Worcester District Medical Society

In April 2006, Massachusetts signed into law a comprehensive health care reform bill to increase health care coverage for our 497,900 uninsured residents who commonly utilize emergency rooms for primary care treatment. Massachusetts hospitals are required to provide care regardless of ability to pay and as a result, hospitals have been left with unpaid bills and mounting expenses for the uninsured. Adding this population to the insured is a laudable and desirable goal as it offers the potential of improved access to health care. Analysts believe this bill will vault Massachusetts ahead of all other states in providing health care insurance to its citizens and it will certainly reinvigorate the ongoing national debate. "The eyes of the nation are on us," adds Senate President Robert Travaglini.

This approach may be unaffordable as it aims at insuring everyone, but it has not yet paid enough attention to adequacy of coverage and cost controls. If insuring everyone were as easy as this, it would have been done decades ago. I worry that the current law is under-financed and that Massachusetts may face increasing premiums, eroding benefits, and demands for greater state subsidies. Rising costs can undermine efforts to cover everyone unless there is respect for the physicians' vital role in spending money wisely.

Concerns for cost are evident in the numerous debates over the past year on benefits, premiums, and out-of-pocket costs. The premiums and high out-of-pocket costs may leave the newly covered financially stressed. If our focus is just on putting insurance cards in everyone’s pocket, that coverage can end up being inadequate. The good news is there has been and continues to be a healthy debate on these issues and considerable progress has been made over the last year. Much more needs to be done to achieve affordable, universal coverage. However, if we can expand coverage and evade the day of reckoning when the cost of the plan comes home to roost, we should all stand up and cheer!

You are the Medical Society and we want to help make your personal goals our Society’s goals. The Medical Society can further your goals in myriad ways, but to be effective we need your help and energy to focus. Currently, we are focusing a large effort with the Public Health Committee to reclaim our role in mass vaccination. In time, we hope to create a yearly vaccination day in the City of Worcester where we dispense flu shots and use the format to prepare our emergency dispensing capabilities. This year, as we ramp up toward that goal, we hope to vaccinate up to 10,000 people on Oct 13th in three sites across the city. We will need 400 volunteers with 100 vaccinators whom we will recruit and train this summer. We have secured funding for the uninsured. The immunization committee has met two to three times a month for a year and a half and the attendance has been exemplary. With a good project and good staff support the work is exciting and fun. What is the next project? Projects large or small need your input and energy. When you feel that there is a worthy project for the Society, we want to help you engage other Society members to make it our project. To that end, write your thoughts down and we will try to find other like minded members to create a critical mass and propel your project along.

Health Care Reform: A Message from the Commissioner, Worcester Division of Public Health (WDPH)
By Leonard Morse, MD

For the past two years the WDPH has been collaborating with the Worcester District Medical Society to accomplish widespread Seasonal Influenza immunization for the high-risk population of the City and to test our Emergency Dispensing capabilities. This year Maxim Health Systems, a national company that provides immunization services often in non-medical venues has joined our effort as well as the University of Massachusetts, Graduate School of Nursing and the WDMS Alliance.

We propose to immunize up to 10,000 Worcester adult residents in an attempt to accomplish Community Immunity as the best defense against seasonal influenza (and perhaps avian influenza) and to test our emergency preparedness capabilities. We plan to administer the vaccine at several Emergency Dispensing Sites (EDS); there are nine designated in the City.

The exercise will test our Metropolitan Medical Response System (MMRS) and a growing list of volunteers (Medical Reserve Corp). Last year we undertook the exercise at the Worcester Senior Center and immunized approximately 650 people in four hours.

We will welcome all adult residents regardless of their ability or inability to pay for the vaccine and have sought funding for that need. Every adult resident meeting the CDC indications for receiving the Seasonal Influenza vaccine will be welcome, regardless of their economic or health insurance status.

(The WRMRC is a group of medical and non-medical professionals who are trained and dispatched to a public health emergency in the Central MA region. It is a City of Worcester Public Health Division program)

Massachusetts Health Care Reform Law - Employer Obligations
By Peter J. Martin, Esq. is a partner in the Worcester office of Bowditch & Dewey, LLP, whose practice concentrates on health care and non-profit law.

Massachusetts’ landmark health reform law, being phased in over the next two years, emphasizes the shared responsibility of government, employers, individuals and health care providers to ensure that citizens of the Commonwealth have access to affordable health insurance. A good deal of attention has been paid recently to the so-called “Individual Mandate” and what is an “affordable” health insurance plan. There has also been discussion of the impact of the new law on health care providers (see the Nov./Dec. issue of Worcester Medicine). To fully understand the new law, attention must also be paid to how health reform affects employers and health insurance plans (see the accompanying article by Dr. Dennis Batey).

In general terms, there are four obligations imposed on employers by the new law. The first obligation is summarized by the phrase “pay or play.” Employers with eleven or more full-time equivalent employees must make a fair and reasonable premium contribution for their employees’ health insurance or the employer will be assessed a “fair share contribution” of $295 per employee per year. The law imposes two tests for determining what a fair and reasonable premium contribution is. First, the employer-sponsored plan must enroll at least 25% of eligible employees. If the employer does not pass that first test, then the second test is applied: the employer must offer to pay at least 33% of the premium cost of individual coverage under any group plan offered to full-time employees.

Only if the employer fails both tests, by either not enrolling enough employees in an employer-sponsored plan or not meeting the premium contribution standard, would that employer be required to pay the “fair share contribution” of $295 per employee. Employers, including health care providers, need to assess whether they are subject to, and if so, whether they satisfy this requirement. If the employer is subject to the requirement, it must then determine if it meets one or the other test. For example, to calculate the 25% of enrolled employees test, employers need not count independent contractors or seasonal or temporary employees.

Some employers may determine that in their particular situation, it makes more sense to pay the $295 “fair share contribution” rather than to offer an employer-sponsored health plan. In that case, their employees would likely have to obtain their health insurance through the Commonwealth Health Insurance Connector in order to meet the Individual Mandate. There are no penalties imposed on employers who choose not to offer an employer-sponsored plan, other than perhaps a competitive disadvantage in hiring and retaining employees who may prefer to work for employers who offer such a plan.

The second employer obligation under the new law is that employers with eleven or more employees in Massachusetts must adopt and maintain a so-called Section 125 cafeteria plan. Such plans allow employees to use pre-tax dollars to make health insurance premium contributions. This “Cafeteria Plan Mandate” does not require employers to make employer contributions to any health plan, but merely to make the salary reduction feature available to their employees. Employers subject to this Cafeteria Plan Mandate must file a copy of their plan document with the Connector. The Connector has made available through its website www.MAhealthconnector.org a set of model cafeteria plan documents that employers may use to meet this mandate.

