|
Worcester Medicine
"We have met the aging...and they are us." Letter To the Worcester Medicine Editor: February 23, 2003 Remembering the Hospital Cottages for Children
Legal consult
Worcester Medical Library members have access to
"We have met the aging...and they are us." Black and white newspaper photos of persons with wrinkled faces happily blowing out candles on birthday cakes totally obscure the myriad of problems associated with aging. The elderly, and that includes you and me as we move along life's continuum, have medical issues that are much different from the problems of younger patients. Clinicians need to be aware of such differences if medical encounters are to be effective. And with changing demographics, who will actually deliver these services in Worcester? This issue of Worcester Medicine looks at these questions. Dr. Gurwitz eloquently describes the medical and social problems, both local and national, associated with Americans growing older. Dr Wilmer's letter raises an additional perspective on this critical issue. Dr. Matt Collins muses over the power of collective good vs. individual good in achieving medical goals in this edition's "As I See It" article. We are also happy to include several thought-provoking letters written by our new president, Dr. George Abraham, which were published in the Boston Globe. And of course this issue also includes the usual fine pieces by our regular Worcester Medicine writers, Peter Martin and Sande Bishop. J. Paul Lock, MD
President's Message Dear Colleagues, I trust you have all had a good and restful summer. The Society has been busy planning a number of activities and events that will have broad appeal to our all our members. On October 7th, we hosted `Career Nite' for our junior members (medical students) featuring a panel of physicians talking about career choices and their strengths. WDMS is the only district society in Massachusetts to be accredited to provide CME programs for physicians. Our latest program was on October 15th, entitled `Child Obesity: An Impending Epidemic.' We also look forward to seeing you at the Fall District Meeting on November 19, to recognize distinguished colleagues among us and to also hear Dr. Thomas E. Sullivan, MMS President, speak on `Critical Condition: The Massachusetts Practice Environment and What We Can Do About It'. Many of you have given us positive feedback on the articles that we wrote in the Worcester Telegram & Gazette. Additionally we provided poignant rebuttals to articles in the Boston Globe on medical injury compensation and breast cancer screening. These articles are reprinted on page 6. There will be an additional public media campaign highlighting tobacco cessation, which we as a Society have participated in. Promoting `Public Access Defibrillation' in Worcester and making the city a `Heart Safe Community' were topics of testimony by Drs. Jay Broadhurst and Matt Collins of the public health committee, at a hearing of the Worcester Health Committee on July 2, 2003. Additionally, we have been assisting the MMRS (Metropolitan Medical Response System) and the Worcester Department of Public Health implement a quick response system in the event of a disaster. The WDMS Resource Guide has been updated to include the most recent information about access to indigent care in Worcester. For easier use, it has been divided into two parts: `Medical Care for the Uninsured and Underinsured in Worcester County' and a listing of support groups, services and hotlines. The complete guide and ways to access the WDMS prescription fund, can be viewed online or downloaded for printing at our website, www.wdms.org. Last but not the least, our television series `Health Matters', continues to be a great resource to the community and an occasion for our member physicians to share their expertise. Under the auspices of our Public Relations Committee, 22 taped segments are currently being aired in Worcester, Shrewsbury and Hopkinton. We trust all of you have received the membership cards listing some of the membership benefits. It is noteworthy that in spite of very lean times, we have managed to maintain a positive balance sheet without raising membership dues. It is exciting to be part of such a dynamic organization and I look forward to your feedback to make the WDMS more meaningful to all of us. Sincerely,
The following letters by George Abraham, MD, MPH, were published recently in the Boston Globe and the Worcester Telegram & Gazette COMPENSATING
MEDICAL INJURIES, IN HIS May 14 front-page article "A malpractice verdict's human dimension," Raja Mishra misses the point. There is a better system to compensate medical injuries that the tort system, which emphasizes blame rather than just compensation. Let's stop arguing about which case
reaches some ill-defined threshold of bad practice In a worker's compensation system, payment to injured patients would double without increasing malpractice insurance rates. Let's heed quality experts who look at systems, not individuals , to reduce errors. Diseases and their treatments can injure patients despite competent and conscientious care. Poor outcomes don't come from just doctors' mistakes but from a variety of causes, most of them unidentified. The Board of Registration, not the tort system, removes incompetent physicians from practice. The current reliance on the tort system to manage malpractice only traumatizes physicians without addressing competency. If we consistently punish those who are working to help people, no one will enter specialties with a high risk of lawsuits, such as obstetrics or neurosurgery, limiting access to health care for all.
