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Worcester Medicine
Editorial
School Violence, A Public Health Issue Guns, Gangs, and the Culture of
Violence
Responding to School Violence School Violence and Bullying: K-6 Awareness and Prevention Violence on Campus
and at the Clinic Gun
Control and Mental Illness Legal Consult Financial Advice for
Physicians As I See It Off Call In Memoriam Society Snippets President's Message Dear Colleagues, Our “Community Immunity” project scheduled for Saturday, October 13, 2007, demonstrates the greatest benefits of belonging to our district. This project propels our mission to educate the community on health issues in ways seldom matched. We have assembled leaders from the Worcester Division of Public Health, the Medical Reserve Corps (MRC), Metropolitan Medical Response System, (MMRS) the WDMS Alliance, the University of Massachusetts Medical School and the Graduate School of Nursing, the area colleges and private industry. We have met with common purpose every other week for a year and a half to develop herd immunity against the Seasonal Flu. I know of no other organization with the ability to pull these diverse institutions together to achieve such goals. Now I challenge the membership to do its part. Please consider registering to volunteer on October 13th and signing up for the MRC. In other matters, we have created the Partnership for a Healthy Community, which includes representatives from all the major health systems. We have had an initial meeting and have identified an area of common concern: Patient information exchange for all physicians. Under the able leadership of Dr. George Abraham, we are exploring the development of a city-wide, secure e-mail system that would enable physicians to share information. When operational, every physician could e-mail other physicians regardless of affiliation. All the participants agreed that such a system would save their institutions time and money. Who but WDMS could pull the community together this way? We continue to work for you and with you. We are heartened by the hard work of the members who work on these projects. We hope to provide other similar projects that engage you, our members, in meaningful ways. We look to you for ideas for more projects. We look to you to join our efforts on October 13th. Editorial: No More School
Violence One thing that most parents count on is that when you send your child off to school either by bus or by driving them yourself, you plan on your child being safely ensconced in a building whose purpose is to educate, cultivate friendships with schoolmates, and perhaps develop extracurricular talents in music, arts , sports, etc. You expect the day to be busy, informative, fun and ~ most basically ~ SAFE. With the recent tragedies of Columbine and Virginia Tech, and the more local tragedy at Lincoln-Sudbury High School, there is an increasing sense that schools are no longer the safe havens they once were. As the Director of the Pediatric Trauma Program at the UMass Memorial Children’s Medical Center, I can attest to the fact that we admit roughly 400 of the 500 patients yearly that arrive to us by ground ambulance or helicopter or by parent’s private vehicle. There is a small number of these who are sent to us from school settings. Over the years, we have seen a shift from simple playground/sports related injury at school or the occasional mishap with school bus/pedestrian related injuries to an ever-increasing number of admissions because of assaults and over zealous-horseplay. The reasons for this shift are probably too many to review here. Some blame media-induced exposure to violent acts; current estimates are that the average child may witness tens of thousands of such events yearly by watching an average of 4 hours of TV a day. Or is it because of the availability of violent video games to which many children are drawn? And what is the effect of the gangsta rap form of music video in which misogynistic, homophobic, and violent messages are promoted because of their “coolness?” In our more urban schools, gang influences have certainly become a major factor in promoting a culture of violence amongst children as young as middle-school age. According to the Gang Task Force of the Worcester Police Department, there are an estimated 30 gangs active within the Central Massachusetts community. With this type of background noise, the increase in school violence that we are observing doesn’t seem that mysterious. To address the issues of school violence, Worcester Medicine has assembled a panel of experts representing the perspectives of teachers, police, primary care physicians, psychiatrists and other health care professionals. We don’t know if we can answer the question “Could it happen here?” but we hope to present some ideas about early warning of potential problems and some preventive solutions to help avoid tragedies that are becoming an ever-increasing part of headline news in this day and age. Let’s hope this will help us renew our commitment as a community to keeping our schools as bastions of learning and safety for our most precious commodity: our children. Warning Signals of
Violence in Disturbed Youth School violence has occurred in schools in many varied communities and has become a major public health issue. What are some of the warning signals of violence in disturbed youth? How are the rights of privacy balanced against the needs for public safety? What preventive measures can be taken by family, friends, and school personnel to help decrease the risk of school violence? Below are some thoughts about a complex area with no easy answers, based on my knowledge of literature and clinical experience over the past 25 years. Warning Signs Some youth who are violent in school may be expressing violence within a gang framework in which the violence is socially sanctioned within the gang. These youth often need legal containment to maintain public safety, although with treatment ~ including family/community involvement ~ they may regain a more prosocial developmental pathway. Many youth involved in school violence, however, have no gang involvement. Rather, they are often socially isolated and frequently have been the victims themselves of bullying or more subtle forms of social ostracism and ridicule. In general, violent youth often have histories of previous violent behavior or threats of violence either towards themselves or others. Youth at risk of violence have increased risks both of suicidal and homicidal behaviors. The history of aggression toward others may date from a young age; indeed, prospective studies have found that aggressive behavior towards others in the preschool years is a powerful predictor of likely aggressive behavior towards others during the teenage years. Isolation from supportive peer relationships may be intensified in youth at risk by alienation from parents and/or exposure to domestic and/or community violence. Judgment and impulse control may be impaired by the presence of substance abuse. Comorbidity psychiatric illnesses including, amongst others, bipolar disorder and acute or post traumatic stress disorder may further impair judgment and impulse control. Probably the most important warning sign for violent behavior is access to a means for the violent behavior. Firearms are far and away the most frequent method for successful suicide and homicide. Access by youth to firearms must be as strictly controlled. However, guns are ubiquitous in