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Worcester Medicine Back to School Presidents Message There and Back Again
Staying Out of the Red Pinches Even the Greenest Doctors
A Touching Debut on Foreign Soil
Curiously Cavalier, Call in the Cavalry In my View "Life as a Pharmacy Student" Legal Consult Financial Advice of
Physicians Science Corner As I See It
Massachusetts Medical Society 6th Annual Creative
Writing Contest Off Call Tomatoes - Lore, Legend, and Recipes In Memoriam Back to School Medicine is unique in that we are allowed to practice our craft on the live ones. Our artisans allow apprentices to learn, then hone and someday master their technique on very real, often very sick people. Given the stakes involved, the effective training of young doctors is vital to maintaining our profession’s valued role in society. But in the age of managed care and for-profit hospitals, our master artisans are under increasing pressure to focus more on their own individual guilds rather than on teaching their own apprentices. The educational practices ingrained into our profession are in danger of becoming folklore to present day medical school students ~ besieged by demands to see even more patients and in even less time than the day before. As we enter the fall season, Worcester Medicine ~ in no autumnal state, we ~ spotlights the tumultuous training process of doctors in our “Back to School” issue from a bedside point of view of both mentor and student. Dr. Morris Spierer reflects on a career devoted not only to his patients, but also to the training of newly christened doctors in “Here and Back Again.” Dr. Sumi Vasu, in “A Gentle Landing on Foreign Soil,” shares her first baby steps as a recently (3 years ago) emigrated physician. As outside forces conspire against the education of new doctors, we also asked attending physicians, residents, and medical students from both major teaching hospitals in Central Massachusetts to weigh in on the future of medical education. We hope you find this issue as enlightening, and relevant, as we do. WDMS &
Medical Education Creating medical education opportunities for practicing physicians and trainees has been a major focus of Worcester District Medical Society since its inception in 1794. WDMS has the distinction of being the only district society of the Massachusetts Medical Society accredited to sponsor continuing medical education programs. We first became accredited in 1981 under the leadership of Dr. Guenter Spanknebel, the director of medical education at the time. Over the years we have sponsored many programs, offering our diverse membership timely programs on a variety of topics with broad appeal. I am pleased to announce that WDMS will be sponsoring its First Annual Louis A. Cottle, MD Memorial Lecture on March 21, 2007 with monies received from the Louis A. Cottle Trust. As of 2006, WDMS is the sole beneficiary of Dr. Cottle’s Trust. Doctor Cottle passed away in 1950 after 48 years of practice in Worcester County. The focus of the lecture this year will be physician wellness. Programs in medical education provide an opportunity for clinicians to learn about advances in medical research that have been shown to improve patient care. Attending medical conferences also provides practicing physicians an opportunity to assess the depth of their knowledge in areas of medical care outside of their specialty. Assessment of this type allows the clinician to tailor future educational activities to fill gaps in their clinical acumen. Before leaving the educational environments of medical school and residency training, the practitioner must appreciate the importance of a lifelong commitment to self-directed education in order to maintain the skills needed for quality patient care. Regular participation in the education activities provided by WDMS, Hospital CME offices, and medical school departments represent wonderful opportunities available to practitioners in Central Massachusetts. The education committee of WDMS would appreciate suggestions regarding future educational programming for medical care providers and consumers of medical care. There and Back Again In the summer of 1974, I began the practice of medicine at the Fallon Clinic. In their initial recruitment pitch, I was told that the clinic’s primary hospital was Saint Vincent Hospital, a place rife with medical students, residents, and fellows. I was told I would have a chance to teach. I was never disappointed. I have always believed that interacting with young physicians-in-training is an ideal way to cultivate one’s knowledge base. Back in 1974, I began preparing to be a positive force in the lives of the next generation of doctors as an attending physician in both general internal medicine and pulmonary medicine. At first, most of my exposure to the house staff hinged on patients whom I admitted to the general medical floors (and occasionally to the ICU). As a rookie, though, my experience in teaching was rather limited because I did not have a very large inpatient load. But what I quickly found was that even my very limited exposure to teaching fulfilled my desire to keep up with the latest developments in the field. (House staff quickly sense when one is not up to date.) My appetite now whetted, I hit the books. But after making strides in teaching early in my career, the Fallon Clinic soon drafted me into a new, vastly different job ~ an ever-expanding administrative position as the inaugural medical director of the Fallon Community Health Plan (and later as the medical director of the Fallon Clinic). These positions completely severed me from teaching and reduced my exposure to direct patient care for many years. I was happy in my administrative role, but I regretted missing out on the simple pleasures of clinical medicine and teaching young physicians. Thankfully, I returned full time to clinical medicine several years later in 1995. Much, of course, had changed in that time about the practice of medicine, and now being thrust into the ICU ~ the deep end of any hospital ~ I had no choice but to fully immerse myself. I had been away from patients for too long ~ and knew full well that frequent exposure to house staff would accelerate my return to becoming a good clinician. I vowed to make special effort to teach in the ICU setting. I was fortunate to be well-received by Dr. David Kaufman, chief of critical care at Saint Vincent Hospital, who took a chance on me as part of the hospital’s critical care team. I was given the opportunity to transform overnight from a pencil-pusher into the senior doctor pushing central lines, Swan-Ganz catheters, and arterial lines in critically ill patients. Thankfully, I found a receptive ICU staff that permitted me to retrain in every invasive procedure. My pulmonary and critical care colleagues helped me regain the confidence I needed to work in the stressful world of ICU medicine. But, ultimately, it was the house staff who made me aspire to be a good clinician once again. I thought back to the didactic lectures I attended during my training. I found them ~ then and now ~ to be tiresome and not always relevant to my actual patients. I knew that most of my critical care knowledge came from experiencing firsthand the difficult task of making rapid decisions relating to sick patients. Based on these experiences and observations, I developed a teaching style that I continue to use a decade later. I remembered in my early years of training at Bellevue Hospital in New York that I was forced to perform many lab tests by myself. We were expected to actually do our own gram stains and peripheral blood smears, draw our own arterial blood gases and serum ketone titrations for diabetic ketoacidosis patients. We even transported patients directly to the radiology suites. Although I despised the “scut” work, I now appreciate the value of tests and procedures ~ so that I can understand their limitations. It has since been my practice to look at my patient’s pathology slide; I will frequently go to the lab or to the radiology department to speak directly to those who performed the test. This practice makes me more aware of the limitations of the tests and builds good rapport with technicians who rarely see or interact with the ordering physicians. I remember all this when very ill patients require a rapid diagnosis. Technicians with whom I interacted in the past would come in on a weekend to ensure that pathology slides would be available on a Saturday rather than on a Monday. These efforts have had significant positive impact on the treatment of patients. I attribute their behavior to the fact that over the years they have seen and spoken to me and knew me as a real person and not just an ordering physician. I noted that it is the rare resident who goes to the lab to look at a gram stain or a peripheral smear. I find that many residents don’t even discuss the imaging studies with the radiologists but tend to rely solely on the written reports. I encourage the house staff to have direct contact with the individuals performing or interpreting lab or imaging studies. I arrive early in the morning in the ICU and “pre-round” on the patients so I can be prepared to teach when formal rounds take place later in the day. When rounding, I continuously quiz the residents and interns about possible scenarios that relate to their patients. I often create imaginary crises that could occur to their patients at some time during their ICU stay. I intentionally put them in a position where they have to make hypothetical life and death decisions. While this creates stress and anxiety, the house staff know that this is really a teaching game. They are rewarded with “stars” that I pin on their badges when they give correct answers. These teaching games have become very popular and house staff proudly carry their stars around to demonstrate their proficiency. I very much enjoy the expression of satisfaction on their faces when they do well. The practice of medicine nowadays can be frustrating. The burden of exponentially increasing regulations, bureaucracy, the fear of litigation, and even greater expectations from patients can make life difficult for a physician. But I have found that teaching young physicians is the highlight of my career.
