When children face death 2 Executive changes 7 PERIODICAL RATE PUBLICATION
FEBRUARY 15, 2022
VOLUME 38, NUMBER 3
CommonSpirit teams with Morehouse to mint more minority clinicians Joint undergraduate/graduate medical education program aims to advance health equity By RENEE STOVSKY
Cameron Martin, 32, a second-year physician assistant student at Morehouse School of Medicine, recently completed a clinical rotation in emergency medicine at CHI Memorial Hospital Chattanooga and called it “an absolutely great experience.” “It was very, very busy and involved an incredibly diverse patient load. I did lots of sutures, repaired lots of lacerations, did lots of assessments for COVID-19 and flu. I saw trauma patients, patients suffering from pulmonary embolisms and deep vein thrombosis, pediatric patients and elderly patients with comorbidities,” says Martin. “It forced me to think on my feet and utilize everything I had learned in school,” he adds. “The staff really mentored me
Cameron Martin, a physician assistant student at Morehouse School of Medicine, is part of the first group of Morehouse students to benefit from the More in Common Alliance. That alliance between CommonSpirit Health and the historically Black medical school is expanding opportunities for minority students pursuing health care careers. Martin did rotations at two of CommonSpirit’s CHI Memorial hospitals in and around Chattanooga, Tennessee.
and made every single moment a teaching moment.” Martin’s rotation was significant for more than just his individual education, however. He was a part of the first group of Morehouse students — both fourth-year medical students and second-year physician assistant students — to benefit from the first phase of the More in Common Alliance, a 10-year, $100 million joint CommonSpirit Health/Morehouse School of Medicine initiative to increase cultural competency and expand minority representation in clinical care to improve both access and the quality of care patients receive. For Martin, that is extremely meaningful. A Clemson University graduate with a degree in microbiology, he was an active duty Army officer involved in reconnaissance operations as well as a platoon leader supporting a team of combat medics before enrolling in physician assistant school. Now a captain in the Army Reserve, he says he was drawn to Morehouse School of Continued on 8
Plea to rethink advance care planning draws praise and criticism Ministry providers approach hospice underuse as health equity issue By LISA EISENHAUER
Continued on 6
By JULIE MINDA Providence Institute for Human Caring
While he says he respectfully disagrees with a bold call from some other prominent physicians in end-of-life care to do away with living wills and advance care planning forms — a plea that has been met with pushback — Dr. Ira Byock concurs that the way the process is widely pracByock ticed is ineffective. “I think the controversy is misplaced and I suspect that if the people debating this were in the same room we’d probably come to substantial if not total agreement,” says Byock, a leading palliative care physician and founder and senior vice president for strategic innovation of the Institute for Human Caring at Providence St. Joseph Health.
While hospice care is a covered service for patients with Medicare and most private insurance, not all people who are eligible enroll. Terminally ill patients who are not accessing this care are disproportionately from minority and other vulnerable
Dr. Colin Scibetta and Chaplain Stephanie Ryu visit the bedside of Josephine Courtney at Providence Little Company of Mary Medical Center in Torrance, California. The conversation included discussion of the goals of Courtney’s care and aspects of her advance directive. The visit took place shortly before her death.
Health ministry urges support for public health sector strained by COVID
Ted S. Warren/Associated Press
By LISA EISENHAUER
Medical assistants at a drive-up COVID-19 testing clinic in Puyallup, Washington, near Seattle, fill a cooler with nose swab samples that will be sent to a lab. People using the testing site on Jan. 4 faced waits of several hours. The site was run by the Pierce County Department of Emergency Management. The resources of public health agencies have been stretched thin by the pandemic and many public health officials have taken the brunt of criticism over the nation’s response to the crisis.
The social teachings the Catholic health ministry is founded on create a special responsibility for Catholic health care providers to partner with and advocate on behalf of the public health sector in the view of Mike Slubowski, president and chief executive of Trinity Health. Slubowski points out that the ministry’s mission Slubowski includes reaching and serving the most vulnerable and improving the health of its communities. “We at Trinity think a strong public health infrastructure is essential to building a health care system that can ensure access to high-quality care for all and to public policies that advocate Continued on 3
Kevin Nyack, a nurse with Calvary Hospital in Bronx, New York, cares for a hospice patient in the Bronx, in 2019. Calvary is a palliative care hospital and hospice provider.
population groups. Ministry members have identified hospice underuse as a health equity concern that they are working to understand and remedy. Despite the availability of insurer reimbursement, “we still have about 50% of those who can benefit from hospice care who aren’t receiving it,” said Ben Marcantonio, chief operating officer of the nonprofit National Hospice and Palliative Care Organization. He said some of the most underserved population groups when it comes to hospice care are African Americans, Latino Americans, Asian Americans, people who are LGBTQ and people who live in rural areas. Continued on 4
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CATHOLIC HEALTH WORLD February 15, 2022
End-of-life decisions for children are especially fraught, ethicist says By LISA EISENHAUER
End-of-life care for a child creates a “special sort of heartbreak and brokenness” for parents and care providers and poses ethical issues that are not present as death nears for most adults, says Erica K. Salter. An associate professor of health care ethics and pediatrics at the Albert Gnaegi Center for Health Salter Care Ethics at Saint Louis University, Salter discussed those ethical issues and her thoughts on them during a webinar Dec. 9 sponsored by CHA in partnership with Georgetown University, Loyola University Chicago and Saint Louis University. One of the unique circumstances in pediatric cases is that young patients are presumed to not have the capacity to make their own decisions, Salter says. Another is that parents generally are presumed to be the best surrogate for those decisions. Parents’ authority to make care decisions for their children, which has been backed up by court decisions, is based on several factors, including their knowledge of their child’s best interests, the fact that they bear responsibility for the child in all other aspects of life and the presumption that they are in the best position to make good decisions for their whole family, she notes. Salter calls parents’ responsibility for their child “deeply ontological” in that the reality within which the child exists is largely dictated by his or her parents and the choices the parents make. “I would argue that, altogether, these reasons do justify parental authority in health care decisions and their implications,” she says. “It’s really difficult to extract these decisions from this wider context and to do so would be to sort of isolate them in an artificial way.” Even given this preeminent role for parents when a child is dying, Salter says clinicians’ guidance is nevertheless important
A slide used by Erica K. Salter, a health care ethicist at Saint Louis University, in her discussion of ethical issues surrounding end-of-life care for children illustrates what she considers the ideal model for decision-making, the legal reality and the last resort, with state intervention.
