minnesota physician june 2012

When health is absentWisdom cannot reveal itselfArt cannot manifest

Strength cannot fightWealth becomes useless,And intelligence cannot be applied.

—Herophilus, Greek physician, 335–280 B.C.

For someone who spent much of his professional life dissecting human cadavers,Herophilus had a remarkably astute under-standing of the importance of maintainingbodily and mental health. More than 2,000years later, physicians are coming to under-stand that we need attend to our personalhealth if we are going to improve overall population health.

We know that physicians are not immuneto the effects of disease, both physical andemotional. In fact, physicians may experience

STRESSED to page 10

Volume XXVl, No. 3

June 2012

A better toolboxPalliative care comes to the outpatient oncology clinic

By Charles Bransford, MD

In September 2006, I began doingpalliative care consultations inour outpatient oncology clinic. I

admit that my motive for working inour oncology clinic stemmed fromthe strong bias that much of my workwould entail helping patients stopchemotherapy. I assumed it would beobvious when chemotherapy wascausing more harm then good andpatients were continuing therapysimply because they thought they hadno other viable choice.

This is often the fear oncologistshave of palliative care doctors—thatthey will encourage oncology patientsto stop chemotherapy too soon.Initially, my consultations involvedstage IV metastatic cancer patientswho had no further options for treat-ment and the oncology team wasstruggling with how to tell theirpatient it was time to stop, especially

TOOLBOX to page 14

The Independent Medical Business Newspaper

Strategies to handle the stresses of today’s medical

practice environmentBy Keith Stelter, MD

IN THIS ISSUE: Architecture Page 20Stressed

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CAPSULES 4

MEDICUS 7

INTERVIEW 8

Vital signs 18By Steve Brown, CCIM

Reforming health care design 28By Deborah Sweetland, FACHE,MBA, EDAC, and Michael Moran,AIA, ACHA, LEED AP

Building an optimal healing environment 30By Terri Zborowsky, PhD, EDAC

New “hospice house” 32By Gloria Cade, RN, BSN, CHPCA,and Mark L. Hansen, AIA

DEPARTMENTS

SPECIAL FOCUS: MEDICAL FACILITY DESIGN

C O N T E N T S JUNE 2012 Volume XXVI, No. 3

JUNE 2012 MINNESOTA PHYSICIAN 3

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Ouraddress is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email [email protected]. We welcome the submission of manuscripts and letters for possible pub-lication. All views and opinions expressed by authors of published articles are solely those of theauthors and do not necessarily represent or express the views of Minnesota PhysicianPublishing, Inc., or this publication. The contents herein are believed accurate but arenot intended to replace legal, tax, business or other professional advice and counsel. Nopart of this publication may be reprinted or reproduced without written permission ofthe publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

PUBLISHER Mike Starnes [email protected]

EDITOR Donna Ahrens [email protected]

ASSOCIATE EDITOR Janet Cass [email protected]

ASSISTANT EDITOR Scott Wooldridge [email protected]

ART DIRECTOR Elaine Sarkela [email protected]

OFFICE ADMINISTRATOR Juline Birgersson [email protected]

ACCOUNT EXECUTIVE Iain Kane [email protected]

The

Independent

Medical

Business

Newspaper

Stressed out? 1Strategies to handle the stresses oftoday’s medical practice environmentBy Keith Stelter, MD

A better toolbox 1Palliative care comes to the outpatient oncology clinicBy Charles Bransford, MD

Architecture Honor Roll 20

FEATURES

www.mppub.com

Laurie Drill-MellumMMIC Group

4 MINNESOTA PHYSICIAN JUNE 2012

Health Bills Pass At End of SessionGov. Mark Dayton signed theHealth and Human Services(HHS) omnibus bill at the endof the Legislative session, res -toring $18 million in funding toa range of services that were cutin last year’s budget.

Dayton called the HHSomnibus bill one of the greataccomplishments of the session.He praised leaders from bothparties and agency heads forworking together. “It’s anextraordinary accomplishment,especially in the context ofsome of the other difficultieswe’ve had this session in work-ing together in a cooperative,bipartisan way,” he said.

Dayton noted that addi -tional funds were available toaddress some of the HHS short-falls because of the work ofDepartment of Human ServicesCommissioner Lucinda Jesson,who negotiated a cap on profitsfrom state health plans for theprivate insurers that administerthem. Some of the provisionsincluded in the HHS bill in -

cluded language that increasespayments for personal careattendants, restores funding fortreatments such as dialysis andchemotherapy for people onEmergency Medical Assistance,and the funding of an autismstudy.

One of the reforms muchdiscussed among providers thisyear was the idea of independ-ent, third-party audits of statehealth plans. The measure pro-vides for independent audits tobe conducted biannually, undergenerally accepted accountingstandards. The first audits willtake place for 2014 health plancontracts, so the earliest thepublic and legislators will seeaudits will be 2015.

Another health care issue atthe end of the session was a billthat would expand public dis-closure from medical licensingboards such as the state’s Boardof Medical Practice. Accordingto Dave Renner, lobbyist withthe Minnesota MedicalAssociation (MMA), his groupwas concerned about languagethat would have required theboard to post information about

malpractice settlements by pro viders. After testimony from MMA, the language wasre moved.

“We were trying to ensurethat the information we provideto consumers will be helpful tothem,” Renner says. “Whether acase is settled might not be inthe hands of the physician.There are many reasons for set-tlement, and then there is thefact that many settlements aresealed. … We think the Legis-lature did focus on the informa-tion that will be helpful to theconsumer.”

Hospital FinancesStrong, BaumgartenReport FindsHospitals in Minnesota contin-ued to see good financial num-bers in 2010, according to anew report from AllanBaumgarten’s Managed CareReviews. Baumgarten releasestwo reports on the Minnesotahealth care industry each year,one that examines hospitalfinances and a second on man-

aged care plans. The new report finds that

hospitals continued to seestrong operating margins in2010, one year after datashowed 2009 numbers thatwere the best in the past decadefor hospital finances.

“They’re doing well on therevenue side in terms of therates that they’re negotiatingwith the private insurers, and Ithink they’ve also been attentiveon their expense side, in termsof trying to find efficiencies,”Baumgarten says. “The growingeconomic power of some ofthese outstate systems is alsohelping the profitability.”

The report shows that theaverage margin for outstatehospitals was 10.8 percent,compared to approximately 7percent margins for hospitals inthe Twin Cities metro area.Hospitals are seeing strongincome even while inpatienthospital days have declined.

Baumgarten says the out-state market is being reshapedby the ongoing consolidationamong large health systemssuch as Sioux Falls, S.D.-based

C A P S U L E S

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

| provider assistance: 1-888-531-1493 | ucare.org/providers | ©2012, UCare.


Sanford Health, Duluth-basedEssentia Health, and Rochester-based Mayo Clinic.

“Sanford, Essentia, andMayo have emerged as threevery powerful systems,”Baumgarten says. “It’s reminis-cent of how hospital systemsdeveloped in the Twin Cities; ofcourse the geography is differ-ent, but the pattern and strate-gies are very similar.”

Coalition Works toPrevent Drug Theft A coalition of providers, stategovernment, and law enforce-ment has created a set of bestpractices to enhance security forcontrolled substances at hospi-tals and health care facilities.

The Controlled SubstanceDiversion Coalition, formed inMay 2011, has been working onstrategies to prevent theft of pre-scription drugs by health careworkers, patients, families, andvisitors to health care facilities.

The group has created aroad map and tool kit to im -prove the security of systems bywhich providers procure, store,and dispense controlled sub-stances. More information onthe new tools can be found awww.health.state.mn.us/patientsafety/drugdiversion/.

“This coalition has been agreat example of government,hospitals, and medical profes-sionals working together toproactively address the problemof drug diversions,” says EdEhlinger, MD, Minnesota com-missioner of health. “We’ve pro-duced tools that will help pro-tect patients and prevent someof these relatively rare but attimes high profile cases involv-ing a health care worker illegal-ly diverting prescription med-ications.”

AG Report BlastsAccretive HealthAttorney General (AG) LoriSwanson released a report inApril on debt collection prac-tices by Chicago-basedAccretive Health, saying thecompany crossed a line in try-ing to collect payments frompatients in Minnesota.

The AG began investigatingAccretive’s practices last sum-mer, after a stolen laptop created a security breach forFairview Health Services andNorth Memorial Hospital, twolocal health systems thatworked with Accretive. Aftermonths of investigation,Swanson’s six-volume reportblasts Accretive’s practices withFairview in particular, sayingthe company violated numer-ous state and federal laws andpromoted a “boiler-room” culture that was at odds withFairview’s status as a not-for-profit organization.

“Accretive and its ‘numbers-driven’ culture haveundermined Fairview’s mission-driven culture,” the report says.“The Accretive culture has con-verted the hospital culture fromthat of a charitable organiza-tion to that of a collectionagency.”

Fairview responded to thereport by noting it has severedits ties with Accretive. In astatement released April 24,Fairview said, “We take theconcerns raised by MinnesotaAttorney General Lori Swansonvery seriously. We have been inconsultation with her on theseissues for several months. Weshare many of her concernsand have already taken actionsto address them.”

Accretive responded by fil-ing a motion to dismissSwanson’s case, saying thecharges were baseless and thatshe has “orchestrated a nation-wide media campaign againstAccretive Health.”

The company also got somehigh-profile support fromChicago Mayor RahmEmanuel, who wrote a letter toSwanson asking her to meetwith Accretive executives.Swanson brushed off Emanuel,saying in a statement that herlawsuit was a law enforcementmatter, not a political one.”

Community HealthClinics ReceiveACA FundingCommunity health clinics inMinnesota will receive morethan $15 million in Affordable

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Care Act (ACA) funding, federalofficials announced recently.

More than $728 million infunds will support 398 renova-tion and construction projectsnationwide, officials say. In aneffort to expand access to healthcare, the ACA has set asideapproximately $11 billion toexpand facilities and services ofcommunity health centers inthe United States over a five-year period.

Funding for communityclinics is aimed at improvingthe health of the nation’s under-served communities, officialssay. Currently, these clinicsdeliver care to more than 20million patients regardless oftheir ability to pay.

Since 2009, communityclinics have served nearly 3 mil-lion additional patients and willserve an additional 1.3 millionnew patients in the next twoyears, officials say. In addition,employment at communityhealth centers nationwide hasincreased by 15 percent.

“For many Americans, com-munity health centers are the

major source of care thatranges from prevention to treat-ment of chronic diseases,” says U.S. Health and HumanSer-vices Secretary KathleenSebelius. “This investment willexpand our ability to providehigh-quality care to millions ofpeople while supporting good-paying jobs in communitiesacross the country.”

In Minnesota, seven com-munity health clinics will re -ceive new funding under theprogram, ranging in amountsfrom $358,000 to $4.8 million.These include seven clinics inCook, Duluth, Mankato, Minn-eapolis, and St. Paul.

Fairview, U of M Plan Ambulatory Care CenterFairview Health Services, theUniversity of Minnesota, andUniversity of MinnesotaPhysicians are working on plansto build a new ambulatory carecenter on the U of M campus,and at the same time revise therelationship between Fairview

and UM Physicians. Officials began talking pub-

licly about the plan in May,leading up to a meeting of the U of M regents to discuss thechanges. The construction proj-ect would build a $182.5 millionambulatory care center thatwould include clinics, surgicalsuites, and diagnostic facilities.The center would combine andstreamline many services nowscattered over several buildingson the U of M campus.

Officials note the currentfacilities for outpatient surgeryand related services were builtin 1974 and designed for one-fourth the patient volume thatuniversity providers now see.Since that time, medical prac-tices have changed, with outpa-tient surgery becoming muchmore common, officials say. Inaddition, the new facility willallow the U of M to develop theuse of coordinated, team-basedcare strategies.

“The current proposal willcreate a facility that will allowfor the implementation of newcare models and will improveinterdisciplinary collaboration

in a way that meets the needsand expectations of the currenthealth care environment,” saysBobbi Daniels, CEO of UMPhysicians. “The research andeducation programs of the med-ical school will also be advan -ced by a design that facilitatesboth the teaching of medicalstudents and other trainees aswell as better incorporatingclinical research, which are atthe core of the University ofMinnesota’s mission.”

Fairview and UM Physi -cians are also discussing a new management structurebetween the groups. Accordingto Daniels, the groups havesigned a letter of intent thatenvisions a co-managementmodel be tween University ofMinne sota Medical Center,University of MinnesotaAmplatz Child ren’s Hospital,and U of M Physicians. How-ever, the arrangement is not amerger; Daniels says U of MPhysicians and Fairview willcontinue to operate as separateorganizations with separatefinances.

Capsules from page 5

education that measurably improves patient care healthpartnersIME.com

30th Annual Strategies in Primary Care Medicine September 20-21, 2012 • Post-Conference Activities – Basic Life Support for Health Care Providers – Recertification – ABIM Maintenance of Certification Learning Session

Midwestern Region Burn Conference October 11-12, 2012 • Pre-Conference Workshops October 10, 2012 – Burn Rehabilitation: The Bridge to Recovery – The Pathway to Improving Outcomes for Pediatric Burn Injuries (includes simulation-based learning) • Post-Conference ABLS Provider Course October 13, 2012

Optimizing Mechanical Ventilation October 26-28, 2012

13th Annual Women’s Health Conference November 2, 2012

Pediatric Fundamental Critical Care Support November 8-9, 2012

Emergency Medicine and Trauma Update: Beyond the Golden Hour November 15, 2012

34th Annual Cardiovascular Conference December 13-14, 2012

continuing medical education

Richard Hart, MD, a St. Cloud pediatrician,was recently chosen by peers to receive theCentraCare Health Foundation’s CaduceusAward. The award annually recognizes physi-cians on the medical staff of St. Cloud Hospitalfor their leadership in humanitarian efforts andcommunity involvement. Hart was recognizedfor his dedication to charity care and missionwork, including a program with St. Cloud StateUniversity to develop care plans for severely

disabled children. He has taught emergency medical technician pediatric training in the St. Cloud area, has sponsored variousevents for March of Dimes and other organizations, and has partici-pated in medical missions to Guatemala.

The Minnesota Academy of Family Physi-cians (MAFP) has selected Andrew Burgdorf,MD, of Buffalo, as the 2012 Family Physician of the Year. This award is presented annually toa family physician who represents the highestideals of the specialty of family medicine, in-cluding caring, comprehensive medical service,community involvement, and service as a rolemodel. Family physicians from across the statewere nominated for the award by patients, community members,and colleagues. Burgdorf practices at the Allina Medical Clinic inBuffalo. He has been a family physician in the community for nearly24 years and also serves as the clinic’s lead physician. The awardcited Burgdorf’s energy, his positive attitude, and his commitment to his patients, his family, and his community.

