The Debate Over 76ers Place: City Hall Dreams Chinatown Nightmares &
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Philadelphia County Medical Society
2100 Spring Garden Street, Philadelphia, PA 19130 (215) 563-5343
www.philamedsoc.org
EXECUTIVE COMMITTEE
Domenick Bucci, MD PRESIDENT
Walter Tsou, MD, MPH PRESIDENT ELECT
John M.Vasudevan, MD IMMEDIATE PAST PRESIDENT
David A. Sass, MD, FACP SECRETARY
Sharon Griswold, MD TREASURER
BOARD OF DIRECTORS
Victoria Cimino, MD, MPH
Brian Hannah, MD
Cadence A. Kim, MD, FACS
William King, MD
Pratistha Koirala, MD
Elana McDonald, MD
Max E. Mercado, MD, FACS
Ricardo Morgenstern, MD
Natalia Ortiz, MD, DFAPA, FACLP
Dhruvan Patel, MD
Graeme Williams, MD
Heta Patel
FIRST DISTRICT TRUSTEE
Michael A. DellaVecchia, MD, PhD
EXECUTIVE DIRECTOR
Mark C. Austerberry
Editor Tracy Hoffmann
The Debate Over 76ers Place: City Hall Dreams & Chinatown Nightmares
By William King, MD, PCMS boardmember
The Philadelphia 76ers are an iconic sports franchise in the NBA and a jewel in the crown of Philadelphia Sports. The 76ers players from Julius Erving to Charles Barkley and from Allen Iverson to Joel Embid have played in arenas in South Philadelphia, first in the Spectrum, and then in what is now the Wells Fargo Arena. Over the past several years, the ownership of the 76ers has been planning and now promoting moving the 76ers away from the South Philadelphia sports complex where all of the other major sports franchises play, into space on East Market abutting the Chinatown neighborhood. As plans for this move have become more firm, and support from the construction unions and Mayor Cherelle Parker’s Administration has been clearly visible, the opposition from the nearby Chinatown community has become strong and clear.
The Chinatown community has come together to protect their ten-square-block neighborhood from redevelopment projects in the 1970s, when the Vine Street Expressway cut off the north side of the neighborhood, and Market East malls and the Convention Center cut away the west side of Chinatown. The proposal to place a 18,000-seat 76ers Place Arena at 10th and Market, by demolishing and replacing a large section of the Fashion District mall, became public in 2020 as a concept of the 76ers owners, Harris Blitzer Sports and Entertainment, after earlier attempts to build an arena at Penn’s Landing were outbid. The proposal attracted support from the Parker Administration and the labor unions, when HBSE negotiated to privately fund the 1.3 billiondollar arena, without using public tax dollars, and promising 1000 construction jobs, and hundreds of permanent jobs.
These private benefits have been strongly rebuffed by the Chinese business community. Steven Zhu, the President of the Chinese Restaurant Association, said in a statement, “We know these big sports arenas do not contribute to the neighborhoods that they are in; they serve only their own needs and their own profits.”[7][18] Zhu also used Capital One Arena as a cautionary tale given that the Chinese population and number of Chinese restaurants have declined significantly in Chinatown, Washington, D.C., since the arena’s construction.
The ongoing debate led Mayor Cherelle Parker to call for a town hall to listen to the community arguments. The opposition of the Chinatown neighborhood was joined by the other nearby neighbors in Washington Square, and the Gayborhood, but most of the corporate and business community remained neutral, or supportive of any project to revitalize the languishing Market East business corridor. During the period of studies and community meetings, the medical community remained uninvolved in what appeared to be a business and real estate project. This neutral posture of the medical community has begun to change when the Save Chinatown coalition noticed the significant number of surgical scrubs and stethoscopes in the audience at the town hall who were expressing their reservations about building an arena that would cut off access from the major highway to the center city medical centers. The Chinatown coalition was then joined by voices from the medical community, who have begun expressing grave reservations about the extreme traffic congestion that would occur after games and events, and the danger to access to the nearby Jefferson Trauma Center just three blocks away, and Pennsylvania Hospital Obstetrics Department, just a few blocks further downtown.
The Debate Over 76ers Place: City Hall Dreams and Chinatown Nightmares continued from page 5
Hundreds of supporters of the Save Chinatown Coalition lined up for hours to pack the Convention Center and two overflow rooms with members of the Chinatown community, and allies who included other concerned neighborhood associations near the East Market location of the struggling Fashion District property that is the proposed site of a new arena. The crowd included a significant contingent of health care workers and professionals, who expressed their opposition to the arena, primarily alarmed about the snarled traffic each evening during sporting and entertainment events The voices in support of the Arena were primarily the Black Clergy Philadelphia and many of the labor unions, who supported the large financial impact and jobs promised by the massive construction project. What began as a debate between the Chinese community trying to preserve their neighborhood integrity, and city and labor officials trying to generate economic development, has expanded to include the health care community concerned about the effects on the Chinatown residents as patients, and city residents as a whole who will be delayed in receiving emergency access to center city hospitals.
Medical student Pari Pancholy was quoted by WHYY and described the impact traffic to and from the arena would have on health care in Center City. Pancholy did not identify where she works. Jefferson Internal Medicine – Chinatown is situated on the 800 block of Arch Street, near where the proposed stadium would be built. “My hospital already struggles to get folks into the emergency bay. Just being close to Market Street, traffic and congestion from an arena will make it much harder,” she said. “It’s not just patients who need to reach us quickly. It’s transplanted organs for someone getting a second chance, it’s blood for someone in surgery.” Dr. William King, local general pediatrician, and PCMS board member, told the city representatives, “I don’t want to think about the 50 to 100 nights a year that an impassable traffic jam in center city makes it impossible to direct our patients to center city hospitals.” Dr. King added, “I don’t like the idea of ignoring the clear objections of a marginalized community in Chinatown, when there are so many other options to improve the arena where it already stands.” Mayor Parker listened attentively and promised to present the decision of her administration to all of the interested parties. Emergency room technician Jimmy Low, who opposed the arena, asked “why do they have to put a new stadium where it will destroy my Chinatown community, and block the ambulances coming to my hospital, every night there is a basketball game?”
