orlando medical news may 2016

Jessica Gielow, DO

PAGE 3

PHYSICIAN SPOTLIGHT

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ON ROUNDSBy LyNNE JETER

NEW SMYRNA BEACH — The news was no April foolin’. After six years of a turbulent court-ship, a spoiled engagement, and other relationship foi-bles, Adventist Health Sys-tems quelled rumors and rumblings by swallowing the big fi sh April 1.

Around the same time, Adventist changed Bert Fish Medical Center’s name to Florida Hospital New Smyrna. The $40 million deal closed with a pledge from the Altamonte Springs-based nonprofi t hospital system to invest $35 million in Volusia County. The hospital group plans to enhance the emergency department and surgical ser-vices, spiffy up the hospital exterior, create private patient rooms, and

bring the hospital’s informa-tion technology system in line with Florida Hospital’s.

The 112-bed acute care hospital provides outpa-tient and surgical services, cardiovascular care and a stroke program, oncology, radiology, wound care, and a bustling emergency department. From 2011 to 2014, the Florida Hospital Association (FHA) named Bert Fish, New Smyrna Beach’s largest employer, the Best Hospital Work-place for Small Hospitals.

The Six-Year EngagementOriginally, the Florida Hospital-Bert Fish deal was planned for July

Florida Hospital Finally Swallows Bert Fish Medical CenterDeal Comes at the End of a Rocky Road Trek

By LyNNE JETER

WINTER PARK — Doctors are ticked off, tired of straddling the abyss between independence or signing on as a hospital employee. Many physicians exhausted by the fi ght are retiring early, even a de-cade or two sooner than the traditional retirement mark.

As one doctor asked recently: “How did we go from being at the top to the food chain to being the food?”

That’s why the national Association of Independent Doctors (AID), headquartered in Winter Park, is promoting The Doctors’ Law on Capitol Hill. Marni Jameson Carey presented the proposed legis-lation to the National Physicians Council on Healthcare Policy last month in Washington, DC.

“Voices are merging to speak out against government

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First Proton Therapy Center Opens in Central FloridaOrlando Health Joins Exclusive Club

Central Florida has a valuable new tool in the fi ght against cancer. Orlando Health has offi cially opened The Marjorie and Leonard Williams Center for Proton Therapy, bringing state-of-the-art cancer treatment options to those battling cancer in Central Florida. The center, the fi rst to offer proton therapy treatments in Central Florida, joins an elite group of proton therapy centers around the world. It is the third proton therapy center to open in the state of Florida and only the 23rd in the nation. Currently there are 67 proton therapy centers worldwide ... 4

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(CONTINUED ON PAGE 10)

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Promoting The Doctor’s LawAssociation of Independent Doctors Focuses on Federal Legislation


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For Poinciana Surgeon, Florida’s Welcome is WarmGielow finds comfortable fit in community-based surgical practice

By LUCy SCHULTZE

After completing her training in the chilly Northeast, Jessica Gielow, DO, has found the warm gratitude of her Florida patients to be a pleasant surprise.

“My patients tell me, ‘Thank you for saving my life,’” said Gielow, who joined Medical Specialty Group at Poinciana last August as a general surgeon.

“I admit, I was a little jaded coming from Philadelphia,” she said. “I felt like patients were not very appreciative at all. I never heard, ‘Thank you.’

“Here in Poinciana, the population we care for has limited access to medical care. My patients have been very humble and appreciate what we do for them..”

Gielow’s practice includes a range of open, laparoscopic and endoscopic pro-cedures. Her most common procedures are gastrointestional, such as gallbladder surgery, hernia repair and operations for acute appendicitis and colon cancer. She also provides surgical treatment for breast cancer and thyroid problems, as well as smaller in-office procedures to treat cysts or skin lesions.

Gielow came to Poinciana Medical Center from the Philadelphia College of Osteopathic Medicine, where she com-pleted her internship and residency in general surgery. Her husband, Anthony, is currently in fellowship training for surgical critical care at Orlando Regional Medical Center.

“When I interviewed at Poinciana Medical Center, I enjoyed the hospital and the people I met,” Gielow said. “I’m enjoying the opportunity to practice in a community setting that’s more family-oriented.”

A native of Tennessee, Gielow was raised in a small town as part of a blue-collar family. Her father owns a small business in logging.

“My mom and dad didn’t have much, but they worked hard,” she said. “My drive came from my parents.”

Gielow was attracted to science in her youth, and sought a career in medicine for the challenge it promised. She studied bio-chemistry and cellular and molecular biol-ogy at the University of Tennessee for her bachelor of science degree. She went on to earn a doctorate of osteopathic medicine from Kansas City University of Medicine and Biosciences.

During medical school, Gielow was drawn to surgery for the same reasons most surgeons choose the field.

“I really enjoy using my hands,” she said. “And I like the immediate gratifi-cation of taking a problem and fixing it within a day’s time.”

For her generation of residents, any

barriers against women going into sur-gery seemed easily brushed away, Gielow said.

“You still come across some people in medical school who automatically di-rect you towards women’s health career paths,” she said. “And there were older physicians who assumed that as a female

surgeon, you were going into breast sur-gery.

“But where I trained, half of the residents were females. I think the issue of barriers to surgical practice is some-thing women faced more in the past than today.”

