Improve the health of the people of Wisconsin by supporting and strengthening physicians' ability to practice high-quality patient care in a changing environment.

Volume 105, Issue 7 (October 2006)

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John J. Frey, III, MD
Wisconsin’s health: From the elderly to children
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The articles in this issue of the Wisconsin Medical Journal focus on a variety of topics related to health in Wisconsin covering a wide spectrum of age-related issues.

Mahendr S. Kochar, MD, MS
The J-1 Visa Waiver Program for rural Wisconsin
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This issue of the Wisconsin Medical Journal features Crouse and Munson’s study on the retention and acceptance of the J-1 visa waiver physicians (J-1 physicians) in rural Wisconsin.1 Foreign or international medical graduates (IMGs) who enter the United States on a J-1 visa are required to return to their home country for 2 years before they can come back to the United States to work again. This provision was put in place to encourage IMGs to return to their home countries and utilize their US-acquired knowledge and skills to serve their own populations.


Dennis Berens
Recruitment or retention: J-1 Visa lessons
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The Wisconsin J-1 visa research is a wake-up call for communities that want to retain rural professionals. It’s also a message for medically underserved communities nationwide.

Original Research

Byron J. Crouse, MD; Randy L. Munson, MS
The Effect of the Physician J-1 Visa Waiver on Rural Wisconsin
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Context: One strategy to increase the number of physicians in rural and other underserved areas grants a waiver to foreign physicians in this country on a J-1 education visa allowing them to stay in the United States if they practice in designated underserved areas.

Purpose: The goal of this study is to evaluate the retention and acceptance of the J-1 Visa Waiver physicians in rural Wisconsin. Methods: Sites in Wisconsin at which physicians with a J-1 Visa Waiver practiced between 1996 and 2002 were identified. A 12-item survey that assessed the acceptance and retention of these physicians was sent to leaders of institutions that had participated in this program. Retention of J-1 Visa Waiver physicians was compared to other physicians recruited to rural Wisconsin practices by the Wisconsin Office of Rural Health during the same time period.

Findings: While there was a general perception that the communities were well satisfied with the care provided and the physicians worked well with the medical community, there was a lower satisfaction with physician integration into the community-at-large. This was found to correlate with the poor retention rate of physicians with a J-1 Visa Waiver. Physicians participating in a placement program without J-1 Visa Waivers entering practice in rural communities had a significantly higher retention rate.

Conclusions: Physicians with J-1 Visa Waivers appear to provide good care and work well in health care environments while fulfilling the waiver requirements. To keep these physicians practicing in these communities, successful integration into the community is important.

Kate Troy, BS; Anne Z. Hoch, DO; John E. Stavrakos, MS, MD
Awareness and Comfort in Treating the Female Athlete Triad: Are We Failing Our Athletes?
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Background: Recognition of the Female Athlete Triad (disordered eating, amenorrhea, osteoporosis) has increased significantly since it was defined in 1992 by the American College of Sports Medicine. However, knowledge and treatment of the Female Athlete Triad is still lacking among physicians and medical personnel.

Purpose: We surveyed physicians, physical therapists, athletic trainers, and coaches to determine their knowledge and comfort in treating the Female Athlete Triad. Methods: A questionnaire was submitted to 240 health care professionals (physicians, medical students, athletic trainers, physical therapists, and coaches) in a metropolitan city.

Results: Forty-eight percent of physicians, 43% of physical therapists, 38% of athletic trainers, 32% of medical students, and 8% of coaches were able to identify all 3 components of the Female Athlete Triad. When physicians were subdivided into specialties, 69% of Physical Medicine and Rehabilitation (PM&R) physicians, 63% of orthopaedic surgeons, 53% of family physicians, 36% of pediatricians, and 17% of gynecologists were able to identify all 3 components of the Female Athlete Triad. Only 9% of physicians felt comfortable treating the Female Athlete Triad. When physicians were subdivided into specialties, 17% of orthopaedic surgeons, 13% of family practitioners, 12% of PM&R physicians, and 4% of pediatricians felt comfortable with treatment programs.

Conclusion: Data suggest that a heightened level of awareness and education in the proper treatment of the Female Athlete Triad is needed.

Eric N. Reither, PhD; Paul E. Peppard, PhD; Patrick L. Remington, MD, MPH; David A. Kindig, MD, PhD
Increasing Educational Disparities in Premature Adult Mortality, Wisconsin, 1990-2000
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Context: Public health agencies have identified the elimination of health disparities as a major policy objective. Objective: The primary objective of this study is to assess changes in the association between education and premature adult mortality in Wisconsin, 1990-2000.

Design, Setting, and Subjects: Wisconsin death records (numerators) and US Census data (denominators) were compiled to estimate mortality rates among adults (25-64 years) in 1990 and 2000. Information on the educational status, sex, racial identification, and age of subjects was gathered from these sources.

