Minnesota Physician June 2012 by Minnesota Physician Publishing

Volume XXVl, No. 3

June 2012

The Independent Medical Business Newspaper

A better toolbox Palliative care comes to the outpatient oncology clinic By Charles Bransford, MD

n September 2006, I began doing palliative care consultations in our outpatient oncology clinic. I admit that my motive for working in our oncology clinic stemmed from the strong bias that much of my work would entail helping patients stop chemotherapy. I assumed it would be obvious when chemotherapy was causing more harm then good and patients were continuing therapy simply because they thought they had no other viable choice. This is often the fear oncologists have of palliative care doctors—that they will encourage oncology patients to stop chemotherapy too soon. Initially, my consultations involved stage IV metastatic cancer patients who had no further options for treatment and the oncology team was struggling with how to tell their patient it was time to stop, especially

B.C.

For someone who spent much of his professional life dissecting human cadavers, Herophilus had a remarkably astute understanding of the importance of maintaining bodily and mental health. More than 2,000 years later, physicians are coming to understand that we need attend to our personal health if we are going to improve overall population health. We know that physicians are not immune to the effects of disease, both physical and emotional. In fact, physicians may experience STRESSED to page 10

PAID

By Keith Stelter, MD

—Herophilus, Greek physician, 335–280

IN THIS ISSUE: Architecture Page 20

PRSRT STD U.S. POSTAGE

Strategies to handle the stresses of today’s medical practice environment

Detriot Lakes, MN Permit No. 2655

Stressed out?

TOOLBOX to page 14

hen health is absent Wisdom cannot reveal itself Art cannot manifest Strength cannot fight Wealth becomes useless, And intelligence cannot be applied.

Be protected, stay cool. We protect your peace of mind. It’s what we do for medical professionals. We know your work challenges are unique. And so are we. Sure, we provide medical liability insurance. But we’re also focused on your personal wellness. We want you to feel as groovy as possible, because if you’re at your best, you’ll deliver your best. It’s a Peace of Mind movement, and we’d love for you to join us. Contact your independent agent or broker or check out PeaceofMindMovement.com to see what MMIC can do for you.

MMIC is the preferred carrier of the Minnesota Medical Association and has earned the AM Best industry rating of “A” (Excellent) for 20 consecutive years.

CONTENTS

JUNE 2012 Volume XXVI, No. 3

FEATURES Stressed out? Strategies to handle the stresses of today’s medical practice environment

A better toolbox Palliative care comes to the outpatient oncology clinic

By Keith Stelter, MD

By Charles Bransford, MD

Architecture Honor Roll

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW Laurie Drill-Mellum MMIC Group

SPECIAL FOCUS: MEDICAL FACILITY DESIGN Vital signs

By Steve Brown, CCIM

Building an optimal healing environment

New “hospice house”

By Terri Zborowsky, PhD, EDAC

Reforming health care design

By Deborah Sweetland, FACHE, MBA, EDAC, and Michael Moran, AIA, ACHA, LEED AP

By Gloria Cade, RN, BSN, CHPCA, and Mark L. Hansen, AIA

The Independent Medical Business Newspaper

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR Juline Birgersson jbirgersson@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace legal, tax, business or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

JUNE 2012 MINNESOTA PHYSICIAN

CAPSULES

Health Bills Pass At End of Session Gov. Mark Dayton signed the Health and Human Services (HHS) omnibus bill at the end of the Legislative session, restoring $18 million in funding to a range of services that were cut in last year’s budget. Dayton called the HHS omnibus bill one of the great accomplishments of the session. He praised leaders from both parties and agency heads for working together. “It’s an extraordinary accomplishment, especially in the context of some of the other difficulties we’ve had this session in working together in a cooperative, bipartisan way,” he said. Dayton noted that additional funds were available to address some of the HHS shortfalls because of the work of Department of Human Services Commissioner Lucinda Jesson, who negotiated a cap on profits from state health plans for the private insurers that administer them. Some of the provisions included in the HHS bill in-

cluded language that increases payments for personal care attendants, restores funding for treatments such as dialysis and chemotherapy for people on Emergency Medical Assistance, and the funding of an autism study. One of the reforms much discussed among providers this year was the idea of independent, third-party audits of state health plans. The measure provides for independent audits to be conducted biannually, under generally accepted accounting standards. The first audits will take place for 2014 health plan contracts, so the earliest the public and legislators will see audits will be 2015. Another health care issue at the end of the session was a bill that would expand public disclosure from medical licensing boards such as the state’s Board of Medical Practice. According to Dave Renner, lobbyist with the Minnesota Medical Association (MMA), his group was concerned about language that would have required the board to post information about

malpractice settlements by providers. After testimony from MMA, the language was removed. “We were trying to ensure that the information we provide to consumers will be helpful to them,” Renner says. “Whether a case is settled might not be in the hands of the physician. There are many reasons for settlement, and then there is the fact that many settlements are sealed. … We think the Legislature did focus on the information that will be helpful to the consumer.”

Hospital Finances Strong, Baumgarten Report Finds Hospitals in Minnesota continued to see good financial numbers in 2010, according to a new report from Allan Baumgarten’s Managed Care Reviews. Baumgarten releases two reports on the Minnesota health care industry each year, one that examines hospital finances and a second on man-

aged care plans. The new report finds that hospitals continued to see strong operating margins in 2010, one year after data showed 2009 numbers that were the best in the past decade for hospital finances. “They’re doing well on the revenue side in terms of the rates that they’re negotiating with the private insurers, and I think they’ve also been attentive on their expense side, in terms of trying to find efficiencies,” Baumgarten says. “The growing economic power of some of these outstate systems is also helping the profitability.” The report shows that the average margin for outstate hospitals was 10.8 percent, compared to approximately 7 percent margins for hospitals in the Twin Cities metro area. Hospitals are seeing strong income even while inpatient hospital days have declined. Baumgarten says the outstate market is being reshaped by the ongoing consolidation among large health systems such as Sioux Falls, S.D.-based

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When changes in the local health care landscape promised a major inﬂux of new UCare members coming through metro-area clinics and hospitals, we made sure those providers were prepared. In a span of just two weeks, May Ly was among the UCare staff that personally visited 449 unique health care locations to offer a heads-up and explain the impacts. Because being responsive to our partners’ needs isn’t just talk—it’s what we mean by health care that starts with you.

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MINNESOTA PHYSICIAN JUNE 2012

Coalition Works to Prevent Drug Theft A coalition of providers, state government, and law enforcement has created a set of best practices to enhance security for controlled substances at hospitals and health care facilities. The Controlled Substance Diversion Coalition, formed in May 2011, has been working on strategies to prevent theft of prescription drugs by health care workers, patients, families, and visitors to health care facilities. The group has created a road map and tool kit to improve the security of systems by which providers procure, store, and dispense controlled substances. More information on the new tools can be found a www.health.state.mn.us/patient safety/drugdiversion/. â&#x20AC;&#x153;This coalition has been a great example of government, hospitals, and medical professionals working together to proactively address the problem of drug diversions,â&#x20AC;? says Ed Ehlinger, MD, Minnesota commissioner of health. â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;ve produced tools that will help protect patients and prevent some of these relatively rare but at times high profile cases involving a health care worker illegally diverting prescription medications.â&#x20AC;?

AG Report Blasts Accretive Health Attorney General (AG) Lori Swanson released a report in April on debt collection practices by Chicago-based Accretive Health, saying the company crossed a line in trying to collect payments from patients in Minnesota.

The AG began investigating Accretiveâ&#x20AC;&#x2122;s practices last summer, after a stolen laptop created a security breach for Fairview Health Services and North Memorial Hospital, two local health systems that worked with Accretive. After months of investigation, Swansonâ&#x20AC;&#x2122;s six-volume report blasts Accretiveâ&#x20AC;&#x2122;s practices with Fairview in particular, saying the company violated numerous state and federal laws and promoted a â&#x20AC;&#x153;boiler-roomâ&#x20AC;? culture that was at odds with Fairviewâ&#x20AC;&#x2122;s status as a not-forprofit organization. â&#x20AC;&#x153;Accretive and its â&#x20AC;&#x2DC;numbers-drivenâ&#x20AC;&#x2122; culture have undermined Fairviewâ&#x20AC;&#x2122;s missiondriven culture,â&#x20AC;? the report says. â&#x20AC;&#x153;The Accretive culture has converted the hospital culture from that of a charitable organization to that of a collection agency.â&#x20AC;? Fairview responded to the report by noting it has severed its ties with Accretive. In a statement released April 24, Fairview said, â&#x20AC;&#x153;We take the concerns raised by Minnesota Attorney General Lori Swanson very seriously. We have been in consultation with her on these issues for several months. We share many of her concerns and have already taken actions to address them.â&#x20AC;? Accretive responded by filing a motion to dismiss Swansonâ&#x20AC;&#x2122;s case, saying the charges were baseless and that she has â&#x20AC;&#x153;orchestrated a nationwide media campaign against Accretive Health.â&#x20AC;? The company also got some high-profile support from Chicago Mayor Rahm Emanuel, who wrote a letter to Swanson asking her to meet with Accretive executives. Swanson brushed off Emanuel, saying in a statement that her lawsuit was a law enforcement matter, not a political one.â&#x20AC;?

Community Health Clinics Receive ACA Funding Community health clinics in Minnesota will receive more than $15 million in Affordable CAPSULES to page 6

Telephone Equipment Distribution (TED) Program

Sanford Health, Duluth-based Essentia Health, and Rochesterbased Mayo Clinic. â&#x20AC;&#x153;Sanford, Essentia, and Mayo have emerged as three very powerful systems,â&#x20AC;? Baumgarten says. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s reminiscent of how hospital systems developed in the Twin Cities; of course the geography is different, but the pattern and strategies are very similar.â&#x20AC;?

Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability? If soâ&#x20AC;Śthe TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.

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CAPSULES Capsules from page 5 Care Act (ACA) funding, federal officials announced recently. More than $728 million in funds will support 398 renovation and construction projects nationwide, officials say. In an effort to expand access to health care, the ACA has set aside approximately $11 billion to expand facilities and services of community health centers in the United States over a fiveyear period. Funding for community clinics is aimed at improving the health of the nation’s underserved communities, officials say. Currently, these clinics deliver care to more than 20 million patients regardless of their ability to pay. Since 2009, community clinics have served nearly 3 million additional patients and will serve an additional 1.3 million new patients in the next two years, officials say. In addition, employment at community health centers nationwide has increased by 15 percent. “For many Americans, community health centers are the

major source of care that ranges from prevention to treatment of chronic diseases,” says U.S. Health and Human Ser-vices Secretary Kathleen Sebelius. “This investment will expand our ability to provide high-quality care to millions of people while supporting goodpaying jobs in communities across the country.” In Minnesota, seven community health clinics will receive new funding under the program, ranging in amounts from $358,000 to $4.8 million. These include seven clinics in Cook, Duluth, Mankato, Minneapolis, and St. Paul.

Fairview, U of M Plan Ambulatory Care Center Fairview Health Services, the University of Minnesota, and University of Minnesota Physicians are working on plans to build a new ambulatory care center on the U of M campus, and at the same time revise the relationship between Fairview

and UM Physicians. Officials began talking publicly about the plan in May, leading up to a meeting of the U of M regents to discuss the changes. The construction project would build a $182.5 million ambulatory care center that would include clinics, surgical suites, and diagnostic facilities. The center would combine and streamline many services now scattered over several buildings on the U of M campus. Officials note the current facilities for outpatient surgery and related services were built in 1974 and designed for onefourth the patient volume that university providers now see. Since that time, medical practices have changed, with outpatient surgery becoming much more common, officials say. In addition, the new facility will allow the U of M to develop the use of coordinated, team-based care strategies. “The current proposal will create a facility that will allow for the implementation of new care models and will improve interdisciplinary collaboration

in a way that meets the needs and expectations of the current health care environment,” says Bobbi Daniels, CEO of UM Physicians. “The research and education programs of the medical school will also be advanced by a design that facilitates both the teaching of medical students and other trainees as well as better incorporating clinical research, which are at the core of the University of Minnesota’s mission.” Fairview and UM Physicians are also discussing a new management structure between the groups. According to Daniels, the groups have signed a letter of intent that envisions a co-management model between University of Minnesota Medical Center, University of Minnesota Amplatz Children’s Hospital, and U of M Physicians. However, the arrangement is not a merger; Daniels says U of M Physicians and Fairview will continue to operate as separate organizations with separate finances.

continuing medical education 30th Annual Strategies in Primary Care Medicine

September 20-21, 2012

• Post-Conference Activities – Basic Life Support for Health Care Providers – Recertiﬁcation – ABIM Maintenance of Certiﬁcation Learning Session

Midwestern Region Burn Conference

October 11-12, 2012

• Pre-Conference Workshops – Burn Rehabilitation: The Bridge to Recovery – The Pathway to Improving Outcomes for Pediatric Burn Injuries (includes simulation-based learning) • Post-Conference ABLS Provider Course

