Worcester District Medical Society

Worcester Medicine
September/October 2008

President's Message
By Bruce Karlin, MD

Editorial
The Massachusetts Experiment
By Paul M. Steen, MD

The Massachusetts Experiment
Massachusetts Universal Health Care: A View from the Neighborhood
By Joel Popkin, MD

The Massachusetts Universal Health Care Plan: A Perspective from the Empire State
By Ethan Fried, MD

The Massachusetts View from Pennsylvania
By Eric J. Gertner, MD

Man on the Street - Commonwealth Care
Interviews by George Abraham, MD, MPH

Legal Consult
The Value of a Chance
By Peter Martin, Esquire

Humanities in Medicine
Curing the Body, Healing the Soul - A Navajo Vision of Humanity in Medicine
By Harvey Fenigsohn, Lamar Soutter Library

Off Call
Himalayan Pilgrimage
By Nilima Patwardhan

Globalization of Medicine
By Avinash V. Patwardhan, M.D.

Financial Advice for Physicians
Donor Advised Funds: The Flexible Giving Alternative
By Richard B. MacKinnon and Kenneth G. Y. Grant

As I See It
The Partnership for Healthcare Excellence
By Heather Mills

In Memoriam
WDMS Remembers its Colleagues

Calendar of Events

President's Message
By Bruce Karlin, MD

When I heard that the Massachusetts Medical Society (MMS) was suing the GIC for tiering, I felt that finally we were trying to set a proper limit to the incursions of insurers into the practice of medicine. We had adapted to each limitation and finally we were saying no more. I know that our favorite son, Dale Magee, immediate past President of the MMS, worked for 3 years presenting our position and only resorted to the suit when all else failed. We would have preferred that after reasonable discussion those in power understood our point and explored other avenues for cost savings.

We see the suit as tangible evidence of what organized medicine can do for physicians who might not realize that we negotiate with the insurers all the time. Physicians aren’t aware of the work needed to get their 10.6% rollback overturned and of other fee increases. The suit represents a failure of our usual engagement with the insurers rather than our main effort. I hope that the courts agree that the insurers have committed what we all see as an obvious foul.

I am concerned that physicians will sit back and let the suit do the work of explaining our position. This is not sufficient; we need to win this argument with the public. We need to help all physicians show the problem with this untested and misdirected approach to cost containment. To this end, we ask you to learn about the issues and promote our position. We will be working on creating outreach to hear your opinions and to give you materials. I hope to have more news as our ideas and programs gel.

Editorial: The Massachusetts Experiment
By Paul M. Steen, MD

This issue of Worcester Medicine has taken on the theme of the new Commonwealth Care program, better known as the “Massachusetts Experiment.” We have had articles and even some focus on this topic before, but we took a different approach this time. Now that the first year of the program is over, how do other similar states view this program? Do they see it as a success or a failure? Is this a model to emulate or to learn from its problems (or both)? Across the nation, similar “universal health care” programs are being discussed and slowly heading toward enactment by many legislatures. I think you will find the views from Pennsylvania and New York enlightening. They show the truly amazing speed with which this legislation was enacted.

It is worthwhile to look at the short interview statements in ”Man on the Street.” In a very brief way, these views of ordinary patients under Commonwealth Care reflect the range of benefit and concern that make this plan either a ”great and noble step” or one that will ”break the bank.” It’s possible that it will accomplish both.

Lastly, Joel Popkin’s article, “A View from the Neighborhood,” is another excellent synthesis of the issues from Pennsylvania, New York and Massachusetts. He rightly puts focus on demonstrable improvement in patient care as the most important marker of success. We as physicians must see that this point is not lost in the future as cost issues become louder and more pronounced.

Massachusetts Universal Health Care: A View from the Neighborhood
By Joel Popkin, MD

I have asked two colleagues – both authorities on their respective state health care systems – to air their views on Commonwealth Care, as well as on their own states’ struggles to provide relief for the uninsured. Drs. Eric Gertner and Ethan Fried, whose lucid and timely articles follow, detail the complexities of Pennsylvania and New York proposals respectively.

It is not only our neighbors who are closely watching the Massachusetts experiment. Commonwealth Care has been described as a national model,[1] and it looks like we have gotten off to a pretty good start. Apparently the initial fears “that people might drop private insurance to gain subsidized coverage or that businesses might dump employees on the state program” have not materialized to date. But other problems have appeared: the severe shortage of primary care physicians has left many patients without access to primary care, and it is not clear if that shortage has led to low-income residents’ unexpectedly increased use of emergency rooms for routine care. And of greater concern is the jump in cost from an original estimate of $472 million for this fiscal year to $625 million and from $725 million to $869 million next year. No Big Dig, but real money none the less. There is some good news, though, in that the shortfalls are mostly due to the state’s underestimate of the number of uninsured residents and how quickly they ended up registering. Of course such economic news always carries a dire warning, and it may have led to the demise of the California plan to cover its own uninsured population.[2] And it is certainly a warning to other states to watch their budgets carefully.

Indeed, the complex experimenting in Dr. Fried’s description of the New York and Pennsylvania “local laboratories,” along with the investigations of new systems currently in nearly 20 other states, might result in workable plans. But might we end up replaying the Betamax/VHS and Blu-Ray/HD DVD wars at extraordinarily higher stakes? In technology, one format usually triumphs in the end, but here we are dealing with multiple, extraordinarily convoluted hodgepodges of health care plans. Once in place, they will likely be set in concrete by politicians and the same insurers who currently unleash their own brand of terror upon us, so that the development of any superior systems can only stay local. A scenario could look like this: the citizenry growing increasingly bewildered by impenetrable health care systems – predictably 50 in all – while the country at last gets an economic stimulus through the hiring of myriads of counterproductive administrators.

