Worcester Medicine
Fall 2004

FROM THE EDITOR
By J. Paul Lock, MD

President's Message
By George Abraham, MD, MPH

ONLY CONNECT
The Patient Representative and the Patient-Physician Relationship
By Susan N. Tarrant, MA

The Role of Creative Writing in Medical Education
By Emily Ferrara, MA

:LEGAL CONSULT:
Patient Communication and Consumer Protection
By Peter Martin, Esquire

SOCIETY SNIPPETS
Calendar of Events 2004-2005

Historical Perspective
In the 1890s, Worcester's Dr. Mary V. O'Callaghan Stood Tall
By Sande Bishop


Taking the Time to Listen...
BY J. PAUL LOCK, MD

Taking time to listen to the expectations of patients at the start of clinical encounters makes patients feel respected and is the foundation for building humanness back into what many patients see as a cold and techno-logically driven process.

Nicholas Genes, a fourth year student at UMASS Medical School, asked Susan Tarrant and Emily Ferrara to write original pieces about the skills and art of listening and communicating for physicians. His own article about what television communicates to patients will appear in the next issue of Worcester Medicine.

Our legal expert, Peter Martin, offers very sage counsel why it’s important to communicate. And Sande Bishop finds a case from local history where good came about from not listening.

This issue of Worcester Medicine is special. I think you will like it. Listen well.


President's Message
BY GEORGE ABRAHAM, MD, MPH

In July, 2004 WDMS developed a task force to explore changes and additions to enhance this publication. Worcester Medicine, (formerly Worcester Medical News) was established in 1939 to communicate with physicians on an intimate and friendly note much like a typical small town paper. Forty-five years later, it continues to be a forum for the discussion of important policies in medicine and medical economics. A task force was constituted in response to a readership survey, who have spent an inordinate amount of time to pro-vide new ideas. My heartfelt thanks to Robert Sorrenti, Chair, Publications Committee, J. Paul Lock, Editor, Anthony Esposito, Leonard Morse, Joel Popkin and Paul Steen for their arduous efforts. We anticipate the Spring 2005 issue will provide a ‘new look’ to our current appearance and content. We encourage our members to submit articles and comments for publication.

The WDMS Public Health Committee, under the leadership of Dr. James Broadhurst, continues its strong support of public health initiatives by joining forces with Worcester’s community organizations. Most recently, we partnered with the American Heart Association, Emergency Medical Services, Police and Fire Departments, and the Worcester Public Health Department to implement a Public Access Defibrillation program in Worcester. The result of this collaboration led to Worcester being designated as a ‘HeartSafe Community’ in May, 2004.

At the top of this year’s public health committee agenda is removing unused and unwanted guns from households that include young children, in hopes of reducing gun violence. We will be educating physicians on The ‘Goods for Guns-Worcester Gun Buy-Back Program’ established through the Injury Free Coalition for Kids of Worcester. This is a Robert Wood Johnson sponsored injury prevention program based at the UMass Memorial Medical Center directed by Dr. Michael Hirsh and Dr. Mariann Manno. Please pass the word around that there will be a gun buy-back at the Worcester Police Department Headquarters on December 11 and 18, 9am to 3pm. For more information, please contact us.

As always, I am privileged to be a part of such an active society. We welcome your active participation and feedback on our activities and programs.


The Patient Representative and the Patient-Physician Relationship
BY SUSAN N. TARRANT, MA

When the British writer E.M.Forster advised “only connect,” he might well have been referring to the physician-patient relationship. As a patient representative at a large teaching hospital for the last 25 years, I have heard all manner of complaints voiced by both patients and their doctors regarding their relationships. The complaints express a loss of connection felt acutely by both partners.

In an article on patient / physician communication, Dr. Patricia Barrier writes, “Patients complain that physicians do not listen, are hurried, and do not allow them to participate in their care,” while “physicians complain that they are hurried and hassled and have insufficient time with their patients” (Mayo Clin. Proc.2003;78:211- 214). When physician friends see me in the hospital they often laugh and say, “Patient representative? I need a physician representative!”

Both doctors and patients are beset by the mistrust that has grown between them, encouraged by the current turmoil in health care. In her article, “Resolving Disagreements in the Patient-Physician Relationship,” Wendy Levinson, MD, states “Increasingly, the public is questioning whether physicians are truly making decisions based on the patient’s best interest or are unduly influenced by economic incentives” in the era of managed care (JAMA, vol.282 No. 15). She asserts, “These circumstances lead to the potential for disagreements and conflict in the patient-physician relationship.”