During her residency training, Gielow worked in general, trauma and vascular surgery for Aria Health System in Philadelphia. She also worked in burn surgery and critical care for the Nathan Speare Regional Burn Center. She spent a good deal of time at the burn center during her second and third years, as well as moonlighting with extra shifts there.

“We had exposure to a variety of pa-tients at burn centers ranging from house fires to soft tissue infections,” she said.

In Florida, stepping into her own practice has been both daunting and ex-citing. She is joined in practice by Mario Bernal, MD, who joined Poinciana in De-cember.

“It’s been a big transition, going from having people overseeing your patient care to managing your own patients,” Gielow said. “I’m finding it very reward-ing helping the very sick patients.

“One of my patients came in for fol-

low up and told me, ‘You’re my angel.’ Hearing things like this is a big reminder: This is why we do what we do.”

Over the past few months, Gielow has also had the chance to offer outreach in the community. She has given lectures on topics like gallbladder disease, hernias, diverticular disease and breast cancer at the Poinciana Library and other commu-nity locations.

“Our goals right now are just con-tinuing to grow the volume of our practice and letting people know what we offer,” she said.

Meanwhile, Gielow and her husband are enjoying the Florida lifestyle. They enjoy boating and going to the beach, as well as simply working out at the gym to-gether or running outdoors.

“We always talked about moving to Florida at some point. We both love the warmer weather,” she said. “We’re ex-cited to be here.”

Gielow’s professional memberships include The American Osteopathic Asso-ciation, American College of Osteopathic Surgeons, Florida Osteopathic Medical Association, Pennsylvania Osteopathic Medical Association, American Medical Association and Society of Gastrointesti-nal and Endoscopic Surgeons.

PhysicianSpotlight

Dr. Jessica Gielow


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Central Florida has a valuable new tool in the fight against cancer. Orlando Health has officially opened The Marjorie and Leonard Williams Center for Proton Therapy, bringing state-of-the-art cancer treatment options to those battling cancer in Central Florida. The center, the first to offer proton therapy treatments in Central Florida, joins an elite group of proton therapy centers around the world. It is the third proton therapy center to open in the state of Florida and only the 23rd in the nation. Currently there are 67 proton therapy centers worldwide.

Orlando Health treated its first pa-tients with proton therapy on April 6. The Marjorie and Leonard Williams Center for Proton Therapy will treat cancers of the brain, spine, prostate, lung, breast, gastrointestinal tract, head and neck as well as pediatric cancers. Proton therapy, because it can so precisely target tumors, holds the promise of effective treatment with fewer side effects. This type of therapy limits the dosage of radiation to adjacent organs, thereby potentially limit-ing side effects in all patients, and reducing the effect on growth in pediatric patients.

“Here in Florida we face the second highest cancer burden in the nation. Now patients in Central Florida can receive the most advanced radiation treatment option available close to home,” said Mark Roh, MD, President, UF Health Cancer Cen-ter - Orlando Health. . “By opening this

proton therapy center, Orlando Health is changing the face of cancer care options available to patients and propelling Cen-tral Florida forward as a global healthcare destination.”

The Marjorie and Leonard Williams Center for Proton Therapy is located along Orange Avenue between Orlando Regional Medi-cal Center and UF Health Cancer Center

- Orlando Health. The 15,000 square foot facility, which took four years to build, con-sists of three floors – two above ground and one underground – in order to accommo-date the MEVION S250 superconducting synchrocyclotron proton accelerator. The MEVION S250 is an advanced compact proton therapy system that operates simi-lar to a linear accelerator. The MEVION

system at Orlando Health is the 5th system of its kind operating nationwide and one of only 10 currently planned for the United States and Europe.

“We began the conversation to bring proton therapy to Central Florida a de-cade ago, when there were only a handful of centers around the world and they were huge - the size of football fields,” said Dan-iel Buchholz, MD, chairman, Department of Radiation Oncology, UF Health Cancer Center – Orlando Health. “Now because of forward thinking and development of the compact MEVION system we are able to provide the most advanced proton therapy treatment to our patients.”

The first patient to be treated with pro-ton therapy in Central Florida was Rhea Birusingh, a 37-year-old woman who found out while she was pregnant that she had a benign brain tumor located behind her right eye. The tumor is inoperable and without proton therapy Rhea would face an increased risk of short term memory de-cline, and loss of eyesight. Her treatment is expected to last six weeks.

“Patients such as Rhea help to illus-trate the life-changing effect that proton therapy can have on those facing a difficult cancer diagnosis or, as in her case an in-operable benign tumor that could not be treated as well with conventional radia-tion,” said Naren Ramakrishna, MD, PhD, Director, Proton Therapy, UF Health Cancer Center -Orlando Health. “Proton therapy is a revolutionary treatment option and it is very exciting that we can now offer this to our patients.”

“I am incredibly grateful and excited that I can receive this treatment, by an expert team of professionals, right here in Central Florida where I live,” said Rhea Bi-rusingh, who will be the first proton therapy patient at Orlando Health. “As a mother of a newborn baby this allows me the op-portunity to be treated without leaving my family and to treat this tumor effectively so that I get to savor these precious moments with my son.”

