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Worcester Medicine
Editorial
Non-Traditional Therapies Is Research in Holistic Medicine
Held to a Higher Standard? The
Value of Reiki and Massage Therapy A Review of Herbal
References Traditional Chinese Medicine ~ Can East Meet West? As I See It Cancer - Choices and
Decisions A Patient's Perspective Science Corner Legal Consult Financial Advice for
Physicians Off Call In Memoriam Society Snippets President's Message I want to thank our members for their time and effort for Community Immunity. We achieved a lot. Our exercise was of great value to the Worcester MMRS which had an opportunity to test its capacity for response with “live ammo.” We were prepared for a true emergency. The Department of Public Health learned about details that would never be apparent absent a live test. Further, the effort by the Medical School, bringing medical students and nursing students into a training exercise, was stellar. Thanks to Dr. Broadhurst and Robin Klar, we expect that this exercise will continue to be a part of the Community Medicine Clerkship. The Worcester Medical Reserve Corps developed a major new recruiting tool. The medical students were given expert instruction in injection technique and then got to practice with real patients. The Nursing School got to demonstrate its considerable expertise in preparing the injectors. The WDMS Alliance was outstanding in planning and executing our publicity. We learned a great deal about mounting a publicity campaign and coordinating billboards, internet, TV, newspaper and radio press in the run up to our final days. The City Council proclaimed 10/13/07 Community Immunity Day and all the mayoral candidates came for the exercise. Dr. Suasn Lett, Director of the Immunization program for Massachusetts DPH, visited as well. The glut of vaccine decreased the urgency of our effort and diminished the turnout, but we learned that we could develop partnerships with private industry if needed. Maxim stepped up to assure vaccine early in the process when the supply was not clear. Wal-Mart again stepped forward with supplies and advertising. Fallon Clinic supported us with advertising. The Worcester MRC was pleased with the exercise and I am sure the Worcester DPH will try a similar one next year. The synergy among all the healthcare professionals was exhilarating. We have shown the way and Worcester is better prepared for emergencies because of our efforts. On another front, our Partnership is making great progress in giving our physician community a common, secure e-mail. Dr. Abraham continues to astound us with his ability to get disparate factions to row together. Stay tuned. I am constantly amazed at how much we accomplish when WDMS leads the way. Thanks again to all who have worked so hard. Editorial:
Non-Traditional Therapies ~ Fact or Fiction? Have you ever seen a patient’s condition improve through methods that you can’t explain? We all have. That’s why it’s important for those of us practicing “conventional medicine” to have an open mind regarding therapies that are effective and not harmful, but fall into the categories of “alternative” or “complementary” medicine. If you are skeptical, consider this: non-traditional therapy in the U.S. today is a $39.5 billion industry. The major types of complementary and alternative medicine include the following:
No doubt we would all be surprised by how many of our patients use ~ and see improvement with ~ these therapies. Do we who practice “conventional medicine” have all the answers? The answer is NO. What truly works, no matter what form of medicine you are practicing, is creating an engaged patient ~ one who takes an interest in his or her own health. In this issue, our authors examine various approaches to non-traditional medicine, how they are currently being used, and how they potentially can make your patients improve and feel better. If an alternative therapy is not harmful, seems to work, and motivates your patients to become more involved in their own health care, then why argue with success? Patients are likely to seek out and use alternative therapies anyway. Therefore, as physicians shouldn’t we become better educated about non-traditional approaches? If you still think “traditional medicine” has all the answers, just remember: many conventional medical treatments in the 1800s would be viewed as malpractice today. One hundred years from now, what that we are doing today will be viewed the same way? Many “non-traditional” therapies have been around for centuries, are harmless and truly seem to help patients. Can we say the same of traditional medicine? If you’re wondering, just read the Institute of Medicine’s book To Err is Human and you will have your answer. But even if a non-traditional remedy is seemingly helpful and is helping the patient improve and become engaged in his or her health care, it’s still important to evaluate each and every alternative therapy based on the phrase we all uttered upon becoming physicians: “First, do no harm.” Strong Medicine: The
Origins of Patent Remedies Cocaine, morphine, alcohol, marijuana, turpentine, arsenic, mercury, radium, organophosphates and water. These were the most common ingredients of many of the patent medicines that enjoyed phenomenal success in the 1800s and early 1900s. But there was one more important “secret ingredient” in the patent medicine mix - advertising. Not only did patent medicine promoters pioneer colorful product names and claims, they also pioneered the techniques of advertising their potions directly to consumers. Patent medicines, or “Nostrum Remedium,” Latin for “our remedy,” started in Great Britain in the 1600s and became popular in the United States in the mid 1800s. Amazingly, the only requirement to market these medications was that the formula be owned by the maker. Proving a medication’s effectiveness and safety was not required. Popular medicines of the period included Mud-Wump (for venereal diseases), Obtundia (an opium lotion for itch), Dr. Thurston’s Death to Pain, Clark Stanley’s Snake Oil Liniment, Mrs. Winslow’s Soothing Syrup (containing morphine and used for colicky babies). Even Shredded Wheat, which was manufactured in Worcester from 1895-1900, was originally invented by Henry Perky to ease his own chronic indigestion. Probably the most successful of all patent medicines was Lydia Pinkham’s Vegetable Compound, still on the market today. Lydia Pinkham (1819-1883) began manufacturing her famous compound for “ailments peculiar to women” in Lunenburg, MA. using roots from the local Mulpus Brook. She later opened a factory in Lynn. The reason for Pinkham’s phenomenal success? Smart marketing and the fact that her vegetable compound contained 20 per cent alcohol. Many patent medications contained even stronger ingredients like opium for common, everyday maladies such as colic, diarrhea, pain, and headache. Even radium was routinely used by injection, tablet, suppository or inhalation as a cure for baldness, impotence, and aging (I guess back then a positive review of systems would have included the question, “Do your stools glow in the dark?”). Some of the patent medications did prove to be extraordinarily useful. In 1890s Germany, the Bayer Company found a better way to synthesize acetylsalicytic acid and started manufacturing Bayer Aspirin in 1899. Of course today “aspirin” is a generic name ~ Bayer lost its rights to the trade name in 1919 as part of Germany’s concession at the end of WWI. Several U.S. inventors developed other remedies as enduring as aspirin. Jordan Lambert, who later founded Warner Lambert Pharmaceuticals, marketed a mouth wash for halitosis named after Joseph Lister. Listerine is, of course, still a top brand today. Charles Phillips developed a remedy that combined water and magnesium hydroxide and called it Milk of Magnesia. In North Carolina, Lunsford Richardson developed a salve cold remedy named after his brother-in-law, Joshua Vick, and Vick’s VapoRub endures today. But what happened to some of the disreputable preparations? In 1905, Samuel Hopkins Adams published the exposé “The Great American Fraud” in Colliers Weekly that eventually led to the first Pure Food and Drug Act in 1906. Since then, patent remedies have become more tightly controlled, driving many from the market. But notable exceptions have survived to this day, although they may have changed some of their original ingredients. They include: Absorbine Jr., Bromo-Seltzer, Fletcher’s Castoria, Geritol, BC Powder, Carter’s Little Pills, Chlorodyne, Doan’s Pills, Goody’s Powder, Luden’s Throat Drops, and Smith Brothers’ Throat Drops. Today, drug makers must disclose addictive ingredients and harmful side effects. But last year the pharmaceutical industry spent a combined $2.5 billion advertising directly to consumers. Just how far have we come since the days of patent medicines?