The way around this is to get a successful model out there and do it fast – before the madness of special interests and die-hard reinvention gets out of hand.

What seems to have been lost in the fray, but must go hand in hand with universal health care if it is to succeed, are concrete measures to address administrative/regulatory costs, futile care, crushing paperwork, and tort reform, among others. Regarding the last, Commonwealth Care may have just suffered a giant step backward. With the decision in Coombes v. Florio, not only has the Massachusetts SJC found Dr. Roland Florio, on the basis of prescribing an analgesic, responsible for his patient’s injuries in a car accident, but liable, too, for any other person’s injuries stemming from that accident. Attorney George Annas, the author of a very recent article devoted to this case,[3] thinks the decision is correct and that negative reactions from physicians “would indicate an uninformed overreaction on the part of doctors.” But the reality is that the Massachusetts SJC has now upped the ante for health care expenses (yet more defensive medicine) at the very time we and the rest of the country have come to understand that we have just about run out of money to make this grand experiment fly. And it is just this kind of thinking from Mr. Annas that can prevent the curbing of costs and therefore doom any plan – local or federal.

In an exceptional review of the Massachusetts plan,[4] Jennifer Wilson says, “In the end, whether the Massachusetts health care reform effort is ultimately sustainable may not be its most important legacy. Many health care experts view it primarily as an important experiment because it translates long-held theories about health care coverage, finally, into practice.”

Indeed, the noble experiment has begun right here at home. We can only hope that other “labs” will repeat our studies and come up with a cure for the profound, progressive morbidity that our nation faces. If we fail, the rest of the country may decide health care is unfixable, and that would be a disaster. So, we must get it right, demonstrate success quickly, and in the process prod our absent federal government to once and for all fund universal – and uniform – health care coverage.

References:

NY Times Editorial. The Massachusetts Model for Health Care. June 16, 2008.
NY Times Editorial. Growing Pains of Universal Coverage. February 9, 2008
George J. Annas, J.D., M.P.H. Doctors, Drugs, and Driving — Tort Liability for Patient-Caused Accidents. NEJM. Vol 359:521-525. July 31, 2008.
Jennifer Wilson. Massachusetts Health Care Reform Is a Pioneer Effort, but Complications Remain. Annals of Internal Medicine. Vol 148:492-495. March 18, 2008

The Massachusetts Universal Health Care Plan: A Perspective from the Empire State
By Ethan Fried, MD

In the confluence of an economy in recession, a heated presidential race, growing personal and public dept and the sudden death of iconic figures like Tim Russert, health care gets the public’s attention like few other issues. With over 47 million uninsured Americans and more who are underinsured, and with the United States ranking rather low in the estimates of the quality of care delivered around the industrialized world despite a sum of funds used for health care that is twice what the next country spends, it is no wonder why at least 18 states have started or are planning to provide universal or nearly universal health care.[i]

In 2006, when Massachusetts created the Commonwealth Health Insurance Connecter Authority and mandated that all uninsured residents of the state enroll in a plan and subsidized their premiums according to a sliding scale of income and family size, she became one of the first states to successfully execute such a plan.[ii] That success has certainly turned up the heat on Massachusetts’ neighbor, New York State.

Currently in New York State, the safety net for the 2.1 million uninsured is the public teaching hospital system, which relies on funds for Graduate Medical Education to pay for care. Although 21 states pay for graduate medical education, New York uses $1.4 billion in Medicaid funds for GME, which is a third of all Medicaid GME funding nationally.

Massachusetts used her $610 million “free-care pool” and added approximately $400 million in additional funds to sign up more than half of her 650,000 uninsured. This is mouthwatering to Empire Staters, who pay $847 million plus a portion of the $3.4 billion GME pool to care for the uninsured.[iii] In order to create a public financing system to insure all New Yorkers, the state must first tease apart the complex system of payment for her truly immense Graduate Medical Education enterprise. That would mean calculating how much it truly costs to train the 16,000 residents and then turning the rest of the funding over to the indigent care pool. Part of the Commissioner’s plan might be to better measure the quality of training programs in NY State. He would then offer a portion of the current GME funding to underperforming training programs to get out of the GME business and just stick to caring for the poor. Although this approach does not save any money, it does place the funding in more transparent bins to pay for training and for caring for the uninsured.

The next step in providing this care would be to decide whether insured patients are better cared for than uninsured patients receiving care from hospitals. In theory, insuring these patients would give them access to care in doctor’s offices rather than consign them to expensive emergency rooms and overcrowded hospital based clinics. While many studies confirm that quality of care improves for these newly insured patients, some studies question this assumption.[iv]

What is clear is that what we have currently is not working for more than 15% of our fellow countrymen. In the absence of true federal leadership, states are experimenting with various approaches to the problem. These local laboratories may be just the right prescription for a problem which obviously needs a creative approach. Perhaps the Massachusetts plan will light the way.

Dr. Fried is Vice Chair for Education and Residency Training Program Director for the Department of Medicine at the St. Luke's-Roosevelt Hospital as well as institutional Director of Graduate Medical Education. He is a consultant to the New York State Council on Graduate Medical Education and a member of the governing council of the Association of Program Directors in Internal Medicine.