Optimizing Mechanical Ventilation 13th Annual Women’s Health Conference Pediatric Fundamental Critical Care Support Emergency Medicine and Trauma Update: Beyond the Golden Hour 34th Annual Cardiovascular Conference

education that measurably improves patient care 6

MINNESOTA PHYSICIAN

JUNE 2012

October 10, 2012

October 13, 2012

October 26-28, 2012 November 2, 2012 November 8-9, 2012 November 15, 2012 December 13-14, 2012

healthpartnersIME.com

MEDICUS Richard Hart, MD, a St. Cloud pediatrician, was recently chosen by peers to receive the CentraCare Health Foundationâ&#x20AC;&#x2122;s Caduceus Award. The award annually recognizes physicians on the medical staff of St. Cloud Hospital for their leadership in humanitarian efforts and community involvement. Hart was recognized for his dedication to charity care and mission work, including a program with St. Cloud State Richard Hart, MD University to develop care plans for severely disabled children. He has taught emergency medical technician pediatric training in the St. Cloud area, has sponsored various events for March of Dimes and other organizations, and has participated in medical missions to Guatemala. The Minnesota Academy of Family Physicians (MAFP) has selected Andrew Burgdorf, MD, of Buffalo, as the 2012 Family Physician of the Year. This award is presented annually to a family physician who represents the highest ideals of the specialty of family medicine, including caring, comprehensive medical service, community involvement, and service as a role model. Family physicians from across the state Andrew Burgdorf, MD were nominated for the award by patients, community members, and colleagues. Burgdorf practices at the Allina Medical Clinic in Buffalo. He has been a family physician in the community for nearly 24 years and also serves as the clinicâ&#x20AC;&#x2122;s lead physician. The award cited Burgdorfâ&#x20AC;&#x2122;s energy, his positive attitude, and his commitment to his patients, his family, and his community. Other physicians who received awards at the annual MAFP meeting are Paul Van Gorp, MD (CentraCareâ&#x20AC;&#x201C;Long Prairie Clinic) â&#x20AC;&#x201D;Teacher of the Year; Glenn Nemec, MD (Monticello Clinic) â&#x20AC;&#x201D;Merit Award; Macaran Baird, MD (University of Minnesota Medical School, Minneapolis)â&#x20AC;&#x201D;Presidentâ&#x20AC;&#x2122;s Award; Mark Yeazel, MD, MPH (University of Minnesota Medical School, Minneapolis) â&#x20AC;&#x201D;Researcher of the Year; Laura Wellington, MD (North Memorial Family Medicine Residency Program)â&#x20AC;&#x201D;Resident of the Year; and Ben Pederson (University of Minnesota Medical School, Minneapolis)â&#x20AC;&#x201D;Medical Student Award for Contributions to Family Medicine. Five physicians have recently joined Duluth-based Essentia Health. Othmane Alami, MD, a geriatric psychiatrist, has joined Essentia Healthâ&#x20AC;&#x201C;Duluth Clinic. Alami is board-certified in psychiatry and neurology. In addition to geriatric psychiatry, he specializes in psychosomatic medicine. Alami completed his residency at the State University of New York in Brooklyn and his fellowship was at Columbia University in New York. He attended medical school in Casablanca, Morocco. Laurie Jepson, MD, has joined the Internal Medicine Department at Essentia Healthâ&#x20AC;&#x201C;Duluth Clinic. Jepson is board-certified in internal medicine. She received her medical degree from the University of Minnesota, Minneapolis and completed a fellowship at University of California-Los Angeles Medical Centerâ&#x20AC;&#x2122;s Harbor General Hospital in Torrance, Calif. She also completed an internal medicine internship and residency at Maricopa Medical Center in Phoenix, Ariz. Jay Huber, MD, has joined Essentia Healthâ&#x20AC;&#x201C;St. Maryâ&#x20AC;&#x2122;s Medical Center as a hospitalist. Huber, who is board-certified in internal medicine, received his doctorate in osteopathy at the University of North Texas and Texas College of Osteopathic Medicine in Fort Worth. He completed an internal medicine internship and a residency at Fitzsimons Army Medical Hospital in Aurora, Colo. Cory Ecklund, MD, a family medicine physician, will travel to several of Essentiaâ&#x20AC;&#x2122;s regional clinics to see patients. Ecklund is board-certified in family medicine. He received his medical degree from the University of Minnesota, Minneapolis and completed his residency at the Alaska Family Medicine Residency program in Anchorage.

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MINNESOTA PHYSICIAN

INTERVIEW

A physician’s view of liability ■ As CMO at a professional liability company, how

do you see your role?

Laurie Drill-Mellum, MD, MPH MMIC Group Laurie Drill-Mellum, MD, MPH was named chief medical officer (CMO) for MMIC in February. The Minneapolis-based medical liability insurance company provides a range of services for physicians and providers throughout the Midwest. As MMIC’s first CMO, Drill-Mellum will work with the company’s physician clients on risk reduction and risk mitigation strategies. An emergency medicine physician at Ridgeview Medical Center in Waconia, Drill-Mellum has served on the MMIC board of directors since 2008. She is currently a Bush Medical Fellow and a fellow of the American College of Emergency Physicians.

■ What have been the most significant factors in

the recent decline in malpractice claims?

The overall goal as a medical liability company is I don’t think anybody knows for sure. What we to ultimately decrease adverse events. MMIC has would like to think is that all these patient safety been working very hard on this. We have a system initiatives around the country, along with managefor extracting data so that we can make a lot of ment programs, have made a difference. data-driven recommendations. That being said, the It is absolutely true; the frequency of claims area that I’m going to be interested in when it have gone down. What we call the severity of comes to adverse outcomes is developing programs claims has gone up—the settlements or awards are to help support physicians. much larger. Of course, we would like the number We know that when a physician and other of settlements to be zero. With the practice of medproviders are involved in an adverse event it can icine, it will never be zero but we would like to get impact them deeply, because of course that would it down to as low a number as possible. never be their intention. Some physicians go on to ■ Many lawmakers support tort reform as a way practice very defensive medicine, some develop of holding down health care costs. What is your problems with depression, or problems with chemposition? ical and alcohol abuse. I personally have a huge I think tort reform would be interest around physician I’ve been an emergency wonderful. Courts generally wellness and physician compensate people for their medicine physician for injuries but this whole latiburnout. That will be one of my first initiatives: to try and tude to give juries the ability 21 years. It is not just develop programs along that to say what kind of award is line. Additionally, I am intertheoretical with me. given—this is driving up the ested in behavior at work, cost of health care exponencommunication at work, and tially. If you put a cap on culture at work, because all of these things impact awards, you would be spending a lot less money on the care that people give. awards. Maybe it would not be as appealing to take I anticipate developing not only a variety of as many adverse events to a lawsuit. Maybe there programs but also developing a network of physiwould be more mediation and settlement. cians to help me. For example, we would like to A lot of this malpractice environment drives start involving some of the physicians in our compeople out of medicine. I do not think the public munity who train residents in our claim evaluation knows or understands that physicians quit mediprocess. We would love residents to understand cine and move out of town when it gets to be too what we see and ways they can learn behaviors, much. Specialty groups move out of town or out of communication styles, and techniques to perhaps state, because physicians can choose where they avoid being in a lawsuit. want to practice in this country, and they’d just as We are not just in Minnesota; we are in seven soon practice in a more favorable environment. other states. We anticipate making connections ■ Do patients see physicians as invulnerable? with our insured physicians in other states to involve them in training programs and the evaluaThey are more vulnerable than the average person tion of claims on a more local level. would understand. They also see them as having deep pockets, because of liability insurance. I think ■ You are the first CMO at MMIC. Why did the tort reform would be a good thing. I think expert company decide to create this position? physician juries would be a good thing too, or My understanding is that the current CEO, Bill expert juries. McDonough, saw the benefits of bringing a physiThis is complex stuff. I am not speaking for cian into the leadership team. I feel that I bring MMIC, because I do not know what they think—I value just by giving a physician’s perspective. have never asked that. I have been on the MMIC board of directors The other thing is that I have sympathy for the for four years. I have seen the company working patient who has injuries and long-term medical from that position. These are people who obviously needs. Unfortunately, in our society, it seems that have a lot of knowledge about health care; they this may be the most viable recourse for people to have been working in the medical liability field for get compensated. If you look at Scandinavian most of their careers. So they have medical knowlcountries, they do not pay very much in malpracedge, but I am bringing knowledge from the tice at all, but if somebody is harmed in an event, trenches. I’ve been an emergency medicine the state takes care of them. That is another enviphysician for 21 years. I am practicing frontline ronment. medicine, and I see a lot of the problems and ■ In the debate over expanding the Board of the impacts of adverse events—it is not just Medical Practice’s public reporting to include theoretical with me.

MINNESOTA PHYSICIAN JUNE 2012

out-of-court settlements, there was considerable resistance from the medical profession. What should physicians know about this issue? Many cases are settled because of financial reasons, not because of culpability or malpractice. To include settlements [in public reporting] just does not seem right. People bring claims, but sometimes it is more expensive to litigate claims. It is a drawn-out process and a very psychologically-harmful, spiritually-wounding experience. I do not know how else to describe it. For physicians to be tied up in a claim, if there was not malpractice involved, there are physicians that prefer to just say, “Get me out of this, this is affecting my work, this is affecting my life—I can’t sleep at night.” Sometimes that is just the best option to take. Our position would be that we would not want settlements as a part of [public reporting]. ■ How are recent developments in informa-

tion technology affecting the field of medical malpractice? We have a whole IT department that is working on HIPAA compliance, because there are issues around what is called cyberliability, about data that people have to be mindful of. There is great potential for confidentiality breaches. As you probably know, this is a huge

Congratulations!

new area for physicians, many of who are uncomfortable with and feel burdened by the use of the electronic health record. So we have a consulting department that helps physicians and clinics with this. Another initiative we really want to focus on is early adverse event reporting. By doing early adverse event reporting, we could be sending out news blasts to insureds to try to decrease adverse events. We are all about trying to decrease bad things happening and increase good things happening, to keep people happier and communicating more effectively with each other. All those things add up to a better patient experience.

I would encourage people to do the right thing and worry about the fallout later. The thing I have to say about MMIC—I have been very impressed by how they stand behind their insureds. MMIC supports its physicians and does the right thing and that is why I joined the company. ■ An adverse outcome might be the result

of medical care received from another physician. How do you address those issues? I think that is obviously a dicey issue. I would encourage people not to joust— criticizing somebody else’s care. Of course, we see cases like this, complicated cases at one institution that go to another institution. Jousting in the medical record is not advised. Instead of criticizing former physicians’ care, one might say, “I can’t really talk about that. Let’s deal with what we have right here and do the best that we can do.” You are not in that other person’s moccasins. You do not know what resources they had available to them.

■ What are the issues if physicians are con-

sidering settling out of court? When accepting a settlement, it is reported to the National Practitioner Data Bank. It is something that they carry with them, whether or not they committed malpractice. They have to go through a period of discernment with legal advice about the pros and cons of that. If they go on to an actual court case, the court may find for the physician and then there would be nothing on their record; it would not be reported.

Does liability change with the ACO model, where physicians are part of a team? We have not seen anything along those lines that I am aware of. Ultimately, the physician is still going to be the captain of the ship and responsible for the care provided in these environments.

■ Malpractice concerns might cause some

physicians to hesitate if they find themselves in a Good Samaritan situation. What advice do you offer for that?

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MINNESOTA PHYSICIAN

Burnout teeter-totter Stressed from cover more emotional distress and lower levels of “well-being” than other professions due to the ongoing stress of our jobs. The concept of professional “burnout” was first used by psychologist Herbert Freudenberg in 1974 to describe “a state of exhaustion (most often emotional and mental) observed among volunteer workers” (Freudenberg HJ, 1974, J Soc Issues 30:1). Freudenberg noted that the condition occurred in those who “worked too much, too long and too intensively” and those who “had a need to give.” Does this sound like any physicians you know? It’s not surprising that the profession of medicine is stressful for all specialties. Among the reasons: many years of education and training, repeated highstakes exams of knowledge, student debt issues, high workloads, reduced sleep, high levels of personal accountability for outcomes, a changing medical care environment, and innovations that render our past

Job stress Role conflict Workload Time pressure

Job input/ influence Skill variety Feedback Coaching

Scheduling

Rewards

Work/ home balance

Self-growth potential Social support

knowledge obsolete. We are all well aware of the general, dayto-day stresses of a profession where we routinely perform highly complex work and the stakes for the well-being of others are at risk. The personality traits that made us good students and residents—a well-developed sense of dedication and responsibility, the ability to handle a high level of stress, and compulsive attention to detail—are valued in

MINNESOTA PHYSICIAN JUNE 2012

medicine. They also play a part in physician burnout. It is easy for physicians to feel an exaggerated sense of responsibility, and we sometimes feel guilt and doubt in our decisions; yet we feel we can handle these pressures on our own and are generally reluctant to seek outside help. In addition, physicians are socialized to avoid self-reflection—the focus in medical care is the patient, not the physician—and finally student and resident education in self-care is not usually part of medical training. The ongoing stress of practicing medicine, coupled with these personality traits and a lack of self-awareness, lay the kindling for physician burnout. We have all seen the devastating impact of unmanaged stress on the health of our patients. We have likely seen the effects of stress in some colleagues and we may have experienced it in ourselves. Sometimes the result of this stress is minimal and it does not affect our work or home life. Other times, the impact is great: Physicians who once were very effective in clinical practice lose their edge, and the quality of their lives and their work suffers. How big a problem is stress in physicians’ lives? What, if anything, can be done to minimize the impact of this stress? Can we increase our resilience to stress? How do we know when we are experiencing burnout? More importantly, what can we do to help ourselves and our colleagues prevent burnout?