Other physicians who received awards at the annual MAFPmeeting are Paul Van Gorp, MD (CentraCare–Long Prairie Clinic)—Teacher of the Year; Glenn Nemec, MD (Monticello Clinic)—Merit Award; Macaran Baird, MD (University of Minnesota Medical School, Minneapolis)—President’s Award; Mark Yeazel,MD, MPH (University of Minnesota Medical School, Minneapolis)—Researcher of the Year; Laura Wellington, MD (North MemorialFamily Medicine Residency Program)—Resident of the Year; andBen Pederson (University of Minnesota Medical School, Minneapolis)—Medical Student Award for Contributions to Family Medicine.

Five physicians have recently joined Duluth-based EssentiaHealth. Othmane Alami, MD, a geriatric psychiatrist, has joinedEssentia Health–Duluth Clinic. Alami is board-certified in psychia-try and neurology. In addition to geriatric psychiatry, he specializesin psychosomatic medicine. Alami completed his residency at theState University of New York in Brooklyn and his fellowship was atColumbia University in New York. He attended medical school inCasablanca, Morocco. Laurie Jepson, MD, has joined the InternalMedicine Department at Essentia Health–Duluth Clinic. Jepson is board-certified in internal medicine. She received her medical degree from the University of Minnesota, Minneapolis and com-pleted a fellowship at University of California-Los Angeles MedicalCenter’s Harbor General Hospital in Torrance, Calif. She also com-pleted an internal medicine internship and residency at MaricopaMedical Center in Phoenix, Ariz. Jay Huber, MD, has joined Essen-tia Health–St. Mary’s Medical Center as a hospitalist. Huber, who isboard-certified in internal medicine, received his doctorate in os-teopathy at the University of North Texas and Texas College of Osteopathic Medicine in Fort Worth. He completed an internal medicine internship and a residency at Fitzsimons Army MedicalHospital in Aurora, Colo. Cory Ecklund, MD, a family medicinephysician, will travel to several of Essentia’s regional clinics to seepatients. Ecklund is board-certified in family medicine. He receivedhis medical degree from the University of Minnesota, Minneapolisand completed his residency at the Alaska Family Medicine Resi-dency program in Anchorage.

M E D I C U S

Richard Hart, MD

Andrew Burgdorf, MD


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■ As CMO at a professional liability company, howdo you see your role?

The overall goal as a medical liability company isto ultimately decrease adverse events. MMIC hasbeen working very hard on this. We have a systemfor extracting data so that we can make a lot ofdata-driven recommendations. That being said, thearea that I’m going to be interested in when itcomes to adverse outcomes is developing programsto help support physicians.

We know that when a physician and otherproviders are involved in an adverse event it canimpact them deeply, because of course that wouldnever be their intention. Some physicians go on topractice very defensive medicine, some developproblems with depression, or problems with chem-ical and alcohol abuse.

I personally have a hugeinterest around physicianwellness and physicianburnout. That will be one ofmy first initiatives: to try anddevelop programs along thatline. Additionally, I am inter-ested in behavior at work,communication at work, andculture at work, because all of these things impactthe care that people give.

I anticipate developing not only a variety ofprograms but also developing a network of physi-cians to help me. For example, we would like tostart involving some of the physicians in our com-munity who train residents in our claim evaluationprocess. We would love residents to understandwhat we see and ways they can learn behaviors,communication styles, and techniques to perhapsavoid being in a lawsuit.

We are not just in Minnesota; we are in sevenother states. We anticipate making connectionswith our insured physicians in other states toinvolve them in training programs and the evalua-tion of claims on a more local level.

■ You are the first CMO at MMIC. Why did thecompany decide to create this position?

My understanding is that the current CEO, BillMcDonough, saw the benefits of bringing a physi-cian into the leadership team. I feel that I bringvalue just by giving a physician’s perspective.

I have been on the MMIC board of directorsfor four years. I have seen the company workingfrom that position. These are people who obviouslyhave a lot of knowledge about health care; theyhave been working in the medical liability field formost of their careers. So they have medical knowl-edge, but I am bringing knowledge from thetrenches. I’ve been an emergency medicine physician for 21 years. I am practicing frontlinemedicine, and I see a lot of the problems and the im pacts of adverse events—it is not just theoretical with me.

■ What have been the most significant factors inthe recent decline in malpractice claims?

I don’t think anybody knows for sure. What wewould like to think is that all these patient safetyinitiatives around the country, along with manage-ment programs, have made a difference.

It is absolutely true; the frequency of claimshave gone down. What we call the severity ofclaims has gone up—the settlements or awards aremuch larger. Of course, we would like the numberof settlements to be zero. With the practice of med-icine, it will never be zero but we would like to getit down to as low a number as possible.

■ Many lawmakers support tort reform as a wayof holding down health care costs. What is your

position?

I think tort reform would bewonderful. Courts generallycompensate people for theirinjuries but this whole lati-tude to give juries the abilityto say what kind of award isgiven—this is driving up thecost of health care exponen-tially. If you put a cap on

awards, you would be spending a lot less money onawards. Maybe it would not be as appealing to takeas many adverse events to a lawsuit. Maybe therewould be more mediation and settlement.

A lot of this malpractice environment drivespeople out of medicine. I do not think the publicknows or understands that physicians quit medi-cine and move out of town when it gets to be toomuch. Specialty groups move out of town or out ofstate, because physicians can choose where theywant to practice in this country, and they’d just assoon practice in a more favorable environment.

■ Do patients see physicians as invulnerable?

They are more vulnerable than the average personwould understand. They also see them as havingdeep pockets, because of liability insurance. I thinktort reform would be a good thing. I think expertphysician juries would be a good thing too, orexpert juries.

This is complex stuff. I am not speaking forMMIC, because I do not know what they think—Ihave never asked that.

The other thing is that I have sympathy for thepatient who has injuries and long-term medicalneeds. Unfortunately, in our society, it seems thatthis may be the most viable recourse for people toget compensated. If you look at Scandinaviancountries, they do not pay very much in malprac-tice at all, but if somebody is harmed in an event,the state takes care of them. That is another envi-ronment.

■ In the debate over expanding the Board ofMedical Practice’s public reporting to include

Laurie Drill-Mellum, MD, MPH

MMIC Group

Laurie Drill-Mellum, MD,MPH was named chiefmedical officer (CMO)for MMIC in February.The Minneapolis-basedmedical liability insur-ance company provides

a range of services for physicians and

providers throughoutthe Midwest.

As MMIC’s first CMO,Drill-Mellum will work

with the company’sphysician clients on

risk reduction and riskmitigation strategies.

An emergency medicinephysician at Ridgeview

Medical Center inWaconia, Drill-Mellum

has served on the MMICboard of directors since2008. She is currently a Bush Medical Fellow

and a fellow of theAmerican College

of Emergency Physicians.

A physician’s view of liability


I N T E R V I E W

I’ve been an emergencymedicine physician for 21 years. It is not just theoretical with me.

out-of-court settlements, there was considerable resistance from the medicalprofession. What should physicians knowabout this issue?

Many cases are settled because of financialreasons, not because of culpability or mal-practice. To include settlements [in publicreporting] just does not seem right. Peoplebring claims, but sometimes it is moreexpensive to litigate claims.

It is a drawn-out process and a very psy-chologically-harmful, spiritually-woundingexperience. I do not know how else todescribe it. For physicians to be tied up in aclaim, if there was not malpractice involved,there are physicians that prefer to just say,“Get me out of this, this is affecting mywork, this is affecting my life—I can’t sleepat night.” Sometimes that is just the bestoption to take. Our position would be thatwe would not want settlements as a part of[public reporting].

■ How are recent developments in informa-tion technology affecting the field ofmedical malpractice?

We have a whole IT department that isworking on HIPAA compliance, becausethere are issues around what is called cyber-liability, about data that people have to bemindful of. There is great potential for con-fidentiality breaches.

As you probably know, this is a huge

new area for physicians, many of who areuncomfortable with and feel burdened bythe use of the electronic health record. Sowe have a consulting department that helpsphysicians and clinics with this.

Another initiative we really want tofocus on is early adverse event reporting. By doing early adverse event reporting, wecould be sending out news blasts to insuredsto try to decrease adverse events. We are allabout trying to decrease bad things happen-ing and increase good things happening, tokeep people happier and communicatingmore effectively with each other. All thosethings add up to a better patient experience.

■ What are the issues if physicians are con-sidering settling out of court?

When accepting a settlement, it is reportedto the National Practitioner Data Bank. It is something that they carry with them,whether or not they committed malpractice.

They have to go through a period of dis-cernment with legal advice about the prosand cons of that. If they go on to an actualcourt case, the court may find for the physi-cian and then there would be nothing ontheir record; it would not be reported.

■ Malpractice concerns might cause somephysicians to hesitate if they find them-selves in a Good Samaritan situation.What advice do you offer for that?

I would encourage people to do the rightthing and worry about the fallout later. The thing I have to say about MMIC—I havebeen very im pressed by how they standbehind their insureds. MMIC supports itsphysicians and does the right thing and thatis why I joined the company.

■ An adverse outcome might be the resultof medical care received from anotherphysician. How do you address thoseissues?

I think that is obviously a dicey issue. Iwould encourage people not to joust—criticizing somebody else’s care. Of course,we see cases like this, complicated cases atone institution that go to another institu-tion. Jousting in the medical record is notadvised. Instead of criticizing former physi-cians’ care, one might say, “I can’t really talkabout that. Let’s deal with what we haveright here and do the best that we can do.”You are not in that other person’s moc-casins. You do not know what resourcesthey had available to them.

Does liability change with the ACO model,where physicians are part of a team?

We have not seen anything along those linesthat I am aware of. Ultimately, the physicianis still going to be the captain of the shipand responsible for the care provided inthese environments.


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more emotional distress andlower levels of “well-being” thanother professions due to theongoing stress of our jobs.

The concept of profes sional“burnout” was first used by psy-chologist Herbert Freudenbergin 1974 to describe “a state of exhaustion (most often emo-tional and mental) observedamong volunteer workers”(Freudenberg HJ, 1974, J SocIssues 30:1). Freudenberg notedthat the condition occurred inthose who “worked too much,too long and too intensively”and those who “had a need togive.” Does this sound like anyphysicians you know?

It’s not surprising that theprofession of medicine is stress-ful for all specialties. Among thereasons: many years of educa-tion and training, repeated high-stakes exams of knowledge, stu-dent debt issues, high work-loads, reduced sleep, high levelsof personal accountability foroutcomes, a changing medicalcare environment, and innova-tions that render our past

knowledge obsolete. We are allwell aware of the general, day-to-day stresses of a professionwhere we routinely performhighly complex work and thestakes for the well-being of oth-ers are at risk.

The personality traits thatmade us good students and resi-dents—a well-developed sense ofdedication and responsibility,the ability to handle a high levelof stress, and compulsive atten-tion to detail—are valued in

medicine. They also play a partin physician burnout. It is easyfor physicians to feel an exagger-ated sense of responsibility, andwe sometimes feel guilt anddoubt in our decisions; yet wefeel we can handle these pres-sures on our own and are gener-ally reluctant to seek outsidehelp. In addition, physicians aresocialized to avoid self-reflec-tion—the focus in medical careis the patient, not the physi-cian—and finally student andresident education in self-care isnot usually part of medicaltraining.

The ongoing stress of prac-ticing medicine, coupled withthese personality traits and alack of self-awareness, lay thekindling for physician burnout.

We have all seen the devas-tating impact of unmanagedstress on the health of ourpatients. We have likely seen theeffects of stress in some col-leagues and we may have experi-enced it in ourselves. Sometimesthe result of this stress is mini-mal and it does not affect ourwork or home life. Other times,the impact is great: Physicianswho once were very effective inclinical practice lose their edge,and the quality of their lives andtheir work suffers.

How big a problem is stressin physicians’ lives? What, ifanything, can be done to mini-mize the impact of this stress?Can we increase our resilienceto stress? How do we knowwhen we are experiencing burn-out? More importantly, what canwe do to help ourselves and ourcolleagues prevent burnout?

What research on burnout tells us

According to many researchstudies on physician burnout: • Thirty percent to 60 percent of

practicing physicians reportexperiencing burnout at somepoint.

• Forty-six percent to 80 percentof physicians report high levelsof emotional exhaustion.

• Forty percent of surgeonsreport being burned out.

• Women physicians are 60 per-cent more likely than men toexperience burnout.

• The balance between work-load/scheduling and input/influence is the highest pre-dictor of emotional exhaus-tion.

Published studies have alsoshown that burnout is associat-ed with increased medicalerrors, dissatisfied patients, andriskier prescribing habits—allmajor threats to patient safety.In addition, a physician’s re-duced abil ity to make astutemedical decisions due to stressand burnout can lead to in-creased health care costs. Othersevere consequences of burnoutare depression, anxiety, psycho-somatic complaints, physical ill-ness, and even suicide.

Social and health psycholo-gist Christina Maslach, PhD, andothers have described and stud-ied burnout in health care andhuman service workers. Maslachdeveloped a conceptual model ofpossible causes of burnout basedon a mismatch between the per-son and the job. The areas iden-tified are workload, lack of con-trol, insufficient reward, break-down of community, absence offairness, and value conflict. Thegreater the mismatch, thegreater the chance of burnout.

The most commonly usedinstrument for measuringburnout in clinical practice isthe Maslach Burnout Inventory,which identifies three dimen-sions of burnout:1. Emotional exhaustion: feel-

ings of being emotionallyoverextended and exhaustedby one’s work. It is a feelingof “ having nothing left togive”.

2. Depersonalization: anunfeeling and impersonalresponse toward recipients of

Stressed from cover


Job stress

Role conflict

Workload

Time pressure

Scheduling

Work/home balance

Burnout teeter-totterJob input/influence

Skill variety

Feedback

Coaching

Rewards

Self-growth potential

Social support

one’s service, care treatment,or instruction. It is a feelingof seeing others as “objects”and not fellow human beings.

3. Decreased sense of personalaccomplishment: feelings ofdecreased competence andachievement in one’s work. Itis a feeling of “not makingany difference in the world.”Careful study of patients

with burnout has shown that notall symptoms arise at the sametime. Instead, for many peoplethere seems to be a transitionfrom one symptom to another.When these symptoms deepenand then move to anotherdimension of burnout, the con-dition will eventually manifestitself as full blown burnout.Being aware of these initialsymptoms may help us recog-nize early stages of burnout andtreat it before it becomes morepervasive and severe.