Is Research in Holistic Medicine Held to a Higher
Standard? In 1971, when I returned to medical school from Zululand, having witnessed that only breast-fed infants survived the infectious and nutritional landmines of a Zulu baby’s life, I nearly flunked a pediatric rotation, labeled a regressive hippie heretic for advocating nursing over formula. The following year I found myself staring at a pile of herbs a patient with tuberculosis was hiding in his bedside stand at a prestigious Indian medical school and thus discovered Ayurveda, the medical science of the Vedic culture of ancient India. I wondered whether a time-tested science could survive the scrutiny of scientific inquiry and spent twenty years wrestling with research designs to shed light on this question. I have learned that such research is held to a higher standard. Traditional Ayurvedic practitioners feel that robust research designs, examining one variable while keeping other conditions the same, violate the spirit of their art. Ayurveda may be the extreme example of a holistic medical science, targeting all aspects of a patient’s life to affect the cure: mind, body, behavior and environment. A proper Ayurvedic therapeutic prescription for hypertension, for example, incorporates yoga, meditation, weight control, exercise, a grain and dairy-based diet low in salt and animal fats, “behavioral tonics” such as singing and playing with children, and herbs (the first useful “western” pharmaceutical for hypertension was rauwolfia, an Ayurvedic tranquilizer). So how do you research the question, “Can Ayurveda treat hypertension?” if the traditional intervention is multifactorial? What foolish subject would submit to sham yoga, meditation, exercise and herbs to function as a proper control? Moreover, shouldn’t an ethical review board nix such a study now that individually yoga, meditation, exercise, diet and herbs have been found to improve blood pressure? You can research the effect of an isolated herb, but that diminishes the art of Ayurveda to herbal pill pushing, when its value lies in altering the lifestyle and behavioral underpinnings of the disease. Studying only a part takes the Veda out of Ayurveda, making this holistic science reductionistic and moving both Ayurvedic and western physicians to reject as poorly designed the thousands of positive studies. Meanwhile in western medicine, we continue to kid ourselves that our practice is evidence-based while evidence is lacking for most of what we do. Reducing BP has been shown in controlled trials to reduce stroke, CAD and mortality only for a limited number of agents, yet we extrapolate the findings to any drug that reduces blood pressure and are surprised when an agent turns out to be harmful. Ditto for glucose reduction, cold medications and others.[1] Respected Ayurvedic masters focus on prescriptions affecting consciousness, knowing the patient will adopt behaviors conducive to her disorder. Indeed, research on Transcendental Meditation has shown that practitioners, without encouragement, reduce tobacco and normalize cholesterol, BP and weight, but also reduce their risk of multifactorial pathological processes such as atherosclerosis. Inner city elderly blacks who started TM had significantly reduced intimal thickening of the carotid arteries after 6-9 months, compared to subjects who did progressive relaxation, whose intima continued to accrue plaque.[2] Ayurveda is a Veda for ayu, the span of life, and includes within its scope, yoga and meditation, also conceived for longevity and spiritual growth. The research endpoint should therefore be rejuvenation and freedom from disease. In a study of 1900 subjects, long-term practitioners of TM and Ayurveda had higher serum levels of DHEA-sulfate, which progressively declines with age, that were comparable to non-practitioners 5-10 years younger.[3] Members of an Iowa corporate Blue Cross plan practicing Ayurveda and TM had hospitalization rates that were on average 60-70% lower than similar Iowa BCBS plans in 17 disease categories including cancer and heart disease (-87%). The only exception was obstetrics, showing that subscribers were using health services when necessary ~ and that these practices don’t make you celibate.[4] Elsewhere, analysis of Quebec Health Insurance data showed that people beginning TM had 2% yearly reductions in utilization costs over fourteen years following instruction compared to normative 12% yearly increases. [5] Yet, these and other well-designed studies showing we can change health and its costs are ignored by clinicians and by administrators planning health budget priorities. Is complementary medicine being held to a higher standard of evidence? Or is it simply easier to make token changes in our practice, like prescribing fish oil for coronary risk reduction, rather than profoundly affecting an unhealthy lifestyle? Like it or not, yoga, like breast-feeding, has entered the mainstream, and the radical, complementary medicine of a generation ago is now the community standard. Good research designs to document holistic medicine and the funding to carry studies out will show us what we have to learn from ancient physicians. References:
Jay Glaser, MD is a hospitalist at Leominster HealthAlliance Hospital. Research on Ayurveda and its use in clinical practice can be found on his web site, www.AyurvedaMed.com The Value of Reiki and
Massage Therapy Reiki is defined as universal spirit or energy which permeates all living forms. Ancient civilizations understood that this life force energy flows through the body supporting optimal development and fulfillment ~ the mind body connection. Reiki induces the relaxation response. Studies show that this deep state of relaxation acts through the autonomic nervous system to lower blood pressure and heart rate and relieve tension and anxiety. This deeper state of relaxation augments the abilities of the immune system and stimulates the production of endorphins to decrease the perceptions of pain and create a sense of well being. Reiki has been incorporated into many hospital and clinic settings throughout the country in pre op, post op, labor and delivery and chronic care units. The general public is increasingly interested in this and other modalities of complementary health care. Reiki therapy is applied through an attuned, trained practitioner to a willing recipient by a series of hand placements on or above the body. The practitioner acts as a conduit for the energy to flow in a non-invasive method. Reiki is particularly helpful in the hospice and palliative care settings. Reiki requires the positioning of the therapist's hands but does not require any special positions of the patient or necessitate the removal of clothing; both are advantages for the hospice population who may be extremely debilitated. The Reiki energy compliments the clients' medical regime by enhancing the quality of life, a basic goal of hospice care. It is an adjustment to the medical treatment and has been found to be helpful with end of life patients afflicted with Alzheimer's disease as well. Reiki brings relaxation, peacefulness and a sense of warmth. The Hospice program of the UMass Memorial Medical Center has incorporated Reiki into its Massage Therapy program. These complimentary services are offered not only to hospice patients but to children in the newly established Pediatric Palliative program. Family evaluations strongly indicate that in the adult population relief of anxiety is evident after a session of Reiki or massage therapy. The promotion of peacefulness and restful sleep after each session was well noted. The effects of the one to one energy touch in hospice should not be underestimated in providing quality in end of life care. References:
June Bessette is certified in Reflexology and Level I Reiki. She has worked for UMass Memorial Hospice for 10 years - the last 5 years as a massage therapist. June still fills in as a nurse when needed. A Review of Herbal References Self-medication with herbal products for preventative or therapeutic purposes has greatly increased in recent years. Many people assume that because herbal products come from nature, they are “natural” and safe to use. In fact, herbal products, like any other exogenous chemicals (including medications), have the potential to cause adverse effects and interact with foods and medications. In addition, a lack of product standardization, and the potential for contamination and allergic reactions, pose inherent risks associated with the use of herbal products. Herbal products are medicines and should not be used without proper guidance from a healthcare professional. Many patients, however, believe that healthcare practitioners have negative attitudes toward or are not well informed about dietary supplements. In turn, many practitioners are reluctant to discuss herbal therapies because they are unfamiliar with or skeptical of alternative treatments. Under the Dietary Supplement and Health Education Act of 1994, herbal products are classified as dietary supplements (not as drugs) and are not under the auspices of the FDA. As a result, herbal products are not regulated under federal drug laws; safety and effectiveness need not be demonstrated before these products are marketed. No legal standards are applied to their harvesting, processing, or packaging ~ so the possibilities of poor quality, adulteration, contamination and varying strengths must be kept in mind when evaluating them. Manufacturers of dietary supplements can make claims about the ability of the product to alter structure or function but implied, as well as expressed, claims regarding the treatment, cure, or prevention of disease cannot be made. The FDA becomes involved in safety issues for herbal products only after they are on the market and complaints are filed. Unlike a drug, which must establish efficacy and safety to be marketed, herbal products can be marketed until proven to be unsafe. In recent years, there has been an explosion of references about natural products. This review will assess the usefulness of some of the most common and most easily accessible tertiary references (Table 1) that healthcare professionals employ to answer questions about herbal products and dietary supplements. This information is intended to assist healthcare professionals to more efficiently select a helpful collection of resources to handle requests concerning herbal products and dietary supplements in their practice setting. Overall, AltMedDex, Natural Medicines Comprehensive Database, The Review of Natural Products, and The Natural Standard have consistently proven to be the most comprehensive and helpful references, but can be more expensive than more traditional hardcopy references (1, 2, 3, 4). The electronic format of these four databases allows for frequent updating (daily-monthly) and search by individual ingredient or by product brand name. AltMedDex is available as part of Micromedex; the high cost, however, precludes individual subscription (1). The Natural Medicines Comprehensive Database, The Review of Natural Products and The Natural Standard provide objective, comprehensive, and evidence-based clinical information on natural medicines (2, 3, 4). Information regarding history, purported uses, safety, effectiveness, adverse effects, interactions, dosing, and use in pregnancy and breastfeeding is presented in peer-reviewed monograph format. Information is referenced and rating scales (different for each database) are used to evaluate the quality of evidence. Internet sites for use by healthcare professionals include The American Botanical Council (ABC) and the National Center for Comprehensive and Alternative Medicine (NCCAM) (5, 6). The ABC is a non-profit organization and requires a yearly subscription that includes access to HerbGram (a quarterly, peer-reviewed journal), continuing education materials for healthcare professionals, and herbal information sheets for duplication and distribution patients and consumers (5). The NCCAM (a governmental agency that is a part of the National Institutes of Health) sponsors and conducts research using scientific methods and advanced technologies to study CAM (6). Information at this site is geared toward both the public and healthcare professionals. Numerous herbal information resources are available as bound textbooks. Publication dates vary considerably and some commonly used resources do not provide the most updated information. The print versions of Natural Medicines Comprehensive Database and The Review of Natural Products are updated annually (7, 8). In 1978, the German government established an expert committee, the Commission E, to evaluate the safety and efficacy of over 300 herbs and herb combinations sold in Germany. Published in 1998, the Complete German E Commission Monographs provides information on the approved uses, contraindications, side effects, dosage, drug interactions and other therapeutic information for the use of herbs and phytomedicines (9). In 2000, Herbal Medicine: Expanded Commission E Monographs was published to address deficiencies of the previous publication with added overviews of clinical research, expanded sections on chemistry and pharmacology, more on dosage and administration, and a comparison chart of leading herbal brands (10). Produced under the direction of the Royal Pharmaceutical Society of Great Britain, Herbal Medicines: A Guide for Healthcare Professionals is organized around 141 monographs on individual medicinal plants and has a number of quick reference tables (11). Each monograph includes species, synonyms, plant parts used, legal category of product (in Great Britain), constituents, food use, herbal use, pharmacological actions, side effects and toxicity, contraindications and warnings, and references (11). The Physician’s Desk Reference for Herbal Medicines includes over 700 monographs, compiled using the German Commission E indications, that have been updated to include recent scientific findings on efficacy, safety and potential interactions (12). There are also updated sections on enhanced patient management techniques and nutritional supplements (12). The well-known Tyler’s Honest Herbal includes botanical information, folkloric background, plant sources, traditional uses, evaluation of literature, and laws and regulations pertaining to greater than 100 commonly used herbs (13). Tyler’s Herbs of Choice augments Tyler’s Honest Herbal (but the two texts do not need to be purchased together) and discusses the practical therapeutic application of herbal remedies for over 100 health problems with chapters organized by disease states or symptoms (14). An updated edition of Tyler’s Herbs of Choice is expected in 2008. Practitioners should be aware of the information regarding efficacy and safety of herbal products so that they can provide guidance regarding herbals that may affect their patients’ health or current therapeutic regimens. Reviewing current medical literature will provide limited information on herbal products. While some research studies have been published, most are in languages other than English. Data supporting safety and efficacy are weak due to studies of few subjects, short duration of treatment, and varying doses and formulations of the products. Due to rising consumer use of herbal products, the lack of conclusive evidence for these products, and the absence of formal didactic training in alternative medicines, practitioners must rely on herbal textbooks and databases as a source of primary information. When selecting herbal references, practitioners should evaluate the type of questions they expect to encounter, the format of the resource they would be most likely to use, the timeliness of the information presented, and the cost. Table 1: Herbal and Dietary Supplement References
References:
Anna K Morin, PharmD is Assistant Professor in the Department of Pharmacy Practice at the Massachusetts College of Pharmacy and Health Sciences in Worcester, MA. Email: anna.morin@mcphs.edu Michele Matthews, PharmD is Assistant Professor in the Department of Pharmacy Practice at the Massachusetts College of Pharmacy and Health Sciences in Worcester, MA.
