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Worcester Medicine
Global Health
International
Initiatives at Massachusetts College of Pharmacy and Health Sciences Working Globally: Lessons Learned from Conducting an HIV
Education and Prevention International Medical Education at UMASS Medical
School Medicine and Citizen Diplomacy Cultural Adjustments for International Residents Science Corner Off Call Financial Advice for
Physicians In Memoriam Society Snippets Editorial: Worcester's
Endeavor to Improve Global Health The noun “globalism,” from which the verb “globalization” is derived, was first coined by Harvard economist Raymond Vernon around 1970. The economic phenomenon of globalization has broadly affected the health care industry and the medical profession in general. It has brought to light the world’s biggest health problem ~ world poverty. A huge gap exists between the rich and the poor in our world and the chasm widens. In 1960 the income of the wealthiest fifth was 30 times greater than the poorest fifth; it is now 80 times greater. It is against this background that humanitarian tragedies like that in Kosovo occur. In 2004 WHO reported that the average life expectancy in the U.S. was 69.3 years; in Sierra Leone it was 28.6 years. While population segmentation according to health status is a global socioeconomic reality in both industrialized and developing countries, it is not morally defensible if it excessively rations or completely restricts health care delivery to some sectors. In addition, physicians are being actively recruited to leave their country and take a more lucrative job abroad. This “brain drain” severely limits a developing country’s ability to deal with its health care problems. As I reviewed the articles for this issue of Worcester Medicine, I felt fortunate to be part of the Worcester medical community. I am proud of the efforts of this city in helping to bring health care to numerous developing countries. Wayne Trebbin, M.D. tells of his relationship with WORTH (World Organization of Renal Therapies), a non-profit organization with the intent of placing dialysis units in countries where the diagnosis of chronic renal disease previously was a death sentence. Yet there is still a need for erythropoietin, vitamins, phosphate binders and antihypertensive medications. George Humphrey, PhD describes the Massachusetts College of Pharmacy and Health Sciences’ relationship with universities in Asia, Latin America and Europe that share a common interest in fostering cross cultural competencies among their faculty and students. Carol Bova, PhD, R.N., ANP and Carol Jaffarian, M.S., R.N., ANP report on the lessons learned from their innovative, nurse practitioner managed HIV education and preventive program in a rural village in Armenia. Royce Anderson, PhD informs us of the International Center of Worcester’s hard work in providing citizen exchanges as a way to break down political and cultural barriers. In his powerful article, Dr. Mick Godkin notes with justifiable pride that 47% of the University of Massachusetts medical students have completed an elective abroad compared to the national average of 27%. Gary Blanchard, M.D. once again entertains us with his “man on the street” interviews of international medical graduates as they relate their first experiences in a U.S. medical system. As you read these compelling and effective articles, I hope that you realize all the outstanding work that the physicians, nurses and pharmacists of Worcester are doing to help close the gap in health care delivery in many developing countries. Global Health: Dialysis
in Africa The air in the clinic was hot, humid and stale. The last patient of the day entered the room when the nurse beckoned to him to do so. At 60, he was old in his world. The man was tall and carried himself well, emanating dignity and leadership although he had not yet spoken. The corners of his eyes were enhanced by lines created from his kind smile that he now bestowed on me as he approached, and his mouth was edged by the lines of wisdom. Dressed in a blue, long tunic shirt typical of the style of his culture, with matching loosely fitting trousers, he was the picture of Africa itself. He moved with a slow stately stride towards us, and my first gut reaction was to like him immediately. My colleague, who was hosting my observational visit to the clinic, leaned sideways toward me, and said in a quiet flat tone, “He is a dead man.” My head snapped towards her, and I asked her to repeat what she had just said, although I had heard it perfectly well. “He’s a dead man. But he does not know it.” My hostess was the only real nephrologist in the entire city of Yaounde in Cameroon, and she was tired. In her richly accented English she explained that the man had severe renal failure, but there was no dialysis available to him in the entire country. I looked at the man again, and I felt a tightening of my spirit as I realized she was right. He just didn’t know it yet. That is a statement as to the state of nephrology in Cameroon as it was then, two years ago: a handful of poorly run dialysis units with poorly trained staff and machines that constantly broke down with no hope of repair. People would receive dialysis once every two weeks if they dialyzed at all. Although this was well intended, all it did was prolong their dying. This is a country where the average income equals 640 dollars per person per year, where the average man is dead by 47 years of age and the average woman by 49. Poverty is everywhere, and death stalks the populace. That is the country where I came to affirm my belief that individuals do have the ability to affect change. That is the country where I affirmed my belief that it is morally reprehensible in the West to see tragedy and shrug one’s shoulders while watching the news on television, then dismissively reach for another helping of potatoes at the dinner table. WORTH (World Organization of Renal Therapies) officially came into existence only two years ago. It is an American based non-profit organization with the goal of placing dialysis units in the third world in locations where end stage renal disease is essentially a death sentence. WORTH quickly gained an energetic, upbeat, dedicated core group of men and women, and I am pleased to say that ~ through their untiring work and against tremendous odds ~ as of November 2006 we have a well functioning dialysis unit in the city of Yaounde. It operates on modern standards and so far its quality, as gauged by mortality, morbidity and morale, is every bit equal to what we have here in the United States. It functions in collaboration with the Central Hospital University of Yaounde (CHUY), and is generously supported by Davita and other donors. To date we have accrued eight patients as we approach our capacity of 24. It is our intent to make this unit the polished flagship of our efforts, and when it is ready we will begin to build more units of its kind in Africa. Our lines of contact span 9,000 miles, from California to Central Africa. Hundreds of dedicated people have been recruited. American and Cameroonian lawyers, government officials, the medical establishments of two countries, and industry have all helped…and, incredibly, they have, for the most part, done so as volunteers. Yes, we do live in cynical times, but it does not always have to be that way…not by a long shot. Sometimes my fellow human beings show what can be when people really aim for the