               IN THE SUPREME COURT OF IOWA
                              No. 08–1643

                        Filed December 23, 2010


BROADLAWNS MEDICAL CENTER,

      Appellant,

vs.

ROSE MARIE SANDERS,

      Appellee.



      On review from the Iowa Court of Appeals.



      Appeal from the Iowa District Court for Polk County, Douglas F.

Staskal, Judge.



      Employee seeks further review of court of appeals’ decision in

appeal of workers’ compensation judicial review decision. DECISION OF

COURT OF APPEALS AFFIRMED IN PART AND REVERSED IN PART;

DISTRICT COURT JUDGMENT AFFIRMED IN PART AND REVERSED

IN PART.



      Michael L. Mock and D. Brian Scieszinski of Bradshaw, Fowler,

Proctor & Fairgrave, P.C., Des Moines, for appellant.



      Michael R. Hoffmann of Hoffmann Law Firm, P.C., Des Moines, for

appellee.
                                    2

TERNUS, Chief Justice.

      This workers’ compensation case comes to us on further review

from the court of appeals. The appellee, Rose Marie Sanders, asks us to

reinstate an award of permanent partial disability (PPD) benefits made by

the workers’ compensation commissioner and affirmed by the district

court, but reversed by the court of appeals for lack of substantial

evidence.   We agree with the district court that substantial evidence

supports the commissioner’s award of PPD benefits.          Therefore, we

reverse that part of the court of appeals’ decision reversing the award of

PPD benefits and affirm the district court’s judicial review decision

affirming the commissioner’s award of these benefits.

      We choose not to review the other issues raised by the parties in

this appeal. See Anderson v. State, 692 N.W.2d 360, 363 (Iowa 2005)

(“On further review, we can review any or all of the issues raised on

appeal or limit our review to just those issues brought to our attention by

the application for further review.”).   The court of appeals’ decision

stands as the final ruling on all other issues raised on appeal. See Everly

v. Knoxville Cmty. Sch. Dist., 774 N.W.2d 488, 492 (Iowa 2009).

      I. Background Facts and Proceedings.

      We limit our recitation of the evidence and history of this case to

those facts and rulings that are pertinent to the issue we address on

further review.

      Starting in 1999, Sanders was a certified nursing assistant for

appellant, Broadlawns Medical Center. On July 18, 2003, while working

at Arlington House, a group home for the mentally ill operated by

Broadlawns, Sanders discovered a client who had hung herself. Later,

Sanders was required to clean the room in which the client had

committed suicide.    As a result of this experience, she began having
                                     3

flashbacks, nightmares, and olfactory hallucinations.         Three doctors

diagnosed Sanders with posttraumatic stress disorder (PTSD) caused by

her involvement with the suicide at Arlington House.

      In February 2004, one of these physicians, Dr. Gallagher,

permanently restricted Sanders from working at Arlington House.

Broadlawns then assigned her to another group home, Oakland House.

Sanders was able to work at Oakland House without the same reactions

arising from work at Arlington House because she knew the clientele at

Oakland House and felt comfortable that no client there would commit

suicide. When Sanders had been assigned to Arlington House, she had

worked about seventeen hours of overtime during each pay period. She

earned only about five hours of overtime per pay period when assigned to

Oakland House.
      Nearly a year after the incident, on July 16, 2004, Dr. Gallagher

reported that Sanders was at maximum medical improvement and

reaffirmed her restriction from working at Arlington House.               In a

subsequent report dated July 21, 2004, Dr. Gallagher reiterated these

opinions:

      I believe she is executing her current job well except when
      challenged to return to her former place of employment
      where the individual under her charge, Nicky, took her own
      life. She remains very sensitive to anything resembling
      criticism around this issue and reacts exceptionally strongly
      if there is a request for her to return to that facility. For all
      intents and purposes, I have restricted her from returning to
      work at Arlington and indicated she should stay where she
      is. If this request is honored, I think she will do acceptably
      well. She will quickly regress and become symptomatic if
      this request is ignored. Given her still present fragility, it
      does not help if it is suggested to her that in some way she is
      not “doing her job” by not returning to Arlington.
      I think that Ms. Sanders is at Maximum Medical
      Improvement. The rest will require tincture of time. She is
      free to return to see me on an as needed basis, which was
      reassuring to her. I don’t see any reason to schedule regular
                                           4
      visits, though. She seems to conduct the rest of her life
      reasonably well. At best, I would say that she has a residual
      mild impairment. This impairment will become moderate to
      severe should she be forced to return to her original
      assignment.

