Worcester Medicine May/June 2022

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Volume 91 • Number 3

Published by Worcester District Medical Society

May / June 2022

Fulfilling Lives: Palliative Care DOMAIN 5 Encompassing Spiritual, Religious, and existential aspects delineating quality in palliative care.

GERIATRICIAN PERSPECTIVE Opening communication with struggling patients.

MUSIC THERAPY IN PALLIATIVE CARE Music as a purposeful tool in the therapeutic quality of healing.

PATIENT PERSPECTIVE De-Mystifying the complexity of Palliative Care for patients and their families.

ROLE OF THE PHARMACIST Individualized roles that cater to each patient’s specific needs

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Contents MAY / JUNE 2022

on the cover Day five high grade human blastocyst

Palliative Care

Communicating in the ICU 15

Editorial 4

Connie Ge, BA

Rebecca Kowaloff, DO

From the Curator

President’s Message 5

Terminal Care for Incurable Cancer Victims 16

Spiro Spanakis, DO

B. Dale Magee, MD, Curator

Palliative Care: Once Taboo, Now Overdue? 6

Legal Consult

Gary Blanchard, MD

Caretakers of the Elderly: Risk, Neglect and Injury 16 Peter Martin, Esq.

Domain 5 7 Rev. Msgr. Peter R. Beaulieu, MA, STIL

As I See It

True Palliative Care: A Patient’s Perspective 8

Paul Hart, MD

UMass Palliative Care Team Rebecca Kowaloff, MD

“Talking To Patients” A Lecture Series in Moldova 17 Essay Contest

Music Therapy in Palliative Care 10

The Meyers Health Care Institute Health Policy Essay Contest 18

Maria Carla-McDonald, MA, MT-BC, FAMI Vandana Nagpal, MD, FACP, FAAHPM

Jerry H. Gurwitz, MD Ron Adler, MD

The Role of the Pharmacist on the Palliative Team Symptom/Pain Management 12

A Fresh Start (1st place) 19

Anna K. Morin, PharmD

Palliative Approach to Dialysis Care 13 Ashley Rotella, BSN, MSN

Megan Hansen

Reflections on the Cost of Statins (2nd place) 20 Shervin Rezaei

Society Snippets

What Mrs. T Taught Me 14

Oration/Annual Business Meeting 22

Pawina Subedi, MD

Melissa Boucher

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Worcester District Medical Society

Lisa Beittel, MBA Sonia Chimienti, MD Anthony L. Esposito, MD Heidi Leftwich, DO Rebecca Kowaloff, DO, Guest Editor Anna Morin, PharmD Nancy Morris, PhD, ANP Alex Newbury, MD, Resident Representative Thoru Pederson, PhD Joel Popkin, MD Alwyn Rapose, MD Parul Sarwal, MD Robert Sorrenti, MD Pawina Subedi, MD, Resident Representative Ram Upadhyay, MD Peter Zacharia, MD

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Worcester Medicine does not hold itself responsible for statements made by any contributor. Statements or opinions expressed in Worcester Medicine reflect the views of the author(s) and not the official policy of the Worcester District Medical Society unless so stated. Although all advertising material is expected to conform to ethical standards, acceptance does not imply endorsement by Worcester Medicine unless stated. Material printed in Worcester Medicine is covered by copyright. No copyright is claimed to any work of the U.S. government. No part of this publication may be reproduced or transmitted in any form without written permission. For information on subscriptions, permissions, reprints and other services contact the Worcester District Medical Society.


