January/February 2012

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

Design for

medicine

Design thinking for scientific research Exploring EvidenceBased Design

Design Meets Disability Go Green at the Office Interview with incoming sfms president VOL. 85 NO. 1 January/February 2012

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IN THIS ISSUE

SAN FRANCISCO MEDICINE

January/February 2012 Volume 85, Number 1

Design for Medicine FEATURE ARTICLES

MONTHLY COLUMNS

10 Innovation in Medicine: A Physician and Inventor Examines the Nature of Advancement John Maa, MD

4 Membership Matters

12 Building for Health: A Talk with Richard Jackson, MD, MPH Steve Heilig, MPH 14 Evidence-Based Design: Improving Outcomes through Design of the Built Environment Sara O. Marberry, EADC

16 Medicine and Architecture: Parallel Disciplines Sharon Woodworth

7 President’s Message Peter J. Curran, MD 9 Guest Editorial Amanda Denz, MA 32 Hospital News 34 In the News 34 Classified Ads

19 d.Medicine at Stanford: How Design Thinking Helps Medicine Maryanna Rogers

OF INTEREST

21 Creating Global Solutions: How Good Design Can Save the World Chris Stivers and Kevin Chi

6 Introduction: A Conversation with the Incoming SFMS President Peter J. Curran, MD

24 Cadaver 2.0: Testing a Virtual Dissection Table for Teaching Anatomy Tracie White 26 Design for Healing: The Role of Art and Design in the Health Care Experience Annette Ridenour 28 Going Green: A Practical Guide for Any Medical Setting Todd L. Sack, MD, FACP 30 A Room of One’s Own: Evidence for the Effectiveness of Single-Patient Rooms Dee Mostifi 31 Design Meets Disability: The Ideas of Designer Graham Pullin Amanda Denz, MA

Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

MEMBERSHIP MATTERS A PROFESSIONAL VOICE FOR COMMUNITY HEALTH SINCE 1868 The San Francisco Medical Society (SFMS) has been involved in community health issues since the 1800s. As the only medical association in San Francisco representing the full range of medical specialties and interests, SFMS health advocacy has been broad. Via policy-making efforts with state and national medical and political leaders and an award-winning journal, SFMS has often been influential far beyond the city. The SFMS agenda and activities continue to focus on the community and the following areas of involvement: • Forming HealthShare Bay Area (see below) to improve patient care and reduce costs • Working with the physician community to promote the adoption of electronic health records to better serve patients • Advocating against cuts to Medi-Cal and Medicare reimbursement to provide continued access to care for all San Franciscans • Preserving the health care safety net and public health programs in times of severe budget cuts • Supporting antitobacco legislation and San Francisco’s law banning the sale of tobacco in pharmacies, and smoking in restaurants and other businesses, and eliminating tax credits for films showing smoking • Supporting the Healthy San Francisco program and participating in legal defenses to preserve the program, while helping TO monitor the program’s progress • Providing physicians for medical consultation for San Francisco schools and for volunteer care at community clinics • Working on legislation to allow minors, without parental consent, to receive vaccines to prevent STIs; to prevent bans on medical procedures such as circumcision; and more • Cosponsorship of the Hep B Free program in San Francisco • Advocacy for improving end-of-life care in the Bay Area via new policies, use of new advance directives (such as POLST), and educational outreach to physicians and patients

HOW SFMS SERVES THE COMMUNITY

HEALTHSHARE BAY AREA Working under the auspices of the SFMS Community Service Foundation and guided by a diverse board of San Francisco and Bay Area health care industry professionals, the SFMS worked to develop HealthShare Bay Area to provide the infrastructure for a unified electronic health record system. The project originally targeted San Francisco but now includes partners from the East Bay. This service allows providers to have access to secure community-wide patient data. It also permits patients to gain a complete view of their medical records, irrespective of where individual records may reside. HSBA will launch in 2012.

UNIVERSAL ACCESS TO CARE SFMS leaders have long

advocated that every San Franciscan should have access to quality medical care. Recent SFMS participation in this effort has included the Mayor’s Health Care Reform Task Force, the San Francisco Health Care Services Master Plan Task Force, and the Mayoral Task Force, which designed the Healthy San Francisco program. SFMS also joined in the lawsuits to preserve that program. SFMS advo4 5

San Francisco Medicine January/February 2012

cates have advocated for community clinics since the founding of the original Haight-Ashbury Free Clinics in the 1960s.

ANTI TOBACCO ADVOCACY SFMS advocates were instrumental in the banning of tobacco smoking in restaurants, ahead of the rest of the state and nation. SFMS advocates for ever-stronger protections from secondhand smoke, for removal of tobacco products from pharmacies, for higher taxes on tobacco products, and more.

REBUILDING/PRESERVING SAN FRANCISCO GENERAL HOSPITAL SFMS spokespersons took a lead in advocating for full funding of the seismic rebuild and in advising, as members of the Mayoral committee, where and how that would occur.

HIV PREVENTION AND TREATMENT The SFMS was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, adequate funding, and more.

SCHOOL AND TEEN HEALTH SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, worked on improving school nutritional standards, and provides medical consultation to the SFUSD school health service.

ENVIRONMENTAL HEALTH SFMS established a nationwide educational network on scientific approaches to environmental factors in human health; has advocated on reducing mercury, lead, and air pollution exposures; and much more.

REPRODUCTIVE HEALTH AND RIGHTS SFMS has been a state and national advocate for reproductive health and choice.

BLOOD SUPPLY SFMS has long been a partner of the Blood Centers of the Pacific and seeks to help increase donations.

ORGAN DONATION SFMS has been a leader in seeking im-

proved donation of organs to decrease waiting lists, via education and new polices regarding consent and incentives for organ donation.

OPERATION ACCESS SFMS is a founding sponsor of this local

organization providing free surgical services to the uninsured and has provided office space, volunteers, and funds.

DRUG POLICY SFMS has been a leader in exploring and advocating new and sound approaches to drug abuse, including some of the first policies regarding syringe exchange, medical cannabis, and treatment instead of incarceration.

MEDICAL ETHICS SFMS has developed and promulgated

forward-looking policies and approaches regarding end-of-life care, patient directives, physician-assisted dying, and other topics of interest to patients, physicians, policy makers, and the general public. www.sfms.org

January/February 2012

Activities and Actions of Interest to SFMS Members

Volume 85, Number 1 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

2012 Medicare Fee-for-Service Payment Rates Take Effect 0.18 percent increase in the conversion factor for budget neutrality. The 2012 conversion factor will be $34.0376. CMS/Palmetto didn’t begin processing claims until January 18. Because Congress acted so late in 2011 to prevent the 27.4 percent sustainable growth rate cut, claims will be held for a period of time to allow CMS to develop the new payment rate files, and to allow Medicare claims administration contractors to install and test the files. CMS expects that most, if not all, contractors will have been ready to process claims under the revised rates on or before January 18, 2012, which is the end of the ten-business-day claims hold period (contractors’ time frames may differ). Palmetto will merge held claims (oldest receipt date first) with incoming claims, up to the maximum that can be accommodated by the common working file. New fee schedule will have been posted on the Palmetto website as of January 11, 2012. For detailed information on the changes, please go to http://wp.me/pBDEx-wU.

SGR Cuts Averted until End of February

The House agreed to extend the budget bill for two months and prevent the 27.4 percent Medicare sustainable growth rate (SGR) cut to physician reimbursement from going into effect on January 1, 2012. A House-Senate conference committee will begin work in late January on a longer-term agreement, including a permanent solution to SGR. SFMS/CMA will continue to keep the pressure on Congress when it returns at the end of January to adopt a longer-term solution to the failed Medicare SGR payment system. We appreciate all of the physicians who made phone calls, sent letters, and met with their members of Congress to help stop the cuts. These efforts helped convince the House to stop the cuts while the longer-term negotiations continue.

SFMS Past President Elected to Northern California ACP Leadership

Congratulations to Past President and SFM Editor Gordon L. Fung, MD, FACP! Dr. Fung was elected as the governor-elect of the California Northern Chapter of the American College of Physicians (ACP). His term as governor-elect will begin April 2012, and his four-year term as governor will begin at the Annual Business Meeting in April 2013.

Former CMA President Named to Medical Board of California

Dev GnanaDev, MD, CMA past president, has been appointed by Governor Jerry Brown to the Medical Board of California. The Medical Board is the state agency that licenses and disciplines doctors. It has fifteen members—eight doctors and five public members appointed by the governor. GnanaDev’s appointment requires state Senate approval.

SFMS On-Site Seminars

March 20, 12:00 p.m. to 1:45 p.m.

Strategies to Survive and Thrive in Private Practice Private practice is not dead! Many physicians continue to have successful private practices by offering additional services to increase revenue and by tightening operating expenses. This seminar will provide you with the tools necessary to reduce overhead expenses and increase revenue. $109/each for SFMS/CMA members and their staff ($99 for each additional attendee from the same office); $159/ each for nonmembers. Lunch is included. Contact Posi Lyon, plyon@sfms.org or (415) 561-0850 extension 260, for more information. www.sfms.org

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD Peter J. Curran, MD Stephen Walsh, MD

SFMS OFFICERS President Peter J. Curran, MD President-Elect Shannon Udovic-Constant, MD Secretary Jeffrey Beane, MD Treasurer Lawrence Cheung, MD Immediate Past President George A. Fouras, MD SFMS EXECUTIVE STAFF Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Assistant Lauren Estrada

BOARD OF DIRECTORS Term: Jan 2012-Dec 2014 Andrew F. Calman, MD Arti D. Desai, MD Roger S. Eng, MD Jennifer Gunter, MD John Maa, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Man-Kit Leung, MD Keith E. Loring, MD Terri-Diann Pickering, MD Marc D. Rothman, MD Rachel H.C. Shu, MD

Term: Jan 2010 -Dec 2012 Gary L. Chan, MD Donald C. Kitt, MD Cynthia A. Point, MD Adam Rosenblatt, MD Lily M. Tan, MD Shannon UdovicConstant, MD Joseph Woo, MD

CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate

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INTRODUCTION A Conversation with the Incoming SFMS President Peter J. Curran, MD, was installed as the 2012 SFMS president at January’s annual dinner. An SFMS member since 2007 (the same year he moved to San Francisco), Dr. Curran is a cardiologist at Breall & Associates and is the director of Cardiovascular Rehabilitation at St. Mary’s Medical Center. He was recently selected as a top doctor by 415 Top Doctor.

Dr. Curran received his MD degree from Loma Linda University and completed his residency at Beth Israel Deaconess Medical Center in Massachusetts (internal medicine) and UCLA (cardiology). He has served in the eighty-ninth Medical Operations Squadron in the U.S. Air Force, chaired the MultiSpecialty Peer Review Committee at St. Mary’s, and participated in advocacy campaigns spearheaded by the CMA and SFMS. Dr. Curran has worn many hats for SFMS over the years and is looking forward to adding a “presidential hat” to his stack. He sat down with SFMS to share his viewpoints about organized medicine.

SFMS: Why are you a member of SFMS and why is being an active member in organized medicine important for your patient-care philosophy?

Dr. Curran: I enjoy the camaraderie of SFMS and being around really smart people who like to solve problems.

Organized medicine takes a macro approach to problem solving, which nicely complements the micro approach to solving problems in clinical practice treating patients.

Can you tell us about any goal(s) you hope to accomplish in your new position as SFMS president?

I would like to increase our exposure as an organization in the city of San Francisco. We can accomplish this in many ways, including community outreach activities, supporting local candidates friendly to medicine, and taking the approach of everything physician.

What are some of the biggest opportunities or challenges you see in health care within the next year?

In periods of economic downturn, such as the current environment, there are opportunities for physicians to take an entrepreneurial approach to medicine in developing more efficient health care delivery with better outcomes.

Instead of waiting for the wheels of health care reform to turn, we will look for ways of making this happen now, at the local level. We should be asking, “Is there life in medicine beyond entitlement programs?”

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San Francisco Medicine January/February 2012

Participants from St. Mary’s Medical Center at the American Heart Association Heart Walk, including Dr. Curran (back row, second in from right) How do you balance your work and personal life and still manage to find time to participate in SFMS activities? Any advice for new physicians transitioning into practice from residency?

Sometimes it’s nice to get out of the house! I tell young docs that although we are generally trained as though we will be doing the same thing for the next thirty years in our career, don’t settle for that, and always look for other ways to diversify your career. And if it feels like work, make an immediate adjustment.

What about you would surprise our members?

My five-year-old son speaks Korean and I don’t know a word. Figure that.

If you weren’t a physician, what profession would you most like to try?

