Worcester District Medical Society

Catherine Brennan, RN, MD, who practiced in Worcester her entire career, was a most dedicated physician. She died on July 3, 2007 (Worcester Medicine May-June, 2008). Catherine was born in Worcester and graduated from the Ascension High School. She studied nursing at the Massachusetts General Hospital School of Nursing and received her MD degree from the University of Saskatchewan College of Medicine. She returned to Massachusetts for postgraduate training at Carney Hospital in Boston and the very popular residency program at Worcester City Hospital.

Catherine then “hung her shingle” in Worcester and, with appointments at Worcester City Hospital, Saint Vincent Hospital and Fairlawn Hospital, served over two generations until illness forced her retirement just few months prior to her death.

Catherine was very proud of her family origins in Worcester and recently championed the preservation of Hurley Square, named in honor of her grandfather and disrupted, coincidentally, by the massive reconfiguration of the Route 146 highway connection between the Massachusetts Turnpike and I-290.

Dr. Catherine Brennan was single; her only adversaries were disease and suffering.

I am writing to let you know how grateful I was to read the article “Managing Pain at the End of Life” by Christine McCluskey, RN, in the March/April issue.

For almost five months in 2007, my family and I cared for my 87 year old father with the help of UMASS Memorial Hospice. Three generations of family members participated in his care along with wonderful hospice staff members. My father wanted to be at home and he was until the very end.

In the last several hours of his life, I administered oral morphine every hour as instructed by a hospice nurse. During this time we watched him slip away but knew he was not in pain. He had a very peaceful death but I struggled with terrible guilt until reading Ms. McCluskey’s article. The section on “Fear of Hastening Death” eased such a burden I had been carrying for nearly a year. I felt that I had hastened his death or caused it and this article cleared those fears from mind and gave me the peace I needed.

Now when I think of my father’s death, it is with memories of a dignified man dying a dignified death.

Hopefully other families will benefit from Ms. McCluskey’s research and medical professionals will be more forthcoming in discussing pain management with patients and their families.

We have traditionally focused our summer issue of Worcester Medicine on our Annual Oration and we are continuing this tradition. This year’s oration was by Michael P. Hirsh on “Profiles in Medical Courage - A Message of Hope, Survival, and Transcendence.” He gave us many excellent examples of famous and not-so-famous physicians who exhibited courage in difficult situations. His talk focused on what is courage, how was it manifested in each of his physicians and how difficult it can be to do the right thing.

But this year our approach is a little different as Dale Magee, a member and past President of Worcester District Medical Society, completed his year as President of the Massachusetts Medical Society and delivered an inspiring talk to members and guests at the Massachusetts Medical Society’s Annual Meeting in Boston. What caught my attention is how similar the issues are that both speakers are attempting to bring to our attention. Without giving away too much, the following quote from Dale’s speech is the best summary of his intent:

Those of you with an interest in history might like to know that a fairly complete list of the orations and speakers from 1795 to 2005 is available at: library.umassmed.edu/wdms_orations/display.cfm (it can also be accessed from WDMS main web page). Many of the orations have a synopsis attached so you can see how the focus of the orations has changed over the years.

With those words, Alice Coombs, our new Vice President, began her acceptance speech for her AMA Foundation Award for Health Education in 2006. She was referring not only to herself, but to us as physicians and to us as a Medical Society as well.

This profession of ours provides not only a vital service to our communities, but also a means by which we can gain the satisfaction of knowing that how we spend our days is of help to our fellow man.

My time with the Medical Society has been colored by many events. Few have been more encouraging than when I served on the selection committee for MMS Scholars.

As you know, these young people do more than just excel in their studies. They do far more than is expected. They recognize a need, roll up their sleeves, and help. No one told them they have to do it. They just do it.

Their talent and their commitment are absolutely breathtaking. What is even more impressive is that they are not alone. Every single person who was nominated for that scholarship is inspiring.

All of us can draw strength from and feel pride in the fact that these men and women, with such talent and character, have chosen our profession.

We must ensure that medicine remains a profession of the talented and of the idealistic.

But these ideals and this energy are not just a phase that we go through when we are young. It is something that will define us until our final days.

I see colleagues like Sahdev Passey, and Barbara Herbert, and many more like them. They have organized volunteers and provided health care here and around the world to those who have nothing.

I have spent time with hundreds of our Society’s members who come here to discuss the issues of the day and to try to make things better.

We are all trying to learn and we are all trying to help. In doing this, we feel the satisfaction that being a physician brings. When we keep this idealism alive, good things happen.

Today, in Massachusetts, we are seeing change at a more intensive rate than at any other time in our careers. It is a different kind of change than we remember. In the past, we looked to medical researchers for progress in the science of medicine.

The crisis in health care today is not a crisis in the discovery of new cures. It is a crisis in how we deliver what we already know. Today, we have more choices than ever. How we make these choices will define our role in this system in the future.

The demand for quality and efficiency are here now, but the science and the tools are not nearly as good as they need to be.

Because of this, many in our profession have shied away from addressing cost and quality.

Huge organizations have grown up with the promise of bringing our health care system under control. The economic interests are enormous. We are now part of the largest industry in our economy. Executives in medical organizations, many of them “not for profit,” are paid seven and eight figure salaries.

Those who lead this system believe that competition will solve the problems that we face. Yet, this focus has lead to voracious advertising, duplication of services, and organizations that are preserving their own health at the expense of the community.

We are told that to save money, more people must be hired to oversee what we do.

To improve access, more barriers must be put in place to our providing care to our patients.

Some time ago, a commentator on human nature said, “As you treat me, so I will become.”

Doctors are human, too. We now hear physicians saying that they need to be paid to be cost conscious or to improve the quality of care.

Relationships within the health care community have become adversarial. Doctors are dispirited despite advances in health care that we could not imagine when we entered this profession.