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Editorial

Rebecca Kowaloff, DO

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I RECEIVED “The Lost Art of Healing” by Dr. Bernard Lown from a high school teacher as a gift, and while I read almost exclusively fiction, I happened to read the book years later just after graduating college while applying to medical schools. As the daughter and niece of primary care doctors, I knew the humanistic side of medicine with longstanding and deep patient relationships was one of the most appealing aspects of becoming a doctor. But reading Dr. Lown’s work gave that impetus direction and form. Thinking that medicine was primarily about staving off death, I had not conceived of a role for a physician other than treating with the intent to cure. Dr. Lown’s book made me see how much care there is in treating people facing life-threatening illness and how much our actions as doctors in that sacred time can impact patients and their families. Later, in residency, with a plan to apply to palliative care fellowships, I met Elizabeth in my primary care clinic. She was a thoughtful former high school math teacher who loved to tease me and her daughter-in-law at our visits. Her worsening COPD landed her in the hospital, and her chronic back pain debilitated her increasingly over the months I cared for her. She entered the hospital shortly before Christmas with excruciating back pain such that she couldn’t walk. I sat with her, holding her hand, and looked her in the eyes and gave voice to what she already knew. She was dying. The next words out of her mouth were, “thank you,” and I had never felt more like a doctor. She died at home a few weeks later. The concept of continuing medical education is one that has been central to our craft since before formalized medical education, as the Worcester District Medical Society’s long history as a repository of medical literature and lecture sponsor illustrates. There are some of us who relish the arrival of a medical journal to pore through the latest research advances and collegial debates within. But many of us, like myself, have our favorite topics, and have a stack of journals that we peruse to keep nominally abreast of new developments relevant to our practice. But are not serious illness care and end of life care relevant to all our practices? Leaving aside specialties that deal almost exclusively with serious illness, rheumatologists treat patients with sometimes debilitating chronic illnesses that leave them vulnerable to serious complications as they progress. Gastroenterologists diagnose cirrhosis which limits prognosis and can cripple quality of life. Interventional radiologists emergently treat life-threatening problems, often on patients who are too sick for traditional surgical approaches. We all need to have formal training in how to talk to patients about their illness frankly, honestly, and compassionately. This is not inherent in being a doctor. We all spent part of our education rotating through specialties so that the psychiatrists among us remember snippets of gynecology or the orthopedic surgeons have had some experience with Crohn’s disease. Unfortunately, even

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CAN HONESTLY SAY THAT A BOOK CHANGED MY LIFE.

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obstetrics and pediatrics are not immune from the realities of serious illness and death. Even if we do not think these skills relevant to our practice, they are at the core of being a doctor. If the pandemic has shown us anything, it is that politics and bureaucracy aside, the public still holds our profession in noble regard. There is at least a kernel of reverence for the knowledge and skills we have refined and for our dedication, sacrifice, and selflessness. As serious illness and death are the foundation of medicine, I believe we are obligated to develop our ability to discuss these matters with our patients to be worthy of society’s esteem and of our titles. There are not nearly enough palliative care clinicians for all specialties not to be having these conversations with their own patients. To be a provider devoid of the most basic form of these skills would be like a primary care physician who cannot manage routine hypertension or a surgeon who cannot close an incision. Our patients honor us with a trust above all others and we must match that trust with competence and commitment. We all chose specialties that suit us, but we all chose medicine with its central themes of illness and suffering first. Everything we do is to stave off death, but its inevitability is implicit in all our interventions. As we intervene, we must acknowledge that our power to prolong life is not limitless, and demonstrate that our power to be present is. To be a physician we must be able to address these issues directly with our patients. To be a good physician, we must be able to support them along their illness journey and guide them to the end of their life compassionately. I encourage you to connect with the humanist inside of you who chose medicine and with an open heart and mind to discover your role in delivering the much needed changes in our approach to serious illness in America. + Dr. Rebecca Kowaloff, DO, is board certified in palliative medicine is a member of the inpatient Palliative Medicine team at UMass. She loves to educate lay people and medical providers in palliative care and can be reached at Rebecca.kowaloff@gmail.com.