In the first year Orlando Health es-timates that it will treat 125 patients with proton therapy, approximately 20 patients a day. Once operating at full capacity the proton therapy center is expected to treat 225 patients annually, as many as 26 patients a day. On average, patients undergoing proton therapy receive 25-30 treatments over four to six weeks.

The Marjorie and Leonard Williams Center for Proton Therapy is named in memory of Marjorie Williams, a patient at UF Health Cancer Center - Orlando Health who passed away in September of 2015 follow-ing a courageous battle with cancer. Her husband, Leonard, and the Williams Family Foundation provided a leadership gift in her name to Orlando Health to support proton therapy treatment in Central Florida.

First Proton Therapy Center Opens in Central FloridaOrlando Health Joins Exclusive Club

Oncologists and physicists with Orlando Health cut the red ribbon officially opening the Marjorie and Leonard Williams Center for Proton Therapy. From left, Akash Nanda, MD, PhD, Radiation Oncologist, Mark Roh, MD, President, UF Health Cancer Center - Orlando Health, Leonard Williams, generous supporter of proton therapy, Daniel Buchholz, MD, Chairman, Radiation Oncology, Naren Ramakrishna, MD, PhD, Director, Proton Therapy, Clarence “Buck” Brown, MD, past President, UF Health Cancer Center - Orlando Health, Omar Zeidan, PhD, DABR, Chief, Proton Therapy Physics, Tomas Dvorak, MD, Radiation Oncologist.


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By TODD ANDREW

In my hometown of Orlando, medical construction is booming like never before. Both of the region’s major hospital systems are undergoing massive expansion, and the newly created Medical City in nearby Lake Nona – which features a world-class VA Medical Center, the Sanford Burn-ham Prebys Medical Discovery Institute, Nemours Children’s Hospital and two academic research centers – is changing Central Florida’s healthcare landscape in dramatic fashion.

But that’s just part of the story. Across America, more healthcare systems are building satellite campuses and small- to mid-sized offices that extend their reach deeper into surrounding communities. According to Colliers International, 62 percent of medical office space under con-struction in the U.S. as of March 2015 was located off-campus, and overall tenant de-mand for healthcare real estate continues to increase.

Further, the report found that “many medical systems and third-party develop-ers (are) opting for ground-up construc-

tion, concentrating development near dominant hospitals and health systems and targeted population groups.”

As a general contractor, I regularly field questions from potential clients in the market for building or renovating a medical facility – everything from doctor’s offices to the skilled nursing components of a senior care community. Understand-ably, the topic isn’t second nature to most healthcare professionals, so they’re look-ing for a wide range of information that will make the process as seamless as pos-sible.

My advice boils down to two things: Find the best general contractor for the job, and understand what to expect throughout the process. Let’s explore both areas.

What to look for in a general contractor

The best combine large-firm capa-bilities with a small-firm, customer-centric approach. They want your business – today and tomorrow – and they do that by building strong relationships based on trust, integrity and consistent performance

rather than just bottom-line objectives. When choosing a general contractor

to build a medical facility, here are six fac-tors to consider:

Expertise: What is the firm’s expe-rience with related projects? How knowl-edgeable are they when it comes to your specific medical needs and industry regu-lations? A good general contractor should be able to provide expert advice when it comes to choosing and installing the right kind of flooring, lead-line drywall, mechanical, electrical, plumbing, light-ing, specialty furniture, fixtures, and other technology.

Referrals: What percentage of the firm’s business comes from repeat cus-tomers? (The higher the better.) Ask for recommendations from local industry professionals, subcontractors and trusted professionals. Visit projects the general contractor has built, and ask for a list of client referrals. Consult with the Bet-ter Business Bureau, and look to indus-try organizations that have membership lists, such as the Associated Builders and Contractors or the Association of General Contractors.

Willingness to negotiate: Sophis-ticated clients negotiate contracts with general contractors rather than sacrific-ing quality and service by simply “bidding out” their jobs to the lowest-cost provider. Most owners have a preliminary idea of the cost per square foot. During the bid-ding process, ask for a complete cost breakdown proposal that spells out the conditions and project scope. The general contractor can also obtain multiple bids from subcontractors to ensure competi-tive pricing.

Attention to detail: Make sure the firm provides a detailed schedule and that it is followed. Schedule changes are sometimes uncontrollable and inevitable, so when expected delays arise, the general contractor should provide a written expla-nation and revised completion date.

On-site quality: Professionalism, organization and control are highly im-portant, especially when coworkers or colleagues visit the job site. The best firms employ superintendents who make sure their area is clean and safe – and that the crew is doing its job appropriately.

Red flags: Be wary of general con-tractors who have reputations as “low-cost” providers. Low bidding often creates an adversarial relationship between the owner and architect. A firm that recklessly cuts corners to keep costs down ultimately compromises the overall project quality, schedule and budget.

Communication skills: General contractors must balance the demands of owners, architects and subcontractors, so it’s important to find someone who can communicate effectively with all parties

and maintain a good working relationship. Communication is the key to staying on time and within budget.

What to expect during the buildWhile the approach will vary from

firm to firm, here’s a basic outline of how experienced general contractors will guide clients through the build process:

Initial client meeting and early collaboration can involve everything from clients articulating their vision to (in some cases) presenting preliminary con-cepts and space plans or full construction documents. From there, clients usually choose from a design/assist procurement strategy, a design/build project delivery system (to minimize owner risk and create a one-stop shop and single-source respon-sibility) or a traditional bid/build process (where the client contracts with the design team and contractor separately).