Staying
Out of the Red Pinches Even the Greenest Doctors It is not a coincidence that the turnaround at UMass Memorial was linked directly to a huge allocation of funds ~ both private and public. The man who will one day be anointed our savior (assuming things continue to go well) has an MBA, not an MD, and, therefore, it is going to remain imperative that we stay in the black. So, when things go sour, there is a huge administrative squeeze placed on the attendings. When there are struggles, such as when we temporarily halted our CT surgery program, you see evidence of the squeeze. Patient safety drove the halt, no doubt, but it obviously has a huge financial impact. Now all of a sudden there is a fear that we will again end up in the red ~ so the squeeze is once again on. It's hard to know how much of this comes directly from above, as I'm not privy to the attendings’ meetings and inboxes. But rumors abound of attendings being asked to greatly increase their patient load. As is, they are already double- or triple-booked, which means, in the rare instance that every patient actually arrives, that they are even more hurried than usual. Is this stress obvious on our teaching attendings? Definitely. But I don’t believe it has affected the quality of your education yet ~ at least not from those who are dedicated UMass faculty. It may mean that we round later in the afternoon because their clinics get out later, but I don't think it has led to any corners being cut ~ just a longer day, especially for the attendings. (It sounds strange to say, but residents are now protected by work hour regulations ~ who’s out there watching my attendings’ hours?) I think the story is different for the private practice-based attendings: They sometimes seem too busy to field a phone call about their patients, let alone have time to do some bedside teaching ~ hence the shift toward hospitalist coverage. (Yet the demands on hospitalists continue to grow. At our University campus and around the block at Saint Vincent Hospital, hospitalists are asked to play a primary role in teaching their residents ~ in addition to carrying a full patient load.) As a former chief medical resident, you feel some of that administrative pressure in the trenches. There is a huge movement underfoot at UMass that we discharge patients as early in the day as possible (when medically appropriate, of course). This is a logical request, and one patients prefer, but this need to improve patient flow seems directly linked to monetary flow. The residents feel the pressure to make patient discharges an absolute priority ~ even at the expense of their educational experience. Look, we ask an impossible task of our residents:
And, oh yeah, get your patients out of the hospital before noon. It can't be done! So, we accommodate by shifting some of our conferences in the hope that people can get their discharges done and feel comfortable about coming to their conferences. It’s gotten to the point that every resident team is given their discharge statistics every two weeks ~ average time to discharge, frequency of checking with the case managers, et. al. ~ so we know exactly how well we’re faring at these administrative tasks. (Those crunched stats, incidentally, are posted publicly for all to see.) One of my first lectures as a cardiology fellow ~ before echocardiography or how to emergently place a temporary pacer wire ~ addressed appropriate billing techniques. It was interesting to see how convoluted the billing structures are, and you could tell all the third year fellows were a lot more interested than the first years. But it's telling that this lecture is given at the beginning of July ~ not at the end of June as an educational lecture for those graduating. A
Touching Debut on Foreign Soil My first day in Worcester, I eventually found myself at the old Saint Vincent hospital by religiously following Mapquest’s directions. Inside, a kind soul directed me to the right place. As I started working, much to my surprise, I found that people in the elevator wished me well first thing in the morning. Complete strangers said, “Have a nice day.” Everyone seemed to be smiling. People here might not make much of these commonplace acts of courtesy, but for a new doctor thrust overnight into an entirely new atmosphere with its own dialect and mannerisms, it greatly eased my assimilation from a foreign country. As the days passed, I felt increasingly comfortable with patients. But, as a recent graduate from Thanjavur Medical College in India, I couldn’t shake a nagging, gnawing question: Would I ever be able to transcend this cultural barrier and be able to connect on a deeper, personal level with my patients? Would I ever be able to gain the complete trust of a family here? Early in my intern year, I took care of an 85 year-old lady. One Sunday I walked into a room filled with five granddaughters and many more great-grandchildren. The palpable concern in the room directed toward their family’s matriarch – and the feeling I had right when I walked out of the room – reminded me so much of my hometown. At that moment, I had an epiphany that there was a common thread connecting all peoples of the world – irrespective of birthplace, race, or religion. It is the ability to love and partake in joy, to weep when in sorrow, and to sacrifice and endure when a loved one suffers. This is very much the same in all countries – developed and developing. I was instilled with and buoyed by a confidence that I could now truly relate to my patients after this encounter. Later that year, I took care of a patient burdened by a mysterious illness that was later diagnosed as cancer. During those moments of uncertainty, when none of us knew what we were dealing with, I always made it a point to spend at least 15 minutes talking to her every day. I remember I always set my alarm earlier than usual so I could catch her in the tranquil time of the early morning. She began to share her concerns and the implications for her family with me. I realized how vulnerable a patient feels when in the hospital, often a cold, lonely place. I met her daughter and we soon became good friends. I came back to this patient in the evenings to update her with test results – or just to hold her hand and listen. I was the one to give her the diagnosis. I could feel her pain and the sinking feeling she had as I gave her more information about the cancer. Subsequently, her daughter walked up to me and thanked for my concern toward her mother. In a few minutes, I found myself gripped in the pangs of intense sorrow. Personally, I hate uncertainty and I marveled at this woman’s endurance. Remarkably, I returned home an energized person, feeling empowered and inspired. Equally remarkable, my patient did very well and returned to our clinic two months later. She asked my attending to see me specifically, and I remember vividly my steps to the hematology-oncology practice suites that day. Finally, I felt that I had answers to the nagging, gnawing question in my mind. Finally, I had gained a patient’s trust in the profound manner which I highly regarded. To this day, the patient and I converse over the phone. She may never know how much she and her family helped me to recognize my self-worth and pride in being a physician. My reflections on being a foreign medical graduate would not be complete without a mention of the nurses. As the days went by, I was amazed at the amount of hard work done by the nurses and inculcated a deep sense of respect for their humane work. In other countries, most of a patient’s hygienic and grooming needs are done by family members. Here, I saw firsthand the extremely labor-intensive work that nurses did. Though they were overworked and were expected to multitask on a regular basis, they rarely showed their frustration to the patient. My first day at work, I remember being offended by a nurse’s remarks. I happened to work with the same nurse on my first night-float weekend as an intern. Together we transferred a patient to the MICU. By the morning, we were the best of friends. Having graduated from a different country, one acquires the values of deep insight and introspection. It changes one’s perspective on everything. Whether it is managing a patient with a venomous snake bite or managing a patient who sustained a severe MI – the apprehension of the patient and their families are the same. They may have varying degrees of sophistication in their way of expression – some more articulate than others – but the deeper undercurrent of emotion is a universal one.
