New Developments in Worcester and Biotech
Massachusetts College of Pharmacy and Health Sciences-Worcester: The First
Healing on the Horizon: Why a Healthy Biomedical
Industry Keeps Us All Healthier
Never A Better Time to Get
Involved with Oral Health
As I See It
Hidden Disparities in Mental Health Care for Medical Students: A Local
Financial Advice for Physicians
This issue of Worcester Medicine is
Editor of Worcester Medicine (1973 -
John was a renowned clinician, devoted scholar, persuasive patient advocate, gifted teacher and mentor and supportive colleague. He will be missed by the entire Worcester community whom he served with unceasing dedication.
The focus of this issue is on Worcester medicine ~ what is going on inside our community ~ with articles on nursing, education and the biotech worlds. I’ll start with a very interesting article by Paulette Seymour-Route on nursing’s perspective on their future involvement in healthcare delivery including professional nurses, nurse practitioners and advance practice nursing (APN).The article includes some excellent web references worth looking up.
Moving to the educational front is Michael Malloy’s article on the College of Pharmacy expansion since its opening in September 2000. I doubt that many of us realize how far they have come and how many different programs they offer, especially at the graduate level. For example, in recent years they have added programs on physician assistants and physical therapy. Although not theme articles, for two interesting articles on education look at Ruthann Rizzi’s article on mental healthcare in medical students and Jeroan Allison and Suzanne Cashman’s article on a new paradigm in medical education.
On the biotech frontier are Kevin O’Sullivan’s views on why the biotech industry keeps us healthy. It’s a good discussion on the risks and rewards facing the industry and the uncertainty they face under healthcare reform. He also demonstrates the size of the industry in Worcester and Central Massachusetts. Finally, we wanted to profile one Worcester biotech firm to give a more personal view of this very complex world. Herbert Dean does just that with his article on Verax, a platelet-testing biotech company.
Finally, I want to acknowledge that the Editorial Board is dedicating this issue to John Massarelli, a former editor of Worcester Medicine, book review editor, historian, and all-around role model within the medical society.
Nursing Perspective on the Future Delivery of Health Care
National health expenditures in 2010 are estimated at $2.6 trillion (or 17.5%) of the Gross Domestic Product (GDP). Over the next few years, about 32 million additional people will enroll in the ranks of the insured (Sisko, Truffer, Keehan, Poisal, Clemens & Madison, 2010).1 Those staggering numbers create a tremendous sense of urgency to prepare an adequate workforce of expert health care providers, including physicians, nurses, pharmacists and others who together deliver high quality care. Creating that workforce also implies changes in areas such as regulation and reimbursement to allow providers to practice within their full scope of practice in order to meet the health needs of the nation’s population.
Nursing, like other health professions, exists because there is a social need for our professional services. So the opportunities for professional and advanced practice nursing brought forth by the Healthcare Reform Act (also known as the Patient Protection and Affordable Care Act 2010) start with the individuals needing the health care services nursing can provide. As the largest group of care providers, nurses in the professional (RN) or advanced practice (APN, or “Nurse Practitioner”) role see people across the entire continuum of care. This creates a challenge as we try to get our arms around all the possible implications of healthcare reform for nurses. There’s no question that professional nurses (RNs) will continue to play a critical role in the current acute and chronic care settings and use their expertise in care coordination, care transitions and home care.
Nursing’s Collaborative Consensus
Nursing academic and practice leaders are creating the future for nursing within and across their traditional boundaries locally, nationally, and in partnership with other health professionals. The nursing community, represented by multiple national nursing organizations, has developed the paper “Commitment to Quality Healthcare Reform: A Consensus Statement from the Nursing Community,” which addresses the contributions that nursing can make towards opening access to cost effective, quality care for all who need it. The ability of nursing professionals to practice within their full scope under state law is discussed. Additionally, the paper addresses our ability to educate and retain the appropriate number of professional and advanced practice nurses and recognizes the nursing faculty shortage as an obstacle to maintaining an adequate pool of qualified nurses. www.nursingworld.org/MainMenuCategories/ANAPoliticalPower/Nursing-Community-Statement.aspx.
Reform~ Nurse Managed Clinics and Patient-Centered Medical Homes
The role of the APN has been discussed, debated, and evaluated by many groups over time. The APNs’ ability to provide safe, quality patient care is well documented. The Healthcare Reform Act provides for expanding the number of [APN] Nurse Managed-Clinics and adds the new model of a Physician or Nurse Practitioner led patient-centered medical home. Many other opportunities exist across the continuum of care for APNs independently, or in healthcare teams, to provide primary care and prevention services. The UMass Medical School Center for Health Law and Economics website provides a resource for greater detail on these and other aspects of the healthcare reform legislation: http://www.umassmed.edu/CHLE
Inter-professional Education of Providers
As the dean of a graduate school of nursing, I believe inter-professional educational models that
address curriculum reform, lifelong learning, and teamwork and communication in clinical practice are key to our ability to transform the way we promote health, prevent disease, and care for the acute and chronically ill. The Josiah Macy Jr. Foundation convened an inter-professional conference titled “Who Will Provide Primary Care and How Will They Be Trained,” co-chaired by Linda Cronenwett, PhD, RN, FAAN and Victor J. Dzau, MD. The proceedings provided a series of recommendations that will support our ability to provide access to contemporary primary care services. The findings discuss education, scope of practice, issues and opportunities within and across three groups of primary care providers: physicians, nurse practitioners, and physician assistants. The report provides a thoughtful review of how we got here and where we need to go. The report can be found at www.josiahmacyfoundation.org/index.php?section=publications.
