2024 Gerald F. Berlin Creative Writing Award Winner: “Two True Stories” 21
Elizabeth M. Irvin
Curbside with Dr. Baker 23
Christopher Baker MD, UMass radiologist/contributing cartoonist to Cartoonstock.com
As I See It: Pregnancy Resource Centers: A Valuable Resource for the People of Massachusetts 23
John L. Worden, IV, MD
Bullet 25
Prem Patel
References
For a complete listing of references from the articles in this issue, click or tap HERE.
Robert Sorrenti, MD
Martha Wright, MBA
Peter Zacharia, MD
Alex Newbury, MD, UMass, Radiology Resident
Arunava Saha, MD, SVH, Medicine Resident
Olivia Buckle, Student Representative
Parul Sarwal, MD, Editor-in-Chief
Sloane Perron, Copy Editor
Robert Howard, Designer advertising Inquiries to Martha Wright mwright@wdms.org 508-753-1579
thanks to The Reliant Medical Group, UMass Memorial Health Music Worcester Physicians Insurance
Hanover Theater
Mechanics Hall
UMass Chan Medical School
Beechwood Hotel
Iremember my first time at the Massachusetts Medical Society (MMS) House of Delegates (HOD) as a newly minted attending physician. This assembly is the decision-making core of the MMS and serves as a conduit for healthcare advocacy between the organization and grassroots physicians. As I immersed myself in the proceedings, I couldn’t help but wish I had been involved sooner, perhaps as a trainee or even a medical student. It dawned on me that the frustrations we often vented in the physicians’ lounge were, in fact, actionable, and this was the arena for effecting change. At the start of the session, I felt challenged by the parliamentary procedure and the legalese. But, by the end of the day, that feeling was replaced by a profound sense of belonging, recognizing the importance of a physician’s role in healthcare reform through active participation in policymaking.
As an organization, the MMS is actively promoting several grassroots campaigns to enhance healthcare delivery. By advocating for digital equity and payment parity in telehealth, our goal is to secure its longterm viability and make it accessible to all. We further seek to reduce the administrative burdens associated with prior authorizations, improving patient access to care and allowing physicians to focus on what they are trained to do – practice medicine. Addressing Medicare payment cuts is another crucial campaign; we are pushing for both short- and longterm payment reforms to support and sustain the physicians and patients relying on the Medicare program.
“
After over a decade of advocacy, the City of Worcester is the first in the Commonwealth to receive the green light for an overdose prevention center (OPC), a critical step towards addressing the opioid crisis.
In this comprehensive issue of Worcester Medicine, we cover all the burning topics in healthcare advocacy. We also bring to you an exclusive interview with Dr. Lynda Young, chair of the UMass Memorial Medical Group Board, in which she shares her personal journey in healthcare reform.
After over a decade of advocacy, the City of Worcester is the first in the Commonwealth to receive the green light for an overdose prevention center (OPC), a critical step towards addressing the opioid crisis. Dr. Matilde Castiel, Commissioner of the Worcester Department of Health & Human Services and a staunch advocate for this initiative, shares her own experiences with our readers. Leda Anderson and Casey Rojas
Editor-in-Chief
Parul Sarwal, MD
of the MMS emphasize the power of the physician advocate in implementing OPCs, in addition to the abovementioned campaigns. Dr. Patrick Lowe, chair of the Resident and Fellows Section of the MMS, takes us through the life of the OPC bill “from a student proposal to a board of health endorsement.”
Physicians wield influence both inside and outside hospital walls, driving change effectively. A prime example is the evolution of the concept of Hospitalat-Home, a powerful catalyst reshaping healthcare delivery. Dr. Shiv Sutaria, associate medical director of the Hospital at Home program at UMass Memorial Medical Center, gives firsthand insight into its development, and how it promotes patient-centric care and access. But while physicians continue advocating for their patients, they are also increasingly advocating for themselves and their peers. Resident and physician unions are gaining traction nationwide. Dr. Jasmin Zvornicanin, resident at UMass Chan Medical School, gives his perspective as a union delegate.
At the same time, healthcare reform encompasses more than just doctors and patients; it spans the entire medical landscape. Dinesh Yogaratnam and Valerie Coppenrath, associate professors of pharmacy practice at the MCPHS School of Pharmacy, analyze the Inflation Reduction Act’s influence on drug prices in this issue. Besides the escalating healthcare costs, staffing shortages have only been exacerbated by the COVID-19 pandemic. William Marr and Ellen Burgess, both registered nurses and current doctorate students at UMass Medical School, shed light on this dark reality of our health systems.
This year, I had the privilege of representing my district and state at both the State House and Capitol Hill as a physician. It highlighted the impact of the two letters appended to our names in guiding reform. Lawmakers heed our counsel, recognizing the weight of our expertise. Our capacity to enact change, especially through the framework of organized medicine, stands as an undeniable force in advancing healthcare. +
Dear Colleagues,
President’s Message
Alwyn Rapose, MD
It is an honor to serve as your President. At our Annual Business Meeting on April 10, I had the incredible experience of getting “pinned” by Dr. Giles Whalen our past president who has been an outstanding example of strong, graceful leadership the last two years. Standing up front and seeing all our past presidents and my teachers was indeed a humbling experience. Seeing such a large gathering of colleagues was overwhelming. A big thank you to Dr. Michelle Hadley, our incoming vice president; Dr. Justin Maykel, our secretary; and Dr. Adib Karam, our treasurer, for volunteering their time and talent for these positions of service. We as a team intend to do our best to fulfill the mandate of following the example of prior outstanding leaders in promoting the WDMS as a premier medical society in MA and the USA!
I am sure everyone has ideas of how to improve the activities and functioning of WDMS, and I do too. However, my agenda is to serve you, the members of the Worcester District, and take up the challenge of 1) Increasing the membership of WDMS and 2) Increasing member engagement, as well as exposure of new (and not-so-new) members to the Worcester community via “Health Matters”, the signature television program of the WDMS. We also intend to work hard on the long-term financial stability of the WDMS so that we maintain and enhance the multiple programs we host every year.
To achieve all of this, I request every member be proactive in reaching out to their friends and colleagues to participate and contribute in all our meetings. I encourage you to email and telephone your thoughts and suggestions to the officers and chairpersons of various committees as we press toward our goal of pushing WDMS to greater heights.
A special note to the editorial team of our flagship magazine “Worcester Medicine”: Please carry on publishing wonderful articles on topics relevant to our Worcester community. I wish all success to our Editor, Dr. Parul Sarwal, who is working hard on the print and online versions of our magazine, as well as on the social media presence for WDMS. We look around today at radio, television, and print media, as well as social media platforms and we see echo chambers of one-sided opinions to the exclusion of alternate viewpoints resulting in a loss of integrity and trust in these outlets. At the WDMS, as we try to increase the engagement of existing members and attract new members, we hope to present balanced versions of controversial subjects so that Worcester Medicine stands out as an inclusive (the “I” of DEI) magazine.
I could not end my first President’s Message without a special shout-out to our Executive Director, Martha Wright. She continues working long hours behind the scenes - preparing, and then delivering on so many tasks that go into making our WDMS successful. Thank you, Martha.
Thank you once again to all our members for placing your confidence in our incoming team. +
Lessons in Advocacy: An Interview with Dr. Lynda Young
Parul Sarwal, MD Editor-in-Chief
Dr. Lynda Young
It’s a brisk and damp Tuesday morning, the day of the Massachusetts Presidential Primary. We are seated in Dr. Lynda Young’s living room, surrounded by the timeless Adriatic blue wood that frames the fireplace. Dr. Young, Professor of Pediatrics at UMass Chan Medical, chairs the UMass Memorial Medical Group Board. She has served as President of the Massachusetts Chapter of the American Academy of Pediatrics (AAP) and is a past president of the Massachusetts Medical Society (MMS). In an exclusive interview with Worcester Medicine, Dr. Young shares insights from her extensive journey in advocacy to inspire aspiring healthcare advocates.
What prompted your journey into advocacy, and what were the initial steps you took to embark on this path?
It all started with this [pointing to the glass of water on the table next to her]… Back in 1977, when I was just starting my pediatric practice, I couldn’t ignore the troubling rate of dental decay among children. So, I approached one of the physicians in our group, who happened to also be the Commissioner of Public Health, and asked him, “What’s behind these kids’ poor dental health?” He explained that the absence of fluoride in Worcester’s water was a big part of the problem. As the Commissioner, he’d previously tried to push for fluoride to be added, and the City Council had even approved it at one point. When the issue resurfaced, I joined him and other members of the Worcester District Medical Society (WDMS) and public health officials at the City Council hearing. Despite our efforts, the initiative faced strong opposition, leading to a referendum. To my disappointment, it was overwhelmingly defeated. People were still haunted by Cold War-era fears of communist plots and believed that fluoride would somehow “poison their water”. Despite two more attempts, the proposal met the same fate. And so, Worcester remains the largest city in New England without fluoridated water. This was the beginning of my journey in advocacy. It helped me find my voice to stand up for my patients and their health.
