More Efficiency? More Satisfaction? Private Practice! 6
B. Dale Magee, MD
Medical Practice in the C-Suite 8
Harvey Kowaloff, MD, MMM
Choosing a Career in Graduate Medical Education 9
David A. Bader, MD, FACR
My Reason for Embarking Upon a Single Physician
Private Practice 10
Peter T. Zacharia, MD
My Journey from International Medical Graduate to Dermatologist-Physician-Scientist 12
Medhi Rashighi, MD
Financial Literacy for Physicians 13
Gayle Galletta, MD
2025 WDMS Calendar of Events 15
Navigating J-1 Visa Waiver Options for Physicians: A Comprehensive Guide 16
Zeeshan Gulam Hussain, MD and Parul Sarwal, MD
A Calling Realized: My Mid-Career Shift to Nurse Practitioner 17
Sarah Petrides, DNP, CNP, FNP-BC
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As I See It 20
Joel Popkin, MD, MACP
Curbside with Dr. Baker 21
Christopher Baker MD, UMass radiologist/contributing cartoonist to Cartoonstock.com
Beyond the PharmD: Exploring Residency and Fellowship Paths for Pharmacists 23
Shannon Gallo, PharmD, Anthony Chan, PharmD, MBA and Helen Pervanas, PharmD
Legal Consult: Unfriendly Interpretations of the "Friendly PC Model" 24
Peter Martin, Esq.
In Memoriam
Eileen Wolf, MD 26
Robert M. Black, MD
Louis Frederick Anastasia, MD 26
Sidney P. Kadish, MD
References
For a complete listing of references from the articles in this issue, click or tap HERE.
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Joel Popkin, MD
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WEditor-in-Chief
Parul Sarwal, MD
orcester Medicine has been a trusted voice of our local medical community for nearly a century. First published as Worcester Medical News in 1937, it evolved into the version you’re reading today in 1990. The weight of this legacy is not lost on me. Over the past year, many of you have shared thoughtful feedback, particularly around the need for more practical advice for trainees and early career physicians. In the spirit of being your voice, this issue incorporates your input, and we hope it offers something useful as some of you navigate the next phases of your careers.
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There are parts to practicing medicine…that aren't always covered in formal education.
We all know that medical training leaves some gaps. There are parts to practicing medicine — managing finances, negotiating contracts, or even deciding what kind of career you want — that aren’t always covered in formal education. These things are often learned by trial and error, but I’ve long felt they shouldn’t have to be. One of my personal goals is to find ways to bring these conversations into medical training, and this issue ties into that endeavor.
In this special edition of Worcester Medicine , we highlight medical professionals who’ve walked different paths and share the lessons they’ve learned along the way. Drs. Magee and Zacharia write about starting their own private practices, covering everything from hiring and billing to choosing an electronic medical record system. Dr. Harvey Kowaloff provides a closer look at the executive side of medicine, reflecting on his time as Chief Medical Officer at St. Vincent Hospital. Dr. David Bader shares his experience moving into graduate medical education leadership for those drawn to teaching and mentorship. Dr. Rashighi offers a glimpse into the arduous but rewarding journey of an international medical graduate (IMG) in building a research lab as a dermatologist-scientist.
On the utilitarian side, Dr. Galletta offers a pragmatic guide to physician finances, while Dr. Hussain and I walk you through the complicated but important world of J-1 waivers, something many IMGs spend far too much time piecing together from scattered sources. Dr. Kristin Mattocks and Jose Casares shed light on medical training within the VA health system for those less familiar with this setting. In our pharmacy column, Drs. Gallo, Chan, and Pervanas discuss residency and fellowship options available to pharmacists after their doctorates.
Detours can open doors to unexpected and fulfilling paths in medicine. Dr. Sarah Petrides speaks candidly about pivoting from
a potential tenure-track academic path after completing a PhD in American Studies to work in healthcare, going on to earn a practice doctorate in nursing. Her story highlights that healthcare careers are not always linear. Nor do they need to be set in stone, as Dr. Popkin writes in his perspective piece. He shares his own experience and dilemmas of choosing a fellowship during his internal medicine residency, balancing mentor advice with personal goals.
Beyond these individual experiences, we are seeing broader shifts in medicine that are reshaping how we practice. Home hospital programs and telehealth are expanding rapidly, driven by staffing shortages, bed scarcity, and demand for flexible care models. As medicine continues to integrate artificial intelligence, more physicians are exploring careers in informatics and digital health.
One thing I’ve come to appreciate is how much organized medicine can shape career paths. Whether through mentorship, advocacy, or committee work in professional societies, it’s often the place where ideas and inspirations take root. I hope this issue strengthens that groundwork and encourages you to get involved with the WDMS.
Thank you for continuing to engage with Worcester Medicine. I’m grateful to be a part of this community, and I look forward to what we’ll build together in the new year ahead. +
President’s Message
Alwyn Rapose, MD
Dear Colleagues:
By the time this issue is published, our country will have voted in a new president and will be on the road to recovery from hurricanes Helene and Milton, the Massachusetts Medical Society (MMS) will have concluded its 2024 Interim Meeting of the House of Delegates, and the Worcester District Medical Society (WDMS) will have had hosted the 33rd Annual Women in Medicine Breakfast, the 18th Annual Louis A. Cottle Medical Education Conference, and the Fall District Meeting and Awards Ceremony. Wow! That’s a lot to digest between two issues of Worcester Medicine!
The Medical Student section of WDMS conducted a park clean-up on September 28th, and gosh there was a lot to clean! Thank you dear students for your enthusiasm on that cold and wet Saturday morning. You are much appreciated and we will look for you to be WDMS ambassadors to your fellow students at the medical school. That very afternoon the MMS Alliance had organized a physician-family day event at Tougas Farm in Northborough, and it was a wonderful opportunity to meet physicians and their families from outside the Worcester area. It was my great pleasure that day to meet MMS’s past president, Dr. Maryanne Bombaugh, and our future MMS president, Dr. Olivia Liao!
WDMS is busy preparing for fun activities like our movie night on December 19th, our 229th Oration on February 12th, and our Annual Meeting in April 2025. Please make every effort to attend. Our team is sparing no effort to make these activities meaningful for all of you. I hope you enjoyed the Cottle Lecture “Are You Called?” as much as I did. I was personally touched by Dr. Kerry-Ann Williams’ call harking us back to why we chose our profession, and then her suggestions to sustain that fire.
A reminder again to sign up for “Health Matters” which offers you a wonderful opportunity to showcase your expertise on our local television stations in Worcester, Holden, and Hopkinton. Please also consider joining our delegation to the MMS House of Delegates and/or offering your service on one or more of our Committees. Visit wdms.org for more information.
In this edition of Worcester Medicine, I would like to give a special shout-out to our treasurer Dr. Adib Karam. He is putting in a tremendous amount of time and energy towards the finances of WDMS. I am confident that under his leadership and with the guidance of past presidents, treasurers, Finance Committee members, and our Executive Director, the WDMS is not just on a strong foundation, but is on a positive trajectory for the future. While on the subject, I would like to inform you that your Officers are working on shoring up the Society’s finances by reaching out to local businesses that are committed to the Worcester community and willing to show their support of physicians, their family members, and neighbors in the area. I hope to soon be able to share some positive results on this matter.
Let me end by wishing you a Merry Christmas and a Happy New Year 2025.
PMore Efficiency? More Satisfaction? Private Practice!
B. Dale Magee, MD
rivate practice was not Plan A for me and for good reason. During residency, it was impossible not to understand that private practitioners occupied a lower caste. Our training contained nothing about office functioning, design, billing, personnel, or workflow. The future belonged to multispecialty groups and, besides, multispecialty groups looked very similar to the residencies that we were moving on from.
I chose carefully and picked a location and group that I felt met my expectations for my career. After four years, however, I was ready to make a radical change. I had gotten a look at this model and learned what it was and what it was not. It also became clear to me that the majority of my waking hours were spent in my practice and I needed to make the right choices so I could have career satisfaction. My ability to practice and be satisfied with the results required just as much thought and control as would choosing and furnishing a home (where I would spend less of my time at that point). Imagine the difference between choosing the design of your home, furnishing it, and being able to make changes whenever you feel necessary. Then imagine moving into a predesigned house and having little input into the original design, knowing that any changes that you requested needed to pass through an administration with numerous other priorities.
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…my success in delivering care to my patients was affected by more than my knowledge, skill, and ability to communicate.
From my perspective, my success in delivering care to my patients was affected by more than my knowledge, skill, and ability to communicate. It depended on everything from how the phones were answered, to the staff job descriptions, workflow, wait times, and my workload. As I became aware of this, I became more interested in seeing how I could improve the details that I had not been taught in residency. I decided to go from one extreme to the other and entered solo practice.