One of the more interestingaspects of current research onburnout involves the differencesin burnout between women andmen. A study by Houkes et al. inBMC Public Health (2011) notesthat men usually initiate feel-ings of burnout with deperson-alization and that personalachievement seems to developindependently from the othertwo dimensions. In contrast,women start the process ofburnout with emotional ex-haustion, which leads both toreduced personal achievementand to depersonalization.

Prevention strategies: balance and awareness

Prevention of burnout and main-tenance of emotional health areareas of great interest for profes-sional medical societies andhealth care organizations, sincework productivity and patientsatisfaction are intricately linkedto employee emotional healthand employee satisfaction.Medical schools and residencyprograms are now starting toincorporate burnout preventionstrategies and programs toscreen for burnout. The Ameri-can Medical Association (AMA)and other professional organiza-tions also have developed manyprograms to promote physicianwellness and prevent burnout. Astarting place is the AMA’s web-

site and searching for physicianburnout.

A study of high-functioningphysicians reveals several char-acteristics that can help main-tain emotional health and thatappear to provide both resilienceand resistance to burnout: • Setting limits through self-

regulation; knowing when tosay “no” to taking on othercommitments.

• Spending meaningful timewith family and friends.

• Maintaining self-care throughexercise.

• Maintaining self-care throughrelaxation.

• Using humor to help maintaina healthy philosophical out-look.

Even if you are not experi-encing burnout, it is importantto take steps to prevent burnoutfrom occurring. One of the mostimportant prevention strategiesfor physicians is to find a senseof balance among all the com-peting demands of professionaland personal life and to use thesupports at their disposal tohandle these demands.

Cultivating self-awarenessallows us to see in clearer termsboth the stresses we are experi-encing and the supports we haveat our disposal to improve ouremotional health. Self-awareness(called “emotional intelligence”by psychologist and authorDaniel Goleman) combines self-knowledge with development ofdual awareness, permitting thephysician or clinician to simulta-neously attend to and monitorthe patient’s needs, the workenvironment, and his or her ownsubjective experience.

Among the proven methodsof fostering self-awareness ismindfulness meditation.

Creating an improved “neurologic highway”

Richard J. Davidson, PhD, andcolleagues at the University ofWisconsin-Madison have doneconsiderable research on theneurological effects of medita-tion. In a study published in2003, Davidson wrote that mind-fulness meditation may involveneurobiological changes anddevelopment of neural pathwaysto bolster our “immunity”against burnout (Davidson RJ et al., 2003, PsychosomaticMedicine 65:4).

Research on the science ofneuroplasticity has improvedour knowledge of the brain’spotential and how it can changeover time. In very simplistic

terms, the connections betweenthe prefrontal cortex (our think-ing self) and the amygdala (ourfeeling self) in a certain way dic-tate how we respond to life’schallenges. We know that allow-ing the prefrontal cortex to bemore active before sending afight-or-flight response to ouramygdala can help reduce ourbody’s reaction to stressfulevents. Mindfulness meditationcreates a better “neurologichighway” to the prefrontal cor-tex and helps prevent us fromsending premature inappropri-ate messages to our amygdala.

One of the best ways topractice mindfulness is toengage in the following simpleexercise, described by themnemonic SOLAR:S: Stop and sit.O: Observe (pause, breathe, and

feel exactly what arises inyour experience).

L: Let it be; let everything be asit is without reacting to ortrying to change any of it.

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In a study published in 2003, Davidson wrote that mindfulness medita-tion may involve neurobiological changesand development of neural pathways to bolster our “immunity” against burnout.

R: Return to the presentmoment and turn attention toyour breathing.

Here are some other easypractices to help develop dailymindfulness: • Before you start to drive home

after work, sit in your car for30 to 60 seconds, and use thattime to create a buffer zonebetween work and home life.

• Stop at a window in yourworkplace and notice some-thing in nature, then give it your full attention for 15 seconds.

• Before going into the nextpatient’s room, pause anddirect your attention to yourbreathing for three breaths.

• As you wash your hands,attend carefully to the sensa-tion of the hand gel in yourhands.

• Practice gratitude; end eachday by acknowledging onething you are grateful for.

My personal favorite mind-fulness practice is to considerthe first 60 seconds of eachpatient encounter to be “sacred”:

Relax and breatheintentionally, andlisten deeply to theconcerns of yourpatient without logging onto thecomputer or writ-ing details of the history in the chart immediately.

A burnout prevention action plan

Michael Kaufmann,MD, director of thePhysician HealthProgram at theOntario MedicalAssociation, hascreated a self-assessment tool,described by themnemonic BASIC,that addressesmany aspects ofphysician wellness.The self-assessment and actionplan helps build “immunity”against burnout.

To create your personal planfor burnout avoidance andphysician wellness, review the

following questions,then write down acommitment state-ment that you canaccomplish for eachcategory. B—Body: What oneor two things canyou change toimprove your dietor fitness level?What are someways you could“honor your body”in diet and activity?A—Affect: What canyou do to enhanceself-awareness?Spend some timethinking about whatyou deeply valueabout being a physi-cian. Think aboutways that you mightintegrate some as-pect of mindfulness

into your daily life.S—Social: What relationshipsexist now that you may be ableto deepen? What conversationsdo you yearn to have? What stories need to be told and heardin your life?

I—Intellect: What areas of learn-ing or knowledge do you yearnto study within medicine andoutside of medicine? C—Cosmos: Where can youexplore or deepen your spiritual-ity? What are your sources ofmeaning, hope, and peace? Howcan you best use your gifts tomeet a need that exists in theworld?

Stress is an inevitable conse-quence of working in healthcare; however, our response tothat stress is not predeterminedor predestined. Burnout is oneof the serious consequences ofunrelieved stress. The good newsis that with personal insight andperhaps making some work-lifechanges, we can prevent burn-out and keep ourselves function-ing well—for our own benefitand that of our patients.

Keith Stelter, MD, is an assistant pro-fessor of family medicine and communityhealth in the University of MinnesotaMedical School and is associate director ofthe university’s Mankato Family Medicineresidency program.

Stressed from page 11


Among theproven

methods offostering

self-aware-ness is

mindfulnessmeditation.

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responses to Phase 2. If you would like to be included in future surveys, please contact us via e-mail at [email protected] or call 612-728-8600. The surveys are online, are quick to complete, and are completely anonymous and confidential. We welcome your suggestions for this and future surveys.

Our thanks to those who participated.

Pe

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Agree Does not

apply

Strongly

agree

Strongly

disagree

Disagree0

10

20

30

40

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1.4%

12.9%

8.6%

30.9%

46.0%

Pe

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Agree Does not

apply

Strongly

agree

Strongly

disagree

Disagree0

10

20

30

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60

10.8%

51.8%

2.9%

29.5%

5.0%

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Agree Does not

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Strongly

agree

Strongly

disagree

Disagree0

10

20

30

40

50

4.3%

41.7%

36.7%

14.4%

2.9%

1. The time I spend daily on compliance,

record keeping, prior authorization, etc.

compromises my ability to provide

patients the highest level of care.

4. My employer provides adequate

support services aimed at limiting

physician burnout.

Pe

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Agree Does not

apply

Strongly

agree

Strongly

disagree

Disagree0

10

20

30

40

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4.3%

41.0%

12.2%

32.4%

10.1%

Pe

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Strongly

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Strongly

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5

10

15

20

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2.2%

29.5%

10.8%

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26.6%

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Strongly

disagree

Disagree0

5

10

15

20

25

30

35

40

6.5%

39.1% 38.4%

11.6%

4.3%

2. My employer creates an environment

that compromises the ability of my

physician colleagues to provide the

highest level of care.

Pe

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Agree Does not

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Strongly

agree

Strongly

disagree

Disagree0

10

20

30

40

50

2.9%

16.5%14.4%

41.0%

25.2%

To participate in future surveys or offer suggestions,

please contact us at [email protected].

5. I feel isolated socially by my work.

7. I am less satisfied by my work than

I was when I began my career.

8. I have physical illness related to

burnout.

9. I have physician colleagues suffering

from burnout who do not recognize it.

10. I can manage career burnout issues

on my own.

Pe

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Agree Does not

apply

Strongly

agree

Strongly

disagree

Disagree0

10

20

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8.6%

30.9%

4.3%

41.0%

15.1%

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Disagree0

5

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30.9%

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10.1%

18.0%

1.4%

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Disagree0

10

20

30

40

50

3.6%

20.9%18.7%

40.3%

16.5%

3. I am expected to produce a volume

of daily patient billing that is

compromising my ability to provide

patients the highest level of care.


6. I feel my work has created a negative

impact on my personal life.

in the setting where numeroustimes before, they had come upwith an unexpected solution.The chemotherapy nurses werequite good at knowing when itwas time to stop treatment buthad a hard time communicatingthis to the patient, family, andoncologist. Patients always puton their best face for theironcologist, and it becomes verydifficult for oncologists to admitthere is nothing more to offer—they keep hedging their betswith the possibility of newresearch options.

This article reviews whathas and what hasn’t worked withour clinic’s model of outpatienton cology care combined withpalliative care, in the hope thatothers can learn from our expe-rience.

Integrated palliative/oncologycare: Tom’s story

The case of a patient I’ll callTom illustrates both the chal-lenges and promise of combin-ing oncology with palliativemedicine in the clinic.

Within the space of 24hours, Tom went from being ahealthy vigorous, 48-year-oldman who had never been sick aday in his life to a man fightingfor his life. He had a perforatedcecal colon cancer with obviousomental and liver metastasis,plus the additional complica-tions of multiple pulmonaryemboli and prolonged postoper-ative ileus.

As the initial treating physi-cian, my first inclination was topush for a hospice/palliative careapproach, but our oncologist, aswell as Tom and his family, werequite adamant that they wanted“everything” done. I could com-pletely understand the patient’s/-family’s desire to try all treat-ments possible, but deep down Iwas thinking, here we go againwith another case of medicalfutility. Working as a palliativecare/primary care-oncologyteam, we set upon the goal offinding relief of his pain andnausea—the pillars of good pal-liative care. Until a patient hasgood pain and nausea control(plus the ability to eat and havereasonable bowel movements)

and the confidence that this willcontinue, you can’t really haveany conversations about qualityof life.

Tom and his wife met withme every two weeks until we hadgood control of his primarysymptoms. A typical challengecenters on symptoms that occurfor the first few days afterchemotherapy. In Tom’s case, hewould crash on day three andday four post-chemo with nau-sea, profound weakness, andconstipation, and then, aroundday five, would develop profusewatery diarrhea as a conse-quence of the chemotherapy. Wedeveloped a program of low-doseprednisone for the day three-fourcrash in energy; Remeron atnight for sleep and appetite;Reglan, Phenergan, and Zofranfor nausea; methadone for pain;a few days of lactulose initiallyfor the post-chemo constipation;and then judicious use ofLomotil and long-actingoctreotide for the diarrhea.

The only way to develop acomplicated medical regimenlike this is with the help of acommunity-based home pallia-tive care team that can provideimmediate feedback on the suc-cess and failures of your treat-ment plan and assist with thenumerous titrations necessaryfor success (you cannot predictthe effective dose of methadone,and if you start too high you willlose that medication as a choicefor patients). Palliative carenurses can draw blood and dis-connect chemo at home to helpminimize trips to the clinic.

Once Tom had control ofthese basic needs, we couldbegin to focus on his quality oflife needs—a process that tookseveral months. Tom and hiswife were avid travelers. We setup a chemo program so that hecould again travel. In betweentreatments, he would train forhis next trip. The focus of hislife moved from chemotherapyissues to travel issues, as well asconnection with his family. Heexercised every day. After oneyear of chemo, he looked andfelt like a handsome, bald,tanned athlete at middle age. Hehad an infectious zeal for lifethat positively affected everyonearound him.

Tom and his wife enrolled in

our mind/body program andstudied guided imagery, yoga,and meditation. They seemed to be more and more comfort-able with the chronic nature ofhis illness and the understand-ing that cure was unlikely. Hisscans improved but were neverentirely normal, so chemo treat-ments continued and becamemore and more difficult to toler-ate, as is their nature. Tombecame close to our palliativecare chaplain and began takingcommunion at home.

Late in 2011, Tom and ouroncologist agreed there weren’tany further treatments availableand, after reviewing the variousexperimental programs, Tom en -rolled in hospice. He had devel-oped pulmonary fibrosis andlung nodules and now neededoxygen. After enrolling in hos-pice, Tom and his son took along dreamed-of vacation toAlaska; then, at Christmas, heand his wife took one more tripto Mexico.

On the last day of his life wetransferred Tom to our “hospicehouse,” because caring for hisshortness of breath had becomedifficult. I visited him four hoursbefore his death. When I arrived,he and our chaplain were sing-ing an Irish ditty that had us allin stitches. Tom thanked us forhis care, and we thanked him.Tom asked us to take care of hiswife and children, who were allpresent, and we promised to dothe best we could. Tom diedpeacefully, as a healed man.

Tom represents for me thereason why palliative care is soimportant in the oncology clinic.More and more people withmetastatic colon, lung, pancre -atic, breast, and prostate cancer,to name a few, can live well withtheir disease if their quality oflife issues are dealt with rightfrom the beginning of their ill-ness. If these issues are not dealtwith realistically, their lives canbe a prolonged hell. Because thepatient, family, and oncologistwill encounter unexpected suc-cesses in the patient’s treatmentsand health, it becomes very diffi-cult to see when the treatmentsare no longer working and thepatient’s suffering is becominguntenable.


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Victoza® (liraglutide [rDNA origin] injection)

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BRIEF SUMMARY. Please consult package insert for full prescribing information.

WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treat-ment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions].

INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve gly-cemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied.

CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).

WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiv-ing liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a compara-tor-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have sub-sequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most fre-quently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with on-treatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consis-tent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calci-tonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebo-treated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evalua-tion. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,

pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other poten-tially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medica-tions known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing con-clusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug.

ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparator-treated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer.

Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial

All Victoza® N = 497 Glimepiride N = 248

Adverse Event Term (%) (%)

Nausea 28.4 8.5

Diarrhea 17.1 8.9

Vomiting 10.9 3.6

Constipation 9.9 4.8

Upper Respiratory Tract Infection 9.5 5.6

Headache 9.1 9.3

Influenza 7.4 3.6

Urinary Tract Infection 6.0 4.0

Dizziness 5.8 5.2

Sinusitis 5.6 6.0

Nasopharyngitis 5.2 5.2

Back Pain 5.0 4.4

Hypertension 3.0 6.0

Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials

Add-on to Metformin Trial

All Victoza® + Metformin N = 724

Placebo + Metformin N = 121

Glimepiride + Metformin N = 242

Adverse Event Term (%) (%) (%)

Nausea 15.2 4.1 3.3

Diarrhea 10.9 4.1 3.7

Headache 9.0 6.6 9.5

Vomiting 6.5 0.8 0.4

Add-on to Glimepiride Trial

All Victoza® + Glimepiride N = 695

Placebo + Glimepiride N = 114

Rosiglitazone + Glimepiride N = 231


Nausea 7.5 1.8 2.6

Diarrhea 7.2 1.8 2.2


Victoza® (liraglutide [rDNA origin] injection)

Rx Only

BRIEF SUMMARY. Please consult package insert for full prescribing information.

WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treat-ment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions].

INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve gly-cemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied.

CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).

WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiv-ing liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a compara-tor-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have sub-sequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most fre-quently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with on-treatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consis-tent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calci-tonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebo-treated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evalua-tion. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,

pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other poten-tially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medica-tions known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing con-clusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug.

ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparator-treated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer.

Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial

All Victoza® N = 497 Glimepiride N = 248

Adverse Event Term (%) (%)

Nausea 28.4 8.5

Diarrhea 17.1 8.9

Vomiting 10.9 3.6

Constipation 9.9 4.8

Upper Respiratory Tract Infection 9.5 5.6

Headache 9.1 9.3

Influenza 7.4 3.6

Urinary Tract Infection 6.0 4.0

Dizziness 5.8 5.2

Sinusitis 5.6 6.0

Nasopharyngitis 5.2 5.2

Back Pain 5.0 4.4

Hypertension 3.0 6.0

Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials

Add-on to Metformin Trial

All Victoza® + Metformin N = 724

Placebo + Metformin N = 121

Glimepiride + Metformin N = 242


Nausea 15.2 4.1 3.3

Diarrhea 10.9 4.1 3.7

Headache 9.0 6.6 9.5

Vomiting 6.5 0.8 0.4

Add-on to Glimepiride Trial

All Victoza® + Glimepiride N = 695

Placebo + Glimepiride N = 114

Rosiglitazone + Glimepiride N = 231


Nausea 7.5 1.8 2.6

Diarrhea 7.2 1.8 2.2

While not completelyresistant to the eco-nomic downturn and

real estate fallout, the TwinCities medical office market’svital signs have remained stableand the outlook for long-termdemand is strong. In 2011, theTwin Cities medical office mar-ket comprised 103 medicalbuildings, including on- and off-campus properties, and sat at anoverall vacancy of 11.4 percentwith positive absorption of35,997 square feet, reflecting an increase in occupied space.Off-campus vacancy rates were13.1 percent, slightly higher thanthe on-campus vacancy rate of9.5 percent.

One effect we are seeingfrom the crash of the retail mar-ket is some new and uniquemedical office spaces in high-

profile retail spaces that werenot an option before the crash.As medical providers see theincreased medical needs of agingbaby boomers and feel theimpact of health care reform,they are focused on shoring uptheir internal capacity to meetthe demand. In anticipation ofthese increased demands, theyare also keeping new collabora-tion and partnering options atthe forefront of their facilityplanning. However, as the manyknown and unknown factorsplay out, enacting strict strategicplans will help shape the futureof Minnesota’s medical officemarket.

Impact of “retail effect” on off-campus spaceIn the past year(s), medicaloffice space requirements in -jected a welcome dose of de -mand into the otherwise quietretail leasing market. Healthcare providers took advantage of the opportunity to evaluatehigh-profile retail sites that weredistressed due to market condi-tions, both by leasing existingsecond-generation retail spaceand by building new facilities on land adjacent to existingretail centers.

Due to the soft retail mar-ket, where buildings once occu-pied by retailers such as Bordersbookstores and Blockbuster andVideo Update stores are nowvacant, a number of new clinicsand outpatient facilities havefound an opportunity to fillthese high-profile retail vacan-cies at previously unattainablerates. In recent years, landlordshave had to consider moreunconventional tenants thanthey normally would have underhealthier retail market condi-tions. Medical tenants offer abenefit similar to retail propertyowners: They help drive trafficto the center, which benefitsother retailers.

As medical tenants findacceptance among retail pro -perty landlords, their clinics andoutpatient facilities benefit bylocating to properties that arehighly visible and accessible totheir patients. Local examplesare a Park Nicollet clinic leasinga former Hollywood Video inLakeville; an Urgency Roomfacility now located in a formerMovie Gallery building inWoodbury; and HealthEast tak-ing over a vacated Borders book-store site on Selby Avenue in St.Paul and the former GanderMountain in Maplewood.

Furthermore, in submarketswhere activity is very high, med-ical office prospects are circlingcampuses for space. In thenortheast metro area, St. John’sHospital campus in Maplewoodreports a 0 percent vacancy rate.This has driven strong interesttoward several nearby off-cam-pus developments that wouldcreate additional space options.Currently in this area, at leastthree of four developments areapproved or proposed. If thesedevelopments move forward, theresult could be a repositioningof some on-campus physicians.

By occupying off-campusproperties, medical offices areable to create a presence in theirpatients’ neighborhoods, therebyincreasing visibility and aidingaccessibility. Yet, a number ofquestions remain: How long willthis trend continue, and will theavailability of these well-located,highly visible assets dry up? Willthe window of opportunity closeas retail landlords look for arebound in retail activity and anopportunity to return to tradi-tional retail rents? Or will retaillandlords consider permanentlyrepurposing their projects toincorporate medical uses in thefuture?

Strategic plansIn the Twin Cities’ medical officemarket, significant discussionhas surrounded the increasedmedical needs of aging babyboomers and the future impactof health care reforms as pro -viders prepare for patients whowere previously uninsured.

To meet these future needs,hospitals are focusing on mak-ing health care more accessible,

Vital signs The Twin Cities medical office market

remains strong

By Steve Brown, CCIM

Read usonlinewherever you are!

www.mppub.com


This month’s special

focus articles address the

current state of the med-

ical office market in the

Twin Cities metropolitan

area; the effects of health

care reform on the design

of medical facilities (e.g.,

in response to increased

use of care teams); the

use of studies of health

care environments to

design for improved effi-

ciency and safety in care

and healing; and the

development of a residen-

tial hospice to provide

end-of-life care in a

home-like environment.

S P E C I A L F O C U S : M E D I C A L F A C I L I T Y D E S I G N

with trends moving towardpushing any outpatient servicesinto off-campus buildings wherethey are closer to the patient.This also creates more inpatientcapacity within the hospitals.This shift will increase demandfor off-campus medical officespace.

Physician shortages willneed to be augmented withphysician extenders (i.e., nursepractitioners, physician assis-tants, nursing assistants, etc.) tomeet this additional demand,and the care model that is ulti-mately created will determinehow and where this additionalcapacity is delivered. Certainly,there will be continued collabo-ration and partnering amongdominant subspecialty groupsand hospital systems as theycompete to secure and servepatients. Stronger independentpractices of the same specialtyare also finding ways to collabo-rate to share resources, gain efficiencies, leverage the scale of a larger organization, andstrengthen contract negotiationswith providers and insurers.

While the impact of reformon hospital and physician spacerequirements is not completelyclear, providers are working togauge it and strategically planfor the future. Providers are pri-oritizing projects to determinewhich are most important, whileaccess to capital is driving manydecisions.

OutlookDemand for space is expected topick up in 2012. Absorptioncould be 25,000 to 35,000 squarefeet for on-campus properties.For example, Fairview South-dale’s campus will report posi-tive first-quarter activity whenPrairieCare, a psychiatric andbehavioral health servicesprovider, doubles its space to23,500 square feet. For off-cam-pus properties, absorption couldbe 60,000 to 75,000 square feet,including the opening of the

fully leased 44,000-square-footCrystal Medical Building. The“retail effect” can be expected to continue to affect off-campusspace as physicians considerretail options for clinics and out-patient facilities.

Rates will be flat and con-cessions will continue in weakermarkets. This year, providers’strategic plans likely will beginto be executed. We anticipatesignificant system-drivenannouncements next year for2012–2014 projects. A number of questions loom in the back-ground of the Twin Cities healthcare marketplace, for example:

What impact will SanfordHealth, a Fargo, N.D.-basedhealth system, have as it movescloser to the Twin Cities? Arethey in negotiations already?

What impact will MayoHealth System have on the TwinCities market as it continues its

plans to open an ambulatorycare clinic at the Mall ofAmerica?

What potential hospital sys-tem merger will occur first?

It has always been the casethat, unlike traditional officemarkets, the medical office mar-ket ebbs and flows in a way thatrequires more interpretive analy-sis based on hospital systemsthan simply looking at geogra-phy. Submarket creation by system affiliation is a criticaldynamic in evaluating the healthof a given on-campus or off-campus market. This dynamichas further been exacerbated bythe retail factor, practice acquisi-tion by hospitals, and potentialmergers.

Steve Brown, CCIM, is executive direc-tor of Cushman & Wakefield/NorthMarq’sHealthcare Advisory Group, where he isresponsible for providing real-estate con-sulting and advisory services to health care organizations, corporations, and clinical practices both locally and throughout the U.S.


Medical tenants offer a benefit similar toretail property owners: They help drive trafficto the center, which benefits other retailers.

Appointments:

Online or Call 651-439-8807

Supporting Our Patients.Supporting Our Partners.Supporting You.

Providing care at multiple modern clinics in Minnesota and Wisconsin

In 2008, Tanzanian missionaries brought little Zawadi Rajabu to the U.S. to seek treatment for her two severely clubbed feet. A physician referred Zawadi to Dr. Mark T. Dahl of St. Croix Orthopaedics. Using the Ilizarov Method, Dr. Dahl surgically changed the course of Zawadi’s feet and her life.

Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient. To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.

David Palmer, M.D.& Zawadi’s brother

Russ McGill, OPA-C& Zawadi

t mule aviding carorP

inn clinics in Mtiple moder

onsiniscWnesota and

Type of facility: Specialty hospital

Location: Minneapolis

Client: Children’s Hospitals and Clinics ofMinnesota

Architect/Interior design: AECOM

Engineer: Harris Mechanical and HuntElectric, mechanical/electrical/plumbing;Ericksen Roed & Assoc., structural

Contractor: Knutson Construction Co.

Completion date: March 2012

Total cost: Confidential per owner request

Square feet: 169,500 gsf (new children’s spe-cialty center); 597,695 gsf (hospital new con-struction and renovation); 24,330 gsf (newpower plant); 679-car parking structure

To maintain its status as a regional leader inpediatric care, Children’s Hospitals and Clinicsof Minnesota embarked on the most significantcampus development in its history.Architecture, landscape, science, and art mergeto transform the health care experience ofpatients who come to its Minneapolis campus,revitalizing a sense of place and urban renewal.

Campus expansion to the west of ChicagoAvenue includes a new Specialty Care Centerwith specialty clinics (including the hematol-ogy and oncology clinic), outpatient pharm -acy, retail center, and a new parking structurelinked to the existing hospital by a curved,glass skybridge.

Upgrades to existing facilities to the east ofChicago Avenue include a new hospital entryand a seven-story addition. The addition offersnew patient rooms, enlarged and enhancedoperating rooms, a new emergency depart-ment, renovated neonatal and pediatric inten-sive care units, a new cardiovascular center,and an in-house Ronald McDonald House. Allexisting patient rooms were converted to pri-vate rooms with sleep-in space for parents.

This expansion and modernization provides anew brand image for Children’s, establishes acohesive campus, provides a new experiencefor patients and their families, expands healthcare services, and creates a positive socialimpact on Chicago Avenue and the surround-ing neighborhood.

health care architecture honor roll

Children’s Hospitals and Clinics of MinnesotaMinneapolis campus expansion and modernization

Minnesota Physician’s 2012 Health CareArchitecture Honor Roll recognizes nineoutstanding projects completed in the

past year. This year’s Honor Roll projectsinclude new clinic and hospital con-

struction, remodeled spaces, and facilityexpansions in urban, suburban, and

greater Minnesota. The medical servicesrange from routine clinic visits to

specialized urgent and emergency treat-ment. Populations served also run the

gamut, from pediatric patients to seniorsseeking assisted-living housing and

patients receiving hospice care.

Many of the projects emphasize ties to the community, for example, by incorporating artwork by regional

artists, using locally sourced buildingmaterials, and designing a street

landscape that enhances the facility’ssocial impact on the surrounding neigh-borhood. Principles of sustainability andenergy-saving design support the goals

of patient safety and staff efficiency.

Minnesota Physician Publishing thanks all those who participated

in the 2012 honor roll.


Type of facility: Clinic

Location: Rochester

Client: Olmsted Medical Center

Architect/Interior design:HGA Architects and Engineers

Engineer: HGA Architects andEngineers

Contractor: Weis Builders

Completion date: July 2011

Total cost: Confidential

Square feet: 65,000 sf

Designed for LEED certification, thisreplacement facility expands primarycare outpatient services while integrat-ing numerous sustainable design fea-tures and geothermal technology.Design was oriented vertically insteadof horizontally to accommodate a 20-foot elevation change from one side ofthe site to the other, allowing for afuture two-story vertical expansion.Patients enter along the main entranceor through lower-level walkout entries.Exterior Dolomite limestone is fromMankato; two textures of grey lime-stone address scale and add visualinterest. The stone will oxidize over

time to a warm grey. HGAused a stone panelized sys-tem similar to precast con-crete construction to permit quickassembly of the exterior skin oncestructural steel was installed. The south facade is a glass curtain with silk-screened glazing to assist with sun control.Interior waiting areas stretch along thesouth side of the building, with lightfrom the full-height curtain-wall systemilluminating the space. Departmentreception areas flow into exam areas,with staff and physician offices at thenorth side of the building.

Design features

• A geothermal mechanical system provides heating and cooling for the building through use of ground-water in a closed loop system. Thewell field is located under theparking lot.

• Natural light in the lobbystreams into the lower level viathe open staircase, creating vis -ual connection between levels.

• Corridors with physician work

alcoves enhance patient and staffflow.

• Patient coffee shop in waiting area.

• Physical therapy and cardiac rehabili-tation space.

• Water use is reduced by more than40 percent through water-conservingfixtures and faucets.