For those new to healthcare advocacy, what advice would you offer on building meaningful connections and relationships with policymakers, healthcare professionals, government agencies, and community organizations?
You know that saying about advocacy not being a sprint but a marathon? Well, it really resonates with me. I realized I couldn’t tackle everything solo and change definitely doesn’t happen overnight. So, while it took me a long time, I finally leaned into organized medicine for support. Joining the Worcester District Medical Society - that was a game-changer. I met like-minded physicians who shared my concerns and became key allies in addressing various issues. From there, I got involved with the MMS. It was eye-opening to connect with influential folks, especially the lobbyists. I remember thinking, “Why didn’t I do this sooner?” They handled the research and put me in touch with relevant contacts. I learned the importance of seeking out organizations that could help you and your medical society or your specialty society. I thus got plugged into the state chapter of the AAP, and later, took it to the national level. Really, each step brought fresh perspectives, new connections, and resources that fueled my passion for positive change in healthcare. On a local level, I made it a point to meet with candidates, even if it meant paying a small fee to attend their events or going to their fundraisers. I figured, hey, these are the people representing my city, so I need to know who they are.
“
You know that saying about advocacy not being a sprint but a marathon?
For those starting out: Begin small. Get involved locally, attend meetings, and introduce yourself to your representatives or city councilors. Making your presence known in your community is where it all begins.
Reflecting on your advocacy journey, can you share a specific bill or cause that was particularly important to you?
One significant achievement during my leadership in the MMS was my involvement with Tobacco-Free Massachusetts. It was a massive coalition, comprising
Lessons in Advocacy: An Interview with Dr. Lynda Young Continued
public health officials from organizations like the American Lung Association, the American Heart Association, and the American Cancer Society. I eventually stepped up to chair this coalition. Our focus was advocating for the Tobacco-21 law (T-21), which aimed to raise the legal age to purchase tobacco products from 18 to 21 years.
When advocating for T-21, how did you identify your allies and potential opponents, and engage with them?
So we anticipated fierce opposition from the tobacco industry, but surprisingly, they weren’t our main challenge. Instead, it was the convenience stores that caught us off guard. For them, selling tobacco was a major source of revenue, especially for stores near the borders of New Hampshire and Vermont, where the legal age was still 18. They were concerned that raising the age would drive customers to neighboring states. We had underestimated their influence - even as a small group, they were incredibly vocal and persuasive.
This experience underscored the importance of knowing your adversaries and engaging with them respectfully. I made it a point to sit down with convenience store owners to understand their perspectives. They were cordial, and their primary concern was the business side of things. Recognizing these dynamics is crucial in navigating the advocacy process effectively.
Can you share a time when you encountered a setback in your advocacy career, and how you overcame it to continue advocating for change?
Back in 2015, I decided to throw my hat into the ring for the presidentelect position at the AAP. It was quite the journey. After a series of selections, it boiled down to me and another candidate from Texas. I hit the road, campaigning across the country, and it was honestly a fantastic experience.
But you know what? I didn’t win. And strangely enough, I felt a sense of relief. Winning could have meant being swamped with work and hardly seeing my family. However, two individuals were disappointed by the outcome: a friend of mine who served on the AAP board and the executive director of the AAP. They both reached out to remind me that despite the loss, there was still an opportunity. I had four days left to throw my name into the ring for the chair of the Committee on Federal Government Affairs. It was a bit of a wake-up call because, amidst all the campaigning, I had forgotten that the chair was retiring.
Being in this role required me to spend a significant amount of time on Capitol Hill, which allowed me to build numerous contacts thanks to the credibility of the AAP. It was fascinating to have the opportunity to attend congressional hearings and be part of those discussions. For me, it was a protection against burnout because I constantly reminded myself that if I was not actively engaged in patient care or involved in advocacy efforts, my voice wouldn’t be as powerful.
Ultimately, even if you find yourself on the losing end of a particular battle, well, it’s not truly a loss. You’ve still made valuable contacts and established your presence. Once legislators recognize you as a physician who’s actively involved in the community, they’re likely to seek out your input on healthcare issues. It’s something you truly grasp when you sit down with these policymakers and recognize the platform being a physician affords you. +
The Importance of Using OPCs as a Harm Reduction Tool in Massachusetts
Matilde Castiel, MD
Ihave been closely following overdose prevention centers (OPCs), also known as safe injection sites, for many years. I have dedicated a significant portion of my life and work to supporting Latino men with substance use disorder through the opening of Hector Reyes House, two sober houses, and Café Reyes, where some of these men are employed. What I have found is that we need culturally competent and focused recovery programs, and places that keep our patients alive while in the throes of addiction.
OPCs are facilities where people who use drugs may go to consume previously obtained substances in an environment that is hygienic, monitored, without the fear of arrest. OPCs often offer an array of programs such as drug checking, medical care, case management, along with mental health care, housing services, food and nutrition, and hazardous waste management. On Point NYC even has laundry services and showers, and is working towards opening a pharmacy and barber shop in their facility1. Staff at these centers are specifically trained to work with people who use drugs, and many have lived experience themselves. This creates a supportive and safe environment, safe from judgment and stigma, increasing the pathways to treatment and other resources2. We need places where people who use drugs can feel safe, be monitored, and be able to connect to services when they wish for them to be initiated. In the 147 OPCs located in sixteen different countries, there has never been a fatal overdose.
As a community physician, I have lost so many patients to overdoses, many of whom used alone. Many of these patients feel like there is not a safe, nonjudgmental space for them to seek support. This leads them to continue using in hidden spaces such as bathrooms, hallways, and other places where they can manage their illness, which unfortunately, often results in death. These deaths are preventable, and I think that people too often forget that using drugs is a symptom of a medical condition. We need to start treating it as such.
I believe OPCs are a step in that direction. If my patients had access to an OPC, many of them would perhaps still be here, parenting their children, improving our communities, and living a life they feel is worth living.
The opioid mortality numbers in the country are
the highest they have ever been. The Massachusetts Department of Public Health indicates that in 2022 there were 2,359 overdose deaths - a 3% increase from 2021 and a 9% increase from 20163. Over 93% of fatal opioidrelated overdoses in the Commonwealth from January to April 2023 tested positive for fentanyl3, which is 50 times stronger than heroin.
In our own community, the numbers are concerning as well. In the City of Worcester, we are seeing overdose incidents decrease, however, the fatalities continue to increase. Comparing preliminary data from January to September of 2023 to 2022, we are seeing a 19.3%3 decrease in opioid-related incidents but a 15.6% increase in opioid-related fatalities4*. As Figure A shows, these fatalities have steadily increased over the last decade. The city and county currently have the highest mortality rates in the state5 .
As the drug supply becomes more toxic, we have been losing and continue to lose too many people from substances like fentanyl, xylazine, and other synthetic substances that are poisoning the drug
Figure A: opioid-related fatalities that occurred in the city of Worcester from 2015-20226 supply. Furthermore, people of color continue experiencing higher numbers of overdoses and overdose-related deaths. Even though addiction affects all ethnicities, genders, and social classes, the war on drugs and its policies have targeted communities of color through segregation, poverty, racism, and intergenerational trauma. Due to stigma and a lack of trusting environments, there are many missed opportunities to engage people who use drugs and meet their needs. OPCs are a model to expand harm reduction services and we need that now more than ever.
Support for OPCs in Massachusetts has been present for over a decade. In 2013, the coalition “SIFMA Now!” began advocating for the legalization of such sites. The Massachusetts Harm Reduction Commission, which I was a part of, called to have an OPC pilot program in the state in 2019. Other public supporters include the Massachusetts Medical Society (MMS), American Association of Addiction Medicine (ASAM), American Medical Association (AMA), ACLU Massachusetts, Boston Medical Center, Fenway Health, amongst others. In December 2023, the Massachusetts Department of Public Health released a feasibility study on OPCs, recommending the establishment of OPCs “pending legislative action to extend legal protections7”. If legal protection were to be passed, Massachusetts would be the second state in the nation to pass such legislation.
On March 4, 2024, the Worcester Board of Health unanimously voted in favor of a pilot program for an OPC, making Worcester the first city in Massachusetts to approve a safe injection site. +
Matilde Castiel, MD, Commissioner of Worcester Department of Health & Human Services
Email: castielm@worcesterma.gov
Hospital
at Home:
Innovation in Delivery of Home-Based Care
Shiv Sutaria, MD
For many, the words ”hospital at home” are met with confusion at the seeming oxymoron. What they may not know is the positive impact it is making on healthcare delivery in the Worcester region.