Dr. Walter Tsou, a PCMS board member, is also a board member of Physician’s for Social Responsibility and posted as a member of PSR. “I express my strong opposition to having an arena sit on top of Jefferson Station. To put the arena next to Chinatown, I
think is not only a bad decision for Chinatown, but it’s opposed by Washington Square West, the Gayborhood, and all of the communities that are in that neighborhood. We should oppose this project just on the criterion that the neighbors who know best are opposed, but traffic will be a nightmare for the many years of its construction, and it will tie up traffic on 10th street, the major conduit to Jefferson’s Emergency room, and it’s going to happen that somebody in transit, stuck in traffic, will die.” The physician community at Jefferson Hospital has remained out of the glare of public comment during this controversy, so most of the visible objection has come from retired Philadelphia physicians like doctor Randall Drain, a community pediatrician, who was seen on the local news marching with the No Arena coalition, and Dr. Wilfreta Baugh, a retired former President of the Black doctors National Medical Association. Dr.Baugh, a retired African American internist, and 50-year participant and upcoming 2025 chairwoman of the Philadelphia Flower Show, worries that “a massive arena pushing into Chinatown is less likely to be the steady flow of business the neighborhood could use, and instead likely to be a flood of congestion, overwhelming the district, and obstructing our nearby hospitals. Chinatown doesn’t want this mess, and a lot of Black Philadelphians are on the side of the Chinatown community. If they say no, we should say no.” Our local Philadelphia County Medical Society medical student representatives have also begun listening to this controversy and provided their perspectives, although they asked to remain anonymous. Medical students, at a recent medical society meeting to learn civic engagement, were asked about the 76ers Place being built in East Market. A 3rd Year at Jefferson said, “this sounds like the opposite of what we are learning about trying to listen to community voices.” Addison, a 3rd Year at PCOM, challenged, “If we are trying to be sustainable, why would we leave a billion dollar arena, and build another billion dollar arena in a neighborhood that wants more housing,” and A.M., a second year student from Drexel, wondered, “If Chinatown doesn’t want this, and the nearby hospitals are only seeing a patient transportation nightmare, why would our city force this to happen? I sure hope healthcare doesn’t act this way.”
The Philadelphia County Medical Society has not taken a position on this Philadelphia development proposal, but many of our local retired and private practice physician colleagues are joining the residents of Chinatown in asking the City of Brotherly Love to slow down the plans to build an arena on Market Street that will block traffic in the heart of the city like a coronary thrombosis. •
Scott Nash Senior Vice President
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Management Advisor
Merrill 1200 Howard Blvd, Ste 300 Mount Laurel, NJ 08054
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9/9/2024
Dear PCMS Members:
Please allow me to introduce myself, I am Scott Nash, Senior Vice President, Wealth Management Advisor from Merrill Lynch, the Nash Wealth Management Team. My team and I have been advising and servicing the Philadelphia Medical Society for over 20 years.
As a member of the Philadelphia County Medical Society, you have access to myself and my team for complimentary wealth consultations, cash flow analysis, and investment research. In addition, our specialists in Lending, Banking, and Wealth Management provide our team even more ability to serve you. Your colleagues have greatly appreciated the services we have been able to provide to them.
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Sincerely,
Scott Nash Wealth Management Advisor
The Nash Wealth Management Team
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College of Physicians STORY SLAM
By Mark Austerberry
The 6th Annual College of Physicians Story Slam was held this past May with the event supported by the College of Physicians of Philadelphia; Section on Medicine and the Arts and the Delaware Valley Medical Student Wellness Collaborative. Storytelling is as old as time and it is how we share our history, wisdom, and experience with the world. It is also a way to help expand our understanding of the world and ourselves. It refreshes our perspective and reminds us that people have varied experiences and particular understandings of the world. For the last 6 years, local medical students and healthcare providers have shared their personal experiences through stories and the public has always been encouraged to attend and vote to select the best stories.
Metropolitan Philadelphia medical schools are invited to field a team of two storytellers—one medical student and one physician or medical student at any level. Each contestant is given 5 minutes to tell a medically-related story and at the end, the audience will select the three best stories.
This year’s story slam winners included: 1st place winner Margaret Burzynski, a second-year medical student at Cooper Medical School of Rowan University. She is originally from Milwaukee, Wisconsin and completed her undergraduate degree at Fordham University in the Bronx. She is completing a three-year accelerated degree at CMSRU with a focus on adult primary care. She is interested in Narrative Medicine and how creative writing can enhance and inform the experience of a healthcare professional. Also from CMSRU and the 2nd place winner was Marni Goldstein, now an Internal Medicine Resident at Cooper University HealthCare.
And the Third place winner was Fatema Hashem from the Lewis Katz School of Medicine, Class of 2027. Congratulation to all these winners! Also special thanks to Douglas Reifler, MD, Senior Associate Dean for Student Affairs at Cooper Medical School of Rowan University, for facilitating these annual Medical Story Slams with the College of Physician of Philadelphia.
1ST PLACE Yo entiendo | I understand
By Margaret Burzynski
I feel like the last duckling at the end of the line walking down the hall. Attending, Chief resident, resident, intern, M3, and me. We are rounding on our patients to close out the morning, and our last stop is with a patient receiving dialysis.
“I have bad memories of this place,” the M3 says with a slight shudder, though she doesn’t elaborate.
“This was the first place I ever did compressions on someone,” says the chief resident, “I felt him die under my hands.”
They have placed death inside the room before I can even see it.
Before we enter, the intern attempts to call the interpreter line on his phone, as the patient speaks Spanish. The six of us stand in a semicircle in the hallway and listen to it ring and ring and ring and ring out. The attending sighs, “Do any of you speak Spanish?”
“I do,” I say, raising my voice for the first time that morning since introducing myself. He gestures for me to enter first, and my role transforms in an instant.
The room is filled with the sound of machinery, constant hums, clicks, whooshes, and hisses. The dialysis machines remind me of the first computers, blocks and blocks of circuit boards working together to answer a single mathematical question. In this case, working to keep a single person alive.
I enter and introduce myself to the patient, “Me llamo Maggie Burzynski, soy un estudiante de medicina, voy a interpretar para usted y el doctor.”
He speaks so softly I need to bend down close to his head to hear him, “No puedo hablar inglés, mija.”
“Yo entiendo,” I say, I understand. “Voy a interpretar,” I’ve got you.
The attending introduces himself and I translate his words. He stands at the foot of the bed while I crouch at the head. The patient murmurs his response, too weak to raise his voice, and I translate it in turn.