Traditional Chinese Medicine ~
Can East Meet West?
Oh, east is east, and west is west, and never the twain shall meet, till
earth and sky stand presently at God’s great judgment seat The times have proven Mr. Kipling to be wrong. Visit any part of the world and the power of globalization is evident, the world becoming a happy blend of east and west. But medicine may be the exception, where “western medicine” has become dominant. China is the exception in that Traditional Chinese Medicine (TCM) is still very active. But frankly speaking, physicians in the United States know little of TCM and TCM has not integrated the contributions of western science. Both are reluctant to take into account the other, each quite content to do its own thing. Though acupuncture and other forms of treatment in TCM are still controversial, there is strong reason to believe that, for at least some patients, these treatments may be a good option. Considering that each year in America over 2 million patients suffer from serious adverse drug effects, TCM may provide a safe and effective alternative or complement. While acupuncture is not without some risk, with cases of serious complications being reported, overall TCM is a natural form of therapy, working through enhancing the body’s own self-healing capabilities rather than vigorously attacking the disease agent, and therefore is relatively safe if performed correctly. I saw first-hand its effectiveness while I was at the Longhua Hospital in Shanghai, where I went as a medical student for a 3 month acupuncture training program at the Shanghai University of Traditional Chinese Medicine. Many patients swore by it. For example, one patient had been smoking for several years and had tried to quit numerous times but nothing seemed to work for him, including the patch; after just that one acupuncture treatment he’d been able to cut back from 2 packs per day to just 2 cigarettes daily. Perhaps the greatest testament to acupuncture’s efficacy is its widespread use in China for over 2000 years. Currently, over 200 million patients are seen each year in the over 2,500 TCM hospitals in China. There are over 350,000 full-time TCM doctors in China, each of whom has undergone a rigorous 5 year training. TCM is also rapidly spreading throughout the world; more than 120 regions have set up TCM clinics. America is no exception to this popularity, with over 8 million Americans who have tried acupuncture. Despite this increasing popularity, many westerners remain sceptical about TCM. So where do we go from here? We first need to more convincingly answer the question, “Does acupuncture work?” Global and U.S. organizations, like WHO and the NIH, have “softly” endorsed acupuncture, listing a variety of conditions for which acupuncture may be indicated based on the clinical evidence. Strictly speaking, however, the evidence to date is spotty, with a paucity of trials involving “sham” acupuncture controls, making it difficult to decipher psychosomatic effects from true therapeutic benefit. Second, we need to answer “Why does acupuncture work?” With regard to relief of pain we do have some ideas, with growing evidence of an effect through the nervous system and demonstration that endorphins, the “pleasure chemicals” in the brain, are released in response to acupuncture. Our understanding of how acupuncture works for other ailments, however, is very limited, and more controlled trials with measurements of objective parameters are needed. Third, TCM theories and treatments, which have remained largely unchanged for thousands of years, need to be updated. For instance, acupuncture is believed to work in TCM through an invisible energy, an idea that arose based on ancient Chinese religious beliefs rather than science. Descriptions of certain organ functions, which have bearings on which points are chosen for puncturing, are also clearly contradicted by what is now known in medical science. My experience in China impressed me and has made me enthusiastic having personally seen many of the patients I worked on improve. Some of my classmates have treated themselves (e.g. for migraine headaches) and found relief. Acupuncture appears to work for pain-relief and other conditions and is a safer and more pleasant therapy than drugs or surgery. But acupuncture today appears not to have incorporated the advances that western medicine can offer. More collaboration between acupuncture and western medicine can result in a treatment that is more effective, better understood and more widely used.
As I See It: P4P – The Moral Hazard
or the Moral High Ground? Pay for performance has been implemented by CMS on a pilot basis and by multiple insurers because our current payment system and incentives are not aligned with the IOM’s six quality aims.[1] The goal of the P4P pilot was to create incentives to better performance by evidence based medicine for selected disease states. CMS selected ten group practices and launched the Medicare Group Practice Demonstration in April 2005. It measured the ten groups on their performance in diabetic management: HbA1c management, HbA1c control, LDL levels, testing for urine protein, pneumococcal vaccination, lipid measurement, diabetic eye exams, foot exams, influenza vaccination and blood pressure management. My concern, shared by many, was that CMS would measure cost savings, not quality of care. It linked quality care to immediate cost savings ~ which it would allegedly share with the groups, giving back some of the savings as a bonus. The first year results are in! If you read the AMA News[2], you’d know that two of the ten groups hit all ten targets. All groups met at least seven of the ten clinical quality measures. Yet only two groups got bonuses and that included only one of the two groups hitting all the quality measures! Why did eight group practices actually lose money (they invested in systems and processes) rather than get bonuses? They did not save Medicare enough money to trigger payouts based on Medicare’s mid-stream rule change. CMS says that more practices could get bonuses the second year and onward by learning lessons from the first year. I think the lesson learned is not to trust CMS’s promises. Apparently saving money trumped improving quality as the real goal and the trigger for payouts. This was a high profile year, with much attention and focus. I shudder to think what might happen in future years, when the concept is routinely operational rather than a small-scale high visibility pilot. The espoused goal of P4P is to improve health care and reduce spending cost. Some up front programs can be very effective in creating incentives for physicians to operate under best practices. We saw that in the results of the CMS pilot project. The problem is that while we can be more effective where there are clearly defined best practices, those areas are small compared to those where there are none. If we divide medical procedures into three groups[3] ~ effective care (with best practices), preference sensitive care (which may include trade offs on quality and duration of life), and supply sensitive care (how many visits should a patient with congestive heart failure have?) ~ Wennberg estimates 50% of all medical spending is in the third group! Then there is the potential for the moral hazard in P4P. First is the huge focus on the first group of patients. Here we have a shift in resources to “perfect” care of certain aspects of some patients from other aspects of those patients and patients with other problems. We spend much time and energy and develop systems specifically to address those aspects of best practices that will result in payoffs. Maybe. Second, as a recent survey showed, roughly one quarter of our basis for best practices (the “evidence base”) changes and goes out of date every two years. Anyone think CMS (or other insurers) will keep up that quickly? Can you see yourself changing your practice to a new best practices and getting penalized? Third, the guidelines that insurers (and we) use are imperfect. While there are nearly 2000 clinical practice guidelines listed in the National Guideline Clearinghouse, there are at least two issues: we have to make clinical decisions on living patients, not a dataset fitting into a cubbyhole, and many studies on which these guidelines are based included too few patients of the set most often evaluated and treated![4] (The example cited is congestive heart failure, wherein many trials included few older patients ~ those we treat most often for heart failure. Are the guidelines right despite that?) And then there is the potential for adverse selection. If you create the best systems for dealing with (for example) diabetic patients, you’ll attract more, including the ones whom you may never be able to “control.” Remember the No Child Left Behind Act?