Furthermore, on the matter of the physician’s response to the patient when untoward events happen, there is still much wariness. Whereas in their personal lives physicians may readily apologize for a hurt experienced by a family member or friend, when something goes amiss in the physician- patient relationship, Thomas H. Gallagher, MD, notes that physicians feel they must “choose their words carefully” and not apologize, fearing that an apology might “create legal liability” JAMA, 2003, (Vol.289 No.8).

Paradoxically, such reluctance to apologize occurs at “the time when such communications might be most valued by patients” (Frenkel and Liebman, Ann Intern Med, Vol. 140(6), March, 2004, 482-483). In the article, “Health Plan Members’ Views about Disclosure of Medical Errors” Kathleen Mazor et al review the responses by health plan members to vignettes regarding medical errors and disclosure by physicians. Respondants reported that “full disclosure reduced the reported likelihood of changing physicians and increased patient satisfaction, trust, and positive emotional response.” They concluded, however, that although “patients will probably respond more favorably to physicians who fully disclose medical errors than to physicians who are less forthright…the specifics of the case and the severity of the clinical outcome also affect patients’ responses” (Ann Intern Med, March, 2004, Vol. 140, 409-418).

The physician-patient relationship is clearly under a great deal of tension. As a patient representative who has heard hundreds of patient complaints over the years, I continue to believe that the relationship can thrive when a physician’s expressive skills nurture the relationship with a patient. This is the best protection from patient dissatisfaction.

Not long ago, during a discussion of medical errors and patient complaints, a physician colleague told me that once, after he had disclosed to a patient and her family that he had made a serious mistake in her care, her son wanted to bring a claim against him. The patient “wouldn’t hear of it.” Why? It was because of the relationship the physician had with this patient. Knowing this physician, I am confident that the relationship had become strong from this physician’s natural empathy for his patients and his sincere expression of regard.

In the midst of all the malignant influences on the patient-physician relationship that encourage distrust on both “sides,” I continue to see around me physicians who are able to create and nurture trusting relationships with their patients. Most often, patients tell me, they want physicians who “are real human beings.” What do they mean by that? As Wendy Levinson has put it, these are physicians who orient the patient as to what to expect during the visit, they “laughed and used humor more,” they solicited “patients’ opinions”, checked their “understanding” and encouraged “patients to talk.” In other words, as patients often put it, “they are human” (JAMA, 1997 Jun 4;227(21):1681).

When patients with a medical complaint are referred to my office, they are frequently angry with physician communication issues that lead them to question the nature of the care they have received. In my attempt to heal the physician-patient relationship from the position of mediator, I use some interactive techniques that have helped me to regain the patient’s trust in me, as a representative of the medical center. This renewed trust can then extend to the physician, and help to heal their relationship. I have found that these techniques can be used in a short amount of time, but can have a strong positive effect on regaining trust. Some may be useful as well to the physician who is interviewing an angry patient.

One technique that is effective in making the patient feel at ease during the complaint interview is to let the patient teach me about his illness. I often ask the patient a question such as, “Before we talk about your complaint, would you do me the favor of going back a bit and telling me what brought you in to see the doctor today?” This focuses the patient on the important issue at hand, his illness and its treatment, it gives me time to prove myself to the patient as an empathetic listener before we get to the substance of the complaint, and it shifts the power balance toward the patient at a time when the patient is angry, frequently because he feels powerless. By the time we get to the complaint, the patient’s anger is often defused, and we can talk more openly about what we can do to help him feel better about his experience.

After listening -- with sympathy and without interruption -- to the patient’s account, I will often stay silent for a moment, and then say something like “I’m sorry. That sounds like it was … a nightmare for you.” I apologize for the patient’s experience. However it came about, I am indeed sorry that the patient was upset during his interaction with the hospital and its staff. Then, if I’ve chosen with care the right word that reflects the exact temperature of the patient’s feelings, I often hear the response, “That’s exactly right!” If I choose a word that is too cool, the patient feels that I haven’t understood his position, and starts to turn up the heat of his own expressions in order to convince me. If the word or phrase contains just the right degree of empathy, that brief statement can fuse a strong connection of mutual understanding. I have found that it is important to use an ellipsis of silence before and after my chosen word or phrase so that the patient’s attention is focused upon it. The combination of the apology by a representative of the hospital, and a statement showing empathy with the patient’s perception of his experience, is crucial to healing the relationship with the angry patient.