In Obstetrics and Gynecology, your life is dependent on coverage. No coverage, no life outside of practice. Fortunately, I had colleagues in private practice who were willing to exchange coverage and make this move possible. There was quite a learning curve (especially with billing), but hiring the right people made all of the difference. Because my biller had only one priority, our collection ratios soon exceeded those of larger systems. Because decisions were being made by me, the office overhead was considerably lower than was seen in large organizations with layers of administrators. If I wanted to hire a new person, I could. If I wanted new equipment, I got it (if I was willing to pay for it). If
I wanted to see fewer patients per hour or change the days and hours that I saw them- voila! Done! I also became interested in office design and, thanks to willing landlords, designed four offices during my career. When I grew interested in technology, I studied electronic medical records in the late 1990s, visiting offices where they were used and getting into the details of workflow and implementation. In 2002, before the large systems in Worcester, we implemented an EHR that we had chosen and altered the workflow to accommodate it. Filing went away, transcription went away, the patients seen did not change and I never took computer work home with me. My objective was not to maximize income, but, rather, to create a workspace that I was proud of.
Today there are significant challenges that were not as extreme when I entered private practice. Vertical integration has been favored by the government and the payers associated with fees that are substantially higher. Large groups can make gaining patients (especially if you are new) more difficult since they have large numbers of doctors that they need to support and internal referral patterns (captured lives) that keep the patients in the building.
Still, while most industries have decentralized and outsourced elements of production to smaller, more nimble businesses, health care has just discovered the factory system with higher overhead and more inertia. This is being supported by a system that sets fees based on bargaining power and disfavors the small guy. Interestingly, if we look at Western European countries such as Germany, Switzerland, and others, they achieve universal coverage with multiple health plan choices, but uniform fees. In these models, there are no huge hospital systems and doctor groups with thousands of doctors. With that bargaining chip gone the average doctor group is five or less.
Private practice is more satisfying for the right doctors and more efficient for the system. In the electronic age, patient information can just as easily travel across town as across the hall. Far from being a relic of the past, it is now an option for the future. +
B. Dale Magee, MD
Past president MMS, WDMS Curator, WDMS
Pathways in Medicine
WMedical Practice in the C-Suite
Harvey Kowaloff, MD, MMM
e physicians enjoy the privilege to practice in diverse settings doing work that is highly varied in its substance and style. We occupy central roles in many organizations whose cultures and missions are as different as the range of medical specialties that are available to us. Physicians who elect to join the senior administrative team of a healthcare organization practice a kind of medicine that differs greatly from the myriad of specialties, practice settings, and care delivery models available to clinicians today. In this article I will characterize the physician’s unique role in healthcare administration, comparing and contrasting the administrative medicine practice with the more traditional roles of physicians in the complex modern healthcare sector.
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Arguably, the skills, focus, and challenges of senior physician administrators differ in fundamental ways from those of clinicians.
I completed my training and joined the primary care faculty of UMass Medical School in 1980. From the outset, I sought to take a position that would allow me to combine practice with teaching. It was the penetration into the Worcester market of highly organized managed care and ultimately an experiment by Memorial Hospital to accept large-scale full-risk capitation that led me to accept increasingly senior administrative positions and to concomitantly ratchet back my clinical practice. In 2002, I left practice entirely to accept the position of Chief Medical Officer at Saint Vincent Hospital.
Choosing to abandon clinical practice for a C-Suite position was, in the day, viewed by many as “going to the dark side”. Medicine was largely a private enterprise, with solo practitioners and small groups dominating the scene up until recent decades. Corporate types, a.k.a. “bean counters”, were there to run the institutions but clinical matters were the sacred and exclusive domain of physicians. There was a dogs vs cats antipathy between these groups and the burgeoning administrative physician often endured some not-so-friendly ostracism from one-time colleagues. Fortunately, this is much less the case today as corporate models of practice and consolidation of the massive healthcare sector have made the small medical practice seem almost quaint and physicians’ presence in leadership is recognized by clinicians to be necessary and desirable.
Arguably, the skills, focus, and challenges of senior physician administrators differ in fundamental ways from those of clinicians. In most
cases, the physician executive is charged with managing some critical aspect of a healthcare organization’s clinical performance, whereas the clinician, almost by definition, is concerned with the unique person, the “patient”, to whom they are providing care and guidance. Macro issues of strategy, financial and clinical performance data, regulatory compliance, and group dynamics/communication dominate the professional world of the senior administrator. In contrast, the clinician is chiefly concerned with matters of physiology, diagnosing disease, and therapeutic options for an individual. The differences between these two roles for physicians cannot be overstated. However, the skills developed by excellent clinicians, empathy, active listening, clear communication, and a relentless insistence on considering a broad set of diagnostic possibilities transfer readily to the C-Suite. Thoughtful interpretation of data and context is as crucial in toptier management roles as it is in sound clinical practice. Professionally we all inhabit psychological spaces that interact with the work we do and how it affects us as individuals. The contrast between administrative medical practice and typical clinical practice extends into these spaces as well. I will highlight three areas where the practices differ:
• Conflict: Clinicians are generally conflict-averse in their professional roles usually functioning as fiduciaries for the patient. Administrative work often requires physician executives to manage people and, in that regard, to deliver difficult feedback, and to take disciplinary action.
• Reward and recognition : Patients and their families generally hold us in high regard and offer praise and/or gratitude for the efforts we make on their behalf, especially when the clinical outcome is good. Organizations rarely provide the kind of positive regard for our personal efforts that energizes our efforts in the same way.
• Decision-making: Clinicians retain substantial decision-making authority in managing their patients. While medical practice is increasingly a team effort, usually the final decision maker is the physician in concert with the patient. Most physician executives operate in a complex organizational matrix of responsibility and authority. Key decisions are rarely made by the administrative physician alone. Organizational culture plays a large role in the professional world of the physician executive. Overbearing emphasis on financial performance can undercut the focus on clinical quality and patient safety in the positions often held by administrative physicians. Heavy-handed, top-down decision-making can be an affront to the physician more accustomed to
Pathways in Medicine
collaborative working relationships with peers. The clinician contemplating a career in senior management needs to understand the importance that culture plays in how work is done and in how satisfying the position ultimately will be.
Clinicians considering a move into administrative medicine often wrestle with the question of whether to get additional training to better work with non-clinical peers. The days of promoting the best senior medical staff into administrative positions are, for the most part, gone. In the corporate medical world, physician executives need a set of skills and a language common to contemporary management to most effectively bring their unique perspective into the C-Suite conversations. For clinical leadership positions, in addition to an MBA, the MPH and the Masters in Medical Management (MMM) are very helpful pathways for leadership positions.
Medical practice in the C-Suite is a sea change from most clinical practice. Our unique training and experiences dealing with patients and diseases allow us to bring a dimension to the senior administrative team that is both rewarding and critically important as the delivery of healthcare becomes increasingly corporate in its character and complex in its scope. Aspiring physician administrators should understand the contrasts between clinical and administrative practice and the degree to which cultural attributes can affect their professional satisfaction and the attainment of the mission and goals that motivated them to move into management. +
Harvey Kowaloff, MD, MMM Retired Chief Medical Officer
Choosing a Career in Graduate Medical Education
David A. Bader, MD, FACR
“Two roads diverged in a wood, and I— I took the one less traveled by, And that has made all the difference.”
-Robert Frost
Iwas not aware of it at the moment, but my career-defining fork in the road came in 1988 as a fourth-year medical student at Northwestern University in Chicago. I envisioned a future as a clinical neurologist but wanted to do an elective close to home in Massachusetts and chose diagnostic radiology at St. Vincent Hospital in Worcester. Little did I know that this was the beginning of a journey that would lead me back to St. Vincent and a career dedicated to radiology and graduate medical education.
The road began at the “old” St. Vincent Hospital on Vernon Hill. The facility was a large 1960s-style imposing structure with few recent updates. It was before the age of digital imaging, voice recognition dictation, and high-resolution multi-monitor PACS systems. There were alternators (multi-panel light boxes) loaded with films for interpretation, and reports were typed by transcriptionists with carbon copies for distribution. In short, the hospital and resources were quite ordinary, but everything else was extraordinary.
Walking into the department on my first day, I sensed an energy emanating from the large central reading room. Congregated around the alternators were residents and teaching attendings actively engaged in discussing and debating findings on imaging studies of all types - CT, MRI, ultrasound, nuclear medicine, radiographs, and more. It was a beehive of activity with every study presenting anatomic or metabolic patient care puzzles for the team to solve. At the center of it all was my mentor, Dr. Murray Janower.
Dr. Janower was Chief of Radiology at St. Vincent Hospital and founder of the radiology residency program in 1972. Unbeknownst to me
at the time, Dr. Janower was a renowned radiologist and recognized national leader in graduate medical education. One of his most impactful publications was on the design of radiology departments, a model that he implemented at St. Vincent Hospital. Based on “form follows function” he created a structure that fostered the educational environment in which resident training flourished, physicians collaborated, and patients benefited. Before the end of my fourweek elective rotation, I knew that I wanted to be a radiologist and be part of a teaching program.