youth culture, particularly in communities where community violence is more prevalent. A great difficulty in predicting violent behavior in youth is that while the risk factors noted above are not uncommon, the actual incidence of school violence involving life-threatening assault or suicide attempt is rare. Youth who are preoccupied with thoughts of death, who talk, write or draw about themes of suicide, murder or assault/mutilation, are communicating their sense of despair and their need for increased support and connection. It is essential that youth who have the above risk factors not be pre-judged as criminals, but rather seen as vulnerable youth in need of additional supports. Privacy versus Public Safety The recent murder in the Sudbury schools, allegedly by a student who had communicated thoughts of aggression towards others to a counselor, raises concerns regarding balancing the rights of privacy of the individual against the needs for public safety. When there is a specific target of violence and a feasible means identified by the youth, the duty of the professional to warn the potential victim is clear, as established in the Tarasoff ruling. The professional’s question of what constitutes a “duty to warn” parents regarding a youth’s revelation of threats of unsafe behavior is a difficult one to answer. It is a judgment call, but the effort should be to alert parents about safety concerns for their children and to enlist their help on gaining additional support for the youth. Preventive Measures Primary prevention involves promotion in the youth’s community of a strength-based, non- coercive culture of mutual respect for individual differences. Bullying must be limited. Zero tolerance for violent behavior is fine, but it must be accompanied by adequate supports in response and cannot just rely on punitive sanctions. Parents may need support to engage in non-coercive parenting. More immediately, limiting unsupervised access to guns is extremely important ~ as is greater availability of mental health treatment and other community supports for youth at risk. Metal detectors have been employed in some schools. This is a local decision, but one must not underestimate the adverse impact of public safety on privacy when students must submit to metal detection upon entry. This kind of surveillance is at odds with a non-coercive culture. Of greatest importance is support for communication with the youth about his or her violent urges. Such communication can help identify unmet underlying needs prompting the aggressive impulses or behaviors in order to find better solutions for those needs. Dr. Metz can be reached at peter.metz@umassmed.edu Guns, Gangs, and the Culture of
Violence In terms of gun assaults per 100,000 residents in Massachusetts, the City of Worcester is second lowest to Lowell. The rates for several cities are Lowell (51.7), Worcester (56.3), Boston (107.8), Brockton (109.4), and Springfield (212.3). In fact, the June 18, 2007 edition of Time Magazine reported that the City of Springfield is the 15th most dangerous city in the country. One reason for our success in making Worcester a relatively safe community is that we recognized the emergence of gang activity some 15 years ago and made a strategic investment to address this issue. Our early gang strategy focused on developing intelligence and engaging in enforcement, but we quickly learned that to be effective we needed prevention and intervention strategies. Today we recognize reentry as a fifth strategy. In 2004 and 2005 there were 70 non-fatal shootings and 18 homicides with 12 by means of a firearm in the city. The majority of this violence was concentrated around gangs and occurred over the spring and summer months. In 2005 gun and gang violence was a top priority. In order to deal with this escalating violence we needed to understand the historical trends and demographics. We began to track all shootings and used crime analysis to map the locations and directed police resources into these areas. The gun violence trend reversed in 2006 with 18 non-fatal shootings and 5 homicides with 2 by means of a firearm. Our gun violence response strategy has four components: first, understanding the culture and demographics of gun and gang violence; second, a change in our protocol dealing with non-fatal shootings and homicides; third, a public awareness campaign; and fourth, a focus on prevention, intervention, and reentry. Over the past three years, 80% of our victims and 85% of our offenders were young men of color concentrated within the 21 to 26 year old age group. Most of our victims and witnesses were uncooperative and there was a culture of retaliation amongst this group. We found that while 46 of the 70 non-fatal shootings were unsolved, 43 of the victims refused to cooperate with the police. Further research indicated that today’s victim was tomorrow’s suspect and vice versa and that both the victims and suspects were well-known to the Criminal Justice System. Most of our suspects and victims were on active probation or had prior probation involvement, had been previously committed to a secure facility, and had a felony conviction. In Worcester there are 28 street gangs with approximately 1,000 members and about 5% are considered extremely violent. With regard to our non-fatal shootings, 35% of our victims and 65% of our offenders were identified gang members. From an enforcement standpoint our response to non-fatal shootings is handled in the same manner as a homicide, with significant police resources focused on the uncooperative victims and suspects. Addressing the culture of retaliation and avoiding the escalation of violence is a priority. In January of 2006, we began a public awareness campaign called ASAP (Awareness, Support, Assistance, and Partners). During this campaign we were frank as to the demographics of this violence and the need for community engagement in developing solutions. We presented this information to many segments of the community including the clergy, community leaders, and public health officials. Gun and gang violence in the City of Worcester are concentrated in the 19 to 26 year old age group. There is less violence in the early teen and high school years, partially because there are more school, community, and police programs for young people in the middle and high school age group. In fact, our gang prevention strategies begin with six grade students working in partnership with the Worcester Public Schools and the Boys and Girls Club. These programs include mentoring, a summer camp for inner city youth, numerous athletic programs, and summer employment opportunities. The greatest challenge for our community is finding resources and programs for young people who are no longer supported by programs appropriate for high school aged individuals. Through grant funding we have targeted this group of predominantly young men of color who are gang affiliated or involved. Many of these young men have criminal records, limited education, and/or no job training or employment skills. Working in partnership with the Worcester Community Action Council we provide employment, job and skill training, GED classes, mental health counseling, mentoring, and transportation. Our goal is to reduce recidivism, gang involvement, and a destructive life style and replace them with employment, education, and hope for a safe and productive future. Chief Gemme can be reached at gemmeg@ci.worcester.ma.us Responding