What research on burnout tells us

According to many research studies on physician burnout: • Thirty percent to 60 percent of practicing physicians report experiencing burnout at some point. • Forty-six percent to 80 percent of physicians report high levels of emotional exhaustion. • Forty percent of surgeons report being burned out. • Women physicians are 60 percent more likely than men to experience burnout. • The balance between workload/scheduling and input/ influence is the highest predictor of emotional exhaustion. Published studies have also shown that burnout is associated with increased medical errors, dissatisfied patients, and riskier prescribing habits—all major threats to patient safety. In addition, a physician’s reduced ability to make astute medical decisions due to stress and burnout can lead to increased health care costs. Other severe consequences of burnout are depression, anxiety, psychosomatic complaints, physical illness, and even suicide. Social and health psychologist Christina Maslach, PhD, and others have described and studied burnout in health care and human service workers. Maslach developed a conceptual model of possible causes of burnout based on a mismatch between the person and the job. The areas identified are workload, lack of control, insufficient reward, breakdown of community, absence of fairness, and value conflict. The greater the mismatch, the greater the chance of burnout. The most commonly used instrument for measuring burnout in clinical practice is the Maslach Burnout Inventory, which identifies three dimensions of burnout: 1. Emotional exhaustion: feelings of being emotionally overextended and exhausted by one’s work. It is a feeling of “ having nothing left to give”. 2. Depersonalization: an unfeeling and impersonal response toward recipients of

one’s service, care treatment, or instruction. It is a feeling of seeing others as “objects” and not fellow human beings. 3. Decreased sense of personal accomplishment: feelings of decreased competence and achievement in one’s work. It is a feeling of “not making any difference in the world.” Careful study of patients with burnout has shown that not all symptoms arise at the same time. Instead, for many people there seems to be a transition from one symptom to another. When these symptoms deepen and then move to another dimension of burnout, the condition will eventually manifest itself as full blown burnout. Being aware of these initial symptoms may help us recognize early stages of burnout and treat it before it becomes more pervasive and severe. One of the more interesting aspects of current research on burnout involves the differences in burnout between women and men. A study by Houkes et al. in BMC Public Health (2011) notes that men usually initiate feelings of burnout with depersonalization and that personal achievement seems to develop independently from the other two dimensions. In contrast, women start the process of burnout with emotional exhaustion, which leads both to reduced personal achievement and to depersonalization. Prevention strategies: balance and awareness

Prevention of burnout and maintenance of emotional health are areas of great interest for professional medical societies and health care organizations, since work productivity and patient satisfaction are intricately linked to employee emotional health and employee satisfaction. Medical schools and residency programs are now starting to incorporate burnout prevention strategies and programs to screen for burnout. The American Medical Association (AMA) and other professional organizations also have developed many programs to promote physician wellness and prevent burnout. A starting place is the AMA’s web-

In a study published in 2003, Davidson wrote that mindfulness meditation may involve neurobiological changes and development of neural pathways to bolster our “immunity” against burnout. site and searching for physician burnout. A study of high-functioning physicians reveals several characteristics that can help maintain emotional health and that appear to provide both resilience and resistance to burnout: • Setting limits through selfregulation; knowing when to say “no” to taking on other commitments. • Spending meaningful time with family and friends. • Maintaining self-care through exercise. • Maintaining self-care through relaxation. • Using humor to help maintain a healthy philosophical outlook. Even if you are not experiencing burnout, it is important to take steps to prevent burnout from occurring. One of the most important prevention strategies for physicians is to find a sense of balance among all the competing demands of professional and personal life and to use the supports at their disposal to handle these demands. Cultivating self-awareness allows us to see in clearer terms both the stresses we are experiencing and the supports we have at our disposal to improve our emotional health. Self-awareness (called “emotional intelligence” by psychologist and author Daniel Goleman) combines selfknowledge with development of dual awareness, permitting the physician or clinician to simultaneously attend to and monitor the patient’s needs, the work environment, and his or her own subjective experience. Among the proven methods of fostering self-awareness is mindfulness meditation.

Creating an improved “neurologic highway”

Richard J. Davidson, PhD, and colleagues at the University of Wisconsin-Madison have done considerable research on the neurological effects of meditation. In a study published in 2003, Davidson wrote that mindfulness meditation may involve neurobiological changes and development of neural pathways to bolster our “immunity” against burnout (Davidson RJ et al., 2003, Psychosomatic Medicine 65:4). Research on the science of neuroplasticity has improved our knowledge of the brain’s potential and how it can change over time. In very simplistic

terms, the connections between the prefrontal cortex (our thinking self) and the amygdala (our feeling self) in a certain way dictate how we respond to life’s challenges. We know that allowing the prefrontal cortex to be more active before sending a fight-or-flight response to our amygdala can help reduce our body’s reaction to stressful events. Mindfulness meditation creates a better “neurologic highway” to the prefrontal cortex and helps prevent us from sending premature inappropriate messages to our amygdala. One of the best ways to practice mindfulness is to engage in the following simple exercise, described by the mnemonic SOLAR: S: Stop and sit. O: Observe (pause, breathe, and feel exactly what arises in your experience). L: Let it be; let everything be as it is without reacting to or trying to change any of it. A: and STRESSED to page 12

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Stressed from page 11 R: Return to the present moment and turn attention to your breathing. Here are some other easy practices to help develop daily mindfulness: • Before you start to drive home after work, sit in your car for 30 to 60 seconds, and use that time to create a buffer zone between work and home life. • Stop at a window in your workplace and notice something in nature, then give it your full attention for 15 seconds. • Before going into the next patient’s room, pause and direct your attention to your breathing for three breaths. • As you wash your hands, attend carefully to the sensation of the hand gel in your hands. • Practice gratitude; end each day by acknowledging one thing you are grateful for. My personal favorite mindfulness practice is to consider the first 60 seconds of each patient encounter to be “sacred”:

Relax and breathe intentionally, and listen deeply to the concerns of your patient without logging onto the computer or writing details of the history in the chart immediately. A burnout prevention action plan

following questions, then write down a commitment statement that you can accomplish for each category. B—Body: What one or two things can you change to improve your diet or fitness level? What are some ways you could “honor your body” in diet and activity? A—Affect: What can you do to enhance self-awareness? Spend some time thinking about what you deeply value about being a physician. Think about ways that you might integrate some aspect of mindfulness into your daily life. S—Social: What relationships exist now that you may be able to deepen? What conversations do you yearn to have? What stories need to be told and heard in your life?

Among the proven methods of fostering self-awareness is mindfulness meditation.

Michael Kaufmann, MD, director of the Physician Health Program at the Ontario Medical Association, has created a selfassessment tool, described by the mnemonic BASIC, that addresses many aspects of physician wellness. The self-assessment and action plan helps build “immunity” against burnout. To create your personal plan for burnout avoidance and physician wellness, review the

I—Intellect: What areas of learning or knowledge do you yearn to study within medicine and outside of medicine? C—Cosmos: Where can you explore or deepen your spirituality? What are your sources of meaning, hope, and peace? How can you best use your gifts to meet a need that exists in the world? Stress is an inevitable consequence of working in health care; however, our response to that stress is not predetermined or predestined. Burnout is one of the serious consequences of unrelieved stress. The good news is that with personal insight and perhaps making some work-life changes, we can prevent burnout and keep ourselves functioning well—for our own benefit and that of our patients. Keith Stelter, MD, is an assistant professor of family medicine and community health in the University of Minnesota Medical School and is associate director of the university’s Mankato Family Medicine residency program.

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2012 physician opinion survey 2of 4 7. I am less satisfied by my work than I was when I began my career. 50 Percentage of total responses

We are pleased to present the results from the second of four physician opinion surveys we will publish in 2012.Through a number of sampling methods, we received 139 responses to Phase 2. If you would like to be included in future surveys, please contact us via e-mail at comments@mppub.com or call 612-728-8600.The surveys are online, are quick to complete, and are completely anonymous and confidential. We welcome your suggestions for this and future surveys. Our thanks to those who participated.

4. My employer provides adequate support services aimed at limiting physician burnout.

39.6%

20 10

Percentage of total responses

25 20

18.0%

15 10.1%

10 5 Agree

Does not apply

Disagree

12.2%

10.1%

Strongly agree

Does not apply

25.2%

16.5%

14.4%

10 2.9%

Disagree

Strongly agree

Agree

Does not apply

Disagree

Strongly disagree

3. I am expected to produce a volume of daily patient billing that is compromising my ability to provide patients the highest level of care.

15 10.8%

16.5%

Strongly agree

Agree

Does not apply

Disagree

Does not apply

39.1%

Disagree

Strongly disagree

Disagree

Strongly disagree

40 29.5%

30 20 10

10.8% 5.0% Strongly agree

Agree

Does not apply

2.9% Disagree

Strongly disagree

50 41.7%

Does not apply

10. I can manage career burnout issues on my own.

38.4%

Agree

Strongly disagree

11.6% 6.5%

4.3%

3.6% Strongly agree

Percentage of total responses

30 18.7%

Strongly agree

40.3%

20.9%

8.6%

9. I have physician colleagues suffering from burnout who do not recognize it.

2.2%

12.9% 10

51.8% 26.6%

6. I feel my work has created a negative impact on my personal life.

50 40

30.9%

Strongly disagree

46.0%

30.9%

29.5%

Disagree

1.4% Agree

35 Percentage of total responses

Percentage of total responses

5. I feel isolated socially by my work.

41.0%

Percentage of total responses

Strongly disagree

Does not apply

4.3%

32.4%

1.4% Strongly agree

2. My employer creates an environment that compromises the ability of my physician colleagues to provide the highest level of care.

Percentage of total responses

Agree

50 41.0%

Strongly agree

Agree

To participate in future surveys or offer suggestions, please contact us at comments@mppub.com.

Does not apply

Percentage of total responses

30.9%

Strongly agree

8. I have physical illness related to burnout.

35 30

15.1% 8.6% 4.3%

Percentage of total responses

30.9%

1. The time I spend daily on compliance, record keeping, prior authorization, etc. compromises my ability to provide patients the highest level of care.

41.0%

36.7%

30 20 14.4% 10 4.3%

Disagree

Strongly disagree

JUNE 2012

Strongly agree

2.9% Agree

Does not apply

Disagree

Strongly disagree

MINNESOTA PHYSICIAN

Toolbox from cover in the setting where numerous times before, they had come up with an unexpected solution. The chemotherapy nurses were quite good at knowing when it was time to stop treatment but had a hard time communicating this to the patient, family, and oncologist. Patients always put on their best face for their oncologist, and it becomes very difficult for oncologists to admit there is nothing more to offer— they keep hedging their bets with the possibility of new research options. This article reviews what has and what hasn’t worked with our clinic’s model of outpatient oncology care combined with palliative care, in the hope that others can learn from our experience. Integrated palliative/oncology care: Tom’s story

The case of a patient I’ll call Tom illustrates both the challenges and promise of combining oncology with palliative medicine in the clinic.

Within the space of 24 hours, Tom went from being a healthy vigorous, 48-year-old man who had never been sick a day in his life to a man fighting for his life. He had a perforated cecal colon cancer with obvious omental and liver metastasis, plus the additional complications of multiple pulmonary emboli and prolonged postoperative ileus. As the initial treating physician, my first inclination was to push for a hospice/palliative care approach, but our oncologist, as well as Tom and his family, were quite adamant that they wanted “everything” done. I could completely understand the patient’s/family’s desire to try all treatments possible, but deep down I was thinking, here we go again with another case of medical futility. Working as a palliative care/primary care-oncology team, we set upon the goal of finding relief of his pain and nausea—the pillars of good palliative care. Until a patient has good pain and nausea control (plus the ability to eat and have reasonable bowel movements)

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and the confidence that this will continue, you can’t really have any conversations about quality of life. Tom and his wife met with me every two weeks until we had good control of his primary symptoms. A typical challenge centers on symptoms that occur for the first few days after chemotherapy. In Tom’s case, he would crash on day three and day four post-chemo with nausea, profound weakness, and constipation, and then, around day five, would develop profuse watery diarrhea as a consequence of the chemotherapy. We developed a program of low-dose prednisone for the day three-four crash in energy; Remeron at night for sleep and appetite; Reglan, Phenergan, and Zofran for nausea; methadone for pain; a few days of lactulose initially for the post-chemo constipation; and then judicious use of Lomotil and long-acting octreotide for the diarrhea. The only way to develop a complicated medical regimen like this is with the help of a community-based home palliative care team that can provide immediate feedback on the success and failures of your treatment plan and assist with the numerous titrations necessary for success (you cannot predict the effective dose of methadone, and if you start too high you will lose that medication as a choice for patients). Palliative care nurses can draw blood and disconnect chemo at home to help minimize trips to the clinic. Once Tom had control of these basic needs, we could begin to focus on his quality of life needs—a process that took several months. Tom and his wife were avid travelers. We set up a chemo program so that he could again travel. In between treatments, he would train for his next trip. The focus of his life moved from chemotherapy issues to travel issues, as well as connection with his family. He exercised every day. After one year of chemo, he looked and felt like a handsome, bald, tanned athlete at middle age. He had an infectious zeal for life that positively affected everyone around him. Tom and his wife enrolled in

our mind/body program and studied guided imagery, yoga, and meditation. They seemed to be more and more comfortable with the chronic nature of his illness and the understanding that cure was unlikely. His scans improved but were never entirely normal, so chemo treatments continued and became more and more difficult to tolerate, as is their nature. Tom became close to our palliative care chaplain and began taking communion at home. Late in 2011, Tom and our oncologist agreed there weren’t any further treatments available and, after reviewing the various experimental programs, Tom enrolled in hospice. He had developed pulmonary fibrosis and lung nodules and now needed oxygen. After enrolling in hospice, Tom and his son took a long dreamed-of vacation to Alaska; then, at Christmas, he and his wife took one more trip to Mexico. On the last day of his life we transferred Tom to our “hospice house,” because caring for his shortness of breath had become difficult. I visited him four hours before his death. When I arrived, he and our chaplain were singing an Irish ditty that had us all in stitches. Tom thanked us for his care, and we thanked him. Tom asked us to take care of his wife and children, who were all present, and we promised to do the best we could. Tom died peacefully, as a healed man. Tom represents for me the reason why palliative care is so important in the oncology clinic. More and more people with metastatic colon, lung, pancreatic, breast, and prostate cancer, to name a few, can live well with their disease if their quality of life issues are dealt with right from the beginning of their illness. If these issues are not dealt with realistically, their lives can be a prolonged hell. Because the patient, family, and oncologist will encounter unexpected successes in the patient’s treatments and health, it becomes very difficult to see when the treatments are no longer working and the patient’s suffering is becoming untenable. TOOLBOX to page 34

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MINNESOTA PHYSICIAN

Victoza® (liraglutide [rDNA origin] injection) Rx Only BRIEF SUMMARY. Please consult package insert for full prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions]. INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied. CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dosedependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiving liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a comparator-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have subsequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most frequently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with ontreatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consistent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calcitonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebotreated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evaluation. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,

MINNESOTA PHYSICIAN

JUNE 2012

pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other potentially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medications known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug. ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparatortreated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer. Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial All Victoza® N = 497 Glimepiride N = 248 (%) (%) Adverse Event Term Nausea 28.4 8.5 Diarrhea 17.1 8.9 Vomiting 10.9 3.6 Constipation 9.9 4.8 Upper Respiratory Tract Infection 9.5 5.6 Headache 9.1 9.3 Influenza 7.4 3.6 Urinary Tract Infection 6.0 4.0 Dizziness 5.8 5.2 Sinusitis 5.6 6.0 Nasopharyngitis 5.2 5.2 Back Pain 5.0 4.4 Hypertension 3.0 6.0 Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials Add-on to Metformin Trial All Victoza® + Placebo + Glimepiride + Metformin N = 724 Metformin N = 121 Metformin N = 242 (%) (%) (%) Adverse Event Term Nausea 15.2 4.1 3.3 Diarrhea 10.9 4.1 3.7 Headache 9.0 6.6 9.5 Vomiting 6.5 0.8 0.4 Add-on to Glimepiride Trial All Victoza® + Placebo + Glimepiride Rosiglitazone + Glimepiride N = 695 N = 114 Glimepiride N = 231 (%) (%) (%) Adverse Event Term Nausea 7.5 1.8 2.6 Diarrhea 7.2 1.8 2.2

JUNE 2012

MINNESOTA PHYSICIAN

SPECIAL

FOCUS:

This month’s special focus articles address the current state of the medical office market in the

care reform on the design of medical facilities (e.g., in response to increased use of care teams); the use of studies of health care environments to design for improved efficiency and safety in care and healing; and the development of a residential hospice to provide end-of-life care in a home-like environment.