Something in journalism. Or the governor of Illinois, without going to jail.

www.sfms.org

PRESIDENT’S MESSAGE Peter J. Curran, MD

Not Quite as It Seems Health insurance premiums for individuals in California increase, while incomes remain flat. Blue Cross Anthem attempts to raise individual premiums by 40 percent in 2011. Seven million Californians are without health insurance. Assembly Bill 52 (authored by Assemblyman Mike Feuer, D-LA) seeks to prohibit health insurance companies from increasing health care premiums without obtaining prior approval from the Department of Managed Health Care or the Department of Insurance.

The CMA would naturally be in favor of this, right? Wrong.

AB 52 sailed past the CMA Council on Legislation in March and two CMA Board of Trustee (BOT) meetings, despite an “oppose” position from the CMA. The CMA position is that any rate regulation is a bad idea, because what insurers lose from premium hikes they will simply make up with lower physician reimbursement. The CMA believes it should instead focus on enforcing rate review and “invest in meaningful ways to bring down health costs.” A CMA staff member following the bill put it to me this way: “The reality is that insurers are going to get their Wall Street projections.” When I suggested that this oppose position perhaps gives the appearance of the CMA sleeping with unlikely bed fellows (that is, insurance companies), he quickly added that the CMA does not make policy; the House of Delegates (HOD) that meets each year to discuss and vote on numerous resolutions makes the policy.

In other words, the physicians make the policy and the CMA functions to enforce that same policy. A member of the CMA BOT said the same thing: It is understood that the CMA position on AB 52 is based on established CMA policy. In fact, a similar bill authored by former Assemblyman and current Insurance Commissioner Dave Jones was killed last year and did not have the support of the CMA. When I spoke with a representative from Mike Feuer’s office, she said that the CMA has been approached several times in the past on AB 52 and similar bills and has always been against anything related to rate regulation.

If CMA is against AB 52 and rate regulation, then I should be able to find a resolution from the HOD that supports that claim. The CMA lobbyist mentioned a resolution from HOD 2007, so I went to the archives. All I found from 2007 was adopted resolution 206a-07, Health Insurance Companies as Public Utilities, which resolved that the “CMA study and make recommendations regarding the establishment of a regulatory body . . . to regulate health insurance industry financing, compliance with state and federal laws, and the provision of mandatory health care coverage.” I know from my experience with the CMA HOD that when a resolution is recommended for further study, it usually means there is less than a unanimous consensus of physician opinion at the House.

It wasn’t until I spoke with Ruth Haskins, chairperson of www.sfms.org

the CMA Council on Legislation, that I learned CMA “policy” can be either real policy from the HOD or more like what the CMA has supported in the past. Regarding insurance regulation, Haskins believes there was no guiding CMA policy when it came to AB 52. This is a complicated bill with many ramifications, including not knowing what ultimate effect it would have on patient care or physician well-being. Instead of changing CMA’s position on this bill late in the year (perhaps to a neutral position) and risk losing face with our allies in the legislature, the decision of the BOT in July, with advice from government relations at CMA, was to maintain the oppose position and hope for the opportunity of further study with a two-year bill. This is in fact what happened when the author of the bill decided he lacked the necessary votes in the Senate and determined to try again next year.

When the BOT reconvenes in January 2012 and AB 52 is presented for discussion, the important next step may not be whether the official CMA position remains oppose or becomes neutral, but rather this: Will the CMA support alternative legislation that promotes its own ideals to address the problem of escalating health insurance costs?

If you are interested in this topic or have comments about this article, please join the discussion online at http://bit.ly/ wVYnVl. We welcome your comments!

January/February 2012 San Francisco Medicine

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www.sfms.org

GUEST EDITORIAL Amanda Denz, MA

What is Good Design?

Design is omnipresent in the life of modern people. Everything you interact with was created by someone—from the font used in this publication to the chair in which you sit to read it. Good design, however, is somewhat of a paradox: The better the design, the less you should notice it. Among other things, good design is unobtrusive and it uses as little design as possible to achieve its goal.

In medicine the tools you use, the procedures and protocols you follow, the space in which you practice were all designed to aid in healing your patients without getting in the way. Design impacts how effective you are. This month we’ve assembled a collection of articles investigating where medicine and design meet and how the two fields can inform one another.

One meeting place is the design of spaces. In this realm a movement has grown over the last thirty years called “evidencebased design.” Trends such as the use of private rooms, the effort to mitigate noise in patient rooms, and the increased use of sunlight are features born out of this movement because of scientific evidence supporting their effectiveness.

Another meeting place is the realm of industrial design, defined on Wikipedia as “the use of a combination of applied art and applied science to improve the aesthetics, ergonomics, and usability of a product.”

In the early 1980s, Dieter Rams, a well-known industrial designer, was becoming increasingly concerned by the state of the world around him. He saw it as “an impenetrable confusion of forms, colors, and noises.” Knowing that he was a contributor to that world, he asked himself the question: What makes good design? His answers, the Ten Principles for Good Design, have been widely adopted in the field and are sometimes referred to as the “Ten Commandments” for design.

Deiter Rams’s Ten Principles for Good Design*

*Reprinted from Vitsoe (www.vitsoe.com), the design company of Dieter Rams

Good Design Is Innovative The possibilities for innovation

are not by any means exhausted. Technological development is always offering new opportunities for innovative design. But innovative design always develops in tandem with innovative technology and can never be an end in itself.

Good Design Makes a Product Useful A product is bought

to be used. It has to satisfy certain criteria, not only functional but also psychological and aesthetic. Good design emphasizes the usefulness of a product while disregarding anything that could possibly detract from it.

Good Design Is Aesthetic The aesthetic quality of a product is www.sfms.org

integral to its usefulness, because products we use every day affect our person and our well-being. But only well-executed objects can be beautiful.

Good Design Makes a Product Understandable It clarifies the product’s structure. Better still, it can make the product talk. At best, it is self-explanatory.

Good Design Is Unobtrusive Products fulfilling a purpose are like tools. They are neither decorative objects nor works of art.

Their design should therefore be both neutral and restrained, to leave room for the user’s self-expression.

Good Design Is Honest It does not make a product more innovative, powerful, or valuable than it really is. It does not attempt to manipulate the consumer with promises that cannot be kept.

Good Design Is Long-Lasting It avoids being fashionable

and therefore never appears antiquated. Unlike fashionable design, it lasts many years—even in today’s throwaway society.

Good Design Is Thorough down to the Last Detail Nothing must be arbitrary or left to chance. Care and accuracy in the design process show respect toward the consumer.

Good Design Is Environmentally Friendly Design makes an important contribution to the preservation of the environment.

It conserves resources and minimizes physical and visual pollution throughout the lifecycle of the product.

Good Design Is as Little Design as Possible Less, but better—because it concentrates on the essential aspects, and the products are not burdened with nonessentials. ***** Using these principles, consider a few items you use regularly.

How do the items meet this criteria and how do they fall short?

What about the last thing you designed? The relevance of good design goes beyond an increased understanding of the things we use as consumers; we can also apply these principles to anything we create and aspire to achieve good design in all that we do.

January/February 2012 San Francisco Medicine

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Design for Medicine

Innovation in Medicine A Physician and Inventor Examines the Nature of Advancement John Maa, MD The great innovator Leonardo da Vinci once said, “Human subtlety will never devise an invention more beautiful, more simple, or more direct than does nature because in her inventions nothing is lacking, and nothing is superfluous.” What is so

striking about this fifteenth-century quote by the man who has come to epitomize the Renaissance is that da Vinci was one of the most prolific inventors in modern history, conceiving of inventions and innovations across what are considered widely disparate fields today, including astronomy, optics, architecture, anatomy, aeronautics, and civil engineering. The remarkable and surprising observations achieved through his genius and experience have long illuminated the path to successful invention. Fittingly, one of the major recent advances in medical technology, the “robot” for minimally invasive surgery, conceived by electrical engineer Philip Green, is named the “da Vinci” to honor the man who invented the first robot half a millennia earlier.

In medicine, innovations have been pioneered throughout the ages through a cycle of either quantum leaps catalyzed by the convergence of technical advances or small incremental steps that have revolutionized the current style of practice. Frontline physicians and surgeons were often the first to design new equipment, such as the mechanical heart and machines for artificial kidney dialysis and cardiopulmonary bypass. Some exceptional individuals have experienced repeated success. As a teenager, Dr. Thomas Fogarty patented the first centrifugal clutch for a motorcycle by modifying an existing clutch for automobiles. Later, as a scrub technician, he conceived of a balloon catheter to extract arterial emboli by altering a surgical glove using fly-fishing techniques. His first description of this invention was received with scorn, but Dr. Fogarty remained persistent and eventually published a brief report, after he’d been rejected by nearly every medical journal and labeled as dangerous and reckless. Over his career, Dr. Fogarty patented more than 100 surgical instruments and in 2000 was named the recipient of the Lemelson-MIT Award, the largest prize for invention in the U.S. Clearly, to succeed as an innovator, one must master a field to understand why other attempts to solve a problem have failed. According to Niels Bohr, “An expert is a man who has made all the mistakes that can be made in a very narrow field.” Yet, as physicians, we frequently confront the opposite situation. I recall talking to the head of a company seeking to “cure cholangiocarcinoma.” A brief discussion of the company’s approach made it evident to me that the idea would never succeed because it lacked a basic understanding of the anatomy, tumor biology, and natural history of the disease.

10 San 11 SanFrancisco FranciscoMedicine Medicine January/February January/February2012 2012

Out of curiosity, I asked the company leader if he had ever actually seen a cholangiocarcinoma in a human being. Neither the muted negative response nor the revelation that the company later abandoned its efforts to develop this therapy surprised me. It was eye-opening for me to learn that some biotechnology companies seek only to conceive, market, and sell an idea at a profit as quickly as possible, before negative results accrue questioning its sustainability. I imagine da Vinci and Bohr spinning in their respective graves over this unenlightened approach to “innovation.”

Although great innovators often work out solutions that no one else does, others seize upon the obvious unrecognized answer staring everyone in the face.

Amazingly, some advances require only minor incremental change. Thomas Edison did not invent very much himself, but he often borrowed and improved the ideas of others because he was better than the original inventor at recognizing how valuable an idea was. Steve Jobs was similarly skilled at “tweaking” the ideas of others to make them perfect and popular. When asked by a colleague to describe the solution that he was envisioning, Jobs replied that he was unable to do so now, but “you’ve got to show me some stuff, and I’ll know it when I see it.”

Another essential trait for innovation is the ability and courage to ask important basic questions from the perspective of a novice, freed from the fear of appearing naïve. A successful surgeon entrepreneur once told me, “The further an individual progresses through medical training, the more informed one becomes, and the more likely one is to accept the current art as dogma, and somehow divinely ordained and immutable.” Instead, the ability to contemplate complex problems with an open and unencumbered mind, freed from all assumptions, often results in the clarity to recognize the simplest and most elegant answer. Throughout history, the tale has been repeated of a new tool that does not succeed in its original intent but is later recognized to be enormously useful in a completely unrelated field.

Even after a brilliant new idea to change the world into a better place has been conceived, much of the hard work still remains. Albert Einstein said, “If at first the idea is not absurd, then there is no hope for it.” The pioneering inventor must have the fortitude to withstand the barrage of criticism that will ensue by challenging the status quo. Indeed, perhaps the more intensely vocal and critical opponents are, the more likely one is on to something extraordinary. Fogarty certainly www.sfms.org

had that experience when he introduced his balloon catheter.

Such stories abound in medicine, but a recent outstanding example is the experience of pediatric surgeon Judah Folkman, who was ridiculed as deluded when he presented his first papers on tumor angiogenesis. More than a decade later, his hypothesis would become widely adopted and the focus of research in hundreds of laboratories worldwide and the inspiration for more than fifty angiogenesis inhibitors in clinical trials (including Lucentis and Avastin).

Over my career and through the experience of long hours spent in the operating room, I have helped conceive new ideas to prevent wrong-site surgery, eliminate the problem of retained foreign bodies left behind in the operating room, design a safer central venous catheter, and improve laparoscopic hernia repairs. But the concept I pioneered that has had the greatest national impact is the surgery hospitalist model. In the early 2000s, the acute care surgery model was being championed by surgeons seeking to perform Burr holes and external fixation of fractures to reinvigorate the field of trauma surgery. Simultaneously, our nation was beginning to experience the full force of a crisis in access to emergency surgical care. But it remained unclear to me how the acute care surgery model would resolve the emergency care crisis or be relevant to general surgeons who worked in nontrauma hospitals. At the behest of Dr. Hobart Harris to abandon all assumptions about the structure of emergency care and design a new system from scratch, I began to research the medical hospitalist literature, particularly limitations in the perioperative care of surgical patients. Striving to “think differently” and borrowing and “tweaking” core principles of the medical hospitalist, I conceived of a surgeon dedicated to providing emergency care, without extending into the domains of orthopedic or neurosurgery. The UCSF Surgical Hospitalist program was implemented in 2005, and the initial papers we published on the surgical hospitalist concept were heavily criticized and rejected. The majority of the negative feedback questioned the generalizability and sustainability of this new model. I remained undeterred and reflected carefully on the criticisms in a relentless pursuit to refine and improve the program. With time, the strengths of the surgical hospitalist model were recognized nationally, and it is estimated that today more than 400 programs inspired by the surgical hospitalist model are now in place across the country, each representing unique variations on the original theme.