I know that men and women of incredible talent and idealism are still going into our profession, and, in fact, are going hundreds of thousands of dollars into debt to do so. I know that excellent doctors with decades of experience are finding satisfaction in volunteering -- and frustration in their offices.

Those “others” who boast that they can solve health care’s problems have failed to resolve this paradox.

Competition, barriers and incentives that sound good in the board room are failing in the exam room. Ours is a profession based on trust and goodwill. We don’t need incentives to do the right thing.

We need to have the tools that are necessary to bring our patients the cost-effective care that everyone wants.

We must pledge to ourselves, to our patients and to those who follow us to change the system and center it on compassion, on science and on realistic expectations.

Our Massachusetts Medical Society lives and breathes these values. This Society is active, it is idealistic, it is smart and it is focused on us as professionals and on our patients. Our members and our staff bring their idealism, their energy and their perspective to the issues of the day.

Through our committees, our educational programs, and our ability to convene all who are involved in health care, we articulate the ideals that brought you all to this profession. We will move this system and align the energy, the goodwill and the pride that is within all of you.

This is not easy. It hasn’t been so far. It will continue to be difficult. But that’s OK.

It shouldn’t be easy -- because we have been entrusted with something great and sacred - the care of our fellow human beings.

If you remember the quote that I opened with, you may know that it comes from Luke, in an entirely different context than medicine. What some often forget is the second half of that verse -- and it pertinent here.

President Karlin, Members of the Executive Committee, Worcester District Medical Society Members, Friends and Guests,

I stand before you deeply honored to have been chosen as the Worcester District Medical Society Member charged with upholding the time honored tradition dating back to 1794 of delivering an address that we have euphemistically come to call an “Oration.” When I received the news that I was selected for 2008, that word really seemed extremely burdensome. Dr. Paul Bergin, in his historical treatise on the history of the Worcester District Medical Society, gave some small measure of comfort as I faced the task of coming up with a topic of interest that would be worthy of this illustrious crowd’s precious time. To quote him:

“The title by which this annual paper is dignified is, at first consideration a little oppressive. With the word "Oration," we associate an idea of stately dignity; we think of it as a discourse of weighty matter delivered with power of rhetoric. But this is not so.”

Whew!! That makes me feel a bit less daunted. For any one of you in the audience know, I can schmooze with the best of them. But whether I have the ability to deliver to you all a speech containing the meaning of life or advice about how our organization or profession should proceed is very much up for debate. That being said, I came up with what I thought was an elegant title befitting of an “ORATION:” Profiles in Medical Courage -- A Message of Hope, Survival, and Transcendence. HMM. How did I come up with that? As Darth Vader says in “The Empire Strikes Back, “Impressive, most impressive.”

I wish I could say it came to me on a walk up Everest, or while serving my country in the Armed Forces or whil on some other heroic pursuit. But I actually thought of it while lying on a stretcher in the office of one of our local urologists, having a biopsy of my prostate under ultrasound guidance. Get that mental image. I was curled up on my side, with one of those ridiculous hospital Johnny-gowns that barely covered up my navel, facing a wall. The whole process was prompted by my own PCP’s insistence that I get my first PSA this year. The test indicated prostate problems, and the biopsy eventually led me to what I CONTINUE TO HOPE IS a curative prostatectomy this year. This chain of events put me on the patient side of the doctor/patient relationship in a serious way for the first time. Well, I guess I should back up here and say that the Oration I am delivering wouldn’t be worthy of an audience if I didn’t tell the truth. So I’ll be honest by saying that maybe I wasn’t exactly thinking of this oration while I was in fetal position with my derriere flapping in the breeze. But shortly thereafter it came to me that ultimately one of the most courageous things that any human can do is to put his or her faith and life in the hand of another human being, in this case a urologist, and essentially say, “I really don’t know you that well, I have a potentially serious medical problem that I am wrestling with and I am told you can help me, so here is my prostate -- Have at it!!”

I am not trying, by the way, to imply that I was courageous about the process. I complained about the annoyance and discomfort and imposition like so many of us facing bad medical problems do. But this gave me renewed appreciation for what our patients go through, some much less familiar with the system than I was.

Now perhaps explaining the origin of this year’s Oration may already represent, as my daughter would say, TMI (or “too much information,” for you are unfamiliar with teenage-ese). There is a point to all this. I wanted us as individual physicians and moreover us as a Medical Society and profession as a whole to recognize the everyday acts of courage that our patients display in seeking out our care and our counsel and in so doing, leaving their lives in our hands. The Talmud says that any time one has a chance to save a life, it is a blessing from God. I believe in that proposition deeply. So here we are, blessed with human beings who put their trust in us courageously. I think for me, this whole experience as a patient gave me pause to think about our responsibility to meet such valor with courageous acts of our own.

Some of you Baby Boomers probably remember a young Massachusetts Senator, Jack Kennedy from Brookline, releasing a book in 1956 called “Profiles in Courage,” in which he outlined 8 legislators who had stood tall in the face of overwhelming odds and advanced a position, principle or policy that was unpopular or politically risky. This was the first “book” other than a “Little Golden Book” or collection of nursery nhymes that I had ever received, and I remember how inspirational it was. Kennedy wanted to illustrate the “guts” that being a public servant took. He said, “A man does what he must -- in spite of personal consequences, in spite of obstacles and dangers and pressures -- and that is the basis of all human morality."

So, with apologies to the eloquence and wisdom that our late President displayed in compiling his own episodes of courage that he felt would inspire similar acts of heroism in his countrymen in the Cold War era, I have taken the liberty of collecting a few medical vignettes that I feel merit attention and praise and, I hope you will all agree, imitation.

First, I felt that I had to come up with some solid definitions for courage that we could apply to the medical sphere, not just on the battlefield.