Main Outcome Measure: The effect of education on mortality rate ratios in 1990 and 2000 was assessed while adjusting for age, sex, and racial identification. Results: Education exhibited a graded effect on mortality rates, which declined most among college graduates from 1990 to 2000. The relative rate of mortality among persons with less than a high school education compared to persons with a college degree increased from 2.4 to 3.1 from 1990-2000—an increase of 29%. Mortality disparities also increased, although to a lesser extent, among other educational groups.

Conclusion: Despite renewed calls for the elimination of health disparities, evidence suggests that educational disparities in mortality increased from 1990 to 2000.

Mark A. Sager, MD; Bruce P. Hermann, PhD; Asenath La Rue, PhD; John L. Woodard, PhD
Screening for Dementia in Community-based Memory Clinics
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Problem: Dementia is a significant public health problem that is underrecognized in primary care settings. This study examined the usefulness of 3 brief screening tests in detecting dementia and mild cognitive impairment (MCI) in persons seeking consultation for memory complaints within a network of memory diagnostic clinics in Wisconsin.

Methods: This prospective study of consecutive referrals for memory diagnostic evaluation analyzed data for 364 patients >50 years. Scores on 3 cognitive screening measures—the Mini-Mental State Examination (MMSE), Clock Drawing, and Animal Naming—were compared to clinical diagnosis of normal cognitive aging, MCI, or dementia.

Results: Using the standard cut score of <24, the MMSE identified only 60% of persons diagnosed with dementia. By contrast, using a recommended cut score of <14 words per minute, Animal Naming identified 85% of persons with dementia with a relatively low (12%) false positive rate. Clock Drawing was intermediate to the other 2 measures in screening effectiveness. Conclusions: Animal Naming was moderately to highly effective in identifying dementia. The naming procedure is easy to administer and may have value as a brief initial dementia screen in busy practice settings. More demanding cognitive measures may be needed to improve screening accuracy for MCI. Priti Bandi, MS; Elizabeth Dranger, MS; John M. Hampton, MS; Amy Trentham-Dietz, PhD
Trends in Childhood Cancer Incidence in Wisconsin, 1980-1999
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Objectives: Characterizing the burden of childhood cancer in Wisconsin is the first step to assessing the impact of prevention efforts, identifying especially vulnerable subgroups, and directing etiologic research. To support these goals, population-level data were used to examine trends in childhood cancer incidence among children aged 0-14 years in Wisconsin from 1980 to 1999.

Methods: Data for Wisconsin was provided by the Wisconsin Cancer Reporting System and compared to national data. Annual age-adjusted childhood cancer incidence rates for the entire population and subgroups by age, sex, race, time period, diagnostic code, and geographic region were described. Correlational analysis was conducted to assess the relation between community socioeconomic status and childhood cancer incidence using census data.

Results: Overall, Wisconsin’s annual incidence rate for childhood cancers was 14.4 cases per 100,000 children aged 0-14 years during 1980-1999. This rate increased 10.9% (95% confidence interval 1-22%) between 1980 and 1999. Children in the 0-4 age group (20.9 per 100,000 per year) had the highest incidence rates as compared to 5-9 year olds (10.4 per 100,000 per year) and 10-14 year olds (12.0 per 100,000 per year). In males, the age-adjusted incidence of childhood cancers between 1980 and 1999 was 15.5 cases per 100,000 per year, whereas females had an incidence rate of 13.1 per 100,000 per year. Rates for whites were similar to the rates for all other racial groups combined. Leukemia had the highest age-adjusted incidence rate among childhood cancer diagnostic subtypes (4.3 cases per 100,000 per year); leukemia incidence increased by 32% between 1980 and 1999. Among the 13 hospital referral regions in Wisconsin with reported cancer cases, the Dubuque region had the highest annual age-adjusted incidence rate of 24.6 cases per 100,000, followed by Madison with 15.6 per 100,000, and Milwaukee with 15.5 per 100,000. In general, higher socioeconomic status as reflected by census indicators was positively correlated with higher rates of childhood cancer.

Summary: Wisconsin experienced childhood cancer incidence rates and trends similar to those throughout the United States between 1980 and 1999. Analysis of Wisconsin data, which is subject to small numbers in absolute terms (3138 cases during 1980-1999), suggests that not all children have similar risk—infants and younger children (<5 years of age) as well as children living in areas with higher socioeconomic status may be especially vulnerable.

Review Articles

Alice M. Kuramoto, PhD, RN, BC, FAAN
Therapeutic Benefits of Tai Chi Exercise: Research Review
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Tai Chi is the popular abbreviation for T’ai Chi Chuan (pronounced “tie chee chuwan”) and is translated as “The Supreme Ultimate Boxing System.” Tai Chi began as a martial art form. It is an ancient Chinese exercise consisting of slow, relaxed movements for total self-development; for the body it is an exercise, for the mind it is a study in concentration, for the soul, it is a system of spiritual meditation.1 There are many styles of Tai Chi and each style has its own form. All styles of Tai Chi are usually done in a standing position and can be performed either as a solo or 2-person exercise. Each Tai Chi movement is a series of coordinated sequences. It is often called “meditation in motion,” since it is performed with total concentration and inner stillness. This inner calm within the movement improves the flow of qi (pronounced “chee”), the vital life energy that Chinese philosophy believes sustains and improves health.2