DESIGN

The Twin Cities medical office market remains strong By Steve Brown, CCIM

hile not completely resistant to the economic downturn and real estate fallout, the Twin Cities medical office market’s vital signs have remained stable and the outlook for long-term demand is strong. In 2011, the Twin Cities medical office market comprised 103 medical buildings, including on- and offcampus properties, and sat at an overall vacancy of 11.4 percent with positive absorption of 35,997 square feet, reflecting an increase in occupied space. Off-campus vacancy rates were 13.1 percent, slightly higher than the on-campus vacancy rate of 9.5 percent. One effect we are seeing from the crash of the retail market is some new and unique medical office spaces in high-

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FACILITY

Vital signs

Twin Cities metropolitan area; the effects of health

MEDICAL

MINNESOTA PHYSICIAN JUNE 2012

profile retail spaces that were not an option before the crash. As medical providers see the increased medical needs of aging baby boomers and feel the impact of health care reform, they are focused on shoring up their internal capacity to meet the demand. In anticipation of these increased demands, they are also keeping new collaboration and partnering options at the forefront of their facility planning. However, as the many known and unknown factors play out, enacting strict strategic plans will help shape the future of Minnesota’s medical office market. Impact of “retail effect” on off-campus space

In the past year(s), medical office space requirements injected a welcome dose of demand into the otherwise quiet retail leasing market. Health care providers took advantage of the opportunity to evaluate high-profile retail sites that were distressed due to market conditions, both by leasing existing second-generation retail space and by building new facilities on land adjacent to existing retail centers. Due to the soft retail market, where buildings once occupied by retailers such as Borders bookstores and Blockbuster and Video Update stores are now vacant, a number of new clinics and outpatient facilities have found an opportunity to fill these high-profile retail vacancies at previously unattainable rates. In recent years, landlords have had to consider more unconventional tenants than they normally would have under healthier retail market conditions. Medical tenants offer a benefit similar to retail property owners: They help drive traffic to the center, which benefits other retailers.

As medical tenants find acceptance among retail property landlords, their clinics and outpatient facilities benefit by locating to properties that are highly visible and accessible to their patients. Local examples are a Park Nicollet clinic leasing a former Hollywood Video in Lakeville; an Urgency Room facility now located in a former Movie Gallery building in Woodbury; and HealthEast taking over a vacated Borders bookstore site on Selby Avenue in St. Paul and the former Gander Mountain in Maplewood. Furthermore, in submarkets where activity is very high, medical office prospects are circling campuses for space. In the northeast metro area, St. John’s Hospital campus in Maplewood reports a 0 percent vacancy rate. This has driven strong interest toward several nearby off-campus developments that would create additional space options. Currently in this area, at least three of four developments are approved or proposed. If these developments move forward, the result could be a repositioning of some on-campus physicians. By occupying off-campus properties, medical offices are able to create a presence in their patients’ neighborhoods, thereby increasing visibility and aiding accessibility. Yet, a number of questions remain: How long will this trend continue, and will the availability of these well-located, highly visible assets dry up? Will the window of opportunity close as retail landlords look for a rebound in retail activity and an opportunity to return to traditional retail rents? Or will retail landlords consider permanently repurposing their projects to incorporate medical uses in the future? Strategic plans

In the Twin Cities’ medical office market, significant discussion has surrounded the increased medical needs of aging baby boomers and the future impact of health care reforms as providers prepare for patients who were previously uninsured. To meet these future needs, hospitals are focusing on making health care more accessible,

with trends moving toward pushing any outpatient services into off-campus buildings where they are closer to the patient. This also creates more inpatient capacity within the hospitals. This shift will increase demand for off-campus medical office space. Physician shortages will need to be augmented with physician extenders (i.e., nurse practitioners, physician assistants, nursing assistants, etc.) to meet this additional demand, and the care model that is ultimately created will determine how and where this additional capacity is delivered. Certainly, there will be continued collaboration and partnering among dominant subspecialty groups and hospital systems as they compete to secure and serve patients. Stronger independent practices of the same specialty are also finding ways to collaborate to share resources, gain efficiencies, leverage the scale of a larger organization, and strengthen contract negotiations with providers and insurers.

Medical tenants offer a benefit similar to retail property owners: They help drive traffic to the center, which benefits other retailers. While the impact of reform on hospital and physician space requirements is not completely clear, providers are working to gauge it and strategically plan for the future. Providers are prioritizing projects to determine which are most important, while access to capital is driving many decisions. Outlook

Demand for space is expected to pick up in 2012. Absorption could be 25,000 to 35,000 square feet for on-campus properties. For example, Fairview Southdale’s campus will report positive first-quarter activity when PrairieCare, a psychiatric and behavioral health services provider, doubles its space to 23,500 square feet. For off-campus properties, absorption could be 60,000 to 75,000 square feet, including the opening of the

fully leased 44,000-square-foot Crystal Medical Building. The “retail effect” can be expected to continue to affect off-campus space as physicians consider retail options for clinics and outpatient facilities. Rates will be flat and concessions will continue in weaker markets. This year, providers’ strategic plans likely will begin to be executed. We anticipate significant system-driven announcements next year for 2012–2014 projects. A number of questions loom in the background of the Twin Cities health care marketplace, for example: What impact will Sanford Health, a Fargo, N.D.-based health system, have as it moves closer to the Twin Cities? Are they in negotiations already? What impact will Mayo Health System have on the Twin Cities market as it continues its

plans to open an ambulatory care clinic at the Mall of America? What potential hospital system merger will occur first? It has always been the case that, unlike traditional office markets, the medical office market ebbs and flows in a way that requires more interpretive analysis based on hospital systems than simply looking at geography. Submarket creation by system affiliation is a critical dynamic in evaluating the health of a given on-campus or offcampus market. This dynamic has further been exacerbated by the retail factor, practice acquisition by hospitals, and potential mergers. Steve Brown, CCIM, is executive director of Cushman & Wakefield/NorthMarq’s Healthcare Advisory Group, where he is responsible for providing real-estate consulting and advisory services to health care organizations, corporations, and clinical practices both locally and throughout the U.S.

Supporting Our Patients. Supporting Our Partners. Supporting You. In 2008, Tanzanian missionaries brought little Zawadi Rajabu to the U.S. to seek treatment for her two severely clubbed feet. A physician referred Zawadi to Dr. Mark T. Dahl of St. Croix Orthopaedics. Using the Ilizarov Method, Dr. Dahl surgically changed the course of Zawadi’s feet and her life. Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient. To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.

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JUNE 2012

MINNESOTA PHYSICIAN

health care architecture honor roll

Minnesota Physician’s 2012 Health Care Architecture Honor Roll recognizes nine outstanding projects completed in the past year. This year’s Honor Roll projects include new clinic and hospital construction, remodeled spaces, and facility expansions in urban, suburban, and greater Minnesota. The medical services range from routine clinic visits to specialized urgent and emergency treatment. Populations served also run the gamut, from pediatric patients to seniors seeking assisted-living housing and patients receiving hospice care. Many of the projects emphasize ties to the community, for example, by incorporating artwork by regional artists, using locally sourced building materials, and designing a street landscape that enhances the facility’s social impact on the surrounding neighborhood. Principles of sustainability and energy-saving design support the goals of patient safety and staff efficiency. Minnesota Physician Publishing thanks all those who participated in the 2012 honor roll.

MINNESOTA PHYSICIAN

JUNE 2012

Children’s Hospitals and Clinics of Minnesota Minneapolis campus expansion and modernization

Type of facility: Specialty hospital Location: Minneapolis Client: Children’s Hospitals and Clinics of Minnesota

Architect/Interior design: AECOM Engineer: Harris Mechanical and Hunt Electric, mechanical/electrical/plumbing; Ericksen Roed & Assoc., structural Contractor: Knutson Construction Co. Completion date: March 2012 Total cost: Confidential per owner request Square feet: 169,500 gsf (new children’s specialty center); 597,695 gsf (hospital new construction and renovation); 24,330 gsf (new power plant); 679-car parking structure To maintain its status as a regional leader in pediatric care, Children’s Hospitals and Clinics of Minnesota embarked on the most significant campus development in its history. Architecture, landscape, science, and art merge to transform the health care experience of patients who come to its Minneapolis campus, revitalizing a sense of place and urban renewal.

Campus expansion to the west of Chicago Avenue includes a new Specialty Care Center with specialty clinics (including the hematology and oncology clinic), outpatient pharmacy, retail center, and a new parking structure linked to the existing hospital by a curved, glass skybridge. Upgrades to existing facilities to the east of Chicago Avenue include a new hospital entry and a seven-story addition. The addition offers new patient rooms, enlarged and enhanced operating rooms, a new emergency department, renovated neonatal and pediatric intensive care units, a new cardiovascular center, and an in-house Ronald McDonald House. All existing patient rooms were converted to private rooms with sleep-in space for parents. This expansion and modernization provides a new brand image for Children’s, establishes a cohesive campus, provides a new experience for patients and their families, expands health care services, and creates a positive social impact on Chicago Avenue and the surrounding neighborhood.

Left: The focal point of the new campus is a public space with solar light sculptures designed by Brad Goldberg and named “Healing Stones.” Top inset: The second-floor lobby extends from the parking structure on the west side of Chicago Ave., through the Specialty Care Center, across Chicago via skybridge, and ends with the welcome desk and twostory atrium. Bottom inset: Family rooms on each floor of the new bed tower provide views of downtown Minneapolis and space for patients and families to gather outside patient rooms to relax, read, play games, and socialize. ©2011 Don F. Wong

Olmsted Medical Center, Northwest Clinic Type of facility: Clinic Location: Rochester Client: Olmsted Medical Center Architect/Interior design: HGA Architects and Engineers Engineer: HGA Architects and Engineers Contractor: Weis Builders Completion date: July 2011 Total cost: Confidential Square feet: 65,000 sf Designed for LEED certification, this replacement facility expands primary care outpatient services while integrating numerous sustainable design features and geothermal technology. Design was oriented vertically instead of horizontally to accommodate a 20foot elevation change from one side of the site to the other, allowing for a future two-story vertical expansion. Patients enter along the main entrance or through lower-level walkout entries. Exterior Dolomite limestone is from Mankato; two textures of grey limestone address scale and add visual interest. The stone will oxidize over

time to a warm grey. HGA used a stone panelized system similar to precast concrete construction to permit quick assembly of the exterior skin once structural steel was installed. The south facade is a glass curtain with silk-screened glazing to assist with sun control. Interior waiting areas stretch along the south side of the building, with light from the full-height curtain-wall system illuminating the space. Department reception areas flow into exam areas, with staff and physician offices at the north side of the building. Design features • A geothermal mechanical system provides heating and cooling for the building through use of groundwater in a closed loop system. The well field is located under the parking lot. • Natural light in the lobby streams into the lower level via the open staircase, creating visual connection between levels. • Corridors with physician work

alcoves enhance patient and staff flow. • Patient coffee shop in waiting area. • Physical therapy and cardiac rehabilitation space. • Water use is reduced by more than 40 percent through water-conserving fixtures and faucets.

Top: Interior commissioned art is suspended over an open staircase to lower level, with waiting spaces beyond. Inset below: Main level reception/ check-in desk for family medicine and pediatrics incorporates bright colors and warm wood tones. Bottom: View from southwest of upper level south-facing facade

All photos by Josh Banks Photography.