HOLE
IN DEBATE ON BREAST CANCER EXAMINATIONS, GIVEN THE STATE of the art, we disagree with Raja Mishra's implication in "Breast cancer screening boosted" (City and Region, May 30) that malpractice suits serve the public by forcing extra testing. The science of breast cancer is not yet mature. Mammography misses many tumors while calling many normal breasts tumorous. In fact, the fear of lawsuits has decreased the number of radiologists who are willing to read mammograms and causes the remainder to often over-read small shadows as positive findings. Consequently, many women have to worry unnecessarily while waiting repeat exams. If the test were more accurate, we could develop a system of timely testing (as is the case with Pap smears) for improved public health. Now we must ask our doctors to make clinical judgments weighing pretest odds of breast cancer and the effect of other diseases to best serve each patient. Further, other constraints, such as limitations of facilities for testing engendered by insurers and patient reluctance to get tested, have not even been factored in. Despite good screening and examination, breast cancer still kills. Malpractice is a poor tool for improving care; rather we should apply good science thoughtfully to benefit patients.
NEW
SMOKING LAWS MAKE WORK SITES EQUAL, As a physician with an interest in public health, I have followed the debate on a proposed workplace smoking ban with great interest I believe that a rational discussion of this issue should answer three basic questions.
There appears to be a consensus among the scientific community and the general public that secondhand smoke poses a serious health risk. In its Ninth Report on Carcinogens, the Public Health Service's National Toxicology Program identified secondhand smoke as a known human carcinogen (U.S. DHHS, 2000). The 1986 Surgeon General Report concluded that secondhand smoke causes lung cancer (U.S. DHHS, 1986), and even R. J. Reynolds Tobacco Co. found that secondhand smoke harms lung function (JAMA 281: 1083,1979). Statewide surveys have consistently shown that people believe secondhand smoke is harmful. In a recent survey of more than 1,000 registered voters in Worcester, 87 percent of survey respondents said they believe secondhand smoke causes health problems and 75 percent of survey respondents said that smoking should be banned in all workplaces in the City of Worcester. (Spectrum Health Systems Survey: 2003). Historically, municipalities have played an important role in protecting the community from serious health hazards. Would opponents of a workplace smoking ban support the elimination of a sanitary code requiring adequate cooking and refrigeration of meats to ensure the destruction of pathogens? I think not. Why then should the public and workers not be protected from the carcinogenic substances in secondhand smoke? In our society, adults have a clearly defined legal right to smoke. However, where a smoker exhales is already restricted. I doubt most people would be in favor of turning back the clock to another era when smoking was allowed in schools, hospitals and airplanes. The current smoking ordinance in Worcester bans smoking in restaurants without bars, but not in restaurants with bars; in retail stores, but not in many other work sites. Adoption of a new smoking ordinance would offer equal protection to all workplaces in the city of Worcester. The genie of secondhand smoke cannot be put back into the bottle. It is time for a breath of fresh air. It is time for the City Council to enact a new ordinance that makes all workplaces in the city of Worcester smoke-free.
GOOD
MEDICINE FOR A SERIOUS AILMENT, Count Massachusetts among the many states from coast to coast that are seeing a real awakening within the ranks of physicians, a profession not usually know for its activism. Spurred by several issues, most notably soaring premiums for medical liability insurance, physicians have discovered the need for a political voice and action. Here in the commonwealth, 1,000 physicians bused in from all over the state, gathered on Beacon Hill in April to rally behind legislation, filed last December to reform the state's medical liability laws. Liability insurance premiums for Massachusetts doctors jumped an average of 20 percent July 1, after three years of 9, 14 percent and 12.5 percent hikes. Doctors in high-risk specialties such as obstetrics and neurosurgery will likely pass the $100,000 mark just for insurance. These kinds of numbers are putting medical careers at stake and patient care at risk. The soaring premiums and legal exposure have forced doctors here into intense soul-searching. Should they retire early? Leave the state to practice in a more physician-friendly place or change careers? For some, the current feeling about such a bleak future is despair. Consider this sentiment from a 33-year-old physician practicing in northern Worcester County. "As a family practitioner in solo practice," he says, "I have become concerned that physicians in the state of Massachusetts have been bombarded with restrictions, increasing malpractice premiums, decreases in reimbursements and overwhelming amounts of bureaucratic paperwork. This has direct impact on my patient care and has forced me to give up the obstetrical part of my family practice. As a young physician, currently in practice only four years, this is extremely disheartening, as I foresee in the next five to 10 years the possibility that it will be completely impossible to maintain a private, independent practice". This situation is becoming more common. The Massachusetts Medical Society's 2003 Physician Work Force Study found for the second year in a row that the state's physician labor force has two