Preliminary budget pricing pro-vides early insight into what it will cost without spending money for a full set of design documents. Once the owner is comfortable with the budget, the architect is given approval to proceed with a set of design documents to secure building per-mits.

Final proposal preparation and sub-bidding take place after the design team finalizes the “permit-ready” con-struction plans; meanwhile, the permitting agency reviews the documents for compli-ance. Even more accurate pricing can be obtained during this phase. After contracts are signed, most general contractors will provide a written bar chart schedule and commit to a finish date.

An on-site manager/superin-tendent is assigned to ensure compliance with the schedule and job specifications. A project manager will report to the cli-ent to make sure performance is on bud-get, ahead of schedule and being done in a quality fashion. If changes or logistical problems arise during the project phase, your general contractor should be able to facilitate solutions quickly and effectively.

In the closeout phase, general contractors perform a number of impor-tant activities, including final cleanup, in-spections and internal punch list prior to the final walkthrough. The goal is to instill clients with a sense of satisfaction and clo-sure so they can move forward with other important business matters – like keeping patients’ health top of mind!

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Todd Andrew is president and owner of Andrew General Contractors, a full-service Orlando-based firm he started in 1996 after nine years of management and operational experience in the construction industry. Andrew GC has built and renovated dozens of medical facilities and labs for clients in the fields of dentistry, diagnostics, derma-pathology, OB/GYN, ophthalmology, skilled nursing and general wellness. To learn more, email [email protected].


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encroachment, hospital takeovers, and insurer tyranny,” said Carey, executive director of AID. The association collaborates with other groups fighting for physician freedom, including the Association of American Physicians and Surgeons (AAPS) and American College of Private Physicians (ACPP). “Word is getting out. Together, we’re speaking out about national trends driving up costs, driving out physicians, and compromising care.”

Case in point: “Hospital Job May Hold Rude Shocks for Physicians,” was the headline for a Medscape Medical News article last October.

“Headlines like these weren’t com-mon a few years ago,” said Carey. “Today, we see stories like this daily. This is prog-ress. We need to get consumers informed.”

The Doctor’s Law aims to:Bolster anti-trust laws by forbidding

hospitals from acquiring physician prac-tices, or at least compromising on capping all hospitals in an area from owning a maximum of 40 percent of any one spe-cialty in its community.

Promote parity by requiring third-party payors to reimburse doctors the same amount for the same procedure, whether the doctor is independent or hospital-employed. “This is a recommen-dation Medpac has long advised, but law-makers have ignored,” noted Carey.

Advance transparency by abolishing facility fees, or at a minimum revealing them. In Connecticut, all hospital-owned medical practices and facilities are re-quired to disclose their facility fees to pa-tients before their appointments, disclose the amount of the fee, and inform patients that if they choose an independent doc-tor or facility, a facility fee will not be in-curred. “This should be the law in every state,” she said.

Stop nonprofit hospitals’ abuse of their tax-exempt status by requiring the institutions that behave like for-profit hospitals to pay taxes. “Tax-exempt cri-teria for nonprofit hospitals allows them to justify their exemption by providing charitable care for the community equal or greater to the taxes they’re not pay-ing. However, they should be required to measure charitable contributions based

on Medicare reimbursement rates, not Charge Master prices, which are inflated five to 10 times of actual costs,” explained Carey. “They’re ripping off taxpayers and communities.”

Just as an example, according to data from the Florida Bar Journal’s February edi-tion, comparisons for the average Charge Master (CDM) price versus total Medicare allowable charges for eight diagnoses are:

• Transient ischemia: $30,192 v. $4,724.

• Simple pneumonia and pleurisy: $52,865 v. $9,380.

• Major cardiovascular procedures: $118,169 v. $21,269.

• Permanent cardiac pacemaker im-plant: $86,717 v. $16,268.

• Chest pain: $25,559 v. $3,626.• Laparoscopic cholecystectomy:

$70,545 v. $10,699.• Back and neck procedure excluding

fusion: $51,584 v. $6,881.• Infectious and parasitic diseases

with operating room procedure: • $180, 708 v. $35,452.“How do we get to a place where

there’s parity among doctors, whether in-dependent or hospital-employed? Get our lawmakers on board with a bill. Talk to the media. Educate consumers and busi-nesses. Join forces with AID,” said Carey. “We have to get big and loud to give doc-tors a voice and patients a choice.”

The fact that hospitals can charge a lot more for the same procedure is what makes it possible for them to afford to buy doctors, noted Carey.

“Hospitals love owning doctors be-cause they get more money, and capture patient share/referrals,” she explained. “The fact that the nonprofits don’t pay any property, sales or income tax also gives the hospitals more money to buy doctors. So if we enforce parity, and get hospitals to be honest about what they re-ally give back in terms of charitable care, their appetite for buying doctors would be curtailed. Meanwhile, informing patients about extra fees helps steer them toward independent doctors.”