to help families articulate goals of care. Unlike for adults, she notes, families of young patients generally haven’t thought about end-of-life wishes. To determine the best course of action for the family, Salter suggests that clinicians pose questions to parents such as: What are you hoping for? What is most important to you? What are you most afraid of? Clinicians should document the answers and make recommendations on care decisions with the parents’ preferences in mind, she says. Salter adds that care providers have a duty be mindful of refusals of care by parents that could put their child at risk of harm. To decide whether the risk is signifi-
cant enough to call for outside intervention, she suggests that clinicians follow the criteria outlined by Dr. Douglas Diekema, a pediatric bioethicist, in “Parental refusals of medical treatment: the harm principle as threshold for state intervention,” an article published in the July 2004 edition of Theoretical Medicine and Bioethics. The conditions Diekema suggests should be met to consider intervention are covered in eight questions that include: By refusing to consent are the parents placing their child at significant risk of serious harm? Is the harm imminent, requiring immediate action to prevent it? Is the intervention that has been
refused necessary to prevent the serious harm? Where possible, Salter says, parents and clinicians should involve the child in care decisions. That can be as simple as letting them choose which arm an IV goes into or what time of day blood is drawn for labs or as delicate as talking with a child about a dire prognosis. She references the work of Myra Bluebond-Langner, a researcher who found that, despite attempts from parents and providers to protect pediatric patients from the knowledge that their illness is terminal, children as young as 3 know when they are dying and can feel alone and abandoned if what they are experiencing is ignored. “Probably the most caring thing or kind thing or compassionate thing we can do is to enter into that space with the child, acknowledge that this is terrible news but we’re here, we’re ready to listen and we are companions with them in this difficult process,” Salter says. Salter falls back on a mantra for what families should say to children in the most tragic of circumstances. It comes from Jenny Harrington Lill, who created a blog to document her family’s struggle as her 8-year-old son was losing his battle with leukemia. The mantra is: “You will not be alone. You will not feel pain. We will be OK.” A recording of Salter’s webinar is available for CHA members at chausa.org/ online-learning. leisenhauer@chausa.org
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February 15, 2022 CATHOLIC HEALTH WORLD
Public health
Providence also is advocating for funding increases so public health officials and agencies can do more data collection on health issues, coordinate emergency response training within and across communities and provide more testing and treatment for infectious diseases and chronic conditions to underserved communities, especially those in rural areas where public health services are sometimes the only health care available. “Right now, it’s been all hands on deck working with public health officials on our COVID response, but we hope that we can get to a place to be more proactive to really strengthen our partnerships,” Bombard says.
From page 1
and advance the common good,” he says. Part of Trinity Health’s advocacy agenda is calling for more funding and support for the public health sector at the federal, state and local levels. Similar advocacy efforts are underway at other large Catholic health systems, including Providence St. Joseph Health, and at CHA. The health systems and CHA all see public health officials and agencies as central to ensuring that communities have access to disease testing, vaccines and other basic health services and that the nation is prepared for health emergencies such as future pandemics and environmental catastrophes. They say the crisis created by COVID19 shined a spotlight on how vital a strong public health infrastructure is to the nation. In addition to news reports of public health agencies being overwhelmed and undersupplied during the pandemic, there have been many reports of public health officials being threatened by members of the public, or being fired or having their authority reduced by officials critical of lockdowns and masking requirements. Many public health officials resigned or retired. Kaiser Health News in 2020 described the public health care workforce as being “under assault when it’s needed most.” Meanwhile, a study by the Robert Wood Johnson Foundation and Harvard T.H. Chan School of Public Health released last May found strong support among the public for more federal spending for public health while also finding the positive ratings of the public health system had declined from 43% in 2009 to 34% in 2021. The Centers for Disease Control and Prevention, the nation’s public health agency, has been buffeted by the political divisions in the country’s COVID response since the start of the pandemic. It’s been criticized for confusing and shifting guidance and for a lack of independent guidance. In a January telebriefing with reporters, CDC Director Rochelle Walensky promised to improve communications.
Underinvestment feeds inequity Trinity Health put its case for assisting the public health sector into a position paper it issued last year called “Care for the Common Good” and subtitled “Our COVID-19 Journey.” It notes that, “following years of underfunding and lack of prioritization, America’s public health infrastructure was ill equipped to address the COVID-19 pandemic. COVID-19 has clearly illustrated how this underinvestment is contributing to inequities within our health care system and society.” Slubowski discussed the roles the public and private care sectors have played in addressing the pandemic in an American Hospital Association podcast last summer with Dr. Rod Hochman, president and chief
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The community vaccination site at the Lumen Field Event Center in Seattle opened in March 2021 as a collaboration between the city of Seattle, stadium operator First & Goal Inc. and Swedish Health Services, an affiliate of Providence St. Joseph Health. Before the site closed in June, workers there gave tens of thousands of COVID-19 vaccinations.
executive of Providence St. Joseph Health. At the time of the recording Hochman chaired the AHA board. Both men are past chairs of the CHA Board of Trustees. In the podcast, Slubowski says Trinity Health and other health care providers “have become the de facto public health system during this crisis.” In the podcast and in a recent interview with Catholic Health World, he shared many instances during the pandemic when his system has taken on responsibilities across the communities it serves that the public health sector didn’t have the resources or the coordination among the various agencies and officials to handle. Examples he gave included Trinity Health’s having to secure and distribute scarce supplies and medications across its 25-state service area, educate the general public about how to reduce infection risk, run public testing and vaccination sites including in locales where infection rates were especially high, and linking people with unmet needs to social service providers.
Suggestions for change Trinity Health’s position paper urges policymakers to provide more funding and
A worker moves supplies at a Trinity Health’s 500,000-square-foot warehouse in Fort Wayne, Indiana. Trinity Health’s top executive says his system, like others, have taken on responsibility for distributing supplies such as personal protective equipment and scarce medications across communities because public health officials have at times been unable to mount a sufficient response.
authority for public health officials to take on health care supply chain coordination in times of acute shortage, be a health care information hub for providers and take the lead in health education and efforts to stem the spread of contagious disease. Among its suggestions are that the public health sector have computer systems that allow for the exchange of information with health systems and care providers; that it offer guidance on practices across all three levels of government; and that it provide more training, education and subsidies to bolster the health care workforce. Slubowski says the public-private health care partnership needs to work in both directions. “I think the public sector definitely relies on us to be a backstop for many efforts, but we also have to have a coordinated approach to communication, to resource allocation, to distribution of care across our communities instead of leaving it all in the hands of the health systems to figure out among themselves,” he says. Jacquelyn Bombard, executive director of fedBombard eral relations at Providence St. Joseph Health, says a solid public health sector is vital to advancing some of the system’s primary goals. “One priority of Providence’s is achieving health equity and we firmly believe that we can’t achieve health equity if there’s instability within the public health infrastructure,” she says. Public health furthers the push for equity in a number of ways in Providence’s view. That includes by seeing that everyone has access to health education, medication and quality care.