Ultimately, as da Vinci asserted, a secret in successful innovation is to emulate the genius of Mother Nature, by crystallizing an understanding of the problem to define the simplest, most beautiful and elegant solution.

While it is hard to conceive of a solution that imitates nature to revolutionize the delivery of health care across America, as physicians we can still draw inspiration from da Vinci and, indeed, from other successful innovators. We can analyze the current challenges from a different point of view—one that focuses on both patient need and responsibility and that is www.sfms.org

freed from undue self-interest, excessive profit motives, and the redundant and superfluous. We can ask important basic questions from the perspective of a novice without fear of appearing naïve. We can try to work out new solutions or tweak the work done by others. In all of this, we must have the fortitude to withstand the barrage of criticism that will ensue from challenging the status quo. Finally, we can hope that human subtlety, as championed by da Vinci himself, will succeed in overcoming what Capitol Hill and the White House have been thus far unable to accomplish in reforming health care across America.

John Maa, MD, is an assistant professor of surgery at UCSF and is director of its surgical hospitalist program. He is also a member of the U.C. Office of the President’s Tobacco-Related Disease Research Program Scientific Advisory Committee. Maa is an active member of the SFMS.

January/February 2012 San Francisco Medicine

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Design for Medicine

Building for Health A Talk with Richard Jackson, MD, MPH Steve Heilig, MPH

How does where we live impact our health? It’s a big and complex question, but Richard Jackson, MD, MPH, is leading the way toward answers— and interventions. Jackson is a longtime leading figure in

public health. Trained in pediatrics at UCSF and public health at U.C. Berkeley, he is currently professor and chairman of Environmental Health Sciences at UCLA’s School of Public Health.

Prior to that he has been California’s State Health Officer and director of the CDC National Center for Environmental Health.

Over the past decade, much of Jackson’s focus has been on how the “built environment”—our homes, cities, streets, institutions—affect our health. He has served on the board of directors of the American Institute of Architects and has written and spoken extensively in this arena. He has both recent books and a new television series titled Designing Health Communities, which premieres on PBS in February and is available on DVD. Episodes in the four-part series include “Retrofitting Suburbia,” “Rebuilding Places of the Heart,” “Social Policy in Concrete,” and “Searching for Shangri-La.” Such titles might lead one to suspect Dr. Jackson is a man with his head in the clouds, but he remains a pragmatist who is able to retain lofty goals in terms of healthy futures.

SFM: You trained as a clinician; how did you evolve into a public health leader?

Dr. Jackson: For the first twenty-five years of my career, I was a traditional pediatrician. Then I spent a couple more 12 13

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decades in public health, mostly doing environmental health, especially air quality as it impacts health. And I became reluctantly convinced that we’re not going to deal with air and water pollutants as long as we keep paving over the landscape and driving everywhere, nor will we deal with climate change unless we figure out how to better build our homes and communities, and so forth. So I kept coming back to what we now call the “built environment,” and that led to my books and this new television series.

Why a television presentation of these complex issues?

I soon became aware that though I was constantly talking to clinicians, scientists, and other professionals, the general public was not hearing these messages—particularly the poorer people who are bearing the brunt of the chronic disease epidemic. We need to make this information accessible to “the 99 percent,” if you will. This led to the new public broadcasting series, with the companion book. And in that book I decided to become a bit more personal, to try to engage people.

For clinicians, some of the issues you deal with might seem too broad and complex, even abstract, to deal with in their work.

In my medical training, I was taught to confront the patient’s reality in a focused, direct way, without time to deal with broader issues affecting them. But we know that health is so much a result of how and where people live. Tobacco is the prime example—as every clinician learns, we can tell patients to stop smoking until we’re blue in the face but if we really want to do that, we make it more expensive, less appealing, restrict where smoking happens, and set up a constellation of factors that drive healthier behaviors. Intervening in that constellation is a very complex maneuver, I agree, but we can do it in worthwhile ways.

Can you give some examples of improvement in recent years?

Yes, and some are from San Francisco, in fact. The built environment is where we spend 99 percent of our time, and we can construct things to encourage physical activity and sowww.sfms.org

cialization, such as the band shell in Golden Gate Park, and its trails and walkways. Or we can isolate people and places, like the Hilton in the Tenderloin, or our schools that are built like fortresses, places that are only reached by cars and where only processed food is available. The Octavia flyway coming down and turning into something better is another improvement. For another example, think of the Embarcadero in the 1980s—walking there was loud, dark, dirty, and scary, and nobody wanted to go there. Thanks to public will, plus some help from the 1989 earthquake, we now have a wonderful place that is actually irresistible!

Back to clinical settings; what do you tell colleagues in your talks in this arena?

I learned much from Marty Gershman, MD, a leading pediatrician in San Francisco for many years; he once told me he was worried most about how stressed his patient families were over nonmedical issues like paying bills, not feeling safe to let their kids play and exercise outdoors, and such. My pediatric and internal medicine colleagues often tell me they are at their wit’s end about their many overweight, sedentary, prediabetic, depressed patients, and I tell them the system is rigged against doctors and those patients. The best treatment there is better diet and more exercise, but that requires more than just us telling patients to eat better and get out more, when they too often cannot easily do that.

Obviously, the average physician is not going to redesign the main streets in Fresno; but we can speak out with patients and parents and politicians and say we need more accessible healthy food, no junk food in schools, more parks, more farmer’s markets, bike routes in town, and on and on. And this is also where the CMA and medical societies play such an important role in advocating for these kinds of issues. I want to recognize here how well the SFMS and others are doing that.

Who else is better qualified to speak to the well-being of the people of our state?

Again, these are huge projects where changing things seems daunting . . .

True, we’re talking about reversing two or three generations’ worth of building decisions. It is a huge task, no denying that. There are growing pains as we learn to redo it right. But it is happening in more and more places; New York City has great new bikeways, Copenhagen has become much more livable in my lifetime. We have to start by looking at how we build and rebuild with a view toward health, and toward what is best for our children and their children, because this is about the future.

Really it’s reframing goals from what turns the most profit or is most economical in the short term, but towards a longer view, because when you build you’re really building for three or four generations or more, not the next decade or so. This is why the new National Academy of Sciences panel I cochaired on health impact assessment says you don’t do anything that doesn’t have some health impact, and we need to be conscious of that.

You write in your newest book that you have been attacked for some of your views. Why? There are people who have accused me of being a disloyal www.sfms.org

American for worrying about the society at large, about justice, but I argue that this is in the true American tradition, and that those who hold that we should just be concerned about ourselves are in fact the deviants!

You do seem optimistic, despite the odds. How do you retain a positive outlook?

Well, as I’ve said, there has been real progress in some areas. The other positive thing I want to say is this: If you look at these issues, it is too easy to become discouraged, between the lousy economy, the terrible built environment, the endocrine disrupters and other chemicals, and inequality and more. But what gives me optimism is my students. If you look at many young people now, they have no patience with reductionist, atomized approaches where every problem is isolated; they see we have to come up with systems approaches and solutions. And good solutions solve multiple problems. That’s what working on better built environments is about.

Dr. Jackson’s books

Making Healthy Places: Designing and Building for Health, Well-being and Sustainability. With Andrew Dannenberg and Howard Frumkin. Island Press, 2011. www. makinghealthyplaces.org.

Designing Healthy Communities. With Stacy Sinclair.

Jossey-Bass, 2011. www.josseybass.com/go/jackson.

Dr. Jackson’s PBS series

Designing Healthy Communities. www.designinghealthycommunities.org.

Recent presentation http://designinghealthycommunities.org/video/health/dr-jackson-speaks-annenberg-beachhouse.

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Design for Medicine

Evidence-Based Design Improving Outcomes through Design of the Built Environemnt Sara O. Marberry, EADC

When Ralph Nader’s book Unsafe at Any Speed: The Designed-in Dangers of the American Automobile came out in 1965, it was a wake-up call for the auto industry to spend money to create safer cars. As a result of Nader’s advocacy, motor vehicle and high-

way laws were passed in 1966. Since then, the automobile fatality rate has dropped from 5.49 percent to 1.13 percent in 2009. This in spite of the fact that Americans are driving almost three times more miles per year than in 1966.

The health care industry got a similar wake-up call in 1999 when the Institute of Medicine’s To Err Is Human: Building a Safer Health System was published. Soon, other organizations like the Institute for Healthcare Improvement and the Joint Commission took up the safety cause. And the Centers for Medicare and Medicaid Services (CMS) did its part, too.

Medicare and Medicaid reimbursements are now tied to safety measures.

But the health care industry is still largely clueless when it comes to connecting the design of the built environment to patient and staff safety. Just like the automobiles of the 1960s, many hospitals and clinic buildings are not designed with safety in mind. The design of automobiles is one of the major reasons fatality rates have gone down. The other reason is that laws were passed to change human behavior.

And while there are building codes and standards that address major safety concerns, such as fire and structural is-

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sues, they don’t necessarily regulate all the decisions that are made about the design of the physical environment in which care is delivered. Nor should they. But health care executives who are contemplating investing millions of dollars to replace old and outdated facilities, create additions, or renovate existing units need to look at anything and everything that will impact quality. They can’t just depend on their architect to tell them what to do; they need to be informed consumers and ask the right questions. One of these is, “How can we make best use of our available resources to design a facility that supports the quality of care we aim to deliver?”

Fortunately, a large body of evidence supports the concept that the built environment impacts patient stress, patient and staff safety, staff effectiveness, and quality of care.

Just as medicine has increasingly moved toward evidence-based medicine, where clinical choices are informed by research, health care building design is increasingly guided by rigorous research linking the built environment to patient and staff outcomes and is moving toward “evidencebased design”. www.sfms.org

The term was coined by Roger Ulrich, a professor of architecture at Chalmers University of Technology in Sweden, in an interview he did with The Lancet in 2000. Ulrich’s research in the 1980s on views to nature and their effect on patient outcomes set the stage for evidence-based design, or EBD. When the Center for Health Design, on whose board Ulrich sits, did a literature review in 1998 to determine just how many credible studies linked the built environment of health care to outcomes, it found only eighty.

Since then, the number of published studies that link the design of the built environment of health care with outcomes related to patient and staff safety and satisfaction has grown to more than 1,200. Design interventions that have been shown to improve safety and satisfaction, such as installing noise-mitigation materials, incorporating effective wayfinding systems, improving task lighting, and creating positive distractions through art and music, can be implemented in existing facilities at relatively low cost.

All of these contribute to reducing stress for both patients and staff, which can help improve patients’ sleep and reduce the need for pain medication, as well as reduce medication errors by staff. For example, exposure to daylight was linked to pain reduction in patients undergoing spinal surgeries who were admitted postoperatively to the sunny side of a surgical ward. This 2005 study by Walch and colleagues found that patients admitted to the sunny side reported less pain and stress, took 22 percent less pain medication, and their stay resulted in a 21 percent reduction in medical costs.

Other design interventions that have been shown to improve safety and satisfaction, such as private patient rooms, space for families, acuity-adaptable rooms, access to daylight and nature, and decentralized nursing stations, can also be implemented in new or renovated facilities at relatively low cost, especially when compared to the long-term return on investment for such features. For example, private patient rooms have been shown to reduce infections. With the average cost to treat a hospital-acquired infection around $43,000 per patient, this can result in significant savings. After implementing EBD features in its new facility (including private patient rooms and more visible hand-hygiene facilities, among other things), Dublin Methodist Hospital in Ohio reported an infection rate of about 0.5 per thousand patient days, which is lower than those documented by the National Nosocomial Infections Surveillance System.

The business case for EBD has been made using real-life research and examples gathered from the Center for Health Design’s Pebble Project research initiative and other data.

Told as the story of the Fable Hospital, the premium associated with EBD innovations is about 7.2 percent of the total construction cost. The payback for that investment is calculated to be three years, due to annual savings in reduction in patient falls, transfers, adverse drug events, infections, length of stay, nurse turnover and injuries, and water and energy demand.

As the awareness of EBD has grown and the field has expanded, there has been a need to define what it is and to qualify individuals’ knowledge. A few years ago, the Center for Health Design created the Evidence-Based Design Accreditation and Certification program (EDAC). To date, more than www.sfms.org

1,000 health care and design professionals—including some clinicians—are EDAC certified.