big problems: critical shortages in at least eight specialties and serious problems with recruitment and retention. Thirty-two percent of physicians surveyed said they either plan to leave the state or will leave if the practice environment gets worse. That means we could potentially lose upward of 6,600 physicians nearly one-third of those currently in practice. Further, the Medical Society's 2002 Physician Practice Environment Index, a separate, statistical measure of factors affecting the environment in which doctors provide care, plunged 3.9 percent the second largest drop since 1993. Economist James M. Howell, Ph.D., of The Howell Group, who developed and charts the index for the Medical Society, points out three factors that should be cause for concern. "First, we've had nine straight years of decline; second, since 1999, the rate of decline has accelerated, and third, the Massachusetts index is falling much more rapidly than the rest of the nation." The main driver behind the plummeting index is now the soaring cost of liability insurance. This same concern of professional liability, highlighted in the work force study, is also making doctors contemplate career changes as never before. However, liability is really a triple-edged sword. It affects physicians, the health care system overall and most important, patients. The fear of being sued, confirmed in local and national surveys, has led doctors to prescribe expensive, unnecessary tests as "defensive medicine", to insulate themselves from lawsuits. For the same reasons, it inhibits any real discussion of medical errors. The result is that it drives up the already soaring cost of health care, dampens efforts at patient safety, and further strains a health care system that many experts say is ready to break, if not already broken. Yes, injured patients should be compensated fairly, and bad doctors should be weeded out. No one disagrees about those issues but the liability crisis is not just about physicians. It's as much about our health care system, and most important it's about patient care and patients do care. In a recent survey on the quality of life in the state conducted by the Massachusetts Institute for a New Commonwealth, residents of Central Massachusetts ranked "the way the health care system is working" second only to taxes as issues "in need of major improvement". Physicians are leaving Massachusetts, recruiting them to the state has become a hard sell, and patients are waiting longer and traveling further to get care. We have seen obstetricians give up delivering babies. Neurosurgical staffing at some trauma centers is dangerously low, and at times, even nonexistent. In the 1980's Massachusetts had 150 neurosurgeons; today we have 60. Solving the problems of our health care system will take a huge effort by many interested parties. But reform of the medical liability laws will be a solid first step. It will help to stabilize the system, aid in recruitment and retention of physicians, and lead to better patient care and patient safety. No one can dispute that that's good for all of us.
206th WDMS Annual Oration Many of us prefer not to think about aging, choosing to ignore the profound challenges that our nation, our communities, our families, and we ourselves face over the coming decades. Today, approximately 6,000 Americans will celebrate their 65th birthday, and that number will increase to 10,000 per day ten years from now. We have precious little time before the first wave of baby boomers set off what many refer to as the "Senior Boom." Our nation must prepare to provide health care for an ever expanding population of older citizens. Among the challenges confronting us are: (1) the soaring costs of providing health care for the elderly; (2) an increasing burden of chronic illness and disability among the geriatric patient population; (3) a need to improve the quality of drug therapy in the elderly; and (4) uncertainties regarding who will provide health care for the burgeoning numbers of older patients.
The aging of America will have profound effects on overall health care utilization and costs. While those aged 65 or older currently comprise only 13% of the US population, they account for 36% of all hospitalizations, nearly half of all days of hospital care, and 50% of all physician work hours. The number of dollars spent on health care for the elderly continues to increase. In 1966, Medicare spending accounted for less than 1% of the US gross domestic product. By 1999, that percentage had increased to 2.3%, and it is projected that the percentage of the gross domestic product allotted to Medicare spending will reach 4% by the year 2025. The gap between what is spent on health care for younger Americans versus what is spent on older Americans continues to increase. Without dramatic lifestyle changes, improvements in preventive health care, and efficiencies in the way we care for older persons suffering chronic illness, such trends will only continue leading to an overwhelming financial crisis in the funding of health care services for the elderly.
With the aging of our population, the numbers of persons affected by chronic medical conditions such as dementia, arthritis, and osteoporosis will increase dramatically. For example, the number of Americans with Alzheimer's Disease is expected to double from approximately 4 million today, to 8 million in 2020, to as many as 14 million by the year 2040. Over 30 million Americans will be affected by arthritis by the year 2020, and 45 million by the year 2040. Hundreds of thousands of elderly persons suffer osteoporosis-related fractures every year; one half million hip fracture-related hospitalizations are projected annually by the year 2040.
