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Worcester Medicine
President's Message
Editorial
Can't We All Get Along?
Communication Expertise: What is it? And How Can We
Develop it?
Complex Expectations: The Patient/Physician
Relationship
A Learner's Perspective on the Value of the Humanities
in Medicine
Creative Writing Legal Consult Financial Advice for
Physicians Off Call Humanities in Medicine
A Message from the Executive
Director We hope you like Worcester Medicine's 'new look' that is partially supported by the Louis Albert Cottle, MD Trust Fund. A generous bequest from the Louis A. Cottle Trust was received in 2007 allowing the Worcester District Medical Society to sponsor an annual lecture series in memory of Dr. Cottle, a dedicated Worcester physician, and now lend support to the publication of Worcester Medicine. Louis Albert Cottle was born in Somerville on March 6, 1874, graduated from the University of Pennsylvania Medical School in 1890, interned at St. Joseph Hospital, Providence, RI in 1899-1900; interned at the Boston City Hospital 1900-1901. In 1902, he came to Worcester Emergency hospital at 50 Orange Street where he remained as President of the Corporation until his death. He was associated with Dr. Alston H. Lancaster in the same offices and building for forty-eight years. He was staff physician at Fairlawn Hospital for twenty years. He married Olive S. Davis of East Douglas in 1940, and made his home there. Dr. Cottle died on June 21, 1950 and burial was in Salem, MA. President's Message I am proud to serve as President of the third oldest district medical society in the country, established in 1794 when forty one physicians attended the first meeting at the United States Arms Hotel in Worcester. Thirty five came on horseback. I have been a member since I was a medical student at UMass. We are now 1,600 members strong. We are recognized as the most active district medical society and have been told we serve as a role model for the other nineteen districts. We are proud of the distinction of being the only district medical society in MMS to be accredited to sponsor continuing medical education programs. As President, I look forward to remaining active in the community and to a continued partnership with the UMMS, its Library, the Department of Public Health, the MA College of Pharmacy, the oral health initiative, and many other organizations in the medical community. I commend our committees for their hard work: the Scholarship Committee distributed $39,000 in awards amongst twelve medical students from Central Massachusetts this past year, the Rx Fund continues to offer patients of WDMS members help with medication during periods of transition, “Health Matters,” our cable access TV show, will be celebrating its 100th show this month, and kudos go to a great editorial board and to our editor, Dr. Paul Steen, for their great work with Worcester Medicine. I’ve just named only several of many outstanding accomplishments; please take a few minutes to read the annual report in your packet to learn what else WDMS has been up to. Our Alliance is very strong and active in the community. Most recently, they have been frontrunners in supporting legislation for seat belt laws and both anti-smoking and antiviolence campaigns. Through their volunteer work, they strive to make a positive impact on the health of the community. Bruce Karlin has done a lot of work over the past two years and has been a wonderful mentor and friend. I will not repeat all his projects, but I want to reassure you that they will be carried on into the future. Among the issues I am particularly interested in addressing over the next year are: Violence by intimate partners is the leading cause of injury for women, responsible for more injuries than car accidents, rape and muggings combined. A woman is in nine times more danger of a violent attack in her home than on the streets. We need to do a better job of screening our patients for domestic violence and when necessary help them obtain the assistance they need. Primary Care must be a priority. Bruce has already set the wheels in motion, working with UMass and the Myers Primary Care Institute. These collaborations must be continued. Diminishing reimbursements, aging baby boomers, and the high cost of medical school have all contributed to the problem. Demand for adult medicine is almost insatiable. We have a population that's growing older and more complex and has no one to take care of them. The Alliance has been working with the Elm Park Community School for the past three years on promoting healthy eating and exercise, and they would like to expand their project to include more schools in the Worcester area. There are growing concerns that obesity is disproportionately affecting those who are least able to afford medical care: children covered by public health insurance such as Medicaid.
With the downturn in the economy, the Free Clinics are seeing a lot more patients. Last Tuesday, St. Anne’s saw 82 patients, many of whom have recently lost their jobs and with them, their insurance. Please indulge me while I tell you a story. The patient showed up after the clinic had closed. The door was locked and I just happened to be walking by and saw the young woman standing outside the door crying. She wasn’t knocking on the door trying to get in, she was just standing there crying. I opened the door and she begged me to let her see a doctor for just one minute. She said she had insurance but she didn’t know where to go. We sat down and she said she was sorry to be late but she was working at Wal-Mart and she had to work overtime or she would lose her job. They need the MNA in there. I asked her how I could help her and she told me that she had been bleeding vaginally for 6 months. She had been waiting for 4 months for an appointment with a gynecologist and someone called her the day before her appointment and said they didn’t take her insurance and she’d have to see another physician. She had a list of physicians with her and she just wanted to know to which she should go. The next day I called Alan Albert, who always said he would see any free care Gyn problem. He saw her the same day and called the next day and said her hematocrit was 8. I laughed and said, “You mean her hemoglobin,” and he said, “No, I mean her hematocrit.” The poor lady was working with a hematocrit of 8 and taking care of two small children and her biggest worry was losing her job and not being able to feed her children. Sadly, she had ovarian cancer and died a few weeks later. I want to call on all of the medical staff to consider volunteering at one the Free Clinics. If you are unable to come to the clinic, please consider seeing some of the patients in your office. There is a huge need for subspecialty care. Martin Luther King said, “The time is always right to do what is right.” And that time is now!! I’d like to end with a short poem by a physician in the 1800s: The Human Touch Thank you for your attention. Now, for the moment that you have all been waiting for… Editorial:
Physicians, Allied Health Professionals, Patients, and Society: "Can't We