Top: Interior commissioned art is sus-pended over an open staircase to lowerlevel, with waiting spaces beyond.Inset below: Main level reception/check-in desk for family medicine andpediatrics incorporates bright colorsand warm wood tones.Bottom: View from southwest of upperlevel south-facing facade

Olmsted Medical Center,Northwest Clinic

Left: The focal point of thenew campus is a publicspace with solar light sculp-tures designed by BradGoldberg and named“Healing Stones.”

Top inset: The second-floorlobby extends from theparking structure on thewest side of Chicago Ave.,through the Specialty CareCenter, across Chicago viaskybridge, and ends withthe welcome desk and two-story atrium.

Bottom inset: Family roomson each floor of the newbed tower provide views ofdowntown Minneapolis andspace for patients and fami-lies to gather outside pa tientrooms to relax, read, playgames, and socialize.

All photos by Josh Banks Photography.

©2011 Don F. Wong

Type of facility: Hospital

Location: Minneapolis

Client: Hennepin County

Architect/Interior design: HDR Architecture, Inc.

Engineer: HDR Architecture, Inc.

Contractor: Kraus-Anderson Construction Co.

Completion date: May 2012

Total cost: $4.3 million

Square feet: 6,782 sf (new); 6,612 sf (remodel)

The Hyperbaric Medicine Department provides hyperbaric oxygen ther -apy for patients requiring urgent and emergency treatment as well aspatients who are treated daily for wound healing problems. In addition tothe hyperbaric wound and treatment area, a wound clinic is includedwithin the department. The wound clinic has separate exam rooms and

workspace for providers and sharesreception and support areas withthe hyperbaric department. Thehyperbaric department cares forinpatients and outpatients of allages and treats two distinct types of

patients: patients who are treated daily for wound healingand patients who need emergency hyperbaric oxygentherapy Hyperbaric oxygen therapy sessions typically last1 hour and 50 minutes. In addition to hyperbaricpatients, the department includes a separate wound clinicfor pat ients that are not in the hyperbaric treatment pro-gram. The department must handle scheduled pat ientflow as well as surge volumes of emergency cases.

The new Hyperbaric Medicine Unit comprises a multilock, class A multi-place hyperbaric chamber; class B monoplace chamber; main waitingroom and staging waiting areas; male and female handicap-accessibledressing areas with lockers and toilets; intake areas for vital signs, weight,and point-of-care testing; four exam rooms; technician instrument con-sole; medical console; and department support. The existing monoplacechamber formerly located adjacent to the ICU was relocated to the newhyperbaric unit.

Hyperbaric clinic exam room capacity was increased from one examroom to four in the new department, allowing more privacy and improv-ing patient confidentiality. The additional exam rooms enable the depart-ment to see additional patients in the clinic. During sessions, additionalpatients are seen in the exam rooms for follow-up or new patient assess-ment. Four additional wound clinic exam rooms are provided in thedepartment, located separately from the hyperbaric patient exam rooms.

Top: View inside the hyperbaric chamber

Inset: Hyperbaric chamber leaving Fink Engineering’s hyperbaric chamberfabrication shop in Australia

H O N O R R O L L 2012

Hennepin County Medical CenterHyperbaric Medicine Department and Wound Clinic

Essentia Health St. Joseph’s Baxter Clinic Type of facility: Multispecialty outpatient clinic

Location: Baxter

Client: Essentia Health

Architect/Interior design: Widseth Smith Nolting & Associates, Inc. (WSN), firm of record; HGA, programming,schematic design, and interior design

Engineer: Widseth Smith Nolting & Associates, Inc.

Contractor: Hy-Tec Construction

Completion date: January 2012

Total cost: $12 million


WSN provided architectural, structural,mechanical, electrical, civil, land sur-vey, and landscape architecture servic-es for this project, while HGA providedthe programming, schematic design,and interior design. The building’s material palette includes stone, precastconcrete, glass, stucco, and metal panel, which blend well with the natu-ral surroundings.

The clinic has two levels with multiple specialtyareas that include family practice, women’s health,pediatrics, lab, X-ray, pharmacy, and urgent care.Patient-centered care is the concept that directedbuilding design and is addressed in several ways.

A greeter meets patients immediately as they enterthe clinic, redirecting them to more private, decen-

tralized check-in areas. Natural light and framed views to the exte-rior combine with material selections, artwork, and furnishings tocreate a sense of comfort. The decentralized concept allowspatients to feel as though their visit is one-on-one with the

provider. Insulated walls in the exam rooms, as well as insulated duct-work, decrease transfer of sound, which reinforces the patient-centeredcare concept. The Baxter Clinic will provide a welcoming environmentfor patients in this community for many years.

Top: Decorative, etched glass walls line thewaiting areas, offering privacy while allowingnatural light to stream into the space.

Top inset: Natural light floods the two-storyatrium.

Bottom inset: Exterior with parking lot


Sanford Heart HospitalType of facility: Specialty hospital

Location: Sioux Falls, S.D.

Client: Sanford Health

Architect/Interior design: AECOM

Engineer: AECOM

Contractor: Henry Carlson Co.

Completion date: March 2012

Total cost: Confidential, per owner request


Thirty years after the Sanford Health heart pro-gram began, the hospital sought to consolidatethe programs of Sanford Clinic Health Partnersand Sanford Clinic Cardiac, Thoracic, and VascularSurgery to make quality heart care available topatients in a single convenient location.Attached directly to Sanford USD Medical Center,the new Sanford Heart Hospital means even moreconvenience for patients and their families. The205,000-square-foot building is directly connected tothe main lobby of the existing medical center and con-nects underground to the parking ramp.

The new hospital houses physician offices, outpatienttesting, surgical services, cath labs, and consultation services. It alsoincludes 58 inpatient beds, cardiovascular operating rooms, a hybridoperating room, and clinic and outpatient services.

Patient rooms are safe, secure, state-of-the-art living spaces that promoterest and healing. A range of amenities and technologic updates ensurethat patients have everything they need to heal. Rooms are sized forcapability of acuity-adaptable care to allow patients to remain in one

room from admission to discharge.

Art and music have long been known to comfort and soothe the humanspirit and body. Art has been shown to influence the speed of recoveryand provide distraction for patients and families during challengingtimes. The hospital features 130 works of art by regional artists, furtherconnecting the new hospital to the community it serves.

Photography by Dana Wheelock

Top: Interior of Sanford Heart Hospital

Inset: Hybrid operating room

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

Perkins+Will can be your partner in developing those ideas into reality. Give us a call.

Rick Hintz 612.851.5070 [email protected] www.perkinswill.com

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

ill can be your partner in Perkins+WWi

Rick Hintz 612.851.507

For more information on Kaiser Perman

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e us a call.

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ition” visit:kpnfs.com612.338.2029 | 218.727.8446

Healthcare Planning and Design

Ophthalmology - Essentia Health

Allina Medical Clinic–RamseyType of facility: Outpatient medical clinic

Location: Ramsey

Client: Allina Medical Clinic

Architect/Interior design: bdh+young

Engineer: Krech, O’Brien, Mueller & Associates Inc., structural; Gilbert Mechanical, mechanical; Clark Engineering, civil; HuntElectric, electrical

Contractor: Kraus-Anderson Construction Co.

Completion date: June 2011

Total cost: Building shell, $3.5 million;tenant, $2.3 million


A new Allina outpatient medical clinic ispart of Ramsey’s town center develop-ment. The patient-centered clinic designincludes family exam rooms to accommo-date family members and patient educa-tion functions. Designers also focused onsimplifying patient flow and wayfinding,increasing natural light with skylights, andproviding walk-up and self-check options.The project also incorporates sustainableelements: solar power; renewable buildingmaterials such as bamboo veneer, brick,

and stone sourced regionally; low-VOC paints; andhigh-effi ciency mechanical systems.

Top: Designers created centralized care team stations thatincorporate natural light.

Bottom inset: Sustainable elements include solar power,renewable and regional materials, and high-efficiencymechanical systems.

Top inset: The new Allina outpatient clinic is part ofRamsey’s town center development.



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Allina: J.A. Wedum Residential Hospice HouseType of facility: Independent hospice care facility

Location: Brooklyn Park

Client: Allina

Architect/Interior design: Mohagen Hansen Architectural Group

Engineer: Dunham Associates

Contractor: D.J. Kranz Construction

Completion date: February 2012



Hospice care can be provided in whatever setting a patient calls home. This couldbe in a private home, a variety of nursing facilities, or a residential hospice. Nearly30 percent to 40 percent of patients receive their hospice care in a residentialsetting. Most people say that they would want to spend their last days at home,yet more than 50 percent of patients are dying in hospitals. Therefore, Allina, witha sizable donation from the J.A. Wedum Foundation, set out to build a residentialhospice house.

Upon entering the facility, family members are greeted with warm colors, a richwood archway, and pillars similar to what one would find in a model home. As analternative to hospice care provided in a patient’s home or a hospital, it wasimportant that this facility offer all of the comforts of home. The house has 12 privaterooms, each with a private bath and attached patio. Each room also has a comfortablesofa sleeper, for a family member who wishes to spend the night. Also located withinthe house are two large family rooms that are perfect for spending quiet time withfriends and family outside a resident’s room; a large reflection room; a children’s playarea; full kitchen; and dining room. Visitors immediately sense the beauty and warmthof the building as they enter the facility.

Top: Comfortable family room for patients and their families

Bottom: Exterior view of hospice house front entry from circular drive

HGA createshealthcare environments that inspire patients to heal and staff to perform their best.Contact:

Anne Farrell Associate Vice President 612.758.4425 [email protected]

HGA Architects and Engineers

420 5th Street North, Suite 100

Minneapolis, MN 55401

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Crystal MedicalCenterType of facility: Medical office building

Location: Crystal

Client: The Davis Group

Architect/Interior design: bdh+young

Engineer: Krech, O’Brien, Mueller & Associates Inc.

Contractor: Timco Construction

Completion date: February 2012



The new Crystal Medical Center is a Class A multi-tenantfacility in the growing community of Crystal, Minn. Thegoal of the development was to create a project that wasmutually beneficial to the community and would attracttenants by designing a strong project identity to comple-ment and enhance the surrounding area.

The rentable 44,865-square-foot two-story building is constructed of brick, glass, and metal accent panels andincludes a prominent covered patient drop-off canopy atthe main entrance. A number of design features wereintroduced into the project that closely align with the sus-

tainable principles of the LEED Reference Guide forGreen Building Design and Construction.

Interior design features include highly finished clinic suites with soft lighting, modern carpet andflooring, solid surface counters, and custom-designed patient exam and procedure rooms. The building has prime visibility and easy accessfrom the newly reconstructed Highway 81 and Bass Lake Road, a busy intersection of Crystal, pro-

viding tenants with excellent signage opportunities and 220 surface park-ing stalls on-site.

Currently, there are three suites available to new tenants, totaling a littlemore than 9,000 square feet. The building is home to Northwest FamilyPhysicians, Nova Care, and Crystal Imaging, and brings a variety of qualityhealth care services to the community. The medical center has broughtthis community closer together by providing all of these services underone roof, making one-stop medical care available to patients.

Top: Main front-entry lobby

Bottom: View of stone and brick facade at the main entry to the building


See the video at

For more information, contactKevin Donnay, AIA | Vice [email protected] | 218-316-3618

Baxter Clinic

WIDSETH SMITH NOLTING | Architects & Engineersalexandria | baxter | bemidji | crookston | east grand forks | grand forks | red wing | rochester

Architect of Record: Widseth Smith Nolting. In collaboration with HGA.

NMITHSIDSETHWalexandria | baxter | bemidji | crookston

GNOLTIN | ects & EnhitcArrand forks | red wing rand forks | gn | east g

sngineer| rochester

From project delivery to patient experience, from building design and performance to revitalizing communities, AECOM’s holistic approach enables healthcare institutions to thrive.

Whether at the scale of buildings, campuses, city districts or destinations, we combine creative and technical expertise to help clients forge functional, sustainable, engaging places.

aecom.com/[email protected]

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

BUILDING


Benedictine LivingCommunity of St. PeterSenior Housing ApartmentsType of facility: Assisted living

Location: St. Peter

Client: Benedictine Health System

Architect/Interior design: Horty Elving

Engineer: Horty Elving

Construction manager:Yanik Companies

Completion date: October 2011

Total cost: Confidential


This new, two-story, 66,510-square-foot,46-unit senior housing apartment build-ing, owned by the Benedictine Health System, accentuates and incorpo-rates the four Benedictine core values of hospitality, stewardship, respect,and justice throughout its design while focusing on comfortable, forward-thinking spaces that have exemplary furnishings and services. It was designed so that tenants can live apartment-style with a variety ofservices to enhance quality of life. Meals, activities, housekeeping, laun-dry, and supportive oversight within a secured apartment complex arethe base elements of the tenant living arrangements. With several differ-ent layouts offered, all 46 apartments are designed with fully functionalkitchens and include washers and dryers. Layouts include one bedroom, one bedroom plus den, or two bedrooms.The building features underground parking for residents and additionalstorage space for each tenant.

Cambria natural quartz surfaces are featured in everyapartment and throughout the entire building, which isconnected to the Benedictine long-term care facility, the

St. Peter Clinic, and River’s Edge Hospital. The Live Well Fitness Center,Mankato Chiropractic Healing Touch Clinic, and River’s Edge Pharmacyare also on the campus. These physical and enclosed connections allowaccess to a wide array of health care services and double as a walkingcorridor for staff and residents. The exterior design incorporates many ofthe existing materials and colors featured in the surrounding campusbuildings, yet the new building is positioned to maintain its own identity.The owner and construction manager worked directly with the localmunicipal power agency to secure and maximize energy-saving rebatesfor all compliant appliances. The campus also include outdoor walkingpaths, a gazebo, and a gardening area for residents.

Top: Public coffee/tea area

Inset: Exterior, showing main entrance and underground parking

Psychiatric Nurse PractitionerLocation: St. Louis Park, MNSchedule: Open to Full-time or Part-time, Regular

About Us:The Emily Program was voted #1 Top Midsize Workplace in 2011by the Star Tribune. Established in 1993 in St. Paul, The EmilyProgram has outpatient and residential facilities at officesthroughout the Twin Cities metro, Duluth and Seattle, WA, and isa leader in innovative treatment for people with eating disorders.

About the Position:The psychiatric nurse practitioner is responsible for providing direct client service. He/she will work with other Emily Programclinicians in providing comprehensive treatment to the client.Conducts client assessments; evaluates and assesses clients’need or options for medication management, prescribes medica-tions, and monitors on a regular basis.