THE QUALITY OF DRUG USE IN THE ELDERLY: ISSUES OF COST AN SAFETY One of the critical challenges facing elderly patients today is paying for drugs. Fully two-thirds of the Medicare population have absolutely no drug coverage or only limited coverage. Access to adequate drug coverage does have an impact on whether or not elderly patients use essential drug therapies. A recent study of Medicare patients with coronary artery disease indicated that 27% of those with drug coverage were using lipid-lowering drugs compared with only 4% of those without drug coverage. Drug-related injuries have been recognized as a common problem in older patients and many of these events may be preventable. Among the 38 million Medicare enrollees cared for in the ambulatory setting, there are nearly 2 million adverse drug events per year, a quarter of which are preventable. This includes 180,000 fatal or life-threatening adverse drug events, nearly 50% of which are preventable. Most preventable drug-related injuries in elderly persons occur due to errors in prescribing and monitoring. Fortunately, technological advances offer the promise of substantially reducing the risk of medication errors. With computerized physician ordering of medications, prescribes can be warned about serious drug interactions and can be prompted to intensify monitoring of patients who are at special risk of drug side effects. Demonstrating that such systems reduce drug risks and improve safety will encourage the adoption of these systems across all clinical settings. Unfortunately, fewer than 5% of US hospitals have such systems in place. The use of this approach to improve patient safety in the outpatient and the nursing home settings is far less common.
WHO WILL CARE FOR THE ELDERLY? Less than half of all medical schools in the US have geriatric programs. If geriatric training was required in every medical school today, some have estimated that it would still take more than 40 years for all practicing physicians to be replaced by those with geriatric training. How will it be possible to train this physician work force when less than one percent of medical school faculty are specialists in geriatric medicine? Dr. Robert Kane of the University of Minnesota recently wrote that geriatricians are in danger of extinction. Since the creation of a certification program in geriatric medicine in 1988, the numbers of individuals taking and passing this exam have fallen dramatically. In the year 2002, less than 300 individuals nationwide passed the exam. The numbers of geriatricians being produced in the United States are far too few to have even a small effect on the way care is being delivered to our nation's elders.
NEW MODELS OF CARE FOR THE ELDERLY Fortunately, a number of new geriatric practice models have been shown to be extraordinarily effective in providing care to elderly patients with multiple medical problems and functional impairment. One of these models is called geriatric interdisciplinary team care. In this model, healthcare providers become an interdisciplinary team as they jointly define the patient's complex problems, and share responsibility in caring for the patient. This health care team includes a wide variety of health care professionals, with the physician serving as just one member of the team. In many places, this model of care is called "PACE" (Program for All Inclusive Care of the Elderly). There are 25 national PACE sites (including the Fallon Elder Service Plan in Worcester). These programs strive to allow frail elders to remain in their homes and out of nursing homes as long as medically and socially possible. PACE programs place a heavy emphasis on incorporating the family as active participants in patient care. While less expensive than nursing home care, this approach to caring for elderly patients remains quite costly which presents a barrier to wider adoption of the PACE model across the country.
CONCLUSION Facing up to the many challenges of caring for our aging population will require a multi-faceted approach. First, we must implement a coordinated national strategy to care for older patients with chronic illness through effective programs in health promotion and disease management. Second, every older American must have access to a comprehensive drug benefit plan. Third, there should be renewed efforts to create a health care work force with the knowledge and skills to deal with the complexities of providing care to geriatric patients with multiple medical and functional problems. And finally, there should be broader dissemination of new models of geriatric practice to enhance the opportunity for the frail elderly to remain in the community and out of nursing homes. More than twenty years ago, Dr. Carl Eisdorfer wrote prophetically: "We are facing the impact of a larger aged population, more of whom will have chronic illness and will use the major portion of our healthcare service. To ignore this trend is to risk facing an even more serious crisis. There is one deprived group we will all join, whether we wish to or not: To paraphrase Walt Kelly, we have met the aging and they are us." Jerry H. Gurwitz, MD, is Executive Director of the Meyers Primary
Care
Letter To the
Worcester Medicine Editor: To The Editor: At the recent WDMS Annual Oration, the question was asked of Dr. Gurwitz: "What is taught in geriatrics"? As the coordinator of Geriatric Medicine Training for the Internal Medicine residents at St. Vincent Hospital at Worcester Medical Center, I would like to answer this question. Our medical residents spend a month studying Geriatrics in their second year. They have had extensive experience with sick, hospitalized, older adults but little with the well older adult, the chronically ill older patient, or the frail elder. They can treat the patient's pneumonia but have little concept of the impact of that disease on that frailer older patient. The Medical Residents are introduced to the concept of functional assessment: the idea that the culmination of many different aging and disease processes can affect and impair a person's ability to do their activities of daily living. They are taught to use standardized instruments to assess and follow functional levels and how to impact and perhaps improve their patients' abilities to live productively and be maximally independent. They study the differences between age related changes in the body and the outcomes of disease. The science and art of appropriate prescribing of medication to the older patient is reviewed as there are both pharmacokinetic and pharmacodynamic changes to be considered. The choice of medication, the risks and benefits of prescribing, and even the decision to test are viewed in relation to the patient's current health status, life expectancy, and wishes. Caring for the older patient obliges the physician to interact with and hopefully be a member of a multidisciplinary team. The resident receives training so they can effectively participate in such teams, and they learn about the scope of practice and appropriate use of other health care professionals by visiting with these practitioners. These allied medical personnel include the social workers, geriatric nurse practitioners, physical, occupational, and speech therapists, audiologists, podiatrists, and wound care nurses who are involved with the care of our patients. Historically, medical residents have
finished their residency with little
understanding of the financing of health care for the elderly and the
variety of living options and medical facilities available to the older
person. The curriculum at St. Vincent Hospital has them visit nursing homes
to evaluate long term care patients and short term rehabilitation patients.