The penalty imposed on employers for failing to maintain a cafeteria plan is potentially devastating. If an employer does not maintain a cafeteria plan and a certain number of its employees obtain health care through the free care pool and the cost to the Commonwealth of that free care exceeds $50,000 in a year, the employer will be held liable for some portion of those costs above that threshold ~ up to 45%, depending on the size of the employer and the number of free care admissions or visits by the employees. This cost is referred to in the law as the “Free Rider Surcharge.” Because the cost of emergency care can escalate quickly, and because meeting the cafeteria plan mandate is relatively simple and inexpensive, no employer large enough to be subject to this mandate should be so foolish as not to adopt a cafeteria plan and thus become liable for the Free Rider Surcharge.

The third requirement, applicable to fully-insured health plans but pertinent to employers, prohibits discrimination against lower-paid employees in terms of employer contributions to fully-insured health plans. The law states that employers may not pay a higher percentage of premiums for such plans on behalf of higher-paid employees than lower-paid employees. The law also states that if a fully-insured plan is offered to any full-time employee living in Massachusetts (defined as one working at least 35 hours per week), then the plan must be offered to all such employees.

As is always the case, the devil is in the details here. The requirement does not apply to out-of-state employees, part-time, temporary or seasonal employees, or employees covered by a collective bargaining agreement. Also, the law contains exceptions that permit employers to have higher contribution levels for increasing lengths of service as part of a formal plan that rewards employee longevity, or for employees who participate in wellness programs. Moreover, employers are permitted to offer different plan options with different contribution levels if all options are offered to all full-time employees.

The final employer requirement, that of the “Health Insurance Responsibility Disclosure”, is still being finalized, but it is likely that some form of this requirement will be imposed when implementing regulations are finalized. In its draft form, this mandate requires that each employer of eleven or more report to the Division of Health Care Finance & Policy each November 15 certain information about its employees as of the previous September 30. The required disclosures are: does the employer offer health insurance, does it maintain a cafeteria plan, did any employee decline an employer-sponsored plan, and does this employee have alternative health insurance coverage?

If an employee has declined to enroll in an employer-sponsored plan or in the employer’s cafeteria plan, then the employee must complete and sign a separate HIRD form, which the employer must maintain for three years and provide on request to DHCFP. Since some form of employer reporting is likely crucial to enforcing the Fair Share Contribution, the Free Rider Surcharge and the Individual Mandate, employers will likely face some form of reporting obligation under the new law, but we will have to wait to see exactly what that obligation will look like.

Health care providers who may also be employers subject to these mandates will need to make individualized determinations as to the applicability of the law and how best to navigate the new choices the law imposes on them as employers. Although the exact shape of those obligations may still be a work in progress, what appears clear as of this writing is that health reform in Massachusetts is here to stay. Employers should equip themselves with knowledge of the new law so as to enable them to take up their role in this new era of shared responsibility for health insurance in the Commonwealth.

A Good Beginning
By Dennis Batey, M.D., is Senior Vice President and Chief Medical Officer, Fallon Community Health Plan. He is board certified by the American Board of Family Practice.

When the 145-page health care reform bill was signed into law in April 2006, many questioned whether its lofty concepts could be translated into reality. The law declared that all residents of the Commonwealth must have health insurance by July 1, 2007, or pay a penalty on their state income tax. Its objective was to cover within three years more than 95% of the approximately half million uninsured residents of Massachusetts.

Now, 15 months later, approximately 50% of those uninsured residents have health insurance. These individuals now have a doctor, can get regular checkups, have hospital coverage and won’t face financial ruin if they become seriously ill. While challenges remain, we can be encouraged by how we’ve already improved the health and well-being of so many.

The various elements of the health care reform bill have been implemented in stages. One of the first effects of the law occurred last summer with the restoration of the Medicaid benefits cut in 2002 and the expansion of MassHealth (Medicaid) eligibility for children. The law also provided $3 million for extensive outreach programs to people who were eligible for MassHealth but not yet enrolled. These efforts have added some 50,000 residents to the MassHealth rolls.

A second major step occurred last October when the state introduced Commonwealth Care, its premium-assistance health insurance program for individuals who don’t have employer-based insurance and live on incomes at or below 300% of the federal poverty level. More than 70,000 individuals now have insurance through this ongoing program and there are efforts underway to enroll equally as many who are still eligible.

Fallon Community Health Plan is one of four health plans fully participating in Commonwealth Care. Its impact is made clear by new FCHP members Brian and Phyllis Calvey of Bellingham, who were previously uninsured.

“This program has taken the worry out of our lives,” says Phyllis, age 57. Phyllis hadn’t been to a doctor for years. Her husband Brian had been struggling to cope with gastrointestinal problems. Since joining FCHP’s Commonwealth Care plan, the Calveys are catching up on the preventive care they missed out on over the years and Brian, now under active treatment for his condition, can afford the medications prescribed by his doctor.

A third element of health care reform is Commonwealth Choice. This program, which is currently up and running, allows individuals and small businesses to purchase health insurance on their own, either through the state’s oversight agency, known as the Health Connector, or directly from FCHP and other private health insurers.

The Health Connector set standards, effective January 2009, for what minimum health insurance coverage must include. Plans must cover preventive and primary care, emergency services, hospitalization, ambulatory patient services, mental health services and some prescription drugs. There’s also a guarantee of at least three preventive care visits for individuals, six for families, before any deductible applies.

The Health Connector also established limits to the monthly premiums people would be expected to pay or otherwise be exempted from the law. Affordability remains a concern. However, many will save an additional 25% and more off premium if they purchase coverage on a pre-tax basis through a Section 125 plan, which the law requires certain employers to establish.

The newly insured are beginning to seek ambulatory care from community physicians instead of going to hospital emergency rooms and tapping the Uncompensated Care Pool for payment ~ payments that topped $600 million last year. Prevention and early intervention are being emphasized ~ helping physicians practice better care and engaging patients in the process. Further support comes with the law’s restoration of $20 million for public health prevention programs.

There’s more work to do. For example, we must partner together to combat the drivers of health care costs if reform is to be successful. The price tag for prescription drugs, malpractice suits, misuse of medical technologies and 29 state-mandated benefits, for example, makes health coverage less affordable. To that end, the health care reform legislation also established a state-wide Cost and Quality Council.

We’ve all had a lot to assimilate in the past year. Health insurance is rapidly changing ~ and these changes are affecting how care is delivered. Mid way through 2007, however, more people than ever have access to affordable, comprehensive health care benefits.

The Impact of Health Care Reform on the Business Community
By Richard B. Kennedy, President and CEO, Worcester Regional Chamber of Commerce

By now, everyone knows that the face of healthcare in Massachusetts is changing. But, are they aware that the changes affect everyone? Based on experiences with our membership, the Worcester Regional Chamber of Commerce is concerned that small businesses ~ in fact, those most affected ~ are not aware. With deadlines looming, this lack of awareness may present problems for both companies and plan administrators.

While we believe that the Commonwealth should be applauded for undertaking the very complex task of ensuring that its citizens are insured, these changes have an immense impact on small business. Because the Health Care Reform Act requires ~ among other things ~ that businesses with more than ten employees provide health care coverage, many of these businesses will have to make some difficult decisions.