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Hennepin County Medical Center Hyperbaric Medicine Department and Wound Clinic

Type of facility: Hospital Location: Minneapolis Client: Hennepin County Architect/Interior design: HDR Architecture, Inc. Engineer: HDR Architecture, Inc. Contractor: Kraus-Anderson Construction Co. Completion date: May 2012 Total cost: $4.3 million Square feet: 6,782 sf (new); 6,612 sf (remodel) The Hyperbaric Medicine Department provides hyperbaric oxygen therapy for patients requiring urgent and emergency treatment as well as patients who are treated daily for wound healing problems. In addition to the hyperbaric wound and treatment area, a wound clinic is included within the department. The wound clinic has separate exam rooms and

workspace for providers and shares reception and support areas with the hyperbaric department. The hyperbaric department cares for inpatients and outpatients of all ages and treats two distinct types of patients: patients who are treated daily for wound healing and patients who need emergency hyperbaric oxygen therapy Hyperbaric oxygen therapy sessions typically last 1 hour and 50 minutes. In addition to hyperbaric patients, the department includes a separate wound clinic for patients that are not in the hyperbaric treatment program. The department must handle scheduled patient flow as well as surge volumes of emergency cases. The new Hyperbaric Medicine Unit comprises a multilock, class A multiplace hyperbaric chamber; class B monoplace chamber; main waiting room and staging waiting areas; male and female handicap-accessible dressing areas with lockers and toilets; intake areas for vital signs, weight, and point-of-care testing; four exam rooms; technician instrument console; medical console; and department support. The existing monoplace chamber formerly located adjacent to the ICU was relocated to the new hyperbaric unit. Hyperbaric clinic exam room capacity was increased from one exam room to four in the new department, allowing more privacy and improving patient confidentiality. The additional exam rooms enable the department to see additional patients in the clinic. During sessions, additional patients are seen in the exam rooms for follow-up or new patient assessment. Four additional wound clinic exam rooms are provided in the department, located separately from the hyperbaric patient exam rooms. Top: View inside the hyperbaric chamber Inset: Hyperbaric chamber leaving Fink Engineering’s hyperbaric chamber fabrication shop in Australia

Essentia Health St. Joseph’s Baxter Clinic Type of facility: Multispecialty outpatient clinic Location: Baxter Client: Essentia Health Architect/Interior design: Widseth Smith Nolting & Associates, Inc. (WSN), firm of record; HGA, programming, schematic design, and interior design Engineer: Widseth Smith Nolting & Associates, Inc. Contractor: Hy-Tec Construction Completion date: January 2012 Total cost: $12 million Square feet: 46,000 sf WSN provided architectural, structural, mechanical, electrical, civil, land survey, and landscape architecture services for this project, while HGA provided the programming, schematic design, and interior design. The building’s material palette includes stone, precast concrete, glass, stucco, and metal panel, which blend well with the natural surroundings. The clinic has two levels with multiple specialty areas that include family practice, women’s health, pediatrics, lab, X-ray, pharmacy, and urgent care. Patient-centered care is the concept that directed building design and is addressed in several ways. A greeter meets patients immediately as they enter the clinic, redirecting them to more private, decen-

tralized check-in areas. Natural light and framed views to the exterior combine with material selections, artwork, and furnishings to create a sense of comfort. The decentralized concept allows patients to feel as though their visit is one-on-one with the provider. Insulated walls in the exam rooms, as well as insulated ductwork, decrease transfer of sound, which reinforces the patient-centered care concept. The Baxter Clinic will provide a welcoming environment for patients in this community for many years. Top: Decorative, etched glass walls line the waiting areas, offering privacy while allowing natural light to stream into the space. Top inset: Natural light floods the two-story atrium. Bottom inset: Exterior with parking lot

Sanford Heart Hospital Type of facility: Specialty hospital Location: Sioux Falls, S.D. Client: Sanford Health Architect/Interior design: AECOM Engineer: AECOM Contractor: Henry Carlson Co. Completion date: March 2012 Total cost: Confidential, per owner request Square feet: 205,000 sf Thirty years after the Sanford Health heart program began, the hospital sought to consolidate the programs of Sanford Clinic Health Partners and Sanford Clinic Cardiac, Thoracic, and Vascular Surgery to make quality heart care available to patients in a single convenient location. Attached directly to Sanford USD Medical Center, the new Sanford Heart Hospital means even more convenience for patients and their families. The 205,000-square-foot building is directly connected to the main lobby of the existing medical center and connects underground to the parking ramp. The new hospital houses physician offices, outpatient testing, surgical services, cath labs, and consultation services. It also includes 58 inpatient beds, cardiovascular operating rooms, a hybrid operating room, and clinic and outpatient services. Patient rooms are safe, secure, state-of-the-art living spaces that promote rest and healing. A range of amenities and technologic updates ensure that patients have everything they need to heal. Rooms are sized for capability of acuity-adaptable care to allow patients to remain in one

Photography by Dana Wheelock

Top: Interior of Sanford Heart Hospital Inset: Hybrid operating room

room from admission to discharge. Art and music have long been known to comfort and soothe the human spirit and body. Art has been shown to influence the speed of recovery and provide distraction for patients and families during challenging times. The hospital features 130 works of art by regional artists, further connecting the new hospital to the community it serves.

Healthcare Planning and Design

Perkins+Will, along with our engineering partner M+NLB, was selected as the winning entry in Kaiser Permanente’s year long global “Small Hospital, Big Idea” competition.

Ophthalmology - Essentia Health

Perkins+Will Perkins+W Wiill can be your partner in developing those ideas into reality. realityy. Givee us a call. 612.851.507 70 rick.hintz@perkinswill.com www.perkinswill.com www w.perkin . nswill.com Rick Hintz 612.851.5070 612.338.2029 | 218.727.8446

For more information on Kaiser Perman nente’’s “Small Hospital Big Idea Competi ition” visit: Permanente’s Competition” design. kpnfs.com design.kpnfs.com

JUNE 2012

MINNESOTA PHYSICIAN

HONOR ROLL

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Completion date: June 2011 Total cost: Building shell, $3.5 million;

Allina Medical Clinic–Ramsey Type of facility: Outpatient medical clinic Location: Ramsey Client: Allina Medical Clinic Architect/Interior design: bdh+young Engineer: Krech, O’Brien, Mueller & Associates Inc., structural; Gilbert Mechanical, mechanical; Clark Engineering, civil; Hunt Electric, electrical Contractor: Kraus-Anderson Construction Co.

tenant, $2.3 million Square feet: 25,682 sf A new Allina outpatient medical clinic is part of Ramsey’s town center development. The patient-centered clinic design includes family exam rooms to accommodate family members and patient education functions. Designers also focused on simplifying patient flow and wayfinding, increasing natural light with skylights, and providing walk-up and self-check options. The project also incorporates sustainable elements: solar power; renewable building materials such as bamboo veneer, brick, and stone sourced regionally; low-VOC paints; and high-efficiency mechanical systems. Top: Designers created centralized care team stations that incorporate natural light. Bottom inset: Sustainable elements include solar power, renewable and regional materials, and high-efficiency mechanical systems. Top inset: The new Allina outpatient clinic is part of Ramsey’s town center development.

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JUNE 2012

DESIGN/BUILD PRE-CONSTRUCTION

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Allina: J.A. Wedum Residential Hospice House Type of facility: Independent hospice care facility Location: Brooklyn Park Client: Allina Architect/Interior design: Mohagen Hansen Architectural Group Engineer: Dunham Associates Contractor: D.J. Kranz Construction Completion date: February 2012 Total cost: $3.7 million Square feet: 19,000 sf Hospice care can be provided in whatever setting a patient calls home. This could be in a private home, a variety of nursing facilities, or a residential hospice. Nearly 30 percent to 40 percent of patients receive their hospice care in a residential setting. Most people say that they would want to spend their last days at home, yet more than 50 percent of patients are dying in hospitals. Therefore, Allina, with a sizable donation from the J.A. Wedum Foundation, set out to build a residential hospice house. Upon entering the facility, family members are greeted with warm colors, a rich wood archway, and pillars similar to what one would find in a model home. As an alternative to hospice care provided in a patient’s home or a hospital, it was important that this facility offer all of the comforts of home. The house has 12 private rooms, each with a private bath and attached patio. Each room also has a comfortable sofa sleeper, for a family member who wishes to spend the night. Also located within the house are two large family rooms that are perfect for spending quiet time with friends and family outside a resident’s room; a large reflection room; a children’s play area; full kitchen; and dining room. Visitors immediately sense the beauty and warmth of the building as they enter the facility.

HGA Architects H GA A rchitects and and Engineers Engineers 420 5th Street 100 4 20 5 th S treet North, North, Suite Suite 1 00 Minneapolis, M inneapolis, MN MN 55401 55401

Contact: Contact: Anne F Farrell arrell Associate Assoc iate Vice President President 612.758.4425 AF arrell@hga.com AFarrell@hga.com

Top: Comfortable family room for patients and their families Bottom: Exterior view of hospice house front entry from circular drive

HGA creates HGA creates hhealthcare ealthcare eenvironments nvironments that that iinspire nspire ppatients atients to to hheal eal and and staff staff to to pperform erform their their bbest. est.

JUNE 2012

MINNESOTA PHYSICIAN

HONOR ROLL

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Crystal Medical Center Type of facility: Medical office building Location: Crystal Client: The Davis Group Architect/Interior design: bdh+young Engineer: Krech, O’Brien, Mueller & Associates Inc. Contractor: Timco Construction Completion date: February 2012 Total cost: $11.2 million Square feet: 44,865 sf

The new Crystal Medical Center is a Class A multi-tenant facility in the growing community of Crystal, Minn. The goal of the development was to create a project that was mutually beneficial to the community and would attract tenants by designing a strong project identity to complement and enhance the surrounding area. The rentable 44,865-square-foot two-story building is constructed of brick, glass, and metal accent panels and includes a prominent covered patient drop-off canopy at the main entrance. A number of design features were introduced into the project that closely align with the sustainable principles of the LEED Reference Guide for Green Building Design and Construction. Interior design features include highly finished clinic suites with soft lighting, modern carpet and flooring, solid surface counters, and customdesigned patient exam and procedure rooms. The building has prime visibility and easy access from the newly reconstructed Highway 81 and Bass Lake Road, a busy intersection of Crystal, providing tenants with excellent signage opportunities and 220 surface parking stalls on-site. Currently, there are three suites available to new tenants, totaling a little more than 9,000 square feet. The building is home to Northwest Family Physicians, Nova Care, and Crystal Imaging, and brings a variety of quality health care services to the community. The medical center has brought this community closer together by providing all of these services under one roof, making one-stop medical care available to patients.

Top: Main front-entry lobby Bottom: View of stone and brick facade at the main entry to the building

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Children’s Hospitals and Clinics of Minnesota, Minneapolis Campus Expansion & Modernization

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BUILDING From project delivery to patient experience, from building design and performance to revitalizing communities, AECOM’s holistic approach enables healthcare institutions to thrive. Whether at the scale of buildings, campuses, city districts or destinations, we combine creative and technical expertise to help clients forge functional, sustainable, engaging places.

Kevin.Donnay@wsn.us.com | 218-316-3618

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JUNE 2011

aecom.com/buildingvitality jon.buggy@aecom.com

Benedictine Living Community of St. Peter Senior Housing Apartments Type of facility: Assisted living Location: St. Peter Client: Benedictine Health System Architect/Interior design: Horty Elving Engineer: Horty Elving Construction manager: Yanik Companies

Completion date: October 2011 Total cost: Confidential Square feet: 66,510 sf This new, two-story, 66,510-square-foot, 46-unit senior housing apartment building, owned by the Benedictine Health System, accentuates and incorporates the four Benedictine core values of hospitality, stewardship, respect, and justice throughout its design while focusing on comfortable, forwardthinking spaces that have exemplary furnishings and services. It was designed so that tenants can live apartment-style with a variety of services to enhance quality of life. Meals, activities, housekeeping, laundry, and supportive oversight within a secured apartment complex are the base elements of the tenant living arrangements. With several different layouts offered, all 46 apartments are designed with fully functional kitchens and include washers and dryers. Layouts include one bedroom, one bedroom plus den, or two bedrooms. The building features underground parking for residents and additional storage space for each tenant.

Cambria natural quartz surfaces are featured in every apartment and throughout the entire building, which is connected to the Benedictine long-term care facility, the St. Peter Clinic, and River’s Edge Hospital. The Live Well Fitness Center, Mankato Chiropractic Healing Touch Clinic, and River’s Edge Pharmacy are also on the campus. These physical and enclosed connections allow access to a wide array of health care services and double as a walking corridor for staff and residents. The exterior design incorporates many of the existing materials and colors featured in the surrounding campus buildings, yet the new building is positioned to maintain its own identity. The owner and construction manager worked directly with the local municipal power agency to secure and maximize energy-saving rebates for all compliant appliances. The campus also include outdoor walking paths, a gazebo, and a gardening area for residents. Top: Public coffee/tea area Inset: Exterior, showing main entrance and underground parking

Psychiatric Nurse Practitioner Location: St. Louis Park, MN Schedule: Open to Full-time or Part-time, Regular About Us: The Emily Program was voted #1 Top Midsize Workplace in 2011 by the Star Tribune. Established in 1993 in St. Paul, The Emily Program has outpatient and residential facilities at offices throughout the Twin Cities metro, Duluth and Seattle, WA, and is a leader in innovative treatment for people with eating disorders. About the Position: The psychiatric nurse practitioner is responsible for providing direct client service. He/she will work with other Emily Program clinicians in providing comprehensive treatment to the client. Conducts client assessments; evaluates and assesses clients’ need or options for medication management, prescribes medications, and monitors on a regular basis. Qualifications: • Board Certified in the state of MN and hold a valid state registration or license as specified. • Passion for working with clients with eating disorders. • Related clinical experience/education in the assigned program(s) of care. To Apply: Email cover letter, resume and salary requirements to careers@emilyprogram.com The Emily Program is an Equal Opportunity Employer (EOE).