The residents and the M3 surround us, all focused on my words. I have become the attending and I have become the patient. I am the intermediary of care.
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The attending says, “You have a wound on your foot which has become infected. We are going to take imaging once you are done with dialysis and then the foot surgeon will determine what the next steps are.”
I translate and keep my eyes on the patient’s face as he replies, “Yo entiendo.” I am the only one who can see him softly begin to weep.
“¿Qué es esto señor? ¿Por qué usted llora?” I ask. “He is crying,” I say to the attending, who places a hand on the patient’s knee and makes a comforting sound, understandable in any language.
“Tengo miedo, mija,” the patient says.
“I am scared,” I translate, leaving out the endearment my child, as this is just for me.
“No quiero perder el pie,” he continues.
“I do not want to lose my foot,” I relay to the attending.
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Annual College of Physicians Story Slam continued from page 9
First and Second place winners of the
Burzynski (left) and Marni Goldstein (right), both students at Cooper Medical School of Rowan University
“I understand,” he replies, “we need to get the imaging and then we will see what the next steps are. We do not know yet if the infection is in the bone.”
“Yo entiendo,” I say. And I am the attending and I am the patient and I am myself, looking at this man’s weathered face, tears following the paths of his wrinkles. I translate the rest.
We finish our conversation, and the attending moves on to the dialysis machine, pointing to various numbers, valves, bags, and buttons. “Do you know what this is?” he asks, and the residents dutifully answer. “Do you know what this does?” and they reply with the precise jargon of medicine, gibberish to anyone outside the learned circle.
“Estamos hablando sobre la maquina,” I explain to the patient, unwilling to let go of this thread of interpretation as his connection to the room around us.
I listen to all the languages I hear: English, Spanish, Medical, Machinery. I look around the room and see the people hooked up to these machines, knowing
they would die without them; the tubing, hissing, and humming become as essential a part of them as the two kidneys nestled inside their bodies once were.
We turn to leave the room, and I bend back down to say goodbye to the patient.
“Gracias, mija,” he says, and squeezes my hand in thanks. I do not translate, as this is for my ears only.
“Cuídese, señor,” care for yourself, I reply, though perhaps what I should have said is ‘I hope we can care for you.’ I let go of his hand and leave the room.
“Thank you,” the attending says, with sincerity and as a dismissal. I move back to my place at the end of the line.
2ND PLACE
It’s not her, but she’s here
By Marni Goldstein, MD, Internal Medicine Resident at Cooper University HealthCare
I stepped into the anatomy lab, coughing from the smell of formaldehyde, and my stomach dropped. There were three rows of tables, each with a blue body bag on top.
It’s not her. She’s not here. It’s not her. She’s not here. I repeated silently to myself.
I joined my dissection group, my heart pounding and throat aching as I held in tears. They unzipped the body bag. I saw his hand, skin wrinkled with age and shriveled from embalming fluid. A damp blue towel covered his face, outlining the shape of his nose.
I felt his skin through my glove–cold. My classmate, Paige, made the first incision and sliced through his skin with ease.
Needing to avert my eyes, I turned and saw a hand draped over the side of another dissection table, fingernails painted purple.
It’s not her. She’s not here–but, here she was.
My mind raced back to the previous year, sitting beside my mom’s hospital bed in her bedroom. The TV show Chopped was playing–background noise to cover the sound of the ventilator pushing air in and out of her lungs.
I gently straightened her bony fingers, feeling her muscles atrophied from ALS. I painted each fingernail with purple polish, then lifted her hand toward her face so she could see them. Light danced off the glitter as she smiled with just her eyes.
I ran from the anatomy lab to the locker room and collapsed onto a bench. Holding my head in my hands, I cried so hard I could barely breathe.
I remembered running into her bedroom that day and seeing her lying in bed with her eyes partly closed. Her chest rose and fell, but in my gut, I knew it was just the ventilator. I touched her hands— cold. I put my ear to her chest, listening for a heartbeat—silence. I hugged her lifeless frame, my tears soaking her nightshirt. I turned off the ventilator and called the hospice nurse. She was gone.
Paige joined me in the locker room, putting her arm around my shoulder while I cried. I was grateful for my friend but embarrassed about my breakdown.
Before starting medical school, I grappled with how much of my past I wanted to share with my classmates. At thirty-one years old, I already felt different. I didn’t want to also be the sad girl whose mom just died. I wanted to make friends, and, just like my mom, I never wanted to be a burden.
I was terrified to start anatomy lab, afraid to be so close to a dead body again. To mitigate my fears, I spoke to a professor before our class started dissections.
“Don’t worry, it really won’t look like her,” she said.
As I cried in the locker room, these well-intentioned words echoed in my head.
story slam, Margaret
Of course, the cadavers didn’t look like my mom. But that didn’t make them any less real, less human, or less dead.
I thought back to the day I was accepted to medical school. After getting a phone call from the Dean of Admissions, I ran to my mom’s bedroom to share the news. Our cat, Frankie, followed me in and jumped on her bed.
“Yay, yay, yay!” she said. ALS made every sentence a struggle, and her words were often so slurred that understanding her felt like telepathy. “You will be a very good doctor, like how you care for me.”
“I promise to see you in every patient,” I said. I kissed her forehead and wiped a tear from her eye.
She died exactly one month later.
I envied my classmates, who seemingly had no difficulty in anatomy lab beyond learning the brachial plexus. With only six months between my mother’s death and starting medical school, I hadn’t fully grieved her loss. I needed to move forward. So, I compartmentalized. Stuffing memories, sadness, and regret into a box in the depths of my mind. I felt guilty for repressing my feelings, but it was the only way I thought I could get through medical school. With only two weeks to learn every muscle, nerve, artery, and vein in the upper body, there was no time to cry.
I began to doubt myself and my decision to go to medical school in the first place. If I couldn’t handle anatomy lab—a quintessential rite of passage for all medical students—could I handle caring for patients, particularly surrounding death?
I thought of an elderly patient I saw for her primary care visit earlier that year. Without hesitation, I talked to her about maintaining independence, preventing falls, and end-of-life decisions. I recommended specific shower grab bars that my mom had used. We discussed the meaning of an advanced directive. The conversation came naturally to me, having had it before with my mom. It’s not her, but she’s here.
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I promised to see my mom in every patient. While my experience caring for and losing her has made some parts of medical school uniquely difficult, it has helped me connect with my patients and continues to influence the physician I become.