Promoting The Doctor’s Law,continued from page 1

Save the DateOn Saturday, Nov. 5, the

Association of Independent Doctors (AID) will host “Independence in Action,” at the Walt Disney World Swan & Dolphin Resort in Orlando. The annual conference will feature Richard Gunderman, MD, PhD, a radiologist who will present “The Case for Autonomy.” Michael Reilly, MD, an orthopedic surgeon and whistleblower behind the second largest hospital false claims settlement in U.S. history – a $69.5 million penalty for Broward Health – will talk about “Games Hospitals Play.”

For more information, visit www.aid-us.org/conference.

@orlandomednewsfor updates and breaking news

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Digestive and Liver Center of Florida is pleased to welcome Dr. Megan DelimataDr. Delimata completed her medical residency and fellowship at Cook County Hospital (Stroger) in Chicago.

Dr. Megan Delimata's special interests include digestive health and diseases in women, colon cancer prevention, management of acid reflux, gastrointestinal evaluation of iron deficiency anemia, liver and biliary tract diseases.

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Digestive and Liver Center of Florida is pleased to welcome Dr. Megan Delimata.

Dr. Delimata completed her medical residency and fellowship at Cook County Hospital (Stroger) in Chicago.

Dr. Megan Delimata’s special interests include digestive health and diseases in women, colon cancer prevention, management of acid reflux, gastrointestinal evaluation of iron deficiency ane-mia, liver and biliary tract diseases.

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1, 2010, after the Southeast Volusia Hospital District Board of Commissioners voted 4-2 to exclusively negotiate the merger of both facilities. Before that, Daytona Beach-based Halifax Health and Titusville-based Parrish Medical Center were also wooing Bert Fish. The $51.1 agreement in 2010 also included the option to acquire Bert Fish in 2015.

In 1966, the nonprofit Bert Fish Foun-dation donated the hospital to the Southeast Volusia Hospital District, a special taxing district created by Florida lawmakers in 1947 that collects tax dollars from south-east Volusia residents to cover the cost of indigent care. The philanthropic organiza-tion filed suit against the merger in August 2010 on the basis the deal was made behind closed doors, perhaps because of personal financial gain.

After Circuit Judge Richard Graham voided the Florida Hospital-Bert Fish agree-ment on the grounds the closed-door nego-tiations violated the Sunshine Law, Bert Fish bypassed Halifax Health and Parrish Medical Center to negotiate exclusively with Naples-based, for-profit Health Man-agement Associates (HMA). When Com-munity Health Systems (CHS) acquired HMA, negotiations ended. CHS, also a for-profit hospital system, was uninterested in acquiring the facility.

Cue the Locusts For a spell, Florida Hospital might have

seemed jinxed. Around the same time the judge’s ruling came down, Health Central, another hospital Adventist was pursuing, chose to merge with Orlando Health. Also during the gap between Bert Fish merger talks, former Florida Hospital CEO Lars Houmann was busy fielding legal woes for the healthcare system. (Houmann was promoted to Adventist executive vice president on Dec. 1, 2015.) Within the last year, Adventist has settled the infamous whistleblower case for $115 million and the leftover chemotherapy drugs case for $2 million. Last Thanksgiving, Florida Hospital in Tampa drew headlines for a murder-suicide, after the stepfather of a female shot her and then himself. Both were visitors to the Hillsborough County hospital.

Controversy swirled when Florida Hospital continued construction of its $3.5 million lab in DeLand after the discovery of unmarked graves on the site.

The Southeast Volusia Hospital Dis-trict also seemed snake-bit. The unique district, with seven governor-appointed commissioners, remains one of few special tax districts in Florida charged with levy-ing taxes to support the hospital’s indigent care. The district had weathered troubled waters, from a move to purge the Board to requesting new appointments for three board members whose terms had expired. Property tax hikes for Edgewater, New Smyrna Beach, Oak Hill and some of Port Orange didn’t sit well with residents. For-mer Bert Fish CEO Bob Williams and Dis-trict lawyer Jim Heekin had come under fire for perhaps gaining financially from the merger, thus bringing closed-door negotia-tions under scrutiny. Williams was ousted.

The Bert Fish CEO role has also been problematic. Ed Noseworthy, Robert Deininger, and Steve Harrell have shared the post since 2010.

The Second Go-RoundAt the time of the merger announce-

ment in November 2014, Daryl Tol, then a regional CEO for Florida Hospital’s Volu-sia-Flagler market, said: “The best way to characterize it is we’re getting engaged. Now, we have to do the hard work that comes be-fore we officially get mar-ried.” Since then, Tol has been elevated to CEO of Florida Hospital and Ad-ventist Health System’s Central Florida Region.

In November 2014, Florida Hospital and Bert Fish began the laborious process of ironing out wrinkles for the final transaction, which included a plan to cut the district’s hospital taxing rate by 70 percent over seven years, starting with a first-year 15 percent reduc-tion. Establishing an endowment could eliminate taxes by 2023.

With the transaction completed, Bert

Fish joins Adventist’s East Florida Region as the sixth medical center in Volusia and Flagler counties. Overseen by CEO Rob Fulbright for the East Florida Region, other facilities in the portfolio include Florida Hospital DeLand, Florida Hospital Fish Memorial in Orange City, Florida Hospital Flagler in Palm Coast, Florida Hospital Me-morial Medical Center in Daytona Beach, and Florida Hospital Oceanside in Ormond Beach. Florida Hospital has been busy in Volusia County. The healthcare system re-cently established a $14.5 million outpatient center near Interstate 95 in New Smyrna Beach, and Centra Care in Port Orange.