It is imperative that lawmakers monitor the effect that these mandates have on the small business community. Careful observation will allow them to take remedial steps when necessary so that, in an attempt to solve one problem, they can prevent even larger ones.

The Worcester Regional Chamber of Commerce’s membership is comprised mainly of small businesses ~ those with fewer than 50 employees. Over the past 9 months, we have been educating our membership in preparation of the changes that are now right around the corner. Surprisingly, most are unaware that they will be mandated either as employers or as individuals to have health insurance.

The Chamber’s goal is to ensure that our members are aware of the deadlines and requirements and to direct them to the resources that will help them be prepared. Communications to our membership have included information on: the fair share assessment, free rider assessment, Section 125 plans, the non-discrimination rule, reporting requirements, and the minimum creditable coverage mandate.

Despite our educational efforts, many members are unclear as to whether these mandates impact them and are unaware of the individual requirement to be covered by a health plan. In fact, some smaller companies are not aware that even if their size does not require them to offer a health plan, they still must file certain paperwork with the state.

For the majority of businesses who ~ as of July 1 ~ will be required to provide health insurance to employees, the cost will have a significant impact. In some cases, this impact will be disastrous.

For example, a hair salon operates with a very tight bottom line. For them, the additional cost could result in hard choices. Some might choose to drop below the number of employees that triggers the mandate, others could pass the additional cost to customers, and others may require staff to take a decrease in pay. These decisions affect real people and will reverberate with unknown results.

Because the deadline to comply with the mandate for health insurance coverage was July 1, the fallout to businesses hasn’t been fully realized. Despite our concerns, the Chamber is pleased with the Commonwealth’s progress. We encourage the business community to be proactive on this issue. Understanding the requirements and making informed decisions is the best way to protect the bottom line. Clearly, waiting for the government to enforce the new law is not the way to go.

The Worcester Regional Chamber of Commerce has 3,300 members in Central Massachusetts and throughout New England. For more information, visit www.worcesterchamber.org.

Annual Oration: Synopsis of the 211th Annual Oration
By Michele P. Pugnaire MD, Vice Dean, Undergraduate Medical Education; Associate Professor, Department of Family Medicine and Community Health, University of Massachusetts Medical School

The year 2010 will be a milestone for American medicine, marking the centennial of the Flexner Report and the establishment of the US system of medical education that has spawned four generations of physicians since 1910.

As this landmark year approaches, American medicine will also undergo a generational shift, with “traditionalists” (born in 1922-1943) ceding their seniority to “Baby Boomers” born from 1943-1960 and graduated from medical school in 1960-1980. Who are these baby-boomer physicians? What values and experiences characterize this physician generation and how will they shape and influence the next generation of medical students and practitioners who will follow them?

This oration examines the rising senior generation of baby boomer physicians through the perspective of the medical class of 1980, comparing the trends, themes, and values that distinguish these medical school graduates from today’s class of 2007. Looking back from 2005 through 1980, this reflection offers a snapshot of the changes experienced over a span of 25 years, roughly equivalent to one generation of medical students. In this reflection, seven themes stand out as unifying constructs that provide a foundation for comparing and contrasting medical education “then and now:” diversity, flexibility, choice, learning models, regulation, technology and cost.

Let us begin with diversity. A quick look at today’s medical school campuses shows a very different student body compared to the predominantly “‘single, white male, just out of college” class of 1980. Women now constitute the majority of our medical school applicants, and from 1980 to 2002 the percentage of women graduates has nearly doubled from 23% to 44% (JAMA September 1, 2004). Today’s students are also more diverse in ethnic, racial and linguistic background, with 64.2% of them identifying themselves as “white” compared to 82.6% in 1980 (AAMC Graduation Questionnaire: 80, ‘04). However, a note of caution is warranted: while ethnic and racial diversity among today’s students has increased, our nation’s minority groups that have been traditionally under-represented in medicine remain so. For these under-represented populations, achieving meaningful diversity in medical education continues to be an ongoing challenge.

Riding the wave of diversity, flexibility emerges as another theme when comparing medical education then and now. Since 1980, trends in medical schools have favored more tolerance, less disparity and greater respect for differences, as measured by students’ ratings of “How I am treated” in medical school (AAMC Graduation Questionnaire). From 1990 to 2004, the percentage of students reporting personal mistreatment, sexual harassment or discrimination dropped by more than half, from 30% to 13.5%. While these percentages remain arguably significant, a reassuring downward trend continues, with 12.2 % of graduating students in 2006 reporting maltreatment and discrimination based on gender, race, ethnicity or sexual orientation.

Following the trend of flexibility, choice features prominently as a theme of change in medical education. The number of career options for medical school graduates has grown to unprecedented levels, as measured by the increasing number of residency programs, fellowships and medical subspecialties from which today’s students can now choose. Post- graduate specialties have nearly tripled in 25 years, from a modest number of 36 accredited residency programs in 1980 to 103 in 2005 (JAMA Donini Sept 13, 06). Responding to this expansion of choice, today’s graduating students must contend with greater complexity in their residency planning and devote more time, emotional energy and expenses to their career decision-making.

Not only is there more choice for today’s students, there is also more for them to learn. The information explosion and advances in biomedical sciences have transformed what and how students learn in medical school. Not surprisingly, curricular trends reveal increasing demands on medical schools to add new content to their educational programs. In 1980, the AAMC’s core topics for the medical school curriculum consisted of a modest list of 19 items, growing to 65 content areas in 2004 (AAMC GQ 1980, 2004). This threefold increase reflects not only new content areas but also new technologies for mastering and managing this information. Today’s students learn in a technology-based educational environment supported by computers in the classroom, mobile technology in the clinical care setting, and electronic patient simulators that create a “virtual” patient care experience beyond the bedside.

Following in the footsteps of advancing medical science and state-of-the-art educational technologies, the public demand for quality assurance and regulation in our medical schools has grown steadily over the past 25 years. Emblematic of the increased rigor in regulation is the new clinical skills component of the Step 2 US Medical Licensure Exam which has been required since 2005. All US medical students must now successfully pass a comprehensive, standardized patient-based clinical skills assessment to acquire a medical license.

The final and not unexpected trend in medical education then and now is the issue of cost. Since the early 80s, costs of medical school tuition and attendance have been rising above the consumer price index, representing in constant dollars a 50% increase for public schools and a 133% increase for private schools. The median debt burden for the 1984 medical school graduate was $22,000 in public schools and $27,000 in private, compared to the 2003 graduate with a median debt burden of $100, 000 and $135, 000, respectively (AAMC 2004, Medical School Tuition Report ). Concern about the impact of medical student debt burden has been the subject of ongoing study. Research outcomes demonstrate an adverse effect of rising debt burden on access to medical education for students in the bottom tier of US family income and for students from under-represented minority groups. Higher levels of debt also appear to favor higher income career choices, particularly when debt exceeds a threshold of around $150,000. In 2004, 11.4% of medical school graduates carried a debt burden of greater than $150,000 (AAMC 2004, Medical School Tuition Report).