After the patient finishes his story, and I’ve responded with the appropriate empathetic words, I have found a critical question to be, “What would you like to see happen?” Early on in my career, I made the mistake of assuming I understood what the patient wanted as a resolution to his complaint. Soon I learned that this was not the case. I would propose a resolution to the patient, only to find it was not the one he wanted. It was a waste of time for both of us, and undercut the understanding we had developed in our first conversation. Asking the patient what he would like to see happen makes the patient stop and think about what he truly wants. Some will say, “Oh I just wanted to tell someone how I felt. I don’t need anything more to happen.” Others will say explicitly what they want, which informs you up front whether you will or will not be able to meet their expectations.

Other advice of which I have to remind myself, particularly when I am feeling especially pressured by the work of handling patient complaints, is not to have too ready a response for the patient. Once in a while, in order to save time, I am still tempted to give the patient “the answer” to his question, the reason he found things to be the way they were, but this never works. The patient wants to tell his story, to be fully listened to, and then to have some time go by before he hears my response. Without fail, if I give too ready an answer, the patient feels dissatisfied. He feels that I have not truly understood his discomfort.

End of life interactions between physicians and patients’ families are a rich setting for complaints. I listen carefully when families tell me what kinds of statements from physicians have been most comforting, and what kinds of interactions distress them. A woman whose 18 year old daughter was dying of cancer told me that a resident had said to her daughter, “I am so sorry for your suffering.” The mother said “It was such a simple statement, but so powerful.” Another woman whose husband had died and who had met with me about their end of life experience, was distressed that her husband’s doctor “looked at me and not my husband when he talked about treatment. He said to me, with my husband right there in the room, ‘This is what we can offer your husband.’ He was so blunt, not human.” By contrast, she praised two other physicians as being “very human, caring individuals”, and of the medical student, “he said things that comforted me, like ‘I admire your courage,” and ‘this must be hard.’” When I asked the woman to help define for me what she meant when she criticized one physician for being “not human” and praised the others for being “human,” she said that it came down to a matter of  “showing your caring for another human being in pain.”

As the mediators working with patients’ complaints involving their physicians, it is important for patient representatives to remember that this process can involve pain for the physician as well. It is often the case a physician will have no idea that his patient has a complaint. Patient representatives must be sensitive to avoid shaming the physician in the process. It is one thing for the physician to hear directly from the patient about a complaint, but when the patient decides to voice his issue through a patient representative, and the physician hears a complaint about himself in this way, it can cause understandable anger and defensiveness. A physician may ask us why the patient did not tell him directly about the complaint. Indeed, often, during a meeting with a patient regarding his complaint, I will talk with the patient about whether he feels he can bring his concern to the physician himself. There are some who, after they have had a chance to “talk it out” can take this action on their own behalf. But there are many others who feel they need a third party to assist them.

I have found it a distinct advantage to have worked as a mediator at the same medical center for many years because the medical staff knows me and the way I approach the work of medical complaint mediation. At the same time, I am sure that no physician looks forward to a message with my name on it. In fact, some will see me in the hall, laugh, and hold up crossed fingers as if to ward off the chance that I will need to talk to them on a patient matter. I feel comfortable however, that they know that my goal is to use the complaint as an opportunity to heal a relationship with the patient that has unraveled. We work together to do this.

From the patient perspective, it has seemed that patients want to feel that their experience, their complaint, has not been for naught, that by telling their story to a representative of the hospital, they will help other patients to avoid the experience that has distressed them. Through the process of telling the story of the complaint and receiving a response to it, the patient reconnects the broken threads of a relationship that is vital to him, the relationship with his physician, and he wants to pass on the renewed strength of that bond to other patients.

Susan Tarrant, MA is Director of Patient Care Services, UMASS Memorial Health Care


The Role of Creative Writing in Medical Education
BY EMILY FERRARA, MA

Since 1997, students at UMASS Medical School have been writing and sharing narratives about their experiences of medical school, through participation in a creative writing course. Early on in the process of becoming physicians, the students take stock of the forces acting on their interactions with patients, on their personal relationships, and on themselves. Penning narratives helps the students make sense of these changes, and may help them avoid burnout down the road. The mindfulness that comes from this writing may just make them better doctors, too -- more attentive to their patients’ stories, and perhaps better able to reflect on and learn from difficult or vexing interactions.