The EDAC program teaches that EBD is not a prescriptive solution but rather an eight-step process that should be followed by an interdisciplinary project team to achieve the best results. The steps are: • Define EBD goals and objectives.

• Find sources for relevant evidence.

• Critically interpret relevant evidence.

• Create and innovate EBD concepts.

• Develop a hypothesis.

• Collect baseline performance measures.

• Monitor implementation of design and construction.

• Measure postoccupancy performance results.

Among other things, EDAC certification assures health care organizations that they are getting value-added expertise and confirmation that the design professionals they are dealing with are knowledgeable and qualified. It also establishes a base of knowledge between the design professional and the health care organization’s project team. Finally, EDAC certification provides professional development through learning and education.

As the health care industry moves toward more accountability and incorporating patient perspectives into the design of health care delivery, the design of the built environment becomes more important than ever. It is just not possible to deliver the best-quality care if the settings in which that care is delivered only partially support the care process. The knowledge and research data exists today to design health care facilities that can help improve quality. Those who do not make the design of the built environment a core tenet of their quality initiatives will be missing out on a critical improvement tool.

Sara O. Marberry is a blogger, tweeter, author, and the executive vice president of the Center for Health Design in Concord, California, whose mission is to transform health care environments for a healthier, safer world through design research, education, and advocacy.

Selected Reading Hastings Center Report. Fable Hospital 2.0: The Business Case for Building Better Health Care Facilities. January/February 2011. http://www.thehastingscenter.org.

Hastings Center Report. Case study: Dublin Methodist Hospital. January/February 2011. http://www.thehastingscenter. org.

The Center for Health Design, EDAC Study Guides, volumes 1–3. 2010. http://www.healthdesign.org/edac/resources.

The Center for Health Design and Georgia Institute of Technology. A review of the research literature on evidencebased design (white paper). 2008. http://www.healthdesign. org/chd/research.

The Center for Health Design and Georgia Institute of Technology. The business case for building better hospitals through evidence-based design (white paper). 2008. http:// www.healthdesign.org/chd/research.

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Design for Medicine

Medicine and Architecture Parallel Disciplines Sharon Woodworth the July issue, but most people don’t realize that Laguna Honda is far more than a nursing home. It was designed to not only raise the standard of care (regardless of each patient’s age or disability) but to transform the lives of all who receive care from this valued institution. Here’s a look at how this architectural goal was achieved—and how you, as a physician, might relate to it.

Bringing Order to the Chaos

A physician doesn’t get hung up on details when a patient with multiple system failure enters the ER; if the patient isn’t breathing, that’s one of the first things treated. This firstthings-first thinking is exactly what was needed at Laguna Honda. While the site covered more than 60 acres, much of it was too steep to build on. More important, all of the existing facilities had to remain in operation until the new construction was complete. With little room to build on, we had to make a critical first step: Reclaim the valley. Two narrow hilltops on either side of a neglected valley offered enough footprint for three residential towers; while separate, all three could then be connected via a link across the valley. This triage set the stage for creating physical links across the entire campus, including the historic structures that were to remain; using modern glass between time-honored stucco further reinforced the idea of connecting past to present. And the restored valley’s new entry at the Louise Renne Pavilion, which houses all rehabilitation services, is a symbolic link to the community at large, inviting all who enter to reclaim their highest level of wellness.

The World Is Watching

As a physician, what would you do if asked to oversee the design of a hospital? Where would you begin, and how would you proceed? You spend

the majority of your day in a health care facility, but you may have never thought about directing how that space is configured. Interestingly, the thought process you use to guide patients toward health parallels the architect’s thinking when laying out plans for a hospital or clinic.

As an architect who specializes in health care facility design, I’ve seen time and again how diagnostic thinking is similar to the design process. Much of this observation comes from projects I’ve experienced in the Bay Area, from Kaiser’s Santa Clara Medical Center to UCSF’s three new hospitals at Mission Bay. I believe that to best illustrate the parallel thought processes between medicine and architecture requires looking at a facility that offers the full spectrum of issues, from initial critical decisions to final inspiration. One facility makes a distinctive case study: Laguna Honda Hospital. This long-term care facility was highlighted in

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If our prototype ER patient had garnered as much attention as Arizona Rep. Gabby Giffords, the victim of an assassination attempt, the physician in charge might have felt the pressure of great responsibility. Imagine the pressure of designing 1,200 beds when half of all hospitals in the U.S. have fewer than 100. And we weren’t going to get a second chance; our decisions would have to last for perhaps another 150 years. As the architects, we did what a physician would do: We benchmarked best practice and evidence-based criteria to guide us and our client. Together, we spent more than 18 months touring benchmark facilities across the U.S., followed by building a host of mock-ups, all of which were done long before the new building was under construction.

You Are Not Alone

Again, just as a patient who enters the ER often receives care from a host of specialists, so too with an intensive architectural project. Health care architects in particular are choreographers of many disciplines, from engineers and cost consulwww.sfms.org

tants to food service specialists and artists. The architectural team for Laguna Honda included five architecture firms and more than 47 consultants during the ten years from design through construction. And the full design team included clinicians. The Laguna Honda medical director and chief nursing officer directly influenced the final building because, in the end, buildings do not take care of people—people take care of people. The decade-long effort to construct Laguna Honda is a testament to a diligent user process and the clinical oversight required in any hospital construction project. And while the new building opened in late 2010, the architects for Laguna Honda will continue to honor their client’s needs—not unlike the patient who returns for a follow-up—fine-tuning the new building and renovating the old for many years to come.

Starting with the End Goal

Just as physicians are being asked to achieve “positive” outcomes, so too are architects. Our benchmarks told us that few facilities built semiprivate rooms because of the safety and health benefits of single rooms with private bathrooms, but the Laguna site would not accommodate 1,200 individual patient rooms; especially taxing would be the cost of constructing the associated plumbing. The program called for four-bed rooms (four patients sharing a restroom with cubicle curtains between beds) and few if any private rooms. But we knew patients fared better when afforded as much privacy as possible. So we created a new room type. These dorm-like suites of two or three bedrooms sharing a bathroom increased the level of privacy from less than 5 percent up to 60 percent, with little increase in the construction cost for plumbing and far less long-term operational cost compared to cleaning 1,200 bathrooms. The standards achieved at Laguna are unprecedented, in part because we sought a positive outcome for short-term and long-term goals. www.sfms.org

“Health Care” Costs It is expected that higher standards have higher costs. In a society with great health care advances but limited resources, physicians are often faced with considering the cost of an intervention. The expenditure might be money, time, or outcome; in any case, cost is one of many decisions that must be weighed in order to provide the highest level of care within available means. For an architect, health care construction, more than any other building type, strains the weight of one decision against another. To put this in perspective, the average American spends all but one hour of each day inside buildings, and those buildings are the single most expensive things he or the company he works for will ever purchase. All of this is also true for a hospital. But the cost of a health care construction project is only 10 percent of the cost of operating a health care facility over the life of that building, because—unlike our home or office—we expect a hospital to remain functional for decades.

For Laguna Honda, building private bedroom suites with shared bathrooms conserved construction as well as operating costs, but, more importantly, it achieved the standard expected of a twenty-first-century hospital.

Really, It’s All Just a Guess

In our information-overloaded, new-technology-a-day world, how do you get started? Whereas a physician can see twenty patients in a day, an architect may only build sixty buildings in an entire career. But just as the feedback loop in architecture is slow, so too must the physician depend on the only information available at the time—the patient’s initial complaint. And this guess made on limited information is often just the means for beginning an architectural project: the client’s definition of a problem. But there was no single prob-

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Architecture and Medicine Continued from the previous page . . . lem for Laguna Honda. The old facility was in critical condition, with failing structures that housed up to thirty people in open wards and an operational model of care that, while of the highest quality, was not geared for today’s health care standards.

So the architects made a guess: Upgrade the operational culture along with the building. The new model of care is based on self-contained “households” for fifteen residents, with the option to open up to neighboring households. This gives nursing staff the potential to oversee up to sixty residents on every floor, but with a hierarchy of scale that deinstitutionalizes sixty residents living in one place. While this may not look like putting pen to paper, each line drawn for a new hospital considers how the structure will be built as well as how the building will operate long after the architect is gone.

The Body Is Formed from the Inside Out

So where does all this end up? Just as the biologist’s view of the body is formed from the inside out, ending at the membrane of the skin, so too is the planning of a health care facility. And at Laguna Honda that meant starting with those 1,200 beds. But our mantra was that Laguna would not be about 1,200 beds but about 1,200 places for people to live, so each room is a place in a broader community—a broader body, if you will. Few people realize that in California, the “DNA” of a long-term care facility must be constructed to the same institutional standards as a hospital, and, while no ER was programmed, Laguna essentially has everything a community hospital has, from a small surgical suite and imaging to a full pharmacy and cafeteria, as well as outpatient clinics. With such a large body, it made sense to create a place for the gymnasiums, swimming pools, and exercise courts of the rehabilitation department to act as the new center of gravity in the valley; from this main trunk, residents in any hillside tower are literally within arm’s reach of rejuvenating care.

Mind-Body Connection

Traditional Western medical practice has offered care that addresses the mind and body separately; we now know there are benefits to treating a patient’s mental and physical state together—and that art can connect these two. The field of research called psychoneuroimmunology studies the mind-body connection, and investigations of art in health care settings conclude that thinking well equals feeling well. Successful arts programs promote what is referred to as a “trigger effect” that helps connect mind and body. Basically, art links the power of science and the power of feeling to help center people. With this in mind, over four million dollars’ worth of art was commissioned solely for Laguna Honda Hospital—and none of it was arbitrary. Each piece, from garden sculptures to installed tile and glass mosaics, was placed to guide residents from their bedrooms to the broader community of the campus, reinforcing both physically and mentally a sense of place within the larger community.

If Nothing Else, Shine the Light

Sometimes physicians are faced with few options to heal their patients, and all creativity, research, and insight are of no avail. In this case, as in all cases, the profession of medicine has 18 19

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depended on one guiding principle: First, do no harm. It is my belief that the basis of all good design is the human being’s natural craving for sunlight, and as a health care architect, I believe this paramount need is parallel to medicine’s “do no harm” axiom.

My personal inspiration for Laguna Honda was an achievement you don’t see but can perceive: Natural light on both sides of the building, from sunrise to sunset, from every resident space on the hillside to every public space in the valley.

Our goal was to set the standard and transform the lives of all who receive care at Laguna Honda Hospital. The size and diversity of this institution was used to create not an inhumane warehouse but a campus of smaller neighborhoods and a sense of place, all infused with natural light. During this effort, it may be the process of developing a relationship or “bedside manner” that was key. In the back-and-forth between each guess and follow-up question, every conversation became a joint decision with long-term impacts. The practice of medicine and architecture both require trust, and the trust developed between architect and client needs to withstand the long haul through the ups and downs of construction. It can be and often is a long and rewarding journey.

As an associate principal at Anshen+Allen, the largest international firm dedicated solely to health care, education, and research, Sharon Woodworth has contributed to projects worldwide from the United Kingdom to the Philippines. With more than eleven million square feet of health care facility planning and design experience, she has a wide range of knowledge concerning hospital operations and continuum-of-care issues in areas from pediatrics to senior living. Woodworth has a bachelor’s degree in nursing and a master’s in architecture, and she is a published writer and speaker in both fields. Her aptitude for artistic quality and her skill in writing, combined with the rigor of science, allows her to successfully achieve designs that not only meet her clients’ goals but also allow her to “tell the story” so that others may gain from this success. Her latest article was published in Urban Land Institute on the topic of translational medicine design.

www.sfms.org

Design for Medicine

d.Medicine at Stanford How Design Thinking Helps Medicine Maryanna Rogers Stanford design students are getting their hands into science. Seven years since its official opening in 2005, Stanford’s Hasso Plattner Institute of Design, informally named "the d.school," hosts courses for students across Stanford’s seven schools. Ap-

proximately 700 students took classes at the d.school last year, including product designers, engineers, computer scientists, and education and business students.

In recent years, the school is increasingly reaching out to students in the sciences with topic-oriented courses. For instance, Transformative Design, led by a teaching team including mechanical engineering professor Bernie Roth, is focused on behavior change to improve well-being and health. Last year Perry Klebahn, a consulting associate professor at the d.school, and Dennis Boyle of IDEO initiated a new class called d.health, in which students designed behavior-change interventions for adults at risk for chronic illnesses such as diabetes, hypertension, and high cholesterol.