Looking back and reflecting on the themes of diversity, flexibility, choice, learning models, technology, regulation and costs, how will the experiences of the class of 1980 be remembered? For this generation, medical school featured a comparatively uniform peer group; an educational environment that was relatively inflexible in its tolerance for differences; a more restricted menu of career options in a medical workplace that favored generalism as opposed to specialization; learning methods that focused on the fundamentals of clinical patient care, conducted predominately at the bedside, with pencil and paper and no technology; less regulation and general affordability for those of low and modest income. Today’s students find themselves in a far more diverse learning environment; more tolerant of differences; providing an extensive choice of career options fueled by intense medical subspecialization; with learning driven by more by information and less by experience at the bedside; with new and diverse technologies to use in learning; greater regulation and closer scrutiny of performance; and escalating costs that increasingly limit access to medical education for those who can’t afford to pay.

Looking forward, what are the implications of these transgenerational contrasts in medical education then and now, particularly as the class of 1980 assumes its place as the senior generation of physicians? Foremost is the advice of which our patients often remind us, “My experience is not yours.” For the baby boomer cohort of physicians, this will mean more than simply acknowledging that “times have changed.” Being mindful of contrasting experiences, appreciating the differences, and believing in the strengths of today’s learners will enable today’s senior generation of physicians to understand both the limits and the potential of their collective experience as the medical class of 1980.

Clinician of the Year: Why Would a Girl Like Me Go Into Medicine?
By Mary Costanza, MD, Professor of Medicine, University of Massachusetts School of Medicine, Department of Medicine

The following is an excerpt from Dr. Costanza’s acceptance speech for the Worcester District Medical Society and Massachusetts Medical Society 2007Clinician of the Year Award that was presented to her at the Annual Business Meeting on April 10, 2007.

Dr. Costanza was recognized for the award as throughout her career as an oncologist, she combined state of the art treatment modalities and superb clinical skills with deep compassion and devotion to both the medical and human needs of her patients.

In 1964, girls did not go to medical school, they went into nursing, teaching or secretarial work. I chose Medicine because of my dad, a general practitioner. His office was in our home: what would have been our dining room was his examining room and office. His waiting room was our front hall and staircase. My brother and I were fascinated by the doings “downstairs.” Downstairs was usually crowded with patients, young and old, kids crying and folks sitting half way up the front hall stairs. More often than not, my brother and I were being shushed by mother for making noise while dad was having office hours. I never thought there was anything unusual in this arrangement, but imagine anyone practicing like that today!

I got hooked on medicine the day I saw my first surgery. We were having the usual Italian Sunday dinner at my grandmother’s house. My uncle, also a general practitioner, had arranged for one of his patients to drop by so Dad could remove a very large wen from his back. At some point between the ravioli and the roast beef, dad, my uncle and I trooped down to his office. I was bug-eyed and totally fascinated. And that’s how it all started. I tell you this story about my dad because it was he who exemplified compassion and integrity. He taught me to listen to the patient and to be patient!!

Yet, after college I went to graduate school for philosophy at Berkeley. I learned a lot about Cartesian dualism and California wines (more, I confess, about the latter than the former). At some point, I realized I probably wasn’t going to make a living being a lady philosopher, no big demand for that in 1964 or even today! So, after much soul-searching, I decided to go into medicine.

My first stop was to see the President of Radcliffe College: Dr. Mary Bunting, a distinguished biologist and feminist. I expressed some concern about whether I were too old to start medical school at my age. I was then 27, at that time considered an advanced age for matriculation. Dr. Bunting said, “You’ll be 40 some day no matter what you do. You might as well be doing something you want to be doing.” So I took courage and started applying to various medical schools.

There were some very nasty medical school interviews. The Dean of Admissions at Harvard said that I was too old, that everything I had learned in college pre-med courses was completely out-of-date and, to top it off, that it was very unfortunate that I was a woman. Other interviewers frowned on women in medicine as well. All felt free to ask what I planned to do about marriage and having children. No matter how you answered this question, you were in deep trouble: if you said you planned marriage and the baby carriage, you got knowing and disapproving looks and assumptions: “Taking a man’s place,” “Going to drop out,” etc. On the other hand, if you said that you weren’t planning marriage and babies, you got disapproval as well: “What kind of woman doesn’t want a husband and babies?”

I had two wonderful medical school interviews: one at Dartmouth and one at the University of Rochester. I accepted Rochester’s offer. But medical school did have its ups and downs. At that time, women made up only 5% of the class, only four of us in a class of 80. There were many difficult moments, like the times the physiology professor would look me straight in the eye and address me as “Gentlemen, today we are going to…”

Or the time, as a third year student, I was assigned to urology. A female student had never been assigned to the urology rotation. I got sent to the OR on the first day and was treated to an “accidental” spray of water, blood and prostate tissue. Was this baptism by water or blood? Or was this a nasty welcome to a female medical student? Or was this just the usual prank played on all 3rd year medical students? Whichever, I never found out but I persevered! At the end of my rotation, the Chief of Urology, a wonderful man, urged me to go into urology. Well, urology wasn’t for me, but his supportive words went a long way to making me feel welcome in medicine. Things slowly got better. I found more teachers and classmates who thought being a woman in medicine was OK.

The seventies were a time for feminists, so of course I was involved. I worked with the Boston Women’s Health Book Collective and their wonderful ground-breaking book “Our Bodies Ourselves.” I volunteered at a clinic that served mostly young women with young women’s health problems: urinary tract infections, sexually transmitted diseases, and a great need for contraceptives. Back then, if your patient wasn’t married or hadn’t already had a child, it was illegal in the Commonwealth to prescribe contraceptives for them. You have no idea how many young women needed birth control pills to regulate their “troublesome” periods!!

In my 43 year journey in Medicine, so very much has changed. Now over 60% of the medical school class are women, as are 30% of the UMass faculty. There is still a glass ceiling in medicine. Here at UMass and at most medical schools, women have yet to fully populate the ruling ranks. That must and will change…before long, I hope.

As I See It: It's a Small World After All; The Growing Need to Foster Global Awareness in Physician Training
By Richard DeSouza, University of Massachusetts Medical School, MSIV

Visiting India, I was struck by how it truly has become a small world. The effects of globalization are plain to see. Take the food, for instance; while in India I got to have various types of curries and other dishes particular to Indian cuisine, yet there were also American chains such as McDonalds in addition to an eclectic mix of other types of ethnic cuisine, allowing me to still get a taste of the foods that I was used to back home.

The world, partially due to the ease of travel, is becoming an ever-increasing blend of various cultures and ideas. Globalization is affecting every sphere of life, including medicine. The World Health Organization, in referring to the increasingly evident effect of the globalization of health, states as examples the increasing mobility of health professionals across borders, the increasing mobility of health consumers such as patients traveling abroad for medical care, the increase in private companies providing health services and health insurance in foreign markets, and the use of new technologies to provide more widespread health services and information.