I was fortunate to match for my one-year medical internship and four-year radiology residency at St. Vincent Hospital and returned a year later to begin my training. It was a challenging and rewarding radiology residency with a talented faculty team led by Dr. Janower. My training reinforced my desire to be in academics, ideally at St. Vincent Hospital. Following residency, I pursued a nuclear medicine fellowship at the Harvard Joint Program in Boston. I did not hesitate when a position became available to return to St. Vincent Hospital in April 1997 and I am still there today.
I was immediately immersed in the teaching program as faculty for diagnostic radiology and nuclear medicine and, shortly thereafter, was appointed to the role of Associate Residency Program Director where I trained under the tutelage of Dr. Janower for three years before his retirement. This was my introduction to another facet of graduate medical education, leadership responsibility for oversight of the larger systems and infrastructure of a teaching program. I then transitioned to Program Director and subsequently the Chief of Radiology. In addition, I was the Designated Institutional Official for three years at St. Vincent Hospital, responsible for oversight
Pathways in Medicine
Choosing a Career in Graduate Medical Education
Continued
of all ACGME (Accreditation Council for Graduate Medical Education) teaching programs. All these experiences provided tremendous growth and learning opportunities. For me, it was a natural evolution to not only teach but to be dedicated to creating, maintaining, and advancing a robust environment for residents and teaching faculty to thrive.
I found (and still do today) that I learn as much or more from my residents than I teach them. Teaching makes me a better physician, constantly challenged to stay ahead of the curve of rapidly evolving fields. However, the increasing throughput demands of clinical care and lack of financial and physical resources often hinder a physician’s ability and desire to be in an academic setting in any role.
Another challenge is that the sphere of control for a physician gets smaller the farther one moves from the role of directing clinical decisions for patient care, which is what we are trained to do. Teaching and leadership training are not normally part of medical school curricula and require a different set of skills and expectations. Making a clinical assessment and a patient management decision is more controlled and immediately impactful rather than navigating the complex systems of healthcare and accrediting organizations. Most physicians understandably complain about system issues and inefficiencies, yet few engage in effecting change. Choosing a role in teaching is a challenging but impactful way to be the change needed by setting standards of care and leading by example.
The practice of radiology and graduate medical education are inextricably linked for me, I cannot imagine working in an environment not fueled by the energy of a residency program. I do not view the challenges of teaching and leadership as a distraction from my role as a physician dedicated to patient care, but rather as integral to it. I have had the privilege of playing a role in twenty-eight classes of radiology residents, during which time there have been truly transformational changes in healthcare delivery and stunning technological advances in radiology and nuclear medicine.
The one constant has been the residents. Their intellectual curiosity, passion, commitment, and dedication are aspirational. The graduate medical education path may be one less chosen, but it can be incredibly rewarding. Teaching is a virtuous cycle, an opportunity to pay it forward one resident and, most importantly, one patient at a time. That can make all the difference. +
David A. Bader MD FACR
President Saint Vincent Radiological Associates, Inc.
Chief of Radiology, Radiology Residency Program Director, St. Vincent Hospital, Worcester, MA
Chief of Radiology, MetroWest Medical Center, Framingham, MA
david.bader@stvincenthospital.com 508-363-6060
My Reason for Embarking Upon a Single Physician Private Practice
Peter T. Zacharia, MD
The decision regarding the practice model one chooses for a medical career can be guided by several factors. My decision to embark upon a single physician private practice was not my original intent and not even a consideration when I finished my training. I had to make my choice within a relatively short time frame as an adaptation to an unexpected change in strategy by the academic practice that employed me. After completing my glaucoma fellowship in Boston, I accepted an academic ophthalmology position in Massachusetts and was hoping to continue along this path. Unfortunately, my student loan debt was approximately 95 percentile compared to my peers, with my loan debt-to-income ratio approximately 25%, which required that I evaluate other opportunities. I was offered various practice opportunities including a position within a multispecialty group practice as well as an opportunity to practice at a tertiary care eye hospital in Saudi Arabia, each of which nearly doubled my academic practice compensation at the time.
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…I was willing to accept patients with timesensitive ophthalmic problems late on Friday afternoons and on weekends.
I chose to travel along with my wife and two young children on a career adventure at the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia. Along with a boost in compensation and tax benefits which allowed me to extinguish most of my student loan debt while I practiced there, I gained much more including the chance to interact with truly excellent ophthalmologists of several subspecialties and the experience of treating glaucoma patients with tremendously complex eye
disease. When my wife and I sought to bring our children back to the United States, I was offered a position as director of two satellite offices of an academic practice in Boston. When the goals of the Bostonbased academic department changed, I was offered the opportunity to purchase the Worcester satellite office and take it over as a single physician private practice. This was frankly a frightening choice at the time since I had never considered running a private practice but also had no idea how to manage the business side.
I was fortunate to have several advantages at the time that may not be available to all physicians seeking to start up a singlephysician private practice. My ophthalmic office was fully equipped with functioning exam rooms and even some of the lasers I needed. I was also able to retain most of the staff, including one staff member who had knowledge of insurance contracting and billing. I was also fortunate to be able to finance the purchase of my former satellite practice directly through the seller, the Boston academic institution. These advantages gave me a shortcut so that I did not need to shop around for equipment, hire staff, and apply to banks for financing. Fortunately, I was able to find a local payroll servicer who helped me set up the processes necessary to take on the payroll functions necessary to compensate my employees. The local payroll processor was eventually purchased by a large national payroll and human resources company with which most of the interaction is now automated and online. I learned quickly the importance of establishing helpful business contacts. I purchased business and liability insurance and established relationships with a knowledgeable accountant, and a banker from a small locally-based bank who helped me finance additional equipment purchases. Sadly, the small bank was swallowed up by a behemoth of a national bank with a much less personalized business experience. Along the way, the requirements for running a medical practice became more complex with HIPAA requirements, electronic medical records, patient portals, and CMS requirements. I sought help from consultants to help us navigate CMS-related issues and other requirements, and discovered an excellent IT professional (who replaced a predatory disastrous relationship with an initial IT company that did a poor job of maintaining our electronic medical records system).
A large disadvantage when I took over my practice was the very sparse patient base (we saw about 25 % of our current patient volume) and my dearth of referral sources. I was fortunate to be able to offer niche services after garnering unique glaucoma surgical experience during my time in Riyadh, which allowed me to draw referrals from other practices. As a result, I was presented with a unique opportunity since without my local practice, these patients with complex glaucoma care needs would have had to travel to academic centers in Boston for care. This was important since most of the more routine ophthalmological services were already offered by the other long-established general ophthalmology practices in the area that held established ties to primary care referral sources. To build my referral base, I made myself conveniently available to new referral sources and was willing to accept patients with time-sensitive ophthalmic problems late on Friday afternoons and on weekends. I even distributed my mobile phone number to them. I marketed the more unique offerings of my practice with mailings when I acquired
new equipment and offered procedures not available elsewhere in the Worcester area. I also held didactic sessions at my office for other eye care providers to teach skills pertinent to glaucoma care which provided me an opportunity to showcase my expertise in the subspecialty.
Running a small private practice is not for everyone. I have enjoyed the independence which has allowed me to buy any equipment I needed and to set a direction for my practice without seeking approval from partners. Like any other physician, I often must complete chart work on weekends, but then must play a role in the business side and financial functions of my single doctor practice. I least enjoy having to participate in the hiring and firing of personnel. I invest a great deal of time whenever I make new medical equipment and IT-related purchases and upgrades. I am always involved in selecting contractors or vendors required for repairs or to maintain our office functions. I have always had to do some sort of work 6 or 7 days a week. I recognize that starting a single doctor private practice today would be much more daunting with vastly greater initial complexities and expenses. Hopefully, this narrative describing how I fell into my career path will give early career physicians a very brief summary of what to expect should they contemplate hanging their own shingle, but this will also differ greatly depending upon medical specialty. +
Peter T. Zacharia, MD
Pathways in Medicine
My Journey from International Medical Graduate to Dermatologist-Physician-
Scientist
Medhi Rashighi, MD
My path towards becoming a physician-scientist began at Tehran University of Medical Sciences, where I initially intended to follow in my father's footsteps and pursue a career in ophthalmology. However, a pivotal event early in my medical education shifted my focus. My mother developed lichen planopilaris, a rare autoimmune form of scarring hair loss with a poorly understood pathogenesis. Watching her endure ineffective and painful treatments was deeply unsettling—not only because of the physical consequences of the disease, but also due to the emotional toll it took on her self-esteem. This personal experience sparked my interest in immunodermatology, as I became increasingly motivated to study skin diseases and work toward finding better treatments for patients facing similar challenges.