A current d.school fellow, David Janka, MD, spent part of his time while in medical school taking classes at the d.school, bringing his medical expertise to projects in several courses. His project in Entrepreneurial Design for Extreme Affordability, a course that seeks to bring innovation to developing economies, was health-focused. Janka’s team of four partnered with a hospital in Bangladesh to design a solution for the treatment of severe pneumonia in pediatric patients. The team, which also included a Product Design student, an MD/MBA student, and an MBA student, designed a nasal interface to deliver pressurized oxygen to children in respiratory distress. Their design adapted the hospital’s makeshift bubble CPAP (continuous positive airway pressure) device to provide more effective respiratory support, and his team received funding to carry the project forward after the class ended.

Janka’s first taste of the d.school was in the introductory class, Design Thinking Bootcamp. After a quarter at the d.school, working on interdisciplinary teams with graduate students from the entire campus, Janka was hooked. He finished his last year of clinical rotations and pursued coursework at the d.school fulltime to explore how design thinking might inform his work in medicine. He said his time as a student in the d.school gave him a new perspective on impact. "For me," he explains, "impact had always been through the research you were doing in a lab, or the clinical trial you were on, or directly with patients in a hospital.

Before the d.school I had a very shortsighted, simple view of the impact opportunities possible through business, entrepreneurship, and innovation.” In June he graduated from medical school and accepted a position as a d.school fellow for the next year.

Janka is not alone. www.sfms.org

A number of students in the sciences are coming out of the lab to explore design thinking in interdisciplinary teams at the d.school. A new course this year, d.science: Design for Science, aims to accommodate this growing interest.

Taught by a teaching team in which I join Noah Zimmerman, a biomedical informatics researcher and data scientist, and Mike Migurski, a data visualization designer at Stamen Design, the class fosters collaborations between science and design students who work on problems related to data collection and communication of scientific research.

Zimmerman recently graduated from a doctoral program in biomedical informatics at Stanford, where he created statistical learning methods that he applied to a blood-based food allergy diagnostic. Early in his graduate studies, he recognized the need for a designer’s approach in his field. According to Zimmerman, many of the problems in medical informatics were originally technological, but recent advancements reveal that current challenges lie in human interaction. Many programmers are unaware of the day-to-day realities of medical professionals.

“A lot of that [medical informatics] has progressed, but what hasn't progressed is the human interaction part," he explains. "Most of these systems were made by computer programmers sitting in an office somewhere, who have never been in an emergency room, or who have never followed a doctor in a clinic who's trying to see twenty-five patients in an hour or something crazy like that. So the part that’s been absent from the medical informatics literature, and, in my opinion, the thing causing these large-scale projects to fail, is a lack of empathy and deep understanding of not just what the system needs to do functionally but how people are going to interact with it.”

Zimmerman recalls his first design thinking project, which involved watching people throw away trash for two hours. “It seemed ridiculous at first,” he says, but by the end of the project he realized the value of the method for revealing unforeseen insights.

Beyond the development of innovative products and services, experience in design thinking may inform fundamental practices of medical students and professionals as well as scientists in other fields. Three tools or mindsets of design thinking stand out as particularly relevant to the sciences: building empathy, embracing failure, and communicating across disciplines.

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d.Medicine Continued from the previous page . . .

Building Empathy

Design thinking begins with building emotional connections. The d.school calls this the “empathy” phase. Designers observe and interview individuals in order to understand their needs and develop insights grounded in individual experience.

In addition to the problems that Zimmerman observed in biomedical informatics, where programmers rarely—if ever— venture into medical settings where their tools are engaged, experience building empathy could impact medical practice and scientific research more broadly.

As Janka explains, experience with empathy building could improve medical students’ skills related to practitionerpatient rapport. “I think there are many opportunities for design thinking to be brought into medical education," he says.

"For example, when you're training doctors, you're basically mashing together all of this science and knowledge—book learning—with learning about real people with real lives.

You're wrestling with, ‘How do I translate all of this stuff that I know into real behavior?’ Because it doesn't matter if you only know how the body works or what treatment a person needs to get better. If you don’t understand someone as a complete person, or if someone is incapable or unwilling to participate in his or her care, what's the point? There is an opportunity to use design thinking mindsets to help medical students learn how to communicate with their patients better—understand their patients better.”

Practicing empathy skills within the context of design projects would also provide a safe space to learn.

In scientific research, empathy building could also offer alternative routes to developing new ideas and research agendas. Scientists typically read peer-reviewed articles and trust previous research to guide their study designs. According to Zimmerman, building on previous research in such a way produces mostly incremental advances in the field. In order to generate an innovative leap, alternative strategies may prove useful.

Embracing Failure

At the d.school, students are taught to adopt designer mindsets. For instance, the willingness—and even an eagerness—to fail is essential. Design teams prototype solutions as soon as possible so that they can identify false assumptions early and make better decisions with each iteration. In fact, a good prototype is one that fails, because it offers more opportunities for learning. Designers try to fail.

The medical profession, on the other hand, is built on success and perfection. This makes sense. After all, who would want a doctor who intentionally fails? Human beings, in general, are naturally afraid of failure, and this instinct is heightened when failure means compromising a patients’ health.

If failure is the best way to innovate and the best way to learn, how can we bring failure as a practice to medicine without harm? As David Janka puts it, “There's an opportunity to find spaces in medicine where failure could be encouraged as a safe learning opportunity.” There is room for medical school curricula to explore such opportunities.

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Scientific research, in general, is also geared toward avoiding failure—or at least hiding it. Articles in peer-reviewed journals contribute to the impression that the scientific process is a clean, logical progression of studies and theory building. In reality, the process is messy and full of failures. There is also room for the research community to openly embrace the idea that failure leads to success.

Communicating across Disciplines

According to the design thinking approach, the best design teams are interdisciplinary and nonhierarchical. Close collaboration with individuals from different disciplines inevitably requires a steep learning curve in order to develop effective ways of communicating. This is a challenge that can be uncomfortable and frustrating for those used to the ease of communicating with other professionals in their field, but it is also an extremely valuable learning experience.

An idea often echoing through the d.school is that innovation happens at the intersection of disciplines. However, communication barriers between individuals from different fields can overwhelm and discourage interdisciplinary projects.

Janka observed this phenomenon in medicine and attributed it partially to the hierarchies built into the medical field. “The medical profession is also very hierarchical, and I think sometimes to the detriment of progress. Principles of design thinking and interdisciplinary teams try to level the playing field for a more functional innovation atmosphere, which could be very useful for medicine and research.”

For medical students and emerging professionals, joining interdisciplinary teams offers a rare and valuable opportunity to engage with others as collaborators.

Like Janka and Zimmerman, many d.school students leave with a new perspective on their work. The d.school offers opportunities for students to collaborate in a high-energy, fastpaced environment. It is about adopting a beginner’s mindset, engaging in playful exploration and visualization, and building prototypes. This approach is very different from the typical learning environments of university students, and it is another world from the culture of most science research labs. It is not uncommon for students to come away from classes at the d.school excited to continue using the design thinking process in their own fields.

Students are drawn to design thinking, and design thinking is built to support innovation. Whether as a result of deliberate efforts or student-by-student movement, higher education in the sciences as well as the culture of research labs and medical practice may begin to experience a shift toward empathy building, embracing failure, and communicating across disciplines.

Maryanna Rogers has been involved with the d.school since its inception, first as a student and now as a workshop facilitator and member of the teaching network. With a background in the arts and social sciences, Rogers is currently completing her dissertation at the Stanford School of Education. Her research interests include motivation, creative collaboration, and community building.

www.sfms.org

Design for Medicine

Creating Global Solutions How Good Design Can Save the World Chris Stivers and Kevin Chi When approached to write about our experiences in using design thinking to devise health care solutions, we were not exactly sure how to begin. Then

we thought, “Hey, why not treat this like a design exercise?” So in that sense, this article is a third-version prototype (and hopefully this analogy will make more sense after reading). It’s about how design thinking can be applied to medicine to create innovation.

It’s also about global health and creating products and services for the world’s poorest. But mostly it’s a short story about our experience at the intersection of medicine, design, and social enterprise.

In the Beginning

Who’s writing this thing, anyway? We are Chris Stivers and Kevin Chi, and, along with a third team member, Paul Csonka, we have spent the better part of the past year designing affordable solutions for accurate IV medication delivery in low-resourced settings. Our modest beginnings hail back to the winter of 2011 in a course at Stanford University called Entrepreneurial Design for Extreme Affordability, in which interdisciplinary teams of Stanford students are paired up with organizations that work in developing countries. Our team, which originally included MBA students Matt Tilleard and Seth Norman, partnered with the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), which presented us with our mission: The Infusion Pump Project—Design a low-cost device that can operate without a continuous source of external electricity that will provide constant delivery of fluids/medication for patients in resource-poor settings.

Where does one begin when asked to design a new medical device? Ah, well, that’s where design thinking steps in.

Design Thinking: Creating Global Solutions from Your Own Backyard

What is design thinking? We see it as a way to identify and analyze real problems to create solutions that actually matter to people. It all begins with a need—identifying an as-yet unsolved problem and asking, “What is needed to address this problem?”

It’s worth pointing out that anyone and everyone is capable of participating in the design thinking process. Innovative design is about creating real solutions for real people. The most advanced robot may be an incredible scientific feat, but it means little if few people can understand how to operate it. Design thinking is not rocket science. Human empathy and the understanding of others are sometimes the most valuable assets that anyone can offer. The first key to good design is assembling an interdisciplinary team—in our case, engineering, business, and medicine. With input from several different disciplines, our pool www.sfms.org

of knowledge and creativity expands; all backgrounds work in parallel to achieve a result that satisfies everyone. Great; interdisciplinary team in place. Now what?

Ultra-Secret Design Tip for Damn-Good Design: Know Your User

Call it “user-centered design” or “gaining empathy” or whathave-you, but the bottom line is that it is imperative to really, truly, 110 percent understand everything about the people for whom you are designing. And it turns out that this Ultra Secret Design Tip is especially important when your users are half a world away, follow different cultural norms, speak a different language, and may not even know what they really need. For us, getting to understand the people of Southeast Asia, and Bangladesh specifically, presents a serious challenge when said people are literally on the other side of the world. And in health care, there is never only one “user.” In our story, the various characters include: patient, nurse, doctor, hospital, procurement department, biomedical engineers/technicians, distributors, manufacturers, etc. That’s a lot of people to get to know.

We were fortunate in many ways to go through this process as part of a class, as it provided the opportunity for us to travel to Bangladesh—not necessarily an easy task to coordinate on one’s own. Without this on-the-ground experience, our project would have been doomed for failure from the start; traveling was a must-have. But we didn’t just hop on a plane right away. To make our week in-country truly worthwhile, we spent weeks educating ourselves about our topic, our users, and existing solutions.

We tossed around loads of preliminary ideas in preparation for our journey. We even met up with a handful of Bengali students to learn about cultural differences and what to expect in Bangladesh. When we landed in the capital of Dhaka, we hit the ground

Continued on the following page . . .

January/February 2012 San Francisco Medicine

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Creating Global Solutions Continued from the previous page . . .

on plane tickets to Bangladesh. Based on feedback from testing, we refine our prototype, then go out and test again. Build, test, refine—iteration is the word of the day. And not everyone must be involved with every step of the process, which is why interdisciplinary teams are so essential. While everybody is involved with initial-solution generation, each team member can further contribute based on the strengths of his or her respective skill set. The engineer may begin to create a more refined second-generation prototype while the medical student explores clinical indications and the business student defines the market prospects. Or it may happen that everyone plays a role in each of the challenges, not limited by supposed roles. The unit is the team, and how each team works is unique. As long as the team dynamic is strong and decisions are made judiciously (which is occasionally a point of contention), the project will develop and move forward.

Challenges in Global Health: Designing for the Developing World

running, making the most of the short week we had to try and capture as much information and speak with as many people as possible, extracting key insights and takeaways from each day’s fieldwork. Brainstorming potentially interesting avenues to pursue after returning home. Re-prepping for each day’s itinerary based on what we had learned so far. And then, back to the Farm, with our notebooks, cameras, and heads crammed full of learning and insights, ready to get started saving the world.

Enter the early prototyping stage.