to School Violence David Keller MD is a Clinical Associate Professor of Pediatrics at UMass Medical School who teaches and practices at South County Pediatrics in Webster, MA. He is the recipient of a Physician Advocacy Fellowship through the Center for Medicine as a Profession, formerly known as the Soros Advocacy Fellowship. Villager: An eye for an eye, and a tooth for a
tooth. Schools should be safe places in which our children can learn. Many families in my practice, however, see school as a dangerous place, where violence and even death can come without warning. The reality is somewhere in between. The National Center for Educational Statistics’ 2006 report1 showed that violent deaths are exceedingly rare. In 2005, there was 1 non-accidental death in school for every 2 million students enrolled per year. Put another way, a school of 1000 students will lose a student to violence every 2000 years. Other forms of violence, however, are more common. That same report found that 4 percent of students aged 12-18 reported being victimized in the past six months. While this is less than was reported in 1995, it is still too much. In a school of 1000 students, that means that 30 would have reported a theft and 10 would have reported “violent victimization” over the past school year. Only a few of those would have involved serious violent crime (rape or assault). The most prevalent form of school violence is psychological, not physical, particularly in middle school. In the report cited above, bullying (42%), acts of disrespect to teachers (32%), and undesirable gang activities (31%) were exceedingly common. These numbers may be a factor in the observation that one of every eight children between the ages of 9 and 17 meets criteria for some sort of anxiety disorder.2 In my Pediatric practice, I hear parents respond to school violence in a number of ways. Some try to keep their child safe through supervised activities, scheduling (and over-scheduling) their days with school, sports, music, dance and other activities. Others keep their children at home, feeling that it is safer to play video games than risk the bullies of the playground. Others encourage their children to "fight back" to defend themselves; one gave a 13 year old the key to gun cabinet in case he was assaulted at home. What is the right response to what some have called "a culture of fear?"3 I think that one needs to get past the idea of retribution. As Tevye said in Fiddler on the Roof, revenge is a short-term response that ultimately leads to more problems than it solves. Humans are social creatures and young humans need to learn how to interact in ways that create healthy social networks. We need to teach our children how to cope with conflict in ways that allow them to thrive. The study of resilience in childhood shows that those who have thrived despite adversity have three protective factors that seem to be associated with success:4 Caring and supportive relationships: If children can identify one adult besides their parent(s) to whom they can turn for help, they are much more likely to make through the rough spots. Positive and high expectations: Successful adults can always name the adult who believed in them when they were young and inexperienced, and can discuss the ways in which those high expectations led to success. We need to believe in our youth in the same way. Opportunities for meaningful participation: It’s always better to be part of the solution rather than part of the problem. Many, including the American Academy of Pediatrics5, the American Psychological Association,6 and the Health Resources Services Administration7 have offered advice on how to operationalize these concepts. Here are some points that I try to incorporate into my discussions with families about school violence: Listen to your child: At the heart of a caring relationship is listening. Make time in the day to hear about school and the things that are happening therein. It really is the only way to know what is going on in your child’s daily life. Help them to sort it out: We all learn from experience, generally our own experience. The learning is in the process; expect children to develop workable solutions. Model constructive participation: Go to the parent conferences, join the PTA, help the band organize a trip or sell refreshments at the football games; your involvement teaches kids how to be involved. Like Tevye, I think that the answer to school violence is to reframe the question from “Who is the winner?” to “What can I do to help?” References:
School Violence and Bullying: K-6 Awareness and Prevention The Elm Park School is an urban elementary school in the heart of Worcester that has been a very progressive partner with the Worcester District Medical Center Alliance in looking at means of health/wellness promotion and obesity and injury prevention. We asked Sharon Rogan, MA, Behavior Specialist at Elm Park Community School who teaches “Steps to Respect,” a bullying prevention program, and facilitates “Second Step,” a violence prevention program for children in grades K – 6, to answer some questions that would give us the frontline perspective on violence in the school setting.
Violence on Campus
and at the Clinic On April 16, 2007 the country was stunned as it watched the tragedy at Virginia Tech unfold, rekindling long dormant memories of a similar school tragedy at Columbine High School in Colorado. In the aftermath of the Virginia Tech shooting, where an armed student killed 32 fellow students and professors, colleges and universities across the country convened their crisis management teams and reviewed their emergency protocols. The purpose of these meetings was to determine if individually and collectively they were prepared to meet the omnipresent and ever-evolving threats to campus safety. During a meeting on April 26, 2007 at Clark University, local law enforcement authorities shared with administration and public safety officers from area campuses the importance of developing a functioning and applicable crisis management plan ~ including active shooter responses. An active shooter response involves the primary institution being able to respond quickly and initially to an armed and engaged suspect on its campus with the local authorities arriving to provide support and back up. The intent is that the institutional officers possess the most knowledge about the facilities of the impacted campus. The thirteen member institutions of the Colleges of Worcester Consortium represent a diverse spectrum of academic disciplines. The University of Massachusetts Medical School and the Massachusetts College of Pharmacy and Health Sciences (MCPHS) combine a traditional educational setting with a robust clinical environment, thus posing some unique challenges to their public safety officials to provide a safe learning and practice environment to their learners, teachers and patients. Similar to the other colleges, both UMASS Medical School and MCPHS must prepare for both internal and external threats to their communities. The primary goal of campus public safety officials is to provide for a safe and secure learning and practice environment. Collaboration between campus departments and constituencies and their ability to share critical information are essential in responding to and preparing for behavioral, mental health and communicable illness crisis. Judith Schubert, president of the Crisis Prevention Institute, agrees that collaboration and cross training is essential in