Whether you are implementing delivery system changes in acute care, opening primary and preventive care access for medically underserved populations, improving care coordination and chronic care management, or improving safety, there is a role for nursing. Equally important to recognize is that success is dependent on cooperation and collaboration across all the health care professions. No single group alone can accomplish the changes needed.. The challenge is to open communication, support innovation and remain focused on the people we serve across all settings. As a coalition of the willing, we can collectively meet our professional responsibilities.
Paulette Seymour-Route PhD, RN is Dean and Professor of the Graduate School of Nursing University of Massachusetts Medical School.
The Massachusetts College of Pharmacy and Health Sciences-Worcester: The
First Ten Years
On September 18, 2000, the Massachusetts College of Pharmacy and Health Sciences opened the doors to the inaugural class of the Accelerated Doctor of Pharmacy Program. The program was housed in a single building located at 19 Foster Street in Worcester. The newly renovated building contained state of the art classrooms, laboratories, and office space. If you fast forward to the present, the Massachusetts College of Pharmacy and Health Sciences –Worcester consists of seven buildings, five degree programs, a distance education program in Manchester, New Hampshire, over one hundred employees and over 700 students. The following narrative will provide a detailed description of the development and growth of the Massachusetts College of Pharmacy and Health Sciences –Worcester.
In response to the national shortage of pharmacists, President Charles F. Monahan Jr. and the Board of Trustees of the Massachusetts College of Pharmacy and Health Sciences funded the opening of a School of Pharmacy which housed an Accelerated Doctor of Pharmacy Program in Worcester. The inaugural class, which consisted of 126 students, was seated September 2000. The program was designed to provide a typical four year Doctor of Pharmacy degree in two years and 10 months. Presently, the Doctor of Pharmacy Program enrolls 225 students per class with plans to Increase to a class size of 250 students for fall 2011. This will bring the total number of pharmacy students matriculating on the Worcester campus to 750 by the year 2013.
Beginning in the fall of 2010, the School of Pharmacy enrolled its first group of graduate students (three) and offered graduate degrees in Pharmacology and Pharmaceutical Sciences through the Boston School of Pharmacy Graduate Program. The graduate program will complement the School’s burgeoning Postgraduate Training Program that was started in 2004. This program began with one Fellow placed with Genzyme Pharmaceuticals and now has grown to 16 Fellows from 6 different companies including Genzyme, Biogen Idec, Cubist, Novartis and Clinical Pharmacology Study Group. The postgraduate fellowship program is the second largest pharmaceutical industrial fellowship program in the United States and offers graduating pharmacy students from across the nation the opportunity to train with some of the best pharmaceutical companies in the country. The Post Graduate Training Program also includes two residents participating in a Community Practice residency sponsored by our partner Walgreens.
In January of 2005, the College enrolled its first class of 44 students into the Accelerated Bachelors of Science in Nursing Program in response to the national nursing shortage and to meet the ever-changing needs of our health care system. The first class graduated 28 students, all of whom found positions within the profession. Currently there are 62 students enrolled in the program, which continues to grow annually. The projected enrollment for January of 2011 is 65 students. Also, in September of2010, the School of Nursing enrolled 8 students in a Masters of Nursing program which was designed to provide working nurses an opportunity to obtain their Masters and improve their employment options. The program is hoping to attract approximately 10 new students each year. These programs are housed in the state of the art Borysek Living and Learning Center at 25 Foster Street.
A couple of years later in January, 2008, the College enrolled the inaugural class in the Master of Physician Assistant Studies Program on the Worcester campus in the Borysek Living and Learning Center.. The School of Physician Assistant Studies in Worcester offers an accredited program dedicated to the education of clinically competent medical professionals thoroughly prepared to deliver quality patient care in the context of a dynamic health care delivery system. The program was instituted to help meet the growing primary care demands on the health care system both regionally and nationally. It complements the existing programs on the Worcester campus and fills an educational void in Central Massachusetts. The initial class consisted of 24 students from all around the country. All graduates in the program have found employment upon graduation. The size of the class has grown, with 50 students expected to matriculate in January, 2011.
The newest degree program scheduled to join the Worcester campus is the Doctor of Physical Therapy program, which will be located at 10 Lincoln Square. This program will welcome its initial class of approximately 25 students in January, 2011 with an anticipated graduation in May, 2015. The graduates from the program will help meet the regional and national shortage of physiciansl. It is expected that the Physical Therapy program will also bring an increased opportunity for additional inter-professional collaboration amongst the disciplines on our campus.
In addition to our degree programs, the Massachusetts College of Pharmacy and Health Sciences- Worcester also houses the Massachusetts College of Pharmacy and Health Sciences Outreach Program in the Borysek Living and Learning Center.. The goal of the Massachusetts College of Pharmacy and Health Sciences Pharmacy Outreach Program is to ensure that patients can get the medications they need and are compliant and adherent to their therapy. By calling a toll-free help line, patients can receive personal assistance with accessing affordable prescription drug programs. They can also receive general information about medications and their side effects. This program was established in July, 2001 as the MCPHS MassMedline program through federal and state grants and appropriations. It was designed to service patients in Central Massachusetts as well as patients throughout the entire state. From the start, the program was very well received; it has serviced over 42,000 patients and logged over 149,000 patient calls since its inception.