After graduating from medical school in 2004, I worked as a research assistant at a dermatology research center at Tehran University. There, I gained valuable experience in designing and conducting clinical trials, but the real turning point came in 2006, when I was selected to participate in an exchange program to the U.S. During my visit, I had the opportunity to observe the work being done at the National Institutes of Health (NIH) and other research institutes. At that time, the NIH had launched a new initiative aimed at training a generation of translational scientists who could bridge the gap between bench research and clinical application. The concept of translating scientific discoveries into real-world treatments resonated deeply with me, aligning with my long-term vision for my career.
Inspired by this experience, I made the life-changing decision to pursue training in the U.S. as a physician-scientist specializing in dermatology. However, due to the political situation and the lack of formal diplomatic relations between Iran and the U.S., this plan proved to be extremely challenging. It took five years before I was able to obtain a visa to move to the U.S., and in 2011, I finally arrived, hopeful to advance my training in skin immunology and translational research. Though I lacked formal bench research training at the time, I was fortunate to meet Dr. John Harris at UMass Chan Medical School. His mentorship would profoundly shape my career.
Dr. Harris welcomed me into his lab, where I focused on studying the immunological mechanisms behind vitiligo, a common autoimmune skin disease characterized by white, depigmented patches. Despite its significant psychosocial impact, no targeted treatments were available at the time. Under Dr. Harris’s guidance, my research led to the discovery of a novel immune signaling pathway involved in vitiligo pathogenesis. This breakthrough was instrumental in guiding the development of the first FDA-approved treatment for the disease. Contributing to research that had a direct impact on patient care reinforced my passion for dermatology and translational research. I realized that combining clinical practice with scientific investigation would allow me to help bridge the gap between the lab and the clinic, improving the lives of patients with complex autoimmune skin conditions.
While I was eager to begin formal dermatology training, securing a dermatology residency in the U.S. as an international medical graduate was highly competitive. The path was uncertain, and it took six years of determination and hard work before I was able to enter and complete my dermatology residency at UMass. I owe a great deal to the faculty members at UMass Dermatology who supported me during this time. Throughout my residency, I became increasingly focused on studying connective tissue diseases such as cutaneous lupus and dermatomyositis. These diseases disproportionately affect patients from lower socioeconomic backgrounds, leading to both physical and emotional suffering. My clinical experiences
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…my journey over the past five years has taught me that success in academic medical research requires a diverse skill set beyond just scientific and medical knowledge.
reinforced my commitment to better understanding these diseases and improving treatment options, especially for underserved populations.
After completing my residency, I had the opportunity to establish a new clinic and research center at UMass dedicated to the treatment and study of connective tissue diseases. As the founding director, I aimed to create a space where patients with rare and difficult-to-treat conditions could receive specialized care while simultaneously advancing research. However, launching my career as a physician-scientist during the COVID-19 pandemic presented unexpected challenges. Like many others in the medical community, I had to adapt to rapidly changing circumstances while balancing patient care with the demands of establishing a research program. Despite these obstacles, I was fortunate to receive strong institutional support from UMass Chan Medical School and continued mentorship from Dr. Harris, who is now the chair of our department. With
their guidance, I successfully secured several grants, including NIH funding, to support my research efforts. One of my major ongoing projects focuses on developing innovative ways to study the progression of cutaneous lupus. By leveraging digital health platforms, wearable sensors, and at-home blood and skin sampling methods, we aim to better understand the triggers of disease flares and identify early markers of disease progression. This nationwide, siteless study has the potential to revolutionize how we study and treat complex connective tissue diseases, making clinical research more accessible to patients who may otherwise have limited access to specialized care.
As an early investigator, my journey over the past five years has taught me that success in academic medical research requires a diverse skill set beyond just scientific and medical knowledge. Building and maintaining strong interpersonal relationships has proven critical for successful research collaborations. Navigating the complex landscape of funding opportunities—whether from the NIH, nonprofit organizations, or industry—has become an essential part of my role. This process can be particularly daunting given the field’s competitiveness, where limited funding resources mean often contending with more established investigators. Yet, these challenges have refined my abilities and strengthened my resolve to contribute meaningfully to academic medicine.
At the heart of my work as a physician-scientist is a deep commitment to making a lasting difference in the lives of my patients. Whether through direct patient care or by pushing the boundaries of research to discover new treatments, I am dedicated to advancing the field of dermatology and improving outcomes for patients with autoimmune skin diseases. +
Mehdi Rashighi, MD
Assistant Professor of Dermatology and Medicine
Founding Director, Connective Tissue Disease Clinic and Research Center
Autoimmune Therapeutics Institute
UMass Chan Medical School
Email: mehdi.rashighi@umassmed.edu
AFinancial Literacy for Physicians
Gayle Galletta, MD
s a physician, you have spent years mastering the art and science of medicine. If you are like most, however, your education likely lacked any financial literacy training. Being financially literate is essential for your financial health, gives you options, and may help prevent burnout.
I have no formal financial training, but as a financially successful, late-career emergency physician, I can offer you some advice. I subscribe to the philosophy of the White Coat Investor and highly recommend their website, blog, and podcast. On the website, you can sign up for a 12-week boot camp, where you will be sent one email each week to get yourself a basic understanding of finance.
Why many physicians struggle with money:
The median medical school debt is over $200,000. Many owe much more. This enormous debt, combined with a late start saving for retirement, puts many physicians behind the eight ball in terms of building wealth. In addition, delayed gratification and a large increase in salary after residency can lead one to get on the hedonic treadmill and fall into the high-earner, high-spender trap. There are societal pressures regarding the type of homes and cars physicians should own and where they should send their children to school. To make matters worse, those with “MD” or “DO” after their names often become targets of salespersons masquerading as financial advisors. The good news is that there are simple steps that you can take to get your finances on track.
“ There is no one right way to build wealth. The most important thing is that you start now and stay the course.
Ten tips to achieve financial success:
1. Become financially literate and understand the concept of compound interest. The earlier you start saving, the larger your nest egg will grow. And remember “time in the market is more important than timing the market”.
2. Live like a resident for the first few years as an attending to avoid lifestyle creep. This means living on a fraction of your new income until you have paid down debt and started to save for retirement and perhaps a downpayment for a house.
3. Have a plan for student loans and other debt repayment. Each
person’s plan will be different depending on the amount owed, salary, marital status, and whether or not one is planning on going for Public Student Loan Forgiveness (PSLF). If you are uncertain how best to proceed, StudentLoanAdvice.com can get you a personalized plan.
4. Build an emergency fund of 3-6 months of living expenses and keep this in a high-yield savings account as a buffer against unexpected expenses or job loss. Having a credit card balance is a financial emergency.
5. Get your own occupation disability insurance. You are more likely to become disabled than to die during your working years. As a result, this insurance will be more expensive than life insurance.
6. Get term life insurance if you have anyone who depends upon your salary. It is very unusual for a physician to need whole life insurance. Be very skeptical if someone tries to sell you anything but a term life insurance policy. Do not mix insurance and investing. Agents will make a large commission off of these policies, and off of you.
7. Have an investing plan and stick with it. You can get a feeonly financial advisor to get you started or confirm that you are on the right track. The White Coat Investor website has a list of recommended financial advisors. There are hundreds of reasonable
plans that will achieve the goal of financial success: pick one. You should invest in broadly diversified mutual funds or Exchange-Traded Funds (ETFs). This means that you own a piece of hundreds (S&P500) or thousands (US Broad Market Index Fund) of the largest publicly traded companies in the US. Owning individual stocks puts you at increased risk. Remember Enron? If you are young, it is reasonable to invest 100% in stocks. Just realize that when there is a bear market, the value of your investments will drop. It is important not to panic sell (selling low). When the market is down, think of it as everything being on sale and consider buying more shares instead. Your investment plan can also include bonds, which are less volatile than stocks. Typically, as one gets closer to retirement age, a larger proportion of their retirement portfolio will be in bonds. If you want a simple plan, you can invest in a target-date retirement fund that will automatically adjust the percentage of stocks and bonds as you age and get closer to retirement. Finally, look for passive index funds rather than actively managed funds. Passive funds will have the lowest expenses, which translates to you keeping more of your money.
Financial Literacy for Physicians Continued
Pathways in Medicine
8. Max out tax-advantaged retirement accounts. Physicians often have access to several retirement options such as 401(k)s, 403(b)s, 457(b)s, and IRAs (Individual Retirement Account/Arrangement). By contributing to a traditional, tax-deferred account, you can save on taxes during your high-earning years. Roth IRA contributions are made with money that has already been taxed and have the benefit of never being taxed again.
9. Consider using a Health Savings Account (HSA) if available and appropriate for you. HSAs offer a triple tax benefit: contributions are tax-deductible, earnings grow tax-free, and withdrawals are tax-free when used for qualified medical expenses.
10. Live below your means and, if married, invest in your relationship, as divorce is expensive and can derail your financial goals.