They visit patients at assisted living facilities, rest homes, elderly
housing apartments, adult day health centers and at Worcester's PACE program
(Program Geriatric syndromes are those medical problems common to the elderly and often multi-factorial in etiology. This is the appropriate time to review the work-up and treatment of these syndromes which include dementia, urinary incontinence, malnutrition, falls, dizziness, pressure ulcers, sleep disorders, and chronic pain. Medical care of the older patient will remain the purview of primary care internists and family practitioners. Most specialty physicians and surgeons will spend a significant portion of their practice treating the older patient. Geriatricians can help with the frailest elderly. Since much of our previous medical research excluded elderly patients, academic Geriatricians are performing research to help us understand the most suitable practices with regard to our older patients. The goal of geriatric medicine education is to raise the quality of care our older adults will receive. Most medical schools have not taught geriatric medicine. I am happy to report that the University of Massachusetts Medical School is developing and has already implemented a curriculum so that all graduates will understand some of the unique characteristics of the older patient which affect the care we give. As Dr. Gurwitz so aptly expressed in his Annual Oration, we are all aging and the burden of caring for our elderly will be formidable. Geriatric education and research will allow us to give the appropriate, high quality medical care we want for our current patients, our parents and eventually ourselves.
As I See
It Each day and with every patient encounter, I focus on the individual patient in front of me. I strive to know each patient, so that I may offer them the best possible health care choices. And yet the collective experience of treating large numbers of patients teaches me that there are common problem among my patients that deserve attention on a larger scale. Heart disease is one example. The fact that heart disease is the number one cause of death in the U.S. is no surprise to anyone in health care. In fact, we find out too often that many patients are walking around with as yet undiagnosed coronary artery disease. Some of these people will die of sudden cardiac death (SCD) without the benefit of medical and surgical interventions that could dramatically lower their mortality risk. Fortunately, recent medical technology has improved a reliable and simple to use device that could save even these unsuspecting victims. Cardiac defibrillators have been around a long time and when used early after cardiac arrest can be lifesaving. But the conventional type that is used in hospitals requires sophisticated training in Advanced Cardiac Life Support (ACLS) and ECG analysis. Because of this, a victim of SCD is at the mercy of the time it takes to get the defibrillator and the trained individual to get to his/her side. It is well recognized that time to first shock is the most important element of survival from SCD. In fact, with each minute that passes, the mortality rate from SCD increases by 7 percent. Technology has created a new breed of defibrillator called the Automatic External Defibrillator that is so simple and easy to use it can even be used by untrained individuals. The fact that this tool is now available dramatically cuts down on the "time to first shock." The American Heart Association has created a program to make it easy for communities to develop what is known as a Public Access Defibrillation program or PAD. The PAD is an organized plan involving first responders, trained community members, community leaders and physicians that strategically places AEDs in high population or hard to reach areas to dramatically improve a SCD victim's chances of survival. Places that have enacted such programs have seen survival rates from SCD increase from 5% to 40%and higher. Because of this dramatic improvement in survival rates, PAD programs have been started in many communities and business locations. All of the commercial airlines in the United States have AEDs. Communities that develop such plans achieve recognition as HeartSafe Communities, a designation that a municipality can truly take pride in. As a member of the WDMS Public Health Committee, I have asked our Society to support the pursuit of a PAD program in Worcester. Meetings have been held with area Emergency Services personnel and City Councilors. Much support and interest already exists. The communities of Worcester, Auburn and Holden have already made tremendous progress toward the achievement of the HeartSafe Community designation. Both the will and the technology exist to make our communities the safest they can be for the victims of SCD. It gives me great pride that, for the good of the public health our Society is doing its part to achieve this goal. It gives me comfort to know that I am doing my part to make my patient's lives safer.