So I scoured the quotation books and came up with some good preliminary descriptions of courage. What was striking is that the same gut-wrenching feeling of anxiety that I had when the urologist doing that biopsy said, “You are going to feel an uncomfortable feeling that will feel like you have been punched with a dull blade,” -- that is, “fear” -- was a feeling that many of our great thinkers linked inseparably to courage:

Nelson Mandela said of his years in prison: “I learned that courage was not the absence of fear, but the triumph over it. The brave man is not he who does not feel afraid, but he who conquers that fear.”

Or how about Eleanor Roosevelt? “You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. You must do the thing which you think you cannot do.

Or the great Ralph Waldo Emerson: “A hero is no braver than an ordinary man, but he is braver five minutes longer.”

Perhaps the greatest philosopher of the late 20th century said it best; let’s see if you can guess the author on this one: “Courage is being scared to death...and saddling up anyway.”

So I’ll start with one of the vignettes I have always used for inspiration when attacking some of the injury prevention problems that I have faced.

Take Walter Reed, the famed Army physician who became internationally celebrated for conquering the “Yellow Fever” plague facing our American Forces in Cuba during the Spanish American War. The “Yellow Death,” as it was called, caused more fatalities and morbidity than the actual fighting did in that arena. It essentially had caused other nations’ efforts to build the Panama Canal to be unsuccessful. Dr. Reed did not have much in his medical armamentarium, no antimicrobials and horrible living quarters with poor hospital facilities. And yet he was able to recognize that it was the mosquito that was the VECTOR of the disease, and, working under these deplorable conditions with the men in his military medical units, he was able to remove the areas of standing, stagnant water where the mosquitoes bred, and he was able to improve the netting availability of local servicemen to try to suppress the spread of the diseases. This, coupled with better aseptic technique in hospitals that he supervised, helped to greatly curtail the problem and allowed us not only to prevail in the War, but eventually to supervise the building of the Panama Canal.

Several of Reed’s associates during his time in Cuba died in the pursuit of a solution to this problem, and indeed Walter Reed himself died in 1902 of a ruptured appendix that his devotion to duty had cause him to ignore until it was too late for his own cure. When I have worked in the arena of firearm violence, I have used Dr. Reed’s example of the mosquito and applied it to the major vector of interpersonal violence, the handgun. Just as Reed couldn’t fight the actual germ itself that cause the Yellow Death, trauma centers can’t combat the poverty, racism, depression, hatred, and crime that lead to firearm fatalities. However, by controlling the vector for violence, the handgun, perhaps we can eventually attain even a small modicum of success like Dr. Reed himself. This emphasis on responsible gun ownership and storage has been strongly supported by our Worcester District Medical Society during the six years that we have conducted the Goods for Guns Buyback program. It has seen us retrieve 1493 weapons off the streets of our County and at the same time has witnessed Worcester become the city in MA with the lowest rate of firearm injury. This stand has not been without controversy. We have taken heat even from some our members and from local gun enthusiasts who mistakenly feel we are challenging their 2nd Amendment rights. The WDMS has stood tall with our Coalition and that act of courage has yielded tangible results.

Another icon of my particular specialty of Pediatric Surgery, William E. Ladd, is the subject of my next profile in medical courage. This talented Harvard surgeon was languishing on the vine in the academic system in Boston in the early 1900s, trying to find fulfillment and challenges. The Harvard system had recognized his talent by appointing him Surgeon-in-Chief at the newly created women’s hospital in Boston, the Boston-Lying-in. It was a nice title, but insiders in the surgical old-boy network at Harvard knew this was not considered a prestigious or plum job, it was a bone that William Ladd was thrown to appease him. It did give him the opportunity to try to surgically tackle some of the more difficult birth defects that newborns of that era faced. Unfortunately, the great majority of these anomalies were not surgically correctible in that decade.

This experience established Ladd as one of a few surgeons in the country with some expertise in the surgery of neonates and children. Then came the fateful day about which all pediatric surgeons are taught. On Thursday, December 6, 1917, a munitions ship named the Mt. Blanc, bound to re-supply the World War I war effort, lay loading in dock in Halifax Harbor. A tugboat named the IMO collided with her, creating an explosion of such force that it was actually “heard” in the Boston area, the loudest noise in recorded history up to that time in North America, and the most powerful explosion until the dropping of the A-bomb over Japan in 1945. The Materiel was blasted 8 miles into the sky. The explosion happened in broad daylight on a school day. 2000 were killed, 9000 injured and over 30,000 left homeless. Pleas for medical assistance went out immediately, and Boston responded. In the Harvard system, the most expendable surgeon was Dr. Ladd, which was fortuitous as many of those who survived were school kids who had rushed to the windows to see the fire in the harbor and were then injured by a conclusion blast that knocked out windows and whole buildings for 6 miles around the epicenter of the explosion.

When Ladd arrived, he was dismayed by the lack of availability of any specialized pediatric care. He spent weeks operating on children and adults in Halifax and at the end of his stay, he was the toast of not only both Nova Scotia and the British Empire, but of Boston and Harvard as well. At one of his many testimonials that were held upon his return, Ladd stunned the audience by announcing that he henceforth would dedicate his life and career to the surgery of children only. His fellow surgeons and professor greeted his idea with scorn to a large degree. It was not until 1971 that his dream of setting up a separate specialty of Pediatric Surgery was recognized by the American Board of Surgery. In the interim period from 1916 until he stepped down in 1949, Ladd became the Father of Pediatric Surgery. As the William Ladd Chair of Pediatric Surgery at the newly created Boston Children’s Hospital, he was involved with the training of almost 75% of the pediatric surgeons currently practicing in the USA. His act of bravery and kindness are recognized by the people of Nova Scotia, who every year donate their finest Christmas tree to Boston to display on the Common there.