good. Our nursing staff in Cameroon has been incredible. Many of them had no concept of what dialysis even was when they joined us. However, they were eager to learn and approached their tasks with unabashed enthusiasm. Teamed with American instructors who worked tirelessly with them, they have emerged as a highly competent group, gaining in experience and confidence each day. We are gathering data so that we can report our experience to the rest of the medical world. We want people to know what we have done because we want them to know that it can be done. Imagine if other disciplines take up the mantle of our efforts. Imagine endoscopy suites, open heart surgery and the myriad of other high tech medical support systems we take for granted in the west. I was told by experts before I started WORTH that what I intended to do could not be done. The third world was not conducive to, could in no way support, and would in fact erode, what I wanted to build. The experts were wrong. Despite all this progress there remain needs. We have a great need for erythropoeitin, appropriate vitamins and intravenous iron. We need antihypertensives and will need more phosphate binders in a few months. And of course we need continued funding to perpetuate our work. Some have leveled criticisms at what we are doing. “That’s a lot of money for so few patients,” said one such person to me. What I was tempted to say to her was, “Let’s pretend it is your child being dialyzed. You tell me when we have spent enough money and should stop doing the procedure.” What I said was the simple fact that we have never drained (and never will) money going to other health care projects. The funds we have generated were from sources dedicated to what we are doing, never intended for anything else. Another comment has been, “It’s hopeless; it’s a drop in the bucket.” I answer with a parable a friend of mine told me about a man throwing starfish that were washed up on the beach back into the ocean. When a passerby said to him that it was a hopeless task, that it would not change anything, the man bent down, threw another starfish back into the sea, and, smiling at his critic, replied, “It made a difference for that one.” So how will this play out? No one knows the future. All I can say is that as long as I am breathing I will be in the struggle, and many of my colleagues in WORTH feel the same. I have cared for patients in Cameroon, I have friends there, and I have even had the honor of being made a member of a tribe there. I am a loyal American, but a part of my heart will forever be in Africa. Change is possible. It often comes slowly, with a large price in effort, energy, fatigue, discouragement, but ultimately there comes the thrilling realization that something wonderful has unfolded, not by accident but by the efforts of individuals. Everyone can make a difference. The only question is will they try. International Initiatives at Massachusetts College
of Pharmacy and Health Sciences In response to the rapid globalization of health care education and delivery, Massachusetts College of Pharmacy and Health Sciences has developed collaboration agreements with universities in Asia, Latin America and Europe. The purpose of these “sister college” relationships is to create a network of international partners who share a common interest in fostering cross-cultural competencies among their faculty, students and alumni. Formal pacts have been signed with the School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin; University of Havana, Cuba; Catholic University of Santa Maria, Arequipa, Perú; Niigata University of Pharmacy and Applied Life Sciences, Japan; Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand; and Hangzhou Medical College, Hangzhou, China. The agreements provide a framework for faculty and students to engage in individual research and study projects. In recent years, students have presented scholarly posters in Cuba, taken summer elective courses on tropical medicine and medical anthropology in Perú, and participated in service learning trips to Guatemala during summer break. The College has also hosted pharmacy students from Perú and Spain, as well as guest faculty from Ireland, Cuba, Japan and China. For example, during their holiday break last December seven nursing students from MCPHS-Worcester traveled to Thailand to volunteer in rural health clinics and one city hospital for a period of three weeks. Students were especially impressed with the autonomous role of the nurse within the Thai health care system, and they returned with a first-hand understanding of the cultural aspects of health care delivery. Last summer, an MCPHS pharmacy student did an advanced practice rotation in the Netherlands, working with the International Pharmaceutical Students’ Federation (IPSF) on projects for WHO. In the area of research, the College’s Division of Graduate Studies enrolls students, from several foreign countries, who are pursuing doctoral degrees in pharmacology, medicinal chemistry and pharmaceutics. A PhD candidate from Perú, for example, is conducting a study of the Maca plant, known for centuries among Andean peoples for its medicinal properties, which may be useful as a neuroprotective agent for the prevention or treatment of stroke. In the area of practice, MCPHS faculty have conducted workshops in Cuba, Perú, Japan and Ireland on the role of the clinical pharmacist and the practice of pharmaceutical care. For Latin American pharmacists interested in practicing in the United States, MCPHS has created a certificate program that prepares foreign graduates for licensure in the USA. To date, fifty pharmacists from Perú, Venezuela and Colombia have completed the program and most have either begun internships or have become licensed in Massachusetts, Michigan, Florida or Washington State. MCPHS President Charles F. Monahan, Jr. recently led a delegation of trustees, faculty and administrators to Hangzhou, China in order to launch a new collaboration agreement with Hangzhou Medical College. Among the projects under development with Hangzhou are international programs in nursing, Chinese traditional medicine and Western pharmacy. As a first step, five nursing and pharmacy faculty will be visiting the College this summer to learn more about the MCPHS curriculum and to improve their English language skills. The two institutions have also agreed to co-sponsor an international conference on the globalization of health care, to be held in Hangzhou in early November 2008. George E. Humphrey, PhD is Associate Vice President for External Affairs at Massachusetts College of Pharmacy and Health Sciences. Working Globally:
Lessons Learned from Conducting an HIV Education and Prevention Project in