All hands on deck Bombard says Providence also considers a strong public health sector as essential to the system’s pledge to address climate change and the harsh toll environmental degradation takes on vulnerable communities. Environmental issues such as polluted air and drinking water have a direct impact on population health. Protecting air and water resources requires oversight and action by lawmakers, regulators and public health officials, she notes.
Federal efforts Paulo Pontemayor, a CHA director of federal government relations, says CHA advocates in Congress for increased funding to strengthen the public health sector. Pontemayor “We’ve made public health, especially in the last two years with this pandemic, a big priority knowing full well that a lot of our members have to depend on their state, county and city public health departments to work together to combat COVID-19,” he says. CHA applauded the passage last year of the American Rescue Plan. The Biden administration said that federal legislation, which CHA advocated for, includes $7.4 billion to recruit, hire and train tens of thousands of public health workers. The U.S. Department of Health and Human Services has earmarked $80 million to build up the U.S. public health informatics and data science workforce — particularly by training students from underrepresented minorities in data science as a way to strengthen analysis around race and ethnicity-specific public health data. The goal is to harvest and refine data at the local and state level to improve health equity in future public health responses. However, Pontemayor says much more is needed. “We know that that was just really a down payment,” he says of the American Rescue Plan. “We know that over the years public health has really not been funded as robustly as other federal programs.” CHA supports the Build Back Better legislation that the Biden administration is struggling to guide through Congress. The measure includes additional programs and funding streams to give local public health officials tools to prepare for the next pandemic and to address racial and ethnic disparities in care, especially as they relate to maternal health, behavioral health and substance abuse, Pontemayor says. Trinity’s coordinated response At the onset of the pandemic, Trinity Health activated a systemwide incident command structure that morphed into the framework it uses to address the exigencies of a health crisis now entering its third year. Trinity Health created a systemwide structure to ensure that staffing, supplies and other resources are in place at its facilities as needed and that protocols and best practices are shared across the system in a timely way. “We have a national team that focuses on all of the big issues and then we have COVID response teams in every state and they are totally aligned with what we’re doing nationally,” Slubowski says. The coordinated effort has functioned well, he says, even in the face of differing public policies and public health structures across the 25 states and hundreds of cities that Trinity Health serves. The structure could potentially be a model for the public sector, Slubowski says. “I think public health is something that’s definitely got to have a national set of principles and approaches and guidance,” he adds. leisenhauer@chausa.org
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CATHOLIC HEALTH WORLD February 15, 2022
Hospice From page 1
Conversations on end of life not always happening at right time, say providers
K
yle Terry, director of the hospice program of Saint Francis Health System of Tulsa, Oklahoma, said it would benefit people to start thinking about and documenting how much health care they would want if they were to become critically ill and no longer able to speak for themselves. He suggests people do this in their 50s, before health crises become more likely. But, people don’t want to think about death and dying, he said, and they often turn and walk away when they see the hospice sign on the information booth he staffs at health fairs. Nancy D’Agostino is vice president of community patient services for Calvary Hospital, a Bronx, New York, palliative care hospital and hospice provider. She said oftentimes when a patient is very seriously ill, clinicians, patients and family members understandably become so focused on saving the patient’s life, that it is hard to acknowledge when curative care becomes futile. As a result, hospice may not be considered as a treatment option by the patient or family until death is imminent. (Medicare rules generally prohibit beneficiaries from accessing hospice while also seeking curative treatment, rules that hospice providers are challenging.) Terry noted that during the pandemic many terminally ill patients have delayed seeking care and may have endured preventable suffering and distress as a result. D’Agostino said it should be routine for health care providers from primary care family doctors to palliative care specialists to talk with patients about their end-of-life goals. For patients with progressive, chronic illness, it’s important to have a conversation about advance planning for disease progression. She said clinicians should talk more deeply about patients’ values and wishes if those patients have a serious illness that is worsening. If the condition is terminal and supportive care is needed at home, hospice can provide useful resources. Jennifer Finley, agency manager at Avera@Home Home Health and Hospice in South Dakota, said when patients enroll in hospice, a social worker visits the patient usually with family present to discuss what’s important to the patient and begin to establish a plan to support those goals. Most hospice patients receive services at home or in a nursing home and hospice team members supplement care delivered by the patients’ loved ones or facility staff. Visiting team members normally include a nurse, physician, social worker, chaplain and nurse aide. D’Agostino said hospice care has been shown to lengthen the life of some patients, prevent hospitalizations and relieve pain and anxiety. Importantly, she said, it may enable patients to focus on achieving their goals, which might include resolving emotional pain or family conflict, attending a wedding or graduation, or simply spending more time with the people they love. —JULIE MINDA
The Medicare hospice benefit pays for a multidisciplinary team to provide patientcentered medical care, pain management and emotional and spiritual support. Medicaid, the Veterans Administration and many private insurers also reimburse for hospice services, which can reduce suffering and hospitalizations at the end of life. Calvary Hospital’s Nancy D’Agostino said, “Patients and families are more in control of their situation when they are on hospice, since it is their goals that are being addressed.” D’Agostino is vice president of community patient services for D’Agostino the Bronx, New York, palliative care hospital and hospice provider.