References:

National Conference of State Legislatures website (www.ncsl.org/programs/health/universalhealth2007.htm) accessed July 24, 2008.
Annals of Internal Medicine 148(6): 489-92.
New York State Council on Graduate Medical Education, Policy Recommendations to the Commissioner of Health, March 2008.
Klein, J.D., Shenkman, E., Brach, C. "Prior health care experiences of adolescents who enroll in SCHIP." Journal of Health Care for the Poor and Underserved 17: 789-807.

The Massachusetts View from Pennsylvania
By Eric J. Gertner, MD

The news is filled with articles lamenting our woeful care for the underinsured, our lack of access to services for expectant mothers and the elderly, and patients choosing between food and paying for medications. These stories come from towns and cities across Pennsylvania and the United States. Meeting the growing need for services will continue to be a challenge, one requiring new ideas and partnerships, a commitment to quality, and a collective vision. Fortunately, Pennsylvanians can learn from the lessons of health reform in Massachusetts, celebrating or perhaps recovering from its first full year of implementation.

Despite the challenges of implementing comprehensive healthcare coverage in Massachusetts, one lesson is clear ~ a broad consortium and shared responsibility are critical for successful health reform and should serve as a model for other states. In Pennsylvania, stakeholders have come together over the past year to address the issue of care for patients with chronic illness, leading to the successful implementation of the Chronic Care Model. The Chronic Care Commission is made up of representatives from all major insurers, physicians, medical societies, and nurses, as well as representatives from government, employers, patient interest groups, and unions. Working together, they developed and implemented a payment structure framed around the Patient Centered Medical Home, and resources were re-allocated in the Philadelphia region at an estimated cost of $13 million over the next three years, with roll-outs planned around the state over the next several months.

While the cooperative process has been successful, it has not been fully replicated in other areas of the political process. Coverage for the underinsured is another key element of Governor Rendell’s Prescription for Pennsylvania health care reform plan, but it has hit a critical roadblock. Alternative plans have been proposed in the Democratic-controlled state House of Representatives (Access to Basic Care or ABC) and the Republican-controlled state Senate (HealthNET PA). ABC resembles the Governor’s plan for the uninsured, known as Cover All Pennsylvanians (CAP). All of the plans claim they will cover thousands of underinsured Pennsylvanians through some mixture of government grants, business incentives, community based clinics, and other programs. This confusing alphabet soup of plans was left on the table at the end of the legislative session in July. Multiple stakeholders are hoping to get the process moving again when the General Assembly reconvenes in September. But without the medical community, patient advocates, legislators and the administration coming to the table seeking compromise, the prospects for further reform this election year are uncertain, at least for now.

Unfortunately, there are some big strings attached with some of the proposals, making matters even more complicated. One area of considerable debate has been the linking of care for the uninsured with appropriations for the “Mcare Fund,” a program established several years ago to protect physicians from unaffordable increases in primary malpractice insurance. The ABC plan would fund coverage in part by tapping into the current surplus in the Mcare Fund, the prospects of which are not appealing to Pennsylvania’s physicians. Also, the plan would require all physicians receiving Mcare abatement to participate in the ABC program and CHIP.

In addition, access to primary health care remains a challenge even for those with insurance in Pennsylvania, one which may be further accentuated with expanded coverage, an issue now facing Massachusetts. An important difference between our states, however, is that Pennsylvania ranks behind only Florida and West Virginia in its percentage of population over 65, underscoring the need for advanced services for an aging population.

Still, Massachusetts health reform offers hope to its Keystone cousin. We can put together large stakeholder groups to address aspects of health care reform, including chronic illness management, which can build the political will and political clout that led to Massachusetts’ changes. Adding requirements for minimum reasonable health care insurance, a Connector Authority, and expanding our safety net for those ineligible for care are intriguing concepts we still may borrow from the Massachusetts plan. Expanding our primary care infrastructure, perhaps through the dissemination of the Patient Centered Medical Home, and identifying funding sources for reform will be challenges unlikely to be resolved without some amount of compromise from all parties.

But as we have seen in Massachusetts, starting on the path to making quality health care affordable and accessible for all residents of the Commonwealth must start with a few steps at a time, and it’s a path that can only be taken with a diverse group of stakeholders.

Eric J. Gertner, MD MPH FACP is a general internist practicing in Allentown, PA. He currently serves on the Pennsylvania Chronic Care Management, Reimbursement and Cost Reduction Commission. He is also Chair of the Council on Patient Advocacy for the Pennsylvania Medical Society.

Man on the Street - Commonwealth Care
Interviews by George Abraham, MD, MPH

These snippets are from randomly selected patients from Dr. George Abraham’s office in Worcester. These five short interviews represent a range of reactions to the new Massachusetts program; three of them show the positive effects of the program and two show the cost issues that still need to be addressed. There is no implication that the net effect of the positives and negatives of the program is on the positive side. Only time will tell how the balance works.

In November of 2007, it was determined, based on my income, that I qualified for state supported health insurance. I was told that I would be required to pay $105 per month premium. In May or June I received a letter informing me that my premiums were going to go up to $219.42 per month. This is an increase of almost 114% in six months. I don’t know how I am going to pay this every month! The state is paying for this mandated program on the backs of the very people they are supposed to be helping. It has to stop! (age 56, F)

I had no health insurance since quitting my job to take care of my mother-in-law, so the Commonwealth Care program helped me get the insurance that I could not afford. (age 51, F)

The good part is I have health insurance, the bad part, the rates are going up too high, don’t know if I can afford it. (age 21, M)

The insurance helped me get the care I had never had for fifteen years. (age 40, F)

I got laid off 6 months ago as a parking garage attendant, had to have a bypass, without this insurance, I don’t know what I would have done. (age 60, M)

Legal Consult: The Value of a Chance
By Peter Martin, Esquire

In 1995 a patient saw his new primary care physician for a routine physical at which the patient complained of gastric distress. The patient had a history and other characteristics indicating a higher than usual risk of developing gastric cancer. The physician recommended over-the-counter medications for gastrointestinal reflux disease. Several subsequent visits occurred during which similar complaints were made, but the physician did not order any tests to rule out gastric cancer. This series of encounters culminated in a visit in 1999 at which the patient reported heightened pain, weight loss and vomiting. Shortly thereafter a gastrointestinal series and ultrasound confirmed the presence of gastric cancer of which the patient died some months later.