Massachusetts College of Pharmacy and Health Sciences- Worcester will continue to be the leader in developing new health-related degree programs in the future. The new programs that are selected will complement and enhance the existing programs at the Worcester campus while meeting the health care needs of the city, region, state and the nation. Also, we will continue to work in concert with the numerous hospitals, pharmacies, health care educational institutions and other health care related facilities in Worcester and the state, region and nation to enhance the delivery of health care to all patients. It is our desire to become one of the leaders in Health Care Education and to provide graduates who will be leaders in the delivery of health care for the 21st century and beyond.
Healing on the Horizon: Why a Healthy
Biomedical Industry Keeps us all Healthier
Biotechnology is an outgrowth of an industry that arguably can be described as one of the Worcester area’s most highly visible economic assets. This biomedical field has helped modernize the area's profile as a very attractive place for science related business and health care professional growth. Contributing collaborative partners include the UMass Medical School, UMass Memorial Health Care, St. Vincent Hospital, Cummings School of Veterinary Medicine at Tufts University, the Fallon Clinic, Fallon Community Health Plan, Mass College of Pharmacy and Health Sciences, Worcester Polytechnic Institute (WPI), and all of our other great institutions of higher learning here ~ along with the Massachusetts Biomedical Initiatives (MBI).
Today, researchers in Worcester and throughout Massachusetts are pursuing the next blockbuster medical breakthrough ~ perhaps a drug to prevent heart disease, or cure Parkinson’s, or eradicate cancer. Given our vast array of leading health care, academic and science resources, the Worcester area will continue to capture new technology and move it into the market place using this unified “teamwork” approach.
An example of this success is the Massachusetts Biotechnology Research Park, home to approximately 20 companies and health care related institutions with over 2,000 combined jobs, filling 1 million square feet, with an investment of over $300 million, generating close to $3 million dollars in tax revenue to the City of Worcester alone.
The entire biomedical industry in Central Mass has grown to over 100 companies with 7,500 employees generating yearly revenue of approximately $1billion
And because biotechnology is such a high risk but vital endeavor, we need to ensure that any political plan to reform health care does not undercut the ability of these researchers to discover cutting-edge cures. With everyone increasingly concerned about the cost of comprehensive healthcare reform ~ estimates are that it will cost over $1 trillion over the next decade~ we need to continue to collectively work together in order to provide not only coverage to the uninsured, but to bring about the needed reforms within the existing system as well.
Already, biotech companies spend nearly $1.2 billion, and, on average, close to ten years researching, developing, and bringing to market a typical biologic ~ a complex drug created not from chemicals, but from living organisms. More than 600 such medicines are currently in the development pipeline, despite the dismal odds against success. We need to do better, however, because currently drug discovery takes too long and costs too much.
Nine out of ten drugs fail before reaching clinical trials, and of those making it to clinical trials, more than two thirds fail to win FDA approval. Two-thirds of FDA-approved biologics still won’t generate sufficient revenue to cover the cost of their development.
Despite these facts, more than 127,000 biotech employees keep at it here in Worcester and throughout Massachusetts, which has also long been a hub of biopharmaceutical success. They remain determined to discover the next medical advance, exactly like what is happening with the Biotech Park’s Abbott Bioresearch Center’s development of the drug Humira for rheumatoid arthritis ~ as that is just one specific example.
Expensive to discover and develop, drugs are relatively pricey and they cost insurers and Medicare a lot of money. Pharmaceutical companies and venture capitalists continue sinking money into the often-elusive search for a biologic wonder drug. In fact, most of the major pharmaceutical companies have located here within Massachusetts over the last decade in order to partner up with our innovation and education economy and find collaborations and contract research organizations in order to speed up their drugs to market and reduce the high cost of research and development and delivery to the patient.
Patients rely on drug discovery ingenuity. At any given moment, a Bay State biotech firm could be months or weeks away from a lifesaving finding that could save thousands of lives and billions of dollars. A Lewin Group study, for example, concluded that within five years of a biologic breakthrough for say, Alzheimer’s, annual Medicare spending could decline by as much as $50 billion. We are hopeful that breakthroughs will come from the robust biotech and health care industry right here.
Worcester and Central Massachusetts relies on education, healthcare and the life sciences. Let’s make sure we continue to support these vital regional strengths as our future well-being depends on quality health care along with biomedical company and job formation opportunities, all fueled by education, innovation, and research and development collaboration.
All of these combined strengths certainly benefit us all.
Kevin O’Sullivan is President & CEO of Massachusetts Biomedical Initiatives, Inc. (MBI), an economic development organization which promotes the growth of the biotechnology, medical device, and informatics industry, and as such, operates 3 life science business incubator facilities in Worcester.
Verax was founded in 1999. It is a diagnostic company involved in blood safety testing, and specifically with the development of a rapid, reliable (high degree of sensitivity and specificity) and inexpensive method for the identification of bacterially contaminated platelet units. The company is located at 4 Biotech Park, Worcester, and currently employs 17 people.
I have been associated with Verax since its beginning, first as an angel investor (an individual investor as opposed to other funding sources such as venture capital, or other debt issuances such as bank loans), later as a member of the Board of Directors, and I still carry the title of Medical Director.
The company has secured the key patents for its technology and in late 2009 received its second 510(k) approval from the FDA for the use of its immunoassay test, Platelet PGD, for the detection of aerobic and anaerobic gram-positive and gram-negative bacteria in whole-blood derived platelets. Verax had previously received a 510(k) for use on apheresis single donor platelets.