the prevention of disruptive or violent outbreaks by internal constituencies. Stating in an article for Hospital, School and University Campus Safety Magazine (May/June 2007), Ms. Schubert claims that “…healthcare workers, police and security personnel greatly benefit from training on how to appropriately deal with patients, visitors, and even other employees who become disruptive or violent.” Ms. Schubert continues, “If training is not delivered properly and to the right people than serious issues can result.” One of the many security pitfalls that institutions often experience is training their security or police personnel only to handle crisis situations. While admittedly a sound practice, this narrowness of training is viewed by many experts as being incomplete. In most circumstances, it is the staff, faculty, clinicians or physicians who are most often interacting with an individual when he or she becomes irrational and potentially violent. Initial responses can be critical in diffusing a situation. In the continuing aftermath of the Virginia Tech slayings, the issues of mental health and how colleges and universities address them was brought to the public consciousness. At the heart of the dialogue was the issue of an institution’s responsibility to inform its constituents of the possible violent outbursts of students who may exhibit particularly violent tendencies. The ability to balance the protection of a student’s right to privacy and the responsibility to inform key constituents of the potential threat are developed through deliberate planning and preparation for such scenarios. Recent research has acknowledged that staff, faculty and clinicians working in healthcare institutions are at a great risk for experiencing work related violence. This violence typically takes the form of assault. Lipscomb and McPhaul assert: “…workplace violence is one of the most complex and dangerous occupational hazards in today’s health care environment…Agitated clients in mental health facilities and the emergency department, demented elderly patients in medical and geriatric wards, nursing homes and rehabilitation centers, and any patient with a history of assault in mental health, hospital care, and community health are common sources of verbal and physical violence against nurses and other health care providers.” These situations are not just police matters. Appropriate training, compilation of a safety master plan and installing of appropriate safety technology are all essential components of addressing potential violent incidents. Are classrooms, labs and clinics equipped with e-phones for emergencies? Do supervisors and department heads have alarm notification capabilities to inform faculty and staff that a critical incident has occurred? Can rooms, labs and buildings be locked – down denying external access? These are but a few technological responses to and prevention of internal emergency situations. Since the Virginia Tech incident some colleges and universities have initiated communication systems that alert their faculty and students of emergencies by sending text messages to their cell phones while at the same time alerting external communities via postings to their websites. Many hospitals, clinics, and campuses frequently acquire new property and build additions, and with each new area security risks emerge. The challenge of maintaining access for the public and for employees and also of providing a secure environment becomes more difficult as the threats to public safety evolve. In the post 9/11 era, external perimeter protection is essential for institutions such as hospitals, clinics, colleges and universities. Advancements in perimeter protection technology are evolving to keep pace with the increased safety demands. New technology such as compressible sidewalks, rotating barriers and aesthetically sufficient safety nets are the latest in perimeter technology. These technologies are being paired with fingerprint access and other entryway access to provide adequate safety to campuses and institutions. School, clinic and workplace violence is not an isolated issue; it is a community and public health issue. Solutions for reducing and responding to such violence should also involve multiple facets of each institutional community. As health care professionals, any different response would be contrary to what it means to be a health care provider. References: Allen, Mark (May/June 2007).
Alternatives in Physical Perimeter Protection. Campus Safety Magazine.
Retrieved from Campus Safety Magazine.Com Gun Control
and Mental Illness The tragedy of Cho Seung-Hui’s killing 32 people and wounding 17 others before killing himself on the campus of Virginia Tech University has prompted an outpouring of well-intentioned responses trying to ensure that the possibility of such an event occurring again will become even more remote. Unfortunately, the call for stiffer gun control laws focuses not on the actual risk posed by guns, or the individuals who use them illegally, but rather on a category of persons ~ persons with mental illness. The Gun Control Act of 1968 [18 U.S.C. § 922(g)(4)] makes it “…unlawful for any person…who has been adjudicated as a mental defective or who has been committed to a mental institution… to ship or transport in interstate or foreign commerce, or possess in or affecting commerce, any firearm or ammunition; or to receive any firearm or ammunition which has been shipped or transported in interstate or foreign commerce.” Due to the fact that most states, including the Commonwealth of Massachusetts, do not report the fact of civil commitment to the federal database, enforcement of the statute usually occurs as an add-on to a prosecution for another crime. Several proposals have been introduced in Congress to require states to report to the federal database the names of persons ever committed, whether voluntarily or involuntarily. The current rush to judgment of an entire class of people because of the actions of one brings to mind the admonition of Justice Brandeis writing in dissent in the 1923 United States Supreme Court decision of Olmstead, et al. v. United States; (277 U.S. 438), the makers of the Constitution, “…conferred, as against the Government, the right to be let alone -- the most comprehensive of rights and the right most valued by civilized men.” He was addressing the need for government wiretaps in criminal cases and the impact on the Fourth and Fifth Amendments to the Constitution. The principle applies equally to any loss of a substantive right. This holds true regardless of the nature of the harm sought to be controlled. As Justice Brandies went on to note, “Experience should teach us to be most on our guard to protect liberty when the Government's purposes are beneficent. Men born to freedom are naturally alert to repel invasion of their liberty by evil-minded rulers. The greatest dangers to liberty lurk in insidious encroachment by men of zeal, well-meaning but without understanding.” This is not to say that some persons with mental illness are not at grave risk from being in possession of firearms. Persons who are suicidal, for example, may be at an increased risk for harm if permitted access to firearms. And some persons with delusional beliefs or command hallucinations may also present an increased risk for harm if given access to firearms. Legal history offers numerous examples of the criminal justice system being brought to bear on the system of mental health care. In 1676, the Massachusetts Bay Colony authorized town selectmen to care for individuals deemed “dangerously distracted” so that they not "…dumbify others."1 The solution to the lack of care options and the perceived contagiousness of mental illness was incarceration. If we are to mandate reporting of civil commitments with the consequence of loss of any liberty, then we must ensure that the cure actually addresses the ailment and that there are adequate procedural protections to ensure that those affected have an effective method for demonstrating that they pose no risk. Unless and until we as a society decide that no one should be in possession of a handgun, then depriving any individual of his or her equal rights should come with due consideration to process and to the relation of the compelling governmental interest being asserted. References:
Legal Consult:
Let's Talk: Fostering Communication to Keep our Kids Safe Responsive, secure and accurate communication among parents, school officials, physicians and counselors may reduce the risk of outbreaks of violence by students who are at risk for such behavior. Caregivers who are interested in fostering such links have to traverse a minefield of legal obstacles, however. Nevertheless, the promise of electronic communications technology to enable effective collaboration among those concerned about students at risk of violence is worth exploring. Recent studies have shown that the most prevalent type of school nurse encounter with students, other than episodic care such as illness assessment or first aid, is medication management. Among Massachusetts students on daily prescription medications, psychotropic medications are by far the most common. Yet, the trend toward the use of one-dose, slow-release psychostimulant drugs (such as Ritalin) means that some medications administered at home are not reported to school nurses. Thus, although medication management may be a very significant part of school nurses’ duties, the need for such management may be underestimated, and critical information may not get into the hands of school personnel. Keeping kids safe at school under such circumstances is made more difficult when appropriate clinical information is fragmented, disorganized or inaccessible to those who need such information in time to take action before problems erupt. School nurses and other personnel have current information on student behavior, counselors have information about personal and family dynamics, physicians have medication and other medical information, and parents have their own observations. Sharing these disparate types of information in a timely, secure and useful way among all concerned could be an important tool in preventing outbreaks of school violence. Various proposals have been made to create what have been called regional health information organizations, or community-wide health information systems, which could create clearinghouses for sharing of clinical, behavioral and other types of information. In outline, the creation of such organizations is relatively simple – a new entity which contracts with one or more technology vendors that creates and maintains the technological infrastructure, and then various interested parties who subscribe to the new entity for access to the shared informational resources contributed by the subscribers. In some cases, the organization is virtual in a legal sense – there is no new, separate legal entity, just a series of contractual agreements among the various parties to provide information and resources to the enterprise. However, a host of legal issues must be confronted in order to create this type of collaboration. For example, antitrust laws make unlawful unreasonable restraints of trade, and a joint venture entity that excludes certain potential members might be accused of engaging in cartel conduct. To avoid this issue, such organizations must integrate members’ resources to create services that the individual members could not provide individually; also, care must be taken to ensure that appropriate rules are enforced regarding the admission and exclusion of members, the types of information shared in the network, and the pricing of the enterprise’s services. Likewise, the various federal and state fraud and abuse laws may discourage the participation of hospitals in such collaborations when referring physicians are involved. Under the so-called Stark II law, there is an exception that would permit hospitals to provide information technology resources to physicians who refer patients to the hospital, but only if such items and services are limited to those necessary to participation in a community-wide network and if the network is open to all providers, practitioners and residents who wish to participate. Uncertainty over how to interpret such rules must be resolved before providers can be comfortable proceeding with information-sharing networks. Carefully limiting the scope of use of the technical infrastructure to its core purpose and not the private practice needs of the participants, and providing wide access to the network in the community, may alleviate some of the anxiety over such legal restrictions. Health information privacy and security laws and regulations have a significant impact on such systems. Careful consideration must be given to whether the organization will act as a warehouse of protected health information or serve as a directory or bulletin board service among providers and others. If protected health information is to be stored and accessed, steps must be taken to ensure that appropriate access to the minimum necessary information is provided to only those with a verifiable identity and need to know such information. These issues can be dealt with through technical means such as two-element authentication and through contractual arrangements such as business associate and data use agreements. If the collaborative enterprise is to be structured as a tax-exempt, non-profit in order to attract charitable contributions, care must be taken to ensure that the community at large receives the benefits of the organization. Otherwise, if only the participants derive benefit, the organization may have its tax-exempt status endangered because of the private inurement /private benefit doctrine. Finally, data ownership and intellectual property issues must be resolved. For example, does the organization obtain some form of ownership over the clinical and other data contributed by the various participants? Is a medical record created – and if so, whose is it? Who owns the copyright on the software? If there is the potential for a business process patent on the overall system, who has a claim to ownership of that piece of intellectual property? Although the legal obstacles are many and varied, they should not prevent the creation of the types of collaborations that may enable those who care for our children’s health to share vital information that helps keeps kids safe. Financial