Qualifications:• Board Certified in the state of MN and hold a valid state

registration or license as specified.• Passion for working with clients with eating disorders.• Related clinical experience/education in the assigned

program(s) of care.

To Apply:Email cover letter, resume and salary requirements to [email protected] The Emily Program is an Equal Opportunity Employer (EOE).


With the growing under-standing that healthcare costs appear to be

unsustainable, that physicianswill be in increasingly short sup-ply, and that reimbursementmodels will continue to evolve,the health care field is changingthe way health care is defined,who delivers it, and how it isdelivered. The nimble organiza-tion will be one that plans forthis uncertainty.

Health care reform calls for “accountable care” thataddresses the health of the indi-vidual across the continuum ofcare and the life of the patient,not just during an immediateepisode of care. Other forces ofchange include the evolution ofhealth-care insurance exchangesand value-based purchasing.These and other trends couldlead to more transparency inreporting health care costs andcontinued pressure to reduce thecost of care.

As the practice of medicineand the delivery of health carecontinue to change, the designof the physical environmentmust also change. New environ-

ments must enable efficient care delivery, provide access toadvanced information technol -ogy, support team communica-tion, allow flexibility for futurechange, and support patient-cen-tered care.

Efficient care delivery

Continued increases in healthcare costs along with a concur-rent awareness of reimburse-ment changes have caused manyproviders to investigate what isdriving the increase. This re -search estimates that 45 percentof health care costs are spent onlabor and supplies.

Hospitals, health care sys-tems, and suppliers with large

inventories have begun toreduce costs by going after “low-hanging fruit,” areas that areeasy to impact by applying“lean” management principles toreduce inventory and supplies.

These practices employ just-in-time delivery and one-pieceflow systems. While most hospi-tals have formal quality im -prove ment efforts underway,many are also rigorously adopt-ing Lean and Six Sigma method-ologies to improve processes andreduce variation in care deliveryand support services. This is alsotrue in the planning and designfield, as progressive architec -tural firms use Lean methodsduring planning and redesign tocreate only what is needed fornew construction or to renovatefor more efficient operations.These processes can reduce op -erating costs and aid in balanc-ing the health care cost equation.

Information technology

Information technology hasevol ved in many ways to supportpatient care, improve efficien-cies for staff, and streamline the process for the patient experience.

Preregistration from thepatient’s home computer, as wellas patient registration kiosks,have replaced the front-deskfunction, decreasing the squarefootage required for front- andback-office support. Computeraccess to medical records, elec-tronic diagnostic images, andhealth education informationallow for real-time discussionand teaching by the caregiver.Point-of-care testing and patientmonitoring equipment can sendinformation directly into theelectronic medical record.

Radio frequency devicestrack patients during their visit,track supplies during surgery,and locate large equipment easi-

ly. Pagers alert patients whenstaff or medications are ready.

Information technology alsoextends the capabilities of thestaff. Telemedicine and online-consult capabilities enhancephysician and staff access tospecialists or second opinions.Physicians can access web-enabled lectures or medicalrounds without leaving theiroffice, enhancing their produc-tivity.

Changes in technology affectnot only the mechanical andelectrical infrastructure andbackup procedures in the build-ing, but also the physical envi-ronment, from the flow of thecare process to the criticaldepartment adjacencies. Effec-tive health care design mustaccommodate and enhance thisincrease in technological inter-face between caregivers andpatient. Concurrently, the tech-nology helps us achieve thedesired care outcome.

Open team centers

Because of physician shortages,expanded care teams, and theimportance of patient participa-tion in patient care plans, care-givers are finding that face-to-face, real-time team communica-tion is essential for efficient col-laboration and care planning.While the electronic record isuseful for documentation andpast activities, it cannot fullyreplace real-time team interac-tion in care planning.

Team communication isenhanced through the direct,face-to-face communication thatan open team center can facili-tate. Open team centers clusterand centralize the physicians,staff, and support personnel whocare for the patient. This allowscommunication and collabora-tive patient care.

Open team centers also im -prove visual management of thepatient. Privacy and open visualmanagement are balanced withcreative solutions for pri vacyand noise control. Half walls,partitions, or glass separationsallow some view while alsoallowing some privacy for thestaff. The implementation anddesign of open team centersshould support a defined caremodel (i.e., a team-based modelof care) and have a positive

Reforming healthcare design

Emerging health care trends that affect the physical environment

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


Lake Region Medical Group is seeking a full-time CertifiedPhysicianAssistant to join our Lake Region Healthcare team

of 3 orthopedic surgeons; providing care in a multi-specialty

clinic with 50+ providers.We are looking for a hardworking,

conscientious individual committed to providing quality care

to our patients as we develop our Orthopedic Center of

Excellence.

Duties will include new and follow-up patient visits, assisting

with surgery, post-op visits and hospital rounds in our 108 –bed

community based hospital.The ideal candidate will have 2-5

years experience in orthopedics.

We offer a competitive salary with a healthy benefit package.

Practice Well.Live Well.

Lake Region Healthcare is an Equal Opportunity Employer. EOE

712 Cascade St. S., Fergus Falls, MN

736-8000 • (800) 439-6424

For more information contactBarb Miller, Physician [email protected] • (218) 736-8227

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impact on the efficiency andeffectiveness of frontline care-givers.

Standardization and flexibility

To support changing care mod-els and the type of care that isprovided, health care environ-ments are standardizing fre-quently used rooms and plan-ning flexibility for change. Astandard inpatient room thatcan adapt or flex for patient acu-ity has become a consistenttrend in inpatient environments.A standard procedure room iscommon in ambulatory surger-ies, and a standard exam roomis now common for outpatient/clinic environments. Many inpa-tient settings also incorporate aninterchangeable case cart systemto allow for specialized care orprocedures. This flexibilityaccommodates economies ofscale for the de sign and con-struction of the space. The bene-fits of standardization and flexi-bility are in construction costsavings as well as in increasedoperational efficiencies.

For administrative and sup-port functions, many facilities

are moving to common areasthat can increase communica-tion between staff members.This encourages private discus-sion of patient care or the latesthealth care research article. Forphysicians, who can be easilyisolated from their peers, sharedoffices can provide a greatersense of connection.

Standardization and flexibil-ity can also reduce renovationexpense by making spaces easilyadaptable for future uses.

Patient-centered environments

Environments are changing tosupport concepts of the “patientexperience” or “patient-centeredcare.” Examples include provid-ing a health education library or computer access in waitingareas, separate entrances forurgent care and routine visits,kiosks for self-scheduling and, as health care focus shifts toprevention, community roomsfor wellness and health educa-tion events.

As used by the Institute ofMedicine and Institute forHealthcare Improvement, theterm “patient-centered” means

considering patients’ culturaltraditions, personal preferencesand values, family situations,social circumstances, and life-styles. Patient-centered care sug-gests that we need to considerhow patients want to have theirhealth care delivered, andrequires an active and ongoingconversation with each patient.This drives the need to gobeyond environments that pro-vide access to health education,comfortable rooms, and waitingareas to look further into how tofacilitate active involvement ofpatients and their families in thedesign of new care models andnew environments in which toreceive care.

Dave Moen, MD, presidentof Fairview Physician Asso-ciates, has said, “As long as wethink of who we are or what wedo when we plan and designhealth care delivery, we will con-tinue to design buildings anddeliver health care in the sameway. Only when we have thepatients involved in the fullprocess can we say that we have‘patient-centered care.’”

Ongoing evolution in design

Health care reimbursementmodels will continue to changeand health care reform willundoubtedly continue to evolve.As this happens, the need forflexible operational and facilityplanning that maximizes re -sources, conserves capital, andengages patients in becomingmore accountable and involvedin their care will become moreapparent. Planning and designneed to continue evolving fromthe reference point of “who weare and what we do.” This canbe achieved by continuing toengage the patient to determinehow they want to receive thehealth care we provide.

Deborah Sweetland, FACHE, MBA,EDAC, is a member of the Midwest divi-sion of HKS’s Clinical Solutions andResearch team. She has 26 years of clini-cal, operational, strategic planning, andhealth care facility and process improve-ment experience, and previously was amaster facility planning executive atHCMC in Minneapolis. Michael Moran,AIA, ACHA, LEED AP, is an architectur-al planning and design professional withHKS’s Midwest division. He has 20 years ofexperience in the planning, design, anddelivery of health care projects.


Family Medicine

St. Cloud/Sartell, MN

We are actively recruiting exceptional part-time or full-time BC/

BE family medicine physicians to join our primary care team in

Sartell, MN. This is an out-patient only opportunity and does not

include labor and delivery or hospital call and rounding. Our current

primary care team includes family medicine, adult medicine, OB/

GYN and pediatrics. Previous electronic medical record experience

is preferred, but not required. We use the Epic electronic medical

record system at all of our clinics and admitting hospitals.

Our HealthPartners Central Minnesota Clinics – Sartell moved

into a new primary care clinic in the summer 2010. We offer a

competitive salary, an excellent benefi t package, a rewarding

practice and a commitment to providing exceptional patient-

centered care. St. Cloud/Sartell, MN is located just one hour

north of the Twin Cities and offers a dynamic lifestyle in a growing

community with a traditional appeal.

Apply on-line at healthpartners.jobs or contact [email protected] or call Diane at 800-472-4695 x3. EOE

h e a l t h p a r t n e r s . c o m

CURRENT OPPORTUNITIES AVAILABLE

To learn more, contact Rhonda Buckallew, 320-631-7230, rhondabuckallew@ catholichealth.net or visit

and All for One. YOU.

Family Medical Center, a multi-specialty group practice with 17 employed physicians, and St. Gabriel’s Hospital, a 25-bed critical access hospital, have practice opportunities for Internal Medicine and a Hospitalist. We offer competitive salary and

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

The ancient Greeks wellunderstood the impact ofthe built and natural envi-

ronment on healing. The templeat Epidauris, built in the early4th century BC, was dedicatedto Asclepuis, the Greek god ofhealth and well-being. It incor-porated the healing elements of a pleasant climate, beautifulvistas, and purifying waters—we could all learn somethingabout a true healing journeyfrom its design.

Centuries later, FlorenceNightingale’s “EnvironmentalTheory” yielded incredible in -sight into the impact of the builtand natural environment onpeople as well as communities.Nightingale advocated “utilizingthe environment of the patientto assist him in his recovery” (inNightingale F, 1860, “Notes onnursing: what it is and what it isnot.” New York: D. Appleton andCompany.)

Nightingale cited a numberof environmental factors affect-ing health, including pure freshair, pure water, effective sewerand drainage systems, cleanli-ness, and light (especially direct

sunlight). Deficiency in one ormore of these factors could leadto impaired functioning of lifeprocesses or diminished healthstatus, she noted.

These environmental factorscarried great significance duringNightingale’s time, when healthinstitutions had poor sanitationand health workers had littleeducation and training and werefrequently unreliable in attend-ing to the needs of patients. Her environmental theory alsoemphasized provision of a quietor noise-free and warm environ-ment, and attending to patients’dietary needs by assessing anddocumenting the time of foodintake and evaluating its effectson the patient.

Unbeknownst to her,Nightingale made her mark on a field that today we know asevidence-based design (EBD) as applied to health care. Innomenclature derived from evi-dence-based medicine, the termevidence-based design refers tousing the best available researchand information in designinghospitals, clinics, and otherhealth care facilities. EBD inhealth care draws from a vastnumber of disciplines—environ-mental psychology, culturalgeography, medicine, nursing,ergonomics, engineering, andneurosciences, to name a few.

As a relatively new disci-pline, EBD for health care facili-ties provides plenty of opportuni-

ties and challenges for the future.Substantial opportunities exist tomake an impact by exploringdesigns and methods that havethe best application in healthcare facilities and by helping tocollect data that can advance ourknowledge base. The challengesinclude seeking out fundingsources, validating the return oninvestment of good design(whether it’s design of the naturalor the built environment), andworking through theories thatcan enhance our collectiveunderstanding of the impact ofplace on people and process.

Figure 1 shows a frameworkthat has been developed to helpunderstand the impact of peo-ple, place, and process on thecreation of an optimal healingenvironment. In the figure:• People = health care workers,

caregivers, patients, familymembers, significant others,community members

• Place = built and natural envi-ronments that provide a set-ting for health care practices

• Process = care processes, eitherinternal or provided to an indi-vidual

Building an optimalhealing environment

Evidence-based design to improve health care facilities

By Terri Zborowsky, PhD, EDAC


Family Medicine

St. Cloud/Sartell, MN

We are actively recruiting exceptional part-time or full-time BC/

BE family medicine physicians to join our primary care team in

Sartell, MN. This is an out-patient only opportunity and does not

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is preferred, but not required. We use the Epic electronic medical

record system at all of our clinics and admitting hospitals.

Our HealthPartners Central Minnesota Clinics – Sartell moved

into a new primary care clinic in the summer 2010. We offer a

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practice and a commitment to providing exceptional patient-

centered care. St. Cloud/Sartell, MN is located just one hour

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Apply on-line at healthpartners.jobs or contact [email protected] or call Diane at 800-472-4695 x3. EOE

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An immediate opportunity is avail-able for a BC/BE orthopedic surgeon in Bemidji, MN. Join threeboard certified orthopedic surgeonsin this beautiful lakes community.Enjoy practicing in a new Orthopedic& Sport Medicine Center, openingspring 2013 and serving a region of100,000.

Live and work in a community thatoffers exceptional schools, a stateuniversity with NCAA Division Ihockey and community symphonyand orchestra. With over 500 milesof trails and 400 surrounding lakes,this active community was ranked a “Top Town” by Outdoor LifeMagazine. Enjoy a fulfilling lifestyleand rewarding career. To learn more about this excellent practiceopportunity contact:

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An optimal healing environ-ment can be described as a sys-tems-based framework in whicheach component has an impacton the creation of a healing en -vironment, and together, thethree components can create anoptimal healing environment. Itis these very elements—people,place, and process—that providecriteria for study in the EBDrealm. In this time of doingmore with less and where no -tions of quality improvement,data transparency, and return oninvestment are paramount, itmakes sense to include compo-nents of the built and naturalenvironments as variables tostudy, as they affect patient out-comes, staff efficiency and satis-faction, family members’ stresslevels, and safety.

The three case studiesdescribed below demonstratethe relevance of this new move-ment in health care. All threecase studies involve hospitalemergency departments, high-lighting the variety of techniquesthat can be used in researchstudies of this nature.