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President’s Message Spiro Spanakis, DO WDMS President 2020-2022

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I COMPLETE MY TERM AS PRESIDENT OF THE SOCIETY, I am grateful for the opportunity to serve you all in this role. Over the past two years, I have witnessed the laudable dedication of our officers, committee chairs, committee members, and staff promoting all the initiatives that make our district one of the most active and accomplished among all other districts. We should all be proud! First, I would like to express my thanks to my fellow officers, who all served as mentors to me prior to me being elected to president of the Society. Dr. Whalen, our incoming president, has led our Legislative Committee successfully over the years. The relationships forged between legislators and the Society will continue to yield results for efforts on behalf of our patients in the future. Dr. Magee has spent countless hours streamlining the finances of our society and positioning us on a path that will protect our considerable assets in the future. Dr. Felice’s relationships to the community were valuable as she served as our secretary, and her boundless energy always brought a fresh perspective to our discussions. The district serves our community in many ways, and there is no better example of these efforts than our scholarship committee, chaired by Dr. Michele Pugnaire. Recently, we received a generous donation of $25,000 from our immediate past president, Dr. Sahdev Passey, and his wife, toward our scholarship fund. We also appreciate all your contributions so that we can continue to support our medical students in the future. Our district’s publication, Worcester Medicine, continues to create timely, local content on topics of interest to our Worcester community. I want to thank Dr. Robert Sorrenti and Dr. Jane Lochrie for their leadership and dedication to the continued success of the publication, especially as we transitioned to a completely online platform. Recently, we have adopted a guest editor model which has worked well. If you have an interest in becoming a guest editor on a topic of personal or professional expertise, please contact the office. We also encourage you to view our video publication, Health Matters, online on our website, wdms.org. Our newest committee, the student committee, has made valuable contributions to programming and involving the next generation of leaders in the organization. Student doctor Bennet Vogt and Dr. Anne Larkin’s efforts have contributed to this success, and we appreciate all their efforts. S

Our delegation to the Massachusetts Medical Society continues to be a strong voice on important advocacy

” On the public health front, we were fortunate to have Dr. Michael Hirsh serve as Chair of Public Health Committee, especially as COVID-19 affected our community and patients. Dr. Hirsh’s evidence-based recommendations provided comfort and guidance to all members as we navigated the changing landscape of managing the virus. Dr. Hirsh and the Awards Committee have also identified well deserving awardees for our various member awards. The Medical Education Committee, chaired by Dr. Mary O’Brien, continues to hold informative, timely, and valuable programs for members. The Woman’s Caucus, chaired by Dr. Lynda Young, continues to provide a forum for women members to exchange ideas and network. Finally, I would like to thank Dr. Fred Baker for his efforts as chair of our Personnel Committee. Our delegation to the Massachusetts Medical Society continues to be a strong voice on important advocacy, legislative, and public health issues at the state level and I encourage more of our members to become involved. There are always open seats to be filled given the size of our district. + I would like to thank the leadership of UMass Memorial for always supporting my involvement in organized medicine since my days as a resident. I would especially like to thank Dr. Stephen Heard, the late Dr. Shubjeet Kaur, Dr. Matthias Walz, Dr. Elifce Cosar and Dr. Eleanor Duduch for their support in all my professional efforts. And special kudos to Martha Wright, our Executive Director, who worked diligently to maintain momentum for all the society’s work during the pandemic.

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WORCESTER MEDICINE

Palliative Care

Palliative Care: Once Taboo, Now Overdue? Gary Blanchard, MD “Can you believe this family? They just don’t get it.” “I just don’t understand why they want us to ‘do everything’ for their father… Look at him!” “Why would anyone allow their mother to suffer like this?”