      On September 20, 2004, Broadlawns notified Sanders that it

intended to terminate her employment due to her permanent work

restrictions.   Sanders then asked Dr. Gallagher to lift the restrictions.

Based on her request, Dr. Gallagher recommended “that she be allowed

to try and return to Arlington,” but he “would not go so far to say the

restrictions are eliminated entirely but rather that this be tried on a

temporary basis to see how things go.” Thereafter, Sanders continued to

work at Oakland House and from time to time at Arlington House when

an emergency necessitated her assistance. Sanders tried to work at a

group home outside the Broadlawns system, but she experienced the

same reactions to this home as she did with regard to Arlington House

“due to her anxiety about the unpredictable behavior of certain clients.”

      In   a    report   to   Sanders’     attorney      dated   March     3,   2005,

Dr. Gallagher noted that Sanders’ symptoms of PTSD “have diminished

with the passage of time, as one would expect” and that “she was able to

engage in her limited responsibilities at Arlington House and perform her

duties without undue distress.”          Although Dr. Gallagher did not think

Sanders had any impairment that would prevent her from performing the

duties of her job, he did not recommend “that she ever be reassigned to

Arlington House on a fulltime basis.”

      In   an    October      17,   2005       letter   to   Broadlawns’   attorney,

Dr. Gallagher stated that he did not know of any treatment that would

take Sanders “any further in terms of returning to work at Arlington

House on a fulltime basis.” He concluded that, “if she remains working

at her present location with occasional emergency duties at Arlington
                                       5

House, she will do well as she has been doing.” Dr. Gallagher saw “no

point in scheduling any further appointments” for Sanders.

      On October 24, 2005, Sanders was seen by Kenneth Mills, Ph.D.,

who administered various tests and concluded that Sanders suffered

from anxiety, depression, and PTSD.         He concluded Sanders had “the

potential for further improvement” and “the application of appropriate

psychological therapy techniques may serve to hasten her recovery.”

Because he thought it likely that Sanders “may experience continued

improvement,” Dr. Mills did not believe she had reached maximum

medical improvement.        Nonetheless, he stated that the “emotional and

psychological sequelae” of the traumatic work event Sanders experienced

were “likely to continue to affect [her] for the indefinite future.” Dr. Mills

agreed with Dr. Gallagher that Sanders should not work at Arlington

House and opined that she “is likely to experience difficulty working in

situations that remind her of Arlington House.”
      On January 6, 2006, Dr. Gallagher again stated that Sanders was

at or near maximum medical improvement. He reaffirmed the restriction

against     work   at   Arlington   House   and   again   described   Sanders’

impairment as mild.         Despite this report and his July 16, 2004

assessment, Dr. Gallagher signed an April 3, 2006 letter written by

counsel for Broadlawns, indicating his agreement with the following

opinions:

      1.      Rose Sanders currently has no restrictions or
              limitations other than avoiding the Arlington House.
      2.      Ms. Sanders is capable of performing substantially
              similar employment at locations other than the
              Arlington House.
      3.      Ms. Sanders’ condition is expected to improve and
              should resolve over time.
      4.      You are unable to state that Ms. Sanders’ condition is
              permanent in nature.
                                     6

      Sanders filed this action for workers’ compensation benefits. She

sought PPD benefts based on Dr. Gallagher’s assessment that she was at

maximum medical improvement on July 16, 2004, and had a mild

impairment. Although Broadlawns stipulated that Sanders had suffered

a psychological injury, it contested that her injury was permanent. The

deputy commissioner who heard the case found that Sanders presently

suffered from a psychological impairment and that she had a thirty

percent industrial disability. The decision of the deputy commissioner

who heard the evidence was adopted as the final agency decision by the

commissioner.