All Get Along" This edition of the Worcester Medicine (WoMed) grew out of an interesting series of publications in a decidedly more famous print journalism vehicle than ours, the prestigious New York Times (NYT). On Dec 2, 2008, in their Health Section, the NYT did 2 stories about the bad behavior of physicians. First, Laurie Tarkan submitted an article entitled “Arrogant, Abusive, And Disruptive ~ and a Doctor.” The piece was based on a report from Dr. Alan Rosenstein, the medical director of the West Coast wing of a non-profit hospital alliance called VHA West, that 67% of respondents from over 100 not-for-profit hospitals from 2004-2007 said that there was a link between such abusive behavior and medical errors. The Joint Commission cited in this article seemed to confirm that the bad behaviors were prevalent enough for them to mandate that hospitals have a clear policy and procedure as to how to identify and remediate such abuse. Tales of fist fights between MDs and of verbal abuse of nurses by MDs were titillatingly recounted. More sobering was the implication was that this behavior promoted medical errors and poor patient care. On the same day, the NYT published a story entitled “The 6 Habits of a Highly Respectful Physician” by Dr. Michael Kahn, MD, in which he recapitulated his New England Journal of Medicine (NEJM) submission of 5/8/08 entitled “Etiquette-Based Medicine.” The crux of this article was his observation that now that safety checklists were taking root every time doctors were about to perform procedures on a patient, so too could a behavior checklist be used to ensure a professional interaction during patient-physician encounters. I have listed below the behaviors recommended by Dr. Kahn: 1. Ask permission to enter the room; wait for an answer. 2. Introduce yourself, showing ID badge. 3. Shake hands (wear glove if needed). 4. Sit down. Smile if appropriate. 5. Briefly explain your role on the team. 6. Ask the patient how he or she is feeling about being in the hospital. A quick glance at the list would leave most people skeptical or incredulous that these actions are somehow not automatically part and parcel of the patient encounter and already deeply ingrained in the bedside manner of any physician. When I brought these articles to the attention of my colleagues at WoMed, they agreed these issues swirling about medical practice these days were worthy of a deeper discussion; hence we have this May-June issue. As is the case with many of the topics we cover in our publication, the local medical community and the patients we treat have much to be proud of, as once again Central MA has shown itself to be way ahead of the curve. You will learn in this issue why these behaviors have reared their ugly head and about some of the innovative programs to promote better professionalism and rekindle the humanism that most of our medical students possessed on arrival to medical school. You will also learn about some of the remedial programs available for medical staff identified with deficiencies of professionalism, humanism, or communication skills. In a medical world where almost 1/2 of North American medical schools have found it necessary to promote humanism in their students by joining and electing these students into a national humanism in medicine society, the Arnold Gold Society for Humanism in Medicine, we physicians must come to realize that the basic 6 behaviors described by the NYT are no longer intrinsic or natural to many of our 21st century med students. It may be a sad commentary about society today, but this edition should provide our readers some comfort that proper behaviors and professional/humanistic approached to patient care and team interactions can indeed be taught, and need to be as much as any other skill we impart to these future MDs. “Monitoring
Competence and Enhancing Performance: Effective Ways to Support the
Practicing Physician” - A Summary of The Worcester District Medical
Society’s 213th Annual Oration Delivered to Members and Guests on February
13, 2009 References to medical care found in documents from Mesopotamia and Egypt confirm that political leaders 4000 years ago were concerned about the competence of the physicians serving in their communities. When a physician decided to treat an illness or injury, he was compensated for a good outcome, but he might be punished for a bad result. Since the consequences following a poor outcome (possibly the loss of an eye or a hand) were harsh, physicians of these societies were probably very aware of the limits of their ability. During the 6th century BC, Hippocrates and his Greek contemporaries proposed that good medical care required that the physician treat his patients with respect, and that in turn it was likely that the patient would be respectful of the physician. These examples of ethical standards of the medical profession, and the sanctity of the physician-patient relationship, emerged from the philosophic teachings of Hippocrates, and remain as the expected behavior of the medical professional to this day. Over the last 30 years, the technology available to help the physician diagnose illnesses and injuries has expanded dramatically. The number of available treatment options once a disease or injury is detected has also increased. In many cases, several therapies are considered acceptable even though the clinical results may be similar for the patient in the final analysis. The pace of medical discovery has increased at a rate that often exceeds the ability of the busy practitioner to maintain his/her competence, based on benchmark outcomes data for his/her chosen field. In addition, payers and politicians have electronic access to data describing treatment innovations (sometimes yet to be fully tested) and to data about expected outcomes from the “latest” treatment they should be receiving for their medical condition. Accrediting bodies and lawyers are constantly seeking ways to identify physicians who do not achieve the best possible outcomes, are not using the newest in available equipment, or who prescribe medications in the manner their “experts” view to be less than optimal. While trying to maintain a stable family or personal life, the contemporary practitioner is typically overworked and feeling harassed by administrators and payers. In such an environment, staying on the cutting edge with respect to medical knowledge and skills may easily be put off to deal with all the other pressures of practice. The recent requirement by the Joint Commission that hospitals develop a policy to deal with physician disruptive behavior as defined by the Hospital’s Board and Medical Staff is another example of increasing levels of scrutiny in which the busy practitioner must function. Addressing a physician’s own competence, while preserving the integrity of relationships with patients, are principles that are being tested in the current medical environment. An efficient way for a physician to maintain an appropriate level of competence and efficiency throughout his/her medical career is to adopt the mindset that time must be set aside and a commitment made to participate in a culture of continuous professional development. This commitment should be made along with the members of his/her medical practice staff and and with medical partners. The culture of continuous professional development involves a number of steps including:
A learning technique that appears very promising for busy practitioners seeking to bridge specific gaps in knowledge or professional skills is the Medical Education Theater. This novel educational teaching utilizes professional actors, computerized mannequins, and theatre-style “sets” to demonstrate to learners proper and improper ways to assess and treat patients in “familiar” surroundings. After observing commonly occurring medical care errors as demonstrated by actors, the physician or team members can “step into” the scene and be examined by a master physician educator as he/she performs a difficult task, like informing a patient that he/she has a incurable medical condition, or telling a child that the time has come to arrange for constant supervision of a here-to-for independent parent. In addition to participating in a carefully constructed mock physician-patient encounter, the learner can be taught the use of contemporary treatments that have been shown to improve outcomes. The physician and his/her team can also be coached on how to function most efficiently, in a patient friendly manner under a variety of circumstances. As skits are developed, input from patients and patient advocates should be sought to ensure that good quality care leads to meaningful patient satisfaction. Mannequins can be used when skits that require performance of an immediate intravenous drug to be administered are developed. Mannequins can be programmed to simulate the expected patient response to the learner’s selected intervention. In summary, patients, physicians and society as a whole all have a role in inspiring the practice of quality medical care while preserving the sanctity of the patient-physician relationship, a covenant that has held up to the test of time. A commitment by all members of the medical profession to a culture of lifelong learning has been described as a strategy that should support the achievement of highly acceptable outcomes in humane and caring environments. The development and testing of novel educational techniques (such as this Medical Education Theater) to achieve these goals must be encouraged and should receive the support of patients, government, regulators, and the medical establishment. Research in medical education will help to identify effective techniques to assist the busy practitioner in improving the care provided to his/her patients. Communication