While it is exciting and incredibly awarding to design a medical product, the process is certainly not easy. Regulatory approval, reimbursement consideration, intellectual property rights, and a shaky investment community are just some of the concerns that a medical device entrepreneur must weigh to even hope for a chance at success. Many of these concerns, and others, can become even more challenging in the global health arena, where you are often designing for a country and a culture that is not your own. As we comb our way through this jungle, we learn

Early-Stage Prototyping: AKA, Kindergarten for Adults

Time for our ideas to take shape. This stage of design is essentially organized chaos. Anything goes, from the logical solution of a stripped-down, super-basic infusion pump to the outrageous idea of bike-powered IV pumping. Reason is almost forbidden at this point; just let the ideas flow, no holds barred, aiming for quantity rather than quality. You never know how one crazy idea can inspire the creation of a unique or innovative final solution. Chances are that the obvious solutions have already been produced. Further innovation lies in this creative thinking—finding the hidden solutions among the absurd, simple, borrowed, or archaic. Our preferred tools for capturing ideas are a large blank whiteboard, some dry-erase markers, and a few pads of colored post-it notes. Then, with popsicle sticks, pipe cleaners, and rolls upon rolls of masking tape (blue painter’s tape is ideal since it leaves no sticky residue), we create quickand-dirty models to give form to these ideas. It is arts-and-crafts with some (not much) finesse, driven by the deeper motivation and hope that these MacGuyver-like prototypes will evolve to one day save a life.

From here on out, the product needs to be tested; ideally with the target user group, but not necessarily. Some creative thinking could help you locate a “proxy” group in your local area, such as the maintenance engineers at your local hospital; this could eliminate the need to drop several thousand dollars 22 23

San Francisco Medicine January/February 2012

www.sfms.org

a great deal about many of these questions, while raising even more new questions each week.

But design thinking should always be a part of the process; in fact, at the time of writing this article, we are traveling through Bangladesh and India to gain a more thorough understanding of the needs for and problems with accurate IV medication delivery in low-resource settings. See? Even ten months in, we’re still d-thinking our way through the tough problems. Now, back to saving the world. . . .

User feedback for our prototype story, the essential metric for improving any evolving design, is greatly appreciated and can be sent to Chris at chris@caregivermedical.com.

Kevin Chi graduated from Harvard University with a BA degree in molecular and cellular biology. He is currently a medical student at Stanford University, pursuing a scholarly concentration (the medical equivalent to a major) in bioengineering with a focus in design and global health. While he is new to the field of design innovation, Chi strongly believes that there is a need to bridge physicians who see medical needs on a daily basis with the engineers who have the training and knowledge to create solutions.

Chris Stivers studied mechanical engineering as an undergraduate at Northeastern University. As a type I diabetic, he became interested in the medical device field at an early age. While in graduate school, he served as manager of the Biodesign Collaboratory, a medical device prototyping studio where he designed, organized, and led workshops to teach prototyping and design skills. Stivers graduated with his master’s in mechanical engineering from Stanford University in 2011 and has since been working full-time as founder of Caregiver Medical to develop his team’s affordable infusion device.

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Design for Medicine

Cadaver 2.0 Testing a Virtual Dissection Table for Teaching Anatomy Tracie White So how does this work, exactly? The dissectionist’s usual scalpels, forceps, and probes won’t do the job here. Instead, students peel away layers of imaged

flesh and bone by tapping and swiping the touch-screen tabletop. “You make the diagnosis,” says the anatomy instructor, looking up expectantly at his students. The handful of undergraduates gather around the newest anatomy teaching aid, a life-sized, iPad-like dissection table with an image of a young woman’s injured shoulder.

Peering intently at the screen, the students can’t resist touching it. With a swipe of the forefinger, they zoom in on the image. Then zoom out. One touch, and the virtual shoulder rotates. Another touch, and the muscles disappear, leaving just the bones. One more touch and the bones dissolve, leaving the circulatory system behind.

“I’ve never seen anything like it,” says Meghan Bowler, 21, a junior bioengineering student from Boston.

Only an hour or so earlier in a nearby classroom, instructor Sakti Srivastava, MD, associate professor of surgery and division chief of clinical anatomy, had presented a lecture on the anatomy of the upper limb using visual aids (illustrations and diagrams) and then led the group to the lab for hands-on education using cadavers, some 3-D dissection photos, and the new technology—essentially a virtual dissection table.

With the table, Silicon Valley engineers have now joined a long list of doctors, artists, photographers, and other technology innovators seeking the best way to explore and learn about the anatomy of the human body.

The new virtual dissection table takes advantage of twentieth-century technological advancements in imaging, such as X-rays, ultrasound, and MRIs, and combines them for use in a seven-by-two-and-a-half-foot screen.

At Stanford, the table is being tested as a way to further enhance that age-old teaching method, the dissection of human cadavers.

“The virtual isn’t the same as the real,” says David Gaba, MD, associate dean for immersive and simulation-based learning. “What we want to do is leverage the best of both. It’s not really, ‘Is one better than the other?’ Rather, it’s, ‘What can we do with the two combined?’”

Its creators refer to it as something of a reusable cadaver, with the added benefit of allowing users to easily explore hardto-reach parts of the human body.

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San Francisco Medicine January/February 2012

The table, which made its debut on campus in April, is a loan from Anatomage, a San Jose-based medical technology firm, to the anatomy division at the medical school. Faculty are experimenting with its use as a possible teaching aid for everyone from undergraduate anatomy students to medical students, residents, and even patients.

“We want to see what the educational value of this resource, this tool, might be,” Srivastava says. “Does it complement the cadaveric work of our students?”

The $60,000 device is part of a new wave of technology that makes possible interactive displays of the body using real-life images. The touch screen—created by placing two LCD screens together horizontally—allows users to investigate a realistic visualization of 3-D human anatomy and to delve inside the human body. CT scan images are augmented with 3-D modeling and annotation explaining what the viewers are viewing. (One body-sized LCD screen would have to be custom-made and is thus prohibitively expensive.)

The images morph from soft tissue to hard tissue. The tissue can be sliced much like actual tissue on cadavers in the dissection lab next door, but no knife is needed—just a single slide of a finger will do. Then, with the press of a button, the entire body is restored instantly.

“The idea is you can build the body part by part,” says Paul Brown, DDS, consulting associate professor of anatomy.

The concept for the table sprang to life about a year ago during an informal conversation between Brown and Jack Choi, PhD, the CEO of Anatomage. Choi happened to be visiting Stanford to provide a tutorial on software in use by the medical school. Brown mentioned that he’d been researching and working on the idea of bringing such a table to Stanford for teaching purposes but had failed to find a way to have one made that would be affordable.

For about two years, Brown had scoured the globe for hardware and software vendors to build a table like this. His search led him from the University of Illinois, where engineers were working on a prototype of a life-sized digital video screen, to Sweden, where a company has built a virtual autopsy table.

But neither was quite right for the classroom use he envisioned.

After listening to Brown’s idea, Choi said, “Oh, I can build one of those,” Brown recalls. So Choi put several engineers to work on developing the table.

“Finally, it’s ready for prime time,” Brown says. The Anatomage table is designed to be used for teaching anatomy at various levels of complexity.

“Each image brought up will have a reason for being there.

It’s not meant to be just pretty but to be extremely useful as a teaching tool,” says Brown. “There are so many different normal www.sfms.org

variations in human anatomy, and then there are all the different pathologies.”

Four faculty in radiology and anatomy are building a searchable library of digital anatomical images based on CT scans, MRIs, and ultrasounds of the human body that could be used with the table as well as with other educational technologies. The Stanford researchers know of no resource comparable to what they’re shooting for.

With access to such a library, a virtual dissection table could include many anatomical variations and pathologies, from tumors to fractures to cystic fibrosis. Anatomy professors at Stanford and other schools could use the image library to develop a wide variety of lesson plans.

Srivastava and the three others who are working on the imaging library— called the Searchable Digital Anatomical Library—hope to have it licensed through Stanford’s Office of Technology Licensing. Their goal is to make it available to other educational institutions, nonprofits, and companies such as Anatomage. Any financial proceeds from the library would be divided among Stanford, the faculty, and their departments, as is typical for technology transfers by universities.

The first students to work with the table were in the new undergraduate bioengineering anatomy course taught

by Srivastava. The day’s instruction began with a traditional lecture focused on the anatomy of the shoulder and the arm: the veins, arteries, nerves, bones, muscles. Then students walked over to the lab.

In one room was the traditional dissection lab. It was filled with rows of the medical students’ cadavers, each covered by a blue tarp. Two were uncovered: human arms were on display. With gloved hands, teaching assistants picked up and pointed out the ulnar artery, the brachioradialis muscle—each anatomical piece described and illustrated previously in the lecture hall.

“What artery is this?” asks a teaching assistant, separating one vessel from the other.

“The ulnar,” the group says.

“And this?”

“The radial.”

When they were finished, the students moved to the room next door to www.sfms.org

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tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m view 3-D images of the shoulder and chest from the world-renowned Bassett photographic collection of human dissection. And then on to a third lab room, where the virtual dissection table was open for the class.

At the virtual dissection table, Srivastava asks the students for a diagnosis of the shoulder problem.

“The humerus is out of the socket,” bioengineering student Meghan Bowler answers.

“Right, it’s a complete dislocation,” Srivastava says. “Now, rotate the image a little bit. You can see there are smaller, fractured sections. You can predict the direction of the force that caused the dislocation. This is a rare variety. The patient comes in like this,” he says, holding his arm straight up in the air.

Then, he reiterates the anatomy that he described in the lecture hall: “This is the brachial artery. It divides into two.”

On to the elbow. “I want you to see this little piece of bone, the medial epicondyle.

See that groove there? The ulnar nerve—that’s the funny bone—that’s where that sits.

See the ulnar artery?”

Later, Srivastava says his experiences theMag table are encouraging. “The virtual San Franwith Med dissecting table affords new ways to see and interact with the same anatomy, as well as 01-29-09 providing access to a collection of normal variations and abnormal pathologies,” he says.

But it will take some time to determine how widely it will be used on campus, if at all.

After working with the table for a few weeks in anatomy lab, Bowler is still impressed. “As a modeling tool and a tool for teaching diagnosis, I think the table holds great potential. It possesses the unique ability to allow us to look at the same body at different layers, with different features present and missing,” Bowler says. “But I have personally found the cadavers most helpful in lab, because they allow me to inspect the muscles and bones of a real specimen—nothing is approximated.”

For her at least, the cadaver is still the best learning tool because, well, it’s the real thing.

Republished with permission from the Stanford School of Medicine’s Office of Communication & Public Affairs.

January/February 2012 San Francisco Medicine

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Design for Medicine

Design for Healing The Role of Art and Design in the Health Care Experience Annette Ridenour want a care plan or a wellness plan that recognizes the uniqueness of who they are and what is important to them, not just a plan for reduction of symptoms.

I understand that this is a big job for any health care institution, trying to be cost-effective given today’s reimbursement rates.

Yet there are sites that recognize this and systematically address each of these wants. Destination hospitals are being designed around the world to compete for this business. Baby boomers want nothing less. Health care consumers who can vote with our feet for where we get our services demand a higher level of positive patient experience and organizational accountability than has ever been requested before.

The following is my list of five key actions that any health care group or institution can implement to start creating patientcentered experiences and begin to address their patients’ wants.

Perform an experience assessment to be in touch with how your patients feel about your practice. The

After owning a health care design firm since 1980 and working on hundreds of projects around the country, I have come to the conclusion that my work is about “experience design.” As interior designers, interior

architects, graphic designers, and artists who assist in creating plans and in implementing projects in health care, we must ask ourselves: What aspirations do we have for a space, what do patients want in their experience, and what limitations must we face? How does the physical environment, including the visual, participative, and performing arts, affect the experience of healing?

Physical space designers help create the health care experience in a way beyond what most physicians would guess. In my research over the years, I’ve found through patient surveys that the conceptions of patient medical experiences are formed before any medical treatment occurs; that within the first few minutes of arriving, parking, entering the doors and being greeted, interacting with the environment, and getting information, the experience has been colored in their minds.

What experiences do people want? Having listened to a great many focus groups, I believe that they want the experience of getting to and through the space to be simple, clear, and understandable; they want their abilities and comprehension to be accommodated with respect and dignity; they want to feel warm, safe, and comfortable; they want to understand what is going on with them.

They want choice and control of their treatment and their environment; they want care, compassion, and encouragement; they

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assessment is a systematic review of the entire patient experience, from getting information from the telephone scheduler to being discharged or leaving the clinic and arriving home again. Seeing patients’ reactions to all aspects of the physical environment, communication, and medical experience allows an institution to create a gap analysis between their goals and the reality. Find out if your patient’s experience correlates to your organization’s brand promise. The assessment can create a baseline from which to measure all future change and improvement.

Review your current mission, vision, and values. Do they reflect your current aspirations for customer experiences?

Evaluate whether they are transparent throughout all processes and for all people in your organization. Evaluate whether a visit to your health care institution informs your customers about the uniqueness of who you are and what you are providing to them.