Cultural perceptions According to the 2021 edition of the National Hospice and Palliative Care Organization’s “Facts and Figures Report,” 40.8% of Black decedents insured under Medicare at the time of their death used hospice, as compared with 53.8% of white, 42.7% of Hispanic, 39.8% of Asian American and 38.5% of American Indian/Alaskan Native decedents. The data is based on MedPAC’s March 2019 report to Congress. Roughly 10% of Medicare beneficiaries are Black. The hospice organization’s March 2021 edition of its “Black and African-American Outreach Guide” says that hospice and palliative care organizations that want to be intentional about reaching out to that underserved patient group must address “the unique health needs of Black/ African-Americans,” and take into account how access to care, cultural risk factors and socioeconomic barriers contribute to the prevalence of certain diseases. The guide says cultural competency is crucial to raising awareness of palliative care among Black consumers as it is in providing quality care to Black patients. It recommends outreach that recognizes the influence of church leaders and family, Black media and cultural icons. It says the death in August 2020 of Chadwick Boseman drew attention in the Black community to the fact that colorectal cancer disproportionately impacts Blacks and that screenings for early detection save lives. Boseman, 43, rose to iconic status in 2018 as the superhero lead in the blockbuster “Black Panther.” He had kept private his 2016 cancer diagnosis. The shock of his death was a reminder that African Americans treat a decline in health as a “private, personal journey,” according to the guide, a preference that palliative care and hospice providers should consider in shaping their strategies to advance health equity. The New York City communities Calvary Hospital serves are as diverse as the United Nations, said D’Agostino, and hospital staff have set out to learn why members of certain racial, ethnic and religious groups seek hospice care to a lesser degree than whites. Not surprisingly, they determined that the general distrust many Black patients express toward health care providers based on historic wrongs combined with any individual’s experience of racism or inequity in health care factored into decisions to avoid hospice care. Also, Black consumers may not be getting information on hospice in a culturally sensitive way. Dr. Tammie Quest directs the Emory Palliative Care Center at Emory University. Speaking on a Nov. 1 webinar given by the Institute for Human Caring, part of Providence St. Joseph Health, she asked the audience to ponder how hospice concepts including “quality of life,” “limitations on medical interventions” and the concept of “a good death” might be perceived by and applied to minority populations. The distrust issue also is relevant for people who are LGBTQ, said the National
Amber Nelson, a hospice nurse case manager for Avera@Home, visits patient Margaret Laddusaw in Laddusaw’s home in Sioux Falls, South Dakota, in December. Avera Health is based in Sioux Falls.
Hospice and Palliative Care Organizations’ Marcantonio. “Most hospices recognize that there are a wide range of families in the U.S. that are not defined by blood relations. But there is still Marcantonio education needed to ensure all families are treated with respect and compassion. “Hospices tend to be more flexible and welcoming than many other conventional health care settings, but for a nontraditional family who has been poorly treated (by health care providers) in the past, those fears may be carried over to hos-
pice,” he said. Calvary’s service area includes large populations of Asian Americans. D’Agostino said many older Chinese Americans may have a cultural aversion to speaking about death. Kyle Terry directs the hospice program of Saint Francis Health System of Tulsa, Oklahoma. He said that among some Asians in Saint Francis’ hospice service area there is a Terry perception that if people seek help outside the immediate family by accessing hospice, family members have failed in their duties to their sick loved
This bar graph from the 2021 edition of the publication “NHPCO Facts and Figures” illustrates the usage of hospice by Medicare decedents, broken down by race. NHPCO is the National Hospice and Palliative Care Organization.
Guide helps hospice and palliative care providers become more inclusive T
he National Hospice and Palliative Care Organization published a guide about a year ago to help hospice and palliative care providers to be a more inclusive presence in their communities. The “Inclusion and Access Toolkit” makes a business case for including people of all backgrounds in outreach efforts, on boards and leadership teams, in the workforce and as clients. The 40-page tool kit provides strategies and practical tips for hospice and palliative care providers to assess how inclusive their organizations are and then to make needed improvements. It contains advice for tailoring hospice and palliative care services and marketing to distinctive audiences. An appendix lists common traditions and health beliefs, communication preferences and other relevant characteristics of African Americans, Chinese Americans, Latino and Hispanic Americans, and people in the LGBTQ+ community.
February 15, 2022 CATHOLIC HEALTH WORLD
Community outreach Ministry systems and facilities are taking on the perception issues that are hampering hospice use by intensifying their outreach and education work, particularly among vulnerable populations. D’Agostino said to learn more about the sensitivities of minority populations and how best to reach them with hospice education, she often will talk with hospital staff members from those communities and with community leaders including religious leaders. They help Calvary understand how to gain people’s trust and attention. They also provide advice on developing resources and materials that appeal to people in those communities. Rabbi Rothberger said he has made progress dispelling myths among people in some of the Jewish communities Calvary serves and increasing their understanding of hospice’s benefits. He offers an education program for community leaders and rabbis that includes hospice. He has built relationships with local rabbis and rabbinical organizations, and he’s linked rabbis with Calvary clinicians so they feel comfortable engaging with hos-
pital staff on behalf of families in their synagogues. Calvary has a Shabbos lounge where families observing the strict prohibitions against exertion on the Sabbath can sleep. Two refrigerators in the kosher hospitality room across the hall are stocked with microwavable kosher meals.
Better together Jennifer Finley, agency manager at Avera@Home Home Health and Hospice in South Dakota, said her organization partners with other health care organizations, churches, nonprofit organizations, state agencies and federal agencies including Finley the Department of Veterans Affairs to raise awareness of hospice services among rural residents. Avera@Home taps into this network to bridge any gaps in care that arise because the patient is too far from the health system’s hospice service area. For instance, Avera may provide the nurse practitioner directing a rural clinic outside the Avera network with a hospice standing order set for a patient and offer the Avera hospice pharmacist’s expertise to provide symptom management. Finley said, “Our main goal is to be of help to people in providing endof-life care. We will do what is needed to find ways to support people and be their safety net.” Her colleague Jill CraCragoe goe, regional director of patient care services for Avera@Home, said, “We don’t want anyone to die alone or in pain or without the right level of care for them.” jminda@chausa.org
Covenant Health
one. And among some people of Latino heritage, there is a perception that suffering is God’s will and that pain should be accepted rather than medically palliated, Terry said. Rabbi Yerachmiel Rothberger, Calvary’s Jewish community liaison, said some superstitious people may fear that talking about hospice will invite death. Some people may harbor misperceptions that high doses of morphine will be Rothberger administered even if that goes against a patient’s express wishes not to take treatment that could hasten death.
Virgie Young visits her husband of 80 years, Sterman Young, in his room at a Covenant Health hospital in Lubbock, Texas. They both contracted COVID-19 but Virgie Young was not a patient at the hospital. Hospital staff reunited them shortly before Sterman Young's death on Jan. 19.