Armenia In 2003, we were given an exciting opportunity to work with the Armenian Relief Society, Inc. (ARS) to bring an innovative HIV education and prevention program to a health clinic in a rural village in Armenia. Our initial project was funded by the World AIDS Foundation and included delivering HIV education to over 310 physicians, nurses, teachers, and community members. Our work continued with funds from private donations and Sigma Theta Tau and resulted in HIV testing and counseling services in the rural clinic. The following is a brief summary of some of the lessons we learned while conducting this project. First, we learned that a strong working relationship with an in-country organization is essential for success. We were fortunate to work with the ARS. Our colleagues from the ARS arranged meetings with major stakeholders, facilitated money transfers, and provided in-country support for our project. Through this partnership we were able to meet regularly with members of the Health Ministry and other non-government organizations (NGOs) working on HIV-related issues in Armenia. Second, we found that repeated visits over time were necessary to establish trust and commitment within a transitional country. Repeated short trips (e.g. 2 week stays 3 or 4 times per year) worked well to maintain relationships and sustain the project momentum. From our observations (and reports from in-country colleagues) we became skeptical of the benefit of single trip projects. Admittedly, it may be useful to expose U.S. students and faculty to different cultural contexts; however, we doubt the efficacy of projects with limited ongoing individual commitment. It has taken us four years and approximately fifteen in-country visits to establish trust and a genuine sense of commitment between our project team and that of our in–country collaborators. Third, it is important to “…never pass up a free lunch.” Many of our important ideas about future projects and insights about the culture and working in Armenia came from informal lunch meetings with members of the community as well as major stakeholders. Although you may want to say, “Not another meal,” we found that more is said over dinner than in an office or board room. Fourth, an often overlooked but important issue to consider when working in a transitional country is where to stay. There are typically two ways to think about this issue. Many either head for the most “western” hotel they can find or live among the villagers. We decided to do both. We found that living in the village helped us forge relationships with the community itself and added to our understanding of the day-to-day issues faced by the people we worked with there. However, staying at the hotel allowed us to meet important officials (e.g., Red Cross, USAID, and other NGOs) who were doing work in Armenia. Over the past several years we have developed excellent working relationships with these colleagues that would not have been possible had we stayed exclusively in the village. Fifth, we learned that it is important to “…boldly go where no man has gone before.” In the world of HIV, there are numerous academic, non-profit, and NGOs involved in international HIV work. Funding for HIV programs has been largely earmarked for the high prevalence countries and therefore the programs many go where the funding is available. We chose to work in a country with an unknown HIV seroprevalence (at least that was the case at the start of our project; now we know it is approximately 1% of the population) and limited access to funding resources. This choice afforded us unlimited access to health care providers and policy makers who enthusiastically embraced our efforts to conduct HIV prevention work in their country. In addition, it gave us a breakthrough presence in the international arena. We helped fund, organize, and run the first two National HIV Conferences in Armenia, were invited to present our project findings at the United Nations, and currently hold (Ms. Jaffarian) a seat on the United Nations NGO Committee on HIV/AIDS. In summary, as Nurse Practitioners with more than 15 years of experience caring for HIV-infected adults in the U.S., we thought we were well prepared to take on the challenge of implementing an HIV education and prevention project in Armenia. However, we were not prepared for the roller-coaster ride associated with conducting a major health project in a transitional country. Although this paper highlights only a few of the lessons learned, others will have to wait for later (e.g. always carry diphenhydramine, don’t drink Armenian brandy before giving a presentation, etc.), we hope that this summary will be useful to others who plan to begin similar work. International Medical Education at UMASS Medical
School In academic year 2005-06, ninety two University of Massachusetts Medical School (UMMS) students participated in international learning experiences in 23 countries. In the Association of American Medical College’s Graduation Questionnaire (GQ) for the Class of 2006, 47% of UMMS students reported having completed an elective abroad, compared to the national average of 27%. Why is it important for students to have these experiences? Increasingly, students are recognizing the importance of developing cultural and linguistic skills that they can use with rapidly growing foreign-born populations in the US. In a shrinking world it is also in the best interest of the US and its doctors to be involved in the eradication of diseases that are a mere plane ride from our shores. Tommy Thompson, a former Secretary of the Department of Health and Human Services, has even said medical diplomacy is our best weapon against terrorism1. And then there is what has been called our moral responsibility as a wealthy country to help resource-poor counties, including through a Medical Peace Corps2. U.S. Census data indicate that the foreign-born population in Massachusetts has increased by 34.7% since 1990 and constitutes 12% of the population3. Massachusetts is now the eighth leading state for the number of foreign-born residents. The same data source reports that in Worcester, a city of 172,648 inhabitants, 15% are foreign-born and just under 30% speak a language other than English at home. Recent immigrant populations, including children, also account for a substantial number of people who lack insurance in MA, e.g., 27% of children of non-citizens are uninsured compared to 12% of citizen children. In Worcester, 18% of its families are below the federal poverty level compared to 9% statewide. Separate international electives are one way to enhance the interest and abilities of medical students to serve foreign-born populations. Our own data show that these electives are related to the development of cultural sensitivity and idealism4. They also facilitate learning second, if not third, languages. Sixty percent of UMMS students in the Class of 2006 reported on the GQ that they had learned another language during medical school, compared to 26% of U.S. medical students. An Optional Enrichment Pathway on Serving Multicultural Underserved Populations at UMMS provides a more comprehensive global education program that, over four years, combines international and domestic experiences with prevalent foreign-born populations in MA. These include international electives, an assignment to a local foreign-born family, a local community service project with an immigrant group, and a family medicine clerkship in a Community Health Center. An initial analysis of this program provides encouraging evidence that it may help sustain positive attitudes toward the medically indigent in Pathway students that decline at a high rate in non-Pathway students5. Some students have become leaders of significant projects abroad. These include a sustainable community development project in Tanzania (www.malaikaproject.org), a boarding school program for children at risk for abduction in northern Uganda (www.thechildisinnocent.org), a literacy project in the Democratic Republic of Congo-DRC (www.gomastudentfund.org), a revolving loan program in Zambia, an HIV intervention program for street orphans in Zambia, a worldwide quilt-making project for orphans (www.patchesoflove.org ), and alternative