Standing up for the rights of children to get excellent health care is still a necessary part of what practicing physicians must do. The shocking resistance to even the SCHIP approach to guaranteeing pediatric health care delivery is a reminder of the need for continued advocacy in the spirit of Dr. Ladd. Our Medical Society at the local and state level has been very vocal in support of such legislation, and that act of medical courage should be applauded and reduplicated until we realize this on a national scale.

What I want to point out before my next profile is one of the common themes that you will be able to draw from the vignettes,- that none of the physicians I profile here are infallible or successful all the time. Dr. Ladd presented his case for Pediatric Surgery Subspecialty status to the American Board of Surgery unsuccessfully for over 40 years. Failure and courage are also inexorably linked.

Winston Churchill said, “Courage is going from failure to failure without losing enthusiasm.”

And Soren Kierkegaard seems to echo those sentiments: “To dare is to lose one's footing momentarily. To not dare is to lose oneself.”

Our next vignette illustrates many of these qualities -- a willingness to dare, a willingness to fail, and a tenacity of purpose that makes one persevere and eventually triumph.

The story of Dr. Jonas Salk and his successful fight against the scourge of polio myelitis is probably well known to many of our older attendees tonight and illustrates many of these principles of courage. For like so many diseases that have been eradicated, only a few of us remain with those memories of FDR and his fight with polio and the concern each summer when kids came down with flu-like symptoms that killed about 10% of them and left another 30% of them with paralysis. I am still old enough to have cared for a number of patients on the medical service at Columbia Presbyterian Hospital in 1979 who came in for a week of “iron lung” rest to help them in their life long battle with polio.

Dr. Salk was a NYC kid born to Russian-Jewish immigrant parents. As a NYC born child of Holocaust survivors, I imagine you can see how I can relate well to Dr. Salk’s roots. He was four years old when the great Influenza Epidemic of 1918 took so many lives around the world. He went to City College and NYU Medical School. Initially, medical school held no great attraction for him as he thought he would become a lawyer. He came to see the value of healing people however. To quote him: As a child I was not interested in science. I was merely interested in things human, the human side of nature, if you like, and I continue to be interested in that. That's what motivates me. And in a way, it's the human dimension that has intrigued me.”

After his mother convinced him to abandon his pre-law studies, he started with pre-med studies. Biochemistry caught his attention in a big way: “At one point at the end of my first year of medical school, I received an opportunity to spend a year in research and teaching in biochemistry, which I did. And at the end of that year, I was told I could, if I wished, switch and get a Ph.D. in biochemistry but my preference was to stay with medicine. And I believe that this is all linked to my original ambition, or desire, which was to be of some help to humankind, so to speak, in a larger sense than just on a one-to-one basis.”

Salk became initially fascinated with the prospect of developing a successful influenza vaccine. A lecture he attended in his first year of medical school confused him with contradictory statements –- Faculty, please take note of his words: “In the first lecture, we were told that it was possible to immunize against diphtheria and tetanus by the use of a chemically treated toxin [to kill it]... In the very next lecture, we were told that in order to immunize against a virus disease it was necessary to go through the experience of infection. It was not possible to kill the virus... The light went on at that point. I said that those two statements can’t possibly both be true. One has to be false.

Dr. Salk became convinced that it was polio that could be combated with development of a vaccine. He took an appointment at the University of Pittsburgh Medical School after initial stints at Mt. Sinai and University of Michigan. When my family and I did our 10 year tour of duty in Pittsburgh, we lived across the street form the D.T. Watson Home for Crippled Children (now in the PC 21st century entitled the D.T. Watson Pediatric Rehabilitation Center). This was the location where Salk first administered his vaccine. It should be noted that he did not do so before testing it on himself, his wife, and his own kids. Call it courageous or foolhardy, he was passionate that this would work. He was popularly know as “the man who licked polio.”

His success enabled him to develop his own institute to promote understanding of immunology, employed among others. He was very adamant that the accolades he received did not reflect a need or desire on his part to “profit” from his discovery. Another quote form Dr. Salk: "Who owns my polio vaccine? The people! Could you patent the sun?”

Perhaps Jimmy Carter said it best when awarding Dr. Salk the Presidential Medal of Freedom in 1977: “Because of Doctor Jonas E. Salk, our country is free from the cruel epidemics of poliomyelitis that once struck almost yearly. Because of his tireless work, untold hundreds of thousands who might have been crippled are sound in body today. These are Doctor Salk's true honors, and there is no way to add to them. This Medal of Freedom can only express our gratitude, and our deepest thanks."

It should be noted that Dr. Salk continued to work right until his death in 1995. He was frustrated by his institute’s failure at developing an HIV-AIDS vaccine. His work, so full of success, then taught him that even in failing, knowledge was gained. Perhaps we can learn from his actions and the words of Confucius, who said, “Our greatest glory is not in never falling, but in rising up each time we do.”

Our own District Medical Society’s experience with “mass immunization” would, I believe, make Dr. Salk and Confucius proud. In 2 consecutive years, under the leadership of many of the physicians in this room, with special mention to Drs. Karlin, Broadhurst, and Morse -- and of course to the stellar support staff of Joyce Cariglia and Melissa Boucher -- we have been able to forge a broad-based coalition based in both the public and private sector and within the medical and corporate community to endeavor to provide both a platform to achieve “herd immunity” for the most vulnerable population of Worcester’s citizenry, and to also be able to test our Emergency Preparedness Network and link our Medical Society to its response system. These are noble efforts, well planned, always challenging, not always as successful as we’d like -- but darned if we don’t pick ourselves up each year to try again. We are trying to follow the words of General George S. Patton, who said, “Success is how high you bounce after you’ve hit bottom.”