Elderly pair parted by COVID get a final reunion at Covenant hospital By LISA EISENHAUER
Staffers at Covenant Health in Lubbock, Texas, reunited a 100-year-old World War II veteran who was undergoing care for COVID-19 with his wife of 80 years shortly before his death on Jan. 19. The regional health system is part of Providence St. Joseph Health. Sterman Young was hospitalized for COVID at one of its facilities for several days. His wife, Virgie, battled the virus elsewhere. On Jan. 18, Covenant Health posted pictures on social media of Virgie at Sterman’s bedside. Sterman is in his hospital bed and his wife is next to him in a reclin-
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ing chair. Both are on supplemental oxygen. In one photo, Virgie and Sterman gaze at each other as she holds his right hand in her gloved hand. Sterman Young died the next day. An obituary posted on the website of The Graham Leader newspaper says the pair married on July 3, 1941, when Virgie was 16 and Sterman was 20. Sterman was drafted into the Army and served in Europe during World War II. Covenant Health posted the photos of the pair’s hospital reunion with permission of the couple’s family, which stretches to five generations. The system’s Facebook post about the reunion was shared more than 1,000 times. Several news organizations reported on Covenant Health’s post. Covenant Health said the Youngs’ advice was to love each other and stick together “till death do us part.”
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CATHOLIC HEALTH WORLD February 15, 2022
Advance care planning From page 1
James Robinson, advance care planning coordinator for the multispecialty medical group CHRISTUS Trinity Clinic that serves 200 locations across Texas, Louisiana and Arkansas, has a similar take on the viewpoint piece titled “What’s Wrong with Advance Care Planning” that was published by JAMA Network in October. He is not in favor of ending the practice but agrees improvements could be made. “I think we need to just refine what we’re doing and expand what we’re doing,” Robinson says.
Authors cite lack of validity The JAMA article doesn’t hedge in its indictment of advance care planning that consists of completion of a form saying what treatments are wanted or not wanted far into the future, referred to in the piece as ACP. The article states plainly: “ACP does not improve endof-life care, nor does its documentation serve as a Morrison reliable and valid quality indicator of an end-of-life discussion.”
The two revised and simplified advance directives offered to patients at Providence St. Joseph Health facilities include the options shown here for patients to choose from to guide their health care surrogates and care providers on their care preferences.
Dr. R. Sean Morrison, professor and chair of the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai in New York, is the lead author of the viewpoint. He says the argument it presents is based on findings from dozens of studies of advance care planning that stretch back 25 years.
“We haven’t been able to show that ACP is an effective process of ensuring that people receive goal-concordant care at the end of life,” Morrison says. He considers the call he and his coauthors have issued to end advance care planning to be the only logical response to empirical evidence that the practice is
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Systems simplify, innovate advance directive process
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dvance care planning came into being in medical care in the middle of the last century. California in 1976 became the first state to pass a statute for a living will, a legal document that lets patients make their care preferences known and protects doctors if they follow those wishes in good faith. Nationally, the practice of including patients’ wishes in care delivery was codified in the Patient Self Determination Act of 1990. That federal statute directs care providers to “periodically inquire as to whether a patient executed an advanced directive and document the patient’s wishes regarding their medical care.” Policymakers, health care systems and care providers have used various strategies to put the practice into place, including establishing protocols for discussions and drafting state-specific advance directive forms. It’s only been since 2016 that Medicare Part B has reimbursed for advance care planning services. Some insurers do, too.
Even with its relatively short history, Dr. Ira Byock says he and others who specialize in end-of-life care long have been aware of the shortcomings of advance care planning as practiced. Byock is a palliative care physician and founder and chief medical officer of the Institute for Human Caring at Providence St. Joseph Health. One of the main flaws in the process is that often the documents that patients are asked to complete are both too complex and too generic, Byock says. Some of the directives ask patients to state whether they would want specific treatments at any time, offering them no opportunity to clarify under what circumstances they might be willing to undergo procedures such as dialysis or cardiopulmonary resuscitation. “The large majority of people get to the part of the form with the menu of services and say ‘Gee I don’t know. I have to think about this. I better go home and talk to my family,’” Byock says. “And they take the form with them and you never see it again.”
One is a trusted decision-maker declaration, a brief directive that does not require notarization or the signatures of witnesses to be entered into a patient’s medical records and considered valid by the system. In the declaration, patients name a health care agent who they authorize to speak on their behalf if they lose decision-making capacity. Patients also check one of four boxes to provide guidance on their care preferences. The first box, which Byock says is the one most commonly checked, says: “I am not sure at this time which statements below I most agree with. I trust my health care agent to do what is best for me.” The declaration is signed by the patient and a licensed independent medical practitioner, who vouches for the patient’s “decisional capacity.” “By formal Providence policy, in the absence of an advance directive, these stand as evidence of the patient’s verbally expressed wishes,” Byock says. The process of explaining the declaration to a patient and getting it filled out can take just a few minutes. And it can be done remotely, as has happened often during the pandemic, when Byock and other clinicians with expertise in advance care counseling have helped patients fill out the forms via video connections. The other recently created directive that Providence offers to patients is basically the same form as the trusted decision-maker directive except that it has to be notarized or have the signatures of two witnesses. That document, which the system calls the easy form advance directive, aligns with statutory requirements for advance directives and not just with the system’s policies for a valid directive. Byock says the revised and simplified directives are “far more covenantal than contractual.” He maintains that covenants are based on trust whereas contracts provide legal protections in situations where there is mistrust. In addition to the simplified documents, the Institute for Human Caring has developed advanced communication training curricula to teach providers how to have more meaningful serious-illness conversations. More than 4,000 providers at Providence have taken these courses.
Shorter, simpler forms
Workplace approach
Providence St. Joseph Health has moved in recent years to simplify the process through the use of two short forms.