Now, in my final year of medical school, I’ve carried this promise through
all of my clinical rotations. I saw her on Neurology when a patient, accompanied by her own daughter, was diagnosed with MS, and I shared support resources. I saw her on Internal Medicine when I helped distract a patient from his excruciating pain by showing him pictures of my cat, Frankie.
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Annual College of Physicians Story Slam continued from page 11
I never wanted to see my mom in anatomy lab. However, she was there every time I opened that door and formaldehyde burned my nose—reminding me of my promise to my mom and my patients.
I joined my group at our dissection table. I felt his skin through my glove— cold. It’s not her, but she’s here. I grabbed a scalpel and made my first incision.
3RD PLACE Blue Hands
By Fatema Hashem, Lewis Katz School of Medicine, Class of 2027
I am an ardent lover of paradoxes, so humor me this: In a field that enshrines the healing of wounds and ailments, why is it that the first thing we do is slice through a human being in what feels like an utter defilement – we skin them, peel away at their muscles, pull out their organs, disassemble their limbs, tear their ligaments, saw through bone, crack skulls, disarticulate heads, gawk at their most sacred parts, tug and tug on fascia. Fascia that will soon be nothing but ashes once they are finally cremated and spared from our hands. Those blue-gloved, curious hands.
In the midst of such mauling, I wonder if medicine inherently starts with injury and we, the doers of no harm, we irrevocably assault our first patient.
I would like to share with you a quote from the late Dr. Paul Kalinithi, author of When Breath Becomes Air – I believe he perfectly encapsulates the perspective of a first-year medical student, an ingenue like myself, experiencing medicine at its most grotesque – he writes “in our rare reflective moments, we were all silently apologizing to our cadavers, not because we sensed the transgression, but because we did not.” Somewhere along the past grueling eight weeks, I began to wonder when I stopped seeing a human corpse – at what precise point did I start seeing the body as an indiscernible pile of muscle, bone, tissue, nerves, and vasculature – when did my top priority become locating the hypoglossal nerve instead of reeling at the sight of the mangled corpse before me? This filled me with so much shame. And truthfully, anatomy lab has felt as much a dissection of my character as of our cadaver.
I think I just admitted to having an existential crisis, but that’s for the next story slam.
During one lab session, the beloved Dr. Popoff joined us at our table to help excavate the inferior mesenteric artery. He found it, with great ease I might add, despite the massive aortic aneurysm that had warped our donor’s abdominal anatomy – what took us 10 minutes took him 10 seconds – it’s almost as if the artery was searching for him and not the other way around, the way it effortlessly unfurled beneath his scissors. We marveled at it, our hands reaching over to feel for its lumen. And, at that moment, for just a split second, my eyes drifted to the image of 6 hands clad in blue encircling our donor’s innards – it was picturesque, something Michelangelo might have depicted had he been a physician in the 21st century –there was something so profound about the fluorescent blue of our nitrile gloves, so cold and sterile looking against human flesh.
They say the hands and the eyes are the most significant apparatus of our humanity – Looking at those blue, disembodied gloves, shredding through fascia and viscera, you could almost forget that those were your hands. They weren’t Camila’s hands, or Shayan’s, or Aqib’s, or Sarah’s, or Sravan’s – nor were they mine. They were just blue hands.
At the beginning of this story, I told you all that we irrevocably assault our first patient – but the more I think about it, the more I realize that my first patient was not necessarily my donor. Rather, it was me; I was and am my first patient. Every time I stepped into that lab, I had to remedy a part of myself that so desperately needed to be saved – every time I caught myself conveniently forgetting that our donor was once a person and still lives somewhere in the memories of his loved ones, I had to resuscitate the oath I took –in the face of such a brutal undertaking, it felt as though my principals were at risk of disease – Paul Kalinithi’s words rang in my ears – quote “cadaver dissection epitomizes, for many, the transformation of the somber, respectful student into the callous, arrogant doctor.’’ End quote.
As fascinating as gross anatomy was, it also felt like a slippery slope – we begin by compartmentalizing and desensitizing. Then, before we know it, the human body is no longer conflated with as much sentiment – it’s reduced to parts, mechanisms, angles, landmarks – a means to flexion and extension instead of arms widening to embrace a loved one. I’ll leave you with one last quote, and I heard it from my parents after my very first anatomy lab. But this one is in Arabic so I will translate. The saying goes, “la haya’ fe al ilm” translation: “there is no shame in the pursuit of knowledge.” And so let me return to my paradox – there can be great honor and nobility in the reprehensible act of cadaver dissection – because one day, when I save my first life, I will fondly remember the soul who so generously allowed me to dive into the human body, in the pursuit of knowledge and medicine. And I hope, I pray, that I am worthy. •
The Flexner Report: A Profound Prescription for Science and Accountability in Medical Education
by Dan Kimball, MD, MACP
The 360 plus-page Flexner Report was commissioned under the auspices of the Carnegie Foundation, founded in 1905. Their initial mission was to provide pensions for college professors, a task that would eventually become TIAA (Teachers Insurance and Annuity Association). Under the leadership of its first president, Henry Pritchett, the foundation trustees originally envisioned this proposed medical school study, as the first of many studies about the quality of professional schools, in North American and Europe.
It is notable that the American Medical Association’s Council on Medical Education, which was established in 1904, had as its primary focus when founded, “…the need for a comprehensive study of our medical schools including their curricula, facilities, and faculty” and were enthusiastic supporters and enablers of this study. Since the founding of the AMA in 1846, it was committed to two propositions, first, that “…it is desirable that young men received as students of medicine should have acquired a suitable preliminary education …” and secondly, “…that a uniform elevated standard of requirements for the degree of MD should be adopted by all the medical schools in the United States.” It would be more than fifty years after the AMA adopted those aspirational goals before work on those goals would begin. Many would suggest it began following the release of the Flexner Report in 1910.
Abraham Flexner, who conducted the study and wrote the report for the foundation, was born in Louisville, KY in 1866 and was the sixth of nine children born to Ester and Moritz Flexner. He was the first in his family to attend college. He attended Johns Hopkins University where he earned a BA in classics after two years of study. He also pursued graduate studies in Psychology at Harvard University and the University of Berlin, but never completed work on an advanced degree.