Expertise: What is it? And how can we develop it? Expert physicians and other health care providers certainly must be knowledgeable in their chosen specialties. They must know what they are talking about. But they must also know how to communicate with people. Communication is the process of attributing meaning to your own experience and sharing that meaning with others. Doctors bring a great deal of medical experience and training to the patient encounter that must be shared ~ but so do the patients and their family members. The latter bring the experience of illness, related concerns and fears, and impact of the illness on all of the lives involved. Mutual sharing of experience must occur and be appreciated if communication is to be productive and satisfying. The complexities of modern medicine and everyday life lead to major challenges in the communication process. Technology must be explained in caring and culturally sensitive ways to patients who have unique personalities, literacy levels, hidden concerns and fears. The expert must then effectively communicate with other members of the health care team, various medical consultants, and possibly insurance representatives, pharmacists, social workers, etc. This is a tall order for the expert physician communicator who, in general, has less time with individual patients than ever before. The benefits of expert communication are becoming increasingly clear. There is evidence in medical literature that effective communication ~ between physicians and patients and among clinicians and staff ~ leads to increased patient satisfaction, greater adherence to medical regimens, and better medical outcomes. In addition, the risks of medical error and malpractice are significantly decreased. Most importantly, there is mounting evidence that physicians and other healthcare providers can, with attention and practice, develop expertise in communication, thus improving the quality of health care they deliver. An evidence-based approach to the practice of medicine suggests that healthcare organizations of any size can create a culture of quality and expert communication by focusing on their communication needs, tailoring educational interventions to meet those needs, and continuously assessing communication outcomes. The Center for Clinical Communication and Performance Outcomes (3CPO) has been working with medical students, residents, nurses and physicians to foster such a culture at UMass Memorial Health Care and the Fallon Clinic in Worcester, and with other organizations throughout Massachusetts and the Northeast United States. We conduct communication training programs for all types of health care providers within hospitals, group practices, and health centers. With Surgical faculty at UMass, we train surgical residents in expert communication and other non-technical skills within a highly innovative ”Human Factors” curriculum. A hallmark of our programs is encouraging learners to practice “real cases” with our communication coaches. We also mentor individual physicians who either self-refer or are referred by their organizations.because they have difficulty communicating with patients or colleagues. The first step in all of our programs is to define communication expertise and to help learners use it in everyday life. We break down expert communication into component parts such as anticipation, reflection, and perspective-taking. Experts monitor and manage their communication through planning and regulating communication during the interaction and then by reflecting back afterwards to revise and develop future practices. Expert communicators constantly monitor their communication by providing “real time” monitoring and re-direction. Our programs focus on the development of specific skills such as listening, which consists of many behaviors that allow the patient (or team member) to share his or her experience or story. The behaviors include asking open questions, summarizing to get the story straight and, perhaps most importantly, letting the patient talk. Listening for, and addressing, emotional clues that the patient provides appears to be particularly challenging for the physician. Addressing patients’ clues not only leads to greater satisfaction, but also actually saves time in the interaction and will lead to increased patient satisfaction and better medical outcomes. We also focus on expert communication at the team level where physicians must function as effective team members, leaders, patient advocates and system representatives to ensure the delivery of high quality healthcare. There is evidence that suggests team members often view and value each other very differently. How one perceives his or her role and the role of others on the team is critical to effective communication and might be the best place to begin a cultural awakening in our healthcare organizations. This will set the stage for focusing on communication skills like negotiation and conflict resolution, delivering and accepting effective feedback to and from colleagues, and handing off patients to the next provider via discharge or shift change. At both the provider-patient and team levels, the ability to listen and understand the patient, family, or team member’s perspective, reflect on and assess one’s own communication deficiencies and biases, and establish a self-improvement plan are all key ingredients to communication expertise and quality healthcare These skills can be practiced and, more importantly, become an expectation within the culture of the healthcare delivery system. Healthcare providers work within complex organizations; achieving desired performance outcomes requires a commitment to care, cultural sensitivity, and effective communication networks that include all stakeholders (e.g., referring physicians, patient groups), leadership and teamwork. Our Center for Clinical Communication and Performance Outcomes at UMass Medical School is eager to foster communication expertise for health care providers in Worcester and throughout Central Massachusetts. Mark Quirk, Ed.D., is Professor in the Department of Family Medicine and Community Health, Assistant Dean at the University of Massachusetts Medical School, and Director of the Center for Clinical Communication and Performance Outcomes Complex Expectations:
the Patient/Physician Relationship Talk with any group of people of a certain age who most likely have experienced a number of interactions with physicians over their lifetimes, talk with parents of young children who have had to see a pediatrician for issues more complex than the usual childhood illnesses, and ask them about their experiences with the doctor’s office or in the hospital; no one is at a loss for words. Ask physicians about their perceptions of patients these days, and you’ll find a similar need to talk about what seems to have changed about the patient/physician relationship. Patients, their families, and physicians are passionate about the subject. They often ask, “What’s the matter with doctors/patients today?” Having mediated patient complaints about physicians, and physicians’ complaints about “difficult” patients, for the last thirty years, I am finding that the expectations each group has of the other have become more complex. Patients and their families are less in awe of the physician because of a number of factors: television shows about sometimes dubious medical practitioners, reports in the media on the frequency of medical errors, the high profile of regulatory agencies which patients consult about medical complaints, stories from family members about their difficulties with medical care, and general distress over the cost of medical care, insurance and co-pays. Because of fear of litigation, a basso continuo in the practice of most physicians, physicians may see patients as potential adversaries. Because patients are less in awe of the world of medicine as a whole, too, they are more apt to question an individual physician’s competence and plan for treatment. From the patients’ and parents’ perspective, they are dealing with the highly stressful notion of putting their welfare, or their child’s welfare, in the hands of a stranger. They feel they have the right to compare a physician’s recommendations with those they find on the internet and then quiz the physician about any disparities. When I asked a neighbor recently about his experience with medical care for his kids, he said that it can be a “gut wrenching experience.” As a parent, he feels deeply that it is his role to protect his child from harm. Even though he knows rationally that a pediatric surgeon, say, is there to perform surgery to help his child to recover from an illness, it goes against his deepest feelings to trust a stranger with the life of his child. He said, “Of course you do your research and try to find the best person you can, and then go forward, but it is extremely difficult. It’s not that you don’t trust all physicians, it’s just an awfully frightening experience.” He said he understood why patients and parents go to the internet to do their own research so that they can ask intelligent questions. He’s done it himself. He said he could also understand how physicians can be taken aback by seemingly disrespectful questioning, but, “Like everything else, it’s all a matter of attitude and approach. Some parents are just jerks. One can see it even on the soccer field.” The research my neighbor mentioned often baffles physicians, even if it is put forward in a respectful way, since they see much of it as a clear sign of a lack of confidence in their competence, a lack of appreciation for their years of study and training. Patients and parents look at it as informing themselves as best they can about what they may be up against in a potentially life threatening experience. They feel they know more about medical risks from the internet and they are going to use that knowledge to help them evaluate their choices. They would proceed the same way with other life decisions. Physicians, under more pressure than ever to use their time efficiently, may look at internet or media inspired questions as, at best, a waste of their time, asking themselves how a patient can reasonably believe he can understand the intricacies of a procedure which takes a physician years to perfect. In his editorial, Dr. Hirsh mentions an article by Dr. Michael Khan in the New England Journal of Medicine that recommends a behavior checklist to be used by physicians to ensure a professional physician/patient encounter. Most physicians would think they follow these behaviors automatically when they meet a patient and her family. They would certainly start the relationship off on the right foot. The crux of the matter comes when a decision point is under discussion and the patient or parent immediately questions it. What happens next can make or break the physician/patient relationship. From my experience hearing patients’ complaints about not being listened to by physicians, their complaints that physicians are “arrogant” and do not take their points of view into consideration, and, conversely, what physicians have to say about patients not adhering to their recommendations and asking innumerable questions formed from dubious sources, I think that the following approach can lead to successful discussion and decision making and create a solid physician/patient relationship. It is important for the physician to acknowledge to herself the feelings of irritation and impatience the doubting patient can inspire. When one knows how to do something well in any field, it is natural to feel annoyed when a person untrained in that field does not accept one’s recommendations. One feels stalled in the middle of doing what one knows will be helpful and effective. Being mindful of those feelings of annoyance can, however, lead one to the best place to focus attention and re-start the process of creating a relationship with a patient. What in particular has made the physician feel irritated with the patient? If the patient or parent looked at a web site that the physician knows circulates incorrect and misleading medical information, I have found that the physician’s best approach is first to praise the patient or parent for researching the illness and working hard to understand what he or she is facing. When the physician takes this approach the patient often relaxes, feeling that he is being heard. He is more receptive to education by the physician. The physician can point to helpful web sites which they can review together and this helps to engage the patient in forming the treatment plan. The patient is reassured that the physician is not dismissing the work he has done to educate himself since the physician is showing his appreciation of an informed and engaged patient. Once the physician has complimented the patient or parent on his or her efforts to learn about the illness at hand, if the physician wants to propose another course than the one the patient has read about on the internet, the patient is more likely, in my experience, to accept the recommendation. Patients want reassurance and education. If the physician involves them in the process, they will likely feel they have received both. I do not think that patients are becoming more unrealistic in their expectations, which can often feel to physicians like demands, but they now have more tools with which to learn about their illnesses. If the physician shows respect for the patient’s intention to learn and participate constructively in the treatment process, then the physician’s own perspective will often be respected in turn. My colleagues and I who teach in the Physician, Patient and Society course for first year medical students at UMass Medical School certainly stress the importance of the introductory civilities Dr. Khan lays out in his article, but we emphasize that these civilities need to be carried forward during the exchange over the education about the illness and the plan for treatment. We train students to be sure to ask, “What concerns you most about your symptoms?” and, at the end of the interview, “Do you have other questions or concerns that we have not addressed?” Students understand that uncovering these hidden issues and addressing them squarely and respectfully leads to a strong patient/physician relationship of mutual respect. Patients want to believe that a physician has their welfare at heart, and once they see that the relationship is mutually respectful, they then want to adhere to the physician’s recommendations. New sources of information on the internet and in the media, and new expectations by regulatory agencies, have given patients more reasons to question their physicians and other health care providers. Some patients or parents do not have the skills to do this well, and they can come across as disrespectful and even hostile. These are interactions that often end up in my office. If the physician can, however, ignore the affect and think about the reason he or she is being questioned ~ the parent loves his child and is trying to protect him and make the best decision for him, or the adult patient is fearful of disability his illness may cause ~ then there is a much better chance for the physician and the patient to work well together to achieve the patient’s and physician’s mutual goals. Susan N. Tarrant, MA, is Director of the Department of Patient Care Services at UMass Memorial Medical Center and Clinical Instructor in Medicine at the UMass Medical School. She can be reached at Tarrants@UMassMemorial.org.