[5] Texas did very well ~ by making the very students who were more likely to fail and drop out disappear into thin air! In some school districts, up to 40% of students vanished. The Texas Commissioner of Education decided to disregard unilaterally the NCLB requirements for testing students with learning disabilities.[6] Tufts-NEMC found that they had the lowest mortality for stroke patients admitted to academic institutions in 2003, but the second worst in 2004.[7] The low rate was statistically significant, but the high rate did not statistically differ from the cohort for 2004. Their procedures had not changed year to year. The explanation? The insurer focused on the difference in mortality rate and translated that into a quality issue. Yet there was no attempt to understand that the DRG encompasses diagnoses that have significant variations in severity: ischemic stroke, hemorrhagic stroke, acute subdural hemorrhages and subarachnoid hemorrhages. An intensive review failed to find quality of care issues but did find a significant increase in patients with a diagnosis of cerebral hemorrhage, accounting for most of the mortality difference. I suspect this kind of problem is not isolated. One of the most ambitious P4P projects is between general practitioners and the United Kingdom’s National Health Service. Doctors who can satisfy 76 quality indicators in ten clinical domains of care can receive 50% more in government compensation. But by gaming the hypertension management criteria, each practice could get an additional ₤1800 annually. How? While there is a penalty for not recording blood pressure at least once every nine months, a practice could exclude that value for patients who do not meet the trigger BP level and instead record the BP more often on an equal number of well controlled patients! We have high ethical standards. Yet I suspect there are practices that might terminate relationships with the very patients who need them the most because the patients’ lack of control or compliance would compromise the practices’ chances of getting the P4P reward. Then CMS and other insurers will add a whole new overlay of rules and regulations on terminating patients, and we’ll be faced with another set of problems. And “we,” as usual, generally applies to those who follow the rules in the first place. How do financial rewards for P4P stack up? There are many reports across the country. One model is Hill Physicians Medical Group, a 2100 physician group with headquarters in Ramon, California. They have an internal system that rewards physicians based on individual quality performance (HEDIS and other targets) up to 30%, with an average bonus payout of 15% (or $10,500 quarterly). At the same time, nevertheless, the external P4P bonuses reached only 1% of gross revenues. Most group practices do not reward performance to the extent that Hill does. Even at Hill, one out seven physicians gets no bonus.[8] For the amounts most practices bonus, the individual physician financial incentive is an order of magnitude less. So where do we go from here? How do we take the best care of patients we can, avoid penalties, and avoid adding work onto the backs of already overworked primary care physicians to meet best practices (where they exist)? I suggest we redefine P4P as “Perform for Patients.” We need to do the right thing for all our patients, where “right thing” is well-defined by high quality evidence from appropriate patient populations, and do the right thing as physicians and decision-making partners for those for whom “right thing” may be partially or wholly subjective and a matter of personal choice. We need to delegate to our leaders (physicians and administrators) and lobbyists the task of defining quality for government and insurers as it truly relates to the practice of medicine and getting us rewarded properly; in the meantime, though, we should take the high road and work for our patients. We should task our leaders to go beyond current EHR systems (for which there is painfully little evidence of intrinsic improvement in care) to systems that actually help us do all the things patients need when those interventions are proven and defined. We need systems that are flexible in order to keep up with the rapid changes in evidence-based medicine. And we need leaders who recognize that we should supply “everything each patient needs in a timely fashion and nothing each patient doesn’t need.” Marc Greenwald, M.D. Chief of Medicine at Brockton Hospital, is also president of MLM Consulting, focusing on quality assurance and outcomes systems for hospitals and on patient service training for physicians. The opinions in this article do not necessarily reflect those of Brockton Hospital or the Worcester District Medical Society. References:
Cancer ~ Choices and Decisions The phone call from the doctor confirmed that the source of the pain in my left hip was cancer. I had first gone to the doctor complaining of a slight pain in my left hip in February 2001 and here it was July. I had been to the recommended chiropractor, had numerous x-rays which revealed nothing, and had spent countless hours in physical therapy until the pain had become so intense that I could no longer endure it. This was my second cancer experience; the first was in 1993. Then it was a small lump (no surrounding tissue involvement and all lymph nodes were clean) in my left breast. The treatment that time was a lumpectomy, radiation, and Tamoxifen. I had my concerns about Tamoxifen because I had read that one potential side effect might be uterine cancer. I was, however, declared cancer free. In 1995, my annual pap smear and exam revealed that my uterus walls were thickening. My gynecologist recommended a biopsy; it showed I had endometrial hyperplasia, which I was told could be the early stages of uterine cancer. Several months later, heavy bleeding confirmed that the condition had worsened and at that point, a complete hysterectomy was recommended. It was then that my daughter suggested that I see a naturopathic doctor. I did, and she recommended 3 homeopathic remedies. I immediately followed her advice and informed my gynecologist that I had decided against a hysterectomy; she thought that I was making a poor decision and asked that I consent to a D&C and hysteroscopy in 2 months. I agreed. When the procedure was done, my gynecologist happily informed me that there was no sign of endometrial hyperplasia and that my uterus looked perfectly normal. This news was followed up with several biopsies at 3 month intervals which proved that my uterus had indeed returned to a completely normal state. I was totally devastated with the second cancer diagnosis. How could my body have betrayed me again? I was told that the tumor on my hip, another breast cancer, was attached to bone, tissue, and muscle. Surgery was out of the question. I was told that I had approximately 3 years to live and that those years would be, most likely, dedicated to treating my cancer. Once again, I agreed to radiation. I also contacted the naturopathic doctor who had cured the endometrial hyperplasia. She referred me to another naturopathic doctor who had successfully been treating