During the subsequent medical malpractice trial, the plaintiff’s expert witness testified patients with stage-two gastric cancer have a five-year survival rate of between 30% and 50%. The jury found that the patient had stage-two gastric cancer in 1995 and a chance of survival at that time of 37.5%. It awarded the patient’s family a little more than $600,000, of which nearly half was represented by 37.5% of what the jury considered “full” wrongful death damages. This portion of the jury’s damages award represented in effect the jury’s estimate of the value to the patient of his decreased chance of survival resulting from the physician’s negligence.

Prior to two decisions by the Massachusetts Supreme Judicial Court in July of this year, this award of damages would not have been allowed. Until these decisions, Massachusetts courts did not recognize a cause of action in medical malpractice for the loss of a chance of survival or recovery. The rule had been that damages could be recovered only if the plaintiff could show that the defendant’s negligence more likely than not caused the plaintiff’s ultimate outcome. If the plaintiff’s chance of survival prior to the defendant’s negligence was less than even, then the plaintiff could not show a greater likelihood that the harm came from a cause for which the defendant was responsible rather than a cause for which the defendant was not responsible. Consequently, under the old rule, if the patient’s chance of survival were 51% and the defendant caused that chance to drop to zero, a full recovery of wrongful death damages was possible, but if that same patient’s chance of survival were 49%, the plaintiff would receive nothing.

The new rule recently articulated by the Supreme Judicial Court calls for a proportional damages approach to such cases, as distinct from the “all or nothing” approach under the old rule. Thus, if the total wrongful death damages in a given case were $100,000 and prior to the defendant’s negligence the plaintiff had a 40% chance of survival but only a 10% chance of survival as a result of that negligence, the plaintiff would be awarded $30,000 in wrongful death damages. While the plaintiff still has to prove his case by a preponderance of the evidence, the measure of damages available in a loss of chance case depends crucially on expert testimony as to the probabilities attaching to various disease stages.

The court noted that recognizing loss of chance as a separate compensable item of damages in a medical malpractice action relies on the fact that “at least for certain conditions, medical science has progressed to the point that physicians can gauge a patient’s chances of survival to a reasonable degree of medical certainty, and indeed routinely use such statistics as a tool of medicine.” That “probability of survival is part of the patient’s condition;” thus, any reduction in that quantum of chance is a real injury to the patient, whether it be the loss of a chance to survive, to be cured, or otherwise to achieve a more favorable medical outcome. In this way, clinical tools have enabled the courts to recognize a new theory of injury which may increase practitioners’ liability risks.

Is this an instance in which the data supporting evidence-based medicine, used initially to improve the quality and efficacy of patient care, are now considered sophisticated and reliable enough to be put in the hands of medical malpractice plaintiffs’ lawyers to squeeze some compensation out of a plaintiff’s “diminished likelihood of achieving a more favorable medical outcome?” Or is this just a case of the law catching up to the science of medicine, with the result that all those legally responsible for wrongfully harming patients will be assessed only a precise ~ a “just” ~ measure of blame? However one views this development, ironies abound.

Humanities in Medicine: Curing the Body, Healing the Soul - A Navajo Vision of Humanity in Medicine
By Harvey Fenigsohn, Lamar Soutter Library

“Now, more than ever, patients themselves feel removed and forgotten, powerless in the face of the institutions that were created to help them ... modern medicine has become a one-way system - from physician to patient. Physicians do the directing, talking at their patients ...listening on the part of the physician is becoming lost ... Patients want to be involved ... They want to feel more than a set of organs and bones, nerves and blood, and participate in restoring their bodies to health… ” (The Scalpel and The Silver Bear, 1999, p. 2)

The author of these words, Dr. Lori Arviso Alvord, appeared at the University of Massachusetts on May 21, 2008 as the guest of the Lamar Soutter Library’s Humanities in Medicine committee and the WDMS. The first Navajo woman surgeon, Alvord addressed an appreciative audience of students, staff, and UMass/WDMS physicians. The Humanities in Medicine committee is dedicated to promoting a greater awareness of the values of the humanities in healthcare, medical education, and biomedical research. As a surgeon, medical educator, and the author of the memoir The Scalpel and the Silver Bear, Dr. Alvord exemplifies the committee’s concern for the enhancement of humanistic values in the practice of medicine.

Dressed in full tribal regalia, Dr. Alvord recalled how she grew up on a New Mexico Indian reservation and later attended Dartmouth on a scholarship, followed by Stanford Medical School (1985), where she also completed her surgical training, serving as chief resident (1990-91). She went on to practice surgery on the reservation in Gallop, NM, and is now at Dartmouth Medical School where she serves as Associate Dean of Students and Multicultural Affairs and Assistant Professor of Surgery.