In 1890, after teaching for four years at Louisville High School, he founded and directed an experimental college-preparatory school. Two years earlier, he had published a critical assessment of the state of the American secondary educational system, titled “The American College: A Criticism.” That paper would catch the attention of the Carnegie Foundation, which led them to invite Flexner to engage in his study.
Flexner opposed the then-standard model of education that focused on mental discipline and a rigid structure. His school did not give out traditional grades, it used no standard curriculum, refused
to impose examinations on students, and kept no academic records of students. Instead, he promoted small learning groups, individual development, and a more hands-on approach to education. Flexner was not a physician and had never been inside a medical school before undertaking this study.
He joined the Foundation staff in 1908 and wrote this report in 1910, which is officially titled “Medical Education in the United States and Canada,” which is traditionally referred to as “the Flexner Report.” Although he is best remembered for this report, his greatest educational gift may have been his founding and leadership of the Institute for Advanced Study, a private, independent academic institution located in Princeton, New Jersey which quite notably included Albert Einstein as a resident scholar.
The Flexner Report contains two large major sections. Part I contains multiple chapters that include a review of the history of medical education in the United States, and an assessment of the current medical education process in the late 1800s. Four chapters outline what the four years of medical school should look like, including a chapter on the finances of running a medical school, a short section on “medical sects” to include homeopathy, osteopathy, and eclectic medicine, a short chapter on suggestions about the role of state medical boards in assuring the training of physicians, a short chapter about “the Postgraduate School,” which may be labeled the first internship, and two short chapters on the medical education of women and the medical education of the Negro, which in hindsight have been labeled as sexist and racially biased.
Part II of the report is a detailed listing of the 155 medical schools visited in the United States and Canada. Sixty-nine of these schools were proprietary. There is an appendix which includes a table showing the number of faculty, enrollment numbers, tuition income and the budget of the schools.
In a previous Medical Record article, discussing the career of the 18th Century Berks County physician and Senior Physician to General George Washington at Valley Forge Dr. Bodo Otto, I noted that apprenticeship was the primary method of medical education in our country from the colonial period through the early 19th century. During that time aspiring physicians would typically learn the trade by working directly under the supervision of an established
FEATURE continued
The Flexner Report: A Profound Prescription for Science and Accountability in Medical Education continued from page 13 doctor, gaining hands-on experience and practical knowledge. You might call this the “see one, do one” method of learning. This apprenticeship might last anywhere between 4 to 7 years and included assisting with surgeries, maintaining medical records, ordering supplies and other duties as assigned. The apprentice could begin his own practice when they were approved to do so by their supervising physician teacher. There was no board exam or licensure process.
The earliest medical schools in the United States included the University of Pennsylvania School of Medicine (now the Perelman School of Medicine), founded in 1765; the King’s College Medical School (now Columbia University College of Physicians and Surgeons), founded in 1767; the Harvard Medical School, founded in 1782; and the Dartmouth Medical School (now the Geisel School of Medicine at Dartmouth), founded in 1797. During the American Revolution, King’s College was temporarily closed, when the British occupied New York, and later reopened as Columbia College, which would eventually become Columbia University.
Proprietary medical schools in the United States began to emerge in the early 19th century. These schools were for-profit institutions that were often established by individual physicians or small groups of physicians. These schools would play a significant role in medical education during the 19th century, offering more formalized training compared to that of the apprenticeship model. The first proprietary medical school in the US was the College of Physicians and Surgeons, founded in 1807, and would ultimately become part of Columbia University. By 1900 there were approximately 160 proprietary medical schools operating in the United States. These schools varied widely in their ability to screen applicants for admission, to have a standardized curriculum, to provide clinical experience, and to have appropriate equipment for teaching including laboratory facilities and libraries. Funding to pay the faculty and run the school was totally supported by tuition fees and donations. For the most part these schools were operated to make a profit for the founding faculty members.
Flexner felt strongly that two years of college with emphasis on study of the sciences should be required to enter a medical school but at the time of his report only 16 of the 155 schools had such a requirement, with six additional schools requiring one year of college. Fifty other schools required a high-school education or its equivalent, and about 80 other schools had little to no entrance requirements, other than the ability of students to pay the tuition fees.
Flexner notes in his report an exceedingly high failure rate, exceeding 50% in many of the medical schools surveyed, which he attributed to the lack of preparation by many of the accepted students. He captures some of the views of current professors at these schools with quotes from some of them, such as, “…the facilities are better than the students; …the boys are imbued with the idea of being doctors; they want to cut and prescribe; all else is theoretical; …it is difficult to get a student to want to repeat an experiment in physiology; …they have neither curiosity nor capacity; the machinery doesn’t stop the unfit; …men get in, not because the country needs doctors, but because the school needs the money.” Flexner highlights a professor’s response to his question, “What is your honest opinion of your own enrollment process?” and the professor says, “Well, the most I would claim, is that nobody who is absolutely worthless, gets in.”
There were approximately 163 allopathic medical schools in the United States and Canada at the time of this report and Flexner visited 155 of them. He notes in his report that during the 100-year time before his report, there were over 450 different medical schools established, most of which had come and gone by the time of this study. For instance, the city of Chicago had 14 medical schools, the state of Missouri 47 schools and the state of Indiana 27 schools.
There were 8 Osteopathic medical schools in the United States in 1910 but to the best I can understand, Flexner did not visit many of them. He did include the then-newly established Philadelphia College of Osteopathic Medicine as one of the 7 Pennsylvania schools visited. There were no osteopathic medical schools in Canada in 1910. In addition to osteopathy, there were 10 eclectic medical schools that focused on herbal remedies and 22 homeopathic medical schools at the time of the report.
Today there are 156 allopathic medical schools, and 40 osteopathic medical schools in the United States. There are 5 homeopathic organizations, not medical schools, with 4 in the United States and 1 in Canada, that offer training and certification in homeopathy. To the best of my knowledge, only the State of Arizona licenses homeopathic practitioners.
The following are the (paraphrased) six major findings of the Report:
1. For 25 years there has been an enormous over-production of uneducated and ill-trained practitioners (that is a quite damning statement to start the report).
2. Over-production of ill-trained men is due in large part to the existence of a very large number of commercial (proprietary) schools.
3. Until recently the conduct of a medical school was a profitable business, because the methods of instruction were mainly through didactic lectures.
4. The existence of many of these unnecessary and inadequate schools has been defended by the argument that a poor medical school is justified in the interest of the poor boy.