Curiously Cavalier, Call in the Cavalry I hung up the phone with him only an hour before. I had already admitted six patients that night. The seventh, I would soon tell him, was pretty straightforward. At 2 a.m., one of the residents on the floor called to tell me about number seven. Her page interrupted my only 20 minutes of sleep since early yesterday morning. My contacts now completely desiccated, eye crust glued my lids shut as I searched for the phone in the dark. My eyes, injected with crimson streaks, looked like I had just been infected with the rage virus. Sometimes, it’s not easy being the ICU resident. I was out of adrenaline. Maybe that’s why I was slightly – just slightly – nonchalant about number seven. Or maybe I had cracked open the endorphins a touch too early. Either way, it was a muted sense of complacency that was out of character. Because even though this was my fourth tour of duty in the ICU, I don’t bottle bravado for my overnight calls. Cocksure I am not. When arteries are that calcified, hearts this fragile, too many bad things lurk around every bend in the ICU to reach a comfort zone after just two years as a doctor. Still, how many times had I seen respiratory failure from congestive heart failure before? Twenty? Thirty? I knew how to handle this. Number seven was an elderly gentleman just sent up to the floor from the ER. He had been diagnosed with an acute coronary syndrome now complicated by heart failure – always a poor prognostic sign. The resident on the floor opted – correctly, I thought – against a trial of BiPap given that it would not resolve the underlying damage to his heart or likely calm a heart rate in the 140s. Anesthesia intubated number seven. The nurses wheeled him through our doors. I told seven’s family that he was quite sick, but – with the help of the ventilator breathing for him – stable for the time being. I did not tell them that I thought he could do reasonably well after we diuresed him and he had a cardiac catherization. (In my first two years of residency, I soon learned to emphasize to families just how sick their loved one has to be to come into the ICU. Sometimes, I mention that about one in five people admitted to an ICU will die in the ICU. I say that I don’t really know what’s going to happen, but that we’re doing everything we can for him. I cannot speak any more honest words.) Once settled in the ICU, though, his blood pressure dipped just a little. Just a little, I thought. I was sure it was the medicine I just gave him a few minutes ago. The nurse quickly agreed. Ten minutes later, his blood pressure stubbornly dropped again. A bit lower this time. Could still be the medicine. Must still be the medicine. “We gave him two doses,” I said to no one in particular. Gulp. I updated his very nice, increasingly distraught family three times in the hour. Thirty minutes later, at 3:30 a.m., his blood pressure tanked. It wasn’t the medicine. Oh, crap. He needed a Swan-Ganz catheter to assess the degree of cardiogenic shock from his MI. Unfortunately, no second year medicine resident I know is comfortable doing a Swan solo – complications, potentially fatal, abound. But my intern and I were alone. This guy was likely going to die. Thankfully, I knew I had backup – backup that I wouldn’t have most nights as the ICU resident. At 4 a.m., he arrived under cover of darkness. He might as well have been wearing a cape and spandex pants. Thank God. Every Saint Vincent Hospital medicine resident has muttered that when Dr. Spierer arrives. Thank God, Dr. Spierer’s here now. I’m not sure whether he knew how much I looked up to him. We had worked together some – enough that I felt he trusted my judgment – but not so much for him to suspect the degree of my admiration. He was my gold standard, someone to model a career after. I love that he willed himself into being the clinician he is by coming early and staying late. I love that he loves to teach, and always does right by his patients. I know I hear him when I’m teaching my interns and students now. Medicine is the most humbling profession, he once told me. Pulmonary emboli and congestive heart failure – some of the most common diagnoses we make as physicians – “…fool me all the time,” he said. And when your role model is fooled by everyday occurrences, it leaves a mark. I found it to be the most admirable, mature statement any doctor has ever made to me. But in the middle of the night, baked on those endorphins, it’s tough to always remember that lesson. While medicine can be humbling, it can also be incredibly emboldening and intoxicating. You do make decisions that affect peoples’ lives every day. And, again, I had seen 20 – nay, 30 – cases of congestive heart failure following a heart attack. I had made many of them better. Yet here Dr. Spierer was – after maybe 2,000 to 3,000 such cases – with just the right amount of intensity and stress. And yet I was the one with a little too much confidence that night. Every other attending physician on call that night was asleep in his or her bed. Most would likely get annoyed when rustled from sleep at home by a telephone call. Yet Dr. Spierer came in for his morning rounds at 4 a.m. – our formal rounds not starting for another five hours – because he wanted to teach us all more effectively - and to help his residents in a pinch. Like when supervising us as he cracked his sly smile, with an eager, proud glint in his eye, as we floated the Swan successfully. Dr. Cohen. Dr. Elkerm. Dr. Popkin. I am nothing but an amalgamation of the best traits of the best doctors who trained me. I hear all of them in myself when I teach my interns, now two years younger than I and quite clearly less experienced. Medicine is unique in that we train on live people. I can trace back every medical fact, principle, or pearl hardwired into my Tron-like consciousness to a specific person – patient, resident, attending. Given the gravity of our work, we all need mentors to model ourselves after – to know whom to aspire to be when we wake up in the morning. To know whom you should want to be proud of you. I’m one of the most senior residents in the hospital now. I often preside over my own little personal medical empire, captaining a team of interns and medical students. I tell them of the time I was a little too sure of myself – because we all need to be reminded of that from time to time - To remember to be frequently humbled. And to remember that the best doctors – the best mentors – are the ones who get fooled all the time.