Personal Finance is Personal:
There is no one right way to build wealth. The most important thing is that you start now and stay the course. Develop good habits: slow, steady progress will get you to the goal of financial freedom, which will in turn give you options, such as the ability to cut back on hours, take a sabbatical, negotiate for what you want, or retire early. Finally, determine where you fall on the “You Only Live Once (YOLO)/ Financial Independence Retire Early (FIRE)” continuum and strive for balance. You can enjoy the present without being destined to work into your seventies or eating Alpo in your retirement. +
Gayle Galletta, MD
Professor of Emergency Medicine, UMass Chan Medical School
Gayle.Galletta@gmail.com
WORCESTER DISTRICT MEDICAL SOCIETY 2025 Calendar of Events
Please visit www.wdms.org to view past events
229th Annual Oration
February 12, 2025, 5:30 pm, Beechwood Hotel
Title: Diagnosis
Orator: Lisa Sanders, MD - is the Medical Director of Yale's Long Covid Multidisciplinary Care Center. In addition to her work as a physician and teacher, she writes the popular Diagnosis column for the New York Times Magazine and the Think Like a Doctor column featured in the New York Times blog, The Well. In 2019 she collaborated with the New York Times on an eight-hour documentary series on the process of diagnosis for Netflix.
29th Women in Medicine Leadership Forum
March TBD 2025, 5:30 pm, Mechanics Hall
Speaker: TBD
Co-Sponsored by Physicians Insurance of the Massachusetts Medical Society
Annual Business Meeting
April 23rd, 5:30 pm, Beechwood Hotel
Keynote Speaker: Burton W. Lee, MD, Head, Medical Education and global Critical Care Department at the National Institutes of Health
Meeting includes presentation of the 2025-2026 Slate of Officers, 2025 Bylaws and the 2025 MMS/WDMS Community Clinician of the Year Award
Medical Student Event
May TBD 2025, 5:30 pm
Speaker: TBD
Title: TBD
2025 MMS Annual Meeting and House of Delegates, A-24
April 30, 2025, 7:00 pm - HOD Opening Session – via Zoom May 2025, 8:00 am to close of business - HOD 2nd SessionIn Person/Westin Waltham Hotel
All WDMS members are invited to attend as a guest and may submit a resolution to MMS
WDMS has Delegate seats available (call the WDMS Office to inquire 508-753-1579)
Meet the Author Series
May 2025, 5:30 pm, UMass Chan Medical School
Author/Guest: Lucia Z. Knoles, Professor of English, Assumption University and Instructor and Board Member, Worcester Clemente Course in the Humanities
Ongoing Activities:
WDMS Exhibits and Open House(s)
Music Worcester – Beginning in January 2025, look for select performances for WDMS Members
INavigating J-1 Visa Waiver Options for
Physicians: A Comprehensive Guide
Zeeshan Gulam Hussain, MD and Parul Sarwal, MD
nternational Medical Graduates (IMGs) play an essential role in the U.S. healthcare system, especially in underserved areas facing physician shortages. Many IMGs, particularly in primary care, help fill critical gaps in rural and inner-city communities where healthcare demand exceeds supply. The J-1 visa waiver allows these physicians to continue their work in the U.S. without returning to their home country for two years, a requirement of the J-1 visa.
“
It is essential to understand the different options and their specific requirements.
Understanding the J-1 Visa and Home-Country Requirement
The J-1 visa allows IMGs to receive specialized training in the U.S. but requires them to return to their home country for two years afterward. This policy ensures that their expertise benefits their home countries, but for many, returning home is not feasible due to political instability, personal reasons, or lack of opportunities. Fortunately, several pathways exist for obtaining a waiver of this requirement.
J-1 Waiver Pathways
A J-1 waiver allows physicians to bypass the home-country requirement and stay in the U.S. to work. The U.S. Department of State recognizes four main pathways for J-1 waiver applications:
1. No Objection Statement: The home country's government must issue a statement through its embassy, stating it has no objection to the physician staying in the U.S. However, physicians on J-1 visas after January 10, 1977, for medical training, are ineligible for this option.
2. Federal Agency Request: A U.S. federal agency may request a waiver for a physician if it's in the public interest. Physicians agreeing to work in underserved areas are particularly eligible. Agencies like the Department of Health and Human Services (HHS) and Department of Veterans Affairs (VA) are common sponsors.
3. Persecution: Physicians may apply for a waiver if returning to their home country would subject them to persecution based on race, religion, or political opinion. This waiver involves submitting Form I-612 to U.S. Citizenship and Immigration Services (USCIS).
4. Exceptional Hardship: If returning home would cause exceptional hardship to a U.S. citizen or lawful permanent resident spouse or child, physicians may apply for this waiver, also by filing Form I-612.
Conrad 30 Waiver and Other Federal Programs
The Conrad 30 Waiver is one of the most popular options, allowing each state to sponsor 30 J-1 physicians per year. Physicians must commit to full-time work in a HPSA or MUA for three years at 40 hours per week. The Flex 10 option enables states to place up to 10 physicians in locations outside shortage areas if they still serve patients from underserved regions. Each state manages its program individually, with different priorities and deadlines.
The HHS Waiver Program grants waivers to primary care physicians working in facilities with a HPSA score of 7 or higher. Expanded eligibility since 2020 now includes more healthcare settings in rural and underserved areas. Unlike the Conrad 30 program, there is no limit on the number of waivers HHS can issue. Eligible physicians must have completed their residency in primary care or psychiatry in the last 12 months.
The VA Waiver Program provides waivers for physicians working in VA medical facilities. Physicians must commit to 40 hours per week for three years, with at least half their duties in direct patient care. The VA waiver is used as a last resort when recruitment efforts to hire U.S. citizens or permanent residents fail.
Regional Waiver Programs
Several regional J-1 waiver programs cater to specific geographic areas:
• Appalachian Regional Commission (ARC) Waiver: Covers 423 counties in 13 states, requiring 40 hours of primary or mental health care per week for three years in designated HPSAs.
• Delta Regional Authority (DRA) Waiver: Covers 252 counties in 8 states, requiring 40 hours of primary or specialty care per week in a HPSA, MUA, or MUP.
• Southeast Crescent Regional Commission (SCRC) Waiver: Available in parts of 7 southeastern states, requiring 40 hours per week of patient care in underserved areas.
• Northern Border Regional Commission (NBRC) Waiver: Launched in 2023, covering parts of Maine, New Hampshire, New York, and Vermont. It allows unlimited applications for primary and specialty care, with a 40-hour per week requirement in HPSAs or MUAs for three years.
General J-1 Waiver Process and Timeline J-1 waiver applications are typically filed by
immigration attorneys hired by the employer. The process involves a multi-step review by three agencies and takes about 6-8 months. The general timeline is as follows:
1. State or Federal Agency Review (1-2 months): The relevant state or federal agency (e.g., HHS, DRA, ARC) reviews the application and sends a recommendation to the U.S. Department of State (DOS) if the physician qualifies. Delays of up to 90 days have been reported in some cases.
2. Department of State Review (1-4 months): DOS reviews the application, generally following the state’s recommendation. If approved, DOS forwards the recommendation to USCIS, and the attorney is informed. The H-1B petition is usually filed after receiving the approval notice (Form I-797).
3. USCIS Final Review (1-2 months): USCIS conducts its final review, often agreeing with the DOS recommendation. Upon approval, USCIS issues Form I-797, needed to proceed with the H-1B visa application.
The J-1 waiver process offers multiple pathways for physicians to remain in the U.S. without fulfilling the two-year home-country requirement. It is essential to understand the different options and their specific requirements. The Conrad 30 program, in particular, is vital for addressing physician shortages in underserved areas, and there are ongoing legislative efforts to expand its capacity.
As the Conrad 30 program celebrates its 30th anniversary, its modernization and expansion remain crucial for ensuring healthcare access across the U.S., particularly in the areas most in need. IMGs continue to play an indispensable role in providing care where it is needed most. +
Zeeshan Gulam Hussain, MD
Internal Medicine Hospitalist, St. Vincent Hospital, Worcester, MA
Parul Sarwal, MD
Internal Medicine Hospitalist, St. Vincent Hospital
Assistant Professor, Department of Medicine, UMass Chan Medical School
NOTE: To view an appendix of Conrad 30 Program deadlines and state requirements, click or tap HERE .
IA Calling Realized: My Mid-Career Shift to Nurse Practitioner
Sarah Petrides, DNP, CNP, FNP-BC
am a nurse practitioner. Sometimes, my patients ask me, “Why didn’t you go ahead and just become a doctor?” My two doctorates notwithstanding, I know what they mean: I clearly love the intellectual challenge of medicine and enjoy patient care, so why did I choose this role instead of the better-paid and often more respected role of physician?
Growing up as the daughter of a physician, I found the medical books that littered our home incredibly interesting, and I loved hearing my father talk about the cases he saw at work. However, when the time came to consider my own career, I decided that I didn’t want to go into medicine. It seemed like a wonderful calling that had been diminished into a terrible job: my father endured crushing stretches of long days, missed family events and holidays, and constant exhaustion. He was always away early, home late, and it was notable when he was around on the weekends.