According to the Association of American Medical Colleges, humanities education within medical school curricula is pervasive. In 1998-99, “74% (93/125) of U.S. medical schools taught literature and medicine, and in 39% of U.S. schools, such study was part of a required course,” (Charon, 2000). Since the emergence of the literature and medicine movement in the early 1970s, literary texts have been used to help students better understand and empathize with their patients’ experiences of illness, pain and suffering (Charon, 2000). The incorporation of exercises in literary analysis within medical school curricula -- to shed light on the profound existential questions about birth, life, sickness, suffering and death that routinely confront physicians and their patients -- has typified the use of literature within medical education. However, focusing a curriculum on the medical student as writer, rather than medical student as literary reader and interpreter, is less prevalent.

The research of James Pennebaker and associates, which has focused in the past decade on studying the effects of narrative, has demonstrated positive health and behavioral effects in a variety of groups, including chronic pain patients, first time mothers, asthmatic patients, prisoners, and yes, even medical students.

Pennebaker and associates’ analyses of the underlying mechanisms responsible for writing-induced benefits affirmed the importance of the writing process specifically, as opposed to verbal storytelling or cathartic discussion. “By integrating thoughts and feelings, the person then can construct more easily a coherent narrative of the experience... Essays from those who improved were judged to be more self reflective, emotionally open and thoughtful...” (Pennebaker & Seagal, 1999).

Encouraging medical students to write reflective, emotionally open and thoughtful essays, poems and stories, and supporting them in this process is at the core of the Creative Writing Course offered at UMASS Medical School since 1997. Offered as an elective to second year medical students, the course provides a venue for the “making meaning” work of medical education. Suchman recommended that medical schools provide students with opportunities to explore the personal context, meaning and impact of patients’ illnesses; provide encouragement and support to students to explore their subjective experiences in medicine; and foster the development of communication and relationship skills (Suchman, 1995).

My role in co-teaching the seven-session elective, along with David Hatem, MD, is akin to serving as a midwife for words too tight. We use a self-empowerment model, featuring workshop leaders as “coaches” whose role is to encourage individual participation while fostering the development of a community of writers who in turn offer each other support, feedback and positive reinforcement (Teichmann, 1995).

When prompted with writing assignments, our students often write about those incidents and/or aspects of their training and interaction with patients that raises the greatest amount of distress in them. In addition to building community, the course provides a safe harbor for processing emotions, concerns, and difficult issues, issues for which medical students are hard-pressed to find a productive outlet.

In studying the effect of the Creative Writing Elective on students who participated in the course at UMASS, through analysis of the content of their writings, and through primary interviews with a subset of the participants, we found that the course appeared to have three primary functions: 1) to reduce stress and burnout; 2) to enhance reflection and self-awareness; and 3) to bring attention to the spiritual aspect of the profession.

The Impact of Stress in Medical Education
According to several studies on the subject, medical students are more stressed than are their peers in other professional educational programs (Aktekin, 2001; Firth-Cozens, 2001). By the end of their second year of medical school, students identified dissatisfaction with social activities, worrying about the future, and worrying about examination success (Aktekin, 2001). In a study comparing medical students with law, psychology, and chemistry students, Heins (as cited in Firth-Cozens, 2001) found that medical students’ lives were more negatively impacted; these students reported that their education impinged on the time they could spend participating in recreational activities and developing and maintaining friendships, as well as reduced the amount of time for necessary activities of daily life, such as tending to personal care and sleep. Bjorksten (as cited in Firth-Cozens, 2001) compared medical students with other health professions students, and found that medical students perceived their problems “more intensely.” Coupled with the characteristic of perfectionism, which is closely linked to self-criticism – the foremost characteristic predicting stress and depression according to a longitudinal study of doctors — medical students appear to be at greater risk than peers regarding stress and depression (Firth-Cozens, 2001). In addition, the demands of medical education can limit students’ ability to complete the developmental tasks of early adulthood, including establishing autonomy, competence, and striking a balance between personal and professional lives (Carroll, 1995; Suchman, 1995).

Cultivating Mindfulness in Medical Education
As an antidote to the high degree of stress in medicine, Epstein has articulated the importance of cultivating mindfulness in medical practice. He defined mindful physicians as those who “attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks” (Epstein, 1999). Epstein applied the concept of “mindful practice” to the medical profession, drawing on the work of Buddhist philosophers, including Suzuki and Thich Nhat Hahn.

Mindfulness is characteristic of good clinical practice, according to Epstein, who argues that it is the logical extension of reflective practice. Unfortunately, barriers to mindfulness are widespread in the milieu of medical education. High levels of stress and perfectionism have been noted. After all, errors in medicine may result in death, and high levels of achievement and competitiveness appear to pave the way to premium residency placements. These barriers block students’ ability to process emotions that arise in the course of their education - ultimately impacting on the quality of their educational performance, and the level of satisfaction with their education.