Does the Current Business Model of Medicine Allow for the Training of New
Physicians? “Do you think the current business model of medicine adequately allows for the training of new physicians? Specifically, to attending physicians, do you have adequate time, opportunity, and incentive to help train budding doctors given the constraints of your workday? To students and residents, do you feel your attendings have the time, opportunity, and incentive to adequately train you?” “No. I have noticed a progressive emphasis over the years toward seeing an increased volume of patients, particularly new patients. In this model, practice viability and financial success are directly related to the number of patients seen. These business models do not account for teaching nor for make allowances for time spent (lost) or slowed by training efforts. It is understood that training is to be an added function, not considered part of the daily office routine. Attempts at financial support by teaching programs to compensate for time spent training students or residents are inadequate. In order to provide quality teaching, I find I spend more (non-billable) hours in the office and less time at home.” - Dr. Joseph Cohen III, endocrinologist, Fallon Clinic, Worcester “One of my friends once told me that if you wanted to know what someone's core values were, then just look at their calendar and their checkbook. I think that the same yardstick could be applied to the current business model of medicine. In the private practice primary care setting, there is
neither compensation nor time allocated to teaching, and a physician who is
willing to do so does so at his or her own time and expense. The office
tends to be less efficient and examination space can become tied up as a
student or resident tries to practice the skills of eliciting a coherent
history and obtaining a pertinent physical exam in the oft times vague I think that the current business model of medicine clearly does not reward or encourage practicing physicians to have new physicians in the office. On the other hand, those who do continue to teach are likely to be more motivated by the art, science, and humanity of the practice of medicine, rather than by its business aspect. That may not be a bad set of ideals to try and teach and model for young physicians - if we can just find enough people willing to do it!” - Dr. Kenneth Kronlund, internal medicine, Fallon Clinic, Worcester When I was in the practice of general internal medicine at 1010 Main St in Holden, we (me and Dick Walton, later to be the Founding Chair of The Dept of Family Medicine at UMASS) had medical students in the office. After each patient was seen, we took time to address the patient's specific issues, and the broader medical/social questions raised by those problems. After hospital (Holden District Hospital) rounds, medicine and the life of medicine were often discussed over the dinner table (albeit with Walton's kids crawling over everyone). My discussions with those who practice primary care medicine now in the community lead me to believe that kind of mentoring is difficult to come by in today's world of medicine. Even in the University setting, clinician-educators now feel the weight of RVUs pressing them to rush through discussions of patients in the clinic and in hospital ~ thus the need for adequate funding for excellent physician-teachers. Nonetheless, much medical knowledge must be self
taught, and that is not changed by the "business model" of medicine. And
medical students can still learn a great deal from rushed but skilled
physicians who cherish their work about the importance of a careful history
(careful doesn't equate with long), an appropriately directed exam, and
about the care of and the caring for patients. Despite all the "third
parties" involved in medicine today, in the examining room there are still
only the patient and the doctor ~ and, one hopes, a medical student eager to - Dr. Robert B. Zurier, Chief, Division of Rheumatology, UMASS Medical School “Teaching medicine to future physicians, students, nurse practitioners, and physician assistants has always been important to our group and personally satisfying to me. Time has been the biggest constraint. With changes in medicine ~ the shrinking interest in primary care, the overwhelming amount of paperwork, prior authorizations, referrals for many tests now generated in a primary care office ~ the practice of medicine leaves very little time to teach. It is imperative that future health care providers be exposed to the reality of the practice of medicine. Reimbursement for teaching is minimal at best, and most of us in a non-academic environment do it because we enjoy it, and we hope we have some influence on future generations of practitioners. What is the value of teachers to society? This is a topic in itself, {one doubly important to me as I also have} a son who teaches elementary school. Is the current business model supportive of any teacher? I think not. We teach because it is the right thing to do, not for the money, and to show the next generation of professionals what we have learned and what we can learn from them.” - Dr. Peter C. Lindblad, general internal medicine, Primary Physicians Partners, Worcester “Not having anything to compare with the current model of teaching, I must admit that I am pleased with my medical school education thus far. However, I also must admit that a large percentage of my teaching has been by residents instead of attendings. This is likely due to the "business model" of medicine since time is a large barrier. Additionally, the hierarchical system of medical student education also puts a barrier to the student's learning experience where in some programs students are discouraged from communicating with attendings directly ~ even if it is about a shared patient. I do not think that incentive is an issue because the attendings who wish to teach generally self-select to be in that sort of an environment, knowing fully that there are time obstacles to teaching. Finally, I think that attendings and residents are willing to spend more time teaching medical students if they are actively involved in their own education ~ meaning that the student reads up about a specific topic and is able to ask educated questions about the disease process or treatment options. Efforts to enrich the art of teaching should be focused in on the resident level. If residents were required to take a tutorial on effective teaching, it would impact students in that the students would then hopefully get teaching on rounds, in small groups, by the bedside, etc. It may also serve to create a larger pool of future attendings who wish to stay in an academic setting so that they can teach future students/residents.” - Amy Johnson, MS-4, UMass Medical School “I have time, opportunity, and incentive to ‘train’ students, residents, and fellows by engaging them in the case material at hand. This is especially true for fellows working with me in the cath lab where there is substantial interaction. Other clinical settings, e.g. telemetry or discussing an admission or consultation, frequently provide the opportunity to teach. It is its own reward, and an educated resident or fellow will provide better care for my patient.” - Dr. Allen W. Filiberti, cardiologist, Saint Vincent Hospital The business model of medicine means a no-nonsense endeavor where bottom-line economics replace virtually all other values. Such a model has little room for teaching unless teaching is reimbursed “adequately,” which of course it isn’t. While making medicine a business has had some good features (quality assurance, cost-effectiveness, efficiency, cost containment, documentation, standardization, computerization, regular reimbursement, and so on), we in medicine have paid far too high a price to be “modernized.” Now, we are merely employees, accountable to our employers for our every minute. The driving force of our profession ~ caring for the sick and teaching those learning our profession ~ has been usurped by our employers whether they be hospital administrations, insurance companies, health maintenance organizations or government. Their bottom line intimately governs our behavior with our patients and our students. That replacement has had profound and depressing effect on most physicians, particularly those of us who were fortunate enough to have worked at a time when taking care of patients and teaching was what we really worried about. Those who now take extra (uncompensated) time with patients or offer additional (uncompensated) advice to students do so in spite of it all. Consider this: Last week