Some information regarding the collection and storage of platelets is appropriate for readers to understand the role the Verax test plays in improving and enhancing the safety of platelets in transfusion medicine and clinical practice.
Platelets retain their functional capacity for up to 7 days and require storage at room temperature, as opposed to red blood cells, which must be stored under refrigeration. After day 5, approximately 1 in 2,000 platelet units exhibit serious levels of bacterial contamination, mostly gram positive organisms but in about 10 - 15% of the cases, gram negative bacteria are found. The American Association of Blood Banks recommends platelets not be transfused after 5 days of storage and this requirement is mandated by the FDA.
Platelets are collected in two ways: whole blood derived platelets are collected from a single donor with the unit of blood separated into a unit of red blood cells, a unit of platelets, and plasma. In order to achieve a sufficient increase in the platelet count for transfusion, usually 5 to 6 units of platelets from a corresponding number of donors are pooled together into a platelet unit for administration to a patient; with apheresis-collected platelets the entire dose comes from a single donor. During apheresis collection, blood is passed through a cell separator that permits the re-infusion back to of the donor of red blood cells and plasma while at the same time collecting the equivalent of multiple units of platelets.
The majority of platelets used in the U.S. are derived from apheresis collected platelets. Blood centers that collect apheresis platelets hold the units for 24 hours and then take a bacteria culture. The units are usually held for another 24 hours before being released to hospitals and transfusion centers. Unfortunately, repeated studies have shown that more than 70 % of cultures performed 24 hours after the time of collection fail to detect the presence of bacteria prior to their administration due to several factors. These factors include too few organisms at the time of collection and culture to be reliably sampled, unique growth characteristics of some bacteria that limit growth during the first 24 to 48 hours, and the presence of plasma derived anti-bacterial factors that may be present in some of the retained plasma.
The Verax test is performed when a hospital blood bank or transfusion laboratory is called upon to provide platelets, usually day 3, 4 or 5, and at these times, bacteria have had an opportunity for exponential growth, and the Verax test is able to now detect the presence of bacteria that culture was previously unable to detect.
Some in the medical community hope that once the Verax test is adopted across the entire platelet inventory, the ability to test for bacterial contamination may enable the extension of the shelf life of platelets up to 7 days since any contaminated platelet units can be discarded if the test identifies presence of bacteria.
The Verax Platelet PDG test is an immunoassay and consist of a disposable plastic cartridge that contains a strip coated on either end with a pan-generic antibody for Gram-positive and Gram-negative organisms that is able to detect antigens on the cell surface of bacteria, a central sample well, and appropriate controls. (See diagram.)
The company is currently conducting post-market surveillance studies with apheresis platelets to demonstrate the ability of the Platelet PDG test to detect bacteria previously missed by culture methods and expects to submit data supporting the effectiveness of the test to the FDA in the near future.
Currently, since approval by the FDA, over 40 transfusion centers and hospital blood banks are now utilizing the Verax test to enhance blood safety. Other institutions are conducting validation studies and training personnel and are expected to employ the technology in the coming months. The company has developed a close relationship with Fenwal Inc., and Fenwal is marketing the product both in the U.S. and overseas.
The company plans to explore the application of this technology for detection of bacterial contamination of red blood cells (estimated to occur in 1/50,000 units) and for ensuring the safety of stem cells and tissues and organs used in transplantation.
In conclusion, my experience and involvement with Verax has provided me with an education (Business 101) in employing technology for clinical applications, the multiple steps needed for product development, difficulties associated with financing, various legal issues and time extended with due diligence processes, dealing with regulatory agencies, developing relationships for marketing and distribution, and the frustration of changing the mind set of decision makers within the medical community even when quality and safety improvement is demonstrated.
Herbert M. Dean, MD, FACP is a retired Fallon Clinic physician, an oncology consultant for Unum and MassPro, and the Medical Director of Verax.
Corner: Pandemic Influenza
The 20th century experienced three influenza epidemics that moved beyond initial outbreak zones to gain massive, worldwide footholds, thus termed pandemics ~ in 1918, 1957, and 1968. The so-called Spanish Flu of 1918-19 infected one-fifth of the world’s population and one-fourth of the people in the U. S., resulting in 50 million deaths globally and one million deaths in the United States. The mortality rate was 2.5%, 25-fold higher than the usual 0.1% mortality experienced in previous influenza pandemics. Adding to the horror of the outbreak was its surprising demographic profile ~ most deaths occurred in healthy young adults, whereas influenza typically proves fatal in infants, the elderly, and the infirm.
During the Spanish Influenza pandemic, Dr. Isaac Starr, a medical student at the University of Pennsylvania, was pressed into service as a hospital nurse. Sixty years later, he described the scene at UPenn Hospital: “On admission the patients had fever but little else … Soon they became short of breath and cyanotic … After gasping for breath for hours they became delirious, and many died struggling to clear their airways of blood-tinged froth that gushed from nose and mouth … It was dreadful business … The deaths in the hospital exceeded 25% nightly during the peak of the epidemic … To make room for new patients, bodies of the dead were tossed from the cellar into trucks which, when filled, carted them away … The life of the city had almost stopped … public assembly was forbidden - there were no plays, movies, concerts, or church services, and schools were closed.
Seasonal epidemics of influenza occur annually worldwide, lasting only weeks. Every several decades a mutated virus arises that is unique antigenically. Since few in the population have protective immunity against such a novel flu strain, it is able to escape herd immunity and produce extremely high rates of infection globally, generating a pandemic. In the 20th century, the Spanish Flu of 1918-1919 caused 50 million deaths worldwide, the Asian Flu of 1957-1958 two million deaths, and the Hong Kong Flu of 1968-1969 one million deaths.