As globalization continues to become an ever greater force, doctors are going to need to be prepared by having an ever broader focus and awareness of global issues. As a student now in my last year of medical school, I know that this is a challenge I will need to face as I embark on my medical career. Reflecting on my experiences so far, the greatest degree of preparation has been through my international clinical experiences. I spent two months in Mumbai, India as a hospital volunteer before I started medical school. This experience was extremely rewarding, helping me gain a better appreciation of global health disparities and the diversity of medical conditions throughout the world.

Mumbai is where my eyes were truly opened to the extent of health disparities. It was heart wrenching to see the degree of poverty and the terribly poor sanitary conditions in the municipal hospitals. It is these government-run hospitals which see the most impoverished patients who can’t afford private care. In some wards of one such hospital where I volunteered there were more patients than beds; “overflow” patients had to lie on cots on the floor. There were inadequate supplies and a lack of the technologies we see in America. Though I and the other medical staff at the hospital were exposed to many patients with tuberculosis (TB), there were no masks for us to wear to protect us from exposure; too, the doctors and nurses drawing blood did not wear gloves and would occasionally get blood on their hands, a risky practice considering the very high rate of HIV in India. When I saw patients grimacing in pain during medical procedures such as abdominal paracentesis and thoracocentesis, I was told by the medical staff that only small amounts of anesthestics were available for use because of the cost. As yet another example of limited resources, I remember the father of a 10 year-old boy who had sustained a compound fracture of his tibia from being hit by car pleading with the medical staff for a wheelchair for his son upon discharge; he was told he couldn’t have one and would have to carry the child out of the hospital in his arms.

What was just as shocking as the contrast between this municipal hospital and the hospitals I had been to in America was the contrast between it and the private hospitals in Mumbai. Not only were these private hospitals very clean and sanitary, but I was impressed to see from observing surgical operations and procedures in the cardiac catheterization, and from viewing the ICUs and radiation oncology department, that the technology in them was as advanced as that in American hospitals. However, even within these private hospitals inequalities were present: there were different classes of rooms, with large, relatively luxurious “VIP rooms” on the top floors for those could afford them right down to cramped, single rooms on the lowest floors, each occupied by several of poorest patients.

I also gained a greater awareness of the different types of medical problems faced in developing countries such as India. I saw patients there with a variety of conditions rarely seen in the U.S. ~ typhoid, malaria, and leprosy. TB was especially common, so much so that all children in the pediatric ward were routinely screened with the PPD test, and I got a chance to visit an entire separate hospital just for TB patients. Different social habits also relate to different medical problems seen there; for example, whereas in America lung cancer from smoking is common, in India a type of chewing tobacco called pan is popular and leads to a high incidence of oral and throat cancers. Starvation is another problem that runs rampant. For instance, a three-month old baby was brought into the hospital unresponsive and with severe dehydration and malnourishment. Attempts were made to revive the infant with IV fluids and CPR (I assisted with the bag mask ventilation), but despite our best efforts we could not revive the child. This experience was especially poignant for me since it was the first time I had witnessed someone die. The fact that this particular baby was a girl also reflects a social issue present in India; I was told by the doctors that it is much more common to see females neglected by their parents and dying from malnourishment in India than males due to the perceived greater financial stability promised by male children. During my time in India, I observed other babies with failure to thrive secondary to malnourishment.

Despite the many depressing moments regarding the conditions I saw in India, I was also uplifted and inspired by witnessing efforts to help the situation. The dedication of the doctors who worked in the municipal hospitals was incredible. I was also impressed with their genuine concern for the conditions that existed in the hospital: I remember one pediatrician who lamented the high rate of infections in newborns due to inadequate sterile conditions in the postnatal ward, and it was touching to see how much she hoped that they would receive more funding from the government to set up an appropriate facility. Another doctor I knew was interested in public health and I had the opportunity to help her start a community health program that was being piloted in an especially impoverished area of Mumbai known as Siddharth Colony. The vision of her program was to have some of those young people in Mumbai who were more socially conscious, such as those in India’s National Social Service (NSS), receive instruction about basic health problems such as HIV risk factors so that they could go out into the community to promote healthier practices; I found the idealism behind this program heart warming. As part of this program, in addition to speaking with NSS members, I spoke ~ with the help of a social worker serving that community acting as a translator ~ with people who lived in Siddharth Colony. It was interesting to hear the residents’ concerns about the health problems in this very crowded and unsanitary area. Homes consisted of a tiny room where often 8 members of an extended family were crammed. There were no beds ~ people slept on mats on the floor. They did not have their own bathrooms; either they went outside or to some places with stalls, where I was told there would be about three toilet stalls for every 500 people. I saw young children gathering in buckets the extremely polluted water that ran along the sides of the houses; I was told that this filthy water was used for drinking.

The caste system still exists to some extent in India, and members of Siddharth Colony are members of the Schedule Caste, which is at the bottom of the ladder, and thus have a hard time finding work and improving their social status. This same doctor who let me help her with the community health program also got me involved in a project involving the analysis of data collected from surveys at the municipal hospital about problems encountered by patients there. Her hope was that by characterizing the problems in the hospital as perceived by patients, the need for improvements and change could be better understood, and then positive changes could actually be put into place. There were other examples I saw of people’s efforts to help. I accompanied Mother Teresa’s Roses, a church group that walks among the beggars in the streets of Mumbai offering food and a bath to those who want it. I visited two of the facilities run by the Missionaries of Charity (the order founded by Mother Teresa), one for orphans and the other for the poor, and I accompanied the church group St. Vincent De Paul Society on a visit to a leprosy home which had about 70 afflicted residents. The people in these various church groups were some of the most truly compassionate individuals I have ever met.

The time I spent in India was extremely fulfilling and eye-opening. The knowledge I was able to obtain first-hand couldn’t have been taught by reading books. As globalization continues its rise, the importance of doctors having a greater global awareness will also grow. I encourage all medical students to pursue some sort of international experience prior to becoming a doctor; I think that they will find, as did I, that it will be well worth it.

Science Corner: Nobel Prize in Worcester; The RNAi Revolution - Breakthrough discovery accelerates research and offers hope for a new class of therapeutics
By Lisa L. Decker, PhD, Associate Director of the Office of Technology Management at the University of Massachusetts Medical School.

So often in science, a great discovery or a solution to a vexing problem can be found when you are not even looking for it. Such was the case in 1997, when Craig Mello, PhD, Howard Hughes Medical Institute Investigator and Blais University Chair in Molecular Medicine at the University of Massachusetts Medical School, and his collaborator Andrew Fire, then of the Carnegie Institution of Washington, made a seminal discovery that has revolutionized the way that biomedical research and drug discovery are conducted.

Drs. Mello and Fire were conducting genetic research in a nematode worm model system. In the course of that work, they observed a baffling phenomenon that led to the discovery of RNA-interference (RNAi), a natural process to silence the expression of any targeted gene. The discovery of RNAi is hailed as one of the most important scientific breakthroughs since Watson and Crick revealed the structure of DNA and was honored as Scientific Breakthrough of the Year in 2002 by Science Magazine. The ultimate scientific acknowledgment of the importance of RNAi came last year when the 2006 Nobel Prize in Medicine or Physiology was awarded to Drs. Mello and Fire.