Advice for Physicians: What Type of Bridge Are You Building? Stock markets stumble. Life expectancy is longer. You hope to retire someday. Social Security may run dry. Deductible retirement contributions are limited. Your future is coming. You can control how much you save and where you invest it. Beyond that, you are dealing with an uncertain future. Like a good engineer designing a bridge, you want to over-engineer the load bearing elements so abnormal stresses won’t cause big problems. And, as has been stated in previous articles, it is safe to say that future costs for many key items (such as taxes and healthcare) are going to be much more expensive than most people realize. In retirement planning, this means that saving too much will not get you in trouble. To do this right you need to plan for your retirement future during your working life. You can do this yourself or get some professional planning help. In developing your gameplan you should assess where you are today, project where you want to be, and address the obstacles that might stand in the way. “Lifecycle” planning is the current nomenclature. As a physician, your income comes from work you perform, which we’ll call human capital. Think of your paycheck as bond coupon payments providing a steady stream of income. At retirement, the bond coupon payments stop and in most cases there is no maturing bond principal (sale of your practice) to invest. Are you saving and investing enough of your human capital income to generate the retirement income you’ll need? Most people are not. Unfortunately, the government is not really encouraging high earners like doctors to save enough. Someone earning $100,000 can save up to 15.5% in a tax deductible 401(k) while a radiologist earning $400,000 can only save 3.8% in her 401(k). Government incentives should not drive your retirement savings program, your projected needs should. Physicians Insurance (PIAM) helps doctors whether they work for non-profits (hospitals, clinics, schools, or governments), pass-through entities like S-Corporations, LLCs, and Partnerships (most practices), or C-Corporations (some larger practices). Planning for doctors working for non-profits or S-Corps, LLCs, and partnerships will be the focus of the remainder of this article. You will want to establish an annual household savings objective which should be tied to your projected retirement income goal. Government sponsored retirement plans, called “qualified plans,” like 401(k), 403(b), and profit sharing plans, all with deductible contributions, should be funded to the maximum by you and your spouse. These plans also have tax-deferred growth while the money is accumulating. Taxation occurs only when money is withdrawn. Whether a profit sharing plan is economical for your practice depends upon the contributions required for non-owner employees. Your CPA or PIAM can help you determine these numbers. Nonprofit employees are given an extra tax deductible retirement saving vehicle called a Section 457 Plan. Hospital and clinic doctors can basically save up to an extra $15,500 of tax deductible retirement funds annually. PIAM can help nonprofits establish these special plans which look like and are invested like 401(k) plans. The simplest Non-Qualified Deferred Compensation (NQDC) plan to establish and administer is an Executive Bonus (Section 162) Plan. For doctors working for pass-through entities the funding is not tax deductible. This is because the entity and the doctor are treated as one tax payer. Profits in the practice are taxable income to the doctor whether they are paid to him or remain in the practice. This Executive Bonus plan can be selective and is used to attract new physicians, retain physicians, or reward founders or senior partners. These plans can help fund retirement payments for a retiring partner from age 66 to 80. The funding can be accomplished during the last years of the partner’s participation, for instance from age 56 to 65. The practice deducts the payment and the future retiree receives it as bonus taxable income. This pre-retirement funding can build a greater value for the retiring partner’s ownership interest than an Accounts Receivable Recovery program or a future earnings formula might provide. The investment of choice in these plans is life insurance. Corporate America uses life insurance in the SERP (Supplemental Executive Retirement Plan) arrangements because of insurance’s great tax advantages and excellent asset protection. While not getting deductible funding, the insurance account grows tax deferred and allows tax free access to much of the account’s value. Also, the life insurance can be designed to emphasize the investment component of the account and minimize the insurance part and its accompanying expenses. Be proactive. Consult with your partners, talk with your spouse, engage your advisors, be realistic with yourself, and give this issue the attention it needs. It’s your bridge to build and your future is coming. Michael Halloran represents PIAM, a subsidiary of the Massachusetts Medical Society. He is a Certified Financial Planner™ and Wealth Protection Alliance Member. He holds a Bachelor of Science degree in Electrical Engineering from Cornell University and a Master in Business Administration from Harvard University. Mike is available to meet with your practice or your department. He can be reached at: 8 Grove Street, Suite 300, Wellesley, MA 02482; 781-431-8800 or by email: PIAMrequest@halloranfinancial.com.
As I See It: Relationship Between Physicians and
Drug Companies Raises Questions Current medical journals and the popular press carry numerous articles about the relationships between the drug manufacturing industry and physicians. Newspapers and computer screens roar with disturbing headlines: “Doctors reap millions for anemia drugs,” “Pills for Patients, Payday for Docs,” “Posing as Pals, Drug Reps Sway Doctors’ Choices.” The perception of physicians created by these stories raises many questions. It often appears that physicians and pharmaceutical companies are engaged in an unholy alliance where greed and money rule. Some reports would have you believe most doctors are checking patients with one hand and looking for a handout with the other. It’s true that some physicians (as well as drug company representatives) may lose their ethical compass from time to time. Thankfully, though, the overwhelming percentage of my profession is populated with good, honest, decent, and caring people. Even within the profession, bona fide differences of opinion exist about the physician-drug company relationship. Purists believe that no connection at all should exist between drug representatives and doctors; even the acceptance of a pen or pad of paper should be unthinkable. Others think pharmaceutical representatives serve a beneficial purpose in the continuing education of doctors about new drugs and therapies. The physician’s situation is further complicated by the seemingly incessant direct-to-consumer drug advertising, with the tag line “Ask your doctor.” Physicians are often pressured by patients’ demands for the latest drug, even though a time-tested, less expensive medicine may be more appropriate, effective, and assuredly safe based on experience. The reality is that most physicians will act in the best interests of their patients within the bounds of the many regulations and restrictions put on the profession and in accordance with their own consciences. There’s good reason why physicians must be licensed to practice. But some perspective is needed on this topic of relationships. Business ethics and medical ethics are different. What business considers normal, medicine may often consider unethical. In business, it is common to reward and entice to stimulate sales. Medical ethics prompts physicians to consider that if promotional activities were eliminated, the savings could be used to lower the cost of drugs. However, let’s remember that the medical achievements of the 20th