The deal also gave Florida Hospital 23 medical centers along Central Florida’s In-terstate 4 corridor, from Daytona Beach to Tampa Bay. With 46 hospitals and roughly 8,200 licensed beds in 10 states, Adventist represents the nation’s largest Protestant non-profit health system.

Trickle Down EffectsHalifax Health, whose request for an-

other consideration was denied in original negotiations, lost out in another matter. With the Bert Fish deal, Florida Hospital replaced Halifax Health as the exclusive healthcare provider for Daytona Interna-tional Speedway through 2028.

After the ink dried, Bert Fish CEO Steve Harrell expressed enthusiasm mov-ing forward. “We’re all pleased,” he said, “to see this agreement come to fruition.” A week later, Ken Mattison replaced Harrell as CEO of Florida Hospital New Smyrna. Until May 1, Mattison also remained CEO of Florida Hospital Flagler. Mattison is for-mer CEO of Florida Hospital Waterman and Jellico Community Hospital.

On May 1, Ron Jimenez, MD, took the CEO post at Florida Hospital Flagler. A gynecologist, Jimenez had been CMO of Florida Hospital Memorial Medical Center in Daytona Beach since 2009. He relocated from North Carolina, where he was CMO of Park Ridge Health in Fletcher. Jimenez, a for-mer Resident Teacher of the Year at the Uni-versity of Florida, will oversee completion of Florida Hospital Flagler’s 32-bed expansion.

Florida Hospital Finally Swallows Bert Fish, continued from page 1

Daryl Tol

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By SRINIVAS SEELA, MD

CholecystitisAcute cholecystitis refers to a syn-

drome of right upper quadrant pain, fever, and leukocytosis associated with gallblad-der inflammation, which is usually related to gallstone disease (i.e., acute calculous cholecystitis). Complications include the development of gangrene and gallbladder perforation, which can be life threatening.

Cholecystitis is inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis. Uncomplicated cholecystitis has an excellent prognosis; the development of complications such as perforation or gangrene renders the prog-nosis less favorable.

Signs and symptoms• The most common presenting

symptom of acute cholecystitis is upper abdominal pain.

• The following characteristics may be reported:

• Signs of peritoneal irritation may be present, and the pain may radiate to the right shoulder or scapula

• Pain frequently begins in the epi-gastric region and then localizes to the right upper quadrant (RUQ)

• Pain may initially be colicky but al-most always becomes constant

• Nausea and vomiting are generally present, and fever may be noted

• Patients with acalculous cholecysti-tis may present with fever and sepsis alone, without history or physical examination findings consistent with acute cholecystitis.

Cholecystitis may present differently in special populations, as follows:

Elderly (especially diabetics) – May pres-ent with vague symptoms and without many key historical and physical find-ings (e.g., pain and fever), with localized tenderness the only presenting sign; may progress to complicated cholecystitis rap-idly and without warning

Children – May present without many of the classic findings; those at higher risk for cholecystitis include those who have sickle cell disease, serious illness, a re-quirement for prolonged total parenteral nutrition (TPN), hemolytic conditions, or congenital and biliary anomalies

The physical examination may reveal the following:

• Fever, tachycardia, and tenderness in the RUQ or epigastric region, often with guarding or rebound

• Palpable gallbladder or fullness

of the RUQ (30-40 percent of pa-tients)

• Jaundice (~15 percent of patients)• The absence of physical findings

does not rule out the diagnosis of cholecystitis.

DiagnosisLaboratory tests are not always reli-

able, but the following findings may be diagnostically useful:

• Leukocytosis with a left shift may be observed

• Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels may be elevated in cholecystitis or with common bile duct (CBD) obstruction

• Bilirubin and alkaline phosphatase assays may reveal evidence of CBD obstruction

• Amylase/lipase assays are used to assess for pancreatitis; amylase may also be mildly elevated in cholecys-titis

• Alkaline phosphatase level may be elevated (25 percent of patients with cholecystitis)

• Urinalysis is used to rule out pyelo-nephritis and renal calculi

• All females of childbearing age should undergo pregnancy testing

Diagnostic imaging modalities that may be considered include the following:

• Radiography• Ultrasonography• Computed tomography (CT)• Magnetic resonance imaging (MRI)

The American College of Radiology (ACR) makes the following imaging rec-ommendations:

• Ultrasonography is the preferred initial imaging test for the diagnosis of acute cholecystitis; scintigraphy is the preferred alternative

• CT is a secondary imaging test that can identify extrabiliary disorders and complications of acute chole-cystitis

• CT with intravenous (IV) contrast is useful in diagnosing acute chole-cystitis in patients with nonspecific abdominal pain

• MRI, often with IV gadolinium-based contrast medium, is also a possible secondary choice for con-firming a diagnosis of acute chole-cystitis

• MRI without contrast is useful for eliminating radiation exposure in pregnant women when ultrasonog-

A Look at CholecystitisThe complications can be life-threatening.