it was announced that HCA (Health Care of America ~ Bill Frist’s family’s health plan) was offered in sale at 30 BILLION dollars, which included 10 billion of debt. HCA must have had a really great bottom line! The tail has wagged the dog too long. - Dr. Mary Costanza, Professor of Medicine, UMASS Medical School “I do believe that there is adequate time to train new health care workers. I learned so much medicine in PA school but the clinical rotations provided the most knowledge and enabled me to become comfortable with the management of patient care. There are days when a medical team may be so busy that the attendings do not have as much time to devote to teaching; however, this is usually balanced by days with fewer patients and more time for learning. Medicine is an ever-changing field and the learning never stops. For PAs and residents alike, the learning certainly continues during the first job. We both learn from our attending physicians and the new PAs learn from the more senior PAs on staff.” - Lisa Olender, PA student “No, we as physicians deal with life. Life is a precious gift and it cannot be equated to business. What is our incentive then in this work? The moment we bring the business model into this field our attitudes change. We are human beings. Business is an aspect of our profession but it is not our model. Time is a factor in training the residents. But the most important factor is the incentive from the residents ~ how willing are they, and what do they want to learn from medicine? In our profession I believe the medical knowledge that we utilize on our patients is just 20% ~ the rest of it is something else.” - Dr. Seema Sahib, hospitalist, Saint Vincent Hospital "Medicine has changed and as a result so has residency training. The physician of the past is slowly fading; no more will there be doctors whose morning was spent at the hospital seeing his or her own patients, teaching the residents, and then heading back to the office to spend the remainder of the day caring for patients. Succumbing to third party rules and regulations, physicians have been forced to both cut back the time devoted to the patient in the office and spend less time in the hospital, ultimately affecting the teaching of the residents to their detriment. There are indeed excellent attendings and fellows devoting their time and effectively training the residents; however, I feel that the current model of medicine has put an unduly strain on the time dedicated to train future physicians." - Jennifer Sargent, DO, PGY-2, internal medicine resident, St. Vincent Hospital “Life as a
Pharmacy Student” Peter Marsh graduated from the Massachusetts College of Pharmacy in 2005 and is currently doing a postgraduate pharmacy residency in community practice. Life as a pharmacy student at the Massachusetts College of Pharmacy and Health Sciences can be challenging yet rewarding at times. Pharmacy is a unique field that combines science, medicine, communication and, most importantly, compassion for your patients. MCP tries to instill this level of understanding and compassion in us early on in our training as future healthcare providers. Communicating and listening to the needs of our patients is something that we need to master in order to provide the best pharmaceutical care. It is one of the most important skills that an MCP student and future pharmacist can acquire at the college. I think there is one experience from my time as a student that best illustrates the importance of this skill in the healthcare system. It was a quiet Sunday afternoon and I was interning at a local community pharmacy. A middle aged man came into the pharmacy looking for a hypertension medication for his 8 month old son who had a congenital heart defect. It was a specially compounded medication for his son prepared from a formula from Children’s Hospital. He spoke broken English and was distraught over his son’s condition and the medication. So, under the direction of the pharmacist, I spent some time getting to know him and helping him to understand the best way for his son to take the medication. After I saw that understanding in his eyes, he thanked me profusely for taking the time to explain to him how to best treat his son. I feel that as a pharmacy student at MCP I have learned the proper skills for understanding disease and recommending the best treatment options. More importantly for a future pharmacist, my college has taught me how to really listen to my patients. Legal Consult: Medical
Education and Cultural Competence The Institute of Medicine 2002 report “Unequal
Treatment” concluded that minorities are less likely to be given appropriate The new health reform law in Massachusetts includes
several provisions designed to reduce ethnic and racial disparities in the
provision of health These provisions of the new Massachusetts health reform
law, as well as the conclusions of the IOM report, led to a focus on the
cross-cultural training of health The Association of Ameri It is to be anticipated that medi Disability
Income Insurance: What Every Physician Needs to Know Have you taken steps to protect yourself in case of a sudden disability that prevents you from working? Even if you're young and careful, it could happen to you ~ through an accident, an injury, or a lengthy illness. According to a recent study, although most people believe they have only a 16% chance of becoming disabled during their working years,1 the startling reality is that:
Learning to speak the lingo Before you go shopping for a DI policy, you need to know what features to look for ~ and the language the insurance industry uses to describe them. The following terms are part of the language describing high-quality policies: Non-cancellable: To avoid the possibility of losing your coverage just when you need it most, choose a policy that’s non-cancellable and guaranteed renewable to age 65 ~ with premiums also guaranteed until age 65. With group or association group coverage, you run the risk of being dropped and left unprotected at a time in your life when, due to your age or to a change in your health, it would be very difficult to qualify for coverage from another provider. Conditionally renewable for life: Although premiums may increase after age 65, your policy should be guaranteed renewable for life, as long as you are at work full time. “Own-occupation”: Own-occupation coverage defines “totally disabled” ~ and therefore eligible for benefits ~ as being unable to perform the material and substantial duties of your own occupation even if you are working in a different occupation. As a highly skilled professional, you want to make sure you have genuine own-occupation coverage…so that even if you can teach in your field ~ but cannot practice in your medical specialty ~ you are still eligible for benefits. Group coverage is rarely true own-occupation coverage. Residual Disability coverage: Through a rider, a good individual DI plan can provide you with protection against the income loss you may suffer as a result of partial (residual) disability ~ even if you have never suffered a period of total disability. This kind of residual coverage is not available with many group plans. A choice of “Riders:” Riders offer optional additional coverage such as annual Future Increase Options, Automatic Increase and Cost of Living Adjustments, or “COLA.” Protecting your practice To help meet the expenses of running the office while you are disabled, consider a separate type of disability coverage known as Overhead Expense or OE. Benefits reimburse your practice for expenses such as rent for your office, electricity, heat, telephone and utilities, as well as interest on business debts and lease payments on furniture and equipment. Overhead expense insurance specifically designed for professionals pays some additional costs ~ including the salaries of employees except those who are members of your profession. In a practice such as yours, for example, salaries for the receptionist and nurse would be covered, but not the salary of your physician partner or employee. However, high-quality professional overhead policies will cover at least part of the salary of a professional temporary replacement for you, such as a doctor retained to fill in during your total disability. In addition… Physicians who are partners in a group practice will want to consider a policy known as a Disability Buy-Out or DBO. In much the same way that life insurance benefits can be set aside to fund a buy-out by the remaining partner if one partner dies, DBO is designed to fund the healthy partner’s purchase of the disabled partner’s share of the business. Furthermore, in combination with the disabled partner’s individual Disability Income coverage and OE, a DBO policy can allow the business to continue to generate an income for the healthy partner, while the disabled partner is supported by the benefits from his individual DI policy. Any continuing share of the business expenses is reimbursed by the disabled partner's OE policy until the buyout is effected. For more information on any of these coverages, please call the Massachusetts Medical Society’s subsidiary, PIAM, at 800-522-7426. PIAM Financial Services LLC is a division of PIAM, a subsidiary of the Massachusetts Medical Society. PIAM Financial Services LLC combines the solid reputation of our parent company with a dedicated team of professionals who can provide independent, objective and personalized financial advice. In addition to investment products ~ annuities, mutual funds, college savings plans ~ our products and services include life and disability insurance, group and employee benefits, and long term care as well as professional liability, business insurance, automobile and homeowners' insurance. Our products and services can also be customized to match our clients’ business requirements. References: 1Gallup