Spring Break brigades to the Dominican Republic (www.umassmission.googlepages.com ) in which around 40 students will participate this year. In describing her project in the DRC, Alison Lee (Class of 2007) says, “As a medical student it’s very easy to be extremely self-focused. This project helps me keep my eye on the reason why I went to medical school in the first place.” Students have brought home skills learned abroad and started projects here with immigrant groups. One African mentoring program initiated by a student provides weekly one hour, one-on-one tutoring by medical students with over 40 African children in Worcester. This year, the same student, working with African community leaders, started the African Community Education program, an all-day school on Saturdays for about 45 African students. Other UMMS students are starting Well Being, a health education newsletter in Spanish and Portuguese that will provide important health information and tips on how to access resources. After studying Portuguese in the Azores, another group of students worked with a local physician to start the free clinic in Hudson. It is clear from the reflections that students are required to write that many are greatly affected by their experiences abroad. One such student, an Albert Schweitzer Fellow in a hospital in Gabon that Dr. Schweitzer himself founded, describes her three month elective as “…overwhelming but extremely rewarding. Interacting with patients in a foreign language to diagnose and treat illnesses I had never seen, while trying to understand the patient in the context of a culture I wasn’t familiar with, forced me to become a stronger, more competent and resourceful physician.” References:
Dr. Godkin can be reached at michael.godkin@umassmed.edu Medicine and Citizen Diplomacy In December, 2006 I received a call asking the International Center of Worcester (ICW) to arrange a 1-day program for a group of 16 Iranian physicians traveling on a professional exchange sponsored by the U.S. Department of State’s International Visitor Leadership Program. This was an unusually difficult request because I had only a few days to organize the program. I immediately got on the phone and began calling many of our medical contacts in the Worcester area with whom we regularly work. Some could not accommodate us on such short notice, but others made an heroic effort to host our Iranian guests. Dr. Frances Anthes, Director of the Family Health Center of Worcester, provided a meeting and break-out sessions with several of her medical staff, selected to reflect our visitors’ medical specialties. Dr. Richard Aghababian, Chair of the Department of Emergency Medicine at UMass Medical Center, was traveling when I called but gave approval for his staff to organize a tour of the Emergency Department ~ which he led on his first day back. Dr. Joel Popkin at Saint Vincent’s Hospital welcomed them to the Worcester Medical Center. Edla Bloom and Joe McKeen showed them their operation at AIDS Project Worcester. Although all these visits were planned at the last minute, they exactly targeted the needs of the Iranian doctors. I was struck by the Iranians’ friendliness, gentleness, curiosity, and excellent English. They all expressed their appreciation for the warm attention and useful information they received in Worcester. I later received letters of appreciation (see our website) from the U.S. State Department and the Institute for International Education. The Iranian doctors had other stops on their junket, including Washington, D.C. and the Centers for Disease Control in Atlanta, attending high level lectures and conferences. But they wanted to see medicine working at the grass roots level. When they arrived early at the Family Health Center, just waiting in the lobby and watching people come and go taught them a lot about medical services in the US. Their trip was under high security, and we could not reference the State Department on any documents they might take with them back to Iran. But their experience in the U.S. and contacts with their American counterparts made a tangible contribution to improving international understanding between our two countries. Citizen Diplomacy is simply the power of ordinary people meeting ordinary people from other cultures. Whether government or privately sponsored, citizen exchanges are a vital way to break down political and cultural barriers “…one handshake at a time.” As thousands visit the U.S. each year, stay in our homes, spend time in our workplaces, and visit our schools, we build a growing network of international communication and friendship. We are living in a time of rising international tensions; whatever your political orientation, you can’t help but be concerned about the current trends and the deteriorating trust among the peoples of the world. ICW has hosted many groups of professional people in its 44 year history. Worcester, including its medical community, has opened its doors to welcome them. ICW’s very first programs in the 1960s assisted wives and families of international doctors and scientists at the Foundation for Experimental Biology in Shrewsbury. More recently we have hosted groups from the independent countries of the former Soviet Union. We make an effort to stay in contact with our alumni after they return home. Medicine, as a profession, has an inherently global perspective. Physicians have always shared research and medical knowledge across international boundaries. We find that ICW’s medical alumni, upon their return to their home country, discover that their colleagues are receptive to the ideas they bring from the U.S. and, as a result, are able to implement change. In contrast, many of our other alumni return to encounter resistance from their professional colleagues to “foreign” ideas from the U.S. Doctors seem much more open to the global exchange of ideas. The global medical community has, therefore, a special role in fostering international cooperation and peaceful interaction. While political, economic, and cultural barriers can impede communication and the exchange of ideas among nations, physicians can maintain mutual respect and more open channels of communication, giving them a special opportunity to put Citizen Diplomacy to work. ICW appreciates the willingness of the Worcester medical community to participate in international exchanges. We look forward to continuing our efforts and welcome any dialogue exploring ideas and initiatives for future programs. Cultural Adjustments for International
Residents Forests have been razed to chronicle the culture shock faced by Daisuke Matsuzaka, our most prized Japanese import since sliced sushi:
But on April 11th, when Matsuzaka-san toed the rubber at Fenway for the first time, it was still 60 feet, 6 inches to home plate. As Gene Hackman might say, “I think you’ll find these exact same measurements in our dome back in Tokorozawan.” Now compare that to a foreign medical school graduate, unquestionably a former star in his or her own right back home, taking the field in an American hospital for the first time ~ on his or her first day as a physician, no less. Even American-born interns, after all, with their built-in home field advantage, have been known to lock themselves in a janitor’s closet after getting two simultaneous pages on Day One. But imagine on your first day as a doctor that they suddenly changed the names of many of the medications you spent years assiduously learning in medical school (thank you, American BigPharma). Now, the patients not only openly disagree with you but also question your authority ~ a development especially stunning to Indian doctors, who are used to being venerated as gods back home, their opinion so sacrosanct their patients dare not utter a word of dissent to even the most cockeyed of treatment plans. Oh, and then there’s also the small matter of quickly assimilating a second language and a wholly different culture in order to effectively treat patients. For international medical graduates (IMGs), their first day on the job is something like tumbling down the rabbit hole ~ and awakening to a world run by machines using humans as Duracell batteries… paved in yellow brick roads. That is a culture shock. And, oh yeah, Dice-K could kill my fantasy baseball team. These guys could actually kill someone. ========== Yet they keep coming ~ from Colombia, Syria, New Zealand, parts near Transylvania (Romania), and, of course, India, to name but a few countries among the six continents from where our hospital’s residents hail (St. Vincent’s is even reportedly laying the groundwork for an Antarctic outpost to sign promising 16-year-old rookie physicians.). In 2007, 11,262 IMGs applied for a residency or fellowship through ERAS last year ~ nearly double the 5,912 IMG applicants using ERAS as recently as 2003. During this current application cycle, IMGs accounted for 40 percent of the total applicants ~ compared to 30.8 percent only four years ago. The difference in working in a U.S. hospital is immediately and starkly apparent to an IMG. “Everyone here is so educated and Internet savvy,” said Dr. Anupama Gandhe, a second year resident from Osmania Medical College in India. “It is almost like [the patients] know what they have and are coming to you only to confirm!” “Sometimes I feel like they know more specific details about their diseases and [just] wanted the most up-to-date information,” added Dr. Ananth Vadde, graduate of Kasturba Medical College in India, also a PGY-2 internal medicine resident at St. Vincent Hospital. “I still remember one of my patients asking me, ‘I am told that there were new guidelines for afib. Can you tell me more about [them]?’” Entering a world of unbridled, unapologetic capitalism, where dollars are spent often, liberally, and unequally, also makes for a kind of Wonderland. IMGs are flabbergasted to learn that a doctor can order lab work and imaging studies almost on command. In Romania, for instance, only one CAT scan exists for five hospitals ~ with a waiting list as long as the one for Red Sox season tickets. Obtaining an MRI in New Zealand was “…mission impossible,” according to Dr. Bogna Targonska, an intern from the University of Otago in New Zealand. “It was therefore quite an odd feeling ordering a whole body CT and nobody commenting on that.” But with such easy access to imaging studies, many IMGs fret the loss of reliance on physical exam skills in making a diagnosis and adjusting treatment plans (You have to get good at auscultating murmurs pretty fast when it takes a month to get an echocardiogram.). “I do feel that doctors are forced to do some unnecessary testing just to cover themselves since patients are not always easily satisfied,” said Radha Raghupathy, a PGY-3 at St. Vincent’s. Some IMGs do adjust more quickly than others. “I think if you are a foreign doctor you just need a few days to adjust to the system, and, in the end, it will be better than the one you were used to in your own country, mainly if you come from a third world country like mine,” said Dr. Maria Hincapie-Marquez, a second year resident from the Juan N. Corpas School of Medicine in Colombia. But for others, even fundamental, integral tasks such as interviewing patients remain daunting. Some sense bias from patients who sometimes muse aloud how “It would be nice to be able to pronounce my doctor’s last name for once.” Regardless, feeling overwhelmed on the first day of any occupation is nearly universal. “The first day was a combination of curiosity and excitement about the unknown, as well as a feeling of pressure to prove myself in a new environment,” said Dr. Raghupathy. For an IMG, it doesn’t get much more unknown than on your first day as a doctor on foreign soil. Science Corner: Global
Challenges in the Prevention of Mother-to-Child Transmission of Human
Immunodeficiency Virus (HIV) Dr. Luzuriaga is Professor of Pediatrics and Molecular Medicine; Chief of Pediatric Immunology, Infectious Diseases, and Rheumatology; and Director of the Maternal-Child HIV Program at the University of Massachusetts Medical School Since the onset of human immunodeficiency virus type 1 (HIV-1) pandemic 25 years ago, 60 million individuals have been infected and 39 million individuals are currently living with infection. Nearly 5 million individuals acquire infection each year1. Most (4.2 million; 84%) newly infected people are between 15 and 49 years of age and live in sub-Saharan Africa. Since infection commonly occurs during the peak productive and reproductive years, HIV-1 related morbidity and mortality have adversely affected the social, political, and economic stability of the regions hardest hit by the pandemic. Heterosexual transmission is the predominant mode of transmission globally and 50% of new infections occur in women. In sub-Saharan Africa, HIV-1 seroprevalence rates in antenatal clinics range from 10-40%. Mother-to-child transmission (MTCT) is the predominant mode of pediatric infection. Approximately 2.5 million children are born to HIV-1 positive women per year and are thus at risk for infection; 700,000 children are newly infected per year. One third of HIV infected children in Africa die by their first birthday and half die by their second birthday2. The high mortality associated with pediatric HIV infection has reversed advances in child mortality achieved over the latter decades of the twentieth century through immunization and public health programs. Maternal and perinatal antiretroviral therapy (ART) regimens can markedly reduce MTCT. In 1994, Connor and colleagues3 demonstrated that zidovudine (ZDV) therapy of women throughout pregnancy and delivery, along with post-partum ZDV treatment of their infants, resulted in a decreased transmission rate to 8.3% compared with a transmission rate of 25.5% in the placebo group (67% reduction in MTCT). As more women in the United States and Europe have received continuous combination ART to optimize their own health, overall MTCT rates have dropped to under 2%4. MTCT can occur in utero, during delivery, or post-partum through breast milk, with the majority of transmissions occurring during vaginal delivery or through breastfeeding. A single dose of nevirapine (NVP) administered to a woman during delivery, followed by a single dose of NVP to the baby, can also markedly reduce the risk of intrapartum HIV-1 transmission5 However, while NVP’s manufacturer (Boehringer-Ingelheim) has provided NVP free of charge to MTCT prevention programs, fewer than 10% of HIV positive women in limited-resource settings around the world actually have received prophylactic NVP5. What can be done to advance our ability to prevent mother-to-child transmission of HIV in limited-resource settings? First, there is a great need for operational research to define and optimize health care delivery systems that will ensure that women and infants have access to a continuum of pre-, peri-, and post-natal care ~ including HIV testing and access to antiretroviral therapy ~ if needed. Secondly, currently available ART regimens do not prevent MTCT through breastfeeding and clinical trials must be done to evaluate the efficacy of ART in preventing breastmilk HIV transmission. Finally, given the scope and impact of the pandemic, the development of an effective prophylactic vaccine is a major priority. An infant HIV vaccine regimen, begun at birth, would not only prevent MTCT but might also provide the basis for lifetime protection against HIV-1 infection7. Booster vaccines could be administered in late childhood to protect against sexual acquisition of HIV-1. Utilization of the existing health care infrastructure that already successfully delivers routine childhood vaccines could enhance the feasibility of this approach. References:
Off Call: Wiping Out Eye Drop
Abuse ~ One Case at a Time Parents know that the first year in college is a tumultuous one for their kids. My daughter’s first year at Trinity has been going swimmingly well, eerily so. Not that we had worries about her academically or socially, just the natural worry any parent sending off their baby girl to the wilds of Hartford, Connecticut might feel. So when she popped up with excruciating eye pain in the middle of a rare weekend home, a crisis truly was at hand. Of course we tended to the midnight visit to the ED, though I must admit that as a pediatric surgeon used to responding to all different kinds of emergencies through all hours of the night, I was really pushing for my daughter to take two Tylenol and ride things out to the morning. Fortunately, cooler heads (i.e. Mom) prevailed and we got the diagnosis of corneal ulcer made at 5AM. A subsequent visit to an ophthalmologist got us confirmation of this non-life threatening but potentially problematic diagnosis ~ which can result in corneal scarring if not aggressively treated with the subject of this essay, the dreaded eye drop. In my daughter’s case, not just one but three were originally needed. We were also given extremely close follow-up by the ophthalmologist, whose concern for corneal scarring led him to recommend aggressive treatment including daily visits that forced us to start an almost daily commute to Hartford for about 5 days until the ulcer had stabilized and the eye was out of danger. My daughter took it all like a trooper, managing to stay on top of her studies despite considerable discomfort and the hassle of every 2 hour administration of those blessed little eye savers. You might be asking what I am leading up to; there really is a point to this tale if you are willing to bear with me a bit longer. When the ophthalmologist backed off on his requests for daily follow-ups to weekly, my wife and I figured out a way that she could retrieve my daughter and I could then pick her up from the ophthalmologist and return her to Trinity College in the evening. This was predicated on great support from my partners at work and cooperation from the ophthalmologist himself in giving us an appointment late enough in the day to accomplish the necessary pick up/drop off of my daughter without interfering with her classes. On the particular day that this story seeks to detail, I was assigned to pick her up at 5P from the eye doctor’s suite. He had prescribed another set of eye drops that she would need to take twice daily only for one month followed by once daily for a second month. My daughter, having limited pharmacy access on her college campus, asked if we could pick up the new prescription on the way home to Trinity. We thought we would be very proactive about this, so I called the prescription in to a drive-thru pharmacy. They told me it would be an hour ‘til the scrip was ready, so we went to a nearby restaurant to dine prior to the pharmacy pickup. Of course any private time with my daughter is a rare treat, as most of the time when we see her on campus it’s at very public and noisy parent events, football games, or crew races. Time at home is usually stolen by old high school friends or new college friends living around Central MA who want to see their newly made buddy from Northboro. So we enjoyed dinner and a schmooze, and then hopped into the car to pick up the goods (i.e. eye drops) from the pharmacy drive thru, then head on our way to Connecticut. The drive-thru had quite a long line, and my daughter had a tutorial at get to for Calculus ~ so the pressure was on since we still had a 75 minute drive ahead of us. But this too was a great time for father-daughter bonding. No complaints from this end. When we reached the window, the pharmacist furrowed her brow, called over several colleagues, and created the obvious impression that there was something seriously wrong. I recalled the scene in "It’s A Wonderful Life" when George Bailey saved his boss in the drug store from inadvertently sending out poison to a customer. Perhaps the ophthalmologist had prescribed poison eye drops for my daughter. What was up? When the drive-thru window opened, all was revealed. No poisoning was involved. My insurance company had denied reimbursement for the medication, although the pharmacist said if I came back tomorrow, they could put it though then. I said I could not wait ‘til tomorrow, and from the looks I was getting from my daughter as her tutorial class time approached I probably could not wait for the end of this transaction. I asked how much the out-of-pocket cost would be without the insurance coverage. “One hundred dollars,” replied the pharmacist with a look that made me think she was really wondering if the 5cc of steroid eye drops were made of Ponce De Leon or Holy Water of some sort. Having no viable choices, I handed over the credit card and filled the prescription. I turned to my daughter and explained that the father-daughter bonding was over, that we would have to spend this drive time fighting for our rights as insured patients. I donned my Bluetooth hands-free headset and had my daughter assume the role of designated dialer of the cell phone. So first the call went out to our health plan. After several prompts, each resulting in a period of hold time peppered by some lovely classical Musak (including “Memories” from the Broadway musical “CATS”), I reached a human being. 20 minutes later, the word came down. My group practice plan’s PPO had subcontracted pharmaceutical management to another company, which I needed to call. So my daughter dialed that second number. This time, the MUSAK for the holding period was Barry Manilow’s “Oh Mandy, you came and you gave without taking.” O would but were true for my pharmaceutical management company. After another 15 minute wait, another human appeared on the phone. I explained the situation. This part of the conversation revealed what the Pharmaceutical Management Company’s gripe with my attempt to obtain the eye drops was all about. You see, the original eye drop prescription written by the ophthalmologist for my daughter was for a 14 day supply. We had come back 12 days later for more eye drops. The big bad company computer kicked out the request as something that might indicate drug-seeking behavior or drug abuse. So for that reason, if we waited ‘til the next day, the request would have been OK’d. However, since I had proceeded with the purchase without authorization, the company could not approve it and the $100 I laid out was my responsibility. Translation: I was out of luck. I asked to speak to a supervisor and, after being serenaded by a lovely Musak rendition of Elton