The Hospital at Home (HAH) program is a healthcare initiative aimed at providing hospitallevel care for medically appropriate patients within the comfort of their own homes. It involves delivering acute care services, typically provided in a hospital setting, to patients in their residences. This model allows patients to receive necessary medical attention while avoiding the inconvenience and potential risks associated with a hospital stay.
“ Research suggests that patient outcomes are comparable or with improved clinical metrics…
Our program here at UMass offers daily physician visits with patients and family via telehealth, at least twice daily in-home nursing or paramedic visits, twice daily multidisciplinary team huddles, urgent rapid response services, continuous remote vital sign monitoring, in-home diagnostics including point of care lab testing, send-out laboratory testing, electrocardiogram, mobile x-ray, and ultrasound. The program accommodates transportation for advanced imaging (CT, MRI) as required, and even specialty provider consultation. We are able to deliver all the usual therapeutics including oral, inhaled, and intravenous medications, oxygen, durable medical equipment. When needed, we are able to provide interventional radiology or surgical procedures.
Brick-and-mortar facilities offer a full spectrum of medical services ranging from emergency care to acute medical care, to intensive care. Given the full spectrum of care provided in brick-and-mortar facilities, there is rarely a concern for accessibility to diagnostics or therapeutic medical equipment, logistical, or staffing issues that prevent or delay providing timely care.
Healthcare Advocacy
Hospital at Home: Innovation in Delivery of Home-Based Care Continued
Since HAH programs are designed to provide acute medical care for patients who would otherwise be admitted on a med-surg floor in the hospital, they are not well equipped to handle emergent situations or situations that warrant more intensive care. There are also numerous logistical challenges that require innovative solutions since the patient is not physically located down the hall from a provider.
HAH care requires a lot of planning and coordination among different providers. For this reason, our program offers multidisciplinary synchronous rounding with the patient, family, nurse/paramedic in the home, and physician (joining via telehealth). This is in contrast to asynchronous rounding with nurses and physicians in the hospital where there is very little input from the patient’s family and caregiver. As a guest in our patient’s home, we get more insight into how they are taking their medications, what they are eating, when and how they are sleeping. All these little things really allow a hospital-at-home provider to provide holistic care.
Research suggests that patient outcomes are comparable or with improved clinical metrics, including reduced mortality rates, lower rates of hospital readmission, and higher patient satisfaction levels when compared to brick-and-mortar care.
So far we have received overwhelmingly positive feedback from our patients and their families. They often send us letters, cards, notes, and emails expressing gratitude for their care and allowing them to live their life in the comfort of their home while receiving medical care. Some patients who end up getting readmitted often ask for our program by name as soon as they get to the emergency department because of their trust in our program.
Ironically, the biggest challenges for this program do not come from health system leadership or costs, but from the cultural change within the institution. We have made significant progress over the past few years. When this program was first starting, we were struggling to get patients referred to us; now we get so many referrals per day that we are not able to take all the patients. We are likely at least the 6th largest program in the country based on the average daily census quoted in the article in Becker’s Hospital Review [1]. Strikingly, despite outreach and the cultural change, there are still many providers and patients who are hearing of the program for the first time.
While such a program sounds promising,
successful execution relies on several key factors. Our program has been well supported by visionary executive-level support. This enables alignment of institutional resources and goals without which the program could not deliver this carefully coordinated care at home. The program design centers on equitable delivery with telehealth equipment designed to be able to be used by anyone and in any home including those without a tablet device or internet. Patient referral to the program can be a limiting factor as it is a complex and dynamic process, which is under constant improvement. Similarly, accommodating the program scale as referrals increase, while providing robust ancillary services and supply chain support for increasing patient acuity, are critical for implementation success.
We would like to continue growing this program and offer more services to our patients. For instance, we recently started offering patients blood transfusions. Before this, we had to temporarily transfer the patient back to the hospital to transfuse blood and then bring them back home. We also recently partnered with the OB-GYN team to transfer patients who are at least two days post cesarean section for ongoing care with our team. To my knowledge, we are the first HAH program in the country to offer these types of services.
The UMass Hospital at Home program delivers hospital-level care to patients in their homes. Delivery is made equitable by designing a program that can be implemented in nearly any home environment. We have achieved broader recognition in our health system and I would like to keep seeing this team continue to push boundaries and offer care to more and more people. +
Shiv Sutaria, MD
Virtual Home Hospitalist
Associate Medical Director, Hospital at Home, UMass Memorial Medical Center
Assistant Professor, UMass Chan Medical School
TThe Power of the Physician Advocate
Leda
Anderson, Esq. Casey Rojas, JD, MBE
he impact of private equity in health care. A crisis in access to primary care. Burnout. Health care workforce shortages. Hospitals beyond capacity with emergency department overcrowding. More than 2,300 overdose deaths in 2022. A system on the brink of imploding. The stakes could not be higher, which is why the physician voice in advocacy could not be more important than it is now.
Advocacy is a central component of the Massachusetts Medical Society's mission to be a trusted leader in healthcare and to advance the medical profession, on behalf of you and the patients you serve. As physicians, you are the key to our collective success – our most powerful advocates. Yours is a trusted voice on Beacon Hill, Capitol Hill, and beyond – it is your patient stories, clinical experience, and subject matter expertise that is truly compelling when it comes to influencing policymaking. The physician voice is often the bridge that connects a policy with the real-world impact on patients and the practice of medicine.
Physicians are the backbone of our healthcare system and improving the practice environment in medicine will have a meaningful impact on addressing so many of the challenges impacting our healthcare system. One example is the excessive administrative burden. According to the Medical Society’s most recent member well-being report, more than 55% of physicianrespondents reported experiencing symptoms of burnout. Unsurprisingly, respondents cite prior authorization as one of the top stressors contributing to that burnout, amongst other factors including workforce shortages, escalating practice costs coupled with inflation, and unstable revenues. On its face,
administrivia seems banal and frustrating at best, but upon digging deeper and exploring the impact of prior authorization on patient access to care and practice burden, the associated impact becomes clearer, and the need for reform acute.
Last fall, the Medical Society helped organize more than a dozen physicians and patient advocates to testify at the Massachusetts State House in support of H.1143/S.1249, An Act reducing administrative burden. As advocates, we can share data underscoring the risk of patient harm when medically necessary care is delayed or denied – how it leads to treatment abandonment and adverse health outcomes. But lawmakers were blown away by the stories shared by physicians to illustrate that point – one patient with sickle cell anemia who had to be hospitalized twice because he could not access his medication to treat his pain due to prior authorization; another patient who was hospitalized with a cardiac event when he could not access his blood pressure medication after switching insurers. Lawmakers were similarly appalled to learn that physicians spend hours battling insurance companies to appeal prior authorization denials and have to employ multiple staff for a small practice solely to administer prior authorizations.
On the federal level, the Medical Society continues to advocate reforming Medicare payments toward a more stable, sustainable, and reliable system. With annual payment cuts included in the Medicare Physician Fee Schedule, it has become standard practice to mobilize
The Power of the Physician Advocate Continued
our grassroots advocacy tool to collect physician stories regarding how decreases in Medicare reimbursement negatively impact physician practices and patients of the Commonwealth. These stories, coupled with real-world data, have a tremendous impact on policymakers’ actions on Capitol Hill. This advocacy bridges the gap between well-intended statutes and the tangible implications on the front lines of medical practice. While we clearly see how a 3.37% cut in Medicare reimbursement can be fatal for a physician practice, our legislators need to know the dire consequences that such a cut can have in their constituent communities. Crafting thoughtful, forward-thinking reform to such a large and critical system takes tremendous knowledge and perseverance. The practice of medicine relies on physicians’ skills, and the Medical Society’s advocacy similarly relies on physicians’ expertise and dedication to the cause.
“ Your voice is powerful, and we urge you to use it.
It’s not just practice of medicine issues where physicians can make a difference. Combatting the opioid overdose epidemic is one of the Medical Society’s top public health priorities, and our key policy initiative on this issue is to legally authorize overdose prevention centers (OPCs), also known as safe consumption sites, in Massachusetts. The MMS is proud to have been the first state medical society to support OPCs almost 7 years ago, and we have been advocating for their establishment ever since, but to many, OPCs are still a radical concept. The physician voice has been essential in educating lawmakers about the nature of addiction as a chronic illness and the importance of harm reduction tools to combat overdose death. Hearing directly from physicians about the tragedy of losing patients who might have otherwise been saved were they able to be clinically supervised while consuming drugs has helped humanize an otherwise complex and abstract concept. Physician advocacy has made meaningful strides in advancing legislation to authorize OPCs, which has been endorsed now by two legislative committees and heads to the respective branches for consideration.
Your voice is powerful, and we urge you to use it. Please visit the Medical Society’s new Grassroots Action Center to learn more about how to be an effective advocate and to directly participate in one of our many issue campaigns by contacting your legislators in support of the issues that matter to you and your patients. +
Leda Anderson, Esq., Director of Advocacy & Government Relations, Massachusetts Medical Society
Email: landerson@mms.org
Casey Rojas, JD, MBE, Federal Relations & Health Equity Manager, Massachusetts Medical Society
Email: crojas@mms.org
Will the Inflation Reduction Act Deflate Drug Prices?