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S A RESIDENT PHYSICIAN,

I STILL REMEMBER FIRST HEARING THESE rueful, exasperated sighs in the face of overwhelming perceived futility from my physician and nursing colleagues taking care of frail, older adults nearing the end of life. It was the first time I was forced to really confront what palliative care was, could be, or should be. My initial emotional reaction, I remember, was mostly one of groupthink nodding to these comments: it really did seem, from our perspective, like these families were being “unreasonable,” “stubborn,” and, above all, “difficult.” From our perspective, we were bandying terms like “widely metastatic,” “ejection fraction of 10-15%,” and “non-revascularizable.” How could these families not appreciate that more of the “do everything” panoply had clearly become more burdensome than beneficial? We all felt disheartened and helpless in the face of suffering. Fifteen formative years later, I believe that the phrase “palliative care” is still the most widely misunderstood medical term among not only the lay public (see: news coverage of any celebrity/politician choosing to “stop fighting” their cancer “battle” when opting to enroll in hospice care) but also physicians, who often Pavlovianly associate palliative care with imminent death. But, what I’ve come to realize as a practicing geriatrician and Saint Vincent Hospital’s palliative care medical director is that the families that we perceive to spar with us — those who “just don’t get it” — have often times never had someone actually sit down with them at any point of their loved one’s illness to assess their understanding of their disease, let alone offer a kind, but clear, prognosis or expected disease trajectory. I’ve observed that the common thread when contentiousness arises is that a physician has not tried to align with a cognitively and functionally vulnerable patient and their family on their overall goals for their treatment plan, even when they might have widely metastatic disease, severe HFrEF, or non-revascularizable ischemic heart disease. The data from a 2014 JAMA Internal Medicine review article bears this out, as seen through the facts here: • 69% of patients with metastatic lung cancer and 81% with metastatic colon cancer did not understand that chemotherapy was very unlikely to cure their cancer. • The first conversation about end-of-life care took place an average of 33 days before death for patients with metastatic lung and colorectal cancer. • 90% of hemodialysis patients reported that their physicians had not discussed prognosis. I would at this point offer forgiveness and a healthy dose of empathy for my physician colleagues and for myself as well. For even in someone who practices palliative medicine, it is never easy being present, trying to align competing cultural and religious differences, and trying to unravel years of family dynamics through a goals of care conversation. And very few physicians up until recently report having received formal training on how to hold goals of care discussions, with communication very much being a skill to be learned as a cen6

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tral line. I do not always navigate perfectly for sure. Inpatient medicine increasingly feels like a turnstile with frequent ports of re-entry, not enough time for well-meaning physicians to be present, and feeling shackled to the electronic patient. Often times we end up changing someone’s diuretic regimen from a pill to IV, back to the same pill at the same dose they came on, knowing that there is a ~35% chance they’ll be back within a month. And yet, the ecosystem in which we practice does not make it easy for us to ask our patients, “What do you think of all this? How do you see this all playing out?” It is often a dehumanizing experience to be a patient in the hospital, often with a runaway locomotive momentum of care plans that you don’t really, truly have a say in. Palliative care is a great many things, from aggressive symptom management to a bridge to allow for more services to more collaborative care. But, in essence, it is an active reflective process — “goals of care” discussion — that tries to align a patient’s medical plan with who they are as a person, mindful of their personality, background, upbringing, cultural preferences, and religious preferences. It is being present through active, shared-decision-making. It is asking, “What matters most to you in all this?” And, remember: Being a palliative care provider does not mean that you automatically deescalate everyone’s care. Far from it. Geriatricians and palliative providers are often the ones advocating for more care for an older adult, trying to overcome the bias of ageism. When we survey Americans, typically ~85% often say that they value quality of days over quantity of days. But, 85% is not 100% by my napkin math and we need to be comfortable in honoring a heartfelt care plan expressed by a patient who values something different than we might choose for ourselves or our families. We are all inundated with incessant multitasking, but I would urge all my colleagues to try to emotionally triage their time to allow for a five minute conversation with one patient, once a day, either in the inpatient or outpatient setting. For someone who has perhaps had frequent readmissions, or worsening frailty, you might ask, “What do you understand about all of this? What matters most in all of this to you?” I believe that only by normalizing these sorts of conversations upstream — not at 3 am — can we tint our perspective away from patients being “difficult” and “unreasonable.” + Gary Blanchard, MD Geriatrics and Palliative Care Medical Director, Saint Vincent Hospital Head of Kelley House, University of Massachusetts Chan Medical School


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Palliative Care

Domain 5 Rev. Msgr. Peter R. Beaulieu, MA, STIL

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FTER EXTENSIVE CONSULTATION AMONG VARIOUS

end-of-life organizations, a consensus among them coalesced into what has become known as “Clinical Practice Guidelines for Quality Pastoral Care.” Among the eight domains generated from that effort, covering the scope of palliative care, Domain 5 encompasses the spiritual, religious, and existential aspects that delineate quality in palliative care. One of those domains incorporates aspects of hospice and palliative care, which are related to the spiritual needs of the dying patient and their family. There are also methods to assess the need for spiritual care, communicating with the family about such needs, the role of the spiritual advisor, sensitivity toward cultural and religious diversity, and the need for specialized palliative care spiritual advisors to build relationships with area clergy.