The next vignette I’d like to share with you is about another pediatric surgeon who had achieved great fame in that field before walking onto a national stage when the country and the world needed him. I am speaking of Dr. C. Everett Koop, whmo many of you know only from his tour of duty as Surgeon-General under Presidents Reagan and George Herbert Walker Bush from 1982-1989. Dr. Koop had served prior to this time as the Chief of Pediatric Surgery at the VENERABLE Children’s Hospital of Philadelphia for 35 years. He had pioneered in the treatment of many surgical anomalies including Hirschsprungs’ disease, duodenal atresia and the surgical complications of cystic fibrosis. Brooklyn born and a descendent of the original Dutch Patroon settlers who help colonize New Amsterdam, Dr. Koop was a proud and notoriously righteous individual. This stood him in good stead when he took on the duties of Surgeon General. The role had been relegated to a largely ceremonial one, but the sweeping healthy issues of the ‘80s mandated that the person occupying this role demonstrate leadership and understanding.

The HIV virus changed the landscape of international health care, and Dr. Koop was among the first to recognize that this crisis needed aggressive worldwide attention; his realization resulted in improvements in treatment systems and transfusion medicine and in general openness about discussing the problem. He also stood steadfastly in favor of a woman’s right to choose when it came to abortion, and refused to bend to unmitigating pressure to state that abortions permitted by competent health professionals were a maternal health risk. Dr. Koop had single-handedly been involved in the surgeries of 475 Downs Syndrome children with surgical anomalies while he was in Philadelphia, and his experience with these children helped craft policies and legislation establishing the rights of the disabled and physically or developmentally challenged children as both citizens and patients. He also took a strong stand against the tobacco lobby in pushing to curtail the use and marketing of tobacco products.

None of these stances that he took were in lockstep with the Presidents under whom Dr. Koop served. He also received flack from the Christian right and the militant left about these positions. But with his forthrightness and genuine medical expertise, Dr. Koop stood tall against withering attacks from all sides in advocating positions that were in the best interest of the public health of the USA. I had the privilege of spending a few days with Dr. Koop in 1996 when he came to cut the ribbon on a museum exhibit that I helped to establish on the grounds of the Pittsburgh Children’s Museum called Safety Street. The exhibit was designed to teach kids from kindergarten to grade 3 how to avoid becoming a trauma statistics. We of course chose Dr. Koop as our inaugural celebrity guest because, working with Johnson and Johnson and Dr. Martin Eichelberger (one of Dr. Koop’s trainees) at the National Children’s Medical Center in Washington DC, he had founded the National Safe Kids Campaign to help promote Pediatric Injury Prevention, something for which the country also owes him a debt of gratitude. I use the following quotation from Dr. Koop in almost every one of my injury prevention lectures: “If a disease were killing our children at the rate unintentional injuries are, the public would be outraged and demand this killer be stopped.”

Things brings me to my last profile in medical courage, highlighting the career of a woman whom I am honored to say is a personal friend and mentor: Dr. Barbara Barlow, the longstanding Chief of Pediatric Surgery at Harlem Hospital, a Division of the Columbia University Medical System in Central Harlem, NYC. Dr. Barlow was one of those pioneer types in Pediatric Surgery. She was the first woman trained at Columbia. All through her career, she was forced to confront and shatter the glass ceilings that limited the potential of women in surgery, hospital administration, and surgical society leadership. I first met Dr. Barlow when I was an intern at Columbia’s Surgery Department in 1979 and she had just taken on her Chief’s position at the part of the Dept. of Surgery that was looked upon as an outpost in the Third World. I went to weekly conferences with her where I was always struck that the best questions being raised and the toughest issues being addressed always came from her. She received the nickname of “The Crying Surgeon“ because when she would tend to the many gunshot wound victims in her practice or try to save another child who had fallen out of a tenement window and died, she would cry as she tended to them. We cried together at the funeral of one of my fellow surgical residents, John Chase Wood, who was shot by a 15 year old with a Saturday Night Special right out side Columbia-Presbyterian’s front door. Dr. Barlow’s legend grew as she single-handedly developed the “Kids Can’t Fly” Campaign that was designed to push NYC slumlords to put window guards on their high-rise windows so kids would not fall out. She pushed so hard that Mayor Koch passed legislation to that effect, effectively reducing these injuries -- which carried with them a 70% mortality rate -- by 90%. She next decided to look for the first time at population-based demographics to analyze the cause for injury in Central Harlem. She determined that pedestrian injuries and gunshot wounds were happening because the gangs and drug traffic had completely taken over all the safe play places in Harlem, forcing the kids to play on the street. One by one, she worked with the NYPD, Community Coalitions, and the Parks Departments to take back the area Park by Park. 55 parks later, she has reduced the injury rate in Central Harlem by over 60%, and had reestablished for kids in this area activities such as the Urban Bike Corps and the Harlem Little League, which, you may recall, played against Worcester a few years ago when we fell one short of winning the Little League Championship.

Not satisfied with brightening her corner alone, Dr. Barlow kept encouraging like-minded Pediatric Practitioners across the country to duplicate her successes. The Safety Street Project that C. Everett Koop opened up for my program in Pittsburgh was a copy of a successful one she had in Harlem. She was able to show to the Robert Wood Johnson Foundations that Injury Prevention for kids made sense and was reproducible. They endowed her with a grant to clone her program nationally, and I was fortunate enough to have established three out of the now 44 programs around the country, with Worcester the 15th site so chartered. Dr. Barlow, in making Injury Prevention a National Priority with the National Association of Children’s Hospitals (NAHCRI), has also expanded her work to another 140 sites nationally. She has stood up to politicians, gang leaders, drug dealers, cranky administrators, and even George Steinbrenner, whom she persuaded to donate equipment to the Harlem Little League. She is President of the Harlem Hospital and a Professor of Surgery and Public Health at the Mailman School of Public Health at Columbia in NYC. Through it all, Dr. Barlow remains optimistic yet realistic. She knows that if the Cause is just, a way through will be found. She has been criticized by some who say this should not be a priority in Pediatric Surgery, despite the fact that injury is the number one killer of kids. She probably would agree with Theodore Roosevelt’s assessment of critics from a speech he gave in Paris at the Sorbonne in 1910: “It is not the critic who counts, not the man who points out how the strong man stumbled, or where the doer of deeds could have done better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood, who strives valiantly, who errs and comes short again and again, who knows the great enthusiasms, the great devotions, and spends himself in a worthy cause, who at best knows achievement and who at the worst if he fails at least fails while daring greatly so that his place shall never be with those cold and timid souls who know neither victory nor defeat.”