Remembering the
Hospital Cottages for Children The young physician Lucius W. Baker was convinced that chronically ill and epileptic children had a better chance of cure if treatments began at a young age in fresh country air. Thus, in 1882 he incorporated Hospital Cottages for Children in his hometown of Baldwinville, Massachusetts. Local histories claim the facility was the first in America to provide both medical care and schooling for its children-patients and the first in the country to specialize in the treatment of epilepsy in children. For almost six decades, Annual Reports of Hospital Cottages for Children tell of the care of "three classes of incurable children for whom no other provision is made First, those tendered invalids for life from congenital diseases, paralysis and kindred aliments. Second, epileptic children. Third, a class known as `asylum cases.'" In each Report, the number of epileptic patients outnumbered all others. The history of epilepsy is as old as man. Those experiencing seizures, until recently, suffered socially while they also lacked effective medical treatment. In 1815, Jean-Etienne Esquirol organized a special hospital for epileptics, separating them from the insane because he feared their seizures would frighten and worsen the mentally disturbed. By 1860, special asylums in France, England and Germany commonly housed those with epilepsy. Physicians, perhaps in desperation, seeking to help those forgotten in institutions, resorted to many brutally aggressive, invasive and highly experimental treatments. Camphor and other agents were administered, producing convulsions so violent that patients regularly suffered broken bones. In the nineteenth century, bromide and, in the early twentieth century, phenobarbital were the medicines of choice. In 1880, after completing his training at Bellevue Hospital in New York, Baker received financial backing from several local businessmen and bought three neighboring houses on Pleasant Street in Templeton. There, he established the Hospital Cottages for Children. Two years later, he read a paper entitled "Cottage Hospitals" before the Massachusetts Medical Society. Baker cited Albert Napper of Cranleigh, England, with creating the first cottage hospital in1859. He read, "A strong conviction exists in the minds of some that large many-storied hospital buildings where numbers are gathered under one roof, do not afford the patient the best possible chance for speedy recovery; it is claimed that small, one story buildings, detached the one from the other, and so situated as to allow at all times the freest exposure to air and sunlight, furnish the best results.... In that country [England] it has been found that cheap wooden buildings, under the care of neighboring physicians, assisted in the management by committees of ladies, provide admirable accommodations..." The Fifth Annual Report of the Corporation, 1887, lists forty children under treatment, including twenty-two with epilepsy, three each with spinal caries, rachitis and hip-joint disease, two each with infantile paralysis, feeble-mindedness and suffering general debility, and one each with heart disease, knee-joint disease and tetanoid paraplegia. The majority of patients paid a small sum weekly towards their care, the rest being charity cases. Weekly fees ranged from fifty cents to six dollars. The sum of $100 supported a bed for a year. Also in 1887, Baker resigned his position from the hospital to open a new institution in Templeton, named Riverside, to assist those "overcome by bondage of drug habituation" (opium and alcohol). Everett Flood M.D., who had recently worked at Worcester Lunatic Hospital, became the new superintendent of Hospital Cottages for Children. By this time, the facility had moved to a lovely site, "standing at an altitude of 1200 feet above sea level, on the crest of a hill fronting south and west, free from every influence which can contaminate the air." The farm/school allowed "the care of dumb animals and out-of-door amusements [to] give healthy employment both to mind and body." Animals included a cow, three pigs, a horse and eight hens. No child was ever refused admission to the hospital if the facility had room, and eventually the hospital housed more than 250 children. The Trustees and the Lady Board of Visitors, "ladies of prominence from all over the state," led the campaign to provide funds and donations for the institution. Listed among the gifts were livestock, clothing, household goods, medicines, books, musical instruments, carriages, harnesses, sleighs, sleds, fruits and vegetables. And although the hospital was private, further funding came from the state. A petition to the Legislature for $10,000 was granted and later amended to $55,000. Annual reports claim some patients were entirely controlled by treatment, some were "withdrawn from treatment too early to obtain permanent results," and in some there was no improvement. Unfortunately, nowhere is the treatment described. In 1889, the superintendent wrote, "From the great variety of causes of this disease, reaching far back to the sins of excess in sturdy ancestors, sending an augmented taint with each succeeding generation down to puny and suffering progeny it seems well worth our while to enter the lists as professed educators of the people. Heredity is not always present ...as a predisposing cause; for many cases of epilepsy arise from injuries...When the mischief has been long done we can still cure some." In the early twentieth century, the hospital reported that "much pioneering surgery took place ...in the main building," and orthopedic surgical procedures became increasingly important. The 1924 Annual Report claims "3,588 surgical dressings done." The laboratory performed blood counts, chemistry, sed rates, clotting time and blood-typing. Then, as children's hospitals in Boston gained prominence, Hospital Cottages for Children became less convenient and closed in the late 1940s. The final chapter for the "Cottage Kids" was reported in May, 2003, in the Gardner News. Thirty-seven small concrete squares, each marked with only a number, in Greenlawn Cemetery were replaced by thirty-seven new granite gravestones. Alan Mayo, superintendent of the Parks and cemetery department, researched records in town libraries to learn the names of the children and where they came from. The new markers were donated by Ann Reever, the sister of `JoJo' Kelliher, the last child to die at the Hospital Cottages in 1942. In one particularly touching instance, one child was not buried with his peers. Harry Jones's father purchased a single plot next to the railroad tracks that pass the cemetery. Mayo reported, "His father used to commute by rail. He wanted to see his son when he passed by the cemetery during his commute from Keene." Soon, the Victorian buildings will be demolished. The bucolic hilltop site, so strategically chosen more than a century ago for its healthy air and beautiful vistas, however, continues as a residential institution. In 1998, Y.O.U. Inc purchased the property, now Cottage Hill Academy, and the school is being transformed into one of the finest residential facilities in Massachusetts for troubled adolescent girls.