I’d always been a lover of disciplines that consider existential questions. What could be more relevant than trying to make sense of our human lives and deaths? This being so, academia was my first choice of career. I taught, wrote articles, and had the flattering experience of hearing my own work referenced at a conference presentation as germinal in a field. I was certain I was on my way to a coveted tenure-track academic job. However, while I was completing my PhD in American Studies at Brown University, I made a decision that was the undoing of my academic career: I had children.
My oldest child was born with a disability and had significant challenges during her first few years. There was no longer hope of moving for an academic job, when her clinicians and my family supports were local. During one particularly fraught stretch, she was hospitalized for an illness that brought her close to dying. After she was out of harm’s way, I seriously reconsidered my life’s trajectory. Academia was now out of the question, and I needed a job. Having seen the drama of illness and recovery up close, I realized that I couldn’t get away from my deep interest in medicine. The field spoke to the issues that I’d studied in my academic career--questions of meaning and mortality could not be more salient in the immediacy of grappling with illness and death.
Knowing that I had to make a change, I briefly considered medical school, but I was in my early 30s with old science classes on my transcript, and a family to support. Medical school was impractical: the tuition was too expensive, the application process too fraught (who would want a middleaged career changer?), and even if everything went well, I’d be asking a tremendous amount of my family with regard to relocation for training and residency. Further, it would be a long time before I’d make any significant income. Having been raised by a doctor, I’d had no idea what nurses knew and did before I spent time with my daughter in the hospital, and I was amazed at their clinical acumen and the support and education they offered us. Nursing school seemed attainable- it was less expensive and held the promise of a decent job without the need for relocation. There were also possibilities for advancement within the field. That’s the path I chose, and eventually, after working as a floor nurse for a time, I became a nurse practitioner and have been in practice for over 10 years, now holding a practice doctorate in nursing.
Pathways in Medicine
A Calling Realized: My Mid-Career Shift to Nurse Practitioner Continued
I’m happy with this choice, and I enjoy being a part of a multidisciplinary team currently working in hospital medicine. I have worked in a variety of practice settings, and while I have spent most of my time as a generalist, I have also had the opportunity to work in a subspecialty field. I know APRNs who have gone back to floor nursing (with improving reimbursement, a viable opportunity for some), obtained specialty certification, or gone into administrative roles. The flexibility remains a substantial plus of this role--flexibility that my physician colleagues often do not enjoy, saddled in many cases by massive student debt, difficulty changing roles after extensive specialization, and in the case of my colleagues who choose to have children, the overlap between the most intense periods of training and the years usually spent in childbearing and raising small children.
In my practice, I depend on physician experts to create the knowledge that I am applying clinically. My initial training focused on practical patient management, and while my practice doctorate gave me the skills to create new knowledge about how to deliver patient care, establishing the evidence basis of new treatments delivered depends on the scientific training offered as a part of medical education. Further, while many of my advanced practice clinician colleagues go on to distinguish themselves on specialty teams, those teams must be anchored by someone who has the deepest level of scientific training and expertise in the specialty discipline. Meanwhile, my colleagues and I provide valuable insights about integrating the lived experiences of our patients into the plan of care.
While there are border skirmishes between physicians and other clinicians, these need to be contextualized in terms of who benefits from these arguments. I was correct in my initial assessment of the lifestyle of a diagnosing and prescribing clinician: it can be pretty terrible. We are all burdened by the increasing needs of our very ill patients, for whom we care within the context of a medical system whose priorities have little to do with our education, licensure, and the values of our respective disciplines. Nothing weakens a potential transformative force more than infighting. There are valid discussions to be had about collaborative models and clarity in roles and training, but these can be had while moving forward as an allied team, dedicated to improving not only the lives of our patients, but also to meeting our own human needs. +
Sarah Petrides, DNP, CNP, FNP-BC
Sarah holds a doctorate in American Studies from Brown University and a nursing doctorate from the University of North Florida. She has been a nurse practitioner since 2014, currently at St. Vincent Hospital.
IA Beautiful Partnership: Rich for Medical Training and Practice
Kristin
M. Mattocks, PhD and Jose Casares, MA
n November 2021, Veteran Affairs Central Western Massachusetts (VACWM) Healthcare System held a ribbon-cutting ceremony at its new 48,000 sq. ft., community-based outpatient clinic (CBOC) located on the UMass Chan Medical School campus. The clinic provides veterans with access to primary and specialty health care in a new space designed for patient-aligned care teams. The clinic is able to provide care to the 16,800 enrolled veterans in Worcester County.
The close proximity of the VA CBOC to UMass Chan has greatly expanded the educational partnerships between these institutions. At present, VACWM trains UMass Chan residents and fellows in internal medicine, psychiatry, rheumatology, forensic psychiatry, and nurse practitioner programs with additional training programs planned for the future in neurology, neurology/ psychiatry, and geriatrics. The internal medicine program has grown significantly over the past five years, tripling the number of residents from UMass Chan who train at VACWM and expanding into the primary care track. Across the country, the VA plays a significant role in educating and training future healthcare professionals. The VA has formal partnerships with over 1,800 educational institutions, including medical schools and universities. These partnerships allow medical students, residents, and fellows to train at
VA medical centers, gaining hands-on experience in a diverse clinical environment. The VA operates as one of the largest training grounds for healthcare providers in the U.S., with more than 70% of U.S. doctors receiving at least part of their medical training at a VA facility. The VA also provides medical students and residents opportunities to engage in research, with some of the world’s most advanced medical studies conducted at VA facilities. The VA provides funding for residency programs, contributing to the education of over 45,000 medical residents and fellows each year. This funding helps support salaries and benefits for medical trainees while reducing the cost burden on affiliated academic institutions. The VA fosters a patient-centered care model that exposes trainees to a comprehensive healthcare system focused on both acute and long-term care, providing valuable experience with chronic diseases, mental health, and geriatric care. By integrating clinical training with patient care at VA hospitals, VA ensures that new physicians not only receive excellent medical education but also gain a deep understanding of the healthcare needs of veterans and underserved populations.
According to the Chief of VA Specialty Care, Dr. Nicole Kirchen, “The VA provides medical students the opportunity to learn about health care needs specific to
Pathways in Medicine
A Beautiful Partnership: Rich for Medical Training and Practice Continued
veterans through lectures in the first year, a month-long elective focusing on military and veteran health, longitudinal clinical experiences, and two-week clinical rotations at the outpatient VA clinics. Through lectures, working in different clinics, and meeting with providers from specialties such as mental health, primary care, specialty care, and whole health, students can experience how comprehensive medical care is provided by a fully integrated national health care system.”
In recent years, the VACWM has also trained medical students from UMass Chan. In 2023, the VA welcomed its first medical students from UMass Chan who rotated with providers across a variety of clinics and specialties. Last year, VACWM hosted all second-year medical students from UMass Chan for a two-day walkthrough which allowed students to meet with and interview veterans and VA providers, tour the new CBOC, and learn more about VA healthcare.
In addition to training focused on medical residents and fellows, VACWM recently launched a summer research training program focused on women veterans’ health for undergraduate, graduate, and medical students. The VACWM Summer Research Program (SRP) trains 6 to 8 students from diverse backgrounds on all aspects of VA women’s health research, including qualitative and quantitative methodology as well as VA programs and policies related to women’s health. In addition to VA training, the students interact with UMass Chan faculty members to learn more about specialties from the UMass Chan Chair of Obstetrics and Gynecology, Dr. Tiffany Moore Simas, and the UMass Chan Chair of Pediatrics, Dr. Larry Rhein. Students also have the opportunity to meet with Dean and Provost Dr. Terry Flotte to learn about UMass Chan Medical School. Over the three-year course of the SRP, the VA has trained 12 students from UMass Chan, Clark University, UMass Amherst, Mount Holyoke, University of Pittsburgh, Rutgers, and Smith. In 2024, VACWM received new funding to extend this training program for an additional five years with a new round of 6 to 8 students slated to train at the VA each summer.