The Role of Spirituality in Medical Education
Spirituality in the context of doctoring is an area of burgeoning interest in medical education. The fact that all students go through a natural grieving process as part of the transformational experience of education (Scott, 1997) is one compelling reason to include spirituality in the medical school curriculum. Another is that a holistic approach to training medical students will likely result in students’ ability to use a holistic approach in their interactions with patients, ultimately leading to the preservation of humanity in health care and meaning in the profession. The narrow focus of health care in the physical dimension – at the expense of the emotional, psychological, and spiritual dimensions – is partially responsible for “a profound dissatisfaction with health care by subjects and practitioners alike, and may adversely affect its efficacy. Reaffirmation of an integrated perspective and concern for the whole person could rectify this” (Hiatt, 1986). Ultimately, an awareness of one’s own spirituality can enhance the ethical aspects of medical practice by providing a larger context of meaning and purpose. Physicians need a sense of connection to patients in order to feel fulfilled in their work. The alternative can lead to professional as well as personal burnout (Suchman, 1995).

Narratives of Resistance
In analyzing the content, tone and themes of second year medical students’ writings in the Creative Writing Elective at UMASS, I discovered that the expression of narratives of resistance was a common theme.

For example, we regularly give students an assignment that asks them to write from the patient’s point of view. Medical student Chet explored both the patient’s and the health care professionals’ perspectives in a first person story, from the point of view of an overweight 33-year-old patient who recounted his own death from cardiac arrest, struck down while doing his laundry on a hot summer day.

"They took me right into a room and a bunch of nurses went to work on me...I know I needed to do laundry and I know I needed a shower, but I hadn’t planned on being stripped naked in a room with ten strangers, okay. Well I guess my feet must have smelled bad but these are nurses and doctors for god’s sake, I thought they were supposed to be used to shit like that. This one nurse….was carrying on about the smell and next thing I know, she’s sticking these plastic bags on my feet...Some of the other cats got a real hoot out of it, believe me.”

Despite the patient’s less than appealing physical characteristics, he is a sympathetic character. The student-author of the piece effectively makes his point about the callousness of the doctors and nurses, while at the same time, through the detail of description, the minutia of a “Code Blue,” he also conveys the horrific nature of emergency room work. The student wants to resist identifying with the medical professionals (one he is becoming), and chooses instead to identify with the patient. Second year medical students who complete this exercise commonly identify with the patient. Writing a piece in the patient’s voice may enable these students to preserve a sense of empathy, even as they take on the mantle of “MD.”

Who am I becoming?
This same student also wrote about how the process of medical education was changing him. He wrote about his experience with the dissection of a cadaver in which he and fellow students discovered a tumor that had grown to the point of crushing one of the cadaver’s lungs. Chet confronted his fears of the negative impact of medical education:

"Some changes are innocuous enough: you sometimes smell funny, you wash your hands more often, you tell people what you do and they are more impressed than they used to be...But worst of all there are the changes lurking in the coming years that I only catch glimpses of, things to come, if I’m not careful, things that might already be there, growing: callousness, because sometimes it’s just easier than giving a damn; loss of perspective, when being a doctor crowds out the people who deserve better; and loss of identity, loss of the things you love to do and the parts of you that used to be special until you let them atrophy, crushed by the tumor that is your new life as a doctor."

Through the creative writing course, we provide students with a supportive venue to grapple with the conflicting emotions they undoubtedly will experience in caring for patients across the many interpersonal barriers — the race divide, the class divide, the doctor-patient divide. Medical student Colleen struggled with her lack of empathy in a situation with a patient, a response that was reinforced by her fellow health care workers who held disdain for the patient, whose psychiatric issues precipitated regular visits to the ER. As an inexperienced trainee (referred to as a ‘JAFO’ in the excerpt below), Colleen was torn between being the compassionate doctor and the distant and polished professional.

"One of the medics took a look and rolled his eyes; he seemed to know the patient, and now he was annoyed. ‘Get UP,’ he said. The patient did not move. JAFO (“Just Another F---ing Observer”) had missed it – just another nut. Nuts are dishonest and usually try to manipulate you. Nobody likes nuts. Embarrassed that she’d almost taken a nut seriously, JAFO quickly adopted the polished, cavalier indifference appropriate for such a case. It is safer to construct such an air than be vulnerable to a nut’s theatricals."

In writing the piece, the student confronted her lack of empathy, something she became aware of upon witnessing a caring and empathic interaction between the same patient and a compassionate physician. The student appeared to be stunned by her own cynicism -- a cynicism all too seductive as a defense mechanism against patients’ pain, suffering, and death.