Legal consult Physicians who are owners of a medical practice usually do not think of themselves as corporate employees. However, a United States Supreme Court decision earlier this year indicates that physicians who are directors and shareholders in a professional corporation may also be considered to be employees for purposes of employment discrimination laws. The issue arose when a four-member gastroenterology practice in Oregon terminated a bookkeeper. The bookkeeper sued the practice claiming her termination constituted disability discrimination under the Americans with Disabilities Act. Since the ADA covers only employers with 15 or more employees, the practice argued that it was too small to be covered by the ADA. The practice would reach the 15 employee threshold only if the four physicians who were directors and shareholders were counted also as employees. The trial court ruled that the four physicians were more akin to partners than to shareholders and therefore were not employees. The appeals court argued that once the physicians elected the professional corporation form of organization, they could not then disclaim that status and instead claim to be a partnership in order to avoid employment discrimination liability. The Supreme Court stated that asking whether a director-shareholder is akin to a partner is the wrong question. Instead, the question is how to define "employee" in the context of a given statute when that statute does not define the term. The Court's answer was to look at the common-law rules defining the master-servant relationship. In so doing, the Court found that the element of control is the "principal guidepost" to be followed. In the ADA context, use of the element of control is particularly appropriate given that the Equal Employment Opportunity Commission, the entity that enforces the ADA, looks to control when determining who is an employee for purposes of deciding whether a statute applies to a given employer. Generally, the EEOC's position is that if a shareholder-director operates losses and liabilities of the organization? The Court stressed that neither an individual's title nor the mere existence of a document called an employment agreement is necessarily dispositive on the question of whether the physician is an employee. Physicians participating in professional corporations and other practice formats should carefully consider the legal consequences of allocating control within their organizations. This is particularly important if the number of employees will determine if the organization is subject to regulatory or other requirements. In addition to the ADA example cited here, some HIPAA requirements pertain only to practices with a minimum number of employees, as do requirements to provide continuation coverage under COBRA, and the rules imposed by a wide variety of Massachusetts discrimination and health insurance laws. Peter Martin is an attorney with Bowditch & Dewey in Worcester.
Worcester Medical Library members have access to the "Humanities in Medicine" collection The staff of the Lamar Soutter Library and its patrons would like to extend their thanks to the Worcester Medical Library for the creation and continued support of the Humanities in Medicine Collection. This collection offers invaluable opportunities for both present and future health care professionals to explore the human issues involved in practicing medicine. The LSL looks forward to an ongoing collaborative working relationship with the members of the Worcester Medical Library. Although the Humanities in Medicine Collection is physically housed at the Lamar Soutter Library, all Worcester Medical Library members are welcome to borrow materials from the collection. Please note that a maximum of two items from this special collection may be checked out at any time. If you do not already have an LSL library card, please come to the circulation desk during regular LSL business hours to get your free library card. Worcester Medical Library members with an LSL library card can borrow materials in the following ways:
COMING
SOON:
HORATIO TURNER, MD Dr. Horatio Turner died quietly on May 31 at the Notre Dame Long Term Care Center at the age of ninety. He leaves his wife of fifty years, Rosemary (Brown) Turner, their son Mark of Lexington, MA, and several nieces and nephews. He was a family practitioner for thirty years and a member of the Worcester District and Massachusetts Medical Societies. Dr. Turner was born in 1912 in London, England and received his primary education at St. Olive's school there. A married, older sister, living in Stratford, CT encouraged him to emigrate from the UK to the United States in 1938 at twenty-six years of age. He worked in the Stratford area for a couple of years before entering the U.S. Army during WWII where he served as an enlisted man, in the Signal Corp, in Africa and Europe. Following service, he took advantage the GI Bill of Rights and chose the six year college-medical combination degree program at Syracuse University in New York. It was there he met his future wife and life-long partner, Rosemary Brown who was also a student at the university. With MD in hand, he chose Worcester City Hospital for his internship and residency and thereafter was always closely associated with that institution. For a number of years he headed City Hospital Health Service, and Washburn and Belmont Nursing Homes, while carrying on a large family practice based out of a home-office. He retired in 1988 and enjoyed his leisure years. As a young man in England, he had been very active in sports such as soccer and golf, but now he chose to follow them in the media. However, many will recall him at the annual City Hospital outing at Wachusett Country Club, following the golf foursomes down the fairways and encouraging the players. Dr. Turner will be remembered as a quiet, caring physician and gentlemen by all who knew him.