century have been spectacular. Both our personal and public health are at levels of care never before imagined. Vaccines have eliminated diseases such as poliomyelitis and smallpox and now prevent ones like influenza and whooping cough. New developments will protect against shingles and meningitis. Organ transplantation is now common, and lifespan has increased. Advances in technology have allowed us to diagnose and treat diseases earlier and faster, continuing the chances of a better outcome for patients. Millions of lives have been saved, and much suffering has been averted. The drug companies have played a major role in the evolution of this story. To continue the progress of medical discovery, the pharmaceutical industry and the medical profession must work together in a relationship devoid of self-interest and greed. It should be all about the patient and the betterment of health and relief of suffering for everyone. Indeed, the Pharmaceutical Research and Manufacturers of America in 2001 aligned itself with the American Medical Association in defining acceptable guidelines regarding gifts to physicians. So where does the patient fit in? With the soaring cost of health care, everyone should become more cost-conscious, especially about medicines because no other product is purchased so blindly. Patients can begin by taking better care of themselves. To begin, maintain a proper diet, get ample exercise, and avoid high-risk behavior. Follow through with periodic medical check-ups and screenings. The healthier we are, the fewer drugs we need. If you do need medicines, discuss with your physician the most appropriate medicine for your condition. Don’t be dazzled by the latest drug advertisement. Often, the tried and true may be the best for you. I believe the principles I learned in medical school many years ago hold true today: prescribe as few medicines as possible, and when doing so, use medicines that are therapeutically effective, have a wide margin of safety, and cost the least. That approach should work best for both physicians and patients. Dr. Leonard J. Morse is commissioner of Public Health for the City of Worcester, past member and Chair of the Council on Ethical and Judicial Affairs of the American Medical Association, and past President of the Massachusetts Medical Society. Off Call: Michael Moore’s
Sicko For starters, Michael Moore’s films are not documentaries. They are propaganda statements at best, although that’s not necessarily all bad. With our national leaders having said little or nothing at all about the catastrophe that Health Care USA has become, some counterbalance from Mr. Moore, despite the grandstanding, must be welcomed. The propaganda does come on fast and furiously. For the uninsured man who sliced off two fingertips with a circular saw, the hospital gave him a “choice” of which one to put back. Being a “hopeless romantic,” the patient chose the ring finger. Next scene: the town dump where the middle finger tip was allegedly delivered. Yet the tragedy was most certainly due to lack of insurance, and consequently affordability, not the Sophie’s Choice that Moore presents. Moore then interviews a woman who suffered a concussion in an auto accident and then received a bill for an unauthorized ER visit. Craziness, of course, but we never heard the follow-up. Does anyone think that a probable clerical error wasn’t fixed with a couple of phone calls? And so the problem with Sicko – and Michael Moore. We never hear the other side. There is no gray. Canada, as Mr. Moore would have it, seems to do no wrong when it comes to health care. For example, there’s no waiting – ever – in emergency rooms, eh? Last month I listened to an NPR interviewer relate to Mr. Moore his own Canadian family’s experiences of waiting 18 hours in an ER. “That’s a lie!” Mr. Moore shouted, and that was the end of the discussion. The documentary director made clear that he would not accept even the mildest challenge of his belief system. I wonder what outrage the following would provoke: In 2004, the median wait in Ontario for a CT was five weeks and for an MRI was thirteen weeks.1 (Here’s an easy explanation: The latest available numbers show that Canada had 151 MRI scanners at the beginning of 2004.1 As of 2006, the U.S. had 7225 MRI sites.2) France, mon Dieu. Could life or life expectancy be better in the best health care system in the world? A wonderful scene that I think may even have been lost on Mr. Moore shows him walking down a street among throngs of typically fit and trim Parisians. Let’s just say that Mr. Moore, er, stood out among the crowd, as would an ever increasing number of Americans. My own unscientific guess is that if the French aren’t outliving us by 10 years, something is wrong with their system. And ¡viva Costa Rica! It ranks above us for health care (After all, if the WHO says so, who’s to argue?). How about a scenario with Mr. Moore developing chest pain. Would he rush to Miami International Airport for the first flight south? No, when it comes down to common sense, which even he displays at times, best guess is that Mr. Moore’s cardiac cath would be in whatever American city the chest pain developed. After all, he and we all know that he would get cathed and stented immediately and skillfully, wherever in the US he was issuing his latest rant. Yet please don’t get me wrong. I said up front that this subject must be welcomed and urgently be placed squarely in the public’s lap. And the most effective (and probably only remaining) public learning format is the movies, where a captive audience is forced to listen beyond sound bytes, sans the remote control. So Michael Moore’s entertainment will in fact bring many to take notice, and maybe for the first time seriously consider, the most important issue facing us today. That Mr. Moore would consider Costa Rica for a cardiac catheterization is a preposterous supposition, of course, just as is the idea of Queen Elizabeth using her own NHS. But that doesn’t mean all is well here. Our access to the best health care facilities in the world (with all due respects to the WHO’s opinion) is uneven and expensive because as a society we won’t set limits and we’re not willing to pay for our endless expectations. We do have profound inequities, although not anything like those in Costa Rica. But to point the finger at for-profit HMOs and state simplistically that they are the cause of the mess is naïve and dangerous thinking. Mr. Moore should be more responsible than that and, at the very least, emphasize that we Americans – himself included – must take more personal responsibility for our own health and therefore the health of our nation. References:
In Memoriam: WDMS Remembers its Colleagues Richard J. Broggi, MD Richard J. Broggi, M.D. practiced ophthalmology in Worcester during parts of five decades, his career spanning from the 1950’s until his retirement in 1995. During this period of time he developed a medical practice which became one of the busiest ophthalmology practices in central Massachusetts. Dr. Broggi did his undergraduate work at Boston College and Brown University in the 1940’s and went on to get his medical degree at Tufts University Medical School in 1948. He served in the Navy in both the Second World War and the Korean War after which he did his ophthalmology training at the Massachusetts Eye and Ear Infirmary, the Cleveland Clinic, and the University Hospitals of Western Reserve University. Dr. Broggi started his private practice in Worcester in 1956. During his nearly 40 years of private practice, he became an active member of several local, national and international ophthalmic specialty societies and even served as president of the Massachusetts Society of Eye Physicians and Surgeons. He published several papers in peer reviewed journals and lectured at meetings of various ophthalmological professional societies. Among these publications were descriptions of innovative surgical techniques and ophthalmic surgical instruments which he devised or modified. Dick Broggi, as I had the great pleasure of knowing him, did not limit his creative and inventive skills to ophthalmology. He enjoyed tinkering and repairing various things in his home workshop, and a few years ago bestowed upon me the honor of owning one of the beautiful lamps which he crafted as a hobby, and which has since illuminated my desk. I have had the privilege of carrying on his ophthalmology practice for the last several years, and am always amused when I find myself caring for a patient with exam notes in my chart dating back to a time before I was born. In addition to a long and successful career as an ophthalmologist, Dick Broggi, with his wonderful wife of 56 years, Mary Ann, raised 8 children and is survived by an additional 12 grandchildren and one great grandchild. Richard J. Broggi, MD passed away at his home on April 18, 2007 and will be missed by all of us who had the pleasure of knowing him personally or professionally. Peter T. Zacharia, MD Alan Clark Brewster, MD Dr. Alan Clark Brewster died on Saturday, July 14, 2007 in Stuart, Nebraska. Dr. Brewster, formerly of Grafton Center, died of complications of Alzheimer’s disease. He was born in Rushville, Nebraska on July 19, 1938 to Joseph G. Brewster, a noted attorney and banker, and Vera Hart Brewster, a renowned vaudeville dancer. He attended the University of Nebraska and Creighton Medical School where he was a member of Alpha Omega Alpha Medical Honor Society. After a residency in Internal Medicine at St. Joseph Hospital in Omaha, he completed a fellowship in Gastroenterology at Boston City Medical Center where he was appointed Associate Professor at Harvard Medical School. In 1971, he became Chief of Gastroenterology at St. Vincent Hospital in Worcester and later became Medical Director. I knew and worked with Alan during the 1970s and 1980s when he established a reputation as an extraordinary and creative developer of quality assurance software. He started his work on healthcare quality with the Joint Commission on the Accreditation of Hospitals and in 1984 co-founded MediQual Systems Inc in Westborough. MediQual was the first commercial enterprise devoted to development of software to assist healthcare professionals to evaluate the quality of care delivered by physicians and hospitals. Alan was a tirelessly creative individual who sought and found innovative ways to asses and quantify the impact of severity of illness on medical outcomes. He was a pleasure to work with and pushed all who worked with him to be as creative as he was. I personally owe him a debt for all he taught me about the analysis of healthcare and how to solve difficult problems in an innovative manner. Alan retired in 1994 and the void he left has never been filled. Paul M. Steen MD Alfred Peter Iacobucci, MD Nearly 33 years ago, a few days into one of the scarier facets of life ~ becoming a medical intern ~ I asked my resident about diagnosing and managing what turned out to be a very complex case. He said, “I just saw Dr. Iacobucci down the hall. Find him and get the answer. He knows everything.” “But I don’t even know what he looks like.” “You’ll know.” Down the hall two attending physicians were talking. One was telling the other how to patch a wall. He detailed how to place the mesh and which plaster to use. And after getting a lot of thanks and praises for the good advice, he said, “It’s nothing. Give an Italian a hammer and a couple of nails and he’ll build you a house.” I obviously wasn’t in the right place. I wasn’t looking for a carpenter and besides, with the name “Yakobuchi,” I thought I was looking for someone Japanese. But a kindly nurse, recognizing the typical vacant look of a new intern, directed me to a cautious introduction. “What can I do for you, young man? First of all, it looks like those pants are a 33 waist [they were], and you might want the 31 length another inch longer.” I really wasn’t sure where this was heading, but what then followed was an explanation to my question that was so scholarly yet so disarmingly simply explained, I thought it just couldn’t be right. Well, it was ~ just like everything else Dr. Iacobucci would teach me and the rest of the residents for the next three years…and me in particular for the rest of my career. Back to my resident with Dr. Iacobucci’s answer: “Yeah, sounds like a good idea. A whole lot easier than spending 3 hours in the library and still doing the wrong thing.” And so my introduction to Dr. Alfred Iacobucci, the guy to go to when a patient had a set of symptoms that wouldn’t fit any diagnosis, or for a patient who was simply “funny looking,” or when medical management didn’t work, or when nobody else had an answer for you. How did Al get that way? Yes, he was inherently very, very smart. As smart as just about anyone in medicine I’ve come across in the ensuing 33 years. Yes, he had a Masters in Pharmacology, an MD from Tufts, a residency at St. Vincent Hospital, an endocrinology fellowship at the Mayo Clinic, and served as Chief of Medicine at Fallon Clinic and the Director of Endocrinology both there and at St. Vincent Hospital. Yes, he was a member of a huge list of prestigious medical societies, too. But there was more ~ in fact there had to be much more in order to earn the respect bestowed upon him by all of his colleagues and students. Al loved Medicine, he loved caring for patients, and he loved to teach. He did it all as naturally as one goes for a walk. Near the end of my residency I was the very first resident to spend a month in the ambulatory arena, and I’d gotten permission to do so because it was going to be under Dr. Iacobucci’s guidance ~ soon to be “Uncle Al’s” guidance. And I learned and learned and learned that month. Not all of it Medicine, but all of it important, even if not always perfect. Al was, for example, the worst record keeper in the world. “But Dr. Iacobucci, if you don’t write it down, how are you going to remember the presenting complaints, the family histories, the labs?” “It’s all here, nephew,” he would say, tapping his head. And it was. Some of it still is, I’m sure. Al knew everything about his patients because he loved taking care of them, and they all knew it. When he introduced this young resident who was working with him, the moment of panic that predictably ensued required from me: “No, he’s not retiring, and I’m not taking over his practice.” He also knew everyone else in town, it seemed, and everyone knew him. So, the legacy I know best of Uncle Al ~ my mentor, colleague, and dear friend ~ are the multitudes of students and residents over the years who will never forget what he taught us about Medicine and about life. Not coincidentally, the derivation of “doctor” comes from the Latin “docere” ~ to teach. Al was our teacher in the truest sense of the term, and that’s as good as it gets. Joel Popkin Society Snippets: Worcester "Community Immunity Day" FLU SHOT
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