survey conducted for UNUM Corporation (508 respondents ages 30 to 65),
reported by Best’s Review. Science Corner:
“More than Just Mannequins: An Overview of Medical Simulation
“ From the front page of the Boston Globe1 to a feature article in “The New Yorker,”2 medical simulation has become common parlance for health professionals and the public alike. Today’s advances in simulation include diverse innovations such as standardized patients (actors portraying patients), electronic patient mannequins, and “virtual-reality” surgical trainers replicating the look and feel of complex procedures. But despite these impressive high-tech advances, medical simulation is best conceptualized not as a “technology” but rather as an “educational technique” that promotes learning through experience outside of the patient care setting in a risk-free, immersive, hands-on environment, providing the opportunity for practice, feedback and self-assessment.3 In the words of a UMass medical student, “Simulation allowed me to safely experience a dynamic high pressure situation in a hands-on environment…without consequences.” With that definition in mind, this review will highlight the major milestones in medical simulation, its potential for advancement and the challenges it will face in the future. Beginning in the 1970s, standardized patients (SPs) were first used to teach and assess basic “bedside” skills such as history taking and physical assessment. Today, SPs are arguably the most widely used form of medical simulation and are often “hybridized” with other simulation technologies to replicate diverse medical conditions and exam findings. “Harvey,” the first cardio pulmonary mannequin simulator, was specifically developed to teach the cardiac exam. Equipped with a variety of authentic pulses, heart sounds and murmurs, “Harvey” has been used world-wide with research studies demonstrating his effectiveness in learning bedside cardiac exam skills.4 Following in Harvey’s footsteps came the next generation of patient simulators, high-fidelity, full-body patient mannequins that are programmable for any desired clinical condition. These so-called patient simulators have been primarily used in critical care training and performance improvement of medical teams in high-stakes situations like cardiac arrest, multiple trauma, and even high-risk deliveries. Although the effectiveness of patient simulators in error reduction and in improved clinical outcomes has not yet been demonstrated, liability carriers have recognized the value of team simulation by offering malpractice discounts to participating physicians in certain specialties.5 Advancing beyond patient mannequins, today’s technology has created virtual reality (VR) simulation that replicates surgical procedures through interactive computer-generated video, audio and tactile modalities.5 VR trainers are available in over 20 skills areas ranging from simple catheter insertion to complex minimally invasive surgery. The usefulness of VR in procedure training is supported by recent research studies demonstrating the transferability of enhanced skills from the VR training environment to the real environment.6 These studies and others contribute to a growing body of educational research addressing critical challenges in the advancement of medical simulation: Does simulation training improve patient outcomes? Is it cost effective? What criteria should be used to measure performance? Recognizing the potential benefit of simulation in health care, the Agency for Health Care Research has launched a recent grant initiative to study improvement in patient safety through simulation training.7 While this research is promising, experts have cautioned that rigorous, evidence-based studies will require long periods of investigation.8 In the meantime, we can count on the experiences of our students to support the development and expansion of simulation in our teaching programs: “What strikes me is how quickly I learned from observing my mistakes and how confident I felt performing tasks that were physically shown to me…the highlight of medical school to date.” References:
The Hector E Reyes House On Sunday, Sept. 19, 2004, a community forum was convened at the request of federal, state and City of Worcester officials. The purpose of this forum was to initiate discussion on creative options to stem the increasing level of violence in our community. The Latino Substance Abuse Task Force was formed in response to the request of these civic leaders to study the relationship between crime, violence, and drug and alcohol abuse. Research suggests that drug treatment would be a best practice to improve the whole community and reduce the impact of family disruption, homelessness, joblessness, social disconnection, HIV infection, violence, crime, and the plethora of associated health issues endemic to the Latino substance abuse population. Our immediate goals to provide comprehensive substance abuse treatment to our Latino population by establishing a 25 bed, culturally sensitive residential substance abuse facility. Our program will operate in an environment that is conducive to cultural traditions and will provide client/family centered services. Integral to our plan is the introduction of a primary care medical component within a multidisciplinary treatment setting to provide a continuum of care for a population that comprises 30% of all treatment admissions in the area and is notoriously under-served. We intend to promote treatment interventions ~ i.e. ethnic matching of clients, primary care physician involvement ~ that have superior treatment outcomes for many substance-related disorders. Our approach offers extensive medical administration and supervision, thereby providing crucial linkages to a continuum of integrated bio/psycho/social clinical treatment services. Our assertions, that outcomes will improve when treatment occurs in an environment where language, beliefs, customs, etc. are culturally sensitive, are forward-looking and widely accepted. Included in our ambitious curriculum is the development of new programs to teach nurse practitioners, medical students, and residents the implications of cultural competence and sensitivity, and eventually to offer a national model of creative and innovative advancements. A completely integrated continuum of care will enable this project to provide a wealth of material for analysis and research. Starting with a comprehensive assessment, our program will measure social, emotional, and economic irregularities along with incidences of their exacerbated chronic illness and disease. Treatment plans identifying specific problems in medical, social, and clinical deficiencies will have well-defined statements of goals, objectives, and interventions and will chronicle outcome data. This project will assess several domains of addiction-related treatment outcomes and will use various self-report mechanisms to monitor efficacy. Abstinence, employment/education, crime/criminal justice, housing, and social compatibility are a partial listing of areas to be measured. We will use a sophisticated treatment outcome measure reporting system, thereby providing data for program quality monitoring and accountability. Our program will allow significant research, but its true value ~ the benefit it will provide to the community at large as we address crime, violence, homelessness, and hopelessness ~ should prove invaluable.