Severe complications of influenza take three forms: 1) rapid decompensation in patients with chronic heart and lung diseases, 2) less often, superinfecting bacterial pneumonia, due to respiratory tract bacteria, such as Streptococcus pneumoniae and Staphylococcus aureus, and, 3) least often, primary viral pneumonia. Ordinarily the mortality rate associated with seasonal influenza outbreaks is low ~ about 0.1%. Most deaths occur in high-risk populations ~ the very young, the elderly, and individuals with severe chronic medical conditions such as heart and lung disease.
The secret to the success of this virus lies in its evolutionary ability to change its surface appearance and escape immune defenses. The virus has two key chemical signatures on its surface ~ neuraminidase (N) and hemagglutinin (H), two antigenic proteins against which the infected individual develops long-lasting protective immunity. Intramolecular rearrangements of the H antigen (16 varieties; only H1, 2 & 3 occur commonly in humans) and N antigen (9 varieties; only N1 & 2 in humans) create new variants of the virus which, to some degree, appear to humans as new viruses. Influenza viruses are able to infect and circulate among swine and fowl, both wild and domestic, as well as among humans. In doing so, the virus exchanges and recombines genes from all three species, periodically creating a radically new virus, unrecognized immunologically by most of the human population, and possibly with novel virulence properties, thereby creating the opportunity for a worldwide pandemic. The 1918 Spanish Flu was termed H1N1, the 1957 Asian Flu was H2N2, and the 1968 Hong Kong Flu was H3N2, designations based on the particular versions of the two surface antigens carried on the viruses.
In the spring of last year, we experienced the appearance of a new H1N1 Swine Flu, initially in Mexico, with rapid spread around the globe. Because this novel H1N1 variant resembled the H1N1 virus that caused the horrific Spanish Flu pandemic, and because an H1N1 virus had not circulated among humans in ninety years, public health authorities in the U. S. justifiably were alarmed that it could lead to a global pandemic, possibly of high virulence. After the first cases were reported in the spring of 2009, mobilization of resources occurred in the United States. Public health measures were instituted, including: 1) broad surveillance to detect cases, 2) closing of schools experiencing outbreaks, 3) public education to encourage individuals with influenza-like illness to remain home, 4) use of anti-viral drugs, which can attenuate the course of the infection and shorten the period of viral shedding, and 5) accelerated production of an H1N1 flu vaccine, with an aggressive public health program to promote immunization.
Fortunately, the 2009 Swine Flu pandemic proved less virulent than predicted. Western countries experienced attack rates of about 10%, far lower than anticipated. Mortality rates were only 0.03% in the United States, somewhat lower than during seasonal flu outbreaks, and 80-fold lower than during The Spanish Flu. The benignity of the 2009 Swine Flu was due not to public health interventions, such as the immunization campaign, which did not achieve full mobilization until after the epidemic had peaked in late October 2009 and ended in late November, with only 61 million people (20% of the population) immunized. Many European countries did not launch large-scale immunization programs, yet also were spared major outbreaks. Rather than public health interventions, the primary factors that averted a severe global pandemic were viral ~ the 2009 H1N1 pandemic strain turned out to lack genetic mutations required for enhanced pathogenicity and virulence, a fortuity that could not have been assumed at the start of the outbreak.
Three decades earlier, in 1976, after a few severe cases of fatal swine influenza (HswN1) were detected at Fort Dix, New Jersey, an ill-conceived crusade against a predicted flu pandemic was launched in the U.S. Fearing a virulent pandemic like the Spanish Flu, the Ford administration began a nationwide immunization program; 43 million people, 20% of the population, received the vaccine. Unrelated to this program, the outbreak fizzled quickly and failed to spread beyond the Fort Dix military installation. However, in subsequent months, there was a dramatic increase in the incidence of Guillain-Barré Syndrome, likely caused by hypersensitivity reaction to the HswN1 flu vaccine. For years this debacle chilled enthusiasm for annual flu immunization programs.
In 2009 the world dodged a bullet, due primarily to the unexpected tameness of the new Swine Influenza virus, not because of the power of public health measures or the power of modern medicine. However, if this novel 2009 H1N1 Swine Influenza virus, during its likely ongoing traffic among swine, fowl, and humans, acquires mutations that enhance its virulence, we could experience another deadly outbreak. On the other hand, mortality rates in future pandemics are unlikely to approach those of the Spanish Flu, due to modern advances in medicine such as high-tech ICU care and antibiotics for treatment of secondary bacterial pneumonia. Although the seasonal genetic scrambling of influenza viruses cannot be predicted or averted, we can learn from past pandemics and take some comfort in the extraordinary advances in critical care and infectious disease practices as domains of medical science ever more equipped to manage the influenza patient.
Richard H. Glew, MD, is Professor of Medicine and Molecular Genetics & Microbiology and Vice Chair of Medicine for Undergraduate Medical Education & Faculty Affairs at University of Massachusetts Medical School.
Never a Better Time to Get Involved with
There is a lot going on in dental/oral health in Massachusetts right now, and we need medical professionals to play a more active role in addressing oral health as part of addressing overall health. 1 in 20 children in our state has oral pain in elementary schools; stronger links are being found between periodontal disease and heart disease, diabetes and rheumatoid arthritis. Get involved and do your part for your patients’ overall health!