Many medical residents and fellows who train in the VA ultimately decide to become VA physicians as part of their career path. The VA is one of the largest healthcare systems in the U.S., providing stable, long-term employment in an often uncertain job market. Working for the VA often comes with strong job security, even during economic downturns. VA physicians receive competitive salaries and a generous benefits package, which includes health, dental, vision, life insurance, and long-term care coverage. Additionally, the VA offers comprehensive retirement plans, including a pension after a certain number of years of service, along with access to the Federal Employees Retirement System (FERS) and the Thrift Savings Plan (TSP). VA physicians may also be eligible for student loan repayment programs such as the Education Debt Reduction Program (EDRP), which can provide significant assistance with repaying medical school debt. Finally, VA physicians treat veterans from all walks of life, with a wide variety of healthcare needs, ranging from acute injuries to chronic conditions and mental health issues like PTSD. This diversity offers physicians the opportunity to develop a broad range of clinical skills and build meaningful relationships with patients who have served the country. +
Kristin M. Mattocks, PhD
Associate Chief of Staff/Research and Education VA Central Western Massachusetts Healthcare System Associate Dean of Veterans Affairs/Professor of Population and Quantitative Health Science, UMass Chan Medical School
Email: Kristin.mattocks@va.gov
Jose Casares, MA
Director of Graduate Medical Education, VA Central Western Massachusetts Healthcare System
FAs I See It
Joel Popkin, MD, MACP
rom internal medicine training to deciding a career trajectory is complex – to say the least. In fact, I will never forget the craziest episode of my life, when nearly 50 years ago I was grappling with the next steps after residency.
Years later, as an internal medicine program director, I often advised our residents who struggled with these same dilemmas. I would tell them about my own conflicts with indecisiveness so many years before, when my initial approach had been to seek guidance from the ten or so physicians on our staff whom I most respected. They were all entirely well-meaning, of course, but each said essentially the same thing: You must do my subspecialty because… Recovery from their well-intentioned advice took a lot of time.
Now long retired, back in my working days I did also ask the fundamentals: What are your goals in life and what kind of work environment are you most comfortable in? How important to you are research, community-based work, hospitalism, and academics? Are you a depth vs. breadth person? Do you want to be a consultant, or does a piece of primary care lurk somewhere in your innards?
However, I was much briefer with advice: First, if you decided as a second-year medical student that you were going to be a cardiologist (hopefully not your mom’s choice), how about using your training to see what the rest of the medical world looks like? And therefore please don’t do all your electives in cardiology. Secondly, the reminder: don’t ask for career advice from your mentors who are established subspecialists. Instead, get a Socratic approach like that from Philip Masters of the American College of Physicians (ACP) [1] who has written a lovely
Pathways in Medicine
summary of important, germane, and wise questions for dispassionate guidance on subspecialty choices. He avoids the burdens brought about in the formats of "Dear Abby" or even AI. Instead, he poses, is a fellowship right for me? It’s nuts-and-bolts material that provides the thought process and rational steps to pursue this elemental self-inquiry.
Once that semi-tortuous self-reflection is over, you’re on your own. Again, don’t listen to me or any other well-intentioned mentor, because the only initial guidance you can use is what feels right in your head. It’s different once you are now leaning toward a honeddown choice of fields. At this point, trying to decide what’s best for you includes the nitty-gritty of job availability, hours, salary, various settings, etc. This is when it’s finally time to turn to trusted mentors for advice. For residents who are still agonizing over decisionmaking, the reality is that half of the graduates will change jobs or even careers within five years after graduation. After all, there are no perfect medical careers.
So, to reestablish normal sleep it is essential to accept that a career decision is not a finality. If a prior infatuation with, say, the kidney seems to have lost its glory during the first year of fellowship, it’s alright to just turn the page and try something else. In the meantime, wherever the new career path goes, it will include valuable expertise gleaned from that year in nephrology. The bottom line is to listen to oneself and to appreciate that a career choice is not an irrevocable decision. +
Joel Popkin, MD, MACP
Professor of Medicine, UMass Chan Medical School
Program Director Emeritus, St. Vincent Hospital
Email: jpopkin6244@gmail.com
Curbside with Dr. Baker
Christopher Baker MD, UMass radiologist/contributing cartoonist to Cartoonstock.com
Pathways in Medicine
Beyond the PharmD: Exploring Residency and Fellowship Paths for Pharmacists
Shannon Gallo, PharmD, Anthony Chan, PharmD, MBA, and Helen Pervanas, PharmD
I. Introduction
As the role of pharmacists in healthcare continues to expand, postgraduate training has become a critical step in career advancement and professional growth for many. Pharmacists typically spend 5-8 years completing their PharmD through undergraduate and graduate studies, but many opt for additional postgraduate training to further specialize and align their expertise with their career goals [1].
Two common pathways for postgraduate training are residency and fellowship. A residency is a postgraduate training program that allows pharmacists to further hone their direct patient care skills within a healthcare setting [2]. In contrast, industry fellowships provide pharmacists the opportunity to gain hands-on experience in a specific functional area of the pharmaceutical industry [3,4].
II. Pharmacy Residencies
A pharmacy residency is a one- or two-year postgraduate training program that provides hands-on experience working in a clinical setting alongside other healthcare professionals. It also includes focused mentoring, leadership development, and research experiences which prepare pharmacists for more advanced pharmacy positions in a hospital or healthcare system.
Postgraduate year one (PGY-1) is generalized training, to build on the knowledge gained from pharmacy school while providing exposure to managing medication use and supporting optimal medication therapy outcomes in a broad range of disease states. Pharmacists may choose to complete a PGY-1 in hospital, community, or managed care settings.
Postgraduate year two (PGY-2) is an optional more specialized training that builds upon year one of residency training. A PGY-2 focuses on a specific area of practice, for example, oncology, or critical care. As an extension of a PGY-1, a PGY-2 increases the resident's depth of knowledge, skills, and
expertise in medication therapy management and clinical leadership in their area of focus [2].
Completing a residency is a great way to start a career as a clinical pharmacist. The extensive training affords a pharmacist more opportunities than an entry-level staff pharmacist, accelerating their career growth. Furthermore, residency provides pharmacists with a competitive advantage in the job market. Another benefit of completing a residency is that it helps a pharmacist define their career goals, by providing them the perspective of practicing in a variety of areas [5].
The residency application portal opens in December and pharmacy students apply during their final year of pharmacy school using the online tool, Pharmacy Online Residency Centralized Application Service (PhORCAS), where they interview with programs and rank their preferences, and programs rank the candidates. The results are released on Match Day, where candidates and programs are matched as determined by their rankings [6]. While the official application process doesn’t begin until the final year of the PharmD program, students can start preparing as early as their first year in pharmacy school by building a strong application consisting of their Curriculum Vitae (CV) and letters of recommendation, while also readying themselves for interviews. Students' academic performances, CVs, and interviewing skills are key to differentiating themselves from the other candidates [7].
III. Industry Fellowships
A fellowship is a 1 to 2-year postgraduate training program within the pharmaceutical industry that allows pharmacists to gain experience in specified functional areas. There are several reasons why PharmDs are valuable in the industry including their extensive drug knowledge, experience with interprofessional collaboration, and training in developing and utilizing evidence-based guidelines.
There are several types of fellowships that focus on defined functional areas such as clinical research, regulatory affairs, medical affairs, commercial, and pharmacovigilance/safety. Completing an industry fellowship is not a requirement to pursue a career within the pharmaceutical industry; however, fellowships provide PharmDs with leadership skills, networking opportunities, and specialized knowledge in their chosen functional area, and these added benefits can help propel one's career path. Upon graduation, many fellows achieve upper management positions, whereas those who pursue direct-entry roles within the pharmaceutical industry may require more years of employment to secure similar positions [8].
The fellowship application process is less centralized compared to the American Society of Health-System Pharmacists (ASHP) residency match and more like a typical job application process. Many organizations offer fellowship programs including Rutgers University, Massachusetts College of Pharmacy and Health Sciences, the Food and Drug Association (FDA), Industry Pharmacists Organization, and individual pharmaceutical companies. Crafting a strong CV and Letter of Intent is equally important in the fellowship application process, whereas industry experience, leadership, and research are highly valued. Interviews showcasing the applicant’s experience and personality are the key differentiators for employers when selecting a candidate. Interviews can involve presentations, site visits, and often attendance at the ASHP Midyear Meeting. Fellowship offers are not organized through a match
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Beyond the PharmD: Exploring Residency and Fellowship Paths for Pharmacists Continued process; rather, individual companies extend offers and the applicants can accept the offer that is best for them [3,4].
IV. Comparing Residencies and Fellowships
Choosing between a residency and a fellowship depends on a student’s career aspirations. It’s important that a student takes time to reflect on their interests and their strengths and weaknesses to choose the right path. A major difference between the two is direct patient care. Residencies involve direct patient interactions, while fellowships are more for those who seek a role in drug development.
After completing postgraduate training, most pharmacists continue to work in their respective areas. For residency, the next step is becoming a clinical pharmacist and/or specializing in a specific disease state, perhaps with the intention of advancing to leadership positions in a hospital or a healthcare system [5]. For fellowships, the next step in career development is becoming a full-time employee in a specified functional area, usually starting out in a managerial role, with the intention of progressing to higher-level management [8].
V. Conclusion
Overall, there are many different paths that PharmDs can pursue within the field of pharmacy with or without postgraduate training. It is important that students consider their individual goals and interests when it comes to choosing a career path, whether that be residency, fellowship, or direct entry roles in community, hospital, or industry settings. PharmDs are equipped with versatile skill sets, therefore it’s important that pharmacy schools provide resources for students to explore the multitude of options available to them post-graduation. +
Shannon Gallo, PharmD, Global Regulatory Affairs Fellow at Sanofi/MCPHS.