A Learner’s
Perspective on the Value of the Humanities in Medicine Introduction As a poet and educator on the UMass Medical School faculty since 1997, I believe wholeheartedly in the value of humanities in medicine. We must find a way to make it possible for medical students, residents, and practicing physicians to reflect on and integrate the complexities of their experiences, to engage their creative minds, and even to step outside their roles as “MD” in order to recall their own humanity. The medical school is in the midst of a major curriculum redesign, affording the opportunity to ensure that the “Physician as Person” competency ~ one of six cornerstone competencies ~ will be an integral aspect of the curriculum alongside “Scientist,” Clinical Problem Solver,” “Professional,” “Communicator,” and “Patient and Community Advocate.” Currently, our curriculum offers a range of humanities electives and extracurricular opportunities. Medical student José Abad enrolled in the Medical Creative Writing elective during 2nd year, and designed a 4th year independent study to delve into writing medical narratives. He wrote essays on ethical issues, poetry reflecting on patient encounters and on life outside medicine, and a script for a play that grapples with the thorny interface between a patient’s culture and the “culture of medicine.” In his essay for Worcester Medicine, José offers a learner’s perspective on the value of the humanities in medicine. ~ Emily Ferrara, MA, Assistant Professor of Family Medicine and Community Health. The summer between my junior and senior year of college I stayed on campus to study for my medical school admissions test. I remember one particular day very well. I laid out a blanket under a tree on the green in front of my dorm and plopped myself and my books onto the ground. I first picked up the physics review book and started to answer some questions. My eyes began to wander and they found a small book written by poet and physician Rafael Campo in the stack, almost over-taken by the thick review books. I surrendered my scientific studying for a poem. I read about vulnerability. I read about non-verbal communication. Dr. Campo was making very clear that much was not spoken in medicine. I eventually turned away from the poem, with regret, to return to my scientific studies review, to pursue my goal of becoming a doctor. I was an English major and knew I would get to return to the humanities in the fall. It has not been until as of late that I realized my humanity is like a muscle ~ needing to be tested and flexed on a regular basis to remain strong. The simple act of enjoying a painting for its form or finding strength from writing a poem invokes a notion of commitment to communication at a fundamental level ~ an exchange of ideas (with some formality) and emotion. The humanities allow for this exchange in a permanent manner, perhaps through a piece of art or prose/poetry that is published and therefore allows for reflection. The humanities in medicine ~ more specifically the writing of medical narratives/reflection ~ allow for the physician to keep that kind of sharp acumen while also grounding the physician in the shared experience of humanity. The science taught in medical school is rigid, esoteric, and learned through experience, whereas the humanities remain open for interpretation ~ not just in the analysis but in their very creation. Therefore, the humanities allow physicians to reflect emotionally in a safe environment and allow for shared experience to bridge difficult-to-establish relationships in times of need and suffering. As part of the medicine clerkship for third-year medical students, I was required to write a reflective work. I chose to write a poem about a patient who died from cancer. All the students shared these writings as a group and saw that the emotions we felt were a common quality amongst us. We were all joyous, sad, and honored to be in the profession of healing. I returned the next day to my clinical studies stronger ~ both emotionally and mentally ~ to help the next patient I encountered who was dying. Inexorably, love and death are the truths that bind us ~ if medicine is the art and science that tries to prevent the latter and the humanities are what communicate the former, then living sustains love and the physician wards off a world without love ~ but at a price. Gibran says, “It is the bitter potion by which the physician within you heals your sick self/Therefore trust the physician, and drink his remedy in silence and tranquility;/For his hand, though heavy and hard, is guided by the tender hand of the Unseen,/And the cup he brings, though it burn your lips, has been fashioned of the clay which the Potter has moistened with His own sacred tears.” A healer is no farther than one’s own self, but a true physician can enable that healing in others. Without the humility that comes from humanity, there can be no healing, much like how the depth of our happiness comes from the void created from our sorrows. Eventually, I wised up and began to demand from myself the very same reflection that Rafael Campo enacted. It was during my senior year of college that I produced a documentary on alternative approaches to Western medicine. Rafael Campo was an Amherst alum whom I had sponsored for a poetry reading during my junior year and after what some would call begging, he was happy to discuss his views in front of my camera. I asked him, without hesitation, how poetry played a role in healing. Rafael replied that he would occasionally sneak in a few poems into a packet of information for a patient dealing with a new diagnosis. He was surprised and humbled to find out that patients returned with more questions about the poems than about their illness. I did not understand it at the time, but it seems that the humanities allowed for Rafael to build stronger relationships with his patients because they shared something, a thirst for communication and the shared experience of living. As I am about to graduate from medical school and enter my chosen profession, I find that my most valuable lifelong learning lessons come not from a scientific text book, but from the lessons that literature or the arts have taught me. In a time when physicians are often perceived as arrogant, angry, and inhumane, at a time when our profession has been turned into a business of service, we must remember that, like our patients, we too are vulnerable. We must be humbled by the shared experience represented in the arts and work towards reviving our profession’s long history of the ”art of medicine,” the humanity of doctoring. For what other profession has the privilege of being intimate with life and death? As Gibran says, “Work is love made visible.” And so, too is the work of doctoring. José Francisco Abad graduated from Amherst College with an English major. He will graduate from UMass Medical School in June, 2009 and will be a Family Medicine Resident at UC Davis Medical Center in Sacramento, CA, with a desire to care for underserved/multicultural populations. MMS Creative Writing