How You Can Get Involved
First, you can apply fluoride varnish in your office if you are in pediatrics or family medicine. MassHealth reimburses medical providers $26 to apply fluoride varnish to pediatric patients from age 6 months to 21 years. The varnish costs $1. If you apply varnish to 5 children a day, 5 days a week, for 50 weeks a year – that is $31,250 of revenue! And you are doing the right thing by reducing caries in children by 38%. As of October 1st, your Medical Assistant (MA) (in addition to nursing staff) can apply the varnish too. For more information, please contact me at 508-334-8846 or visit www.mass.gov and search for “fluoride varnish.”
Secondly, The Society of Teachers of Family Medicine and the American Academy of Family Physicians recently released the third edition of the award-winning “Smiles for Life: A National Oral Health Curriculum.” You can use this to educate yourself, your staff, or other learners with whom you work, The edition includes interactive online courses and clinical cases, downloadable PowerPoint modules, instructional videos, and patient education materials.
“Smiles for Life” is the nation’s most comprehensive and widely used oral health curriculum designed for primary care clinicians. The 7 modules cover the relationship of oral to systemic health, childhood oral health, adult oral health, dental emergencies, oral health in pregnancy, fluoride varnish, and the oral examination. Curricular components of the first two editions of “Smiles for Life” haa been downloaded over 100,000 times. Visit www.smilesforlifeoralhealth.org to explore and take CME courses today.
Lastly, on July 1st, 2010, MassHealth dental benefits for adults ~ including restorative services (fillings, root canals, crowns,), dentures, and periodontic treatment ~ were cut. Emergency and preventive treatment for adults (such as X-rays, cleanings, and extractions) is still covered. Fortunately, there was no change to services for those under the age of 21.
If your MassHealth patients are having difficulty finding dental coverage, they can look for resources through the Health Safety Net by calling the MassHealth Dental Customer Service Center (1-800-207-5019). You can also visit http://tinyurl.com/hsndental for a list of community health centers with MassHealth dental services.
If you or your patients are upset about the MassHealth adult dental cut, please contact your State Senator and Representative (617-722-2000) and the Governor (617-725-4005) to let them know how this cut has impacted your patients’ ability to receive treatment and its affect on their overall health.
Hugh Silk, MD, FAAFP, is Associate Professor, University of Massachusetts Medical School, Department of Family Medicine and Community Health.
Determinants of Health: A New Paradigm
for Medical Education
With the Flexner report of 1910, medical education made a paradigm shift to focus on scientific evidence and rigorous curricular standards. Over the past several decades, an emerging body of scientific literature describing the relationship between social and economic conditions with health has been leading medical education to what may be another paradigm shift. This new paradigm teaches medical students to incorporate patients’ life circumstances in their management plans rather than focusing exclusively on biomedical facts. We know that this “new” perspective is already shared by many physicians who have learned from their real-world practice of medicine. However, the schism between real-world practice and medical education in the United States has persisted far longer than our understanding of the contributors to ill health has warranted.
The evidence linking social and economic circumstances to health is overwhelming. The association of better economic status with longer life expectancy is almost linear for both developed and developing countries. Medical care, which often enters the equation only when the patient has presented with advanced disease, is only one determinant of health. For example, economic difficulties limit the opportunity to buy healthful food. Stressful life circumstances increase vulnerability to poor health habits such as smoking and overeating. High crime neighborhoods make it difficult for residents to get adequate exercise by walking. In addition, stress itself contributes to allostatic load, which slowly erodes the immune system and the ability of human physiology to maintain proper function. Poverty, pollution, crime, and poor health are highly clustered by neighborhood. These issues have been thoroughly explored in California Newsreel’s highly acclaimed series, “Unnatural Causes: Is inequality making us sick?” This series aired on public television stations in the spring of 2008.
Recently, our nation has focused on health care reform, particularly on ensuring that citizens have insurance. However, having medical insurance does not guarantee access, nor does it ensure a healthy life. Even as health care reform moves forward, troubling health-care disparities still persist. The Agency for Healthcare Research and Quality publishes an annual report on health disparities; it documents that the quality of care received by patients if often influenced by their race, ethnicity, or economic status. The report also identifies other health disparities such as the excessive number of HIV cases among African Americans and Latinos. Rates of heart disease and stroke are much higher among the African American population, and much of the excessive mortality and morbidity are directly attributable to uncontrolled risk factors such as hypertension and diabetes.
Concurrent with this changing practice environment, the University of Massachusetts Medical School (UMMS) has benefitted from the educational leadership and dedication of our faculty, who have long supported community-based education as a required experience for our medical students. Under the leadership of Senior Associate Dean Michele Pugnaire, MD, a comprehensive five-year process of curriculum redesign was launched with a focus on cutting-edge models and national benchmarks for medical education. Spearheading the curriculum redesign process, Melissa Fischer, MD, MEd, Associate Dean for Undergraduate Medical Education, has brought together the talent and innovative recommendations from a wide and diverse range of faculty, students and graduates to develop new courses and curricular methodologies featured in our Learner-centered Integrated Curriculum (“LInC”).
One of the courses included in this new curriculum entitled “Determinants of Health (DOH)” prepares students to act beyond the isolated perspective of the biomedical model. In this course, we review the pervasive nature of health disparities, explore the powerful health consequences of overall life circumstances, and begin demystifying the health care system. In the course’s initial lecture, Dr. Joseph DiFranza explained how he had moved from clinical observation to focus more on research and then on policy change. Early in his years of practice, Dr. DiFranza observed that many of his adolescent patients became addicted by smoking only a few cigarettes. This inspired his discovery of how adolescents could easily purchase cigarettes in Massachusetts, ultimately leading to changes in federal law. With an aim of further understanding the addiction process, Dr. DiFranza is now conducting functional magnetic resonance imaging studies that demonstrate remarkable changes in brain structure after only a few doses of nicotine.