Bring evidence-based design consciousness to your organization. Over the past decade, more than 1,600 peer re-

view studies have demonstrated how design of the physical environment can improve health outcomes. The Center for Health Design has published a meta-analysis of research studies for health care organizations to review and apply to their projects. The U.S. Military Health System has created an Evidence-Based Design Review Checklist that outlines how to improve any health care facility experience. Entries include improving patient sleep and rest, reducing medication errors, reducing noise stress, and improving speech intelligibility. Following this checklist goes a long way toward creating positive patient experiences. For truly great customer experiences, we must create customized personal patient experiences. www.sfms.org

Design patient journeys that are customized for who the patients are and what they want. This requires a

more inclusive patient intake questionnaire that allows a deeper dialogue between our physicians and our patients. Tracy Gaudet, MD, inaugural director of the VA Office of Patient Centered Care and Cultural Transformation, talked about what will be necessary to transform health care in the future. She believes that a shift from physician-centered to person-centered care, which is based on relationships built on knowledge and trust between the patient and the caregiver, is crucial. St. Joseph Mercy Hospital in Pontiac, Michigan, has been involved in a cultural transformation during the past five years to design such custom patient journeys for its patients.

Think about your art program as a healing intervention. Just as the physical environment has demonstrated its role

in improving both health outcomes and patients’ and visitors’ experiences, so has art in health care. A 2009 State of the Field report states: “Research demonstrates the benefits of the arts in health care in hospitals, nursing homes, senior centers, hospices, and other locations within the community. Arts in health care programs and creative arts therapies have been applied to a vast array of health issues—from posttraumatic stress disorder to autism, mental health, chronic illnesses, Alzheimer’s and dementia, neurological disorders and brain injuries, premature infant care, and physical disabilities—to improve patients’ overall health outcomes, treatment compliance, and quality of life.” The arts are not merely www.sfms.org

decoration in doctor’s or hospital offices but are complementary therapy with specific goals and measurement.

In 2009, I coauthored (with Blair Sadler) a book called Transforming the Healthcare Experience through the Arts, written for both health care organizations and consumers. We outlined more than thirty case studies of how the arts made a difference in patient, staff, and visitor experiences and provided a business case, resources, and practical action steps to effectively design art programs in health care institutions.

After working in health care design for many years, my ultimate objective is to work with teams of people who are willing to break down the traditional boundaries between physical design, cultural design, and clinical care to design customized patient experiences using the research we have accumulated through studies on the built environment and the knowledge we have acquired by asking our patients what is important to them. By doing that, I’ll know I’ve done my best to create great patient experiences.

Annette Ridenour has been a leader in health care design through the work of Aesthetics, Inc., the multidisciplinary design firm of which she is president and founder. In the early 1990s, Ridenour expanded her practice to interior design, wayfinding, and interpretive displays to create a cohesive visual environment to enhance and sustain healing. Under her leadership, Aesthetics designs optimum patient experiences that support patients and families along their healing journeys. For more information, go to http://www.aesthetics.net or call (619) 683-7500.

January/February 2012 San Francisco Medicine

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Design for Medicine

Going Green A Practical Guide for Any Medical Setting Todd L. Sack, MD, FACP “This year our office will go green.” How many times have you said or thought this? How many times

has this been a topic at your office staff meeting—one that was never quite accomplished? Maybe you are partly green because your office recycles or has switched to compact fluorescent light bulbs (CFBs). Maybe your office has a plan to turn off appliances at night, but you’ve noticed that this isn’t really happening. Here we offer a complete, simple-to-follow plan to actually create your green office this year. We will show you how to do this: how to save money; how to gain community recognition through your green doctor certification; and how to accomplish something that will make your office colleagues, your patients, and you truly proud.

Why Go Green?

First of all, what do we mean by “green,” and why should this be a goal for your office? “Green” means to become an office that has achieved established benchmarks in managing its environmental impact. These concern issues such as how energy, water, paper products, chemicals, and other resources are used. It includes topics related to how office staff members and patients travel to and from the office, since our transportation decisions have a large environmental impact. It includes other behavioral concerns, such as the foods we choose to have in the office and how we communicate to each other and to our patients about topics that concern their health and the environment. There are three key points to emphasize to your colleagues about becoming a green doctor office: First, it involves many facets of the office; second, it is meant to be an ongoing, continuous team process of gradual change and improvement; and third, office staff members can look forward to significant satisfaction from what will be accomplished.

The benefits are real and nearly immediate. Your office is likely to easily save electricity and water, which is real money.

For example, a five-office practice in Pensacola, Florida, is saving more than $14,000 each year on its electric bill. In addition, the people who join your office “Green Team” will truly enjoy it, because each person will be contributing to making the office safer, cleaner, and healthier. This builds office morale and a teamwork approach to problems.

Your patients will see recycling bins in your waiting room, brochures or posters for them to read, and other measures that will tell them that you have a modern, progressive office with a broad interest in their health.

This article describes how to use office teamwork to gradually transform your office over six to twelve months.

The Florida Medical Association developed an online resource to help guide physicians through this process, www.

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San Francisco Medicine January/February 2012

mygreendoctor.org. The website is a free, nonprofit service managed by member physicians of the association. It is designed for doctor offices, is based on solid science, and is written in language that can be understood by anyone working in a medical office. The website offers a straightforward process for achieving their “Green Doctor Office Recognition” within six months and they will send you a certificate to display in your waiting room if you complete the program.

Forming the Green Team

The first step is to form an office Green Team. The Green Team consists of members of the office staff who are willing to meet over lunch once every two to four weeks on an ongoing basis. Members are volunteers, and the best Green Teams include people from various sectors of the office—nurses, frontoffice staff, cleaning personnel, managers, physicians, etc. At these meetings, the Team members will consider Action Steps that they want to adopt for the office and will decide how to implement them. At subsequent meetings, the Team will review the progress made, as well as the setbacks, and will consider other Action Steps to pursue. Along the way, the Team will talk about how to share this information with other staff members, with their families, and with patients.

You’ll need to find someone to lead the Green Team. This person might be a physician, an office manager, or anyone who wants to help out. The leader will schedule the Team meetings, send reminders to members, and manage the meetings to be sure that each Action Step has a person who takes responsibility for it and reports back at the next Team meeting. The position of Team leader can rotate every few months.

Whoever it is, be sure that the office hierarchy—be it your office manager, board of directors, physician owner, or CEO— supports the idea of your Green Team moving forward.

Five Tips for Green Team Success

1. Find a Team leader, someone to schedule each meeting and delegate responsibilities. This position can rotate every few months.

2. Be sure you have management buy-in—the support of your office manager.

3. Meet regularly. By meeting every two to four weeks, your Team will see its successes and remain excited about the process.

4. Communicate. Use your office e-mail, Facebook, meetings, or memos to keep everyone in the office engaged.

5. Reward your Team with thanks, praise, and more. This is real work that saves the office real money. www.sfms.org

Planning Your First Meeting

Education Steps: Your Strongest Impact

Getting started is easy. Your Green Team will not need any experts, outside consultants, or prior knowledge—www. mygreendoctor.org will guide you through the process from start to finish. Plan your first meeting by scheduling a lunch or another convenient time at which people in the office can meet for forty-five minutes. Ask that they bring interested colleagues and their laptops, if available, and that each register at www.mygreendoctor.org (no passwords are needed). If your team won’t have laptops or a projection computer with Internet access at the meeting, simply bring photocopies of the first four to five pages of one of the workbooks, such as the Energy Efficiency workbook.

Whatever your office does, you will want to talk about it, perhaps even brag a bit! Your Green Team will only be truly effective if you are able to educate those around you. Becoming a green doctor office includes talking to your fellow office workers, to your families, to your patients, and even to your community. In this way your office will play a small but real role in improving the health of your entire community. People in the community look to their doctors and health providers as role models—when we recycle, keep organic gardens, bicycle to work, or drive energy-efficient cars, our patients and neighbors pay attention.

The www.mygreendoctor.org site offers dozens of Education Steps. These can be a powerful part of each Green Team meeting. An Education Step could be a short text message or memo to coworkers, a brief report at each staff meeting, or an item in each office newsletter. For patients, they can take the form of a poster in the waiting room or a sticker on light switches, such as “Let’s Go Green Together—Please Turn Me Off.” The website offers many free, downloadable brochures that you can print and place in your waiting rooms for your patients to take home (see the Brochures tab).

The First Meeting

Begin at www.mygreendoctor.org at the “Quick Start, Now!” tab. There you will choose from any of the seven workbooks to get started. It is easiest is to pick from Energy Efficiency, Solid Waste & Recycling, or Drug Disposal & Chemicals.

Each of these workbooks has an introduction, a “Background Information” section, an “Action Steps” section, and a Green Team Notes form on which to record your plans and progress.

For the workbook you choose to begin with, read the first two sections together and then go to “Action Steps,” where you will find “Quick Start, Now!” choices.

The Green Team likely will pick two or three Action Steps at the first meeting. For example, you may choose from the Energy Efficiency workbook for the office to adopt a policy to turn machines off at night and to reset thermostats to save money. For each Action Step, discuss how it will be implemented, how you will share your plans with the entire office, who will be the Green Team member responsible for following this, and when the Team will need a report on the Action Step. Someone should write down your decisions on a copy of the Green Team Notes form, and be sure to set the date for the next meeting.

Your Next Meetings

Plan for your Green Team to meet every two to four weeks for the first three months, and then once a month. At each meeting, review the progress and setbacks experienced with the Action Steps that you have adopted and begin to look at other workbooks, starting with those that have the easy “Quick Start, Now!” steps. Read the Introduction and Background Information sections together, because these sections provide the knowledge base that will engage and empower each member of your Team.

With your later meetings, consider some of the more ambitious but interesting options for your office. For example, you might build a comprehensive energy use plan for the office to save big money, or reconfigure people’s work schedules to minimize their transportation environmental impacts, or eliminate Styrofoam or bottled water or a certain chemical from your office. You might agree to sponsor a community garden, or to start one yourselves. You could install a solar water heater. You might even purchase renewable energy credits (RECs) to offset the carbon dioxide pollution from your office’s energy use. www.sfms.org

Achieving Green Doctor Office Recognition

A doctor office that holds Team meetings every two to four weeks can achieve its initial Green Doctor Office Recognition and an office certificate within six months. The office must meet the standards established and maintained by the Environment & Health Section of the Florida Medical Association in Tallahassee. These include completing five Green Team Meetings, implementing five Action Steps, and completing five Education Steps. The “Nuts & Bolts” tab of www.mygreendoctor.org describes how to record your Green Team notes and how to submit your documentation for recognition status.

Going Green for Good

Businesses large and small have been going green for decades. Their motivations are as diverse as their business plans and profit margins. Like doctor offices, most start because they want to save money, and most manage to do just that.

But many businesses report that nonmonetary advantages are even more significant over the long term when businesses not only go green but also stay green. These are offices that develop a culture of teamwork and mutual respect with their green initiatives. You will all be proud to work in your clean and healthy green doctor office.

Todd L. Sack is a graduate of the University of California School of Medicine, San Francisco, and a past assistant professor of medicine there. He is a practicing gastroenterologist as well as an expert in the “built” environment. His email is tsack@ bgclinic.com. www.mygreendoctor.org is a free, nonprofit site that is based on solid science and is managed by physicians. It is easy to use and confidential, plus it has no ads, pop-ups, banners, or passwords.

January/February 2012 San Francisco Medicine

29

Design for Medicine

A Room of One’s Own Evidence for the Effectiveness of Single-Patient Rooms Dee Mostifi

A room of one’s own. Virgina Woolf considered the personal space it provides essential for artists to flourish. In recent years, hospital planners have realized it’s also

key to patient recovery and health. New hospitals across the country are being built with private rooms, and existing facilities are scrambling to eliminate shared rooms when possible.

The trend was fueled by a 2006 report by the nonprofit Facilities Guidelines Institute and the American Institute of Architects’ Academy of Architecture for Health, which extolled the health benefits of the all-private room model and issued guidelines accordingly for new hospitals. For patients, a private room has an enormous impact on physical and emotional health. Among the benefits: Private rooms reduce the spread of hospital-acquired infections, which kill nearly 100,000 people a year, according to a 2002 report by the Centers for Disease Control. The old shared-room model, where often only a cloth curtain separates patients and roommates have to share bathrooms, is rife with opportunities for hospital staff, patients, and family members to inadvertently spread germs. Single rooms are also easier to clean and decontaminate.

They reduce the possibility of medical errors, since medical personnel are less likely to administer medicine or perform procedures on the wrong roommate. They provide the privacy patients need to discuss their condition with doctors and staff without fear that they may be overheard—an especially important consideration since the HIPPA rules on privacy went into effect.

Private rooms reduce the stress of a hospital stay and give patients more control of their experience. In private rooms, patients can make phone calls, turn on reading lights, chat with visitors

30 San 31 SanFrancisco FranciscoMedicine Medicine January/February January/February2012 2012

whenever they want to—and have sole control of the remote. They provide more opportunities for family members to be involved. Patients tend to stay in better spirits when they are in close contact with loved ones. In many facilities, private rooms include setups that even allow a family member to stay overnight. They promote better sleep, which promotes healing, which leads to shorter hospital stays. Private rooms provide a quieter environment and reduce the number of interruptions patients have to endure during a hospital stay.