breast cancer for over 20 years. This was a huge step for me to take but I felt strongly that I needed to pursue another course of action. I started on a very strict regiment of holistic remedies, including monthly REIKI and body works therapy, in September of 2001. The naturopathic doctor explained to me that everyone has cancer cells. The critical issue then becomes what each person’s immune system does with those cells. A well working immune system will not allow these cancer cells to grow into tumors while a compromised immune system like mine cannot stop the process. I’ve had both Crohn’s Disease and Graves’ Disease. Now, more than 6 years after I started with naturopathic medicine, I am cancer free and living a perfectly normal and healthy life, aside from all the extracts and supplements I take each day. I have no aches, no pains, no ailments. As a result of my ongoing experience with naturopathic medicine, I have recommended the same for many people with all types of problems from dry skin and cracked nails to ALS to cancer to high blood pressure to thyroid disease to arthritis and so much more. The one thing they all have in common is that their ailments have been arrested with naturopathic medicine. I have also altered the way I eat to exclude all meats and farm raised fish. The rationale behind this decision was simply that farmers will feed their livestock hormones in order to increase the size and, consequently, the monetary value of their product. My cancers were both hormone receptor positive. I have no idea if the hormones used by farmers contain either estrogen or progesterone, but I’d rather be safe than sorry. I am also very careful with the produce and diary products that I eat and always seek out the organic varieties. I thank God every day for my life, the quality of it, and the wonderful people in it who supported and cared for me through hard times. I hope that they know that they have made a difference. Science Corner:
Probiotics ~ Microbes to the Rescue A probiotic is a live microbe that, when administered in adequate amounts, confers a health benefit to the host. An increasing awareness of the importance of probiotics in the United States has followed the publication of studies reporting remedial effects on a variety of gastrointestinal (GI) disorders, allergic conditions, and vaginal infections. Most research has focused on the potential role of probiotics in disorders of the GI tract. Probiotics occur naturally in fermented foods such as yogurt, kefir, sauerkraut, kimchi, and soybean-based miso and nattō. The most common commercially available forms of probiotics are dairy products and probiotic-fortified foods. However, tablets and capsules containing the bacteria in freeze-dried forms are also available. Genetically engineered microbes designed to deliver specific products to the GI tract are being developed. The precise mechanisms of probiotic action have not yet been fully established. However, based on the standard definition, a probiotic is understood to be nonpathogenic and viable at the time of consumption and following contact with gastric acid and bile salts. After overcoming chemical barriers, probiotics adhere to the intestinal surfaces where they compete with pathogenic agents and modulate the host’s inflammatory and immune responses. Probiotics do not multiply quickly and therefore do not permanently colonize the digestive tract. In addition to inhibiting the growth of other microbes by increasing intestinal acidity, producing metabolically active proteins (i.e., bacteriocins) and competing for nutrients and intestinal adhesion receptors, probiotics promote digestion. Probiotics also have the potential to stimulate the immune function of the gut associated lymphoid tissues, enhance mucosal barrier function, and induce T-cell apoptosis in the lamina propria. The impact of different probiotics on a particular disorder varies. Moreover, alternate strains of the same species may exert different probiotic functions. Such results are typical among divergent strains of Lactobacillus. Mechanisms that lead to specific health effects are often not known. When these are better understood, it may be possible to predict functionality in vivo. Thus, clinical trial results from one probiotic in one population cannot be generalized to other strains or to different populations. Although a listing of all studied probiotics is beyond the scope of this article, an outline of agents demonstrating promise in specific conditions is noted below.
Antibiotic associated disease due Clostridium difficile (C. difficile) is a prevalent, serious and costly problem in healthcare facilities. Central to the pathogenesis of the disorder is the disruption of the normal colonic flora by antimicrobials and the overgrowth of institutionally acquired and toxin producing C. difficile. The concept that an innocuous microbe might prevent or treat disease due to C. difficile has appeal. Indeed, studies have shown that probiotics given prophylactically (Lactobacillus casei, Lactobacillus bulgaricus and Saccharomyces thermophilus) can reduce attack rates of C. difficile in adults receiving antibiotics. Other probiotics (Saccharomyces boulardii) enhance the response rates of patients with C. difficile who are treated with vancomycin or metronidazole. However, the available data remain limited and as a result, a firm role for probiotics in disease due to C. difficile has not yet been established. Similarly, promising data in support of probiotics for simple antibiotic-induced diarrhea need to be supplemented with larger studies. Probiotics have been widely used in food products for the past several years and have an excellent safety record. However, there have been several case reports suggesting that their use in high-risk individuals, especially premature infants and debilitated or immunocompromised adults, might cause sepsis. For example, S. boulardii has been associated with fungemia, and Lactobacillus rhamnosus and other lactobacilli have caused bacteremia in patients with severe underlying illnesses. In summary, probiotics have been shown to be effective in managing a wide range of clinical conditions in both children and adults. Although there is a mounting list of health benefits provided by the consumption of probiotics, their precise mechanism of action remains largely unknown. Current guidelines suggest that strain specific probiotics are to be administered only for clinically proven conditions and in appropriate doses based on the levels found to be efficacious in human studies. Further research will be necessary to define the conditions for which probiotics might prove beneficial and to expand knowledge regarding their therapeutic actions. Selected Reading Bai AP and Ouyang Q. Probiotics and inflammatory bowel diseases. Postgrad Med J 2006;82:376. Boyle RJ, Robins RM, et al. Probiotic use in clinical practice: what are the risks? Am J Clin Nutr 2006;83:1256. Chen CC and Walker WA. Probiotics and prebiotics: role in clinical disease states. Adv Pediatr 2005;52:77. Falagas ME, Betsi GI, and Athanasiou S. Probiotics for prevention of recurrent vulvovaginal candidiasis: a review. J Antimicrob Chemother 2006;58:266. Floch MH, Madsen KK, et al. Recommendations for probiotic use. J Clin Gastroenterol 2006;40:275. Guandalini S. Probiotics for children: use in diarrhea. J Clin Gastroenterol 2006;40:244. Hammerman C and Kaplan M. Probiotics and neonatal intestinal infection. Current Opin Infect Dis 2006;19:277. Katz JA. Probiotics for the prevention of antibiotic-associated diarrhea and Clostridium difficile diarrhea. J Clin Gastroenterol 2006;40:249. Madsen K. Probiotics and the immune response. J Clin Gastroenterol 2006;40:232. Marco ML, Pavan S, and Kleerebezam M. Towards an understanding of molecular modes of probiotic action. Curr Opin Biotechnol 2006;17:204. Nichols AW. Probiotics and athletic performance: a systematic review. Current Sports Med Rep 2007:6:269. Probiotics. Have they been shown to be effective? Medical Letter 2007;49:66. Riordan SM and Kim R. Bacterial overgrowth as a cause of irritable bowel syndrome. Current Opin Gastroenterol 2006;22:669. Rioux KP and Fedorak RN. Probiotics in the treatment of inflammatory bowel disease. J Clin Gastroenterol 2006;40:260. Szajewska H, Setty M, et al. Probiotics in gastrointestinal diseases in children: hard and not-so-hard evidence of efficacy. J Pediatr Gastroenterol Nutrit 2006;42:454. Deepu A. Thomas MD, George Abraham, MD, MPH, and Anthony L. Esposito, MD practice in the Department of Medicine, Saint Vincent Hospital, Worcester, MA