DOH will continue the Community Health Clerkship, a highly rated, two-week experience dedicated to community health. The clerkship has been a cornerstone of the UMMS educational experience over the past two decades under the leadership of Dr. Mick Godkin. As part of the DOH course, the clerkship will bring together students from the School of Medicine and Graduate School of Nursing for an ”immersion” experience at one of approximately 25 community sites devoted to improving the care of vulnerable populations. In addition, students will acquire new epidemiologic knowledge to characterize their chosen populations. The clerkship also features service learning through which students will carry out action-oriented projects and focus on the role of advocacy in population health improvement.
Judy Savageau, MPH, is leading the Epidemiology/Biostatistics DOH module, through which students learn to understand the medical literature and apply it to their own clinical decisions. Students will work with data from their chosen community clerkship population as well as data from a survey about health behavior administered to their own class. DOH content is also integrated into the more basic biomedical and clinic experiences of the first two years.
As co-leaders of DOH, we are most pleased to be at the forefront of an important paradigm shift in medical education. With the evolving understanding of the multiple determinants of health, we are better able to prepare medical students to face the complex and difficult challenges of the real-world practice of medicine and to act beyond the isolated biomedical perspective to improve health outcomes for patients, families, and communities.
Jeroan. J. Allison, MD, MS is Professor and Vice-Chair, Department of Quantitative Health Sciences, and Associate Vice-Provost for Health Disparities, University of Massachusetts Medical School.
Suzanne Cashman, Sc.D., is Professor and Director of Community Health, Department of Family Medicine and Community Health, University of Massachusetts Medical School.
Hidden Disparities in
Mental Health Care for Medical Students: A Local Perspective
Given their immersion in medical culture, it is difficult to imagine that medical students would have problems with gaining access to mental health care. After all, college/university mental health is a field marked by growing usage rates and the availability of increasingly sophisticated services. A recently published review of this clinical phenomenon, Mental Health Care in the College Community, reflects a growing global awareness of these issues. This awareness is especially important when it comes to mental health care, as many chronic mental health issues begin in young adulthood (or even sooner, as with the anxiety disorders).
Yet medical students differ in a crucial way. Unlike many other students, they are involved, intimately, in the care of patients. The dawning realization that how one appears to colleagues, patients, and society at large carries a heightened level of importance is a burden that must be considered as the medical student settles into the larger medical culture. However, this is a culture with “low priority given to physician mental health…despite evidence of mood disorders and an increased incidence of suicide.”1 Paradoxically, untreated mental illness is more likely to lead to impairment in one’s ability to practice medicine than a properly treated illness. National rates of “probable” depression in medical students hovered at approximately 25% in a six-site survey of over 2000 medical students and residents published in 2009 2; it is likely that the total percentage of medical students with any mental health issue is even higher. Yet the same paper concluded “…students are concerned that treatment for depression could jeopardize their career. Few…utilize services because of issues of stigma, cost, and accessibility, despite previous studies showing the desirability of such programs.” More recent studies have issued a “clear invitation to intervene with depressed and at-risk students, particularly…when suicidal thoughts and the wish to leave medical training may be greatest.” 3
Local experience at the University of Massachusetts Medical School (UMMS) Student Counseling Service (SCS) belies this overall picture. While a range of mental health issues bring students to SCS, the number of students presenting with non-mental health needs is kept very low by the availability of other support services on campus. Yet 44% of the graduating class of medical students (class of 2010) was seen at SCS at some point in their medical school career. This is not an aberration: the percentage of students treated at the UMASS SCS has increased over the past few years, without gross evidence of a greater burden of illness for our particular campus’s medical student population.
Why is the UMMS SCS able to reach such a high proportion of students in need? UMMS and the Department of Psychiatry have made a unique commitment to the mental health and wellness of the students. First, access to care is emphasized: SCS provides care for medical, nursing, and graduate biomedical sciences students in a private suite located centrally on the Worcester campus. Initial visits are offered within 24-48 hours of first contact with rare exception, and students are seen for psychotherapy and/or medication management for as long as clinically needed.
Second, students’ confidentiality is prioritized: SCS clinicians are relieved of any teaching burden, exceeding Liaison Committee on Medical Education (LCME) recommendations for student counseling staff of medical schools. Charts are segregated within SCS, and do not become part of any other medical records. No information about a student is released without the student’s request, save for immediate danger towards self or others.
Finally and importantly, while SCS services are covered by a health fee assessed on all students at the start of each semester, there are no further costs for our services to any students once they walk through the door, relieving them of insurance visit limitations and out-of-pocket visit fees. This is a model paralleled by the Physician Health Services, Inc. (PHS) of the Massachusetts Medical Society, through its own confidential monitoring and referral services. Although not involved in treatment, PHS offers its services free of charge to any physician or medical student (from any Massachusetts medical school) who is seeking help. Their numbers reflect a similar picture of growth at the state level: from 1978-2007, 40 medical students were assisted. In the three years since 2007, PHS has assisted 31 more medical students.4
It is encouraging to see the resulting rates of utilization, as we suspect they are a reflection, at least in part, of services designed to reduce the barriers unique to medical students. This allows us to reach more students with more adequate care, for clinically appropriate lengths of time. As a school-based service, we directly impact and educate the medical school (and the larger medical environment) regarding the most pressing issues concerning the mental health of medical students. We can aggregate data more quickly than loosely-affiliated community providers, empowering our liaison role with the faculty and school administration. We have a greater impact on students while they have the time in their medical career to make good use of treatment.