Wouldn’t our own Dr. Leonard Morse like to read that quote to a City Council Meeting as he valiantly fights for Operation Yellow Box, a program that makes medical sense but is politically fraught with hazards for all its advocates?

So now that you have been patient enough to sit through my Profiles in Medical Courage, perhaps it behooves me to come to the point. The common themes that I would want you to draw from these 5 individuals are as follows: They all demonstrated vision, they demonstrated passion. They all failed at some point in time. They all had the courage to persevere and in most cases win opponents over to their side with their scientific expertise and their steadfast determination to do the right thing. Earlier this year, I was asked to think about ways to improve membership in Societies like WDMS and MMS. In putting together these vignettes, I believe I have come to the conclusion that an organization that demonstrates the collective courage that these individuals I have portrayed posses will inspire membership. Look at the issues facing us and what we need to do:

We must accomplish this for our citizenry in a way that preserves principles of quality and choice and doesn’t just get run by bean counters and politicians.

This is a travesty of managing care in which non-medical business types are allowed to grade our performance like no other industry faces.

Such cutthroat medical organization competition is negatively influencing collaboration and progress in public health arenas.

The further entrenchment of malpractice precedents will eventually make practice of medicine impossible. If our judicial system in MA decides that if a physician’s successful treatment of a patient for a medical or surgical ailment makes the patient well enough to drive a car, but then the patient causes an injury to someone else, that I as the treating physician of the driver become liable for the injuries -- then the insane are truly running the asylums.

We all know intuitively that we must begin investing in prevention programs that will help cut down on injury, obesity, substance abuse, cardiovascular disease, adult onset diabetes, cancer. When we start standing up for this expenditure instead of throwing billions at hopeless end-of-life care after all of these conditions have occurred, then we will be an organization of substance

An organization that will advocate for courageous stances on these issues, that will not cow tow to HMOs, lawyers or politicians but will do what is in the best interest of the PATIENT-- for in the end we know that will benefit us as well -- that is an organization worthy of consideration for membership.

I think we at the level of the WDMS and MMS have much of which to be proud. We have shown glimpses of courage in the positions for which we advocate. We can always do more. WE must reach out to the next generation of physicians, the generation to which Dr. Pugnaire referred in her terrific 2007 Oration from this podium, and be willing to advocate strongly for their patients’ needs and for the needs of these young MDs and their families. They are loaded with talent, but loaded with debt and not facing a medical economic situation that will help them to recoup those debts easily or without being tempted by the Dark Side, quoting Darth Vader once again.

This will not be easy. But any or all of the individuals I described would tell you that nothing worth accomplishing is easy. I feel honored to have gotten a chance to perhaps stimulate you all to think about the courageous people, both patients and physicians, that you’ve know in your lives. Perhaps I’ve made you think about what it is about them that can be reproduced in your behavior. Remember my original premise that perhaps the most courageous act of all is a patient trusting you to do the right thing. Therefore, I urge you to do just that. You and I together, we can do it.

John Kennedy deserves the last quote here, and once again his words ring true: "In whatever area in life one may meet the challenges of courage, whatever may be the sacrifices he faces if he follows his conscience -- the loss of his friends, his fortune, his contentment, even the esteem of his fellow men -- each man must decide for himself the course he will follow. The stories of past courage can define that ingredient -- they can teach, they can offer hope, they can provide inspiration. But they cannot supply courage itself. For this each man must look into his own soul.”

I would like to thank my family for giving me the courage to experience a number of failures and a few successes over the years, and the Society for the privilege of the floor.

Legal Consult: Improving "Clinical Performance Improvement"
By Peter Martin, Esquire

Over a year ago, this magazine published an issue (March/April 2007) focused on physician “tiering” and performance measurement. That issue described some physicians’ responses to efforts in other states to differentiate among physicians based on quality of care and cost-efficiency measures. For example, the Washington State Medical Association filed suit against Regence Blueshield for such a program, and Regence subsequently discontinued its proposed select physician network.

Physicians’ battle against such programs has now formally been joined in Massachusetts, with the filing in May of this year of a lawsuit by the Massachusetts Medical Society against the Group Insurance Commission and two plans implementing self-insurance plans for GIC insureds. Those plans implement the “Clinical Performance Improvement” Initiative. The Initiative requires contracting plans to assign physicians in six specialties into three tiers, based upon clinical guidelines and cost efficiency measures. The GIC’s guidelines indicate that 20% of all evaluated physicians should fall within the highest tier, 65% within the second tier, and 15% within the third tier. Patients of physicians in the higher tiers pay lower co-payments.

The lawsuit alleges, among other things, some of the same types of claims as did the litigation in Washington: for example, breach of physicians’ contracts with the plans which do not call for “tiering,” defamation of physicians through statements to patients implying that physicians not in the highest tier are not high-quality, cost-effective physicians, interference with the physician-patient relationship by intentionally taking steps (defamatory statements, higher co-pays) to induce patients to end such relationships, and unfair and deceptive practices such as false disparagement of physicians’ services and interference with patient-physician relationships. The lawsuit seeks monetary damages for three named physician-plaintiffs who were improperly “tiered” and suffered harm as a result.