Dr. Alvord believes that there is more to medicine than science. She explained how the Navajos strived to live a life in harmony with the natural world. Concerned with the whole being of a person, tribal medicine was based a healing philosophy called "Walking in Beauty." The Navajos sensed their mystical connection with the universe, seeking a balance between the physical and the spiritual. Dr. Alvord pointed out that respected medical journals report the benefits of community and spirituality in reducing patients' mortality and promoting their healing. Showing slides of her southwestern homeland, she recalled her tribe’s regard for the spiritual values of nature and how this respect informs their traditional healing practice.

Dr. Alvord maintained that modern medicine, so concerned with health insurance and advanced technology, often loses sight of the patients’ need for individualized care and the human touch. She told the audience how, in her first practice at the reservation, she learned to merge her medical expertise as a skilled surgeon with the holistic medicine of a native healer. She recalled an incident on the Gallop reservation when an elderly man became sick with cancer and was treated by a hataali, or medicine man, who conducted a ceremony of chanting known as a “sing.” Treated with chemotherapy, radiation, and surgery, the patient only began to recover after the revered shaman performed this ritual. The tribal healer provided a sense of hope, something too often omitted from modern medical practices.

Dr. Alvord realizes that today's physicians might well dismiss the unscientific practices of an ancient culture, considering them to be based on ignorance and superstition. She did not advocate today’s medicine adopting the healing rituals and ceremonies of the Navajo. Instead, she emphasized how much modern medicine can learn from the native healers’ model of personal concern. Her ideal hospital would combine state-of-the-art technology with a serene, warm, and comfortable setting, one with natural light and free of the harsh, sterile, clinical atmosphere of so many modern facilities.

Dr. Alvord spoke of why it is so important for physicians to empower their patients and help them to help themselves. She emphasized the value of the patient’s role in bringing about healing. To her, healing must be a joint venture between doctor and patient, one based on mutual respect. The patient must respect the care and competence of the doctor while the doctor must respect the dignity and spirit of the patient.

In today’s hospitals, constrained by the time limits of managed care, physicians urgently seek, often successfully, to overcome physical disease. However, in the process they often ignore their patients’ spiritual needs, which if heeded could significantly advance the progress of healing. Alvord offered no immediate solutions to a problem which may only be solved by a complete reform of our healthcare system. Nevertheless, in identifying the problem so clearly, and in revealing the solutions of her ancient culture, she challenges us to find more humane ways of practicing medicine. For example, Dr. Alvord prepares herself mentally and spiritually for a surgical procedure. Since her Navaho background imbued her with a reverence for the life of her patient, she feels a great sense of responsibility in being allowed entrance into the body of another human being. To Dr. Alvord, the person lying before her is more than a machine of flesh to be repaired. Rather, she feels she must prepare herself with the proper state of mind to perform what is to her almost a sacred duty. In her operating room, she insists that her surgical staff maintain a state of calm as they harmoniously perform their duties.

Following Dr. Alvord’s remarks, an obstetrician in the audience commented on how much she appreciated the speaker’s approach to the spiritual side of medicine. This physician revealed that when she felt rushed or pressured in the O.R., she remembered to pause and reflect on the true meaning of her endeavor both in caring for and in caring about her patients. Not surprisingly, many undergraduate and medical schools include Alvord’s memoir in their curricula, and her book is popular in reading groups around the country. She has garnered numerous honors including two honorary degrees and an Outstanding Woman in Medicine Award.

Dr. Alvord’s talk and book signing was one of a variety of events sponsored by the Humanities in Medicine committee. Founded in 2002 by Dr. H. Brownell “Brownie” Wheeler with financial support from the WDMS, the group is composed of faculty, staff, and students as well as WDMS representatives: co-chairman, Peter Schneider, MD, and Joyce Cariglia, Executive Director, along with Elaine Martin, Director of the library. Co-chaired by David Hatem, MD, the committee helps maintain a special collection of over 600 HIM books and sponsors speakers and programs dedicated to advancing the medical humanities in the UMass community.

Off Call: Himalayan Pilgrimage
By Nilima Patwardhan

I wanted to see the beautiful Himalayas and the four sources of the river Ganga. This region is called ”Dev Bhoomi,” land of the Gods, and is sacred for Hindus. The belief is that those who undertake this pilgrimage achieve salvation or ”moksha.” Previously, travel in this region was long and difficult, but now it is comfortable. We went on this adventure in the first two weeks in August, which is the rainy season in the Himalayas and associated with an increase in landslides and road closings. The recommended months are April-May or September.

Our first stop was the religious city of Haridwar. We stayed at the Haveli Ganga, situated on the banks of the river Ganga. That night, we attended the Ganga Aarti, a daily prayer offered at sunset. The sheer volume of people, their faith and devotion, was humbling. After that, sitting on the terrace, with a full moon shining through the trees, the sound of the river flowing, and devotional songs sung by a simple old man, was an indescribable spiritual experience.

Next morning, we drove to the origin of river Yamuna- Yamunotri. Halfway up the mountain we had our first landslide. The road was completely blocked and many locals helped us cross the wet mud and rocks. The faith in the pilgrims is very strong and most walk to the temple. On the path there was an old woman stooped double, walking with a cane, and a man on crutches with bilateral clubfeet wearing flip-flops. As we went up the narrow path, I realized that there was a high potential for injury in this remote place with narrow slippery roads, two way traffic, and landslides. Each time we came around a corner or hairpin bend, we were nervous about colliding with a truck or another vehicle. At all times there was a drop of several hundred feet to the river with no guardrails.