Case Reports

Kristen K. Volkman, MD; James G. Merrick, MD; Michael C. Zacharisen, MD
Yacht-maker’s Lung: A Case of Hypersensitivity Pneumonitis in Yacht Manufacturing
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We present a case of hypersensitivity pneumonitis in a 46-year-old female working at a yacht manufacturing company. She reported a 2-month history of progressive dyspnea, chest tightness, and daytime, nocturnal, and exertional cough in temporal relationship to work where she was exposed to chemicals involved in the manufacture of yachts. Treatment with systemic antibiotic therapy, inhaled bronchodilators, and inhaled corticosteroids provided minimal relief of symptoms. Spirometry revealed a restrictive defect and a chest x-ray demonstrated a diffuse interstitial pattern. She improved on oral corticosteroids and with avoidance of her work environment had resolution of her symptoms and normalization of her spirometry. Among the various chemicals the patient was exposed to, the most likely causative agents for her symptoms were dimethyl phthalate and styrene. Although the specific chemical or antigen could not be determined, the history and objective findings are consistent with occupational hypersensitivity pneumonitis. This represents a case of hypersensitivity pneumonitis related to the manufacture of yachts.

Letters to the Editor

Michael Robiolio, MD
Constitutional amendment sparks more debate
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In the September issue of the Wisconsin Medical Journal are two editorials encouraging a “no” vote on the impending marriage amendment. The first article by Paul Wertsch, MD, starts by defining the problem as one of access to health care but then goes on to defend the homosexual lifestyle because it is claimed to be biological in origin. The second article by Paul Grossberg, MD, cites governmental data, medical political policy, and a lack of evidence of harm to children by homosexual parenting to likewise make the marriage amendment a health care access issue rather than a moral clarification. My major point is that the issue of defining marriage and the issue of health care access are two totally separate issues. They are only joined by an ineffective health care payment system, which needs to be addressed separately. To blend these issues together will only bring more confusion to both. My minor point is that both authors make assumptions and draw conclusions that are not as rigorously correct as they claim.

Richard Miller
Database reference should be made
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As a staff person in the Wisconsin Department of Health and Family Services, Bureau of Health Information and Policy, with some responsibility for maintaining and developing the Web-based interactive query system Wisconsin Interactive Statistics on Health (WISH), I noted with some interest its use in the recent paper “Monitoring Racial/Ethnic Mortality Disparities in Wisconsin: 1991-2000” by Carty et al. (WMJ. 2006;105(6)26.)

Your Practice

Michelle Leiker, JD, Assistant General Counsel
Retail clinics: Coming to a location near you?
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Wisconsin, like many states, has seen a recent increase in retail health clinics. The trend of placing such clinics in big box stores, grocery stores, drugstores, and even shopping malls is increasing rapidly. According to an industry survey conducted by the California HealthCare Foundation in July 2006, the number of retail health clinics is expected to increase from about 90 today to several thousand by the end of 2007.1 Many retail health clinics are operated by outside companies and are affiliated with medical establishments to comply with state physician-ownership requirements. The clinics that have opened in Wisconsin have been tied to medical establishments to meet the requirements of practicing medicine under state law.

Jay A. Gold, MD, JD, MPH
Immunization season: For more than just flu
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Influenza season is upon us, and now is the time to immunize your patients who are at risk. And providing influenza immunizations is a perfect time to make sure your patients are also up-to-date on their pneumococcal and hepatitis B vaccinations.

Brian H. Reamer
Hedge funds: Are they appropriate for your portfolio?
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Hedge funds are investment vehicles that seek positive absolute returns, regardless of the direction of the market. Hedge funds tend to be more popular in bear markets, because they hedge what they own. In a bull market, hedge funds may not perform as well.

Your Profession

Richard B. Anderson, MD
Of creationism and stem cells
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Once upon a time, a long time ago, primitive man looked to God for comfort and understanding of the terrible plagues and illnesses that beset mankind. This of course was long before there became different religions, each with their own God. Here again each religion sought comfort in their God and all respected their fellow man as well as tolerance for each other.

Michael J. Dunn, MD
Physical Medicine and Rehabilitation has strong history at Medical College
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Born of the wars of the 20th Century, physical medicine and rehabilitation was a field developed in direct response to the considerable need for wounded soldiers to recuperate and return to duty. As medical and surgical care improved, survival despite profound injury became more common, further underscoring the need for care that stressed rehabilitation over bed rest. Soon, the field had expanded from Army hospitals to the civilian sector.

Amtul R. Ahmad, MD
Citizens and doctors: Taking control of health care
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The challenges in our health care system are many, but Kenosha County’s experience with the Wisconsin Medical Society-sponsored Citizen Congress gives me reason to be optimistic. This forum gave physicians and patients the power to develop a vision and dream, and start the process of changing the health care system for the better.