Legal Consult: New Security Breach Law This summer, the Governor signed into law a new
statute, Chapter 93H of the General Statutes, that, effective October 31 of
this year, imposes notice requirements on entities that maintain, store, own
or license “personal information.” Although the new state law is intended
to be consistent with federal requirements such as the HIPAA security
standards, it goes far beyond HIPAA in its scope and practi The HIPAA security standard applies only to prot Not only does the state law apply to a larger set of
data held by health Cont What is not unclear is what the statute requires if the
breach of security actually takes place. Any owner or licensee of personal
information who knows or has reason to know of a breach of security will
notify the Massachusetts Attorney General, the Dir The notice must be forwarded by the holder of the
information to such consumer reporting agencies and state agencies as
identified by the Dir Health Financial
Advice for Physicians: "Until You Die" Wouldn’t it be nice to have a monthly income stream for retirement which lasts forever? In your case, this means until “the day you die.” Your parents, if they worked for large corporations, had a shared commitment with their employer. They worked hard for the company for many years and at retirement the company would provide a fixed monthly income for life. Usually, the company hired an insurance carrier to do the actuarial calculations, to manage the pool of retirement assets, and to make the fixed monthly payments to your parents. At retirement, your father chose whether to receive a fixed monthly income for life or a lesser monthly amount for both his and your mother’s life. At death, the monthly payments stopped. There was no inheritance for the children or grandchildren. Both the employer and the employees were only interested in the employee’s financial well-being in retirement. Unfortunately, today the government has allowed employers to end their financial obligations to their employees at retirement. Perpetual inflation combined with greater life expectancy has made these traditional pension plans too expensive for companies to provide for employees. These plans became too expensive for companies and too good a deal for employees. For retirement income you are on your own!! Today’s employees and self-employed professionals must provide their own retirement funds by diverting some W-2 earnings into Qualified Plans. Government sponsored “Defined Contribution” plans like 401(k) plans are very poor substitutes for guaranteed retirement income programs. The money must come from the workers themselves. The tax incentives, the actual government share of citizens’ retirement programs, are really very minimal. For successful people, accounts funded with annual 401(k) contributions of $15,500 do not come close to providing adequate retirement income. We are discussing retirements which will last 20 to 35 years. “Where’s the beef” in the government sponsored retirement programs? Resources well beyond your Defined Contribution Plan balances are going to be needed to maintain your retirement lifestyle. Building large retirement fund balances is Phase I of a comfortable retirement. Winston Churchill was right when he said, “Savings is a wonderful thing.” Consuming your retirement assets judiciously is the Phase II of your successful retirement. You and your financial planning advisor need to project your income needs throughout your retirement. Your income generating portfolio will change over time. Since your longevity is uncertain, a portion of your monthly income should be guaranteed for life. While businesses have stopped paying the traditional pension “Until You Die,” the life insurance companies still offer Lifetime Guaranteed Monthly Income products called Immediate Annuities. You can buy your own guaranteed monthly income stream which you can not outlive. This should be part of all retirees’ income planning programs. The older you are, the higher monthly income an immediate annuity generates. Since males die before females actuarially, a male will receive a higher monthly income than a female the same age. In today’s financial markets, Treasury Bonds pay about 4% and bank CDs pay about 5%. A 70 year old male will get 8.9% lifetime income while his female peer will get 8.2% from Immediate Annuities. An 80 year old male will get 11.8% lifetime income and his female peer will get 11.1%. That additional income is the consumption of principal in an organized fashion which can not be outlived. These Immediate Annuities can be phased into your portfolio over time depending upon your circumstances. For instance, 10% of your investment assets can be annuitized at age 70, another 10% at age 75, and another 10% at age 80. In this scenario, 30% of your investment assets would have been turned into a lifetime monthly income stream paying over 10% monthly income on the funds so committed. Your beneficiaries and your advisors may object to your purchasing these immediate annuities. These immediate annuities will maximize your monthly income but will not benefit anyone else. With immediate annuities, at your death the income ends and there is no asset to be inherited. Some beneficiaries will not like this arrangement. Also, many of your advisors earn fees from the management of your assets and once the assets are transferred to the insurance company, there are no assets to manage any longer. Like the old traditional pension plans, the monthly payments are for you and for you alone. However, that really isn’t so bad. After all, it is your money, so enjoy your retirement. Michael Halloran is a PIAM Representative, Certified Financial Planner™ who works with the Worcester District. He holds a Bachelor of Science degree in Electrical Engineering from Cornell University and a Master in Business Administration from Harvard University. Mike is available to meet with you, your practice or your department. Call (781)431-8800 or email: PIAMrequest@halloranfinancial.com Off Call: Edward Hopper ~
Offering a window into the lives of our patients This summer I visited the Museum of Fine Arts exhibit featuring Edward Hopper’s artwork. Fifteen years ago I was introduced to Edward Hopper while teaching a course at Harvard University with Robert Coles entitled “The Literature of Social Reflection.” In an attempt to offer a visual perspective on that social examination, Coles showed slides of Hopper’s paintings. I was moved by them. I had spent summers trying to make connections with the world around me to give my privileged life some meaning. I worked on an assembly line making cars, worked road construction, and worked on a farm. In that Harvard auditorium, upon the screen, were the images of ”real” people. We were linking them to the stories of Raymond Carver and James Agee. There I was this summer, immersed in those images again, this time as a physician. I was thinking of the ways we get our medical learners to learn about where our patients are ”calling from.” Sometimes the link is made by volunteering in a free clinic, doing an overseas elective, or making a home visit. The Humanities in Medicine committee at UMASS Medical School would argue – what about through the arts? Stories, poems and paintings can take us to places about which we don’t know very much. In Hopper’s paintings, he offers us a chance to peer into the lives of the lonely, the desperate, and