Wild flowers and numerous waterfalls accentuated the scenic drive. The terraced fields of monsoon crops of rice and corn appeared well cultivated. There were orchards of apples and lemons. Monkeys were the most common animal along the roadside. We passed picturesque valleys. The villages consisted of houses built close together. Bazaars and tiny shops selling religious shawls, statues, and rudraksha beads filled the sidewalks. Many sold small plastic bottles for collecting the water from the river Ganges, known as “Gangajal.” Some of these villagers had never left the mountains that sheltered them from the outside world.

We met many “sadhus.” A sadhu is someone who has given up the material world for a life of wandering and contemplation. They rely on charity for food and shelter. One sadhu asked for my sneakers, another for my walking stick.

We crossed many confluences of the tributaries of the river Ganga. In India, these junctions are sacred, and are the sites of important towns. The Ganga river is not placid but has white water currents and roars as it flows. Kedarnath was at an altitude of 12,000feet. It was the most beautiful and spiritual of the four sites. We were drenched and cold when we arrived. Even a hot cup of tea could not stop my teeth chattering or warm my numb palms. Our last stop was an ashram in the holy city of Rishikesh. We ended our trip the way we started it - with a Ganga Aarti, prayers to the holy river Ganga.

Nilima Patwardhan is a Professor of Surgery, UMASS Medical School, Worcester, MA.

Globalization of Medicine
By Avinash V. Patwardhan, M.D.


Dr. Aaron Lazar, Chancellor, UMMS	Dr. Michele Pugnaire Dean Undergrad. M.E.	Dr. Michael Godkin Director, International M.E.	Dr. Avinash Patwardhan Asst. Prof. Medicine, UMMS

I have always enjoyed teaching medical students and helping them become compassionate, caring physicians. After my retirement from Fallon Clinic in 1997, I wanted to add a new dimension to medical education. It was obvious that advances in cable networks, travel and informational technologies had brought to medicine a new perspective just as they had done in every human endeavor from business to popular culture. My dream was to “globalize” medical education.

Towards the end of 2002, with some trepidation, I took my thoughts to the University of Massachusetts Medical School (UMMS) and met with Dr. Michele Pugnaire and Dr. Michael Godkin. To my amazement, they embraced my suggestions and encouraged me to go ahead with my proposition to set up a fourth year medical student exchange program with my alma mater, the Seth G. S. Medical College and King Edward Memorial Hospital in Mumbai (GSMC/KEMH).

A vision statement was drafted at UMMS which stated:

“Cultural and educational exchange is critical for the development of medicine in the 21st Century. The Seth Gordhandas Sunderdas Medical College (GSMC) in Mumbai and the University of Massachusetts Medical School (UMMS) in Worcester realize that here we have an unprecedented opportunity to work together in the areas of medical science and education. Therefore, the UMMS and the GSMC are proposing an academic affiliation between the two colleges to foster exchange and collaboration of medical education. As opportunity and mutual interest develops, this program will benefit each institution to develop an increased level of cultural understanding, mutual respect for differences in educational philosophy and approach to health care.”

Thus began the “UMMS – GSMC Student Exchange“ program. To support and augment the program with the help of the “UMASS Memorial Foundation,” we collected donations from alumni and friends and have been able to give a scholarship of $2000.00 to every student participating in this program. To date, three fourth year medial students from UMMS have gone to India and they have all enjoyed and learned a lot from their experience at GSMC/KEMH in Mumbai. The first student from GSMC is expected to come to UMMS for his / her elective rotation in 2009.

GSMC/KEMH

KEMH was founded in 1909 at a cost of $44,641. The hospital opened with 125 beds and the associated medical college, GSMC, enrolled its first student in 1926. Today GSMC - KEMH together have 2000 beds, the campus occupies an area of over one square mile, has 19 specialty buildings and is rated among the top five medical colleges in India. It has 390 faculty physicians, 550 resident doctors, handles 1.8 million outpatient visits, 68,000 inpatients visits and trains 2000 students on a budget of $40 million.

GSMC – KEMH Campus in Mumbai, India

On the strength of this relationship, two new programs were started.

1. The Molecular Biology and HIV Research Department at UMMS has proposed an HIV research project at GSMC/KEMH. As part of this project, a post doctoral fellow from GSMC has been receiving her training in HIV research at UMMS since April 2007.

2. An “Observership” program was established in 2007 at the Fallon Clinic and Worcester Medical Center. Of the four interns from GSMC/KEMH who came here as observers in 2007, two were offered internships at St. Vincent Hospital (SVH). This year, eight interns from GSMC/KEMH have signed up for observership at Fallon Clinic.

THE FUTURE

As we begin to accept that other traditions and philosophies of healing can work seamlessly at the boundaries of our most advanced techniques, we must start looking at the as yet unexplored practices in medicine. I believe that in the years to come this academic relationship amongst the three active medical institutions in Worcester ~ UMMS, Fallon Clinic, and SVH ~ will open up unique opportunities for research and advances in medical education. Standardizing medical education programs for students, interns and residents, and appreciating the impact of all these factors on health care delivery across the world, is the essence of such an international affiliation.

Financial Advice for Physicians: Donor Advised Funds: The Flexible Giving Alternative
By Richard B. MacKinnon and Kenneth G. Y. Grant

Recently, PIAM has made available the special banking and investment services of Boston Private Bank and Trust. One of its many services is Donor Advised Funds. This article describes the advantages of charitable giving using Donor Advised Funds.

In recent years, donors large and small have discovered Donor Advised Funds (DAFs) and the reasons are simple: DAFs are easy to establish and very flexible. These charitable funds accept tax-deductible donations and invest the assets until the donor requests that grants be made to another IRS qualified charity.