Dinesh Yogaratnam, PharmD, BCPS, BCCCP
Valerie Coppenrath, PharmD
Zamir Latif, PharmD
Joseph Sidoti, PharmD
The cost of prescription drugs is a growing concern for the U.S. healthcare system. Annual drug spending has increased from $30 billion (about $92 per person in the US) to $335 billion (about $1,000 per person in the US).1 Drug prices are also rising at an alarming rate. Nearly half of the 4,200 drugs that had their price raised between January 2022 and January 2023 increased at a rate that outpaced inflation2. Some reasons for these soaring costs are clear: the aging population is expanding and there is an ever-increasing arsenal of medications entering the market to meet their health needs. Unfortunately, these reasons alone do not fully explain why per-capita drug costs in the United States are more than double that of other industrialized nations3 The tangled relationships between employers, public and private insurance, pharmacy benefit managers (PBMs), drug manufacturers, federal regulators, wholesale drug distributors, and patients have resulted in a complicated, even opaque, drug marketplace. Single-pronged solutions can be undermined by exploiting loopholes in rebate programs, tiered pricing arrangements, and patent extensions. On the bright side, recently passed, comprehensive legislation offers hope that meaningful drug price reductions could be on the horizon.
President Biden signed the Inflation Reduction Act (IRA) into law in August 2022. This sweeping legislative act included policies to help curb climate change, promote investment in clean energy, capture corporate taxes, and provide additional funding for the Internal Revenue Service. The IRA also brings significant reforms to Medicare and prescription drugs. These changes are anticipated to reduce federal drug spending by $237 billion over 10 years. This article will touch upon a few of the drug-price reduction policy changes introduced with the IRA, including:4,5
• Capping out-of-pocket spending for Medicare Part D enrollees
• Expanding eligibility for the Medicare Part D LowIncome Subsidy Program
• Eliminating cost sharing for adult vaccines covered
under Medicare Part D
• Limiting monthly cost sharing for insulin to $35 for people with Medicare
• Empowering Medicare to negotiate prices with drug manufacturers
The IRA significantly changes how prescription drug costs are shared between enrollees, plan sponsors, drug manufacturers, and the federal government (i.e., Medicare). Most notably, out-of-pocket spending by Medicare enrollees will be capped at $2,000 annually starting in 2025. For an individual, this financial relief could be life-altering. Prior to implementing this rule, Medicare enrollees had to spend at least $8,000 to even qualify for “catastrophic coverage”. For a society that spends $335 billion on prescription drugs, this could be transformative. A study from 2020 estimated that nearly 16.5% of Americans (4.9 million people) spent catastrophic-level amounts on prescription drugs in 2020.6 The IRA doesn’t stop there.
Previously, when Medicare Part D enrollees entered the catastrophic coverage phase, they would be required to pay 5% of their total drug costs above the threshold until the year ended unless they qualified for low-income subsidies. The IRA eliminates this 5% coinsurance requirement. Furthermore, Medicare Part D has expanded eligibility for its low-income subsidy (LIS). This program helps cover enrollees’ premiums, deductibles, and cost-sharing obligations. Previously, enrollees would qualify for either full or partial LIS benefits if they had assets <135% or between 135-150% of the poverty line, respectfully. With the IRA, all enrollees with assets below 150% of the poverty line will now qualify for full LIS benefits.4,5 In addition to changes in Medicare cost sharing, the IRA includes policies aimed at improving access to vital medications.
The IRA is eliminating patient cost-sharing for vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). No copays, no deductibles, no out-of-pocket expenses. This includes vaccines for shingles, tetanus/diphtheria (Td), tetanus/ diphtheria/pertussis (Tdap), hepatitis A, and hepatitis B. Prior to the IRA, certain vaccines (e.g., COVID-19, influenza, and pneumococcal) were available without cost-sharing under Medicare Part B. However, for these other vaccines, enrollees could be responsible for 20% of the cost. With the IRA, all ACIP-recommended vaccines will be covered at no cost to enrollees of Medicare Part D, state Medicaid programs, and the Children’s Health Insurance Program (CHIP).4,5
Vaccines weren’t the only life-saving medications targeted by the IRA. In response to rising insulin prices, the IRA included a provision that limits the out-of-pocket costs for insulin to $35 per month for part D enrollees.
While this provision does not mandate the same benefit to noninsured or commercially insured patients, the major insulin manufacturers, Eli Lilly, Novo Nordisk, and Sanofi, have since voluntarily followed suit and are limiting patient co-pays to $35 per month7. While this is great news for patients who take insulin, the IRA also includes a powerful provision that may lead to drug price reductions for a broader scope of agents.
Perplexingly, and unlike most other national health services here and abroad, Medicare has never been allowed to negotiate drug prices with manufacturers. This is about to change. The IRA is finally granting bargaining power to the Centers for Medicaid and Medicare Services (CMS) to negotiate a maximum fair price with manufacturers. While participation is technically voluntary, manufacturers will be subject to an excise tax starting at 65% and growing to 95% of drug sales if they decide to participate in Medicare or Medicaid without negotiating. Drugs for this program are selected based on their highcost burden to Medicare Part D, and this new legislation is expected to save US taxpayers $25 billion by 2031. However, there are some notable criteria for drugs to be eligible for negotiation8
Drugs must be at least 9 years out (for small-molecule drugs) or 13 years out (for biologics) from their Food and Drug Administration (FDA) approval or licensure date, they must not have any generic or biosimilar equivalent agent available, and they must contribute to at least $200 million in annual Medicare spending. In addition, orphan drugs for a single rare disease, plasma-derived drugs, and certain drugs manufactured by small biotechnology firms are exempt from negotiation8 .
The first batch of eligible drugs was announced in August 2023. These 10 Part D drugs include the anticoagulants Eliquis (apixaban) and Xarelto (rivaroxaban), the diabetes drugs Jardiance (empagliflozin), Januvia (sitagliptin), Farxiga (dapagliflozin), and Fiasp/Novolog (insulin aspart), the heart failure drug Entresto (sacubitril and valsartan), the biologic drugs Enbrel (etanercept) and Stelara (ustekinumab), and the anticancer drug Imbruvica (ibrutinib). The results of the negotiation process will be published in September 2024, and the new prices will take effect in January 2026. There will be 15 additional drugs eligible for negotiation in 2027, another 15 drugs for 2028, and then 20 drugs per year thereafter. For 2028 and beyond, drugs from Part B (e.g., clinician-administered drugs) will be eligible for negotiation, too8
The IRA has the potential to reduce medical debt for beneficiaries and to save Medicare billions of dollars. However, pending lawsuits from drug manufacturers, an upcoming election that may introduce political powers seeking to overturn the IRA, and the exploitation of loopholes that reside within the complex drug marketplace may still derail the realization of these benefits9-10. Time will tell if the Inflation Reduction Act can succeed in deflating drug prices. +
Dinesh Yogaratnam, PharmD, BCPS, BCCCP is an Associate Professor of Pharmacy Practice at Massachusetts College of Pharmacy and Health Sciences School of Pharmacy Worcester/Manchester
Valerie Coppenrath, PharmD is an Associate Professor of Pharmacy Practice at Massachusetts College of Pharmacy and Health Sciences School of Pharmacy Worcester/Manchester
Zamir Latif, PharmD is a post-PharmD fellow of Clinical Sciences and Innovation at Novartis Institutes for Biomedical Research
Joseph Sidoti, PharmD is a post-PharmD fellow of Clinical Sciences and Innovation at Novartis Institutes for Biomedical Research
AFrom Student Proposal to Board of Health Endorsement:
How a Decade of Advocacy May Bring Worcester’s First Overdose Prevention Center
Patrick Lowe, MD, PhD
new approach to addressing the opioid pandemic may soon be coming to Worcester. And along with it, an example of advocacy may be coming to fruition.
Supervised injection sites offer a location for people with opioid use disorder to use drugs with an added layer of safety – with a medical professional close by and ready to administer a lifesaving antidote if someone needs it – to reduce the risk of deadly overdose. For this reason, these sites are often called overdose prevention centers (OPCs).
In Massachusetts, the idea of OPCs has been percolating for over a decade in medical circles, even as public discourse began focusing on rising opioid use and overdose deaths. With examples of harm-reducing safe injection sites in Europe and in Canada, a group of medical students from across the Commonwealth, including UMass Chan, joined with leaders of the Massachusetts Medical Society (MMS) in 2016 to propose the policy that the MMS support supervised injection sites.