Medical students in the creative writing elective often construct narratives of resistance such as these, as a natural part of the process of reconciling their personal and professional identities. Writing as a form of reflective practice, both within the required curriculum and within extracurricular courses and workshops, can provide a mechanism to support the holistic integration of all aspects of self. Providing medical students with the opportunity to share personal narratives in a supportive environment humanizes the intensely demanding experience of medical education. Ultimately, it is our aim to enrich the educational experience for these future doctors, as well as to enrich the quality of care they will be prepared to provide to their future patients.

This article was adapted from Ferrara, Emily R. (2004) The Saving Grace of Vulnerability: Fostering Reflective Practice in Medical Students Through Creative Writing in Julia Gentleman Byers & Michele Forinash (Eds.) Artists, Therapists and Educators on Reflective Practice, Peter Lang Publishing, Inc., 2004.
See References for this story on page 14

Emily Ferrara, MA is Assistant Professor of Family Medicine and Community Health and Director, Grants and Special Projects in the Office of Medical Education, UMASS Medical School.


Patient Communication and Consumer Protection
BY PETER MARTIN, ESQ.

When a surgeon allegedly performed a procedure other than the one discussed with the patient, the claim that the surgeon’s behavior was an unfair or deceptive practice under the state consumer protection statute went all the way up to the Massachusetts Supreme Judicial Court. Although the claim was rejected by that court, the case illustrates the difficulties physicians can find themselves in when they don’t take the opportunity to provide a high degree of communication with patients.

The case involved a patient who complained of rectal bleeding and pain; her doctor recommended a fissurectomy. The physician’s consultation notes indicated he discussed with the patient the possibility of performing a hemorrhoidectomy if surgery indicated a hemorrhoid was the cause of the rectal bleeding, but the patient denied that any such discussion occurred. Prior to the surgery, the patient signed, but claimed she did not read, an informed consent form consenting to the fissurectomy. That form authorized the surgeon to perform necessary or advisable procedures in addition to or different from the one currently contemplated. During the procedure, the physician did not tell the patient, who was awake, that he was performing a hemorrhoidectomy. Only after the procedure did the surgeon inform the patient that a hemorrhoidectomy was performed instead of a fissurectomy. The patient claimed that if she had known that such a procedure was going to be performed, she would not have consented to it.

The patient brought suit against the physician under the Massachusetts consumer protection, or “Chapter 93A”, statute, which makes unlawful any unfair or deceptive acts or practices in the conduct of any trade or commerce. The statute provides for double or treble damages for willful or knowing violations. The patient’s consumer protection claim was rejected at both the trial and appellate levels, and was heard by the Supreme Judicial Court, which rejected the claim because mere negligence, if proved, is not enough to support a consumer protection action. Something more, like dishonesty, fraud, deceit or misrepresentation, is required to show that the negligence was or resulted in an unfair act or practice barred by Chapter 93A.

The court suggested that Chapter 93A might be applied to the entrepreneurial and business aspects of providing medical services, such as advertising and billing. The court provided one example of such a claim: where a physician selects a treatment solely for his/her financial benefit. While the court acknowledged that Chapter 93A is a statute of broad impact whose limits are not precisely defined, its discussion of the statute in this case is significant in that it suggests how the statute might be applied in the future to medical practitioners.

Rejection of this patient’s consumer protection claim does not appear to break any new legal ground in Massachusetts. The facts in this case suggest that no reasonable amount of communication with this patient might have avoided this lawsuit. Put another way, what the case provides is yet another example of the role that clear, timely and specific communication with patients can have in preventing misunderstandings, unexpected outcomes and their legal consequences.

Peter Martin is an attorney with Bowditch & Dewey, Worcester.


Calendar of Events 2004-2005
 

November 5,6 Friday,Saturday 9am
Sheraton Framingham Hotel
2004 INTERIM MMS HOUSE OF DELEGATES
All WDMS members are invited to attend as guests and may submit a resolution to the Massachusetts Medical Society.

November 16 Tuesday,5:30pm
Beechwood Hotel
FALL DISTRICT MEETING
Speaker: Christine C. Feguson, JD, Commissioner of Public Health, The Commonwealth of Massachusetts. The dinner meeting includes the A. Jane Fitzpatrick Community Service Award, the WDMS Career Achievement Award and scholarship award presentations.