Contest Winner - A Lump in the Throat The discomfort started two days before I was scheduled to begin my locum tenens in the Southwest. I was sitting in the living room of the tiny apartment that had been provided me under my locum agreement, eating some warmed-over ravioli and watching CNN. Wolf Blitzer was interviewing a man with a thick Cajun accent who had lost his house after Hurricane Katrina. Suddenly, I felt my throat tighten up. I was able to breathe without difficulty, so I figured I must have gotten a piece of ravioli stuck somewhere in my esophagus. But try as I might to wash down the offending morsel, my throat still felt strange ~ like I had swallowed a large grape, or like my tie was on too tight. I had a history of gastroesophageal reflux, but this had been managed pretty well on omeprazole for many years ~ so it was hard to pin this weird sense of mild strangulation on GERD. Since I knew I wasn’t in any immediate danger, I decided to do a little digging on the internet. After about twenty minutes, I felt a sense of grateful relief sweep over me. I had found an article by a Dr. James P. Thomas on a phenomenon I wasn’t very familiar with: cricopharyngeal spasm. The symptoms Dr. Thomas described fit mine to a tee. The treatment was simple ~ a little diazepam, Dr. Thomas assured his readers, would do the trick. It so happened that my GP from back home had written me a prescription a few months earlier for diazepam, 2 mg tabs, after my back locked up on me ~ the result of some over-zealous yard work ~ and I had packed a few tablets just in case. I took one, sat back on the couch, flipped through an old copy of the New England Journal, and waited for relief. Sure enough, after an hour, I felt about 90% better ~ the Western medical tradition had triumphed! Later that night, lying in bed and staring at the cracked plaster on the ceiling, I began to feel an odd, tingling sensation wash over me. It began in the pit of my stomach, and spread like a spot of oil on a paper towel, soon extending to my legs, chest, and throat. “I’m having a heart attack” was my first thought, but I really had none of the classic signs of an MI ~ no shortness of breath, no substernal pain radiating to the arm, no nausea, clamminess, or any of the usual suspects. At 40 years of age, and in pretty good shape ~ I could jog three miles a day without breaking a serious sweat ~ an MI seemed highly unlikely. The feeling passed within a minute or two, but an unbidden thought popped into my head and nearly unnerved me: this locum tenens was a horrible mistake. Back in September, when I had signed up for the deal, two months in the tiny town of Pico, Arizona (population: 803) seemed like just the ticket. It would not only get me out of Boston’s miserable winter for January and February, it would also pay the bills and allow me to see a part of the country I had never really visited, except for a few stop-overs in Phoenix or Flagstaff. And, as a family practitioner, I figured I’d learn a lot from the ethnic mix in Pico ~ a rich hodgepodge of Anglos, Mexicans, and Native Americans from the Zuni, Cherokee and Navajo populations. But now ~ at three in the morning, in the white-walled confines of my postage-stamp bedroom ~I wondered what the hell I had been thinking. Was it really the New England winter I was trying to escape, or the whole seamy aftermath of my divorce last summer? The calls from Janet’s lawyers had stopped, thank God, as had the frosty phone calls from Jan herself. But I knew how much she blamed me for the break-up, and for the bleak and fruitless decade we had inflicted upon one another. By 8 a.m., Dr. Thomas’s benzo-magic had worn off. Once again, my throat felt stopped up and swollen. I was beginning to doubt my self-diagnosis, and wondered whether some huge, malign tumor had blossomed in my gorge overnight ~ not the thoughts of a Harvard-trained physician, I knew, but my sodden brain was no longer attuned to the vibrations of Western science. By ten o’clock, I was sitting in the cramped, fiberboard-paneled waiting room of the very doctor I was supposed to be helping out in another day, leafing through year-old copies of National Geographic. The intake nurse ~ a rotund young woman whose features had a strong Native American cast ~ raised her eyebrows and shrugged when she read the word “Physician” on the screening form I had filled out. “So,” Dr. Adsila Lawrence said with somewhat strained levity, “I see that my locum has arrived a day early! I have a feeling that’s not a good sign.” Dr. Lawrence was a trim, compact woman with jet-black hair who looked to be in her mid-30s. Her crisply pressed white coat was set off by a large turquoise necklace that formed a sunburst pattern. Her furrowed brow and tight smile gave the impression of someone trying to master her own discomfort upon seeing her would-be partner in this embarrassing predicament. “Honestly, I really feel kind of silly,” I said, extending my hand for what I hoped was a sufficiently reassuring collegial handshake. “I had this weird lump in my throat last night ~ figured it was just a muscle spasm and took a little Valium. It went away for a few hours, but now, it’s back like a son-of-a-bee. Feels like I swallowed a damn golf ball. Sorry to make my medical debut as your patient, Dr. Lawrence!” Dr. Lawrence smiled, and I was suddenly aware of the dark, complex colors of her beauty. Although her facial features might have been described as “Oriental,” I imagined that somewhere in her family’s bloodlines were the first native peoples of the desert Southwest. Months later, in the comfort of my Cambridge study, I discovered that the name “Adsila” means “blossom” in Cherokee. “Well, Dr. Bremer, I’m sure you would not make this kind of debut unless the situation were serious! I can certainly take a look at your throat ~ we might end up getting a barium swallow or sending you up to Flagstaff to get ‘scoped. But, well, why don’t you tell me some more about how all this began ~ and uh, anything else that might be going on in your life these days.” I have to confess, I was a little miffed at the implication that my condition might be related to unspecified “goings on” in my life. At this point, I was fairly sure that some kind of primary esophageal problem was the culprit, or maybe something exotic like de Quervain’s thyroiditis ~ even though, as best I could recall my thyroid lectures, de Quervain’s was accompanied by constitutional symptoms like fever and malaise, which I certainly wasn’t experiencing. For twenty minutes, Dr. Lawrence listened to my story. I felt as if her soft, brown eyes were opening like wells, drinking in the sorrows of this last miserable year I had spent in Boston: the sorrows of a marriage coming to bitter nothingness, the sorrows of Iraq, the sorrows of the poor bastards who lost everything in Katrina, and the knife-stab sorrow of the custody battle that cost me my eight-year-old daughter Rachel, “…with the exception of visitation rights no less than twice, but no more than four times per month, under conditions to be negotiated as per the best interests…” By then, I was holding my head in my hands and sobbing softly. I felt the tug of a warm sea of loss and yearning, and had no idea where this strange current was carrying me. “I guess I should never have come out here without getting my head screwed on right first,” I said miserably. “You know what?” Dr. Lawrence said, leaning forward in her chair, and placing her hand on mine. “I still have this nice, Anglo last name, ’Lawrence.’ But I don’t have Mr. Lawrence anymore. I was a total wreck for two years.” By then, the lump in my throat had melted like a life-saver in hot tea. “You know, I don’t think I’m gonna need that endoscopy in Flagstaff,” I said. “Will tomorrow work for getting started on my locum?” Legal Consult: Getting
Along Through Clinical Integration Competition is a fact of life in the health The Federal Trade Commission has allowed physician
joint ventures where physicians share substantial financial risk, and has
stated that a joint venture that features “clini The The FTC does permit physician network joint contracting
ventures without such financial risk-sharing if they pass a two-part test.