John’s “Someone Saved my Life Tonight” (that would not be referring to the Pharmaceutical Control Company to which I was speaking), I reached one. I explained in as dispassionate a way as I could what the situation was, that my daughter was on a college campus and couldn’t wait to get the drug tomorrow, that failure to be compliant with the medication could cause her permanent visual impairment, that I understood that the big bad company computer was flagging early refills for the company to prevent drug abuse, but that common sense would dictate that as a recreational drug steroid eye drops would probably never catch on. The supervisor listened, put me on hold for one last round of Musak presents Sammy Davis singing “I Got to be Me” (which I heartily agree is a great song to hear when you are jousting with a bean-counter), then came on to tell me that the part of the story that got her was my daughter being alone on the lonely Trinity Campus in Hartford without pharmacy access (What could be more lonely??). “Just this one time,” she told me, “the company will override the computer’s warning. If you go back to the Pharmacy, they will refund your purchase minus the co-pay.” Perhaps she thought I would break down and cry over the generosity of this decision. Since a total of over 2.5 hours had elapsed since I first called in the scrip for the 5cc vial of this witches’ brew, I did not feel particularly grateful. But taking a cue both from my daughter, who discouraged me from “flaming out,” and from Harry Chapin’s “Taxi” where he talks about how “…another man might have been angry, but I stuffed the bill in my shirt,” I merely said my thanks and dropped my daughter off at her dorm. We said goodbye and she ran off to her tutorial yelling, “Sorry about the hassle!” as she hurried off… I drove the long way back to Worcester thinking about the days when my father-in-law, who ran a small-town pharmacy in Western Massachusetts for almost 40 years, would have fielded a problem like this. He would have known that there was no possibility that we were up to no good by asking for a refill of eye drops a day early. If the insurance company had hassled him, he would have given us the drug and submitted the bill with the insurers the next day so that the claim would have been approved. I drove straight back to the drive-thru window and discovered that the pharmacist who served me earlier was already off. I explained what had transpired to a new pharmacist. He reprocessed the prescription and found that this time, the insurance claim was indeed approved. I received an $85 refund. After all this commotion and discussion, I arrived home full of satisfaction that I had beaten “The Man.” I just had to call and tell my daughter that all the awful posturing and verbal sparring had yielded some positive results. She replied, “Wow, Dad, strong work. This was probably good for you to see what your patients have to go through with worse insurance and less medical knowledge than you.” Don’t you hate it when the kids show more wisdom than their parents? Maybe their generation will be able to undo all the crazy things we’ve put into place in our health care system to prevent eye drop abuse. Financial
Advice for Physicians: Using Technology and On-Site Care, a Local
Company Helps Seniors Remain in Their Home: Introducing Dovetail Health In recent years, PIAM has developed more and more resources for physicians looking at issues associated with retirement and aging. Recently, we had the pleasure to meet with Steven Aubrey, President of Dovetail Health, and with Medical Director Michael Cantor, MD, JD to discuss the new company. Physicians understand that most seniors want to remain in the home as they grow older. Many medical conditions and their complicated list of medications can make that goal a challenge. This problem is exacerbated as adult children get squeezed between raising their own children and caring for aging relatives. Data from the AARP indicates that nine out of ten Americans age 60 and older wish to remain in their own homes and communities as they age. Needham-based Dovetail Health was launched earlier this year to help seniors live independently at home as long as possible by personally monitoring and managing their health and medication needs. To help seniors stay in the homes they know and love, Dovetail Health has developed an in-home care management model that takes into account the reasons seniors often have to move into care facilities ~ medication errors, deteriorating chronic illnesses, and falls and injuries. The result is a service that combines personal care with easy-to-use technology. Starting with a thorough in-home assessment by a registered nurse, Dovetail creates a comprehensive, personalized care plan for each client’s health and medication management. The nurse remains at the heart of the Dovetail care team throughout the year, calling clients regularly and performing at least six in-home follow up visits. Dovetail clients also work with a licensed pharmacist who will come to their homes and is available by phone to help them understand their medications. Personal assistants are also available to clients by phone to coordinate these services and to provide health and lifestyle referrals that help seniors live safely and well at home. Dovetail clients and their assigned care team are also supported by simple technology from Philips Electronics, which monitors clients’ weight, blood pressure, and blood sugar. This information is reviewed by the Dovetail nurse every day, helping her assess client progress and detect problems before they become emergencies. The in-home device is also tailored to send messages, health and wellness tips, and reminders to each client about his or her medications, exercises, and other health-related needs. “Long-term care has traditionally consisted of two options for older adults ~ move in with a family member, or move into a nursing home,” said Leslie Hoyt, Chief Care Officer, Dovetail Health. “But today’s seniors are living longer and they want the same level of choice and independence that they’ve had all their lives. This is what Dovetail Health will help provide.” The company does not take the place of older adults’ physicians or caregivers, including their adult children. Instead, through telemonitoring and personal contact from the care team, Dovetail strengthens these relationships by collecting and summarizing valuable information about a client’s health needs and status. With client approval, Dovetail shares this information with designated providers and caregivers, helping them to remotely and confidently monitor the older adult’s well-being. “With Dovetail, everyone benefits,” said Stever Aubrey, CEO and Managing Partner, Dovetail Health. “Seniors stay healthy and are confident about their decision to live at home. Their children feel less worried, and their doctors get the information they need to make informed care decisions.” Dovetail Health hopes to make it possible for seniors to fulfill their desire to live independently in their later years despite certain health conditions. The company has created a new way for seniors to remain in their own homes with hope and dignity. For many, this will defer the need, worry and expense of moving into a senior care facility. Dovetail’s Clinical Advisory Board is made-up of the following physicians: Juergen Bludau, MD, Geriatrician Len M. Finn, MD Richard Dupee, MD Alejandro Mendoza, MD Kim Saal, MD Michael D. Cantor, MD, JD, Medical