November 18 Thursday,7pm
Society Headquarters, Mechanics Hall
Women In Medicine Reception
An informal evening to allow women physicians to meet their peers to exchange ideas and receive support on balancing career/personal lives.

February 16 Wednesday,5:30pm
Beechwood Hotel
208th ANNUAL ORATION
“Old Dog, New Trick s ” Orator: B. Dale Magee, MD, MS Gynecologist, Private Practice Chair, MMS Committee on the Quality of Medical Practice Assistant Professor of Clinical OB-GYN, UMMS.

March 16 Tentative Wednesday,7pm
Rare Book Room, University of Massachusetts Medical School
MEET THE AUTHOR SERIES
Co-sponsored by WDMS and the Lamar Soutter Library at the University of Massachusetts Medical School “The Midnight Disease ” by Alice W. Flaherty, MD. A neurologist & author, Dr. Flaherty explores what causes writer ’s block and unravels the secrets of the creative brain.

April 13 Wednesday,5:30 pm
Location and speaker to be announced.
ANNUAL BUSINESS MEETING

May 12,13 Thursday,Friday,9am
Seaport Hotel &World Trade Center, Boston,MA
2004 MMS ANNUAL MEETING & House of Delegates All WDMS members are invited to attend as a guest and may submit a resolution to the Massachusetts Medical Society.


In the 1890s, Dr. Mary V. O'Callaghan Stood Tall
BY SANDE BISHOP

Get up to let your brother sit down”, an admonition frequently heard in the homes of Worcester’s early Irish community was heard less often by the second generation of Irish-American women. Dr. Timothy Meagher writes, in Inventing Irish America, that these women “were at least as well educated, and perhaps even more occupationally successful, than Irish men of either generation and yet they played almost no role in the social, cultural, or political leadership of their community.”

Mary V. O’Callaghan, who was instrumental in the founding of Worcester's St. Vincent Hospital, was at the forefront of successful women -- Irish or not -- of her time. She was born in Leicester in 1852, educated in the Worcester public school system and graduated about 1870 from the Worcester Normal School. At that time, the School was the only three-year program for teachers in Massachusetts, and, it claimed, its graduates were “cultivated women.” For ten years after graduation, she taught second grade at the Ledge Street School. In 1873, her salary was listed as $550.

Mary and Thomas, according to Dr. Meagher, like many of their generation, “enjoyed a relatively comfortable, unburdened, and socially active life as adult children in their parents’ household. To choose marriage was to give up these comforts and benefits.” Meagher writes extensively about the resilience of ideas from the old country continuing in the new -- especially the dichotomy of expectations for married women and unmarried women. He notes that Catholicism “exerted a significant influence in maintaining the ideal of motherhood….Irish families might forego the economic contributions of wives working outside the home, but encouraged -- even expected -- single Irish women to work… Worcester’s Irish consistently attacked women who deviated from either of these norms. They condemned ‘idle’, ‘frivolous’, daughters who avoided work with the same vehemence that they attacked ‘irresponsible’ wives who ‘flitted’ from club to club neglecting their motherly chores.”

Mary’s family seems to have worked as a unit. Where one was involved, we see other family members. Mary’s younger brother Thomas graduated, then taught Chemistry, at Holy Cross College before earning a medical degree from McGill University. A few years“ later, Mary followed in his footsteps, graduating from Woman’s Medical College of Pennsylvania in 1885. Such a career, according Meagher, “belied the frequent proclamations of church and ethnic leaders that Worcester’s Irish community believed marriage and motherhood was the only worthwhile role for women.”

Mary and Thomas helped create St. Vincent Hospital and both served on the staff of the newly established institution. Thomas, a surgeon, was the first staff president. Both O'Callaghans maintained offices in Trumbull Square, Thomas at 48 and Mary at 44. Records at Worcester District Medical Society note, “The area of Trumbull Street running from Front down to Park at Trumbull Square had many physicians in residence at the turn of the century. The names were mostly on single dwellings with front lawns…particularly at the square.” In 1890, Mary and Thomas combined their offices at 42 Trumbull Street, until Thomas’ early death in 1901. By then, their niece, Dr. Clara Fitzgerald, was also included. In 1907, Mary and Clara bought a house, which also served as their office, at 137 Pleasant Street.

Tracing the life of Mary V. O’Callaghan (1852-1930) has been an exercise in frustration. Being a woman in the 19th century, as well as being Irish, has made her nigh invisible. She left a remarkably light footprint for such an active and successful professional.