CHRISTUS Health also is being innovative in its approach to advance care planning. In January, the system began an incentive
Shortcomings
program to encourage its employees to fill out advance directives. Those who do so through the program, which includes watching a short video and uploading their signed documents, get points that can be cashed in for gifts. James Robinson, advance care planning coordinator for the multispecialty medical group CHRISTUS Trinity Clinic, thinks his system’s program is one that insurers and other employers easily could adopt. It could help address the challenge of reaching people in a community where many don’t have primary care doctors and don’t make regular visits to clinics, he says. Robinson coordinated the employee program for CHRISTUS Health but his main job is to talk with patients at family medicine clinics in San Antonio about advance care planning. Most of the people he speaks with are elderly patients who are at the clinics for Medicare wellness visits, though his services are available to any patient. He says he keeps the conversations broad. His goal is to educate patients about care directives and to encourage them to fill out the documents so that they identify a trusted surrogate and their preferences are known by their loved ones and by doctors. In addition to its employee program and its outreach efforts in clinics, CHRISTUS has a section of its website devoted to advance care planning. The postings include an appeal from San Antonio Archbishop Gustavo Garcia-Siller for patients to have health directives on file with their care providers. Archbishop “I think what we’ve Garcia-Siller done at CHRISTUS is a good example of what can be done elsewhere, so we’re very excited about that,” Robinson says. CHA’s advance care planning tools are available at chausa.org/palliative/ advance-care-planning. Byock and Dr. Daniela J. Lamas discuss the merits and new frameworks for advance care planning on the Institute for Human Caring’s Hear Me Now Podcast, at HearMeNowPodcast. org. Lamas is a pulmonary and critical care physician at Brigham and Women’s Hospital in Boston. — LISA EISENHAUER
not working. He compares it, for example, to how the medical community changed course on the use of estrogen supplements when research showed they were not beneficial and potentially harmful to postmenopausal women. “And as a scientist, I have to look at the data, no matter how hard that is, and the data on this are crystal clear,” Morrison says. As to the timing of the opinion piece, he says one of the driving factors was what he has witnessed during the COVID-19 pandemic. Too often, he says, he has seen overwhelmed and exhausted clinicians relying on living wills and other advance directives for guidance on patient care, rather than having meaningful, in-the-moment discussions with patients or their families about potential treatments and outcomes.
Shortcut for some clinicians Dr. Diane Meier, one of Morrison’s coauthors and a colleague, says that the use of advance directives such as living wills as “shortcuts in place of thoughtful, considered conversations with patients about their current situations” didn’t start with the pandemic. Meier is founder and director emerita of the Center to Advance Palliative Care that is part of the Icahn School of Medicine. She says advance care planning grew out of a movement to give patients who can no longer speak for themselves a say in their own care rather than allowing physicians to have sole discretion in treatment decisions. But that laudable and successful movement, she says, too often has given way to having patients fill out documents that, when a patient needs care and can’t speak for himself or herself, are ignored or used as a blanket statement for care preferences. “The best example is the overinterpretation of the do-not-resuscitate order to don’t do anything,” Meier says. “And that happens all the time. The public is perhaps not aware of this phenomenon, but clinicians working in the system know how do-not-resuscitate orders are often interpreted as a surrogate for comfort measures only.” She says she has had a “long-term increasing level of disquiet” about advance care planning as it has come to be practiced. She worries, for example, that Medicare, by giving care providers financial incentives to encourage patients to file advance directives is essentially rewarding those providers for “completing a form and checking a box.” “There is no measurement of the quality of the conversation, of whether the clinician billing for advance care planning has ever been trained in how to initiate these conversations (most of us have had no training), and of whether the patient or surrogate understand what they are signing,” she says. Wrong incentives What in her view instead should be incentivized is ongoing conversations about care preferences as well as continuity of care for patients so that they can develop trust-based relationships with their cli-
February 15, 2022 CATHOLIC HEALTH WORLD
A group of Providence St. Joseph Health workers in California fill out advance directives for themselves. In recent years, the system has begun offering patients simplified versions of a trusted decision-maker declaration and an advance care directive. The system’s Institute for Human Caring has developed training curricula for clinicians on how to have more meaningful conversations with patients about serious illnesses.
nicians. In addition, she says, clinicians should be trained on communication skills so they are proficient at talking with patients and understanding patients’ preferences. “We don’t incentivize continuity of relationships or demonstrating competencies in communication skills, but we could,” she says. In the opinion piece, Meier, Morrison and their co-author, Dr. Ronald M. Arnold, a specialist in palliative care and medical ethics at University of Pittsburgh Medical Center, argue that “treatment choices near the end of life are not simple, consistent, logical, linear, or predictable but are complex, uncertain, emotionally laden, and fluid. Patients’ preferences are rarely static and are influenced by age, physical and cognitive function, culture, family preferences, clinician advice, financial resources, and perceived caregiver burden.” It is no surprise then, say the authors, that the gap between hypothetical scenarios set out in advance care plans and a patient’s circumstances and care options at the end of life can be yawning. Meier’s advice to patients is to do two
things: name someone they trust to represent them if they are no longer able to make their own medical decisions, as often happens during serious illness, and discuss with their proxy what they would want if they become permanently unable to recognize and interact with loved ones. Some people say they would want care focused on their comfort if they were in a vegetative state, while others opt for all possible life-prolonging treatment, regardless of the quality of that life, she says. “I present this question to my patients and ask ‘Which kind of person are you?’ so that I do not bias their choice,” Meier says. “Full stop. That’s it.”
Praise and criticism Meier and Morrison say, as expected, they have gotten praise as well as criticism for their viewpoint. The praise has included gratitude that they were bold enough to start a dialogue; the criticism has included that they haven’t presented an easy alternative means for patients and families to make their wishes known to caregivers. While they welcome the discussion of
the merits of advance care planning, Byock and Robinson aren’t endorsing an immediate end to the practice. Their systems are committed to counseling patients on advance care planning and, in fact, have recently acted to improve how that service is offered. (See sidebar, Page 6.) Byock takes issue with the argument made in the JAMA viewpoint in part because he finds it unclear what metrics the authors are using as the basis for their conclusion that advance care planning has failed to achieve the desired ends. “I don’t think the field has ever decided what the measure of goal concordance would be,” he says. His own research and observations have shown that many patients and families are greatly relieved at having a trusted surrogate named and preferences for end-of-life care documented. He says he takes comfort in knowing that his own directive is in place. “There’s an old saying in medicine: absence of evidence is not evidence of absence,” Byock says. “The fact that our measures aren’t good enough to detect diminished stress at the time of decision-making or my own current feelings of having more confidence that I’m taking care of my family, that doesn’t invalidate the benefit.”