Case Study #1:

Impact of emergency depart-ment built environment ontimeliness of physician assess-ment of patients with chestpain(Hall K.K., et al., 2008,Environment and Behavior 40:233–248)EBD Elements: People: Patients who presentedwith the complaint of chestpain.Process: Time to patient assess-ment.Place: Elements of the builtenvironment, such as distance topatients and potential physicalbarriers such as doors.Research methods: Retrospec -tive data collection.

This retrospective cohortstudy was conducted by re -searchers at the University ofMaryland, led by Kendall Hall, a

physician who is also anarchitect. The study evaluat-ed the effect of the builtenvironment of an emer-gency department (ED) onthe timeliness of physicianassessment of chest painpatients. The main outcomevariable was time to initialphysician assessment. Potentialpredictor variables included pres-ence of a solid door; distance oftreatment room from work area;staffing team; day of week; andthe patient’s age, sex, and triagelevel. After multivariate adjust-ment, the only predictors of timeto initial assessment greater than10 minutes were being placed ina room with a door (adjustedodds ratio [OR] 1.58; 95% confi-dence interval [CI] 1.01-2.48) andbeing placed in a room 25 feet ormore from the main physicianwork area (adjusted OR 1.38;95% CI 1.13-1.67).

These findings suggest thatthe ED built environment can bea barrier to providing timelycare for this group of patientsand may have implications forfuture ED architectural designs.

Case Study #2

Effects of emergency depart-ment layout on staff efficiency (Bunker Hellmich, L., Zilm, F.and Zborowsky, T. (2010). Emer-gency Department Operations orLayout—Which is the TrumpCard in Improving Efficiency?Healthcare Design 2010 confer-ence, Las Vegas.)EBD elements:People: ED physicians and EDnursing staff.Process: Overall efficiency ofthe ED layout/floor plan. Place: Evaluation of three typi-cal ED layouts/floor plans.Research methods: Pedom eters;behavioral observation.

Informal observations ofnew emergency departmentfacilities have raised questionsregarding the potential impactof design on the short- and long-term efficiency of an emergency

service. Is there a correlationbetween the design of an emer-gency service and its perform-ance? To evaluate this question,a pilot study was undertaken toevaluate the effect of ED layouton one measure of staff effi -ciency: staff walking distance.Contemporary emergency ser -vices are typically organized intoone of three layouts. These arefrequently referred to as ball-room, pod, and linear plans (seeFig. 2).

The working hypothesis forthe pilot study predicted that thelinear layout would be the most

efficient ED layout. In linear EDdesigns, dual-entry rooms sepa-rate staff from patient and fam -ily traffic. In theory, the decen-tralized distribution of worksta-tions and supplies place staff incloser proximity to patientrooms (without intervening cor-ridors), reducing walking dis-tance and improving efficiency.The three types of ED layoutswere evaluated using pedome-ters to compare walking dis-tances, per patient seen, forphysicians and nurses workingin nine EDs across the U.S. Data


BUILDING to page 38

FIGURE 1. Framework for an optimalhealing environment (Kreitzer, M. andZborowsky, T. (2009), CreatingOptimal Healing Environments. InSynder, M. and Lindquist, R. (eds.),Complementary & AlternativeTherapies in Nursing, 6th ed. NewYork: Springer Publishing Company).

FIGURE 2.Various emergencydepartment layouttypologies. (Providedcourtesy of Frank Zilm)


The word “hospice” has itsroots in the Latin word“hospitium,” meaning

guesthouse. End-of-life carefocused on managing the symp-toms of a terminally ill patientdates back to the 11th century,when medieval hospices pro -vided a place where religiouscrusaders could rest, receivetreatment, or die. Since then,hospice care has evolved in its philosophical beliefs andpractices.

From the 1860s onward,British hospices served as mod-els of homes for the dying. The establishment in 1967 of St. Christopher’s Hospice, nearLondon, ushered in the modernera of hospice in which care forthe dying is combined with paincontrol. In 1971, Hospice, Inc.was founded in the UnitedStates and became the firstorganization to bring the princi-ples of hospice care to the U.S.At that time, the emphasis wason the use of volunteers to helppatients psychologically preparefor death. Since 1982, whenMedicare added hospice servicesto its coverage, the hospice in -

dustry has rapidly ex panded.The National Hospice and Pal -liative Care Organization reportsthat in 2010, an estimated 1.58million patients received hospiceservices (“NHPCO’s Facts &Figures on Hospice,” Jan. 2012).

How and where hospice care is provided

Hospice care can be provided inwhatever setting a patient callshome. This could be in a varietyof nursing facilities, a privatehome, or a residential hospice.Allina Hospitals & Clinics hasfound that 30 percent to 40 per-cent of patients receive theirhospice care in a residential set-ting. Most patients say that theywould want to spend their lastdays at home; yet at present,more than 50 percent of patientsdie in hospitals. It’s clear that as

the population ages, the need forhospice care and hospice bedswill continue to grow.

Hospice care is not centeredsolely on providing comfortfrom symptoms, but rather takesa holistic approach toward thepatient’s mind, body, and soul.Dignity, compassion, and provid-ing comforts of home are thecornerstones of hospice care. Ahospice care team is comprehen-sive and may include physicians,nurses, hospice aides, medicalsocial workers, pharmacists,spiritual care, bereavement ther-apists, massage therapists, andmusic therapists. Hospice con-siders the patient and thepatient’s family as the unit ofcare, and thus provides comfortand support to both patients andtheir caregivers, allowing themto spend quality time with their

loved ones during the final daysof their life.

Allina Hospice Foundationdescribes its hospice care phi-losophy this way: “Quality of lifeis emphasized, for whatevertime remains. Hospice care ispatient- and family-centered,and addresses physical, spiritu-al, emotional, and practicalneeds during a vulnerable time.We provide pain relief, familysupport, gentle guidance, andfocused activities such as musictherapy, that help patients andfamilies recall and enjoy thetimes they have spent together.We support loved ones in effec-tive grieving before the patientdies and for a year after theirdeath.”

Gratitude leads to a great idea

In 2003, Minnesota businessmanJohn Wedum had cancer andwas facing the end of his life. He received in-home hospicecare from Allina Hospice. In hishonor, the J.A. Wedum Foun-dation issued a challenge grantto Allina Hospice to build a resi-dential hospice. John’s wife,Mary Beth, said that “the build-

New “hospice house” An evolution in care provides comfort and compassion when it’s needed most

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


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Working with and for America’s Veterans is a privilege and wepride ourselves on the quality of care we provide. In return foryour commitment to quality health care for our nation’s Veterans,the VA offers an incomparable benefits package. They all cometogether at the Sioux Falls VA Health Care System.

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• Orthopedic Surgeon

• Emergency DepartmentPhysician

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ing of a residential hospice has been a dream of the Wedumfamily of many years.”

In April 2011, thanks to the generous support of donors,community members, the J.A.Wedum Foundation, and AllinaHospitals & Clinics, construc-tion began on the 12-bed resi-dential hospice. The J.A. WedumResidential Hospice opened itsdoors in February 2012.

The J. A. Wedum ResidentialHospice House, designed byMohagen/Hansen ArchitecturalGroup for Allina, embodies allthat is important to patients andtheir family. This facility, whichis one of four freestanding hos-pice facilities in the Twin Cities,helps fulfill Allina’s vision ofchanging the way end-of-lifecare is provided in this country.The J.A. Wedum ResidentialHospice was designed to meetAllina’s goal of being the goldstandard for end-of-life care.

The journey begins

Given the challenge to developan independent hospice facilityin a quiet, residential setting,Allina set out to find the rightdesign partner, teaming withMohagen/Hansen ArchitecturalGroup, which provided the exterior building design andinterior build-out of the facility,and DJ Kranz Construction,which served as general contrac-tor. Together with Allina and theAllina Hospice Foundation, theplanning of a beautiful facilitywas underway.

The design process beganwith a work session that in -cluded all project stakeholders.Sharing ideas helped the archi-tects and interior designersascertain the design style thegroup preferred. During thiswork session, a series of wordswere used over and over todescribe the desired outcomesuch as comfort, healing, cele-bration, life, flexibility, and car-ing. Those words were carriedthrough to all design discus-sions. The design style wasdefined as one that included: • Texture • Lighting• Color • Wood• Glass • Connections

to natureRenderings were developed

of both the building exterior and

the interior in order to commu-nicate the character and feelingof the space for fundraisingefforts. These efforts attracteddonations from the communityat-large, a large portion of whichwere the result of what has now become the Allina AnnualHospice Foundation Benefit.The J.A. Wedum Foundationalso agreed to match, dollar fordollar, the first $2 million ingifts raised from the community.

Like going home

The building is strategicallyplaced on the site to take fulladvantage of views of natureand wildlife. As you enter thebuilding, family members aregreeted with warm colors, a rich wood archway, soft lightingand pillars similar to what onewould find in a model home. As an alternative to hospice carebeing provided in a patient’shome or the hospital, it wasimportant that this facility offerall of the comforts of home withproper medical support. Thehouse has 12 private rooms eachwith a private seating area, andan attached patio. Residents areencouraged to personalize theirrooms with photos and othermemorabilia or accessories that make them feel comfortableand “at home.”

Each room has a privatebathroom and a comfortablesofa sleeper for a family memberwho wishes to spend the night.There is also a full, shared guestbathroom for family use. A largehydro therapy tub is also avail-able to all residents.

The house has a number ofgathering spaces. There are twolarge “family rooms” that areperfect for spending quiet timewith friends and family outsideof the resident’s room. A large“reflection room” was designedas a peaceful space, overlookingthe pond and natural edge of thesite, where family and residentscan quietly focus on theirthoughts, spirituality, and lovedones. Children of all ages arewelcome in the house. A sepa-rate children’s play area is avail-able for children to play games,watch television, and connectwith friends online.

Residents are given a choiceof meals, which are served three

times a day in each resident’sroom. There is a private diningarea and a kitchen area for fam ily and friends where theycan prepare a meal and enjoy it together. The many attributes of home provided within theHospice House allow residentsto remain comfortable whileextending that same comfort to their family and friends, whoare encouraged to come to thehouse and offer support and love at any time.

A dream becomes reality

Since opening in February 2012,the J.A. Wedum ResidentialHospice House served morethan 25 families in its first twomonths, with a length of stayclose to the national average of17 days. Staff members reportthat the beauty and warmth ofthe facility have an immediateimpact on visitors as they enterthe house, and that familiescomment every day about thewonderful care their loved onesare receiving.

Though Medicare covers thecost of hospice care, the roomand board costs, which total

nearly $400 per day, are theresponsibility of the resident. It is the hope of the Allina Hos-pice Foundation, that throughcontinuous fundraising effortsand generous contributions fromothers, they will continue to beable to provide quality, compas-sionate, hospice care to all whowish to receive it.

Although John Wedumpassed away before the journeyto de velop a residential hospicehouse began, his wife Mary Beth was instrumental in theprocess. Her inspiration andextreme generosity set the tonefor the success of this facility.Sadly, Mary Beth passed away at the end of February 2012, notlong after cutting the ribbon forthe grand opening of the J.A.Wedum Residential HospiceHouse. The entire project teamtakes solace in knowing that she was able to see the dreamshe and John shared become a reality.

Gloria Cade,RN, BSN, CHPCA, is direc-tor of Hospice and Palliative Care for AllinaHealth System. Mark L. Hansen, AIA, ishealth care principal and partner atMohagen/Hansen Architectural Group.

www.altru.org

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Contact:Kerri Hjelmstad, Physician Recruiter

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1-800-437-5373 Fax: [email protected]


Learning from our experience

What have we learned from ouroncology clinic experience sofar?

First, the positive aspects:The oncologist and palliative

care physician must becometrusted partners. Sitting next toeach other in clinic is a greathelp. Also, having a regulartumor conference where casesare discussed from both oncol -ogy and palliative perspectivescan be very helpful.

Getting to see oncologypatients early in the course oftheir disease helps the primarycare/palliative care physiciandevelop a trusting relationshipwith patients and staff, andallows us to see the positivechemotherapy effects that wepalliative care physicians wouldotherwise miss.

Working closely withchemo therapy nurses is invalu-able. Most palliative care refer-rals start with the gentle nudgeof the chemotherapy nurse whocan see the patient’s sufferingfirst hand. (Patients always want

to present a positive face to theironcologists because they want tomake them happy).

Developing a communitypalliative care program that fol-lows the same treatment para-digm as hospice, but uses a lan-guage suited to palliative care,has worked well. We discuss ourpalliative care patients at ourhospice team meetings and basi-cally use the same resources asfor our hospice clients, includingchaplains, volunteers, nurses,and bereavement specialists. We

know that some of our reim-bursements for palliative caremay not be so good, but thatthis is the best treatment for ourpatient—and hope that in futurethe success of this approach willlead to earlier appropriateentrance into hospice for thepatients. We try to raise philan-thropic dollars as much as possi-ble for this loss of income. Atpresent, we follow almost asmany palliative care patients ashospice patients in our clinic’sprogram.

We have developed severalretreats and seminars combiningour hospice and oncology staffs,focusing on their shared desiresfor patient well-being.

There were also things thatdidn’t work so well:

We tried doing palliativecare under a home care model.Home care is the Medicare reim-bursement arm that coversthings like changing wounddressings or administering IVantibiotics. It has the primaryeligibly requirement that thepatient be homebound. Becauseof this requirement, patientskept being turned away becausethey were not homebound.

Trying to do palliative carealone in the clinic created diffi-culties because so much of thework required ongoing real-timeevaluations in the home. To besuccessful, you need a full-timehome palliative care team madeup of all the components typi -cally associated with hospice(nurses, social workers, volun-teers, chaplaincy, and bereave-ment coordinators). Originally,we designated one day a week


fairview.org/physiciansTTY 612-672-7300 EEO/AA Employer

Fairview Health Services

Leading the way in innovation Fairview is seeking compassionate and adventurous caregivers—four full-time physicians and eight full-time nurse practitioners/physician assistants—to join us in developing a unique new outpatient care model. Highlights of this opportunity include:

• Care for adult patients with complex medical and behavioral needs—those not well-served in the traditional outpatient clinic—through development of a primarily home-based practice

• Partner with a Fairview Medical Group team who has demonstrated the capacity to provide compassionate, high-quality and effi cient care for a similarly complex patient population

• Provide outpatient care only; inpatient care provided by our team of hospitalists and our community and academic medical centers

Candidates must have 7+ years experience as a practicing clinician. Emphasis in hospital-based medicine, cardiac, pulmonary or end-of-life care preferred.

Visit fairview.org/physicians to explore this and other opportunities and apply online, call 612-672-2277 or email [email protected].