5. A hospital under complete educational control of the medical school is as necessary as a laboratory of chemistry or pathology.
6. Throughout the eastern and central states, the movement under which the medical school articulates with the second year of college has already gained such impetus that it can be regarded as practically accepted.
In summation, “Our hope is that this report will make plain once and for all, that the day of the commercial medical school has passed.”
There were 7 major recommendations of the Report:
1. There should be greater Standardization of Medical Education. The Report recommended that medical schools should adhere to high standards of admission and education, requiring at least a high school diploma and two years of college studies including premedical courses in biology, chemistry, and physics.
2. There should be Integration of Medical Schools with Universities. The Report advocated for medical schools to be part of a larger university system to ensure oversight, resources,
and academic integration.
3. There should be greater emphasis on Scientific Method and Research in the teaching. The Report emphasized the importance of scientific research and the scientific method in medical education, which includes a strong foundation in laboratory sciences.
4. There should be more Clinical Experience. The Report emphasized that medical education should include practical clinical experience in hospitals and dispensaries that would be affiliated with medical schools, allowing students to apply their knowledge in real-world settings.
5. Specifically, there should be a Reduction in the number of medical schools. The Report called for the closure of the proprietary and substandard medical schools that did not meet the proposed standards.
6. About Licensing and accreditation. The report urged stricter licensing of graduates and an accreditation process to assure that medical schools met the new standards.
7. And a recommendation to focus on the quality of medical graduates as opposed to the number of medical graduates.
The Flexner Report received a mixed reception in the medical community. Those schools already affiliated with colleges and universities were largely positive, while the proprietary schools were clearly threatened. The demands of this Report would put a strain on already inadequate funding streams for medical education. It was clear that tuition fees alone would be inadequate to support the future medical school.
Some have held that the Report reflected racist and sexist views that were inappropriate, while others would say that the report reflected the segregated and gender-biased norms of the time in 1910. It did result in the closure of five of seven historically Black medical schools, many in rural areas, with only the Howard University and Meharry Medical College being left to train African/American physicians. Today, there are four historically Black medical schools in the US.
While Elizabeth Blackwell was the first female graduate from one of our medical schools (the Geneva Medical College, in Geneva, NY) in 1849, the number of female medical students in 1910 at the time of the Flexner report was very low. Dr. Blackwell had applied to many schools and was refused admission.
Today, just under 55% of our entering medical students are female. Enrolling qualified historically underrepresented students into our medical schools continues to be a challenge. Data reflects that in recent classes of students entering our medical schools, 25% are Asian/Pacific, 11% are Latino, 8.5% are African/American, and 0.2% are native American/Alaskan native.
In summation, clearly the Flexner Report has played a defining role in the establishment of medical education as we know it today. It has had a lasting impact leading to more qualified candidates for training, the establishment of standardized curricula, improved training of students, and a focus on scientific research, and led to the earliest forms of post-graduate medical education, giving rise to the many residency and fellowship programs which are essential to professional development and quality patient care. •
concerts at THE COLLEGE
Experience this rare opportunity as musicians from the Philadelphia Orchestra play in historic Mitchell Hall at The College of Physicians of Philadelphia!
DECEMBER
16, 2024
Hear works by Vaughan Williams, Anna Weesner, and Brahms in the College’s historic Mitchell Hall.
JANUARY
24, 2025
A special performance featuring the Philadelphia Orchestra Musicians and Music and Artistic Director, Yannick Nézet-Séguin
MARCH 10, 2025
Don’t miss out on the final concert of the season! Hear works by Britten, Bridge, and Beethoven in Mitchell Hall.
Lincoln’s Brush with Death: Smallpox in 1863
by RENÉ F. NAJERA, DRPH
In November 1863, shortly after delivering the Gettysburg Address, President Abraham Lincoln fell ill with a serious case of smallpox. The disease, caused by the variola virus, was one of the most feared illnesses of the 19th century. Smallpox epidemics routinely swept through cities, killing about a third of those infected.
Lincoln first showed signs of illness on the evening of November 18, 1863, while traveling back to Washington, D.C. from Gettysburg. He developed a severe headache, backache, and fever. A few days later, the characteristic rash of smallpox blisters erupted on his skin. Lincoln was bedridden with the disease for three weeks.
Although Lincoln’s doctors tried to reassure the public that the president only had a mild case of “varioloid” smallpox, more recent analysis suggests Lincoln actually suffered from the serious, unmodied form of the disease. Smallpox vaccination, while available at the time, was not widespread. Lincoln himself appears not to have been immunized earlier in life.
Lincoln ultimately recovered, but the disease proved fatal for his valet William H. Johnson. Johnson, an African-American man who was Lincoln’s close personal attendant, cared for the president during his illness. Johnson contracted smallpox shortly after and died from it in January 1864. Lincoln paid off Johnson’s debts and arranged for him to be buried at Arlington National Cemetery.
Some historians speculate Lincoln’s bout with smallpox could have altered the course of history had it ended differently. At the height of the Civil War in late 1863, Lincoln’s steady leadership was crucial. His death from the disease would have thrown the country into chaos.
Smallpox continued to be a global scourge until the 20th century. A worldwide vaccination campaign led by the World Health Organization finally eradicated the disease in 1980. Lincoln’s frightening encounter with smallpox demonstrates how this now-extinct virus terrorized people for centuries. It’s a reminder of how far public health has advanced, and the devastating toll that infectious diseases once incited on humanity. •
T2024 Election
By Larry L. Light
he 2024 Presidential election cycle was always going to be epic. A rematch of the 2020 race won by Democrat Joe Biden and the incumbent president he defeated, Republican Donald Trump, guaranteed that this was not going to be a lackluster contest. In a country that is by all accounts already sharply divided politically, and with high profile domestic issues such as immigration and border control, women’s reproductive rights and in vitro fertilization, the struggling economy and gun control the focus of debates, op-ed pieces and media reports, it was obvious that the American political system is under stress.
Then, it got even more epic if that is possible. For the first time ever an incumbent president comfortably on track to accept his party’s nomination in August, resigned that nomination in June after the first presidential debate of the cycle. When his party’s nomination swung to Kamala Harris, the first ever African American Asian American female Vice President, an unprecedented presidential election cycle was launched.