More significant in the Massachusetts litigation is the effort made by the plaintiffs to outline conditions under which such “tiering” programs might be acceptable. The lawsuit seeks a judicial injunction that prohibits GIC and the plans from placing physicians into tiers. Alternatively, the lawsuit asks the court to rule that the plans must take a number of steps to alleviate various problems with the “tiering” program.

One such measure is to afford a physician at least 60 days to respond to a proposed “tiering” by providing the physician with patient-specific data underlying the tier designation. Such a mechanism would enable the physician to evaluate the significance of the quality and cost measurements used to assign the physician to a tier.

Another measure is to institute a formal “feedback and correction” process for any physician proposed to be placed in one of the two lowest tiers. This mechanism would require the plan to delay releasing the physician’s tier assignment to patients and the public pending a physician’s written request for reconsideration of that assignment. The reconsideration would be conducted by an independent external reviewer.

The plaintiffs also ask that prior to implementing any revised clinical performance improvement measurement or “tiering” program, the GIC and the plans take some further steps. First, they should allow the MMS to provide input on such topics as the timeliness of the data used to “tier” physicians, how the costs of services are attributed to individual physicians, and the comparability of patient populations used to compare physicians.

Second, the plaintiffs ask that prior to such implementation, the “tiering” program include some additional features. One such feature would be a program that accounts for differences in clinical case-mix, socio-economic factors, physician practices that are small, new, rural or highly specialized, and outliers that may skew results. Another would be to assure that patients, diagnoses and care be attributed only to the physician responsible and not assigned on the basis of billing or payment practices. The plaintiffs also seek an order that the pre-implementation consultation with the MMS and these additional features of a revised “tiering’ program be overseen by an independent body.

The outcome of this litigation should be of great interest to physicians who are concerned about ongoing attempts to stratify reimbursement on dubious measures of “quality” and “efficiency.” Massachusetts law affords the public directly affected by a hospital’s plan to discontinue essential services or to convert to for-profit status an opportunity for input prior to such changes. It seems only fair that physicians, either individually or through the MMS, have the opportunity to weigh in on and potentially alter decisions that may adversely affect their practice, their income and their professional reputation.

Financial Advice for Physicians: Administering Retirement Plans is More Than Watching 403(b) Plans Grow
By Michael Halloran

Most “tax-exempt” organizations have developed retirement savings programs for their employees using 403(b) plans. The “for-profit” world works with 401(k) plans. 401(k) plans are heavily regulated under ERISA while 403(b) plans have had minimal regulation until now. Regardless of the type of employer, employees fund their own retirement with income tax deductible contributions to their personal retirement accounts. These plan designs are called Defined Contribution Plans and the funding of the accounts comes directly from the employee’s personal savings called salary deferrals.

403(b) Contribution Limits

	2007	2009
403(b) Elective Deferral	$15,500	$15,500
Age 50+ Catch Up	$5,000	$5,000
15 Years of Service Catch Up	$3,000	$3,000
415© Defined Contributions	$46,000	$46,000

The IRS established 403(b)s in 1958 to help employees of educational and nonprofit institutions save for retirement. Unfortunately, the IRS never established a clear set of guidelines to regulate these plans. Over the last 50 years, a hodgepodge of market driven provisions have shaped the operation and administration of the 403(b) market. To correct this situation, the IRS issued its Final 403(b) Regulations last year. These regulations will go into effect on January 1, 2009 and need to be addressed now. Employers who are 403(b) plan sponsors need to ensure that their plans operate in accordance with these regulations by the end of 2008. Failure to comply with these regulations can have dire consequences. The IRS’s ultimate “big stick” is that all your employees’ 403(b) assets could become immediately taxable and subject to penalty. No hospital or healthcare provider wants to face this possibility.

The 403(b) market is very large, with current retirement assets totaling about $607 billion. Hospitals and healthcare providers represent about 20% of this market, with current assets totaling about $117 billion. The government wants better control and understanding of what is going on in this large market. Prior to these new regulations, the employees would control their accounts exclusively. The employee, called the participant, would choose an investment manager, called a provider. The provider is usually an insurance company or a mutual fund company and a 403(b) plan can have many different plan providers. The employer’s only role was choosing the providers who could access their employees.

Under the new regulations, 403(b)s will be established and maintained by the employer. As a result, employers will need to take a much more active role in plan oversight and management. All employers who offer a 403(b) program must adopt a written plan which conforms to the new regulations relative to: eligibility, contribution limits, benefits, distributions, and providers. Plans can have additional features like loans, hardship withdrawals, transfers, exchanges, Roth conversions and other provisions. These features all have to be addressed in the written plan. Employers will need to implement an appropriate infrastructure to ensure that all providers offered under the plan abide by the terms of the plan document. Since the employer is now the responsible party, the sharing of information between the product provider and the employer will be essential to operating a compliant plan. Having open plan designs which allow multiple providers will become less attractive. In the regulated 401(k) world, Third Party Administrators (TPAs) help plan sponsors with plan administration and compliance. TPAs will likely perform a similar function in the new “tax-exempt” retirement climate.

The PIAM Financial Services team has experience in the retirement market with both “tax-exempt” and “for-profit” entities. Contact us if you want help getting your 403(b) program compliant with the new regulations prior to the end of 2008.

Michael Halloran, MBA, CFP, is a PIAM Representative, Certified Financial Planner™, and Wealth Protection Alliance Member. He holds a BS in Electrical Engineering from Cornell University and a MBA from Harvard University. He is available to meet with your practice or your department. He can be reached at 8 Grove Street, Suite 300, Wellesley, MA 02482, by calling 781-431-8800, or by emailing him at PIAMrequest@halloranfinancial.com.

The editorial board of the Worcester Medical News held an annual dinner meeting on the last Thursday in December (Barring national holidays, can anyone think of a worse time for such an occasion?). This was changed to the same date as the regular December meeting of the Worcester District Medial Society, but after a few years common sense prevailed and the current spring date was adopted. In the month of May, the editorial board began to hold its annual dinner meeting at the Worcester Club where the front entrance was framed by a profuse, colorful display of Wisteria flowers.