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raphy has not yielded a clear diag-nosis

• Contrast agents should not be used in patients on dialysis unless abso-lutely necessary

Treatment Once a patient develops symptoms or

complications related to gallstones (biliary colic, acute cholecystitis, cholangitis, and/or pancreatitis), definitive therapy (chole-cystectomy, cholecystostomy, endoscopic sphincterotomy, medical gallstone dissolu-tion) is recommended. Without treatment to eliminate the gallstones, the likelihood of subsequent symptoms or complications is high. Complications include the devel-opment of gangrene and gallbladder per-foration, which can be life threatening

Treatment of cholecystitis de-

pends on the severity of the condition and the presence or absence of complications.

For acute cholecystitis, initial treat-ment includes bowel rest, IV hydration, and correction of electrolyte abnormali-ties, analgesia, and IV antibiotics.

Patients with acute cholecystitis should be admitted to the hospital for sup-portive care, which includes intravenous fluid therapy, correction of electrolyte disorders, and control of pain. Antibiotics may also be indicated.

The selection and timing of defini-tive therapy depends upon the severity of symptoms and the patient’s overall risk for cholecystectomy.

If gangrene or perforation are sus-pected, or if the patient develops progres-sive symptoms and signs such as fever,

hemodynamic instability, or intractable pain while on supportive therapy, emer-gency cholecystectomy or gallbladder drainage may be needed.

Low-risk patients without emergent indications for intervention generally un-dergo laparoscopic cholecystectomy pref-erably during the same admission.

High-risk patients without emergent indications for intervention are treated with a gallbladder drainage procedure if symptoms do not improve with support-ive care. For patients whose medical status can be optimized to allow surgery, chole-cystectomy can be considered.

For cases of uncomplicated cholecys-titis, outpatient treatment may be appro-priate. The following medications may be useful in this setting:

• Levofloxacin and metronidazole for prophylactic antibiotic coverage

against the most common organ-isms

• Antiemetics (e.g., promethazine or prochlorperazine) to control nausea and prevent fluid and electrolyte disorders

• Analgesics (e.g., oxycodone/acet-aminophen)

• Surgical and interventional proce-dures used to treat cholecystitis in-clude the following:

• Laparoscopic cholecystectomy (standard of care for surgical treat-ment of cholecystitis)

• Percutaneous drainage• ERCP• Endoscopic ultrasound-guided

transmural cholecystostomy• Endoscopic gallbladder drainage

Morbidity and Mortality The overall mortality of a single

episode of acute cholecystitis is approxi-mately 3 percent. However, the risk in a given patient depends upon the patient’s health and surgical risk. Mortality is less than 1 percent in young, otherwise healthy patients, but approaches 10 per-cent in high-risk patients, or in those with complications.

A study of the American College of Surgeons National Surgical Qual-ity Improvement Program (NSQIP) database evaluated outcomes follow-ing treatment of acute cholecystitis in 5460 patients with and without dia-betes. Mortality among 770 patients with diabetes was significantly higher than in the 4690 patients without di-abetes (4.4 versus 1.4 percent). The risk for complications including car-diovascular events and renal failure was also significantly increased.

A Look at Cholecystitis, continued from page 11

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By RAUL L. ZIMMERMAN, MD

There are several different types of conversations I find myself having with patients facing life-limiting illness. These include:

• The advanced directive conversa-tion,

• The delivering bad news conversa-tion,

• The hospice conversation. These conversations may happen

all at once or might be given at different times. At some point, I have to have the conversation that always seems to get me emotional – the real end-of-life conversa-tion.

If the patient/family wants to know, I will try and give my best estimate of life expectancy as one of the following ranges — minutes to hours; hours to days; days to weeks; weeks to months.

Whether they want me to be that spe-cific or not, I need words that will allow patient and family to hold on to hope while allowing them to prepare for ap-proaching death.

I want to share some of the words I use as I struggle to be the physician, whose duty it is to inform/explain, and the fellow human being who is emotionally present for a frightening and potentially over-whelming discussion.

The patient’s journey is changing - going forward, it will be less of a medical journey and

more of an emotional/spiritual jour-ney - and I need to help with that transi-tion. The patient needs to feel that I know about the disease while caring deeply for him/her as a person.

It might be something like…“I know you have had a lot of bad

news in the past few days. I can only imag-ine how hard this has been for you and your family. How are you holding up?”

(I listen and acknowledge expressed emotion, both verbal and non-verbal.)

“Please know that every medical team member involved in your care is hoping and praying that everything goes well for you in the days ahead. It’s impor-tant not to lose hope. We’re hoping for a lot of things, but high on our list is that we’ll soon have you feeling better and that you’ll have good quality time ahead at home with your family. I wouldn’t be doing my job well, however, if I didn’t talk to you about some concerns. These are concerns I try and go over with every patient who has had bad news like you have had. It’s not an easy conversation to have, but it’s important. Do I have your permission to talk about these concerns?”

(I listen, and I stop the conversation if the patient indicates he/she is not ready for it. There’s always another day.)

“It’s impossible to predict the exact course of any illness or exactly how long someone might live. But things can

change very quickly with a condition like yours. It’s good to hope for the best, but it’s equally important to make sure we have plans in place in

case things don’t go as we want them to.”

Being prepared means “taking care of business” and I am thinking not only of financial/legal business, but emotional and spiritual business.