How does it work? A donor opens a Donor Account with a sponsoring public charity. Boston Private Bank, for example, partners with Advisors Charitable Gift Fund. The donor ~ let’s call her Donor A ~ funds her donor account and names it the Donor A Family Fund. She may receive a tax deduction; Boston Private Bank’s portfolio managers invest the funds. Later, Donor A can recommend grants to qualifying nonprofits over a period of time.

DAFs remove time pressure and help make giving strategic instead of impulsive. If Donor A wants to give 10 percent of the proceeds from the sale of her medical practice to charity, but in the flurry of activity leading to the closing of the sale does not have a chance to reflect on the gift, a DAF easily takes the pressure off. Under current law, Donor A gets an immediate tax deduction in the year of the sale and has time to plan her giving.

Although gifts to a Donor Advised Fund are irrevocable, DAFs typically allow the donor to recommend gifts from the fund to any IRS-approved public charity. Generally, there is a choice of investments and the donor may request that the gift be allocated to the various funds. If you fund your account with appreciated securities the value, for tax purposes, is the midpoint of the price spread for the stock on the day the gift is received. As is the case with any investment product, contributions to a DAF are not bank-guaranteed or FDIC-insured against potential losses in market value.

Donor Advised Funds are a great alternative to private foundations, unless, of course, you are Bill and Melinda Gates. While we always recommend that you consult legal and tax counsel in these matters, you may want to consider replacing an existing private foundation with a DAF. Why would you do that? Privacy is the first consideration. When you file your 990PF each year you are effectively posting the names of all involved ~ yourself and your board ~ on the internet. That filing is public information. With a DAF you gain privacy. Then there is the fact that you have to file a 990PF in the first place. This, too, is eliminated, along with the excise tax. The minimum distribution rule doesn’t apply either under current law. Larger donations can generate deductions of up to 50 percent of your adjusted gross income (AGI), as opposed to the 30 percent allowed with a private foundation. Finally, your DAF can go on in perpetuity as you name successors to continue grant making.

That final point leads us to one of the best advantages of DAFs over ad hoc giving. Many families find DAFs to be wonderful vehicles for teaching children and grandchildren the joys, benefits, and responsibilities of philanthropy. What better way to teach than to set up a family grant committee involving the children? You might consider giving them a budget and helping them develop their own granting program. The possibilities are endless, but the transfer of values is priceless.

Donor Advised Funds are modern giving tools that today’s more sophisticated donors have embraced in great numbers. The simplicity of implementation, ability to make grants over time while suggesting asset allocation for the investments, and the lack of paperwork and filings make Donor Advised Funds perfect for a busy donor who wishes to make his or her giving strategic and more rewarding.

Richard MacKinnon is Senior Vice President of Investment Management and Trust Services at Boston Private Bank & Trust Company. Kenneth G. Y. Grant is Senior Vice President at Advisors Charitable Gift Fund. For information please contact PIAM at 781-434-7288.

As I See It: The Partnership for Healthcare Excellence
By Heather Mills

The Partnership for Healthcare Excellence is a new non-profit organization whose mission is to educate Massachusetts residents on how to improve the quality of their own health care. The Partnership seeks to motivate consumers to be more engaged in their health care. Research has repeatedly shown that more involved consumers receive better care and have better outcomes.

The Partnership’s website, www.partnershipforhealthcare.org, features a “One Stop Guide to Quality Health Care” with links to useful ~ and trustworthy ~ information on picking a doctor, preparing for a physician visit, preparing for surgery and taking medications safely.

If you want to become more active in your own health care and want to take more control of your care, The Partnership for Healthcare Excellence can help you do that ~ and lead you to make better decisions for you and your family's well-being.

A Prescription for Medication Safety: A List that Could Save Your Life

A lot of us use “to-do” lists to help organize our lives. But what if there were a list that could help you and your doctor improve your health? Well, that's what keeping a list of every prescription medication and over-the-counter treatment you are taking can do for you.

Keeping an up-to-date list of all of your medications is a simple thing you can do to partner with your doctor to improve the quality of your health care. Here are some other things you can do to ensure your medications help you get better rather than make you sick:

Keep your medication list in your wallet so you always have it with you, and make sure to share it with your doctor. If you have loved ones ~ children or elderly parents ~ who take medication, make sure you have their lists too.
Double-check your medication when you pick it up from the pharmacy to see that it's the medicine and dose the doctor ordered. If you have any questions, speak to the pharmacist.
Take your medication only as prescribed. Be aware of possible side effects and of what you do if you forget to take a dose. Always take the full prescription ~ don't stop partway through.

In addition to your own medication list, it’s important that you keep a list for your children taking medications and remind adults in your family to have one. If you care for elderly parents, work with them on their lists.

Share your list with a loved one who may be called on during an emergency when you may not be able to speak on your own behalf. Keep your list in your wallet.

For these and other tips to improve the safety, quality and effectiveness of your health care, please visit www.partnershipforhealthcare.org

Be active and involved in your own health care. And be well.

Heather Mills is a Campaign Associate for Partnership for Healthcare Excellence, 1135 Tremont Street, Suite 420, Boston, MA 02120, Tel: 617 399 8368, www.partnershipforhealthcare.org

In Memoriam: WDMS Remembers its Colleagues

John E.D. McGuigan, MD, FACS
1925-2008

Writing about a deceased individual is not always easy. However, it can be heartwarming, rewarding and even humorous; so it is with these words about J.E.D. McGuigan, my mentor, friend and colleague.