First, the network must achieve sufficient integration to demonstrate that
the venture is likely to produce signifi The The program requires a number of commitments from
physicians. They must agree to participate in all payer contracts
negotiated by the program and The FTC evaluates the level of physician network
integration in terms of the physicians’ signifi The FTC accepted the The non-exclusive nature of the network makes it
possible that physicians contracting outside the network could engage in
unprot Although the FTC’s advisory opinion makes it clear that
its approval of the Financial
Advice for Physicians: Mortgages:
Taking Charge
of Your Practice’s Malpractice Program The incidence of malpractice claims has stabilized in recent years. Although claim severity has inched upward, malpractice premiums have also been relatively stable since 2005. If the number of malpractice claims and premiums has stabilized, then why are malpractice costs still a problem? The fact is that many practices are still reeling from the large premium increases that took place between 2000 and 2005, when the carriers were experiencing financial difficulties. Many specialties are now paying malpractice premiums that are more than double what they paid in 2000. Adding to malpractice premium woes, many of the credits and dividends that once softened the effect of higher rates have all but disappeared. The net result is that high premiums, combined with increasing operating costs, are a major concern for medical practices throughout Massachusetts. When it comes to malpractice insurance, too many practices assume that their only role is to pay the invoice. This is a big mistake. Taking control of your practice’s malpractice program does require some work and in the end, it may not always result in financial success. Yet a surprising number of practices can and do substantially reduce their malpractice costs once they start looking deeper, asking questions, and making decisions. A significant part of taking charge is gaining knowledge about your coverage. The place to start is making sure your malpractice premiums are correct. The policy face sheet or Declarations Page provides little insight about how the bottom-line premium was determined. Here you will need a skilled ally ~ typically a broker who knows malpractice insurance thoroughly and can do a policy and cost analysis. The skilled broker will also look for policy errors which can be very costly and are far more common than most people realize. Understanding your practice’s hidden strengths can help lower malpractice costs. A good claims history is like a good credit rating. As you know, when seeking a mortgage, customers with an excellent credit rating are in a stronger bargaining position. The same holds true for practices that have good claims experience ~ they will have a much better chance of lowering their premiums. A good claims history will also open up opportunities to consider alternative carriers. You should look into the new Modified Claims Made coverage that has recently become available in Massachusetts. Last year, the Connecticut Medical Insurance Company (CMIC) developed a new type of malpractice insurance called MQI, created for groups of three or more physicians with superior claims histories. This coverage has the “tail” costs built in, similar to occurrence, and can also provide coverage for prior acts. With Modified Claims Made coverage, physicians never have to pay for a tail. MQI premiums tend to run on average about 30% less than typical occurrence malpractice rates for most specialties. The combination of pre-paid tail and lower premiums is a great fit for practices looking to lower their malpractice costs. In the end, the practice that takes control of its malpractice program will be the one that spends less and gets more for its hard-earned dollars. Let that practice be yours. For more information or for a review of your policies, please call PIAM at (800) 522-7426 or go online to www.piam.com. Jack King is President of the Physicians Insurance Agency of Massachusetts. Off Call:
My “Retirement”
As A Master Gardener As a lifelong gardener (OK, it’s only been 55 years of gardening), I was searching for a way to make my passion a major part of my retirement. I discovered (via the internet) a great gardening program that has indeed become the major component I was looking for: the Master Gardener Program was created in the late 1970s by land-grant colleges as a supplement to their own information services to the public. It has grown from a handful of states to all 50 states. In Massachusetts, there are currently four programs: 1) Western Massachusetts Master Gardener Association, 2) Massachusetts Master Gardener Association (formerly run by Massachusetts Horticultural Society), Barnstable County (Cape Cod) Master Gardeners and 4) Boston Natural Area Master Urban Garden Program. There are some ongoing discussions that might bring a program to Tower Hill around 2010. Becoming a Master Gardener requires a training program that typically involves 80 hours of classroom work spread over 13 weeks and culminating in a written exam. At this point, you have become an Intern Master Gardener. To become a Certified Master Gardener, you need to complete 60 more hours of supervised horticultural experience in education of the public. There is also a requirement for continuing education on a yearly basis. The types of activity that Master Gardeners are involved with include: holding education seminars, leading garden tours, answering questions from the public through our own call-in Help Line (617-933-4929), and staffing Master Gardener information booths at flower shows, nurseries, plant sales and other garden events. We also run a Speakers Bureau to provide educational opportunities for garden clubs and other organizations that ask for garden talks. Most importantly, we run educational projects to improve the public’s knowledge and application of horticulture principles including water-wise gardening and education on invasive plants and organic gardening principles. If you are interested in more information on becoming a Master Gardener, check out this web site: www.masshort.org/Master-Gardener-Program Paul M. Steen, MD, is a Certified Master Gardener for the Massachusetts Horticultural Society, President of the Massachusetts Master Gardener Association, and an Instructor at Tower Hill Botanic Garden
Humanities in Medicine: The Wisdom of
Wit: the Challenge of Empathy at the End of Life
“Death be not proud,