Dr. Mary V. O’Callaghan opened her practice and joined the WDMS in 1885. She practiced until her death in 1930 when, according to her obituary, “she was struck in front of her home by an automobile driven by John J. Riordan …Mr. Riordan told police Dr. O’Callaghan was carrying an umbrella, stepped from the curb in front of his automobile and that he was unable to turn his automobile to avoid hitting the woman. He immediately took her to City hospital where she remained unidentified until her niece, Dr. Clara P. Fitzgerald, with whom she lived, called at the City hospital and found her in the accident ward, suffering from a fracture of the skull.” The newspaper noted in a subsequent article “despite the span of her career she might have been spared for more years of activity had she not fallen victim to one of the forms of accident which menace us so constantly in modern time.”

Mary was a charter member of Worcester Woman’s Club, where she attended various programs. In 1897, she was among a number of Worcester physicians present to hear the Club-sponsored discussion “School Hygiene.” Mortality rates in Massachusetts then were reported for children under the age of fifteen as 160 per 1000 children; in Worcester, the rate was given as 135 per 1000. The program concluded, “Health was the responsibility of the home rather than school.”

The following year, Worcester Woman’s Club presented “Domestic Problems,” “The Relation between Mistress and Maid” and “Domestic Service.” If Mary O’Callaghan were in the audience of 200, it would be interesting to know her reaction. The press reported, “Ignorance, lack of domestic training and absence of good moral principle in many of the foreigners who come to this country to enter domestic service…. Another question was to the advisability of allowing girls of Irish parentage and Roman Catholic faith out on Saturday evenings, some saying that it was dangerous to the good moral character of the girls to be on the crowded streets where there was so much skylarking and others contending that they had sufficient confidence in them to allow them out if they wanted to attend the confessional…”

In November 1880, Worcester-Irish women organized a branch of the Ladies Land League, a movement started by Charles Stewart Parnell, who was sometimes referred to as the “Uncrowned King of Ireland.” Parnell, who is especially associated with Home Rule, founded the Irish National Land League to teach Irish farmers to assert their rights. The Worcester Ladies branch was one of the most active in America, raising in two years more than $5,000 to support Irish peasants – much more than their larger brother organization. Meagher writes, “More important, the Worcester’s Ladies Land League defied the conservative male leadership of the local Land League.”

From 1880-1882, when Worcester’s Irish priests dominated the conservative men’s organization, the Ladies Land League was in radical opposition. Meagher continues, “Indeed, the branch was truly a surprising phenomenon in Worcester no matter what its political stance. Aside from parish sodalities there were no Irish women’s organizations in Worcester in the early 1880s… Puzzling too were the class and generation of women leading this radical organization. No lists of the branch’s members remain, but various sources suggest that second-generation teachers and professional women played critical roles in the branch.”

Dr. Mary V. O’Callaghan is cited in several reports as being a principal in the organization and a member of the finance committee for the Emerald Bazar [sic]. The Worcester Daily Spy described the Emerald Bazar, a fundraiser held in February 1882, which featured “Miss Fanny Parnell, sister of the great agitator.” The paper reported “Good attendance though not as large as usual when a speaker from the Emerald Isle is announced…With perhaps one or two exceptions not a Catholic clergyman has been in the hall since the fair was opened.”

Meagher suggests, “women who responded with such energy and enthusiasm and who braved the opposition of the church and political leaders of their community were inspired and moved by more than the simple desire to follow distant national leaders. The branch’s furious activity and heated rhetoric suggested deeper causes… The League provided women with a chance to assert themselves in a public cause. It allowed them to prove their competence as well as challenge the male leaders of their community.” Mary’s obituary also suggests this. It says she was the first Catholic woman to enter the profession of medicine in the city, she was visiting physician at the State Industrial School for Girls and a member of the state Prisons’ Commission.

Among the throngs at St. Paul’s church for Mary’s funeral were Mayor O’Hara with members of city government, state legislators, staff of various Worcester hospitals, representatives of the local and state medical societies, a long list of priests and members of various religious orders, including the “Sisters of Notre Dame de Namur who were present at a public lay funeral for the first time in their history by special dispensation from their provincial. They were seated at the left of the main aisle while 20 nurses from St. Vincent hospital made a picturesque appearance as they marched into the church in their uniforms of blue and white with white caps.”

It would appear that Mary V. O’Callaghan was a strong and successful woman, respected in a community often hostile to professional women. Likely, she never listened if told, “Get up to let your brother sit down.”

Sande Bishop is a local historian who specializes in the development of medicine in Worcester.

With thanks to Nancy Gaudette at Worcester Public Library and Robyn Christensen at Worcester Historical Museum for assistance with this story.