JUNE 2012

MINNESOTA PHYSICIAN

SPECIAL

ith the growing understanding that health care costs appear to be unsustainable, that physicians will be in increasingly short supply, and that reimbursement models will continue to evolve, the health care field is changing the way health care is defined, who delivers it, and how it is delivered. The nimble organization will be one that plans for this uncertainty. Health care reform calls for “accountable care” that addresses the health of the individual across the continuum of care and the life of the patient, not just during an immediate episode of care. Other forces of change include the evolution of health-care insurance exchanges and value-based purchasing. These and other trends could lead to more transparency in reporting health care costs and continued pressure to reduce the cost of care. As the practice of medicine and the delivery of health care continue to change, the design of the physical environment must also change. New environ-

FOCUS:

MEDICAL

DESIGN

Reforming health care design Emerging health care trends that affect the physical environment By Deborah Sweetland, FACHE, MBA, EDAC, and Michael Moran, AIA, ACHA, LEED AP ments must enable efficient care delivery, provide access to advanced information technology, support team communication, allow flexibility for future change, and support patient-centered care. Efficient care delivery

Continued increases in health care costs along with a concurrent awareness of reimbursement changes have caused many providers to investigate what is driving the increase. This research estimates that 45 percent of health care costs are spent on labor and supplies. Hospitals, health care systems, and suppliers with large

Practice Well. Live Well. Lake Region Medical Group is seeking a full-time Certified Physician Assistant to join our Lake Region Healthcare team of 3 orthopedic surgeons; providing care in a multi-specialty clinic with 50+ providers.We are looking for a hardworking, conscientious individual committed to providing quality care to our patients as we develop our Orthopedic Center of Excellence. Duties will include new and follow-up patient visits, assisting with surgery, post-op visits and hospital rounds in our 108 –bed community based hospital.The ideal candidate will have 2-5 years experience in orthopedics. We offer a competitive salary with a healthy benefit package. For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227

712 Cascade St. S., Fergus Falls, MN 736-8000 • (800) 439-6424 Lake Region Healthcare is an Equal Opportunity Employer. EOE

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inventories have begun to reduce costs by going after “lowhanging fruit,” areas that are easy to impact by applying “lean” management principles to reduce inventory and supplies. These practices employ justin-time delivery and one-piece flow systems. While most hospitals have formal quality improvement efforts underway, many are also rigorously adopting Lean and Six Sigma methodologies to improve processes and reduce variation in care delivery and support services. This is also true in the planning and design field, as progressive architectural firms use Lean methods during planning and redesign to create only what is needed for new construction or to renovate for more efficient operations. These processes can reduce operating costs and aid in balancing the health care cost equation. Information technology

Information technology has evolved in many ways to support patient care, improve efficiencies for staff, and streamline the process for the patient experience. Preregistration from the patient’s home computer, as well as patient registration kiosks, have replaced the front-desk function, decreasing the square footage required for front- and back-office support. Computer access to medical records, electronic diagnostic images, and health education information allow for real-time discussion and teaching by the caregiver. Point-of-care testing and patient monitoring equipment can send information directly into the electronic medical record. Radio frequency devices track patients during their visit, track supplies during surgery, and locate large equipment easi-

ly. Pagers alert patients when staff or medications are ready. Information technology also extends the capabilities of the staff. Telemedicine and onlineconsult capabilities enhance physician and staff access to specialists or second opinions. Physicians can access webenabled lectures or medical rounds without leaving their office, enhancing their productivity. Changes in technology affect not only the mechanical and electrical infrastructure and backup procedures in the building, but also the physical environment, from the flow of the care process to the critical department adjacencies. Effective health care design must accommodate and enhance this increase in technological interface between caregivers and patient. Concurrently, the technology helps us achieve the desired care outcome. Open team centers

Because of physician shortages, expanded care teams, and the importance of patient participation in patient care plans, caregivers are finding that face-toface, real-time team communication is essential for efficient collaboration and care planning. While the electronic record is useful for documentation and past activities, it cannot fully replace real-time team interaction in care planning. Team communication is enhanced through the direct, face-to-face communication that an open team center can facilitate. Open team centers cluster and centralize the physicians, staff, and support personnel who care for the patient. This allows communication and collaborative patient care. Open team centers also improve visual management of the patient. Privacy and open visual management are balanced with creative solutions for privacy and noise control. Half walls, partitions, or glass separations allow some view while also allowing some privacy for the staff. The implementation and design of open team centers should support a defined care model (i.e., a team-based model of care) and have a positive

impact on the efficiency and effectiveness of frontline caregivers. Standardization and flexibility

To support changing care models and the type of care that is provided, health care environments are standardizing frequently used rooms and planning flexibility for change. A standard inpatient room that can adapt or flex for patient acuity has become a consistent trend in inpatient environments. A standard procedure room is common in ambulatory surgeries, and a standard exam room is now common for outpatient/ clinic environments. Many inpatient settings also incorporate an interchangeable case cart system to allow for specialized care or procedures. This flexibility accommodates economies of scale for the design and construction of the space. The benefits of standardization and flexibility are in construction cost savings as well as in increased operational efficiencies. For administrative and support functions, many facilities

are moving to common areas that can increase communication between staff members. This encourages private discussion of patient care or the latest health care research article. For physicians, who can be easily isolated from their peers, shared offices can provide a greater sense of connection. Standardization and flexibility can also reduce renovation expense by making spaces easily adaptable for future uses. Patient-centered environments

Environments are changing to support concepts of the â&#x20AC;&#x153;patient experienceâ&#x20AC;? or â&#x20AC;&#x153;patient-centered care.â&#x20AC;? Examples include providing a health education library or computer access in waiting areas, separate entrances for urgent care and routine visits, kiosks for self-scheduling and, as health care focus shifts to prevention, community rooms for wellness and health education events. As used by the Institute of Medicine and Institute for Healthcare Improvement, the term â&#x20AC;&#x153;patient-centeredâ&#x20AC;? means

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considering patientsâ&#x20AC;&#x2122; cultural traditions, personal preferences and values, family situations, social circumstances, and lifestyles. Patient-centered care suggests that we need to consider how patients want to have their health care delivered, and requires an active and ongoing conversation with each patient. This drives the need to go beyond environments that provide access to health education, comfortable rooms, and waiting areas to look further into how to facilitate active involvement of patients and their families in the design of new care models and new environments in which to receive care. Dave Moen, MD, president of Fairview Physician Associates, has said, â&#x20AC;&#x153;As long as we think of who we are or what we do when we plan and design health care delivery, we will continue to design buildings and deliver health care in the same way. Only when we have the patients involved in the full process can we say that we have â&#x20AC;&#x2DC;patient-centered care.â&#x20AC;&#x2122;â&#x20AC;?

Ongoing evolution in design

Health care reimbursement models will continue to change and health care reform will undoubtedly continue to evolve. As this happens, the need for flexible operational and facility planning that maximizes resources, conserves capital, and engages patients in becoming more accountable and involved in their care will become more apparent. Planning and design need to continue evolving from the reference point of â&#x20AC;&#x153;who we are and what we do.â&#x20AC;? This can be achieved by continuing to engage the patient to determine how they want to receive the health care we provide. Deborah Sweetland, FACHE, MBA, EDAC, is a member of the Midwest division of HKSâ&#x20AC;&#x2122;s Clinical Solutions and Research team. She has 26 years of clinical, operational, strategic planning, and health care facility and process improvement experience, and previously was a master facility planning executive at HCMC in Minneapolis. Michael Moran, AIA, ACHA, LEED AP, is an architectural planning and design professional with HKSâ&#x20AC;&#x2122;s Midwest division. He has 20 years of experience in the planning, design, and delivery of health care projects.

Family Medicine St. Cloud/Sartell, MN We are actively recruiting exceptional part-time or full-time BC/ BE family medicine physicians to join our primary care team in Sartell, MN. This is an out-patient only opportunity and does not include labor and delivery or hospital call and rounding. Our current primary care team includes family medicine, adult medicine, OB/ GYN and pediatrics. Previous electronic medical record experience is preferred, but not required. We use the Epic electronic medical record system at all of our clinics and admitting hospitals. Our HealthPartners Central Minnesota Clinics â&#x20AC;&#x201C; Sartell moved into a new primary care clinic in the summer 2010. We offer a competitive salary, an excellent beneďŹ t package, a rewarding practice and a commitment to providing exceptional patientcentered care. St. Cloud/Sartell, MN is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with a traditional appeal. Apply on-line at healthpartners.jobs or contact diane.m.collins@ healthpartners.com or call Diane at 800-472-4695 x3. EOE

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S P E C I A L F O C U S : M E D I C A L FA C I L I TY D E S I G N

he ancient Greeks well understood the impact of the built and natural environment on healing. The temple at Epidauris, built in the early 4th century BC, was dedicated to Asclepuis, the Greek god of health and well-being. It incorporated the healing elements of a pleasant climate, beautiful vistas, and purifying waters— we could all learn something about a true healing journey from its design. Centuries later, Florence Nightingale’s “Environmental Theory” yielded incredible insight into the impact of the built and natural environment on people as well as communities. Nightingale advocated “utilizing the environment of the patient to assist him in his recovery” (in Nightingale F, 1860, “Notes on nursing: what it is and what it is not.” New York: D. Appleton and Company.) Nightingale cited a number of environmental factors affecting health, including pure fresh air, pure water, effective sewer and drainage systems, cleanliness, and light (especially direct

Building an optimal healing environment Evidence-based design to improve health care facilities By Terri Zborowsky, PhD, EDAC sunlight). Deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status, she noted. These environmental factors carried great significance during Nightingale’s time, when health institutions had poor sanitation and health workers had little education and training and were frequently unreliable in attending to the needs of patients. Her environmental theory also emphasized provision of a quiet or noise-free and warm environment, and attending to patients’ dietary needs by assessing and documenting the time of food intake and evaluating its effects on the patient.

Family Medicine St. Cloud/Sartell, MN We are actively recruiting exceptional part-time or full-time BC/ BE family medicine physicians to join our primary care team in Sartell, MN. This is an out-patient only opportunity and does not include labor and delivery or hospital call and rounding. Our current primary care team includes family medicine, adult medicine, OB/ GYN and pediatrics. Previous electronic medical record experience is preferred, but not required. We use the Epic electronic medical record system at all of our clinics and admitting hospitals. Our HealthPartners Central Minnesota Clinics – Sartell moved into a new primary care clinic in the summer 2010. We offer a competitive salary, an excellent beneﬁt package, a rewarding practice and a commitment to providing exceptional patientcentered care. St. Cloud/Sartell, MN is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with a traditional appeal. Apply on-line at healthpartners.jobs or contact diane.m.collins@ healthpartners.com or call Diane at 800-472-4695 x3. EOE

Unbeknownst to her, Nightingale made her mark on a field that today we know as evidence-based design (EBD) as applied to health care. In nomenclature derived from evidence-based medicine, the term evidence-based design refers to using the best available research and information in designing hospitals, clinics, and other health care facilities. EBD in health care draws from a vast number of disciplines—environmental psychology, cultural geography, medicine, nursing, ergonomics, engineering, and neurosciences, to name a few. As a relatively new discipline, EBD for health care facilities provides plenty of opportuni-

Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community

ties and challenges for the future. Substantial opportunities exist to make an impact by exploring designs and methods that have the best application in health care facilities and by helping to collect data that can advance our knowledge base. The challenges include seeking out funding sources, validating the return on investment of good design (whether it’s design of the natural or the built environment), and working through theories that can enhance our collective understanding of the impact of place on people and process. Figure 1 shows a framework that has been developed to help understand the impact of people, place, and process on the creation of an optimal healing environment. In the figure: • People = health care workers, caregivers, patients, family members, significant others, community members • Place = built and natural environments that provide a setting for health care practices • Process = care processes, either internal or provided to an individual

An immediate opportunity is available for a BC/BE orthopedic surgeon in Bemidji, MN. Join three board certified orthopedic surgeons in this beautiful lakes community. Enjoy practicing in a new Orthopedic & Sport Medicine Center, opening spring 2013 and serving a region of 100,000. Live and work in a community that offers exceptional schools, a state university with NCAA Division I hockey and community symphony and orchestra. With over 500 miles of trails and 400 surrounding lakes, this active community was ranked a “Top Town” by Outdoor Life Magazine. Enjoy a fulfilling lifestyle and rewarding career. To learn more about this excellent practice opportunity contact: Celia Beck, Physician Recruiter Phone: (218) 333-5056 Fax: (218) 333-5360 Email: Celia.Beck@sanfordhealth.org AA/EOE - Not subject to H1B Caps

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FIGURE 1. Framework for an optimal healing environment (Kreitzer, M. and Zborowsky, T. (2009), Creating Optimal Healing Environments. In Synder, M. and Lindquist, R. (eds.), Complementary & Alternative Therapies in Nursing, 6th ed. New York: Springer Publishing Company).

An optimal healing environment can be described as a systems-based framework in which each component has an impact on the creation of a healing environment, and together, the three components can create an optimal healing environment. It is these very elements—people, place, and process—that provide criteria for study in the EBD realm. In this time of doing more with less and where notions of quality improvement, data transparency, and return on investment are paramount, it makes sense to include components of the built and natural environments as variables to study, as they affect patient outcomes, staff efficiency and satisfaction, family members’ stress levels, and safety. The three case studies described below demonstrate the relevance of this new movement in health care. All three case studies involve hospital emergency departments, highlighting the variety of techniques that can be used in research studies of this nature.

physician who is also an architect. The study evaluated the effect of the built FIGURE 2. environment of an emerVarious emergency gency department (ED) on department layout the timeliness of physician typologies. (Provided assessment of chest pain courtesy of Frank Zilm) patients. The main outcome variable was time to initial service. Is there a correlation physician assessment. Potential predictor variables included pres- between the design of an emergency service and its performence of a solid door; distance of ance? To evaluate this question, treatment room from work area; a pilot study was undertaken to staffing team; day of week; and evaluate the effect of ED layout the patient’s age, sex, and triage on one measure of staff effilevel. After multivariate adjustciency: staff walking distance. ment, the only predictors of time Contemporary emergency serto initial assessment greater than vices are typically organized into 10 minutes were being placed in one of three layouts. These are a room with a door (adjusted frequently referred to as ballodds ratio [OR] 1.58; 95% confidence interval [CI] 1.01-2.48) and room, pod, and linear plans (see being placed in a room 25 feet or Fig. 2). The working hypothesis for more from the main physician the pilot study predicted that the work area (adjusted OR 1.38; linear layout would be the most 95% CI 1.13-1.67). These findings suggest that the ED built environment can be a barrier to providing timely care for this group of patients and may have implications for future ED architectural designs.