JOHN T. HOWARD, MD Dr. John T. Howard of Shrewsbury, a surgeon at St. Vincent's Hospital in Worcester Medical Center, died November 26 2002 after a brief illness. He left his wife of 43 years Sarah Bafaro Howard, three sons, John Jr., Matthew F., and Michael J., two daughters, Tracy Dubay and Lori Howard and six grandchildren. Dr. Howard was born in Yonkers, NY, son of John M. and Gladys (Mack) Howard and lived in Shrewsbury for forty years. He graduated from Gorton High School in Yonkers and from the College of the Holy Cross in Worcester and from the New York Medical College as a member of the National Honor Society and Alpha Omega Alpha. Dr. Howard was President of the Medical Staff and Chairman of the St. Vincent Hospital Trauma Committee as well as the hospital's former Chief of Surgery. He was an Associate Professor at the University of Massachusetts Medical School, a member of the American College of Surgeons, American Board of Surgery, the American and Massachusetts Medical Associations and the Worcester District Medical Society. An avid baseball fan, an ardent follower and champion of many sports, "Jack" at one time tried out for the New York Yankees with Mickey Mantle. Jack confronted the challenges of physicians' rights and responsibilities with great resolve. He was a skilled surgeon highly respected by his patients and fellow physicians. His surgical prowess and teaching ability were exceeded only by his love and compassion for his patients. Combined with these attributes, his love for all aspects of life, as well as his devotion for his family, made him the complete husband, father and physician. By John H. Donovan Jr., MD
DR. JOHN MARONEY Dr. John Maroney, a retired general and thoracic surgeon died at his home in Oldsmar Florida on August 16 at the age of 95. John was born in Boston. He received his undergraduate degree from Tufts College and his medical degree from Tufts University School of Medicine. His internship at Worcester City Hospital was followed by a general surgical residency at the Boston City Hospital. He then completed a residency in thoracic surgery at King's County Hospital in New York. John practiced general and thoracic surgery in Worcester hospitals for many years. He contributed to these hospitals and the wider community in many different capacities. Dr. Maroney served as the Chief of Surgery and president of the Staff at Worcester City Hospital and as president of the Worcester District Medical Society. He was also editor of the Worcester Medical News. As a Colonel in the US Army during World War 11, John received a citation for his work during the Omaha Beach landing. I worked with John both as a surgical resident and a staff surgeon. And although he could be a terror in the O.R., anyone who worked with him knew he was capable of almost any kind of surgery. From early in his career, John was also an advocate of early ambulation. Once during his military service, he removed a patient's appendix and then walked him from the O.R. to his room! As a reward, he lost his job as Chief of Surgery and was promptly transferred overseas. John Maroney was one of the true characters of a time long past in the practice of medicine and beyond. He will long be remembered with a smile, especially by those of us who were lucky enough to know him in his "hey day". He is survived by his long time friend and companion, Edythe Armstrong of Oldsmar, Florida, two sisters living in San Clemente, CA and several nieces and nephews. By Felix Cataldo, MD
HERBERT HAMBURGER, MD Dr. Herbert Hamburger, a highly respected colleague, died on April 27, 2002 at the age of 89. Dr. Hamburger served the greater Worcester community for 39 years, retiring in 1984. He was born in Germany, studied medicine in Freiberg, completed his medical education at the University of Pisa in Germany, studied medicine in Freiberg and completed his medical education at the University of Pisa in Italy. He came to America in 1938, a year that brought many German Jewish physicians to central Massachusetts as they and their families fled the horror of Nazi cruelty. Dr. Hamburger came to a new country, learned a new language, completed residency training and then settled here in the practice of general medicine. He was greatly admired by his patients, colleagues and the house staff at St. Vincent Hospital because of his warm personality, gentle manner, superb medical judgment and his brilliant appreciation of art, especially classical music. Dr. Hamburger is survived by his wife Erna, also a physician, his daughter Susan, an educator in Chicago and his son Ronald, a physician in Reading, MA. Herbert Hamburger was a splendid person. He will be fondly remembered. By Leonard Morse, MD
|