those looking for human connection. Hotel Room is a familiar image for Hopper: a woman, half dressed, sitting on a bed lost in thought. Her focus is on a book; her expression is flat. There are bags ~ is she coming or going? Who else is with her? As I think about patients of mine who describe having few people in their life, few interests, and few opportunities, I think of this woman, finding solace in a story perhaps. As I look into the painting I can feel her loneliness. Other Hopper characters venture out into the world but continue to be lonely. In Automat, a woman is in the midst of a busy city yet Hopper hones his lens to show her alone. She has only a cup of coffee to cling to; she is so close to others and still so far. Perhaps she suffers from anxiety or social phobia. Hopper lets us sit with her and understand the feeling of not having someone to talk to. Loneliness can happen even when we are with people we know well. In A Room In New York, Hopper shows us how people disconnect. How many people do we hear from in our busy practices who tell us they need more from their partner? Here is a well-to-do woman waiting for her well-to-do husband to put down that paper. “What about my needs? What about my day?” her body calls out as she mindlessly taps at the piano. These are two people so close physically and yet so far emotionally. Hopper offers us glimpses of relationships that lack hope. You can feel the quiet in the room and fear for the fight that is coming. One of Hopper’s most famous paintings, Nighthawks, was also on display this summer,. Witness the other side of Hopper: hope. There are fragile connections that spring from the faintest thread of similar interest. Late at night, a man, a woman, a diner operator ~ perhaps the topic is baseball, or politics, or the weather. We are all human; we eat and sleep and love. We live in places that rally around teams or national holidays or tragedy. And in the quiet of the night, the silence is broken by conversation over a cup of coffee and a slice of pie. Raymond Carver would call it “a small, good thing,” a chance to leave loneliness behind, a chance to share with another human being who may be very different and yet very interesting and colorful in his or her own way. These people are sharing something.. Hopper reminds us medical types that we too can connect with our patients. It is only a painted image and yet it speaks volumes of how we hand one another along, day by day, hour by hour. Hopper’s world is a celebration of people. He gives us the gift of relationships ~ good and bad ~ and reminds us what a privilege it is to be let into their lives each and every day. Williams Carlos Williams wrote, “Outside, Outside myself there is a world;” Hopper and medicine help us to explore it. Hugh Silk, MD, is Assistant Professor of Family Medicine and Community Health at UMass Medical School and Family Medicine Residency. In Memoriam: WDMS Remembers its Colleagues Richard W. Aspen, MD Richard W. Aspen of Barre, MA, died peacefully in his home Sunday, July 8th, 2007 at the age of 87. He leaves a daughter, Deborah A. Aspen, a son, Richard V. Aspen, a sister, Anita J. Aspen, and five nieces and nephews. His wife, Dorothy B. Aspen, to whom he was married in 1948, predeceased him in 1989. Dr. Aspen was born in Hubbardston, MA, May 1, 1920. He graduated from Gardner High School and then went on to Harvard University, taking additional classes at Yale University. He graduated from Harvard in 1944 and then entered Tufts University School of Medicine, graduating in 1948. He completed his General Rotating Internship at Memorial Hospital in Worcester in 1949. Dr. Aspen served in the U.S. Army Medical Corps during WW II and was a Captain in the Army Medical Corps during the Korean War, receiving a medal of commendation for outstanding and meritorious medical services and care. He was in general practice as a primary care physician in Barre, MA for over twenty-five years and later served as a house physician at Youville Hospital in Cambridge where he practiced internal medicine. Dr. Aspen was a Federal Aviation Medical Examiner for 25 years, the medical examiner in the 10th Worcester District for 8 years, a police surgeon in Barre, MA for 12 years, and a deputy sheriff in Worcester County for over ten years. He was a member of the U.S. Coast Guard Auxiliary for 30 years, a member of the American Legion for 58 years, and was a 32nd degree Mason and member of the Mt. Zion Lodge of Masons for over fifty years. Dr. Aspen was additionally a past Vice-President and Member of the Board of Governors for the Massachusetts Federation of Physicians and was a Diplomate of the National Board of Medical Examiners. He was a member of the Massachusetts Medical Society and the AMA and was a member of the Worcester District Medical Society for over fifty years. He was also a member or on the board of numerous town committees in Barre and was on the Board of the Worcester Regional Transit Authority for over a decade. An avid fisherman and sportsman, he had hobbies that included fly-fishing and boating. He also enjoyed maintaining his property and was particularly fond of riding his garden tractor even when he was no longer able to walk. In his memory, donations may be made to The Leukemia and Lymphoma Society Donor Services, P.O. Box 4072, Pittsfield, MA 01202. Deborah A. Aspen, PhD Paul H. Martin, MD Paul Martin was born into a working class family in Biddeford, Maine in 1925. In 1942, upon graduation from high school, he could have entered the priesthood as many of his friends did, but instead opted to join the United States Army. He was stationed in Panama. Upon discharge at the end of WWII, he decided to continue his education with the help of the GI bill. He chose the College of the Holy Cross. Following commencement, he did graduate work at Boston College before entering Laval University Medical School in Quebec. He had to hone his language skills as all of his courses were taught in French. He returned to Worcester to begin his post graduate studies at St. Vincent Hospital then underwent specialty training in rheumatology at Tufts-New England Medical Center. Paul then embarked upon medical practice in Worcester. He became a very respected physician and spokesperson for private medical practice. He convinced St. Vincent Hospital to sell him a parcel of land for one dollar and upon it he directed the construction of the Vernon Medical Center. At age 67, he retired and promptly enrolled in a three year Master’s Degree program in the combined disciplines of philosophy, theology and science at Assumption College. He graduated with honors and was the recipient of the prestigious John Templeton grant. For the next several years, he also served as a consultant for the Unum-Provident Co., becoming an authority on fibromyalgia while continuing to manage the expanded responsibilities of the Vernon Medical Center; known as “the house that Paul built.” Paul Martin was a renaissance man. He had a joie de vivre ~ a zest for the finer things in life. He was an unabashed romantic unafraid to cry when truly moved, whether during an operatic performance or a movie like “La Vie En Rose.” He taught us to appreciate fine food and wine. He took us on trips to far away places during which we learned to appreciate other cultures and what they contributed to the world in the form of, amongst other things, art, music and .architecture. He opened our eyes and broadened our horizons. Every interaction with him was an enriching experience. He was a tireless seeker of knowledge and grappled with the big questions in life. Paul Martin’s patients, colleagues and friends respectively have lost a great doctor, knowledgeable confrere, and sincere confidant. Collectively they join the Greater Worcester community in extending their sympathy to his wife Margaret, his children Denise, Susan, James, David and John, and his stepchildren Dawn and Darlene and their families. Paul died on August 3, 2007. Arthur A. Church, MD |