Massachusetts Medical Society 6th Annual Creative Writing Contest Deja Vu John certainly was an unusual man. I had known him for about ten years now, as we both worked in the same section of the university. We often had supper together when there was a deadline to reach and we both had to stay overtime to finish our work. My husband had always been tolerant of these transgressions, and John was not married so he had no problems with the late suppers. I had always suspected that John may have had some romantic interest in me, but he respected my marriage and never was out of line when we were together at our late evening mealtimes. We always had many interesting conversations about different topics and I found his insights on many of them to be remarkable indeed. He seemed to enjoy my company very much and I felt the same about him, but there never was any incidence of a romantic attachment between us; we were just good friends. The unusual thing about John was that he was often absent from work for short periods of a day or two, and he never spoke about where he had been or what he was doing there to anyone. Considering all of the other fairly intimate and wide-ranging things he confided in me, it seemed a little strange that he never volunteered anything about these short hiatuses from work. It apparently never affected his production or status at work because he was so well-known and highly respected in his field of physics that he never was admonished for these frequent absences by his superiors in the department. I had often tried to coax him to tell me about where he had been, but he always turned it off with almost always the same statement of “Oh, no special place, Julie; someday I’ll take you to see for yourself.” And that would be the end of it no matter how much I kidded and cajoled him about it. He apparently had funds from some source so that he was able to finance his work and himself handily with them. He always made comments about the stock market and how he had been able to make a killing there from time to time using his knowledge of physics; it always amused me to think of a physicist trading in the stock market. Two years went by at the university with similar late meals and my continuing friendship with John until one day I was called at work and informed that my husband had died at his office from a sudden massive heart attack. I was overwhelmed with grief and John comforted me and took me to the funeral home where they had brought my husband. My husband and I had no living relatives, so John helped me with the funeral and other arrangements and was wonderful with everything he did to help me get over this devastating happening in my life. He visited me in my apartment and helped me to weather the overwhelming storm of grief that I went through during this terrible period. He was completely supportive in helping me to pass through this time period as quickly as possible. We continued our friendship at the university when I finally was able to return to work there. I was very appreciative of what John had done for me during the period of my grief and told him so. He responded by becoming more attentive to me and we soon became even closer friends. Inevitably, we became romantically involved and began to spend more and more time at each other’s apartment. At these times in each other’s apartment we continued our great discussions that we always enjoyed in each other’s company. In time we decided to live together but had not planned whether we would live at his apartment or mine. John suggested his apartment might be best since it was closer to the university and contained some things he said he needed for his work in the physics department. We finally made the move to his apartment and I sold mine for a nice profit. On the evening John had moved Julie into his apartment and after they had had supper, he began another of the discussions they had both grown to love so much. “Julie, have you ever had deja vu about places or occurrences in your lifetime?” “Of course, John,” she answered, “everyone has deja vu from time to time. Why do you ask?” “Well,” he began, “psychiatrists give us four reasons for this phenomenon. The first is that we encounter something that is similar to a fantasy deep within our subconscious that the brain recognizes and interprets to us that we have been there or seen it before. The second reason is that an event we encounter is similar to one we have in our memory or similar to many smaller pieces that the brain matches and induces the feeling of familiarity for the event. The third is that our short term memory for some reason is bypassed and a current event is relegated to our long term memory instead of our short term memory. Then if we access that memory a second or so later the brain thinks since it is in the long term memory bank it must have occurred in the past and so makes us feel this is so. The last reason they give is that the brain stores images sometimes as holograms in bits and pieces. Thus, if an event is similar to a piece like it stored already in the brain, it may interpret the whole event as having happened in the past like the piece it is extrapolating it from.” “A very admirable explanation, John,” said Julie. “That would seem to explain it well.” “But is it the only explanation?” John countered. “To explain what I mean I will throw out this possibility. What if time were what creates the universe or universes if it could be traversed backwards and forwards? Along one timeline or universe you would have developed memories in your brain that you remember. Now supposing a man were to go back in time but change the future in only a minor way by what he does in the past. In this new universe he and time have created you might have been only minimally affected by the timeline change. Could it not be possible that new activities that develop in your daily life might be similar to what was already present in your past memory when you were on the old timeline? It would obviously require that your old brain’s memories not be totally changed by what happens in the new change in the timeline. And if this were true, you could have some memories still present in your brain that might trigger the feeling of déjà vu. Another situation to consider are the frequent unusual dreams we all have that come out of nowhere and seem to be totally unrelated to anything we have seen or felt before? Might they not be past time line memories still present in our brains after someone has gone back in time and changed the timeline in another minimal manner? Of course, as I said before, for this concept to have merit you would have to postulate that the incident in the past done by the time traveler was minimal enough not to cause the new time line to completely change the old one.” “That is a very interesting concept indeed, John,” said Julie, “but until we get a time machine, we’ll never know if your theory is correct or not. I’m afraid I’ll have to go along with the psychiatrists’ explanation until we get the proof from that time machine and the time travelers you theorize about.” “Julie,” replied John, “now that we’ve finished another of our great discussions and you’re here to stay in my apartment, I’d like to show you my lab in the basement. Do you remember when I told you I’d show you where I went on those short absences I often take from work? Well, tonight’s the night. Come with me.” “Well, you’re very mysterious tonight, John,” Julie smiled. “Lead on!” John unlocked the door to the cellar and proceeded down the stairs with Julie right behind him. As she reached the bottom of the stairs her eyes widened and she looked around in amazement at three walls of blinking lights from an enormous machine! On the middle wall were two chairs side by side and connected to the rest of the machine by many tubes and wires. Was John a time traveler and was this his time machine? “What century would you like to visit tonight, Julie, my love?” smiled John. Off Call: My Trip to Cremona,