The MMS represents over 25,000 physician members and has a loud and strong voice on public health, healthcare delivery, and other issues related to doctors and medicine. Incorporated in 1781, the MMS has long supported medicine and public health through policy advocacy and medical education, including publishing the New England Journal of Medicine. In working through the MMS to support supervised injection sites, the students of UMass Chan and their colleagues were asking one of the oldest and most prominent medical societies in the country to support
a progressive, patient-focused harm reduction strategy to help protect the lives of our patients and neighbors.
The proposal from UMass Chan students and their collaborators went before the members of the MMS House of Delegates, an assembly similar to Congress, which debated the merits and practicality of the proposal and, after a year of further debate and consideration, eventually adopted the group’s recommendation. The MMS now had a formal policy stating its support as a physician-led organization for the establishment of supervised injection sites in Massachusetts. It also promised to study how to make these sites legal and sustainable in the Commonwealth and to evaluate patient outcomes.
With the full weight of the Medical Society behind the idea, members of the MMS began advocating to the public, politicians, and policymakers. The President of the MMS wrote national articles. Prominent physicians advocated in local media through the Boston Globe, WBUR, and other outlets. With strong support from Massachusetts, the American Medical Association joined in the advocacy effort and also endorsed OPCs as a harm-reduction means to combat
opioid overdose deaths.
Years of advocacy, starting with a resolution proposed by medical students nearly a decade ago, have led to the recent vote of the Worcester Board of Health which will now “support the reduction of overdose deaths in the city…[and] approve the creation of an overdose prevention center…” Local champions of this initiative have been working to reduce overdose deaths in Worcester for decades and now the City is poised to move forward with something that was once thought a radical approach. But with years of advocacy from students, physicians, community organizations, and physician groups like the MMS and the Worcester District Medical Society (WDMS), we will hopefully see a meaningful effort to prevent overdose deaths and bring treatment to a much-needed patient population.
The story of OPCs in Massachusetts is not complete, but it is inspiring. It shows how even “radical” ideas to improve patient care can come from anywhere – even from students nearly a decade ago. By collaborating with powerful stakeholders, such as local, state, and national medical societies (WDMS, MMS, AMA), an idea can gain the support it needs to become a reality. Many of those invested in preventing overdose deaths will be watching – and advocating – to see the Commonwealth’s first OPC come to reality in Worcester. +
Patrick Lowe MD, PhD Chief Resident Department of Emergency Medicine
Massachusetts General Hospital Brigham & Women’s Hospital PLowe1@bwh.harvard.edu
RMedicine and Resident Unions
Jasmin Zvornicanin, MD
esidency and fellowship are challenging times physicians must pass through to practice medicine. It is well known how arduous this challenge is, but it is another experience to be able to empathize with it. Every physician you have met has gone through this. My journey has been eleven years in the making: four years of undergraduate education, four years of medical school, and three years of internal medicine residency. Other residencies range from three to seven years. Many of my colleagues work longer, pursuing fellowships of typically two to three years on top of residency and some even further specializing a year after that fellowship. To reach this goal one typically would have to be amongst the best of their class in high school, among the best in undergraduate, and then thrive in the medical school process. In medical school, you are taught through the sheer volume of knowledge that your time is not your own, that your time belongs to your studies. Time that belonged to family, friends, experiences, and memories is instead tucked away into the next exam. We became accustomed to 12-hour long study sessions almost as if it were preparation for the 12-hour shifts that would soon follow. Once we survived the slew of notoriously difficult tests, some of the most difficult in higher education, we were congratulated and thrown into the arena of residency and fellowship. For many, residency comes with baggage; many take two hundred and fifty thousand dollars or more in student loans, others must move to whichever state offers a residency spot if they have not already moved for medical school.
“
With our union, we have helped increase pay to increase affordability of housing and childcare.
Historically, the roots of American residency were crafted by Dr. Willliam Osler at Johns Hopkins in the 19th century, but such programs did not grow in national popularity until after World War 2. We were called residents since we used to reside in the hospital. It was simply assumed that immersion in nothing but work would produce an effective doctor. Residency changed after cases of sleep-deprived residents working more than one hundred hours a week ended up in lawsuits. The Libby Zion case in 1984, a missed serotonin syndrome diagnosis that led to a death, pushed for regulated work hours of less than eighty hours weekly. This was recommended by the Association of American Medical Colleges in 1988, but not until 2003 did the Accreditation Council for Graduate Medical Education mandate these hours nationally.
During residency, the resident or fellow is vulnerable. The typical resident or fellow now has 1 day off a week, 12+ hours shifts, limited pay considering expectations of the job, no overtime pay, rare holidays, poor funding for childcare, etc. The hospital receives a certain amount of governmental funding for each accredited resident, of which only a portion goes to the resident’s salary. The hospital benefits from the available labor with governmental pay and the residents are rewarded an education — such agreements last up to 7 plus years depending on the residency or fellowship. The resident has just spent a significant portion of their life working toward a goal and they have enormous debt, almost so large as to suspect purposeful inflation to keep the resident moving forward. Keep in mind that it is difficult to even declare bankruptcy on such kinds of school debt. If you are seen as a troublemaker, you run the risk of gathering complaints
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and becoming expelled from your residency, the sort of black mark that is difficult to ever reverse. To worsen matters, residency tribulations were exacerbated by the outbreak of COVID-19. During this time, residents worked more and more intensive care unit shifts with patients suffering high mortality rates, spent more time with infected patients with limited personal protective equipment (nursing staff faced the worst of this burden), and electives and breaks were compromised. This was the push that led UMass as well as thousands of residents across the country to unionize.
In unionizing, we can stand together on a more even playing field and argue for changes we wish to see. With our union, we’ve helped increase pay to increase the affordability of housing and childcare. We have language in our contract to make vacation times longer. We have modified the terms by which residents are investigated if they have been accused of wrongdoing. We have become a platform on which unfair circumstances can be addressed purposefully. We no longer have to solely hope for institutional change through management. As residents, we hold power through the Accreditation Council for Graduate Medical Education (ACGME). Collectively, we can affect the accreditation of programs through our yearly surveys and now have the power to submit grievances for contract breaches. Currently, residency as an institution in America is unlikely to change without increasing available medical school and residency spots and decreasing the costs throughout training. The inertia to change should not keep residency difficult. Many residencies have made good strides to improve the working conditions of residents but much more work needs to be done. My hope is that medical education one day is not thought of as such a herculean task– that this system can grow into a system of greater ease and accessibility while maintaining its training quality that protects our patients.
Physicians are privileged to do what few can. The ability to stabilize, guide, and potentially cure the ill is gratifying and meaningful work. The growth I have experienced since my training began is hard to imagine; I have learned many wonderful things through working with my attendings, fellows, and co-residents. This wisdom and work are meant to be passed down to the next generation and, through our Union, I hope to give the next generation of physicians tools to make the path a little easier. +
Jasmin Zvornicanin, MD
3rd-year internal medicine resident at UMass Chan Medical School and Union Delegate
Email: Jasmin.Zvornicanin@umassmemorial.org
ASafe Staffing Saves Lives: A Call to Action
William Mar, RN, PhD Student
Ellen Burgess, RN, DNP Student
s nurses, we know the “real” crisis in hospitals: safe nurse staffing ratios. Our healthcare system faces many challenges. Nursing staff shortages were increased amid cost-cutting decisions, an aging population, and increased patient complexity/needs, which stressed working conditions for nurses and ultimately affected patient care and overall outcomes [1]. In 2014, Massachusetts was the second state where lawmakers passed a law requiring a 1:1 or 1:2 nurse-patient staffing ratio in the intensive care unit, depending on the patient’s condition and the assigned nurse’s discretion [1]; however, there are no laws regarding the nurse-to-patient staffing ratios outside of this setting. This article will discuss the challenges nurses face with unsafe staffing ratios, the implications those have on patient care, and finally, a call to action for healthcare administration to create environments wherein safe staffing is not only an expectation but a reality.
On March 1, 2022, the American Hospital Association wrote a letter to Congress demanding immediate attention to the workforce challenges, calling them a national emergency [2]. Similarly, the Surgeon General issued a public advisory declaring healthcare clinician burnout an urgent public health issue [3]. This notable workforce shortage is likely related to the unprecedented number of nurses who left the workforce during the COVID-19 pandemic, which amplified long-standing issues of burnout, stress, and staffing shortages [4]. Berlin and colleagues are projecting a 250,000 to 450,000 shortage in the registered nursing workforce in the US by 2025 [5].
Nurses are integral to the healthcare system, making up roughly 30% of total hospital employment [6]. Often, leadership attempts to reduce costs by reducing the nursing workforce. However, low nurseto-patient ratios are associated with increased medical errors, infection control, and accidental deaths [7]. Each additional patient over four per nurse is associated with a 7% increase in the likelihood of dying within 30 days of admission [8]. Similarly, there was a 16% increase in 30-day patient mortality, with each patient above nurses’ average workload [9]. Lower nurse-to-patient ratios are also strongly associated with emotional exhaustion, job dissatisfaction, and fatigue/burnout [10]. Each additional patient over four per nurse carries a 23% risk of increased burnout and a 15% decrease in job satisfaction [8].