Before RNAi, drug developers had been limited by the finite number of suitable, “druggable” targets on which to focus their research and development efforts. Pharmaceutical agents are developed traditionally by first identifying a disease associated protein ~ one that is over-expressed, under-expressed, or expressed in the wrong cell type ~ and then targeting that protein with a small molecule or another protein to either agonize or antagonize the physiologic effect of the defective protein.

Due to the biochemical nature of proteins and their varying functions, mechanisms and/or locations in the cell, only a fraction of the proteins encoded by the human genome, such as receptors and enzymes, are classified as “druggable” targets. As a result, many of the medicines in use today are not as effective as they could be because the ideal target of drug development efforts, the root cause of a disease, often cannot be directly “hit.” The discovery of RNAi, however, changes that paradigm.

RNAi is a mechanism of gene regulation triggered by double stranded RNA (dsRNA). In order for a cell to make protein, DNA is transcribed into a messenger RNA (mRNA). The mRNA carries the molecular message encoded within DNA to the cellular machinery that translates the message into protein. Drs. Fire and Mello found that introducing a segment of dsRNA into cells, matched precisely to the sequence of the gene they were targeting, robustly and specifically silences the message and hence prevents its cognate protein from being synthesized. Importantly, since virtually any mRNA can be silenced via RNAi and since dsRNAs are amenable to being developed into drugs, essentially every disease-causing gene can now be considered a druggable target.

In the remarkably short period of time since Drs. Fire and Mello first reported their groundbreaking work, RNAi has transformed the way biomedical science is conducted. RNAi is being used around the world to unlock the secrets of the human genome in ways never before possible. It gives scientists the tools needed to understand how genes work and what they do ~ crucial pieces of knowledge for the traditional drug discovery process. In fact, RNAi has become the method of choice for drug discovery and is used by virtually every big pharmaceutical company and almost every biotechnology company interested in developing drugs.

In addition to using RNAi to discover disease-associated genes, the direct therapeutic application of RNAi itself is being aggressively pursued. Currently, RNAi based therapeutics are in development for various cancers, neurodegenerative diseases such as amyotrophic lateral sclerosis and Huntington’s disease, hypercholesterolemia, neuropathic pain, cystic fibrosis, diabetes, obesity and infectious diseases such as pandemic flu and hepatitis C. Clinical trials of small interfering RNAs, effectors of RNAi derived from dsRNAs, are currently underway for age-related macular degeneration and respiratory syncytial virus. Other clinical trials are planned to begin this year for hepatitis C and pandemic flu.

Despite the scientific accolades, much work remains to be done to translate the basic discovery of RNAi into therapies. Currently, researchers are looking to develop new ways to systemically deliver siRNA to specific cells or tissues. Nanotechnology and lipid based delivery systems may offer some solutions in this area. Gene therapy vector approaches, in which DNA is introduced into cells or tissues that encodes the desired siRNA, are also in development. While the full realization of the therapeutic potential of RNAi is years in the future, we have already benefited from the increase in scientific knowledge of fundamental biological processes thanks to the work and creative minds of Craig Mello and Andrew Fire.

Off Call: It's Elementary, My Dear Doctor
By William Gaines, MD, a general internist and site chief at The Fallon Clinic in Auburn, and Instructor in Medicine at UMass Medical School.

In one of the many memorable scenes in 1977’s Academy Award-winning film “Annie Hall,” Woody Allen’s character Alvy Singer engages in ~ and wins ~ an esoteric argument with a fellow theatergoer regarding the meaning of philosopher Marshall McLuhan’s writings by magically producing Mr. McLuhan himself on the spot, and of course McLuhan completely supports Alvy’s interpretation and understanding of his work. I was reminded of this scene recently when, while serving as an internal medicine teaching attending for a month, and feeling somewhat frustrated that I was not “getting through” to some of the house staff about “how to think differently” about the logic and process of establishing a differential diagnosis, I saw, bought and promptly read Dr. Jerome Groopman’s new book How Doctors Think, which effectively, eloquently and authoritatively makes the point(s) that I was trying to make, coming as it does/they do from one of America’s finest contemporary medical writers. The book is targeted to a general audience, but at the same time serves as a primer and reminder to clinicians everywhere who are interested in thinking about how they do what they do, and “how to do it better.”

Dr. Groopman is an experienced hematologist/oncologist, a Professor of Medicine at Harvard Medical School, the Chief of Experimental Medicine at Beth Israel Deaconess Medical Center, and with his colleague Atul Gawande serves as a staff medical writer for “The New Yorker.” Dr. Gawande studies and writes extensively about the nature of medical errors; so now does Dr. Groopman. In an introduction, he writes “I can recall every misdiagnosis I’ve made during my thirty year career.” He knows and cares of what he speaks. In How Doctors Think, Dr. Groopman draws on a wealth of educational and social psychology research which he integrates and weaves into many extensive interviews with other thoughtful (and equally fallible) physicians and patients (including himself), resulting in an exploration of the “how and why” of past diagnostic and therapeutic errors, and what can be done to prevent, or at least minimize, them. Rarely does “the mistake” relate to a lack of medical knowledge, but instead to how we as doctors, partnering (or sometimes not) with our patients, obtain, use, weigh and integrate information to put the “diagnostic and therapeutic puzzle” together. What “rings so true” to an experienced clinician about this book is that so many of the contributing sources of poor decision making identified by Dr. Groopman, including time pressures, patient-doctor personality clashes, how doctors cope differently with uncertainty and thinking “inside the box” (some hoof beats really are coming from zebras), to name a few, are challenges and potential pitfalls that present themselves on a regular basis.

Arthur Conan Doyle, another wonderful physician author, writing stories in “The Strand” over one hundred years ago, coined the phrase “It’s elementary, my dear Watson,” spoken by his sleuth Sherlock Holmes when explaining his case-cracking logic to his colleague. In a thoughtful, engrossing and well-written survey of clinical medicine, Dr. Groopman’s How Doctors Think makes the same point today; so effectively in fact, that I gave a copy to each of the house officers in our attending rounds group. I hope they read it. Dr. Groopman, meet Marshall McLuhan!

Creative Writing: The Gerald F. Berlin Creative Writing Award
By Margot Newburger, Class of 2008, University of Massachusetts Medical School

“Creative writing gives medical and nursing professionals-in-training a special opportunity to reflect on their experiences, to maintain their humanity, and to heighten their empathy for the suffering of their patients,” said Dr. Berlin. Established in 2005 by Richard M. Berlin, MD, poet and UMMS associate professor of psychiatry, the Gerald F. Berlin Creative Writing Award encourages creative writing among biomedical and nursing students as well as residents, and honors his father who struggled with a severe chronic illness.”