      On   judicial   review,   Broadlawns   argued   the   commissioner’s

conclusion that Sanders suffered a permanent disability was not

supported by substantial evidence in the record.        The district court

affirmed the award of PPD benefits, concluding “[i]t was the agency’s

right and responsibility to resolve the apparent inconsistencies in the

medical evidence regarding the permanency of Sanders’ condition.”

      Broadlawns appealed, and its appeal was transferred to the court

of appeals.   That court held the record lacked the necessary expert

testimony “that Sanders’s injury was permanent,” and so it reversed the

award of PPD benefits.      We granted Sanders’ application for further

review.

      II. Scope of Review.

      Our review in a workers’ compensation action is governed by Iowa

Code chapter 17A. See Iowa Code § 86.26 (2009). Under that chapter,

we may reverse an agency decision when

      a determination of fact clearly vested by a provision of law in
      the discretion of the agency . . . is not supported by
      substantial evidence in the record before the court when that
      record is viewed as a whole.
                                       7

Id. § 17A.19(10)(f); accord Kohlhaas v. Hog Slat, Inc., 777 N.W.2d 387,

391 (Iowa 2009).     Because “ ‘factual findings regarding [an] award of

benefits are within the agency’s discretion, . . . we are bound by the

agency’s findings of fact if supported by substantial evidence.’ ”

Keystone Nursing Care Ctr. v. Craddock, 705 N.W.2d 299, 304 (Iowa

2005) (alteration in original) (quoting Clark v. Vicorp Rests., Inc., 696

N.W.2d 596, 604 (Iowa 2005)).

      “In   assessing   evidentiary    support     for   the   agency’s     factual

determinations, we consider evidence that detracts from the agency’s

findings, as well as evidence that supports them, giving deference to the

credibility determinations of the presiding officer.” Lange v. Iowa Dep’t of

Revenue,    710   N.W.2d   242,   247      (Iowa   2006)   (citing   Iowa    Code

§ 17A.19(10)(f)(3)). We also consider “the agency’s explanation of why the

relevant evidence in the record supports its material findings of fact.”

Iowa Code § 17A.19(10)(f)(3). In our evaluation of the evidence, we focus

not on whether the evidence would support a different finding than the

finding made by the commissioner, but whether the evidence supports

the findings actually made.     Meyer v. IBP, Inc., 710 N.W.2d 213, 218

(Iowa 2006).

      III. Permanent Partial Disability Benefits.

      Broadlawns contends the commissioner erred in finding that

Sanders sustained a permanent injury because no expert testified that

her injury was permanent and two experts testified that her condition

“should continue to improve.”         Before we examine the evidence, it is

helpful to review the controlling legal principles.

      Injured employees are entitled to compensation “for permanent

disabilities.” Iowa Code § 85.34. For unscheduled injuries resulting in a

permanent partial disability, such as the mental injury sustained by
                                       8

Sanders, compensation for the disability is based on the employee’s

reduction in earning capacity.       Id. § 85.34(2)(u).     Compensation for

permanent partial disability begins “at the termination of the healing

period.” Id. § 85.34(2). The healing period ends when (1) “the employee

has returned to work,” (2) “it is medically indicated that significant

improvement from the injury is not anticipated,” or (3) “the employee is

medically capable of returning to employment substantially similar to the

employment in which the employee was engaged at the time of injury.”

Id. § 85.34(1).