Case Study #1:

Case Study #2

Impact of emergency department built environment on timeliness of physician assessment of patients with chest pain (Hall K.K., et al., 2008, Environment and Behavior 40: 233–248) EBD Elements: People: Patients who presented with the complaint of chest pain. Process: Time to patient assessment. Place: Elements of the built environment, such as distance to patients and potential physical barriers such as doors. Research methods: Retrospective data collection. This retrospective cohort study was conducted by researchers at the University of Maryland, led by Kendall Hall, a

Effects of emergency department layout on staff efficiency (Bunker Hellmich, L., Zilm, F. and Zborowsky, T. (2010). Emergency Department Operations or Layout—Which is the Trump Card in Improving Efficiency? Healthcare Design 2010 conference, Las Vegas.) EBD elements: People: ED physicians and ED nursing staff. Process: Overall efficiency of the ED layout/floor plan. Place: Evaluation of three typical ED layouts/floor plans. Research methods: Pedometers; behavioral observation. Informal observations of new emergency department facilities have raised questions regarding the potential impact of design on the short- and longterm efficiency of an emergency

efficient ED layout. In linear ED designs, dual-entry rooms separate staff from patient and family traffic. In theory, the decentralized distribution of workstations and supplies place staff in closer proximity to patient rooms (without intervening corridors), reducing walking distance and improving efficiency. The three types of ED layouts were evaluated using pedometers to compare walking distances, per patient seen, for physicians and nurses working in nine EDs across the U.S. Data BUILDING to page 38

JUNE 2012

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SPECIAL

he word “hospice” has its roots in the Latin word “hospitium,” meaning guesthouse. End-of-life care focused on managing the symptoms of a terminally ill patient dates back to the 11th century, when medieval hospices provided a place where religious crusaders could rest, receive treatment, or die. Since then, hospice care has evolved in its philosophical beliefs and practices. From the 1860s onward, British hospices served as models of homes for the dying. The establishment in 1967 of St. Christopher’s Hospice, near London, ushered in the modern era of hospice in which care for the dying is combined with pain control. In 1971, Hospice, Inc. was founded in the United States and became the first organization to bring the principles of hospice care to the U.S. At that time, the emphasis was on the use of volunteers to help patients psychologically prepare for death. Since 1982, when Medicare added hospice services to its coverage, the hospice in-

FOCUS:

MEDICAL

FACILITY

DESIGN

New “hospice house” An evolution in care provides comfort and compassion when it’s needed most By Gloria Cade, RN, BSN,CHPCA, and Mark L. Hansen, AIA dustry has rapidly expanded. The National Hospice and Palliative Care Organization reports that in 2010, an estimated 1.58 million patients received hospice services (“NHPCO’s Facts & Figures on Hospice,” Jan. 2012). How and where hospice care is provided

Hospice care can be provided in whatever setting a patient calls home. This could be in a variety of nursing facilities, a private home, or a residential hospice. Allina Hospitals & Clinics has found that 30 percent to 40 percent of patients receive their hospice care in a residential setting. Most patients say that they would want to spend their last days at home; yet at present, more than 50 percent of patients die in hospitals. It’s clear that as

the population ages, the need for hospice care and hospice beds will continue to grow. Hospice care is not centered solely on providing comfort from symptoms, but rather takes a holistic approach toward the patient’s mind, body, and soul. Dignity, compassion, and providing comforts of home are the cornerstones of hospice care. A hospice care team is comprehensive and may include physicians, nurses, hospice aides, medical social workers, pharmacists, spiritual care, bereavement therapists, massage therapists, and music therapists. Hospice considers the patient and the patient’s family as the unit of care, and thus provides comfort and support to both patients and their caregivers, allowing them to spend quality time with their

loved ones during the final days of their life. Allina Hospice Foundation describes its hospice care philosophy this way: “Quality of life is emphasized, for whatever time remains. Hospice care is patient- and family-centered, and addresses physical, spiritual, emotional, and practical needs during a vulnerable time. We provide pain relief, family support, gentle guidance, and focused activities such as music therapy, that help patients and families recall and enjoy the times they have spent together. We support loved ones in effective grieving before the patient dies and for a year after their death.” Gratitude leads to a great idea

In 2003, Minnesota businessman John Wedum had cancer and was facing the end of his life. He received in-home hospice care from Allina Hospice. In his honor, the J.A. Wedum Foundation issued a challenge grant to Allina Hospice to build a residential hospice. John’s wife, Mary Beth, said that “the build-

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ing of a residential hospice has been a dream of the Wedum family of many years.” In April 2011, thanks to the generous support of donors, community members, the J.A. Wedum Foundation, and Allina Hospitals & Clinics, construction began on the 12-bed residential hospice. The J.A. Wedum Residential Hospice opened its doors in February 2012. The J. A. Wedum Residential Hospice House, designed by Mohagen/Hansen Architectural Group for Allina, embodies all that is important to patients and their family. This facility, which is one of four freestanding hospice facilities in the Twin Cities, helps fulfill Allina’s vision of changing the way end-of-life care is provided in this country. The J.A. Wedum Residential Hospice was designed to meet Allina’s goal of being the gold standard for end-of-life care. The journey begins

Given the challenge to develop an independent hospice facility in a quiet, residential setting, Allina set out to find the right design partner, teaming with Mohagen/Hansen Architectural Group, which provided the exterior building design and interior build-out of the facility, and DJ Kranz Construction, which served as general contractor. Together with Allina and the Allina Hospice Foundation, the planning of a beautiful facility was underway. The design process began with a work session that included all project stakeholders. Sharing ideas helped the architects and interior designers ascertain the design style the group preferred. During this work session, a series of words were used over and over to describe the desired outcome such as comfort, healing, celebration, life, flexibility, and caring. Those words were carried through to all design discussions. The design style was defined as one that included: • Texture • Lighting • Color • Wood • Glass • Connections to nature Renderings were developed of both the building exterior and

the interior in order to communicate the character and feeling of the space for fundraising efforts. These efforts attracted donations from the community at-large, a large portion of which were the result of what has now become the Allina Annual Hospice Foundation Benefit. The J.A. Wedum Foundation also agreed to match, dollar for dollar, the first $2 million in gifts raised from the community.

times a day in each resident’s room. There is a private dining area and a kitchen area for family and friends where they can prepare a meal and enjoy it together. The many attributes of home provided within the Hospice House allow residents to remain comfortable while extending that same comfort to their family and friends, who are encouraged to come to the house and offer support and love at any time.

Like going home

The building is strategically placed on the site to take full advantage of views of nature and wildlife. As you enter the building, family members are greeted with warm colors, a rich wood archway, soft lighting and pillars similar to what one would find in a model home. As an alternative to hospice care being provided in a patient’s home or the hospital, it was important that this facility offer all of the comforts of home with proper medical support. The house has 12 private rooms each with a private seating area, and an attached patio. Residents are encouraged to personalize their rooms with photos and other memorabilia or accessories that make them feel comfortable and “at home.” Each room has a private bathroom and a comfortable sofa sleeper for a family member who wishes to spend the night. There is also a full, shared guest bathroom for family use. A large hydro therapy tub is also available to all residents. The house has a number of gathering spaces. There are two large “family rooms” that are perfect for spending quiet time with friends and family outside of the resident’s room. A large “reflection room” was designed as a peaceful space, overlooking the pond and natural edge of the site, where family and residents can quietly focus on their thoughts, spirituality, and loved ones. Children of all ages are welcome in the house. A separate children’s play area is available for children to play games, watch television, and connect with friends online. Residents are given a choice of meals, which are served three

A dream becomes reality

Since opening in February 2012, the J.A. Wedum Residential Hospice House served more than 25 families in its first two months, with a length of stay close to the national average of 17 days. Staff members report that the beauty and warmth of the facility have an immediate impact on visitors as they enter the house, and that families comment every day about the wonderful care their loved ones are receiving. Though Medicare covers the cost of hospice care, the room and board costs, which total

nearly $400 per day, are the responsibility of the resident. It is the hope of the Allina Hospice Foundation, that through continuous fundraising efforts and generous contributions from others, they will continue to be able to provide quality, compassionate, hospice care to all who wish to receive it. Although John Wedum passed away before the journey to develop a residential hospice house began, his wife Mary Beth was instrumental in the process. Her inspiration and extreme generosity set the tone for the success of this facility. Sadly, Mary Beth passed away at the end of February 2012, not long after cutting the ribbon for the grand opening of the J.A. Wedum Residential Hospice House. The entire project team takes solace in knowing that she was able to see the dream she and John shared become a reality. Gloria Cade,RN, BSN, CHPCA, is director of Hospice and Palliative Care for Allina Health System. Mark L. Hansen, AIA, is health care principal and partner at Mohagen/Hansen Architectural Group.

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MINNESOTA PHYSICIAN

Tibetan Yoga workshop and lecture Toolbox from page 14 Learning from our experience

What have we learned from our oncology clinic experience so far? First, the positive aspects: The oncologist and palliative care physician must become trusted partners. Sitting next to each other in clinic is a great help. Also, having a regular tumor conference where cases are discussed from both oncology and palliative perspectives can be very helpful. Getting to see oncology patients early in the course of their disease helps the primary care/palliative care physician develop a trusting relationship with patients and staff, and allows us to see the positive chemotherapy effects that we palliative care physicians would otherwise miss. Working closely with chemotherapy nurses is invaluable. Most palliative care referrals start with the gentle nudge of the chemotherapy nurse who can see the patientâ&#x20AC;&#x2122;s suffering first hand. (Patients always want

The distinctive Tibetan practice of yoga, known as Tsa Lung (vital breath and channels), incorporates breath, awareness, and physical movement. In July, the Tibetan Healing Initiative at the University of Minnesotaâ&#x20AC;&#x2122;s Center for Spirituality & Healing will sponsor a Tibetan Yoga lecture and workshop by M. Alejandro Chaoul, PhD. Chaoul is an assistant professor in the Integrative Medicine Program, Department of General Oncology, at The University of Texas MD Anderson Cancer Center in Houston and an assistant professor at the John P. McGovern, MD Center for Health, Humanities and the Human Spirit at the University of Texas Medical Schoolâ&#x20AC;&#x201C;Houston. His research has explored the use of Tibetan mind-body techniques for cancer patients. Tibetan Yoga: Awaking the sacred body with M. Alejandro Chaoul, PhD. Friday community lecture, July 27, 2012 3:30â&#x20AC;&#x201C;5:30 pm, Mayo Auditorium Saturday workshop, July 28, 2012 9 a.m.â&#x20AC;&#x201C;4 p.m., Minnesota Landscape Arboretum For more information, go to: www.csh.umn.edu/programs/programeventscalendar/home.html

to present a positive face to their oncologists because they want to make them happy). Developing a community palliative care program that follows the same treatment paradigm as hospice, but uses a language suited to palliative care, has worked well. We discuss our palliative care patients at our hospice team meetings and basically use the same resources as for our hospice clients, including chaplains, volunteers, nurses, and bereavement specialists. We

know that some of our reimbursements for palliative care may not be so good, but that this is the best treatment for our patientâ&#x20AC;&#x201D;and hope that in future the success of this approach will lead to earlier appropriate entrance into hospice for the patients. We try to raise philanthropic dollars as much as possible for this loss of income. At present, we follow almost as many palliative care patients as hospice patients in our clinicâ&#x20AC;&#x2122;s program.

We have developed several retreats and seminars combining our hospice and oncology staffs, focusing on their shared desires for patient well-being. There were also things that didnâ&#x20AC;&#x2122;t work so well: We tried doing palliative care under a home care model. Home care is the Medicare reimbursement arm that covers things like changing wound dressings or administering IV antibiotics. It has the primary eligibly requirement that the patient be homebound. Because of this requirement, patients kept being turned away because they were not homebound. Trying to do palliative care alone in the clinic created difficulties because so much of the work required ongoing real-time evaluations in the home. To be successful, you need a full-time home palliative care team made up of all the components typically associated with hospice (nurses, social workers, volunteers, chaplaincy, and bereavement coordinators). Originally, we designated one day a week TOOLBOX to page 36

Fairview Health Services Leading the way in innovation Fairview is seeking compassionate and adventurous caregiversâ&#x20AC;&#x201D;four full-time physicians and eight full-time nurse practitioners/physician assistantsâ&#x20AC;&#x201D;to join us in developing a unique new outpatient care model. Highlights of this opportunity include: â&#x20AC;˘ Care for adult patients with complex medical and behavioral needsâ&#x20AC;&#x201D; those not well-served in the traditional outpatient clinicâ&#x20AC;&#x201D;through development of a primarily home-based practice â&#x20AC;˘ Partner with a Fairview Medical Group team who has demonstrated the capacity to provide compassionate, high-quality and eďŹ&#x192;cient care for a similarly complex patient population â&#x20AC;˘ Provide outpatient care only; inpatient care provided by our team of hospitalists and our community and academic medical centers Candidates must have 7+ years experience as a practicing clinician. Emphasis in hospital-based medicine, cardiac, pulmonary or end-of-life care preferred. Visit fairview.org/physicians to explore this and other opportunities and apply online, call 612-672-2277 or email recruit1@fairview.org. Sorry, no J1 opportunities.

THE STRENGTH TO HEAL

and stand by those who stand up for me.