Email: shannon.gallo@sanofi.com
Anthony Chan, PharmD, MBA, Global Regulatory Affairs Fellow at Sanofi/MCPHS.
Email: anthony.chan@sanofi.com
Helen Pervanas, PharmD, Professor of Pharmacy Practice Massachusetts College of Pharmacy and Health Science.
Email: helen.pervanas@mcphs.edu
ILegal Consult: Unfriendly Interpretations of the “Friendly PC Model”
Peter Martin, Esq.
n the decade ending 2021, private equity firms purchased 6,000 physician practices. These transactions typically involve separating the clinical assets from the non-clinical assets of the target practice and having a management services organization (MSO) own the non-clinical assets. The creation or designation of a physician practice, usually a professional corporation (PC) used to hold and operate the clinical assets of the practice, and a management services agreement and other agreements between the PC and the MSO that may include restrictions on successor ownership of the PC. This has been referred to as the “friendly PC model”. The bankruptcy of Steward Health Care has focused new attention on private equity transactions in the healthcare industry. Two recent developments exemplify different approaches that might gain momentum as businesses seek to aggregate or manage professional medical practices and other healthcare providers.
A recent Massachusetts development was the passage in July 2024 of Senate Bill 2881, “An Act Enhancing the Health Care Market Review Process”. This bill seeks to expand the scope of the Commonwealth’s existing Health Policy Commission’s powers to review significant healthcare transactions through the Material Change Notice (MCN) process. That process normally concerns only transactions where the net patient service revenues (NPSR) exceed $25 million. The bill would permit separate transactions to be aggregated to meet this $25 million threshold, meaning that a series of practice acquisitions designed to create a “platform” of practices each below the threshold might in the aggregate trigger the MCN requirement.
The bill also seeks to expand the type of transactions requiring a MCN to include significant for-profit investments in, asset purchases, or acquisitions of direct or indirect control of providers. Currently, an MCN is only required if a provider organization with at least $25 million in annual NPSR proposes to engage in a merger or affiliation with, or acquisition by, an insurer or a hospital or hospital system, or any other such transaction with other providers that increases NPSR by at least $10 million. An entity proposing any significant for-profit investment in a provider organization must disclose extensive information about its prior healthcare practice acquisitions. A private equity firm with a financial interest in a provider organization must post a bond with the Department of Public Health to ensure that its acquired practice complies with significant operational requirements, such as not exceeding a maximum adjusted debt to adjusted Earnings Before Interest, Taxes, Depreciation, and Amortization (EBITDA) ratio, not becoming highly leveraged, and not performing stock buybacks.
Finally, the bill also strengthens the existing corporate practice of medicine prohibition by stating that MSOs and corporate employers of healthcare practitioners may not interfere with practitioners’ clinical judgment. The bill requires that the healthcare practice maintain ultimate decision-making authority over clinician employment status, coding or billing decisions, the number of patients seen in a given period of time, and referral decisions. Finally, the bill prevents a person from being a director, officer, or employee of both a healthcare practice and an MSO.
A second development took place in California. A Los Angeles County
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Superior Court ruled in Art Center Holdings, Inc. et al. v. WCE CA Art, LLC et al. to convey control over a reproductive health practice and its affiliates back to the original physician owners from WCE, a management services organization. The relationship between the physician practices and the MSO used the “friendly PC model” in which a continuity agreement entitled the MSO to select a successor physician owner of the PC in the event of death, loss of license, etc., and a consulting agreement whereby the physician owner would provide nonclinical services to the MSO in return for a separate fee. Termination of the consulting agreement would trigger the MSO’s right under the continuity agreement to require sale of the practice to the MSO’s selected physician.
After the practice sale, the physician owner claimed the MSO underinvested and mismanaged the practice, particularly by undercollecting accounts receivable and causing nonclinical staff to resign. The physician owner filed suit and asked the court to appoint a receiver to transfer control of the practice back to him. This relief was granted by the court.
The court considered whether the MSO engaged in the unlawful practice of medicine. It found that the contractual provision requiring sale of the practice to a physician selected by the MSO constituted “undue control of a medical practice”. This would be the case even if the MSO vested control of the practice in the hands of another California-licensed physician. The court also granted the receivership in part because the continued operation of the practice as controlled by the MSO would be “against public policy and subject the parties to the risk of professional and criminal repercussions.”
The California case is under appeal and does not at this time have precedential significance. Likewise, the state legislative proposals summarized above are not current law. However, the Superior Court’s analysis in At Center Holdings and these state legislative efforts emphasize the role of the corporate practice of medicine doctrine in seeking to limit MSO authority in “friendly PC model” transactions to only non-clinical aspects of a medical practice. This reduced authority would prohibit an MSO from selecting a successor physician owner.
The Massachusetts bill combines both the corporate practice of medicine approach and the expanded use of an existing regulatory process for evaluating significant healthcare transactions. We can anticipate that both approaches will characterize the legal response to private equity-related activities in the healthcare industry.
In light of these legislative activities and litigation outcomes, physicians and other caregivers considering entering into a practice sale with non-professional business entities should pause and consider how best to preserve their professional clinical autonomy in return for ceding control over the business aspects of their practice. Some of the specific restrictions on clinical decision-making described above could form part of a physician practice’s negotiation posture when considering such a sale. +
Peter Martin, Esq.
Eileen Wolf, MD
August 4, 1954 – August 11, 2024
WDMS Member 1988 – 2002
Dr. Eileen Wolf, former Chief of Nephrology at Worcester City Hospital and former member of the Renal Division at St. Vincent Hospital, died on August 11, 2024, at the age of 70.
Eileen was valedictorian at Natick High School and graduated Magna Cum Laude and Phi Beta Kappa from Tufts University. In 1980, she graduated from Albert Einstein College of Medicine where she met her future husband, Dr. James Feldman.
Eileen completed her medical residency at St. Vincent Hospital. She chose the hospital in large part because of Dr. Bud Rose, who had written the primary renal textbook, Pathophysiology of Renal Disease, and served as the Chief of Nephrology at St. Vincent Hospital. Years later, Dr. Rose would create UpToDate.
As might be expected, Eileen was highly motivated to become a nephrologist. After completing her medical residency at St. Vincent, she began her nephrology fellowship at Boston University School of Medicine where her husband was, and still is, on the emergency physician staff.
Eileen was an outstanding physician and teacher. She excelled in Worcester throughout all of the hospitals in the city and at UMass Chan Medical School. Her patients adored her, and her devotion to them was the most important aspect of her career.
Eileen continued to excel in nephrology, even after she faced challenges that resulted from the development of transverse myelitis at the age of 42 as well as a progressive lung disease that ultimately took her life. Her courage and determination were always present. She had an extraordinary sense of humor that carried her through the most difficult times. After retiring from her clinical practice, she continued to speak on behalf of women in medicine and was a driver of the literacy program in the Framingham elementary schools where she volunteered, teaching math and reading.
The most important aspect of her life was Eileen’s devotion to her family and friends. In addition to her husband, she leaves two daughters, Dr. Stephanie Feldman and Dr. Hope Feldman, her son-in-law, Dr. Joshua Allen Dicker, and her two grandchildren, Vivian and Zachary.
Eileen will be missed by her family and friends and by those of us who were fortunate enough to work with her in the field of medicine.
Robert M. Black, MD
Former Chief of Nephrology, St Vincent Hospital Professor of Medicine, UMass Chan Medical School
Louis Frederick Anastasia, MD
October 7, 1935 – August 4, 2024
WDMS Member 1969 – 1999
It is with sadness that I report the passing of Dr. Lou Anastasia on August 4, 2024, at the age of 89. Lou was born in Newark, NJ. He attended Georgetown University, graduating in 1956. He went directly to Georgetown Medical School, receiving his MD in 1961. He enrolled in the Boston University four-year surgical residency. This was interrupted by military service in the U.S. Navy, where Lou served as a battalion surgeon in the Marine Corps. He married Diane Doherty in 1965 and took thoracic surgical training at the University of Michigan. After this thoracic surgical fellowship, he worked as a thoracic surgeon at Boston City Hospital.
Lou came to Worcester in 1974, and together with fellow thoracic surgeon, Gerald Carroll, worked in private thoracic surgical practice until 1987. He was appointed Chief of the Medical Staff at St. Vincent Hospital from 1996 to 1998. He had an academic appointment at the UMass Chan Medical School as an assistant professor. He was a loyal and faithful member of the Worcester District Medical Society.
Lou retired in 1998, engaging in golfing and fishing on Cape Cod.
Lou will be remembered for his good humor and gentle manner. His devotion to his patients was exemplary. He was a great thoracic surgeon, and we will miss him.