Economics, of course, are also a driver in the private-room trend. Because privacy is in demand, especially as baby boomers age, hospitals that can accommodate that preference tend to have higher occupancy rates. Costs are also offset by the reduction in medical errors, germ transmission, and length of stays. Providing private rooms for patients is a win-win, benefiting hospital overhead, physician effectiveness, and, above all, patient health and well-being.

Dee Mostofi is the director of marketing for both Saint Francis Memorial Hospital and St. Mary’s Medical Center, member hospitals of Catholic Health Care West. Both hospitals have taken the benefits of private rooms into consideration since the 1960s, when they built and remodeled facilities to include the amenity. The new 15,000-squarefoot critical care unit at St. Francis, currently in the planning stage, will offer world-class views of the Golden Gate Bridge—a perk that’s also available in many St. Mary’s and St. Francis hospital rooms now.

Staff members at both hospitals are proud to offer private rooms to all patients and believe that privacy contributes to patient satisfaction as well as improved care. www.sfms.org

Design for Medicine

Design Meets Disability The Ideas of Designer and Medical Engineer Graham Pullin Amanda Denz, MA According to Graham Pullin, lecturer in interactive media design at the University of Dundee in Scotland and medical engineer, the medical and design worlds have been at odds for far too long. He says peo-

ple have been seeing the disciplines as separate rather than as complementary fields that can inform one another. In his book, Design Meets Disability, Pullin cites the few examples of the fields working together, explores the great innovation that resulted, and makes a case for a harmonious working relationship going forward.

Pullin’s book opens citing the case of the iconic curved-wood furniture of American midcentury designers Charles and Ray Eames, which evolved directly out of their leg splint design for wounded service members during World War II (pictured right).

The technique for shaping wood to support a wounded leg also applied when the designers decided to shape a chair to support the entire body. This example is case in point about the benefit of merging the design and medical engineering worlds. The two can share lessons, techniques, and successes.

Pullin, using eyeglasses as an example, also delves into the idea that good design can transform the perception of disability.

“The very fact that mild visual impairment is not commonly considered to be a disability is taken as a sign of success of eyeglasses,” he writes. “But this has not always been the case: Joanne Lewis has charted their progress from medical product to fashion accessory. In the 1930s in Britain, National Health Service spectacles were classified as a medical appliance, and their wearers as patients. At that time, glasses were considered to cause social humiliation.”

According to Pullin, one success of eyeglass designers is that they did not attempt to make their product invisible—a goal many medical device designers strive for. Instead, they made the product beautiful and stylish.

In a recent interview with the Boston Globe Pullin was asked, “How do you square the idea of making a hearing aid or a prosthesis beautiful, and even visually noticeable, with the seemingly reasonable goal of making them as inconspicuous as possible?”

Pullin replied, “I’m not trying to negate that as a valid priority. I think the trouble is, once it’s adopted as a priority, it can preclude some other good qualities. . . . I designed a prosthetic hand for amputees, and I spoke to a lot of amputees. Many of them had some very surprising views about the prostheses being prescribed to them. I heard amputees talk about the fact that they didn’t like the feel of their prosthetic hand in their other hand.

That’s something that’s wrapped up in what you put in the list of priorities. If the surface of a hand is designed predominantly to look like human skin . . . then that leads you down the path of silicone gloves and a sort of rubbery feel, because of the visual www.sfms.org

qualities that you want. I heard amputees say they sometimes didn’t wear a prosthetic hand at all, because what they feared when they did wear one—one that was a very good disguise— was that moment when the people they were speaking to for the first time realized that it was artificial. Some of them said they’d actually like to get that moment over and done with at the very beginning, and would welcome a hand that was obviously not a human hand, but had other good qualities.”

Pullin is not disabled. Beyond eyeglasses, he relies solely on the information collected by interviewing people who use medical products for disability. “The issues around disability are very political and complex and loaded,” he told the Boston Globe, “and I’m not trying to make any statements about disability per se.

The message I’m simply trying to get across is that by actually embracing disability, and the issues disability puts to the forefront, it can unlock ideas about universal design.”

It can also make for better products to serve those who need them. “It’s not universally acknowledged by any means that design actually has a role to play in anything quite as serious as products for people with profound disability,” he said. “[This] seems very strange to me, when I know how important those skills are when anything is being designed, from buildings to surgical equipment.”

Pullin hopes that his work will continue to bridge the gap between design and medical engineering, using shared knowledge to create better products for those with and without disability.

January/February 2012 San Francisco Medicine

31

HOSPITAL NEWS KAISER

Veteran’s

CPMC

Robert Mithun, MD

Diana Nicoll, MD, PhD, MPA

Michael Rokeach, MD

A patient’s care experience is determined by many factors, including the environment they enter into upon arrival at a hospital or a medical office building. Through the work of Kaiser Permanente’s National Facilities Services, the organization has developed architectural and design guidelines to ensure that in every new and renovated hospital and clinic, the total health environment of our patients is taken into consideration.

These environmental elements include ecologically sound building materials and design, the use of natural light when possible for cost-effectiveness and energy conservation, hospital rooms that allow for round-the-clock family visiting, and innovative transportation and parking options.

The total health environment takes into consideration individuality among our patients and the fact that, often, one-size design does not fit all needs. When patients arrive at a Kaiser Permanente facility, they may need a soothing meditation room in which to calm their nerves or a lactation room for new mothers—both of which are available at our San Francisco Medical Center.

Additionally, the design tools available through the total health environment have helped redefine waiting areas by supporting an active process of work, respite, education, and play when appropriate. Cafeterias at Kaiser Permanente facilities offer healthy food options to both visitors and staff in dining areas that support communication and connectivity. Reconfigured and refreshed signage now helps ensure easy wayfinding upon arrival at facility campuses.

Locally in San Francisco, we have been renovating and upgrading several areas of our facility, including our Neonatal Intensive Care Unit (NICU). Designed with a better understanding of the needs of neonates and their families, the NICU footprint will be doubled, all bassinets will be positioned for natural light, and rooms will allow greater privacy when construction is complete.

Women are playing an increasingly large role in the United States military. Women make up 12 percent of U.S. forces in Iraq and Afghanistan, 20 percent of new recruits, 15 percent of active duty personnel, 17 percent of National Guard and Reserve, and 8 percent of America’s veterans. More military roles are open to women; they now serve as combat pilots in all service branches and on all naval vessels including submarines.

As a result, “women are exposed to more trauma than in prior wars because of the ways in which they are directly involved,” says SFVAMC psychologist and researcher Shira Maguen, PhD. Though women are officially restricted to combat support roles, “they have weapons, get shot at, are in Humvees and tanks, have exposure to dead bodies, and witness taking another life in war just as do other troops.”

In 2009, Dr. Maguen and colleagues reviewed records of 329,000 Iraq and Afghanistan veterans seeking first-time VA health care. They found women veterans were more frequently diagnosed with depression; men were more often diagnosed with PTSD and alcohol use disorder. Women also had more anxiety and eating disorders than men.

In a 2011 study, Dr. Maguen found that among Iraq and Afghanistan veterans with PTSD, 31 percent of women screened positive for military sexual trauma (MST), compared to one percent of men. Veterans with PTSD and MST had more mental health diagnoses than those without MST. Women veterans with PTSD and MST were more likely to exhibit depression, anxiety, and eating disorders.

Dr. Maguen notes several areas requiring more research: reproductive health, impact on families of women with PTSD, long-term combat effects, and traumatic brain injury.

“There is no shortage of areas of investigation with regard to women warriors. The amount we know pales in comparison to what we have yet to learn.”

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San Francisco Medicine January/February 2012

Physicians at CPMC performed a threeway kidney exchange in California this past November. The procedure, which is known as “paired donation,” occurs when each patient has a willing and able donor who isn’t a compatible match, but the donor matches someone else who needs a kidney. The complex procedure lasted about six hours and involved nine doctors, six patients, and three operating rooms. All six patients are doing well. The three-way swap was only the second involving more than four people at CPMC last year. In April, doctors performed a fiveway swap, which was the largest single-hospital kidney exchange in California.

CPMC has been named among the top hospitals in the nation for both kidney and liver transplant by HealthGrades, the leading provider of information to help consumers make informed decisions about a physician or hospital. HealthGrades’ annual evaluation of the nation’s top-performing hospitals in organ transplantation includes clinical quality data, based on patient outcomes. Among the 263 adult and pediatric acute care hospitals that perform transplants, CPMC is one of only three that were honored for more than one organ program.

Two CPMC physicians were recently recognized for their work with a group that provides medical care to patients who don’t have health insurance. Operation Access (OA), which provides free outpatient surgery and specialty care, will honor Dr. Michelle Li with a Legacy Award for performing surgeries with OA; her work included hernia repair and cholecystectomy. Dr. Li has volunteered with OA since 2006, seeing about one patient per month. OA will also award Heidi Wittenberg, MD, the only urogynecologist in OA’s Bay Area program, an Unsung Hero Award. Since 2010, Dr. Wittenberg has provided life-changing surgeries to women who have suffered from pelvic disorders.

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IN THE NEWS Cancer Screening Reform Needed Since the National Cancer Institute developed the first guidelines on mammography screening more than thirty years ago, advocacy and professional groups have developed guidelines focused on who should be screened, instead of communicating clearly the risks and benefits of screening. This view is stated in a commentary by Michael Edward Stefanek, PhD, the associate vice president of collaborative research in the Office of the Vice President at Indiana University, published online on November 21 in the Journal of the National Cancer Institute.

The U.S. Preventative Task Force (USPTS) recommendations against routine mammography for women aged forty to forty-nine sparked controversy followed by more studies on screening, notably by a Norwegian study comparing cancer-specific mortality in screened and unscreened women, which found a small and statistically insignificant breast cancer mortality reduction in the screened group. Stefanek writes that “similar ambiguity” exists for prostate cancer screening, noting that the two largest and highest-quality studies gave conflicting results, with the USPTS recently issuing recommendations against PSA testing in healthy men.

The National Lung Cancer Screening Trial reported a 20 percent relative decrease in lung cancer deaths among subjects undergoing CT scans compared with those receiving chest X-rays, but with the majority of positive results being false positives. Overall, this situation leads Stefanek to the conclusion that, despite all the analyses to date, we are on unsteady ground when we attempt to dictate who should and shouldn’t undergo medical screening.

Stefanek poses the question of what we have taught the public about cancer screening, since people invariably seem to feel that screening is almost always a good idea and that finding cancer early is the key to saving lives. He cautions that the public may persist in holding a biased view of screening if we continue to engage in guideline debates. Furthermore, new technologies, despite the potential for combating cancer, will likely result in false positives, false negatives, overtreatment, and undertreatment and will incur important patient harms.

Stefanek writes that we have failed to truly educate the public about cancer screening, and that our approach to screening needs to be reformed. He says we need to engage patients in shared decision making, track the total number of patients provided with information related to the harms and benefits of screening instead of just those who are screened, and unite scientific and advocacy organizations with primary care provider organizations in efforts to inform about costs and benefits. “If we agree on the premise that individuals are supposed to be informed before making medical decisions, including decisions about cancer screening, then the time and talent of such groups could be much better spent educating the public on the harms and benefits of cancer screening,” Stefanek writes. “Screening can be very beneficial (or not), and screening messages should reflect the complexity of this decision.”

UCSF Conference

Developmental Disabilities: An Update for Health Professionals March 8-9, 2012, at UCSF Laurel Heights Conference Center This interdisciplinary, interprofessional conference provides a practical and useful update for primary care and subspecialty health care professionals who care for children, youth, and adults with complex health care needs and developmental disabilities. The 2012 topics address current and new perspectives, research findings, and clinical guidelines on autism spectrum disorders and other developmental disabilities across the lifespan. This year’s conference also includes talks on Down syndrome, fetal alcohol disorders, cerebral palsy, psychopharmacology, dental health, school health, transition to adult services, and more.

Lucy Crain, MD, MPH, and Gerri Collins-Bride, MSN, are the conference cochairs. The fee schedule is as follows: $375 for physicians ($450 after 3/1/12); $250 for nurses and other health professionals ($300 after 3/1/12); $100 for parents, family members, and caregivers of individuals with developmental disabilities. UCSF Association of Clinical Faculty vouchers are accepted for this course. For more information, please call the Office of Continuing Medical Education at (415) 476-4251. Credit: 14.75 AMA PRA Category 1 Credit(s).

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San Francisco Medicine January/February 2012

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