though some have called thee On January 9, 2009, at the UMass Medical School, the actress Megan Cole performed her one-woman show The Wisdom of Wit, An Artistic Portrayal of Life, Relationships, and the Human Spirit, sponsored by the Department of Family Medicine and Community Health, the Humanities in Medicine sub-committee of the Lamar Soutter Library, and the Worcester District Medical Society. Cole also met with faculty of the “Physician, Patient, and Society” course, and interacted with students before performing for over one hundred staff, students, and physicians, including members of the Worcester District Medical Society. Earlier, she performed at Fitchburg State College and met with residents at UMMHC Fitchburg. Ms. Cole’s performances were arranged by Mick Huppert, Associate Dean and Director, Office of Community Health, with support from the Library. Megan Cole’s performance, gripping and powerful, is based on Margaret Edson’s Pulitzer Prize winning play Wit, later an HBO film starring Emma Thompson. Working closely with the playwright to refine the work and explore the depths of its characters, Cole originated the role of Vivian Bearing in the play’s world premiere (1995). After winning the Los Angeles Drama Award, she composed The Wisdom of Wit, a condensed adaptation of Edson’s drama specifically designed for an audience of healthcare workers. In her solo version, Cole enacts key scenes from the play, dramatizing the mental, emotional, and psychological issues confronting cancer patients and their caregivers at the end of life. Cole has toured the country performing in a variety of healthcare venues including medical schools, hospice organizations, end-of-life/palliative care conferences, nurses’ conventions, and chaplains’ gatherings. After each performance ~ including this one ~ Cole leads the audience in a discussion of how the play exposes crucial problems in clinical care, particularly the challenge of empathy between caregiver and patient. In her moving performance, Megan Cole transforms herself into Vivian Bearing, a fifty year old English professor of 17th century literature, a highly respected scholar of the metaphysical poetry of John Donne. The play begins with Professor Bearing hospitalized for stage four metastatic ovarian cancer. Arrogant and egotistical, the professor uses her formidable intellect to prove her superiority and distance herself from others. Characteristically, she attempts to outwit the cancer itself, railing against the indignities she suffers as a patient and mocking the medical staff around her. Soon overpowering her habitual hauteur, ovarian cancer ravages Professor Bearing, as does the experimental treatment for which she has volunteered ~ an unprecedentedly intensive course of chemotherapy. Megan Cole uses only a wheel chair and a shaw as propsl, but her timing, movements, and voice utterly convince us of her characterizations. As in the original play, hospital scenes during the last two hours of the professor’s life alternate with revealing flashbacks from her past in which Cole plays the younger Vivian Bearing. We learn how she came to love words at age five, and how she developed a passion for the elegantly crafted, intellectually daunting poetry of John Donne, who struggles in the Holy Sonnets, as does Bearing, to uphold his faith despite death’s inexorable onslaught. At times, the professor speaks directly to the audience, reflecting with mordant humor on the irony of her situation ~ a brilliant and accomplished woman now reduced to a completely bald, emaciated cancer victim in a shapeless hospital gown. Monologue became dialogue as Cole also plays Susie, the nurse, E.M. Ashford, Vivian Bearing’s mentor in graduate school, Jason, a hospital resident, and Dr. Kevekian, the patient’s oncologist. The haughty professor meets her match in the overbearing Dr. Kelekian, more concerned about his patient as a research subject than as a suffering human being. Jason, Dr. Kelekian’s protégé, remembers Professor Bearing as one his best teachers, but he too regards her as mainly a laboratory experiment. Like Dr. Kelekian, his role model, the promising young researcher seems oblivious to his patient’s demeaning ordeal, too self-absorbed to listen when she tries to speak to him seriously. At the end of the play, Jason desperately attempts to keep his research subject alive despite her clear instructions that she not be resuscitated. Of those responsible for Professor Bearing, only Susie, her nurse, has the empathy to comfort a dying woman beset by merciless pain. Compassion, too, comes from E.M. Ashford, the professor’s revered teacher, who visits Vivian, reads to her from The Runaway Bunny, and cuddles her prize student, now barely conscious and seemingly beyond consolation ~ a scene Cole renders with impressive skill. As death closes in, Vivian Bearing’s rational defenses collapse. In anguish, the professor, finally appreciating the values of humility and compassion, at last gains the humanity she long resisted. Just as the professor sometimes addresses the audience directly, so, too, does Cole periodically shed her stage roles to speak to us in her own voice, commenting on the significance of her characterizations as they apply to caretakers and their patients. In doing so, she breaks down the wall separating actor and spectator, establishing a seamless rapport between the two. The wall comes down for good once Cole enacts portions of the final scene ~ Vivian Bearing’s transcendent death, facing her end with dignity and peace of mind. Following a hushed silence, the UMass audience honored Ms. Cole with a standing ovation. The UMass audience then shared highly personal reactions to the performance. Considering the breakdown of communication occurring in the play, several audience members spoke of the great value of truly listening to their patients’ concerns. One physician spoke of how doctors must be “bilingual,” speaking only plain English to their patient, saving medical jargon for conversations with peers. Another, insisting that patients are not their disease, spoke of how doctors demean their patients when referring to them as “the kidney failure in Room 203” or “the appendectomy in Room 101.” A medical student insisted that physicians must care for their patients as human beings, even as they perform the most challenging treatments. He said he realized the precarious equilibrium this requires. Another healthcare provider spoke of how draining sympathy, if not empathy, can be, and that caregivers must protect themselves from burn out. Most affecting was a physician who spoke of the heartbreak of witnessing his own spouse dying of cancer, a loss that brought him a renewed awareness of the suffering of his patients. At the conclusion of the program, the audience realized they had participated in something truly special. They expressed their appreciation by granting Cole a second standing ovation. We all felt we had indeed experienced The Wisdom of Wit. Harvey Fenigsohn, Lamar Soutter Library, University of Massachusetts Medical School |