As we entered the mountains approaching Libertad, clouds drifted between peaks. It was rainy season, and vegetation covered the landscape in brilliant shades of green. I was riding in the back of the pickup truck “El Anciano” chatting with Luis, a small-framed, bright-eyed twenty-year-old from Libertad who, like me, had just completed his third year of medical school. “This,” I told him, “is the most beautiful place I have ever been.” He agreed on the beauty of his home, but pointed out that the terrain had served well as a base for the revolutionary guerilla fighters during the civil war. As we turned from pavement to a rock-and-mud road it began to rain, so we stood up and held tight to the truck’s side rails, bouncing as we descended into the valley. We had arrived in Libertad, where I would spend the next eight months.

Libertad is a cantón of about 3,000 people located in the mountains of El Salvador. In the 1980s, this region was a stronghold of the revolutionary forces that fought during the civil war. Now the bombs and bullets have stopped, but poverty continues to bring early death, and the community is mobilizing against the threat of a dam that, if compromised, would drown out most of its best land. Equipped with three years of American medical school, I came here to work with a community-based organization. In a place where most cannot afford the two bus rides to the nearest hospital, people looked to me as “la doctora” despite my assertion that I was a medical student.

Around Christmas, I stopped by the home of Luis’s mother Rosa, a health promoter, to discuss a young woman named Ana whom we had just brought to the nearest hospital extremely ill. Without our transportation, she would not have sought medical treatment. She had signed out against medical advice ~ with an agreement to return to the hospital after the holidays ~ after receiving her diagnosis of tuberculosis. Upon return to the hospital, she was refused care because she had “run away.” The social worker arranged an appointment, but the doctor would not touch her. Though it was the weekend and vacation, Rosa decided to accompany me in visiting Ana at home.

From Rosa’s house low in the valley, we walked uphill. Her four-year-old daughter Delmi, hair neatly braided for the journey, marched between us hand-in-hand. We began to speak of Luis, now back at school. Having won a scholarship at a Venezuelan medical school, he will be the first doctor from this community where very few are able to complete high school. “I know that Luis was born during the war,” I said. “Was he born here in Libertad?” “Yes,” she told me, her voice calm but expression distant: during her labor, planes flew over the valley dropping bombs. No midwife was able to get to the house; she was sure that they would both die. She had just turned seventeen years old, and Luis’s father had already been killed fighting.

I looked down at Delmi, who was happily swinging between us. Rosa and Luis initially lived with her brother’s family. Having left Luis at home one day to carry a letter for the revolutionary army, Rosa was on a bus in the local capital when soldiers captured her. Upon arrival in the military complex, she recognized various other captives, but they all knew the importance of pretending to be strangers. Soldiers threw her into a room with piles of body parts. “There was a pile of breasts,” she told me, her voice quickening, “and there were women’s heads. They told me they were going to kill me.” Torture followed. Her cruelest tormenter was a large American with cruel eyes and a poor command of Spanish. “They were going to kill me,” she explained, “but then the Red Cross arrived and liberated us.”

Now we were high up above the valley. We could see the river snaking through the mountains, and the red roof of the tiny clinic where I work. As we began the ascent of another steep part of the path, Delmi pulled back on our hands and complained that she could not stand walking further. “Ya no. Ya no me aguanta ya.” Fortunately we were near Marleny’s house, where Delmi could stay while we visited the patient. A rare household without any young children, Marleny and her mother were thrilled with the visit.

We continued our ascent, picking up sticks as we neared the house. The dogs came towards us barking, and an elderly woman reprimanded them. Ana lay in a hammock on the front porch. A resonant cough rattled her cachectic frame, and she made half-hearted gestures to cover her mouth. Her young son clung to her and warily fixed his large brown eyes on me ~ I had taken his mother away when she had gone to the hospital. Ana was grateful for the visit, but told us how the medicines made her feel even worse. Her mother brought us coffee and quesadillas while we discussed her treatment. “The pills will make you feel worse at first,” Rosa explained to her, “but you should start to feel better in a few weeks.” Rosa would monitor Ana’s children for clinical signs of tuberculosis, but they would receive no testing or prophylaxis. We talked about the recent upsurge of tuberculosis in the community.

We promised to visit again soon and headed back towards Marleny’s house. After gathering Delmi and a huge bag of plantains, we headed back down the path and ended up on the same descent I had made that first day on the back of the truck. Rosa gave plantains to three skinny sisters playing on the side of the road. It was now dry season, and instead of sinking in mud, I intermittently slipped on dust. At the entrance of the rock-and-dirt road, a new sign proclaimed that the people of Libertad are “decided to fight to the death” against the flooding of their valley. Everything was drying up, green turning to brown in patches of deforestation. The beauty of the mountains had come to feel bittersweet, and I realized how many stick huts were camouflaged into their surroundings.

The noun for hill, cuesta, is the same as the verb for difficult. Here in Libertad, flat ground is scarce. Going up, sweat pours down my face, my heartbeat pounds in my ears, and my mouth quickly dries up as my thirst intensifies. Going down, my feet skid, and my toes stub against rocks. It occurred to me that I was beginning to understand Luis’s view of his home. In this community, as in the landscape, beauty resides amid great hardship ~ and in the people’s continuing uphill struggle for health, dignity, and self-preservation.

Financial Advice for Physicians: When is $1,000,000 not $1,000,000 - Funding Post-Retirement Medical Expenses
By Francis “Chip” Moynihan, Director of Operations, PIAM Financial Services

Many of us are beginning to realize that paying for medical expenses after retirement will be an enormous challenge. The projected amount needed to pay for medical costs varies widely but it’s a big number no matter who’s doing the estimating. For example, Fidelity Consulting says that to retire in 2007, a couple age 65 with Medicare covering a significant portion of their costs needs to have saved $215,000 just to pay for their medical costs1. If the couple is age 55, that number jumps to $615,000.

Having significant savings to self-fund medical expenses or to purchase individual health insurance may be only part of the answer. If you’re using a typical savings vehicle or retirement income to pay for your healthcare, you’re probably using “post-tax” dollars to do so; hence the Million Dollars That Isn’t. Depending on your tax bracket, you could need $1,000,000 to cover the $615,000 in medical bills and the associated income tax.

While none of these methods will fully resolve the problem of how to adequately fund medical expenses after retirement, adopting one or more of them can get you moving in the right direction. If you would like more information, please call Chip Moynihan at 781-434-7398.

1 Fidelity Consulting, 2007. Based on a 65-year-old couple retiring in 2007. Assumes no employer-provided retiree health care and life expectancies of 17 years for a male and 20 years for a female

Dr. Paul J Gramling, former Chief of Emergency Medicine, St. Vincent Hospital, passed away peacefully in South Dartmouth, MA, on March 6th 2007 after a long and brave battle with his terminal illness.

He was born in Madison, Wisconsin, was a graduate of Boston College, and received his medical degree from the University of Wisconsin medical school in 1970, completing his internship and residency at Hartford Hospital, CT.

He was the Chief of Emergency Medicine at St. Vincent Hospital from 1979 to 1999 and was part of the staff at St. Luke’s Hospital, New Bedford, MA until he retired.

