the quarter and making sure people are doing their job, regardless of injuries. Common sense says “Well, it’s going to cost us more money in the long run if we just don’t do things right in the first place.” That’s more philosophically where we should be. 

Occupational medicine/preventive medicine presents unique perspectives on public health. What can you share about these intersections?

Preventive medicine specialists are required to get a Master’s of Public Health or equivalent to be board-certified. Public health is built right into it. Public health, at the end of the day, is designed to ensure the health and safety of our populace are protected with the consideration of the people who are the most vulnerable. COVID has proven that we definitely do not subscribe to true public health principles in this country, not based on that definition. At the end of the day, we’re relatively a new country, and I don’t think we’ve decided where we want to live on that spectrum. We juxtapose extremes of, “Great, we’re going to protect everybody as much as we can, regardless of what they think or want to say about it,” with “People can just choose to do whatever they feel like and we’re going to take our hands off of it.” In some cases, where we live on one end, for example, gun control. In the United States, you can have as many guns as you want and unfortunately, this leads to common school shootings and other gun violence in our society. That’s a big public health problem. But we as a society believe that’s something in the control of the individual, and we don’t want to talk about it. On the other end, we have things like seat belt laws, where we’re just dictating we know we need to protect the populace from their own risks regardless of what they think about it. And sometimes we’re in the middle. But I think we’re kind of neurotic as a country as it pertains to public health. 

In the ways I just mentioned, these specialties serve as the eyes into the soul of medicine. Every specialty can benefit from the work of occupational medicine. Many times, physicians may not consider the role good public health policies, or the lack thereof, can play in what it is that brought a patient to their exam room or how those considerations will impact treatment outcomes. It can be a misunderstood field and better connections between  individual physicians, health systems and payers with occupational medicine will produce better results for everyone involved. Due to residency funding through the federal government being related to time spent seeing patients, many occupational/preventive medicine residency programs are underfunded. Our specialties require non-clinical work, such as with public health departments, in administrative settings such as employee health, or with employers and insurers. As a consequence, most or all occupational/preventive medicine training programs operate at less than full capacity. I run one of those residency programs and we are exploring several funding initiatives that may include legislative proposals. 

One way of addressing the health care work force shortage crisis could involve better utilization of community resources. Can you share some examples of how this could happen?

It’s been proven time and time again that community-oriented or community-delivered resources for prevention and public health are famously good. I worked in the community over the past year or so. We had a community vaccine clinic at my barbershop on Fridays and Saturdays. There have been similar efforts in many community spaces that addressed issues for people with hypertension, high blood pressure, diabetes, cholesterol, screening and other chronic conditions. Those are all great, but how can those efforts interact with someone’s physician, clinician or health system? How does a health system know those community resources can screen a person for their hemoglobin A1C without them coming to the system doctor and be sure if something looks pretty bad that person will be pushed to the clinic really fast?

Let’s say I run a clinic at my barbershop taking hemoglobin A1Cs for diabetic patients and may be monitoring them for symptoms of diabetic neuropathy, retinopathy or other concerns. There’s no way for me to push that data into the HealthPartners system, the Fairview system or the Allina system, other than to hand somebody a piece of paper that they then take to the doctor or I fax it over. That’s where, in theory, personal health records could help. A lot of people are trying to make a place in that space, e.g., Microsoft, Google, Apple and others, but we’re not there yet. The intent is for people to control their own health records and be able to distribute it or provide access, ad hoc, to different systems.

What are the biggest obstacles to the health care delivery system taking more advantage of community resources to improve patient outcomes?

Community centers may be doing health screenings, health fairs and so on, very commonly on the order of probably all the time. One problem is that they do not know how long they’re going to be able to continue doing them. The next source of money is not always there. I have never seen one of these things running in perpetuity. In fact, our vaccine clinic at the barbershop ended, because the money from the CARES Act for COVID-19 issues ran out and the Minnesota Department of Health didn’t have any more money to support us. Right now, I would love to any day, go over there and start something where we can check blood pressure, hemoglobin A1C and cholesterol. But again, who’s going to run those labs, and who’s going to pay to even have them done by staff, with me or whomever. And then there are the issues around how we close or maybe open the loop to get that data out of there and into a place where somebody can use it in an intersection with their medical professionals.

The Twin Cities Medical Society recently changed its name to Advocates for Better Health, and you recently became their president. Please tell us about the thinking behind the name change.

That stemmed from the fact that historically Twin Cities Medical Society served as the metro component of the Minnesota Medical Association, the state branch of the American Medical Association. Because of some philosophical differences in approach, the Minnesota Medical Association and Twin Cities Medical Society have split and they are no longer connected in any way. And in general, one of the goals, or probably the primary goal that the Twin Cities Medical Society has been focused on is community-oriented public health efforts. And as a consequence, we felt that in order to best serve the community, we probably needed a name that reflected who we are and what we do. Twin Cities Medical Society doesn’t mean anything, it’s completely nebulous. It doesn’t say anything other than to relate to the metro area, that it has a medical orientation and that’s it.

As president, what goals do you have for the new organization?

We will not be focused, like medical societies, on improving the practice of medicine in ways, such as lobbying for laws that change reimbursement and medical licensing. Much of our mission will be around patient advocacy, though we will also focus on very physician-centric issues. For example, our physician wellness collaborative helps physicians find behavioral health care outside of their employers that is non-punitive and provided by peers and people who understand what goes on in the clinical world. We will provide public health support for the community, asking the community what they need and how we as physicians with power, privilege, a voice and maybe some money can do something about it. We hope to provide technical assistance to people who may want to write a grant for an organization to improve health care and may need a doctor to help iron out some of the details. We will provide education around what people with diabetes should do from a diet perspective. We need to have some town hall sessions where people can ask questions. If we are needed to advocate at the legislature, with local insurers or local health systems, we will help.

How can other physicians become involved with this work?

We’d like to serve the whole state. Our footprint has primarily been in the metro area, but as we continue to grow, we welcome members from Greater Minnesota. They face huge issues of health care access, health care need and health care disparities. These are some of the issues we are addressing. Everyone is welcome to join. So if you live in Bemidji and think there’s something you can do in your community to help public health or help people do better overall, we can provide assistance. If you think some doctors with expertise or wisdom, a voice, power or money could help you help your community, we want to be those people.

Zeke McKinney, MD, MHI, MPH, is the program director of the HealthPartners occupational and environmental medicine residency and an affiliate assistant professor with the University of Minnesota School of Public Health in the division of environmental health sciences.