Here are some things I recommend to patients with an illness like yours:

• Now is the time to make sure that you let all the very important peo-ple in your life know how much you love and care about them. Hope-fully, you do that anyway, but it’s very important now. Reach out.

• It’s time to consider asking forgive-ness from those you feel you might have wronged.

• It’s probably time to also consider forgiving those who may have wronged you.

• It’s time to make sure financial and legal affairs like wills, living wills, etc. are in order and that those you trust have access to information they might need when you may no longer be able to communicate.

• And, if you are a religious or spiri-tual person, it’s time to make peace with your God or higher power.

“I am not telling you these things be-cause I think you are going to die tonight, tomorrow, or next week. No one knows for sure how much time you have left. What I can tell you with some certainty, however, is that there are going to be some better days and some worse days ahead of us. I am hoping that by unburdening yourself of some of these concerns now, you will be able to make the best of the good days ahead and more easily slide through those not-so-good days. What are your thoughts about these concerns?”

(I listen and acknowledge expressed emotion, both verbal and non-verbal.)

“Though you haven’t brought it up, I know many patients wonder if they will have uncontrollable pain or suffering ahead of them. I want to let you know that the vast majority of time we are able to control symptoms in cases like yours. This is teamwork, however, and you are the most important part of the team. If you promise to let us know when you’re hurting in any way, we promise to do ev-erything we can to keep you comfortable.”

“I know this conversation has not been easy for either of us. I appreciate your willingness to talk about these dif-

Hard Words to SayWords Can Comfort When the Foundation is Caring


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GrandRoundsficult issues. In my heart, I know being open this way is the right thing to do, and I hope you feel the same. I also hope you will feel free to speak with me regarding other issues that might be on your mind. Are there any questions or other things you want to share now?”

(I listen.)Even if the patient does not want to

hear specifics about prognosis, from this talk they clearly understand that there is some urgency in “taking care of business” while holding on to hope. Though this is about all that a patient/family can take at one sitting, the conversation tends to open a communication door that allows for some honest give and take in future talks.

This conversation usually gets two reactions:

• Everyone in the room (including the doctor) is tearful,

• The patient (and family members if present) express gratitude.

Just a few closing words of wisdom on conversations like the one above:

• They shouldn’t happen from the doorway. Sit down next to the pa-tient with your eyes preferably at the same level as their eyes.

• If you don’t have time to do the “lis-tening” part of the above conversa-tion, you may want to postpone the conversation altogether.

• Touch can be incredibly meaning-ful during these conversations.

• I will usually reach out to hold a hand at the first sign of tears. Or if no tears, it usually feels right to reach for that hand during the last paragraph.

• Your tears, should they come (and mine often do), are a sign to the patient of genuine caring, not of weakness.

• Sometimes our words and our pres-ence are our most important tools and they can be very powerful.

WHAT’S YOUR STORY, DOC?PROSPECTIVE PATIENTS WANT TO KNOW. Today you must differentiate yourself and your practice. Word-of-mouth is no longer enough.

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Hard, continued from page 1

Raul L Zimmerman, MD, is medical director at Halifax Health Hospice. Visit www.HailfaxHealth.org/hospice.

Dr. Phillips, Inc. Unveils New Senior Living and Health Care Campus

With construction now underway, Dr. Phillips, Inc. unveiled much-anticipated de-tails about its Spring Lake Health and Living Campus on 26 acres in the heart of the Dr. Phillips neigh-borhood. During a special beam-signing event April 14, representatives from Dr. Phillips, Inc. and its project partners will dis-cussed how they are building the future to better serve residents of southwest Orange County.

The $75 mil-lion Spring Lake Health and Living Campus takes a holistic approach to health care and senior living that is rare not only in Florida but across the nation. Dr. Phillips, Inc. is partnering with industry leaders Orlando Health and Harbor Retirement Associates (HRA) on this project, which combines a 60,000-square-foot medical office building on the same campus as a 180-unit senior housing complex. A three-level parking garage will be adjacent to the health pavilion.

The state-of-the-art senior community at Spring Lake will feature the tantalizing Chef’s Fare dining program, which provides a wealth of choices tailored to each indi-vidual’s preferences. It also will offer HRA’s signature Life Enrichment Program, designed to provide social, devotional, fitness and recreational opportunities that have a positive influence on residents.

The goal is to provide residents of the close-knit communities of Dr. Phillips, Bay Hill and Windermere the opportunity to age in place near their families, their churches and their friends.

This integrated approach carries over to the design of the Orlando Health Medi-cal Pavilion at Spring Lake, which will have offices for both primary care physicians and specialists from Physician Associates and Orlando Health Physicians Group, two of the area’s most comprehensive practices. Experts in internal medicine, orthopedics, geri-atrics, oncology and cardiology will be located in the three-story medical pavilion on Della Drive. On-site imaging and diagnostic centers, a pharmacy and a café reinforce the integrated experience patients can expect when the area’s first community health pavilion opens.

Dr. Phillips, Inc. selected Brasfield & Gorrie as the general contractor for the Spring Lake campus. Orlando Health also chose Brasfield & Gorrie as the contractor for the interior build out of the medical offices, which will open in 2017. HRA expects the first housing units to be available in 2018.


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