Learn the latest treatments and play an important role in the care of Soldiers and their Families. As a physician on the U.S. Army Reserve Health Care Team, youâ&#x20AC;&#x2122;ll continue to practice in your community and serve when needed. Youâ&#x20AC;&#x2122;ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. Youâ&#x20AC;&#x2122;ll make a difference. 7R OHDUQ PRUH FDOO RU YLVLW ZZZ KHDOWKFDUH JRDUP\ FRP T ÂŠ 2010. Paid for by the United States Army. All rights reserved.

fairview.org/physicians TTY 612-672-7300 EEO/AA Employer

MINNESOTA PHYSICIAN JUNE 2012

Opportunities available in the following specialties:

Olmsted Medical Center, a 150-clinician multi-specialty clinic with 9 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Family Medicine Rochester Northwest Clinic Wanamingo Clinic Chatfield Clinic Dermatology Southeast Clinic

St. Cloud VA Health Care System is accepting applications for the following full or part-time positions: • Associate Chief, Primary & Specialty Medicine (Internist-St. Cloud)

Child Psychiatry Southeast Clinic Hospitalist OMC Rochester Hospital Emergency Medicine OMC Rochester Hospital

• Chief, Primary & Specialty Medicine (Internal Medicine) (St. Cloud)

• Medical DirectorExtended Care & Rehab (IM or Geriatrics) (St. Cloud)

• Dermatologist (St. Cloud)

Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 1650 4th Street SE

• Internal Medicine/ Family Practice (Alexandria, Brainerd, St. Cloud, Montevideo)

• NP/PA (Montevideo)

• Disability Examiner (IM or FP) (St. Cloud)

• Psychiatrist (Brainerd, St. Cloud)

• ENT (St. Cloud)

• Radiologist (St. Cloud)

• Geriatrician (Nursing Home-St. Cloud)

• Urgent Care Provider (MD: IM/FP/ER) (St. Cloud)

Rochester, MN 55904 email: egarcia@olmmed.org Phone: 507.529.6610 Fax: 507.529.6622

EOE

www.olmstedmedicalcenter.org

• Hematology/Oncology (St. Cloud)

NEW POSITIONS:

Family Practice Urgent Care Dynamic, independent 3 location, single-specialty practice in northwest Minneapolis suburbs is seeking additional associates for its Rogers site and has Full Time/ Part Time shifts in the Crystal and Rogers Urgent Care. • • • • •

Partnership opportunity after 2 years Competitive salary with incentives Excellent benefits, 401k/employer paid pension Practice at one site/one hospital Physician-owned

Please contact or fax CV to: Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429 763-504-6600 • Fax 763-504-6622

Visit our website at www.NWFPC.com

US Citizenship required or candidates must have proper authorization to work in the US. J-1 candidates are now being accepted for the Hematology/Oncology positions. Physician applicants should be BC/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible relocation bonus. EEO Employer.

Excellent benefit package including: Favorable lifestyle

Competitive salary

26 days vacation

13 days sick leave

CME days

Liability insurance

Interested applicants can mail or email your CV to VAHCS

St.Health Cloud VA Care System Brainerd | Montevideo | Alexandria

Sharon Schmitz (Sharon.schmitz@va.gov) 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-654-7650 or Telephone: 320-252-1670, extension 6618

JUNE 2012 MINNESOTA PHYSICIAN

Getting to see oncology patients early in the course of their disease helps the primary care/palliative care physician develop a trusting relationship with patients and staff.

Toolbox from page 34 for palliative care consults at the clinic. However, most palliative care consults start as emergencies. We learned that it worked best to have a few open slots each day, rather than one designated day per week. A role for complementary/ integrative care

Another major challenge for palliative care physicians is helping patients bridge the gap between complementary/integrative therapies and traditional allopathic medicine. Oncology patients crave integrative therapies and need someone to communicate with. Palliative care physicians are in a unique position to fulfill that role. We must be able to listen with an open mind to our patients’ wishes and communicate clearly our desire to work with them, without trying to be the all-knowing authority on integrative therapies. Our clinic has developed a referral base for most types of integrative therapies, in hopes of getting our patients to reputable practitioners within their spe-

cialty area. The clinic also provides healing touch, reiki, and massage, plus countless therapy dogs—led by a gigantic American bulldog that is the kindest creature I have ever encountered. We try to focus on proven therapies such as acupuncture for neuropathic pain. Lack of energy is the most difficult symptom for oncology patients, and fatigue is a universal symptom for chemotherapy patients. One of the most promising nonpharmacological therapies is Tibetan Yoga. M. Alejandro Chaoul, PhD, of The University of Texas MD Anderson Cancer Center in Houston, has been developing a research program studying the effects of using Tibetan Yoga as part of a comprehensive treatment plan for cancer patients.

This July, he will teach the concepts of Tibetan Yoga and provide preliminary results of his research at a two-day workshop sponsored by the University of Minnesota Center for Spirituality & Healing (see sidebar). For the past five years, our care system has offered mind/body support groups to our cancer patients, teaching therapies such as yoga, meditation, and guided imagery, with the purpose of giving our patients tools that help them have some sense of control over their illness. Research is crucial to unlocking the remarkable potential of these integrative therapies. A bigger, better toolbox

Over the past five years, we have witnessed our oncology clinic gradually transform into a heal-

ing community in which patients gather strength simply by being there. I believe the nurses, doctors, patients, and families all have quality of life as their No. 1 mantra as they move through their cancer journey. The tool of shared decision-making helps patients and families make good, informed treatment decisions no longer driven simply by fear. Several of our research protocols involve symptom management rather than focusing just on length of life. Palliative care physicians can be a great resource for patients trying to survive difficult chemotherapy regimens, and our toolbox keeps getting bigger and better just as our chemotherapy programs are getting more effective. Primary care physicians, palliative care physicians, oncologists, and others providing care to cancer patients need each other to provide the best quality outcomes for our patients. Charles Bransford, MD, is an internal medicine and hospice/palliative care physician at Lakeview Health System in Stillwater, Minn.

Minneapolis VA Health Care System Great place to work, great place to live. You are invited to be part of the Department of Veterans Affairs that has been leading change in the health care sector.The Minneapolis VA is a 341-bed tertiary care medical center affiliated with the University of Minnesota. Our patient population and case mix is challenging and exciting, providing care to veterans and active-duty personnel.The Twin Cities area offers excellent living and cultural opportunities.

In the heart of the Cuyuna Lakes region of Minnesota, the medical campus in Crosby includes Cuyuna Regional Medical Center, a critical access hospital and clinic offering superb new facilities with the latest medical technologies. Outdoor activities abound, and with the Twin Cities metropolitan area just a short drive away, you can experience the perfect balance of recreational and activities.. cultural activities EEnhance nhance yyour our professional professional life life in in an an eenvironment nvironment that that provides provides exciting exciting practice practice oopportunities pportunities iinn a bbeautiful eautiful N orthwoods ssetting. etting. Northwoods welcomes TThe he Cuyuna Cuyuna LLakes akes rregion egion w elcomes you. you.

We invite you to explore our opportunities in:

Opportunities for full-time and part-time staff are available in the following positions:

• Family Medicine

• Cardiology – Non-Invasive & Interventional • Chief of Surgery/Director of Specialty Care Service Line

• Emergency Medicine

• Deputy Chief of Staff

• Hospitalist

• Gastroenterologist

• Orthopaedic PA

• General Internal Medicine

Contact: Todd Todd o Bym Bymark, ark, tb tbymark@cuyunamed.org ymark@cuyunamed.org www.cuyunamed.oorg (866) 270-0043 / (218) 546-4322 | www.cuyunamed.org

• Orthopedic Surgeon – Total Joint/Spine • Physician – Comp & Pension • Physician – Spinal Cord Injury Physician applicants should be BC/BE. Possible recruitment bonus. Interested applicants should email CV to: Brittany Sierakowski, HRMS • brittany.sierakowski@va.gov Fax 612-725-2287 • Telephone 612-629-7873 EEO Employer

MINNESOTA PHYSICIAN JUNE 2012

The Northwest Wisconsin Region of Mayo Clinic Health System has more than 300 physicians representing a wide range of medical specialties in a community healthcare setting. We are a respected and financially secure organization with strong emphasis on high quality care and patient satisfaction. A Mayo One emergency medical helicopter is based in Eau Claire, offering surrounding communities access to the area’s only verified Level II trauma center. Our current opportunities include: Neurology – Adult & Dermatology Pediatric Emergency Medicine Oncology Endocrinology Orthopedic Surgery – Family Medicine General, Sports, & Trauma Gastroenterology Palliative Care General Surgery Psychiatry – Adult Hospitalist Rheumatology Internal Medicine Urology

If you wish to learn more or to express interest in this position, please contact: Cyndi Edwards/Christie Blink by phone (800-573-2580); email edwards.cyndi@mayo.edu or blink.christie@mayo.edu

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Family Medicine • General Surgery • Geriatrician/Outpatient Internal Medicine • Hospitalist

• Infectious Disease • Internal Medicine • Med/Peds Hospitalist • OB/GYN • Oncology • Orthopedic Surgery

• Psychiatry • Pediatrics • Pulmonary/ Critical Care • Radiation Oncology • Rheumatology

For additional information, please contact:

Kari Bredberg, Physician Recruitment karib@acmc.com, (320) 231-6366

Julayne Mayer, Physician Recruitment mayerj@acmc.com, (320) 231-5052

www.acmc.com

Practice Well. Live Well. Lake Region Healthcare is located in a magnificent, rural, and family-friendly setting in Minnesota lakes country where we aim to be the state’s preeminent regional health care partner. Our award winning patient care and uncommon medical specialties set us apart from other regional health care groups. Lake Region’s physicians and their families also enjoy an unmatched quality of professional and personal life. Current opportunities including competitive salary and benefit packages available for BE/BC physicians are: • Dermatologist • Family Medicine • Emergency Medicine

• Internal Medicine • Pediatrics • Psychiatrist • Psychiatric NP or PA

For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227

Emergency Medicine Emergency Practice Associates has immediate full-time, part-time and locums opportunities at our sites in:

Hibbing Little Falls Park Rapids Alexandria Austin For more information contact Tina Dalton or Mike Coulter at 800-458-5003, email:

recruiting@epamidwest.com or visit our website at

www.epamidwest.com 712 Cascade St. S., Fergus Falls, MN 736-8000 • (800) 439-6424 Lake Region Healthcare is an Equal Opportunity Employer. EOE

www.lrhc.org

Your Emergency Practice Partner JUNE 2012 MINNESOTA PHYSICIAN

Building from page 31 were collected during high- and low-volume periods on Monday and Wednesday of the same week. Analysis of the pilot study data indicated that there was no significant difference in walking distance among the ED layouts. However, closer examination of the data revealed that operational characteristics (i.e., triage operational model, work station location, and staffing assignment strategies) may be more important than ED layout in efforts to improve efficiency. The site with the lowest ratio of walking per patient seen implemented a major “lean” analysis of the hospital’s emergency service and applied that analysis to the design of its expansion. Results of this study have direct application in design planning. Understanding the relationship between operations and ED layouts that increase staff efficiency are critical in helping to address the current ED crisis. Further testing of these assumptions will be important, but data from this

research should be sufficient to immediately help guide designers and ED staff. Case Study #3:

Impact of an innovative emergency department model of care and design on patient satisfaction and outcomes, staff satisfaction and operational efficiency in an academic medical center (Christman, J., Kelly, C., and Zborowsky, T. Study in process) As detailed in the 2006 Institute of Medicine Report “Hospital Based Emergency Care—At the Breaking Point,” hospitals throughout the U.S. are increasingly struggling to meet the needs of patients coming through the doors of the nation’s emergency departments each year. ED crowding problems are multifactorial and pervasive across the country. One of the main problems is the persistent backup of admitted patients in the ED. This “boarding” of hospitalized patients in the ED essentially takes ED beds out of service. With fewer beds available for new patients, delays in

A Journey of Opportunity After Hours (Walk In Care) Family Medicine, Med/Peds or Pediatrics Physicians

the care of all ED patients are inevitable. Using tools from engineering and operations research, this ED layout was developed to enhance throughput and improve patient flow by applying an innovative ED concept of care for lower acuity patients. The University of Kentucky design team worked with consultant Jim Lennon to refine the ED design and process flow. Building on Jensen and Crane’s strategy of keeping low-acuity patients out of ED beds, the team devised a chair-centric model. The chair-centric model provides an alternative interim space for patients waiting to see a clinician or to receive test results, so they avoid returning to the waiting room but do not occupy a bed needed for another patient. In addition to increasing throughput, the chair-centric model might increase patient satisfaction by improving comfort. A living lab of this concept was built, and this ED study is currently underway to assess pain levels, length of stay time to physician and staff levels with

number of patients. EBD elements: People: ED physicians, ED nursing staff, and their patients. Process: Efficacy, satisfaction and patient outcomes in the chair-centric model. Place: Comparing the chaircentric model of care and the traditional ED exam room. Research methods: Retrospective data collection; questionnaires; place-based behavioral observation. These studies represent an important array of health-care design research currently being conducted, but there is more to be done. As we move into the next generation of health care in the U.S., it will be beneficial to build into that system ways to understand and measure how the built environment supports or detracts from the larger goals of providing safe, efficacious, and healing environments in all health care settings. Terri Zborowsky, PhD, EDAC, is director of health care education and research and a medical planner at AECOM in Minneapolis.

Internal Medicine?

Yup.

Family Medicine?

NEW clinic in Mahtomedi, MN?

Internal and Family Medicine Opportunities

If work / life balance is important enjoy these Part-time and Casual positions currently available at four of our established clinics: Maplewood Clinic, Woodbury Clinic, Grand Avenue Clinic and Stillwater Clinic. Weeknight and weekend hours, 4 or 8-hour shifts. Benefit eligibility at .5 FTE. HealthEast® Care System, the largest non-profit health care organization in the Twin Cities’ East Metro area, is dedicated to offering physicians the professional journey that works best for them. Your career journey starts here! For more information visit our website or contact Michael Griffin, Manager of Physician/Provider Recruitment at 651-232-2227 or 702-595-3716 (Cell), or email mjgriffin@healtheast.org. EOE

www.healtheast.org/careers www .healtheast.orrg/careers

MINNESOTA PHYSICIAN JUNE 2012

Stillwater Medical Group is an 90+ provider multi-specialty group practice afﬁliated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services in the St. Croix Valley, just east of the Twin Cities metro area. Internal and Family Medicine Physician Opportunities: Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN. Mahtomedi, MN? (Ma-toe-me-dye) So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside ﬂavor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education. For further information please contact: Patti Lewis, Director Human Resources 1500 Curve Crest Blvd, Stillwater MN (651) 275-3304, plewis@lakeview.org stillwatermedicalgroup.com

We’ll make it all better.

You wouldnâ&#x20AC;&#x2122;t give a 1-year-old a beer, so why would you give one to an unborn child? As a physician, itâ&#x20AC;&#x2122;s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy. Share 049: Zero Alcohol For Nine Months.