THE AMERICAN SPIRITUAL & MEDICAL LANDSCAPE According to the late sociologist Peter Berger, in assessing the American landscape, he said, “India is the most religious country in the world, Sweden is the most secular country in the world, and America is a country of Indians ruled by Swedes.” And nowhere is that distinction best revealed than in healthcare. In multiple studies, patients want their physicians to discuss spiritual or religious beliefs with them, and while contrasting studies do acknowledge that physicians consider those questions important, seldom does that happen, even in discussions pertaining to end-of-life care — whether it’s in regard to continuing medical treatment or foregoing non-beneficial, even life-sustaining care. Thus, in many medical situations, and at the utmost during end-of-life care, the decisive questions are those ultimate matters regarding the patient’s understanding of the meaning of death and whether or not there is something beyond earthly life. For patients who believe more life is yet to come, it becomes a matter of how to best care for that hope, when most clinicians either do not share such ideologies or prefer to avoid those ultimate questions entirely and focus on the medical options (or, in some cases, lack thereof ).

MEDICAL DECISION MAKING Among all the possible situations wherein life or death decisions are necessary, at least in principle, most physicians would agree to a Jehovah’s Witness refusal of life-saving transfusions. Less recognized, but equally valid, would be the Orthodox Jewish patient refusing

to discontinue a treatment that the physician judges to be non-beneficial. Thus, in situations where a patient’s life is threatened by illness or the treatment is judged by the providers to be “causing the patient undue suffering,” those ultimate questions about what is divinely commanded, or should almost never be discontinued, often affects the care provided to those two groups. The same respect for such faith-based ultimate decisions should be accommodated for other religious groups, as well. Moreover, death’s meaning differs from the practicing adherents of a faith-based tradition and the predominantly secular nature of contemporary medical decision making.

THE DEFINITION OF SPIRITUAL VS. RELIGIOUS PERSPECTIVE The prospect of death almost inevitably prompts a more frantic search for answers to life’s ultimate questions: Who am I? What is life? Is there more to life after death? Does life have temporal meaning only or is there an eternal character to life itself? According to Dr. Christina Puchalski, “Spirituality is the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred." Religion, on the other hand, is primarily built upon the life and teachings of a recognized leader. Its adherents find in God, regardless of which name they use, answers to where they came from, why they are here, and what it all means. Religion represents the adherent’s faith as the ultimate answer to those questions. Even at the point of death, religious faith often fails to provide followers with definitive answers, but nonetheless, the life of faith constitutes a structure, a code of ethics, and a sense of purpose to a faithful patient’s life. The promise of an afterlife, a fundamental tenet of most organized religions, is another key influence for the religious that can often be threatened by a wrong decision regarding life-sustaining treatment, its refusal, or its withdrawal. While these two elements are often blurred, the apparent triumph of spirituality over religion can often result in generic, end-of-life care that might be more easily provided, but also should never be a substitute for the recognized religious practices which are the exclusive province of ordained clergy. Those who are so designated and endorsed by higher authorities are the only ones who can legitimately provide that religious care to those patients who believe it to be crucial to the prospect of more life to come. For anyone to imitate what are duly outlined formal aspects to end-of-life (which are divinely endorsed signs) and, instead, settle for merely spiritual or generic pastoral care, constitutes, at best, a dereliction of duty and, at worst, a pretense that flies in the face of properly caring for the dying, religiously affiliated patient. In such tragic situations, patients and their families are vulnerable and at the mercy of their caregivers who are duty-bound to ascertain what their dying patient believes and how best to support those in a time of transition, whether to a better life to come or to face the end of earthly life with as much peace as possible. Having engaged in ethics consultation and chaired the Ethics Committee at Saint Vincent Hospital for nearly 20 years, it has become clear to me that combining theological training with clinical ethics often reveals the overlooked impact that faith has in complex decisions as life reaches an end. +