Wisteria is a genus of about ten species of woody climbing vines native to China, Korea, Japan, and the eastern United States. The species outside that building was the Chinese Wisteria, Wisteria sinensis. The vines climb by twining their stems around any available support. They can be trained to grow up and along the walls of a building; they can climb as high as 60 feet above the ground, and spread out laterally for over 30 feet.

Flowering of the Chinese Wisteria occurs in the springtime. The fragrant flowers are purple, violet, pink, or white. They were especially vivid at the time of the annual editorial board dinner meeting, and were always a subject of conversation at those meetings.

About 35 years ago, on the day of the dinner meeting, a patient, Col. George Green, brought Dr. Samuel Bachrach a souvenir from Japan: a picture of the Wisteria blossoms at Nakasendo, near Tokyo. The caption must have been written by a Japanese person, because he or she spelled “blossoms” as “brossoms.” Col. Green had picked up the photo in a jungle in the Philippines during the war, and thought that Sam would like it.

Sam brought the picture to the meeting. He suggested that it be given to an outstanding contributor to The Worcester Medical News, and it was awarded to Dr. Ralph Monroe, a primary care internist in Southbridge who wrote a number of articles for the journal. The award was repeated the following year and became an annual tradition for a time, and then was given sporadically.

There had been 16 awardees up to this year; the last was in 1996. Worcester Medicine Editor Dr. Paul Steen reinstituted the award and renamed it The Editor’s Award. It was presented on May 28, 2008, to two members of the editorial board: Dr. Robert Sorrenti and Michael Malloy, PharmD..

My reflections of Walter F. Crosby, M.D. over the past 69 years from the Perspective of:
1) Patient, 2) Colleagues, and 3) Fellow Musician

"Doc” Crosby came to Sterling, Massachusetts as a young, country family physician in 1941. Prior to opening his practice, my medical needs were met by Dr. Robinson, who did not own a car but made house calls in a horse and buggy. My smallpox vaccination was performed on our front lawn in the shade of a massive elm tree while his horse snacked from a small bucket of oats.

One Sunday in 1948, Doc Crosby answered my call for help: a steel chip had entered my left eye ball while I was removing concrete with a hammer and chisel. After examination, he called ophthalmologist Dr. Theodore Rice and the intraocular chip was surgically removed that evening in the Winslow Surgery unit of Worcester City Hospital. This was one of many services I received from Doc Crosby over the years.

My interest in medicine developed during a Navy enlistment that had me assigned to the hospital corps. Upon discharge in 1947, I sought Dr. Crosby’s help, encouragement, and advice in preparation for applying to medical school. I feel certain that his guidance was very helpful in my being accepted to Tufts Medical School. After graduation, internship, and residency, I established a general practice in the nearby town of West Boylston and covered his patients while he was away.

When Dr. Crosby arrived in Sterling in 1941, he brought more than his medical skills; he was also a seasoned, talented tuba player. I was a trombone player, so we sat side by side in the low brass section of the Sterling Cadet Band, playing weekly rehearsals and Wednesday summer concerts. After 40 years, the Cadet Band dis-banded and we formed a ten piece group called The High Society Orchestra, playing “hot” dance music of the 20s and 30s and he sure was in his element playing this old time jazz.

I last saw Dr. Crosby a year before his death at the Sunrise Home. He was at lunch on my arrival, and he walked from the dining room, stooped, with a walker. We chatted about the good old days, and then I asked him about his tuba. “It’s in the barn,” he said, ”when I walk by it I push on the valves to see if it is still working!”

Dr. Walter F. Crosby died February 1, 2008 at the age of 94. He was President of the Worcester District Medical Society 1971-1972. Despite illness and hospitalization, Dr. Warren Trow most willingly prepared this eulogy, and shortly thereafter, on March 31, 2008, passed away.

Dr. Warren F. Trow, affectionately knows as “Bud,” passed away on March 31, 2008 at his home in West Boylston. He leaves his wife Dorothy and his daughter Kathryn as well as his brother Wesley R. Trow. He was 81 years old.

“Bud” was born in Worcester. Following graduation from North High School, he attended Clark University, where he received his Bachelor’s Degree before going on to obtain his medical degree from Tufts University Medical School. He interned and continued in a residency at Worcester City Hospital. During World War II, he served in the Navy Hospital Corps.

Dr. Trow established his office in West Boylston, where he practiced for thirty eight years, retiring in 1995. He was an active member of the Holden District Hospital medical staff until it merged with Memorial and Hahnemann hospitals. It was always a pleasure to meet him on the wards because of his pleasant and jocular personality. He was respected by his colleagues as a caring and competent physician. He enjoyed his patients and they reciprocated in their affection for him. He always put his patients first.

Besides medicine, Bud’s passion was music, especially jazz and big band music. In 1976, he organized the Tuxedo Classic Jazz Band in which he played trombone and was the leader. His band played at various venues in Worcester County. He was especially welcomed at the Oakdale Nursing Home and at the Senior Center in Sterling. After he retired, he spent a great deal of his time on his farm, tending to his gardens, orchards and animals, especially his beloved horses.

Leonard J. Morse, MD, an esteemed professional highly regarded for his medical skills and compassionate manner, received an honorary degree from the University of Massachusetts Medical School. The award was presented at the Commencement on Sunday, June 1, 2008.

Robert W. Sorrenti, MD, Chair, Publications Committee, In recognition of his innovative, dedicated and invaluable Service to the publication and enhancement of Worcester Medicine

Michael Malloy, PharmD, Editorial Board Member from 2005-2008, in recognition of his outstanding contributions and dedication to Worcester Medicine

Awards were presented at the Wisteria Dinner at the Worcester Club on Wednesday, May 28.