A wonderful, kind, and deeply religious man, he touched the lives of all those who came in contact with him, and was loved by everyone from the janitors to the administrators.

He was responsible for the training of hundreds of residents in Emergency Medicine and Internal Medicine during his tenure.

During the many years I knew him, he was a brother to his colleagues, always gentle, never getting flustered or angry, and could be referred to as a “doctor’s doctor.”

Alex Danylevich, M.D. died on April 14, 2006. Alex was the consummate physician and surgeon. He was proud of his craft and his skill at it. He was meticulous and precise in everything he did, be it at the operating table or at the gym where he worked to regain some of his strength taken away by illness.

I knew Alex in both roles. He operated on my back and relieved me of my disabling spinal stenosis. We worked together at the gym as we both tried to regain our strength and endurance. I watched as he worked and we both knew what was happening as his malignancy began to take over his life. He died as he had lived ~ proud and tough until his ability to fight was not enough and his struggle ended.

Perhaps, I knew a little more about Alec than others. As his patient, I shared with him a pride in our past at the Boston Latin School. I graduated five years before he was born. He always reminded me of that, calling me Sir or Dr. Mason. Alec was a gallant gentle man as well as a superb surgeon.

He was proud of his wife and daughters. In fact, pride in where he came from was one Alex’s traits. He was proud of his Ukranian Orthodox roots. His father was a priest as his twin brother is now. He was grateful for his higher education at Dartmouth and the George Washington University Medical School. Alex was honored by the recognition given him in his work. His joy in the gratification that he received when he helped return his patients to useful lives warmed his time with us.

Alex was, above all, a humble man. His sense of humor was remarkable and helped him through the darkest of times. Very few knew of his deeply religious feelings and origins. His family will remember and mourn him. We share their grief and will miss him. I thank him for my return to health.

The Worcester District Medical Society fondly remembers Nancy Caron, Regional Manager, West Central Regional Office, Massachusetts Medical Society, who passed away on January 8, 2007 and recognizes her contributions to Worcester Medicine with the Massachusetts Medical Society Creative Writing Contest featured in Worcester Medicine from 2000-2006.

We are pleased to share the thoughts of two physician members, Maciej Mrugala and Edward Amaral who worked closely with Nancy over the years:

Nancy Caron was a very special person to me. I met her through the MMS Members Interest Network (MIN). During our first official evening meeting (to which I was almost an hour late, since I got lost on the way from Cambridge to Waltham), she welcomed me warmly and made sure I was fed before we sat down to do business. I must admit that it was an "enchantment from the first sight,” There was something about Nancy that wanted you to be with her, that made you feel like you have known her for years. You trusted her immediately and would tell her your deepest secret. She did listen. She did care! Her enthusiasm and energy for life was contagious. Her smile was magical.

Her love for music, and jazz in particular, was alluring. She also enjoyed the written word ~ poetry and prose ~ in different forms. Emerging talents were Nancy's favorites, and I believe her idea for the Creative Writing Contest emerged from this appreciation of new talent, becoming a solid component of the Arts, History, Humanism and Culture MINs annual work.

Nancy introduced me to the Creative Writing Contest. We spent many hours together via email and phone discussing the submissions, deciding on the judges, selecting winning pieces and arranging them for the Worcester Medicine Magazine. It was always a great joy to see the assembled new Creative Writing Edition. It was our "baby" and we were both so proud of it!

Nancy has influenced my life, she left an imprint that will never fade, she will always be dearly remembered.

Thoughts by Edward Amaral, Chair, AHH&C MIN, Massachusetts Medical Society; Dedication delivered to physician members and guests at the MMS Nancy N. Caron Annual Member Art Exhibit Dedication Ceremony on Saturday, May 19, 2007

Upon recommendation of the MMS BOT, an adhoc committee was established in 1998 with the goal of increasing membership in MMS. This committee would provide a venue for physician- members not interested in governance. Dr. Dom Kuftinek was named Chair. I was asked to be a member of this novel group. The fields of interest numbered six and became known as “Member Interest Networks,” or MINs for short. These Networks included areas such as Public Health, Information Technology, Diversity in Medicine and Arts, History, Humanism and Culture to name but a few. I was elected Chair of the latter group with Dr. Robert Sorrenti as Vice-Chair. We were given a budget and a staff. For the first year or two we struggled to get organized. Part of the struggle was to maintain a steady staff. Finally in Jan. of 2000, a charming, vibrant, witty, energetic, lovely blond became head of our small staff. She was Nancy Caron. Nancy and I “clicked” right off the bat and that relationship continued until she was called to help God with His projects. I say this because even though Nancy was unable to be physically present at the Holyoke office, she continued to help and guide her associate Cathy Salas from home whenever needed.

Nancy provided stimulus and growth for the “AHH&C MIN” from the time she arrived. One of the prime projects she developed and nurtured was this event, “The Members Art Exhibit”

She worked out all the kinks and, with the encouragement of the Executive Board of the MIN, made it happen ~ made it a reality and made it what it has become, what it is this evening. We started out with 30 participants and grew from there to include physicians’ spouses and families as well. Last year there were 50 contributors, several of whom donated their work to be auctioned to assist in the Alliance’s charitable work. This year we have 44 exhibitions of which 18 have been donated for auction!!! All of this and many other projects of our MIN stemmed from Nancy’s vision and efforts and were perpetuated by Cathy Salas and the newest addition to our staff, Linda Rosen. They in turn added to our list of projects to include Digital Photography, Birding, Bonsai Workshops, Music and Medicine and “A Night at Tower Hill,” again to name only a few. Thank you both for your efforts during an emotionally very difficult time!

We were so pleased to have Nancy and her husband, Mark with us at the 2006 Art Exhibit. Even though our Society celebrated its 225th Anniversary in 2006, my focus was to create a piece of stained glass for my friend and in her honor. This year I concentrated on the Society’s anniversary and would ask Dr. Dale Magee to accept the MMS Seal in Nancy’s memory.

Nancy, we miss you and thank you for your efforts on behalf of the “Arts, History, Humanism and Culture MIN” and the MMS.

17th Annual Dr. A. Jane Fitzpatrick Community Service Award
Established by WDMS to commemorate the life-long community contributions and exemplary efforts of Dr. Fitzpatrick in the Worcester Community. To recognize a member of the health care community for their contributions beyond professional duties, to improve the health and well-being of others.

2007 WDMS Career Achievement
Established to honor a WDMS Member who has demonstrated compassion and dedication to the medical needs of patients and/or the public, and has made significant contributions to the practice of medicine.

The Worcester District Medical Society
Congratulates

Jane Lochrie, MD

Recipient of the YWCA's
2007 Katharine F. Erskine Medicine & Science Award

Jane believes that 'health care is a right, not a privilege' and throughout a distinguished career as a physician and educator, she has acted on that belief. She leads students and colleagues by example in treating patients with respect and sensitivity to cultural differences and in her volunteer efforts, directly responsible for improving the health and well-being of people unable to afford treatment or medicine.