My first encounter with Dr. John McGuigan dates back to my internship year at the “old” Saint Vincent Hospital at 25 Winthrop Street in 1961. It was my first exposure to the OR and I was scheduled to “scrub” with Dr. McGuigan on the first case of the day. I was LATE! I expected to get chewed out but to my surprise, my Surgeon was very understanding and we laughed about it. Our friendship began on that day and lasted until his death ~ 47 years later!

We shared many laughs over the years. I remember a trip to an American College of Surgeons meeting in Chicago, circa 1965. John and I shared a room. Each day we were there he insisted we get up early enough to attend the seven o’clock Mass at a beautiful chapel on our way to the meeting at the Conrad Hilton Hotel, a practice I still adhere to today.

Several years later, after my wife Ellen and I had “wasted” many Sunday afternoons looking for waterfront property, John informed me that he was selling his place on Ramshorn Pond in Sutton because his sailboat had gotten “too big” for the lake and he was moving to Jamestown in RI. I initially declined even to look at the place but later recalled how fastidious John was and agreed to meet him there. It was a cold, dark miserable Sunday afternoon. I fell in love with the place and to this day, 38 years later, it is our Shangri-la!

As I told his wife, Margaret, at John’s calling hours, I had contacted him the week before his passing to arrange a get-together at Ramshorn Pond in the early Spring so he could relive old memories. I guess God needed a special and good man for an extra special assignment.

Rest in peace John!!!

Edward L. Amaral, MD

W. Clifford Smith, MD
1917-2008

Born in Verona, Pennsylvania, on May 11, 1917, Dr. W. Clifford Smith departed this world on March 28, 2008, several weeks short of his 91st birthday. His death took place at Memorial Hospital, where he had for many years served as Chief of Pediatrics.

After graduating from Verona High School, where he was valedictorian of his class, Cliff attended and received a Bachelor of Arts degree from the University of Pittsburgh. His Doctor of Medicine degree was granted by the Columbia College of Physicians and Surgeons. Post-doctoral intern and residency training took place at Allegheny General Hospital, Western Pennsylvania Hospital and Cincinnati Children’s Hospital. He married Margie Borland, who survives him, on May 22, 1943.

Like many of his generation, Cliff experienced interruptions in his career due to World War II. After serving in the US Army Medical Corps in Guam and other units in the Pacific Theater, he was discharged with rank of Major.

Initially, Cliff practiced Pediatrics in Champaign, Illinois. In 1957 an opportunity arose in Worcester and Cliff accepted an appointment to the staff of the then Memorial Hospital.

By the late 1960s, the sub specialists in neonatology had demonstrated their effectiveness in reducing morbidity and mortality in the newborn by concentrating their services in a specially equipped and staffed area. Thus came into being a new acronym, the NICU, the Neonatal Intensive Care Unit. With several of his colleagues in Pediatrics and Obstetrics, Cliff undertook the development of a plan to establish a Level One Unit in Worcester. The effort involved, among other challenges, the change in some long-standing hospital staffing policies. Cliff’s efforts were essential to bringing into being the Neonatal Intensive Care Unit at what is now the Memorial Campus of the UMass Memorial Medical Center. He was particularly effective in recruiting the first neonatologists. Frank Bednarek recalls the details of that process, which included an introduction to Margie Smith’s pies.

In 1980, Cliff and Margie moved to Hilton Head, South Carolina, where he sampled activities in other fields: the resort business and the preparation of first class chocolates. The couple returned to Worcester in 1980 and for a few years before retiring Cliff maintained a part time office practice.

Cliff was a Diplomat of the American Board of Pediatrics. He was a member of the New England Pediatric Society, the Massachusetts Medical Society and the Worcester District Medical Society. He was Assistant Professor of Pediatrics at the University of Massachusetts Medical School, and served on the staffs of the UMass Memorial Medical Center, Saint Vincent Hospital, and Hahnemann Hospital.

For his dedication to the needs of this smallest and most vulnerable patients Dr. W. Clifford Smith will be long remembered.

John A. Duggan, MD

Ronald A. Lukert, MD
1926-2008

Ronald A. Lukert, MD, formerly of Leicester and Milford, passed away on February 29, 2008, at the age of 82 in Largo, Florida, where he had moved eleven years ago. Dr. Lukert graduated from Amherst College and the University of Pennsylvania Medical School. Following post-graduate training at the Worcester Memorial Hospital, he established a Family Medicine practice in Milford, MA. Sometime thereafter, Dr.Lukert began a new and long career as Associate Medical Director of the Paul Revere Life Insurance Co. in Worcester.

He was considered very knowledgeable and ahead of his time in his clinical judgment by his co-workers and patients. He also had an exceptional business sense. He had a cheerful personality, greeting his colleagues from behind his desk, which conspicuously displayed a copy of the front page of the New York Times dated on his birth date. His sense of humor was unique and his laughter contagious. He was easy to find in the building, as there was always a small commotion of laughter wherever he happened to be. He had a running debate among football fan colleagues over his concern that those activities would be “taking years off those young athletes’ lives.”

Dr. Lukert served his community as President of the Rotary Club and as a member of the School Committee. He was a fifty-year member of the Worcester District Medical Society and the Massachusetts Medical Society. He served in the U.S. Army between college and medical school.

Dr. Lukert is survived by his wife Joan, two sons Kris and Kurt, and two grandsons. He was preceded in death by his daughter Beth.

Lawrence A. Cignoli, MD
Unum Co.