For now, put that aside and consider the role of Pennsylvania in this epic presidential election cycle. In 2020 candidate Joe Biden campaigned in Pennsylvania as the Commonwealth’s “third Senator.” Having been born in Scranton he had clear ties to PA that had remained strong throughout his political career. When he withdrew from the race it put Pennsylvania directly into the “toss up” state category. The next development was having Democratic Governor Josh Shapiro identified as a strong choice for the vice-presidential slot on his party’s ticket. Pennsylvania was back in the spotlight. Remarkably the decision by Harris to choose Minnesota Governor Tim Walz as her running mate increased Governor Shapiro’s popularity, amplified his chances on running for national office at a future date and brightened the national spotlight focused on Pennsylvania voters and politics.
While Pennsylvania pales in comparison to states like California, New York, Florida and Texas, it is still considered “voter rich” in two ways. First, the two major parties combined have more than 3 million registered Pennsylvania voters. There
are another 1 million plus voters registered as independents. Those voters will play a significant part in the total popular votes won nationally by each candidate. From a party perspective it is significant to note that the statewide voter registration edge held by Democrats has dwindled from over 1 million to roughly 150,000.
Second, even before the traditional Labor Day holiday start of campaign election cycles, the Keystone state emerged as the battleground of battlegrounds among the seven recognized swing states in this 2024 contest. Especially with regard to the Electoral College. The others in that category are Arizona, Georgia, Michigan, Nevada, North Carolina and Wisconsin. But Pennsylvania, among all of those acknowledged swing states, has the largest number of electoral votes, 19, that will be awarded to the candidate who wins the state’s popular vote. History reveals that Pennsylvania has sided with the winning candidate at the national level in 10 of the last 12 Presidential elections. Since Biden vacated his party’s nomination, the compressed election cycle has required both campaigns to spend huge amounts of time and campaign funds, offices and paid workers in our swing state. We live in the potentially decisive swing state that unquestionably matters, perhaps matters the most, in this election.
Another factor at play is that there is a lot more than the Harris-Trump contest on the November 5th ballot. Democrats in the US Senate and Republicans in the House of Representative both have razor thin majorities, and political control of either chamber, or both, could potentially change after votes across the nation are counted.
As part of the 51-49 Democratic majority in the US Senate, incumbent Democrat Bob Casey is in a high-profile race against Republican Dave McCormick. Casey is defending his record while seeking his fourth term. He serves as Chairman of the Senate Special Committee on Aging. David McCormick is a business man who is working hard to overcome criticism of his residential connection to Connecticut and investment
career. While Casey has been holding a polling edge, the race is considered to be highly competitive and one of the most important of the 35 contests across the nation for Senate seats.
At the other end of the US Capitol the slim GOP majority (220-211-4 vacant) in the House of Representatives is also perilous. Across Pennsylvania’s 17 congressional districts, all incumbents are seeking re-election. Three races are in the group of 30 nationwide with the highest “outside” campaign contributions –a measure of the importance of those races. In the Lehigh Valley’s 7th district Republican State Representative Ryan MacKenzie is challenging incumbent Democrat Susan Wild. Her colleague, incumbent Democrat Matthew Cartwright in northcentral PA 8th district, is facing Republican Rob Bresnahan. On the other side of the aisle, southcentral PA Republican incumbent Scott Perry has Democrat Janelle Stelson as his opponent in the competitive 10th district. It’s certainly possible that one or more incumbents will lose, although all of them could be re-elected. Philadelphia Democrat Dwight Evans is the only incumbent congressman without an opponent. Political strategists consider the battle for control of the House to be a toss-up. But there is no question that whoever occupies the White House would prefer to have one or both congressional chambers under the control of their own political party.
incumbent State Treasurer, Republican Stacy Garrity, is opposed by Democrat Erin McClelland, an unexpected primary victor from western Pennsylvania. The only open seat is the race for Attorney General. The Republican candidate is Dave Sunday, the York County district attorney. Eugene DePasquale from Pittsburgh, a former state legislator and Auditor General, is the Democratic candidate.
On their ballot, voters will also encounter races for the Pennsylvania General Assembly. All of the 203 seats in the PA House of Representatives are up for election, even a few that were filled in special elections held in mid-September. After the 2022 general election Democrats held a one-seat edge in the House chamber after many years of Republican control. Both parties are working hard to win the majority for the next legislative session.
Control of the State Senate has been more settled in recent years, with Republicans holding a 28 – 22 majority. However, 15 of the 25 seats up for election this year are currently held by Republicans, making their cycle both more expensive and more challenging. In this election, 5 of the Democrats and 4 of the Republicans are running unopposed.
The most important thing about elections for everyone, including physicians, is to be registered to vote.
Voters in Pennsylvania will have what is considered politically as a “long ballot,” with contests for President/Vice President, US Senator, Congress, Attorney General, Auditor General, State Treasurer, State Senator (25 of 50 seats) and State Representative on their mail-in or machine ballots. As a result, candidates running for those offices may be helped or hindered by the wellknown “down ballot” strength of their top of the ticket candidates.
In the commonwealth there are 3 statewide contests on the ballot to fill the row offices of Attorney General, Auditor General and State Treasurer. Incumbent Republican Auditor General Timothy DeFoor is being challenged by Democrat Malcolm Kenyatta, currently a State Representative from Philadelphia. The
The last day to register to vote before the Presidential election is Tuesday, October 21st. Voter registration will re-open the day after the November 5th election. Registered voters who find going to their polling place inconvenient can apply for either an absentee or mail-in ballot. The last day to receive those requests by mail, online or in person is October 29th. All completed ballots must be in the hands of elections officials on or before November 5th. The electors from Pennsylvania participating on behalf of the candidates for president and vice president winning the statewide vote will meet on December 17th. •
About the Author: Larry L. Light, retired PAMED Senior Vice President for Physician and Political Advocacy.
Think Differently Villanova University Certificate Program for Healthcare Leaders
Every day, physicians navigate a complex healthcare system, facing pressures to improve patient outcomes while balancing operational and economic constraints. By effectively utilizing creative problem-solving methodologies, new technologies, and business processes, physicians can drive positive outcomes for their patients and their organizations.
Villanova University’s online Certificate in Healthcare Design & Innovation is tailored for healthcare leaders seeking innovative solutions. The program consists of four courses covering design thinking, digital health, economic policy, and healthcare supply chains. Participants will gain practical knowledge that can be applied immediately to a variety of healthcare challenges.