A 2002 landmark cross-sectional study by Aikens et al. with data collected from 10,184 staff nurses, 232,342 surgical patients, and administrative data from 167 nonfederal adult general hospitals in Pennsylvania, highlighted that among hospitals with low nurse-to-patient ratios, surgical patients had higher 30-day mortality and higher failure-torescue rates with burnout and job dissatisfaction reported more frequently by nurses [8]. Hospitals that staff 1:8 nurse-to-patient ratios experience five additional deaths per 1,000 patients compared to hospitals that staff a 1:4 nurse-to-patient ratio and a 7% increase in the likelihood of dying within 30 days of admission was noted for each additional patient beyond four that the nurse assumed care of [8]. The most important
comprehensive study by Aitkens et al. compared hospitals in California with a required staff ratio to hospitals in New Jersey and Pennsylvania without one [7]. The study concluded that with laws legally setting nurse-to-patient staffing ratios, patient outcomes were better in lowering surgical mortality rates, reducing inpatient deaths within 30 days of admission, and a lower likelihood of death from failing to respond to systems appropriately [7].
While increasing nursing staff significantly improves hospital patient outcomes, safe nurse staffing improves favorable nurse working conditions and reduces turnover. The American Association of Colleges of Nursing (AACN) characterizes the hallmarks of suitable nursing work environments as those exhibiting a philosophy for clinical care that emphasizes quality and safety, professional collaboration, and accountability, recognizes nurses’ knowledge and expertise in clinical care quality and patient outcomes, and facilitates collaborative interdisciplinary relationships [11]. Schlak et al. suggest that improving nursing work environments alleviates burnout and reduces turnover [12]. The cost of rehiring nurses is high, and hospitals estimate huge revenue losses related to nursing turnover. AACN reports the average cost to hire an RN is approximately $2,820 and the average price of turnover for a staff RN is $52,350, with the range averaging $40,200 to $64,500, which resulted in the average hospital losing $8.55 million in 2022, ranging from $6.57 million to $10.53 million.
Prominent healthcare figures and associations declared short-staffing a national emergency and an urgent public health issue in 2022. However, here we are—over two years later—in the same, if not worsened, position. While policy reform is needed, nurses and patients nationwide cannot wait for legislation. We call on all healthcare workers, providers, and, most importantly, leadership to act. We must put aside our differences, remove barriers, and seek a viable solution for the safety of our nursing staff and better outcomes for patients. +
William Mar, RN, PhD Student, Tan Chingfen Graduate School of Nursing, UMass Chan Medical School
Email: william.mar@umassmed.edu
Ellen Burgess, RN, DNP Student, Tan Chingfen Graduate School of Nursing, UMass Chan Medical School
Email: Ellen.Burgess@umassmed.edu
WDecompensation: A Student Poses the Question of How Best to Advocate for Patients with Alcohol-Associated Liver Disease
Danielle Li, BA
hen I first laid eyes on Mrs. D, she was asleep in her bed. The room was filled with nothing but the quiet sound of her breathing. It was still early in the morning. “I’m sorry,” I murmured, “I need to listen to your heart and lungs.” She stirred but did not respond. Her protuberant belly, jaundiced and marred by patches of purple bruises, was exposed when she lazily pulled the sheets over her head.
Later, I went back to Mrs. D’s room to introduce myself. Sunlight streamed in through the bay window. She was sitting up in bed, chatting away with her personal care attendant. Except, it was not a conversation I was expecting to hear. “You ought to get ready now, you know,” she exclaimed, “you’re going to be late for the bus.” She turned to me when she noticed my presence and said, “Oh, there you are! You really need to tell her that she needs to go to school if she wants any cookies after dinner.”
The interesting thing about end-stage liver disease or decompensated cirrhosis is that it affects so many parts of the body. The brain is no exception. Mrs. D had fluctuating cognition from her decompensation, known as hepatic encephalopathy. This meant that she was not always checked in. As I got to know her, one of our favorite routines was to go over the four orientation questions together. What was her name, what was her location, what was the date, and why was she here? To the last question, Mrs. D, without fail, would reply, “It’s because I almost fell and hit my head.”
True, but not the truth. The truth is that this was Mrs. D’s fourth hospitalization for her liver disease in the past two years. Despite UMass Memorial being one of the main transplant centers in Massachusetts, Mrs. D was not on the transplant list—and would not be— until her alcohol use was in remission.
“But I get bored,” she said to me, “and I forget. No one’s there to remind me.”
“You can’t forget,” I say, firmly.
She swallows and looks away.
I saw myself as one of Mrs. D’s biggest advocates in the hospital. As the medical student, I had far fewer patients to see and much more time. I knew I was one of her favorites, and I consistently visited. But, when it came to conversations like these, I found myself frustrated. My time, empathy, rapport building, and continuous visitations were all but wasted efforts. Every day, they drowned themselves in the vast void that was Mrs. D’s pathological forgetfulness, and neither she nor I could help it.
Ever the hopeful medical student, I sat with Mrs. D a few days before her potential discharge. I explained to her in more detail than ever before what I knew of cirrhosis and its devastating toll on the body. I had just attended the internal medicine grand rounds on caring for cirrhotic patients the day before. I knew her two-year survival rate was no greater than 50 percent. Naively, I wondered if I could change that statistic for Mrs. D. If I could only make her understand, teach her about her discharge medications, explain the warning signs of decompensation, and teach her what to do when she needs medical attention.
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As I spoke about her continually declining quality of life and likely frequent hospital visits, her ever-steady, yellow eyes watched intently. She responded, “But I’ll be all better, right? And I promise I won’t drink anymore.”
Mrs. D had a loving husband, Matt, who was a long-haul truck driver. He understood and shared my frustrations. He remarked that while he was thankful for Mrs. D’s improvement, he thought that she, even at her functional baseline, would inevitably need frequent supervision.
Matt was right, the occupational therapists agreed. As discharge loomed closer, the social worker scrambled to find Mrs. D a long-term care facility that could take her. Unfortunately, the facilities were all uncovered by their insurance and way out of budget for Matt. As the days stretched out, Mrs. D, who was perpetually circling her own delirium, felt physically better and asked me time and time again when she could leave. Meanwhile, Matt, who still visited every day, paced the room, as his easy and cordial smile slowly slipped from his face.
Eventually, out of options and with an ever-growing medical bill, they left, against medical advice.
Many lessons came with taking care of Mrs. D. I remember most the sense of helplessness in the face of pending expiration. Despite the science clearly demonstrating the short time Mrs. D had, we were hopelessly stuck in place. Even after her discharge, Mrs. D challenges me: What interventions can we systematically implement in the hospital so that patients with cirrhosis and their families are better equipped with the knowledge on how to proceed in the short years following decompensation? How do we work with our knowledge of the disease course to eliminate preventable causes of decompensation, offer support for caregivers, and produce a realistic care plan together? Moreover, what do we do about a patient’s social determinants of health once we identify them? Our team never gave Matt a solution to Mrs. D’s need for continuous supervision. We could not help him with financial difficulties either. I shared some online resources with Matt, but that felt mediocre. Mrs. D’s loneliness, which perpetuated her drinking, went unaddressed.
The clock for Mrs. D’s re-hospitalization started ticking as soon as she left her hospital room. Undergraduate medical education rightfully emphasizes active listening and quiet empathy, and I am grateful for the times I was able to listen to Mrs. D share her feelings. The next step is to address the practical limitations providers face daily so that medical student empathy can continue on and be a part of us as we enter residency and beyond. +
Danielle Li holds a BA in art practice from the University of California, Berkeley. She is a current third-year medical student at UMass Chan Medical School and is interested in Plastic Surgery. She can be reached at danielle.li5@umassmed.edu
TAmericans and Compulsory Health Insurance
B. Dale Magee, MD Curator
he United States almost had a universal health insurance system in 1914! Here is the story: When we think of a national medical insurance system, historians point to Otto von Bismark in 1884, Germany. With increased industrialization, there was not only great wealth but also great poverty. To fend off a socialist rebellion, as well as help increase productivity, Bismark instituted a plan for disability and sickness care. The plan included most employees and charged the worker 2/3rd of the premium, with the employer paying 1/3rd. You will see the relevance of this German innovation below.
In 1911, the American Association of Labor Legislation (AALL, a lobbying group) got legislation passed (at the state level) for disability. At the same time, England instituted medical care coverage for workers to pay for generalist doctor bills. Hospitals were charitable institutions and not often used. Specialists were not covered. Doctors were paid a fixed fee per patient per year regardless of how often the patient visited.