Sorry, no J1 opportunities.

Toolbox from page 14

TOOLBOX to page 36

Tibetan Yoga workshop and lecture

The distinctive Tibetan practice of yoga, known as Tsa Lung (vital breath andchannels), incorporates breath, awareness, and physical movement. In July,the Tibetan Healing Initiative at the University of Minnesota’s Center forSpirituality & Healing will sponsor a Tibetan Yoga lecture and workshop byM. Alejandro Chaoul, PhD. Chaoul is an assistant professor in the Integra-tive Medicine Program, Department of General Oncology, at The Universityof Texas MD Anderson Cancer Center in Houston and an assistant professorat the John P. McGovern, MD Center for Health, Humanities and the HumanSpirit at the University of Texas Medical School–Houston. His research hasexplored the use of Tibetan mind-body techniques for cancer patients.

Tibetan Yoga: Awaking the sacred body with M. Alejandro Chaoul, PhD.Friday community lecture, July 27, 20123:30–5:30 pm, Mayo AuditoriumSaturday workshop, July 28, 2012 9 a.m.–4 p.m., Minnesota Landscape ArboretumFor more information, go to:www.csh.umn.edu/programs/programeventscalendar/home.html

THE STRENGTH TO HEAL

Learn the latest treatments and play an important role in the care of Soldiers and their Families. As a physician on the U.S. Army Reserve Health Care Team, you’ll continue to practice in your community and serve when needed. You’ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. You’ll make a difference.

© 2010. Paid for by the United States Army. All rights reserved.

and stand by those who stand up for me.


St. Cloud VA Health Care System

is accepting applications for the following full or part-time positions:

US Citizenship required or candidates must have proper authorization to work in the US.

J-1 candidates are now being accepted for the Hematology/Oncology positions.

Physician applicants should be BC/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction

Program. Possible relocation bonus. EEO Employer.

Excellent benefit package including:

Sharon Schmitz ([email protected])4801 Veterans Drive, St. Cloud, MN 56303

Or fax: 320-654-7650 or Telephone: 320-252-1670, extension 6618

Favorable lifestyle

26 days vacation

CME days

Competitive salary

13 days sick leave

Liability insurance

St. Cloud VAHealth Care SystemBrainerd | Montevideo | Alexandria

Interested applicants can mail or email your CV to VAHCS

• Associate Chief, Primary& Specialty Medicine(Internist-St. Cloud)

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

• Dermatologist(St. Cloud)

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

• ENT(St. Cloud)

• Geriatrician(Nursing Home-St. Cloud)

• Hematology/Oncology(St. Cloud)

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

• Medical Director-Extended Care & Rehab(IM or Geriatrics) (St. Cloud)

• NP/PA(Montevideo)

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

Olmsted Medical Center, a 150-clinician multi-specialty

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Olmsted Medical Center provides an excellent opportunity

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The Rochester community provides numerous cultural, educational, and recreational

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Olmsted Medical Center offers a competitive salary

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Opportunities available in the following specialties:

Family MedicineRochester Northwest Clinic

Wanamingo ClinicChatfield Clinic

DermatologySoutheast Clinic

Child PsychiatrySoutheast Clinic

HospitalistOMC Rochester Hospital

Emergency MedicineOMC Rochester Hospital

Send CV to:Olmsted Medical Center

Administration/Clinician Recruitment1650 4th Street SE

Rochester, MN 55904email: [email protected]

Phone: 507.529.6610 Fax: 507.529.6622

Family PracticeUrgent Care

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Dynamic, independent 3 location, single-specialtypractice in northwest Minneapolis suburbs is seekingadditional associates for its Rogers site and has Full Time/Part Time shifts in the Crystal and Rogers Urgent Care.

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Visit our website at www.NWFPC.com

for palliative care consults at theclinic. However, most palliativecare consults start as emergen-cies. We learned that it workedbest to have a few open slotseach day, rather than one desig-nated day per week.

A role for complementary/integrative care

Another major challenge for pal-liative care physicians is helpingpatients bridge the gap betweencomplementary/integrative ther-apies and traditional allopathicmedicine. Oncology patientscrave integrative therapies andneed someone to communicatewith. Palliative care physiciansare in a unique position to fulfillthat role. We must be able to lis-ten with an open mind to ourpatients’ wishes and communi-cate clearly our desire to workwith them, without trying to bethe all-knowing authority onintegrative therapies.

Our clinic has developed areferral base for most types ofintegrative therapies, in hopes ofgetting our patients to reputablepractitioners within their spe-

cialty area. The clinic also pro-vides healing touch, reiki, andmassage, plus countless therapydogs—led by a gigantic Amer-ican bulldog that is the kindestcreature I have ever encoun-tered. We try to focus on proventherapies such as acupuncturefor neuropathic pain.

Lack of energy is the mostdifficult symptom for oncologypatients, and fatigue is a univer-sal symptom for chemotherapypatients. One of the most prom-ising nonpharmacological therapies is Tibetan Yoga. M. Alejandro Chaoul, PhD, of The University of Texas MDAnderson Cancer Center inHouston, has been developing a research program studying the effects of using Tibetan Yogaas part of a comprehensive treat-ment plan for cancer patients.

This July, he will teach the con-cepts of Tibetan Yoga and pro-vide preliminary results of hisresearch at a two-day workshopsponsored by the University ofMinnesota Center for Spiri -tuality & Healing (see sidebar).

For the past five years, ourcare system has offered mind/ -body support groups to our can-cer patients, teaching therapiessuch as yoga, meditation, andguided imagery, with the pur-pose of giving our patients toolsthat help them have some senseof control over their illness.Research is crucial to unlockingthe remarkable potential ofthese integrative therapies.

A bigger, better toolbox

Over the past five years, we havewitnessed our oncology clinicgradually transform into a heal-

ing community in whichpatients gather strength simplyby being there. I believe thenurses, doctors, patients, andfamilies all have quality of life astheir No. 1 mantra as they movethrough their cancer journey.The tool of shared decision-mak-ing helps patients and familiesmake good, informed treatmentdecisions no longer driven sim-ply by fear. Several of ourresearch protocols involve symp-tom management rather thanfocusing just on length of life.

Palliative care physicianscan be a great resource forpatients trying to survive diffi-cult chemotherapy regimens,and our toolbox keeps gettingbigger and better just as ourchemotherapy programs are get-ting more effective. Primary carephysicians, palliative care physi-cians, oncologists, and othersproviding care to cancer patientsneed each other to provide thebest quality outcomes for ourpatients.

Charles Bransford, MD, is an internalmedicine and hospice/palliative care physi-cian at Lakeview Health System inStillwater, Minn.


Toolbox from page 34 Getting to see oncology patients early in the course of their disease helps

the primary care/palliative care physician develop a trusting relationship

with patients and staff.

We invite you to explore our opportunities in:

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Enhance your professional life in an environment that provides exciting practice opportunities in a beautiful Northwoods setting. The Cuyuna Lakes region welcomes you.

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MinneapolisVA Health Care System

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

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

• Cardiology – Non-Invasive & Interventional

• Chief of Surgery/Director of Specialty Care Service Line

• Deputy Chief of Staff

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• Physician – Spinal Cord Injury

Physician applicants should be BC/BE. Possible recruitment bonus.

Interested applicants should email CV to:

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EEO Employer


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Practice Well. Live Well.Lake Region Healthcare is located in a magnificent, rural,and family-friendly setting in Minnesota lakes countrywhere we aim to be the state’s preeminent regional healthcare partner.

Our award winning patient care and uncommon medicalspecialties set us apart from other regional health caregroups. Lake Region’s physicians and their families alsoenjoy an unmatched quality of professional and personal life.

Current opportunities including competitive salary andbenefit packages available for BE/BC physicians are:

• Dermatologist• Family Medicine• Emergency Medicine

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712 Cascade St. S., Fergus Falls, MN736-8000 • (800) 439-6424

Lake Region Healthcare is an Equal Opportunity Employer. EOE

For more information contactBarb Miller, Physician [email protected] • (218) 736-8227

Emergency Medicine

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Your Emergency Practice Partner

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

The Northwest Wisconsin Region of Mayo Clinic Health System has more than 300 physicians representing a widerange of medical specialties in a community healthcare setting. We are a respected and financially secure organiza-tion with strong emphasis on high quality care and patientsatisfaction. A Mayo One emergency medical helicopter isbased in Eau Claire, offering surrounding communities access to the area’s only verified Level II trauma center.

Our current opportunities include:

Dermatology

Emergency Medicine

Endocrinology

Family Medicine

Gastroenterology

General Surgery

Hospitalist

Internal Medicine

Neurology – Adult & Pediatric

Oncology

Orthopedic Surgery – General, Sports, & Trauma

Palliative Care

Psychiatry – Adult

Rheumatology

Urology

If you wish to learn more or to express interest in this position, please contact:

Cyndi Edwards/Christie Blink by phone (800-573-2580);email [email protected] or [email protected]

The perfect matchof career and lifestyle.

Affiliated Community Medical Centers is a physician owned multi-specialty group with 11 affiliate sites located in western andsouthwestern Minnesota. ACMC is the perfect match for healthcare providerswho are looking for an exceptional practice opportunity and a high quality of life.Current opportunities available for BE/BC physicians in the following specialties:

For additional information, please contact:

Kari Bredberg, Physician [email protected], (320) 231-6366

Julayne Mayer, Physician [email protected], (320) 231-5052

www.acmc.com

• ENT• Family Medicine• General Surgery• Geriatrician/Outpatient

Internal Medicine• Hospitalist

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

• Psychiatry• Pediatrics• Pulmonary/

Critical Care• Radiation Oncology• Rheumatology

were collected during high- andlow-volume periods on Mondayand Wednesday of the sameweek.

Analysis of the pilot studydata indicated that there was nosignificant difference in walkingdistance among the ED layouts.However, closer examination ofthe data revealed that opera-tional characteristics (i.e., triageoperational model, work stationlocation, and staffing assign-ment strategies) may be moreimportant than ED layout inefforts to improve efficiency. Thesite with the lowest ratio ofwalking per patient seen imple-mented a major “lean” analysisof the hospital’s emergency serv-ice and applied that analysis tothe design of its expansion.

Results of this study havedirect application in designplanning. Understanding therelationship between operationsand ED layouts that increasestaff efficiency are critical inhelping to address the currentED crisis. Further testing ofthese assumptions will beimportant, but data from this

research should be sufficient toimmediately help guide design-ers and ED staff.

Case Study #3:

Impact of an innovative emer-gency department model ofcare and design on patientsatisfaction and outcomes,staff satisfaction and opera-tional efficiency in an aca -demic medical center(Christman, J., Kelly, C., andZborowsky, T. Study in process)

As detailed in the 2006Institute of Medicine Report“Hospital Based EmergencyCare—At the Breaking Point,”hospitals throughout the U.S.are increasingly struggling tomeet the needs of patients com-ing through the doors of thenation’s emergency departmentseach year. ED crowding prob-lems are multifactorial and per-vasive across the country. One ofthe main problems is the persist-ent backup of admitted patientsin the ED. This “boarding” ofhospitalized patients in the EDessentially takes ED beds out ofservice. With fewer beds avail-able for new patients, delays in

the care of all ED patients areinevitable.

Using tools from engineer-ing and operations research, thisED layout was developed to en -hance throughput and im provepatient flow by applying aninnovative ED concept of carefor lower acuity patients. TheUniversity of Kentucky designteam worked with consultantJim Lennon to refine the EDdesign and process flow. Build -ing on Jensen and Crane’s stra -tegy of keeping low-acuitypatients out of ED beds, theteam devised a chair-centricmodel. The chair-centric modelprovides an alternative interimspace for patients waiting to see a clinician or to receive testre sults, so they avoid returningto the waiting room but do notoccupy a bed needed for anotherpatient. In addition to increasingthroughput, the chair-centricmodel might increase patientsatisfaction by improving com-fort. A living lab of this conceptwas built, and this ED study iscurrently underway to assesspain levels, length of stay time tophysician and staff levels with

number of patients.EBD elements: People: ED physicians, EDnursing staff, and their patients.Process: Efficacy, satisfactionand patient outcomes in thechair-centric model. Place: Comparing the chair-centric model of care and the

traditional ED exam room.Research methods: Retrospec-tive data collection; question-naires; place-based behavioralobservation.

These studies represent animportant array of health-caredesign research currently beingconducted, but there is more tobe done. As we move into thenext generation of health care inthe U.S., it will be beneficial tobuild into that system ways tounderstand and measure howthe built environment supportsor detracts from the larger goalsof providing safe, efficacious,and healing environments in allhealth care settings.

Terri Zborowsky, PhD, EDAC, is direc-tor of health care education and researchand a medical planner at AECOM inMinneapolis.


Building from page 31

Yup.

Stillwater Medical Group is an 90+ provider multi-specialty group practice affiliated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services in the St. Croix Valley, just east of the Twin Cities metro area.

Internal and Family Medicine Physician Opportunities:Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN.

Mahtomedi, MN? (Ma-toe-me-dye)So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside flavor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education.

For further information please contact:Patti Lewis, Director Human Resources1500 Curve Crest Blvd, Stillwater MN(651) 275-3304, [email protected]

Internal Medicine?

Family Medicine?

Internal and Family Medicine Opportunities

NEW clinic inMahtomedi, MN?

We’ll make it all better.

If work / life balance is important enjoy these Part-time and

Casual positions currently available at four of our established clinics:

Maplewood Clinic, Woodbury Clinic, Grand Avenue Clinic and

Stillwater Clinic. Weeknight and weekend hours, 4 or 8-hour shifts.

Benefit eligibility at .5 FTE.

HealthEast® Care System, the largest non-profit health care organization

in the Twin Cities’ East Metro area, is dedicated to offering physicians

the professional journey that works best for them.

Your career journey starts here! For more information visit our

website or contact Michael Griffin, Manager of Physician/Provider Recruitment at 651-232-2227 or 702-595-3716 (Cell), or email

[email protected]. EOE

www.healtheast.org/careers

After Hours (Walk In Care)Family Medicine, Med/Peds

or Pediatrics Physicians

A Journey of Opportunity

.healtheast.orwww

rg/careers

You wouldn’t give a 1-year-old a beer, so why would you give one to an unborn child?

As a physician, it’s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy.

Share 049: Zero Alcohol For Nine Months.

www.mofas.org

minnesota physician june 2012

Documents

minnesota medical association

inour oncology clinic

oncology patientsto

medical professionals

minnesota physician

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oncology team wasstruggling