       Even when healing period benefits have ceased, an assessment of

the permanency of the claimant’s disability cannot be made until the

claimant’s disability has stabilized, i.e., when “it is medically indicated

that significant improvement from the injury is not anticipated.” Id.; see

Bell Bros. Heating & Air Conditioning v. Gwinn, 779 N.W.2d 193, 199–

200, 202 (Iowa 2010) (holding award of PPD benefits was premature
when    claimant’s   condition   had       not   reached   maximum   medical

improvement).     “[S]tabilization is the event that allows a physician to

make the determination that a particular medical condition [and hence,

the resulting functional impairment] is permanent.” Bell Bros. Heating &

Air Conditioning, 779 N.W.2d at 200; see also Pitzer v. Rowley Interstate,

507 N.W.2d 389, 391–92 (Iowa 1993) (interpreting section 85.34(1)

language, “significant improvement from the injury is not anticipated,” as

referring to stability of those aspects of the injury impacting the

claimant’s industrial disability).     Any disability that remains after

stabilization of the condition will support an award of permanent partial

disability benefits to the extent the residual impairment decreases the

claimant’s earning capacity.
                                     9

      As this review of the statutory scheme for PPD benefits and the

specific statutory language reveals, a claimant is entitled to PPD benefits

upon proof that “it is medically indicated that significant improvement

from the injury is not anticipated.”        Iowa Code § 85.34(1) (emphasis

added).      The    commissioner   relied    on   Dr.   Gallagher’s   multiple

assessments that Sanders had reached maximum medical improvement

to find that Sanders had suffered a permanent injury entitling her to PPD

benefits.    The commissioner considered Dr. Gallagher’s April 2006

statement that he could not say Sanders’ condition was permanent,

explaining why he rejected this statement in determining whether

Sanders had sustained a permanent disability:

      The fact Dr. Gallagher is reluctant to call her condition
      permanent in his response to a letter from defendant’s
      counsel reflects more his hope the condition will improve
      than it does an opinion it is temporary only. It is clearly a
      permanent condition in that it has not resolved over three
      years later. She clearly has a mild psychological condition
      that would limit her ability to compete with other workers for
      similar jobs with other employers.

This interpretation of Dr. Gallagher’s statement regarding permanency––

as his hope for Sanders––is consistent with Dr. Gallagher’s conclusion

that there was nothing further he could offer Sanders in terms of

treatment.

      It is the commissioner’s responsibility to weigh conflicting evidence

and accept that which he finds most credible. Dr. Gallagher stated on

multiple occasions that Sanders had reached maximum medical

improvement.       In the April 2006 letter upon which Broadlawns places

great reliance, Dr. Gallagher stated that Sanders’ condition “should

resolve over time” and that he could not say her condition was

permanent.     (Emphasis added.)     Notably, he did not give a medical

opinion that her condition would improve or that her condition was not
                                   10

permanent.     Moreover, the April 2006 letter did not necessarily

contradict Dr. Gallagher’s earlier opinions that Sanders had reached

maximum medical improvement, i.e., that he did not anticipate

“significant improvement from the injury.” Iowa Code § 85.34(1).

      Given the nature of Dr. Gallagher’s April 2006 opinions, we cannot

say the commissioner was required to accept them as a credible basis

upon which to find Sanders’ condition was not permanent.             See

Kohlhaas, 777 N.W.2d at 392 (holding “the commissioner finds the facts

as they stand at the time of the hearing and should not speculate about

the future course of the claimant’s condition”). Dr. Gallagher’s opinions

that Sanders had reached maximum medical improvement and had “at

best . . . a mild residual impairment” provide substantial evidence in

support of the commissioner’s finding of permanency. (Emphasis added.)

      IV. Summary and Disposition.
      We conclude the commissioner relied upon substantial evidence in

the record to find that Sanders had reached maximum medical

improvement resulting in a permanent disability entitling her to

permanent partial disability benefits under section 85.34. On this point,

therefore, we reverse the court of appeals and affirm the district court

and commissioner. The court of appeals’ disposition of the other issues

raised on appeal stand as the final decision on those matters.

      DECISION OF COURT OF APPEALS AFFIRMED IN PART AND

REVERSED IN PART; DISTRICT COURT JUDGMENT AFFIRMED IN

PART AND REVERSED IN PART.

      All justices concur except Wiggins, J., who takes no part.