Having succeeded without much resistance with disability insurance, the AALL then drew up model legislation for health insurance for workers in 1912. It would have been compulsory, universal, and sponsored by the government. They involved the leadership of the American Medical Association (AMA) and received strong support. The president of the AMA was also the head of the U.S. Public Health Service which added strength to the support. The proposal was cruising to victory when the tide began to turn.
Citizens wondered whether “having the government interfere with our private life” was necessary. Unions, after some thought, realized that they were losing a benefit that they could bargain for (indeed, Samuel Gompers, founder of the American Federation of Labor, came out against it). Doctors in practice were gaining experience with the newly instituted disability insurance and were fighting for payment as well as seeing employers and insurers hiring their own doctors. Their fears of having the government inserting itself between them and their patients only worsened when they heard that in England doctors were practicing “assembly line medicine”. In short order, practicing physicians ran the AMA leadership out and government-sponsored health insurance became a third rail for the future AMA leadership.
Then, the U.S. entered World War I. The Wilson administration undertook a vigorous public relations campaign demonizing all things German. Those who
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opposed the plan quickly referred to it as the “German Plan” (if you want to stand your hair on end, look up Wilson’s Sedition and Espionage Acts as well as his Committee on Public Information).
In 1920, Warren Harding was elected president with a promise of a “return to normalcy”. This included a promise of no universal health insurance. Over the next several decades Presidents (even FDR) would avoid the issue. It was not until the Johnson administration that national efforts moved forward with Medicare and Medicaid in 1965. These programs took what was previously charitable care and provided government payment. Critics will point to the low fees and bureaucracy; advocates find it to be a simpler solution to the complexities of the rest of our system. +
Heartbeats
Rachel Schneider, MPH
The following is “Heartbeats,” winner of the 2024 Narrative Writing Contest held by the UMass Chan Medical School chapter of the Gold Humanism Honor Society (GHHS). This contest was held during Solidarity Week for Compassionate Patient Care, a national celebration of compassionate and patient-centered care.
During my second year of medical school, we learned about something called depression with psychotic features. Basically, your brain copes with depression by creating mood-congruent psychoses—delusions that describe how you are feeling inside. During my third year of medical school, I saw a poignant example of depression with psychotic features that will always stick with me. Matt, a 29-year-old patient, sat across from us in the Berkshire Medical Psychiatric ward hunched over in a chair that was bolted to the ground.
“Please,” he begged. “Someone needs to check my heart again. It’s broken. I can feel that it stopped. I know you listened to it when I came in, and I got all the tests, but I promise you. It’s broken, I can feel that it stopped beating. Someone needs to help me; I swear that my heart is broken.” Matt had witnessed his fiancée die by suicide weeks prior, and in some sense, his delusions were not delusional. His heart, in the metaphorical sense, was truly broken.
During my fourth year, I rotated as a sub-intern at a busy urban trauma center. On busy 24-hour shifts, death would visit the trauma bay often and mercilessly. One night, multiple men with gunshot wounds arrived pulseless at once. One of the young men had suffered a gunshot wound through the chest. His heart had stopped but he was a candidate for an emergency thoracotomy. With incredible calmness, our trauma attending instructed the room through the steps. The residents cracked the young man’s chest open and carefully but quickly exposed his heart. We were instructed to press the heart in our palms to will it to beat again, being careful not to puncture the ventricles with our thumbs. We lined up to take turns performing open cardiac massage. With his heart in my hands, I could feel errant, erratic beats as the broken organ tried feebly to restart. It never did.
The attending physician called time of death. The resident asked me to help stitch up the patient’s chest before his family came in. “It’s the least we can do for him,” she said gently. As I started sewing up the young man’s chest, I tried to softly close his eyelids out of respect. They stayed open, staring directly at me. I wondered what the last thing he saw was. I pulled his skin together, trying to work gingerly even though I knew he could no longer feel it. Our attending came to speak with the team. He had just spoken with the patient’s mother in the emergency department waiting room. This was the second son she had lost to gun violence. Shortly after, we heard her screams cut through the room. Grief and heartbreak saturated the air with a heaviness that made it feel impossible to
breathe. I could feel my own heart beating fast and heavy. Later I arrived home and collapsed for a few hours. I awoke to my parents Facetiming me from one of my childhood best friend’s wedding, which I had been planning to attend until committing to the trauma rotation. The sun is setting over the rolling hills of a sprawling vineyard in Newport. Familiar faces of friends and family from across the country are beaming through the screen, warm with the buzz of wine. Tears sting my eyes as I congratulate the bride, stunning as ever and filled with the heartfelt love surrounding her.
They ask me how I am doing. I don’t know what to say. I am witnessing the biggest joy of someone’s life through my phone, while thinking about how fragile and unfair life can be. My feet are tired, the skin is peeling off from sweating in my surgical clogs and standing while wearing protective lead for hours on end. My eyes feel strained, they have seen too much and been open for too long. My ears are ringing from the beeping, the screaming, and the endless sounds of the hospital. The silence in my lonely apartment now feels jarring. My chest feels heavy; my own heart feels broken.
Tonight, I will crawl into bed. I may be haunted by dreams of the nights prior, but my body will rest, and I will sleep. Unlike so many I have seen whose hearts have stopped or been maimed, I get to wake up tomorrow. I will go to the hospital, still tired but regenerating. My feet will be a bit less sore, eyes a bit brighter, heart slowly healing, weight on my shoulders just a little bit lighter. I have seen the practitioners around me continue to conduct their clinical duties with humanism and empathy, even after heartbreak and repeated tragedy and I am determined to follow in their footsteps. +
(All names changed for privacy)
Rachel Schneider, MPH MD Candidate, Class of 2024
University
of Massachusetts Medical School
Email: rachel.schneider@umassmed.edu
Two True Stories
Elizabeth M. Irvin
The Gerald F. Berlin Creative Writing Award at the University of Massachusetts Medical School honors the poetry, fiction, and essays of medical students, physicians, in training (interns, residents, and fellows), graduate students, and nursing students from the medical school. The award was established to encourage creative writing by health professionals in training and to honor the father of Richard M. Berlin, MD, who sponsors the award.
subtle bend on the rural collector, black walnut tree grown thick and varicose on this landing place between the pine-scarp and the lake’s edge, dust hung in plumes
i crossed the living room to the barn sparrows nesting, gram walked out for the mail, jul arched the hose at her begonia beds, my grandfather scouted the fields for sowing season, and the goldenrod rooted down in the hollows of the cattle plod groove
the dirt bike banked right— roared and slammed against the ditch rim—
we left the red flag cocked–the hose flooded the driveway–
we forgot everything but the mud plug in the tailpipe the half-moon grimace of the boy that no one knew everything happened so slow and so fast my grandfather said later one minute we were all there together— we waited a lifetime for an ambulance on these backroads—
and the next, i boarded the volunteer rig in bloody pajamas, my hand still on the bag valve, jul close behind
and my grandfather hastened to pick up the bits of broken helmet in the grass and then he set them back down
my grandfather, as a child, watched the neighbor’s boy run pale-faced from the mill cradling his crushed rose-petal hand
Elizabeth M. Irvin
MD Candidate, Class of 2026
Population-Based Urban and Rural Community Health (PURCH) Track
University of Massachusetts Medical School
Email: elizabeth.irvin@umassmed.edu
Curbside with Dr. Baker
Christopher Baker MD, UMass radiologist/contributing cartoonist
to Cartoonstock.com
As I See It: Pregnancy Resource Centers: A Valuable Resource for the People of Massachusetts
John L. Worden, IV, MD
In our great Commonwealth, we are fortunate to have many Pregnancy Resource Centers (PRCs), also known as Crisis Pregnancy Centers (CPCs), providing care and counsel to women with unexpected pregnancies and women who are conflicted in their decisions.
Some of these centers are state-licensed medical clinics staffed daily with nurses and a physician medical director. Each PRC is unique in its setup and specific approach but all are similar in that they provide free and supportive services to whomever comes to them. I have been privileged to work closely with several of these centers in Central Massachusetts and have the distinct honor of being the medical director for one of them myself.
A PRC is a place where a woman can come and get a free pregnancy
test. She can then talk with staff about her options. She can receive referrals to various services and to obstetrical care.
In some clinics, she can have an ultrasound to date the pregnancy and check its location. In the clinics I work with, the ultrasound is performed by a nurse ultrasonographer who has received rigorous training and certification in performing limited obstetrical ultrasound. Women leave feeling supported and loved and they know that the door is open to them should they decide or desire to return.
For those who decide to keep their pregnancy, many centers offer birthing instruction, parenting classes, assistance with diapers, baby clothes, and accessing various community resources.
Local communities refer people to PRCs for help as well. The center of which I am director has very good relationships with the local community,
As I See It: Pregnancy Resource Centers: A Valuable Resource for the People of Massachusetts Continued
churches, schools, and even has had referrals from Planned Parenthood. This is a wonderful example of local groups working together for the good of the people they serve.