We hope our model of student care emphasizing access, privacy, and reduced payment burden will continue to evolve and grow and set the stage for a lifetime of attention to the mental health care of our future physicians, and, by extension, the patients they serve.
Ruthann Rizzi, MD is Assistant Professor, Department of Psychiatry and Director, Student Counseling Service, UMass Medical School. She is also a member of the Medical Student Advisory Committee, Clinical Advisory Committee and an Associate Director, Physician Health Services, Inc. (a Massachusetts Medical Society corporation).
Legal Consult: Patient Privacy Versus Physician Punishment
When may the law weigh the privacy interests of
patients against the public interest in regulating physician conduct? A
recent Massachusetts Supreme Judicial Court decision held that the
psychotherapist-patient privilege is not subj
The Massachusetts statute prot
The Court distinguished the Board’s action in seeking
the patient records in a civil a
In the civil context, the Court deferred to the
legislature’s evident balancing of the privilege against competing
Financial Advice for Physicians: Do You Index?
Political pollsters have long known that how a question is “framed” can greatly influence the response. Restaurants understand “framing” too; they offer early-bird or late-night specials; not peak-period surcharges.
Investment products are “framed,” too. With no idea what the future performance might be, the marketing message is designed to appeal to investor behavioral patterns.
Marketing index funds…
The marketing of major market index funds offers good examples of ‘framing.’ Most are sold as core allocations or as opportunities to participate in the markets without the risks associated with individual stock-picking; all send positive messages designed to appeal to investors’ herd instincts.
And why not ~ would investors flock to an S&P 500 Index fund if its marketers told investors, “This index fund will absolutely underperform the S&P 500 and have more risk?”
Of course, the statement is accurate; the fund’s small management fees ensure less-than-index total returns and worse-than-index volatility. If investors are charged additional management fees by financial advisors, the aggregate fees are no longer so small and the underperformance no longer minor.
The herd instinct, to be fair, is not the only reason investors buy index funds: some investors are influenced by the academic notion that passive investing will necessarily outperform active investing ~ in other words, they think they cannot do better.
University of Chicago Professor Eugene Fama fathered this idea; his Efficient Markets Hypothesis suggests that in an efficient market, all pricing anomalies are arbitraged away leaving only stocks that are neither under or over-priced.
Stock market anomalies…
Curiously, Eugene Fama has also unearthed a number of enduring anomalies that, due to overriding behavior influences, do not get arbitraged away and have outperformed the indexes.
The most famous of these is the “value effect;” an observation that stocks with low pricing ratios have done substantially better than those with high ratios ~ and better than the major market indexes, too. Apparently, the “positivity bias” of investors causes them to collectively pay too much for glamorous companies and too little for plodders.Prominent research firm Ned Davis Research has demonstrated another enduring anomaly: over time, dividend-paying stocks have delivered significantly better total returns than non- dividend-payers, and better than the major market indexes as well. Investors’ intense focus on short-term investment
performance apparently causes too-little appreciation of the value of future dividend payments.
Put to the test…
So, which has done better ~ the whole S&P 500 Index or a subsector of the index that owns only the value-priced dividend-paying stocks embedded in the index?The following chart compares the actual performance of the S&P 500 Index to a variation of the index in which all the non-dividend-paying stocks were thrown out each year. A second variation also excludes any dividend-paying stocks with Price/Earnings ratios more than 150% of the average.
Clearly, the value-priced-dividend-paying stocks in the S&P 500 did much better than the Index as a whole. The implication, therefore, is that the high-priced-non-dividend-payers in the Index did quite poorly…which they did. This result does beg the question why investors would want to own stocks with high Price/Earnings ratios that do not pay dividends, or why they would want to own funds that own them, either.
Our firm is often asked to explain the “secret” of our clients’ investment performance and our resulting rapid business growth. “It is quite simple,” we say. “We believe the data.” When we find enduring anomalies in the markets, we try to exploit them; we do not find cause to ignore or excuse them.
Consequently, we do not buy index funds for our clients’ portfolios. Instead, we have steadfastly invested equity allocations in value-priced stocks that not only pay dividends, but have also demonstrated the capacity and propensity to increase their dividends each year, year after year.
If you would like to see a presentation of ThomasPartners composite performance statistics, please visit our website, www.thomaspartnersinc.com, or contact Amos Robinson at email@example.com or 781-431-1430.
PIAM, a subsidiary of the Massachusetts Medical Society, has selected ThomasPartners to be their designated provider of financial planning and investment management services to MMS members at discounted fee arrangements. If you would like additional information, please contact Amos Robinson at firstname.lastname@example.org or at 888-431-1430.
Do you index? is a proprietary publication and the property of ThomasPartners, Inc. Any reproduction or other unauthorized use is strictly prohibited. All information contained in Do you index? was obtained from sources deemed qualified and reliable; however ThomasPartners, Inc. makes no representation or warranty as to the accuracy of the information contained herein. Past performance is no guarantee of future results; investments may lose money.
The Worcester District Medical Society 2010 Scholarship Award Recipients
The Worcester District Medical Society 2010 Nursing Scholarship Award Recipients