Premature conclusion In his previous work as a hospital chaplain, Robinson says he too saw how advance care planning can lift the heavy burden of decisionmaking on families at the bedside of a gravely ill or dying patient. “If those conversations have already happened, that real concern is often alleviated.” In his view, the finality of the argument against advance care planning made by Morrison, Meier and Arnold is premature. He notes that the advance planning directive is still gaining a foothold in health care. Robinson moved from chaplain
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to the newly created position of advance care planning coordinator just a couple of years ago, when CHRISTUS Health decided to offer the service to patients who come to its clinics for care. He said it was a need identified in San Antonio, a community in which many people don’t have primary care doctors and aren’t aware of how they can make their health care preferences known. “The CHRISTUS program came out of the system’s mission integration department,” he says. “It didn’t develop from a clinical standpoint or from operations or anywhere else. It came from mission, which means to me that we’re doing it because it’s something that we should be doing.” leisenhauer@chausa.org
Drs. Diane Meier and R. Sean Morrison talk in a hallway of the palliative care unit at Mount Sinai Hospital in New York. Both are palliative care specialists and two of the three authors of a recent opinion piece in JAMA Network that urged a rethinking of advance care planning.
KEEPING UP
Kuiper
Campbell
PRESIDENTS AND CEOS Organizations within CommonSpirit Health made these changes: E.J. Kuiper to chief executive of CHI Health and president of CommonSpirit Health’s Midwest division, which includes 28 hospitals, two stand-alone behavioral health centers, and more than 150 employed physician practices in Iowa, Minnesota, Nebraska and North Dakota. Kuiper was president and chief executive of Hospital Sisters Health System Illinois, a nine-hospital division. Gena Bravo to president and chief executive of Dignity Health’s Woodland Memorial Hospital in California, from interim president. She previously was the hospital’s chief operations officer and chief nurse executive.
ADMINISTRATIVE CHANGES Steve Mackin, who will become president and chief executive of Mercy of Chesterfield, Missouri, on April 1, has announced his senior leadership team, with the changes already in effect: Shannon Sock to Mercy’s chief operating officer and chief strategist. He was executive vice president and chief strategy and chief financial officer. Dr. John Mohart to president of Mercy Communities, a position that covers Mercy’s
Ness
Dwaram
hospital operations. He was senior vice president and chief clinical officer. Cheryl Matejka to senior vice president and chief financial officer. She was senior vice president of financial operations. Dave Thompson to senior vice president, strategic integration. He was senior vice president of strategic finance. Ajay Pathak to senior vice president and chief strategic ventures officer. He was chief strategic ventures officer. In addition to those named, the following executives will continue as members of Mercy’s senior leadership team: Cynthia Bentzen-Mercer, executive vice president, chief administrative officer; Dr. Jeff Ciaramita, senior vice president, chief physician executive; Dr. Gavin Helton, senior vice president, population health; Joe Kelly, executive vice president, transformation and business development officer; Kevin Minder, senior vice president, mission and community health; Betty Jo Rocchio, senior vice president and chief nursing officer; and Phil Wheeler, senior vice president and general counsel. Separately, Dr. Ray Weick to president of Mercy Clinic St. Louis and Mercy Clinic South. He will continue as interim Mercy Clinic president in the Joplin and Kansas
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Swearingen
communities. Carol Campbell to senior vice president, consumer experience, for Ascension of St. Louis. Sarah Ness to executive vice president of people and culture at PeaceHealth of Vancouver, Washington. Vamsi Dwaram to system vice president of digital health for Covenant Health of Tewksbury, Massachusetts. Facilities within CommonSpirit Health have made these changes: Kim Brown Sims to chief nursing officer for Dignity Health’s Saint Francis Memorial Hospital and St. Mary’s Medical Center in San Francisco. Kiley Grzywa to vice president of patient care services for CHI Health St. Francis, which serves the communities of Breckenridge, Minnesota, and Wahpeton, North Dakota. Carmel Jones to president of the CHI Saint Joseph Medical Group in Lexington, Kentucky. Shana McClone to chief nursing officer of HSHS St. Nicholas Hospital of Sheboygan, Wisconsin. Kenneth D. McCoy Jr. to Providence St. Joseph Health Alaska’s first regional chief diversity, equity & inclusion officer. Providence Alaska is based in Anchorage.
Angela Swearingen to chief operating officer of St. Mary’s Medical Center in Huntington, West Virginia. Fr. Felix Fr. Alaribe Okechukwu Alaribe to vice president of mission integration for CHRISTUS Ochsner Health Southwestern Louisiana.
GRANTS The Federal Communications Commission has awarded Mercy of Chesterfield, Missouri, a $2.2 million grant to expand and upgrade telehealth services for patients across Arkansas, Missouri and Oklahoma. The CHI Saint Joseph Health Foundations of Lexington, Kentucky, and three foundations of CHI Saint Joseph Health facilities have secured grants for “Telehealth Solutions for Rural Kentucky.” The funds will go toward scaling telehealth to 50 Kentucky counties and offering home health services to more than 3,000 patients. As part of this work, CHI Saint Joseph Health Foundations has received $403,191 from the Federal Communications Commission Telehealth COVID-19 Round Two Program. Saint Joseph Mount Sterling Foundation, the Saint Joseph Berea Foundation and the Flaget Memorial Hospital Foundation each received $223,879 in federal grants.