Participants will also connect with leaders across the healthcare ecosystem. This program invites the diverse perspectives of professionals from pharmaceuticals, insurance, medical devices, healthcare administration, frontline personnel, and other healthcare backgrounds. Our goal is to exchange ideas that lead to transformative impact on individuals, teams, and organizations.
This online program is designed to accommodate the demanding schedules of healthcare leaders. Each of the four courses is completed in four weeks and features a weekly live session to engage with faculty and peers. The courses include:
Systems and Design Thinking for Healthcare Innovation
This course explores the problem-solving methodologies of systems thinking and design thinking to identify patient-centered solutions. Physicians can enhance the patient experience through a holistic and structured approach to innovation that drives creative, collaborative, and practical solutions.
Digital Health & Analytics
As artificial intelligence and new technologies reshape healthcare, understanding their integration into patient care is critical. This course enables healthcare leaders to make data-driven decisions, enhance the patient experience, and drive continuous improvement in healthcare organizations.
Economic Forces and Policy Shaping Healthcare
Economic policies significantly impact the healthcare market and patient outcomes. This course examines the economic conditions affecting healthcare, focusing on the balance between access, cost, and quality, and the opportunities for innovation in all three areas. Practical applications and real-world examples will be used to explore ways to increase value and improve patient care.
Reimagining the Healthcare Supply Chain
Supply chains are critical to patient care but pose significant challenges. This course helps healthcare leaders understand the role of supply chains and how effective management can lead to better healthcare. We will examine opportunities to more effectively manage costs, source products, mitigate risks, and drive innovation.
At the conclusion of the certificate program, 97% of participants have reported they immediately applied lessons learned to their workplace.
This four-month certificate program is offered annually, with the next session starting in January 2025. Members of the Philadelphia County Medical Society are eligible for a 15% discount. Enter promo code PCMS25 during the application process.
Please visit www.villanova.edu/hdi to learn more or contact the program organizers at executive@villanova.edu. •
Incorporating Digital Therapeutics into the Stepped Care Model: Enhancing Mental Health Care at Every Step
By Jessica Flannery and Benjamin Alouf
Introduction
Digital therapeutics (DTx) have the potential to expand and enhance the stepped care model of mental health care, the adoption of which requires greater buy-in and understanding by patients, providers and payors. In this edition, we will provide an introduction to digital therapeutics. In the next edition, we will dive into how these solutions can be used in the stepped care model.
The stepped care model aims to provide the appropriate level of treatment and/or support depending on the current need (Bower & Gilbody, 2005), with the goal of offering personalized, timely, and cost-effective mental health care. Digital therapeutics (DTx) are evidence-based interventions delivered through digital platforms, such as mobile applications or web-based programs, specifically designed to prevent, manage, or treat medical conditions. Although there are many digital health technologies that are used for aiding in diagnosis, monitoring, medication adherence, and overall wellness and wellbeing, digital therapeutics leverage technology to deliver treatment that is supported by scientific rigor, clinical efficacy, and adheres to regulatory standards, including safety oversight as well as strict privacy and security measures, setting them apart from other unregulated digital mental health tools. These additional layers of oversights are particularly important given the objective of DTx to target condition-specific interventions and make specific claims about treating, preventing or managing a disease and is particularly important in the mental health space where adherence to these standards is paramount.
Part 1: Debunk what DTx are/ transforming class of medicine
• What are DTx?
• Examples: OTC, PDT
• What aren’t they? (examples of what separates them from other digital mental health)
• Why this matters for patient care (quality care), providers (trust the safety), and payors (costs/why reimbursement pathways are needed).
“Digital therapeutics play a crucial role in a stepped care model for mental health by enhancing patient access and addressing critical gaps in care. Through scalable, evidence-based interventions, DTx enables early-stage treatment, reduces barriers to specialty care, and empowers patients to manage their mental health more proactively. By integrating DTx into the stepped care framework, we can provide timely support, decrease wait times, and ensure that more patients receive the right level of care at the right time.”
— Lani Reilly, VP Patient Access
When attempting to understand digital therapeutics (DTx) it is important to first distinguish them from other digital health technologies. The international Organization for Standardization (ISO) defines DTx as “health software intended to treat or alleviate a disease, disorder, condition, or injury by generating and delivering a medical intervention that has a demonstrable positive therapeutic impact on a patient’s health” [ISO/TR 11147:2023(en) Health informatics Personalized digital health - Digital therapeutics health software systems]. Although there are many health tech solutions out there, only one subset can be considered true DTx. Industry and healthcare provider-facing software such as health information technology software and population health clinician support software do not fall into the digital therapeutics category. Additionally, health and wellness apps and software, patient monitoring devices, care support software that provide patients with disease management education and reminders as well as digital diagnostics also do not fall under the DTx category (Digital Therapeutics Alliance https:// dtxalliance.org/). Finally, virtual care platforms such as telehealth and text-based asynchronous clinical care are not considered DTx.
Common Digital Health Technologies Confused to be Digital Therapeutics
• industry and healthcare provider-facing software such as health information technology software and population health clinician support software
• health and wellness apps and software
• patient monitoring devices
• care support software that provide patients with disease management education and reminders
• digital diagnostics
• virtual care platforms such as telehealth and text-based asynchronous clinical care
The benefit of DTx is that they must adhere to eight foundational principles. These include 1) incorporating design, manufacture, and quality best practices, 2) engage end-users in the product development process, 3) provide patient privacy and security protection, 4) apply product deployment, management, and maintenance best practices, 5) provide published results in peer-reviewed journals, 6) have product claims and intended use that are reviewed and cleared by a regulatory body, 7) make claims that are consistent with the regulatory appropriate intended use and indications for use, and 8) are able to collect, analyze, and apply real world evidence and/or product performance data (https://dtxalliance.org/).
The Digital Therapeutics Alliance has excellent resources to help clinicians evaluate DTx and provides guidance and resources on the topic. They include a flowchart to help clinicians better identify digital tools they might be presented with to identify those that are truly DTx. •
“We are facing critical shortages in mental healthcare providers globally. Because we will not be able to keep up with the demand for mental health resources, there is only one solution, and that is to scale evidence driven interventions through software. These solutions range from the delivery of a cognitive behavioral therapy, VR and AR, to AI driven solutions to individuals’ specific needs.”
— Andrew Molnar, CEO