Director PIAM, a subsidiary of the Massachusetts Medical Society, is currently working with Dovetail Health to help make their services available to Massachusetts physicians, their families and patients. For more information please call Dovetail Health at 866 566 DOVE (3683). In Memoriam: WDMS Remembers its Colleagues George Rodgers Dunlop A distinguished surgeon and engaging man, George Dunlop has departed us. We shall not see the likes of him again. George was born on March 31, 1906 in St. Peter, Minnesota. His family later moved to Cincinnati, Ohio and he was fond of telling how awestruck both he and his father had been as they watched the first motor car come along their street one day amidst the horse-drawn vehicles that were soon to be no more. Throughout his life, those of us who were fortunate to know him heard George passionately tell of his upbringing. He conveyed it with gratitude for its supreme qualities of family and ideals. Many of us listening to our friend tell of those times found ourselves wishing we had known his parents, or even wishing we had been born in those days, a tribute to the descent he had been privileged to have and to his eloquence in reciting it. After medical school, George trained in surgery at New York Hospital-Cornell Medical Center and was an immediate standout. His skills became legend and, in an era in which surgical specialization was then becoming a new career option, it is fitting to recall that he was among the last of that “top breed” ~ what was then called a general surgeon, one whose skills were so great that he was the surgeon to summon for virtually any case imaginable. When George came to Worcester he was among the first in the 20th century to bring here the highest caliber of surgical training. He understood that residents and fellows were the precious future of the profession and he loved teaching. In short order he became Chief at our Memorial Hospital and took Surgery there to a new level. He subsequently was elected President of the American College of Surgeons. But while on the zenith of his career, on the national heights, he never forgot his beginnings in Minnesota and Cincinnati, nor his beloved Worcester. George was an early advocate of the then-controversial idea that the University of Massachusetts might open a medical school and was among those who fought for Worcester as its location. He was also a surgeon who knew what basic biological science could offer to medicine and, toward that goal, he was a catalytic trustee and Chairman of the Worcester Foundation, championing the cause of its scientists who were delving into the cell and its molecular biology. Many of us who knew George socially, as I did, joyfully encountered a man whose commanding presence went beyond his medical stature. He was a brilliant raconteur who deserved, and got, riveted attention. Never boastful but always in control, George’s stories and “teachings” were simply too wonderful to ever elicit anything other than profound admiration. There were some among us who had differences with him on politics but I know of no one who ever took offense at his strongly argued views. He did not look down upon those with whose opinions he disagreed, but looked them in the eye and tried his best to argue his case. No one ever looked away. Sometimes in the company of George Dunlop we, his friends and colleagues, felt like a piece of music should be playing as he walked in, so attractive was his bearing. Perhaps something like Beethoven’s majestic “Consecration of the House.” George Dunlop truly consecrated medicine in Worcester. In his way, he also consecrated us. We shall be forever in his debt, and his memory will long be remembered in this house. By Thoru Pederson, PhD
Richard A. Gleckman, MD His intense gaze marched along the row of nameless ice cream containers perched along the desk’s edge, and after peering a long moment at the last, he rubbed his narrow chin, furrowed his bushy brows and pursed his lips. “The first controlled trial of ice cream supremacy is now closed,” crooned one of the medical residents. The VA house officers standing to either side of lanky Professor Gleckman laughed approvingly. “This is harder than I thought it would be,” Dick murmured. “But worthy of scientific inquiry, Dr. Gleckman, no?” Wincing, Dick Gleckman nodded. “If you’ve taught us nothing else, Dr. Gleckman,” observed a resident, “you’ve taught us to be skeptical of senior physicians who answer every question with the vacuous phrase, ‘In my opinion...’” “Yes, you’ve been incredibly passionate about the importance of controlled trials in expanding medical knowledge..” “Or,” interrupted another, “in supporting claims…claims about patient care or…” ~ here the resident grinned mischievously ~ “…or claims about the best ice cream in Boston. You’ve told us over and over that the Ice Cream Works makes the best vanilla in Boston. Well, here’s your chance to prove it once and for all…scientifically.” “But,” Dick protested halfheartedly, “I didn’t realize there were so many varieties of vanilla…” “The time for data collection is over,” someone shouted. “You’ve tasted each of the ice creams…twice.” She paused before adding, “Time to select, Dr. Gleckman.” Dick shook his head slowly, perhaps unsettled by the thought of choosing one of the commercial brands. He raised his arm and extended his index finger, but before pointing to any of the containers, he glanced right and then left at the bright, expectant faces. And then he smiled broadly, pleased to see his passion for critical thinking and scholarly inquiry ~ and his own playfulness ~ lighting the expressions of the physicians-in-training. “Well,” he said slowly, “I see several design flaws…” ~ the residents groaned with resignation ~ “…and I don’t think the results will be statistically significant…” XXXXXXXXXXXXXXXXXXX Dr. Richard A. Gleckman died at his home in Worcester on February 22, 2007 of gastric cancer. An AOA graduate of Tufts University School of Medicine, Dick interned at Walter Reed Army Medical Center and subsequently served as a Captain in the US Army Medical Corps. He completed his medicine residency at University Hospital in Boston and the Wadsworth VA Hospital in Los Angeles and his infectious diseases fellowship in Boston. Between 1979 and 1990, Dick was on the staff of Saint Vincent Hospital, where he served as the Director of the Division of Infectious Diseases and the Chief of Medicine; he was also a Professor of Medicine at the University of Massachusetts Medical School. Dick authored over 150 publications and several infectious diseases texts and over his career held academic appointments at Tufts, Harvard, Boston University and Mt. Sinai Schools of Medicine. During his tenures in Worcester and beyond, Dick was recognized as a savvy diagnostician, a mentor to students and residents, a beacon of integrity, a vocal advocate for quality and compassionate patient care, and an uncompromising champion of scholarship. And while Dick certainly took pride in his exemplary professional accomplishments, his abiding love ~ which he unfailingly displayed in measures large and small ~ was for his wife, Brenda, his children Emilie, Philip and Aaron, and his grandchildren. By Anthony L. Esposito, MD Society Snippets: 2007 Call for Nominations Take a moment, nominate a deserving colleague. To nominate an individual please include:
Awards Available 17th Annual Dr. A. Jane
Fitzpatrick Community Service Award 2007 WDMS Career Achievement |