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CATHOLIC HEALTH WORLD February 15, 2022
right circumstances. CommonSpirit serves a lot of poor communities across the country, and while we do From page 1 a good job, we know a more diverse, frontline workforce could improve Medicine because he “loved its mission and trust issues and diminish cultural commitment to address health inequity.” misunderstandings. Morehouse has His rotation at CommonSpirit Health’s a great vision, and Dr. Rice is a very 349-bed CHI Memorial Hospital Chatstrong leader who is willing to take tanooga in Tennessee and at the nearby risks. Together we see an opportu74-bed CHI Memorial Hospital Hixson, nity to do something spectacular.” helped him to round out his experience, he Cooperation between Moresays. Many Morehouse School of Medicine house School of Medicine and students spend the majority of their time CommonSpirit sped the distribuat Atlanta’s Grady Memorial Hospital — a tion of a tool that has helped people large, publicly owned safety net hospital find doctors, vaccines and COVID with a Level 1 trauma center. Martin says he tests. Morehouse School of Medicine appreciated the contrasting experience of received a $40 million grant from his rotations at CHI Memorial community the U.S. Department of Health and hospitals. Human Services as part of the HHS’ The school provided a rent-free apartNational Infrastructure for Mitigatment for him in Chattanooga that was 15 ing the Impact of COVID-19 within minutes from CHI Memorial Hospital ChatRacial and Ethnic Minority Commutanooga. “When I wasn’t on rotation, I could nities initiative. enjoy the city, the opportunity for outdoor Sami Hudaib, a fourth-year medical student at Morehouse School of Medicine, completed a four-week rotation in The medical school used a porexperiences, and the Southern hospitality the neurology department at CHI Memorial Hospital Chattanooga. Hudaib was one of the first two students weltion of the grant on “communitythere,” says Martin, a native of Spartanburg, comed as part of a 10-year effort by the hospital’s parent system, CommonSpirit Health, and the medical school engaged participatory research South Carolina. “I would definitely consider to add to the diversity of the clinician workforce in the U.S. into vaccination rates and accurate locating in Chattanooga after graduation.” sources of information,” says Sutton. patient relationship requires immediate Meeting of the minds “We then developed an app to allow Transient to transplant and profound trust, unlike any other relaChicago-based CommonSpirit, one diverse communities to plug in their ZIP That consideration meets another one tionship I can think of, and one thing that of the largest health systems in America, codes to determine where to find doctors, of the goals of the More in Common Alli- builds trust is the perception that you have serves some of the most diverse communi- vaccines and COVID tests.” ance — to support a pipeline of students something in common with your doctor ties in the country and is a leading provider Then, according to O’Quinn, Commonfor communities experiencing a shortage of — that he or she under- of Medicaid services. Morehouse School Spirit brought in data experts to help roll out providers. stands the way you view of Medicine, along with three other his- the app and a link to it on the Morehouse “Welcoming these students into our the world. That can go a torically Black medical schools — Howard School of Medicine website. hospital and partnering in their training long way to overcoming University College of Medicine in WashOf even greater consequence, though, is will help them feel more comfortable in the hesitancy to get care.” ington, D.C.; Charles R. Drew University the launch of the education sites designed and connected to our community, which That, in fact, was a large of Medicine and Science in Los Angeles; to diversify the clinician workforce. Rotaincreases the likelihood part of the motivation and Meharry Medical College in Nashville, tions for Morehouse School of Medicine’s they return to our wonder- Sutton behind the formation of Tennessee — produce the majority of the undergraduate medical students and phyful city to practice once the More in Common Alli- nation’s Black physicians. sician assistant students at CHI Memorial their training is complete,” ance. According to Dr. Erica Sutton, associBoth Dean and Rice were well aware Hospital Chattanooga began in September says Lee Jackson, medi- ate dean of academic programs and affilia- of the sobering statistics concerning the 2021, with emergency room and neurology cal director of surgical tion at Morehouse School of Medicine, the dearth of diverse clinicians throughout the rotations. In July, anesthesia and general services and physician idea for that alliance was hatched in Novem- U.S. Only 5% of physicians identify as Black, surgery rotations will be added as well. adviser at CHI Memorial. ber 2019 by a chance meeting between only 11% of the registered nurse workforce Two other first phase undergraduate Jackson “African Americans CommonSpirit Chief Executive Lloyd H. is male, and just 27% of board members at training sites — at CommonSpirit’s Saint make up 31% of Chattanooga’s population Dean and Dr. Valerie Montgomery Rice, the top 100 U.S. hospitals are women. More- Joseph Hospital in Lexington, Kentucky, and 20% of Hamilton County, Tennessee. president and chief executive of Morehouse over, in 2019, 22,000 students entered the and Virginia Mason Medical Center in There’s a huge disparity between that and School of Medicine. They were attending the country’s 155 accredited medical schools, Seattle — are slated to open this spring. The the percentage of Black medical staff we funeral of their mutual friend, Kaiser Per- but only 1,626 were Black — and only 619 alliance is also initiating the accreditation currently employ,” he says. “The physician- manente Chief Executive Bernard Tyson. were Black men. process to establish new postgraduate resiIn an effort to advance health equity, dencies and fellowships in three Commonthe pair began discussing a collaboration Spirit California locations — Bakersfield, to create a joint undergraduate/graduate Santa Cruz and Ventura County — and medical education program. A major goal transferring academic sponsorship for an is to ensure a minimum of 300 clinicians existing program in Los Angeles. Morefrom Black and other minorities underrep- house School of Medicine will be the acaresented in health care complete residen- demic sponsor of these programs. cies each year. The initiative will open five regional campuses and graduate medical A leg up education programs in 10 markets with In addition, a $3 million CommonSpirit CommonSpirit facilities. Equity Impact Scholarship program also The collaboration also will allow More- was announced in October to “break down house School of Medicine to expand its barriers in education and create a pathway student population by 6% every year for for job opportunities, promotion, higher five years, according to Sutton. And it will compensation and leadership positions help develop research programs to impact that may otherwise seem out of reach,” says illnesses that disproportionately affect Afri- O’Quinn. can Americans, such as sickle cell disease. To finance the 10-year More in Common Alliance initiative, Morehouse School ‘Something spectacular’ of Medicine and CommonSpirit are each Strategic planning for the alliance began contributing $21 million in seed money in earnest early in 2020, and sped up dra- from their operating budgets for the first matically with the onset of the COVID-19 two years of the program. Fundraising will pandemic, which laid bare health inequi- be the third source of financing. ties in American society; “These remote medical education proand the murder of George grams and regional campuses are a tremenFloyd, which awakened dous win-win for both hospitals and the the country to social jus- communities they serve,” says Sutton. “The tice issues, says Marvin locations of training opportunities students O’Quinn, president and have greatly influence where they will ultichief operating officer of mately practice.” CommonSpirit. He took And, at the conclusion of the alliance, O’Quinn charge of the project, Sutton adds, “both MSM and Commonworking directly with Rice with the goal Spirit are hoping to be able to show the of creating a more diverse workforce as a value and garner the support to continue means to address inequities in health care this investment.” access and outcomes “That’s what relationship building is all “We know we are not going to solve all about — engagement with the community of the country’s issues, but we are hoping to foster a pathway by which we will be able to begin to have some impact, and cre- to measure our impact through a diversified ate a template that others can follow,” says workforce and the achievement of health Nicolai Samuels, a fourth-year medical student at Morehouse School of Medicine, at work in the CHI O’Quinn. equity,” she says. Memorial Hospital Chattanooga emergency department. Samuels completed his four-week ER rotation as “This was a case of having the right part of the CommonSpirit/Morehouse School of Medicine More in Common Alliance. people get together at the right time in the
Morehouse