The staff at PRCs take their work and their clients very seriously. People who come into a PRC will be welcomed and their life will be affirmed and valued. PRCs are generally faith-based, so PRC staff see those who come to them as of great value and dignity and treat them thusly. Patients are not judged because they have had an abortion or decide to have an abortion. No, they are loved, and counsel and support are offered and, if desired, provided. So many young women who have come through our doors confused and scared have left feeling supported and loved and knowing that they have somewhere to turn. They do not pay anything for their visits or services provided. This is ultimate equity. No insurance, no copay; rather, simple care and concern.
However, let us make no mistakes about it, the environment in which we now live is ideologically charged. This unfortunately makes it difficult for those who see PRCs as on the “other side of the ideological divide” as anything but bad. It is thus very unfortunate that so much misinformation has been propagated about PRCs. Groups such as the American College of Obstetricians and Gynecologists (ACOG) blithely malign all PRCs with blanket statements that are, from my experience and the experience of those who work with PRCs, false and unsubstantiated. Unfortunately, well-meaning physicians then repeat this information and as we all know: if something is repeated enough
times it becomes “true”. Even in our own journal, there was recently an article that restated many of the negative statements about PRCs in general.
There was a time when an obstetrician tried to convince his fellow obstetricians to wash their hands because it would help prevent post-partum fever. He was ridiculed by the establishment of that time. But now we all know that he was right even though at that time ACOG would have ridiculed him. With regards to PRCs in Massachusetts, I recommend you look at the facts rather than at an ideologically driven position paper or article that is not derived from actual evidence. Those of us physicians in Massachusetts who work with PRCs know their value and that is why we give our time (also uncompensated) to support them. We are, after all, the “boots on the ground”. The evidence is before us. We did not get it from a boardroom in a fancy office building.
Another very valuable (albeit controversial due to the ideological divide) service some PRCs provide is help in reversing the effects of mifepristone when a woman regrets having taken it. I personally have been involved with a good number of these cases and the mothers are delighted to have their baby after all when the reversal is
successful. The PRC is invaluable with respect to being able to quickly do an ultrasound to confirm pregnancy location and help the patient through getting started on the medication and getting regular follow-ups. I have never seen a significant side effect from such treatment. In summary: PRCs are a valuable and very cost-effective resource in our Commonwealth. Far from being a public health threat, PRCs provide a compassionate, cost-free, clinically sound environment for pregnancy discussion and support. Let us celebrate their existence and not try to exterminate them simply because their faith-filled staff and supporters do not align with certain political agendas. They are present to help women (of all faiths, creeds, colors, races, economic statuses, etc.) in need and they will continue to do so. We need to be aware of them and should be willing to work with them for the good of our people. +
John L. Worden, IV, MD Family Practice Gardner, MA
We at Worcester Medicine uphold freedom of expression. Individual opinions expressed in this magazine do not reflect the collective stance of the WDMS or its Editorial Board.
ABullet
Prem Patel
small spherical object enters your body; immediately it is a death sentence. Whether the death is imminent or prolonged, it is almost certain. Such is the nature of a bullet. In India, the word for a bullet is “goli”. A multifaceted word, it not only represents the idea of a bullet but also of a pill. Yet, the definition of “goli” in the context of medicine is somehow more damning than that of a bullet. How can that be possible?
Although society has experienced significant scientific progress in the treatment of diseases, we have not witnessed the same advancement in understanding the perceptions of disease and medical interventions for different types of people. Charles Darwin was key to revolutionizing this understanding when he first proposed his theory of evolution by natural selection in 1859. With a radical break from conservative scientific thought, Darwin contended that the organisms that have the best ability to pass on genetic material will do so, allowing for the propagation of that genetic material. While less widely known but equally as important, Darwin was also the first to propose the idea of sexual selection which posits that mates prefer specific traits causing those traits to be passed on from generation to generation. How does disease fit into these evolutionary schemas? In terms of natural selection, disease can reduce an organism’s fitness to survive, mate, and pass on genes. In terms of sexual selection, an organism may seek a mate who displays a healthy phenotype and may have an aversion towards an organism that displays a diseased phenotype to promote the likelihood that their progeny does not inherit the same diseasecausing genes. While all of this may not be in our conscious awareness in daily life, evolution’s subtle hand certainly guides our behavior.
The implications of a diseased phenotype or perception of a diseased phenotype have externalities that extend far beyond the self. This holds especially true in rural South Asia. In Eastern cultures, the idea of self is eclipsed by the idea of family. Osyerman et al show the differences in individualism between regions, with East Asia, Africa, and the Middle East scoring low on individualism scores and English-speaking countries like the United States and Canada scoring high on individualism scores [1]. In measures of collectivism, the opposite held true: English-speaking countries, especially the United States,
scored low on collectivism while regions like East Asia, Africa, and the Middle East scored higher on collectivism. In many regions, Eastern conceptions of collectivism take the form of the family unit and can be traced back decades. Evident in recent history, many young Japanese men fighting during World War II sacrificed their lives to become ‘kamikaze pilots’ to bring honor to their family name. For them, losing the war or giving up was not an option as it meant bringing shame to their family [2]. In these collectivist regions, it is often that wins and losses are attributed to the family more so than the individual. Similarly, in rural South Asian communities, the mark of disease often damages the family image beyond just the individual. Since genes are inherited from parents and passed on to offspring, a single diseased phenotype colors the entire familial water.
This unconscious evolutionary tilt away from disease deeply pervades life. It is even ingrained into the language exemplified by the double entendre of “goli”. The SapirWhorf hypothesis of linguistic relativity describes how language can prime our thoughts and experiences of life. It is evident that the word “goli” is surrounded by a connotation of danger and harm, whether it refers to a bullet or a pill. In Southeastern Asian societies and Middle Eastern societies where arranged marriages may be more common, the aversion to disease and the appropriate medical intervention is also present in marital situations. Rather than a union between two people, marriage is believed to be a union between two families. Although it may not be recognized, ideas of sexual selection come into play here. Oftentimes even having a grandparent who is ill or even shows signs of illness can prove worrisome for the fitness of a potential spouse or suitor. Hence there is a culture of keeping details of one’s health within the bounds of the family. In general, the perception of disease is different. In these societies, disease implies a fundamental flaw in people as evolution may intimate. This is especially
Healthcare Advocacy
Bullet Continued
true in regions and cultures that champion ideas of karma and reincarnation. Karma is the concept that actions lead to consequences, namely good actions lead to good consequences and bad actions lead to bad consequences. If your actions are the sole catalyst of your fate, then you get everything you deserve. Even if you were born with a congenital defect, it can be explained by the karma accrued from your previous life, giving you personal culpability for your own disease. Therefore, the disease is not only seen as a diagnosis, but it is a condemnation that you are broken and, in some way, deserve to be. The entanglement of disease to life and self-worth creates tremendous pressure to reject modern medicine and reject the notion that your disease defines you.
The disdain for illness is paralleled by the disdain for subsequent medical intervention. A 2017 study by Nyblade et al interviewed 147 residents of Karnataka, India regarding cancer diagnoses and found that cancer stigma was prevalent due to the beliefs that cancer was contagious, people were responsible for their cancer, and that cancer was a terminal and debilitating illness [3]. While stigma may exist, it is also important to understand the implications of this stigma and how it ties into healthcare-related decision-making. When looking at the location of deaths, countries in the Eastern Hemisphere like Pakistan and India have a significantly higher percentage of home deaths when compared with countries in the Western Hemisphere even when controlled for socioeconomic status. The study also mentions the cultural preferences these countries have for home deaths over inpatient deaths [4].
As far as modern medicine has come with fancy technologies and therapies, we still overestimate our ability to naturally overcome biologically hardwired biases and perceptions against disease. With end-of-life care becoming more complicated and treatments increasingly requiring social support and competency, we need to re-evaluate how the disease is viewed by different groups of people and how this may affect the treatment paradigm. +
Prem Patel
University of Massachusetts Chan Medical School Class of 2027
Email: prem.patel8@umassmed.edu
The Scholarship Fund Worcester District Medical Society Giving Back to the Community
The Scholarship Fund began with $14,000, monies unexpectedly realized when WDMS organized and led a massive poliomyelitis immunization program in 1963.
The charge for the live oral polio vaccine was 25 cents per dose. Thousands of people came to clinics held on Sundays in the schools and manned by WDMS physicians and the Alliance.
Since the program was not intended for profit, the Society returned the money to the community by establishing a Scholarship Fund.
Now more than ever, our medical students face overwhelming debt burdens, with median educational debt exceeding $206,000, but as much as $350,000 form some students.
Please consider supporting the future generation of physicians, by making a donation today, simply by clicking or tapping the donate button below:
Heartfelt thanks to the Scholarship Committee and all who have contributed to the Scholarship Fund.