Italy - The Violin and its Birth Place It was just three months ago that my family traveled to the Netherlands to visit my in-laws. My wife and her family emigrated from Vietnam to the Netherlands about 25 years ago. I told my wife that no matter what else we do this time I have to visit Cremona, Italy ~ the place where violin makers started to craft violins about 450 years ago. I am an amateur violinist. When I was a teenager, my dream was to become a violinist. It did not work out for me so I became an ophthalmologist. We traveled by car from the Netherlands, crossed Belgium, Luxemburg, Germany and Switzerland to Northern Italy. We arrived in Milano late the next evening. The traffic in the city was very chaotic for people unaccustomed to driving in five-car wide traffic on a street with three lanes. The cars zigzagged in back and in front of us. I navigated, and my wife was the driver. The next day we headed for Cremona, about 100 km southeast of Milano. It is a nice and quiet medium- sized town. The weather was enchanting, not too hot and not too cold. The locals were very friendly and gave us directions to the Stradivarian museum located in Cremona. They were talking Italian, and we were speaking English. Through gestures, pointing and a few shared words we managed to understand each other. First we went to the museum of Cremona where they display the tools used to make violins, show a video of the history of violin, and exhibit a collection consisting of lesser known violins and violas. When we arrived at the square of Cremona, it was about 4:30 pm. Many people were sitting outside, relaxing and enjoying the sunset. The square remains as it was four hundred years ago. There is a Cathedral (Duomo) on the east side. The west side is Town Hall. There is not a single new construction. In the Town Hall about 15 violins made by the famous Amatis, Stradivari and Guarneri are kept in the Violin room under heavy security. We spent about an hour in the room just looking at these 15 violins and 2 cellos. It puzzles me that even though I have seen many violins before and even though I have read a lot of books about them, I could still not tell the difference between a million dollar masterpiece and my thousand dollar violin. Andrea Amati (c. 1500-1577) was the first violin maker in Cremona. He was the person who started to develop the modern violin-making methods which are still practiced today. He had two sons, Antonio (1540-1607) and Hieronymous I (1561-1630), who both learned the violin-making from his father. One of Hieronymous I’s children was Nicolo Amati (1596-1684), who became most well-known violin maker of the Amanti family. Nicolo had many pupils, including the two most famous violin makers of all time: Andreas Guarneri (1626-1698) and Antonio Stradivari (1644-1737). Stradivari is considered the greatest violin maker of all time. Today, one of his violins would cost about $1 to $2 million. There are still quite a number of violin makers in the city. The price of their violins ranges from about $1,000 for a simple one to $15,000 for a better one. After I saw the violins, I felt I could go home with a sense of great satisfaction and with my purpose for the trip to Europe fulfilled. When we came back to my in-laws’ home, our son Thomas (who just turned 2 years old before we went to Europe) was so happy to see us. He missed my wife so much and from that time on, he just followed me every where just to make sure that he would not be left behind again. Our daughter Victoria (at that moment she was almost 12 months) did not recognize us at all after 5 days and looked at us like we were strangers.
Tomatoes - Lore, Legend and Recipes Until the end of the eighteenth century, physicians warned against eating tomatoes, fearing they caused not only appendicitis but also stomach cancer because of tomato skins adhering to the stomach mucosa. As the story is told, Colonel Robert Johnson of Salem, N.J. brought the tomato plant home from abroad in 1808. To prove to the public that the plant was not poisonous and was safe for consumption, Colonel Johnson stood o the steps of the Salem courthouse and bravely consumed an entire basket of tomatoes without suffering any ill effects. This attracted a crowd of over 2,000 people who were certain that he was committing public suicide. The local firemen’s band even played a mournful dirge to match the somber event. By 1842, farm journals were touting the tomato as the latest craze and America’s love affair with the tomato was off and running. The tomato is a fruit and can be further classified as a berry since it is pulpy and has edible seeds. In 1893, an importer claimed the tomato as a fruit in order to avoid vegetable import tariffs imposed by the United States. This dispute led to the Supreme Court ruling that, for taxation purposes, the tomato should be classified as a vegetable, since it was primarily consumed in the manner of a vegetable rather that a of fruit, which was usually used in desserts. Cooking Tips and Hints
Recipes Here are two of my favorite recipes using garden ripe tomatoes. Don’t bother making these with store bought tomatoes. Both recipes are easy to make and a great summer treat. Pasta Primavera 3 cups ripe cherry tomatoes cut into quarters Mix all ingredients in a bowl and let stand at room temperature for at least 2 hours. Pour over freshly cooked pasta. Mix well and serve immediately. (I like to use rotini). (I like to substitute artichokes ~ try Birds’ Eye frozen artichokes ~ for the black olives; microwave them on high for 8 minutes and drain before adding to the mix.) Pasta Puttanesca 1 ½ lbs very ripe fresh tomato Rinse and peel tomatoes. Add all ingredients to blender and puree until blended well. Refrigerate for at least 2 hours. Pour sauce over hot pasta. Mix well and serve at once. (Use pasta suitable for catching sauce – penne, rotini or small shells.)
In Memoriam Rajesh Sharma, MD Dr. Rajesh Sharma, 51, of Berlin, MA, a loving father and husband, tireless worker, and visionary thinker, passed away on March 9, 2006. He lived a vibrant life and leaves a lasting legacy. Rajesh’s first priority was always his family, and he worked selflessly to build a life for his mother Suraksha, wife Saroj, and two sons, Gaurav and Shivam. In more than two decades as a physician in Central Massachusetts, he touched thousands of people with his warmth and wit ~ from colleagues and patients to neighbors and friends. He will be remembered as a man of great compassion, always willing to lend a helping hand to others around him, a value instilled at a young age by his parents. Rajesh was passionate about his job and distinguished himself as a first-rate gastroenterologist at area hospitals, earning the title of Director of Gastroenterological Endoscopy at Hubbard Regional Hospital. Even as he found tremendous success in his own career, Rajesh never hesitated to offer his mentorship to young aspiring physicians, serving as an assistant professor at UMASS Medical School and an attending gastroenterologist in the UMASS Memorial Health Care system. Rajesh was full of energy, and his presence was always felt from the moment he entered a room. His interests were broad ranging: In a single conversation he could cover everything from medicine to world religions, all delivered with his trademark sense of humor. He knew something about everything, and was a voracious reader. In one day, he could accomplish more than most people could hope for in a week. Rajesh lived life to the fullest and inspired others around him to do the same. As he leaves us, may his soul find peace. “Everything I’ve ever wanted I have, because everything I don’t have, I realize I never wanted badly enough.” – Dr. Rajesh Sharma “He was more like a best friend than a father. I could talk to him about everything, and he looked to me for friendship. That’s why I loved our relationship. He never told me how to act or what to do. He led through the example of his life, and I learned so much from watching him. He built such a strong character in each of us that will carry our family though this tough time.” – Gaurav Sharma |