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WORCESTER MEDICINE

Palliative Care

True Palliative Care: A Patient’s Perspective UMass Palliative Care Team Rebecca Kowaloff, DO

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MANZARO DIDN ’ T KNOW ANYTHING ABOUT palliative care when his wife of 47 years was diagnosed with cancer. It’s a good thing her oncology nurse did. Valerie’s cholangiocarcinoma had progressed with painful bone metastases and after hospitalizations and rehab, her nurse recognized she needed more support and coordination of her increasingly complex care. As caregiver, her husband Daniel needed it just as much. Pamela Lane, NP, and the rest of the outpatient palliative care team at UMass guided the couple through a serious illness that placed different burdens on each spouse. When her doctors recommended a new port for a stronger chemotherapy drug, Valerie refused and transitioned to home hospice care. The team helped Daniel to recognize when he needed more help at home, for which he remains grateful. Valerie died at home with Daniel by her side: “It was brutal, but I had help”. Daniel barely had time to process her death before he had another serious illness to contend with — his own. Doctors diagnosed him with pancreatic cancer, and he immediately found himself back in the palliative care clinic with Pamela and now Sara Lyon, RN, MS. He was hesitant to pursue chemotherapy after Valerie’s experience, but his team encouraged him to do so. His palliative care team worked alongside his oncology nurses, medical providers, and GI nurse navigator Miranda to check his vitals, monitor swelling in his legs, and make sure his port and chemotherapy pump were functioning properly. When he was hospitalized with a blood clot, his palliative team visited him in the hospital for seamless integration of care, a visit as much for the heart as for the body, as Daniel doesn’t have children. “Any time I have a problem, I call them, and they solve it… They have more time than a regular doctor’s office, they get right on it. When you’re sick, you don’t want to be doing all that stuff.” Daniel says compared to other doctors, the palliative care team is “a little more attentive, like you’re the only patient they have. They spend time on the phone with you.” They have straightened out medication issues with the pharmacy, titrated his pain medication to achieve a comfortable pain level, and given medications for symptoms and side effects, such as insomnia. “When it comes to meds, they know just what to do for you. That’s where the help really comes in,” he says. Even though he has received constant support, he’s only had to see them in person twice over the past six months, as the rest of his issues are dealt with via telephone,

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ANIEL

The Palliative care team is a little more attentive, like you’re the only patient they have

” something he especially appreciated when his pain medication was being titrated. Many seriously ill patients and their families don’t know about Palliative care or hold misconceptions that lead them to avoid it if referred. If offered what is in some hospitals now called “supportive care”, a team to help them navigate the many doctors and medications, to process complex information and their fears, and to help them access resources to ease the burden of care on their families, many more would accept such a referral. To make that change for patients, we first have to change our understanding as medical providers. Because cancer care is such a multidisciplinary endeavor, perhaps the palliative care team’s most important role for Daniel — whose only local support is his brother — has been as “a liaison between [my people].” They have “taken the pressure off ” to allow Daniel to focus his strength on treating, and now beating, his cancer — as his doctors have now deemed him cancer free. Especially amidst the loneliness left by Valerie’s death, Daniel says ringing the bell as he left UMass’ eighth floor cancer free was “the most uplifting thing.” Daniel is focusing on recovery, both physically and emotionally. He has increased his daily walk from one mile to two, and plans to work toward three this spring, as he also adjusts to a house, and a life, without his wife. Valerie taught him as much as she could about household management, an opportunity made possible by the guidance from palliative care and hospice about prognosis and progression. He continues to turn to the palliative care team as an ear to listen, especially when he gets new aches and pains and worries what might be causing them. He wishes more nurses referred patients to palliative care as “something in between nursing and hospice.” And he wants everyone to know that accepting palliative care doesn’t mean your time is coming to an end. Daniel is living proof of that. +

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Palliative Care

Music Therapy in Palliative Care Mary-Carla MacDonald, MA MT-BC FAMI Vandana Nagpal, MD FACP FAAHPM

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LI* WAS ROCKING, STRAINING, AND TEARING AGAINST

his restraints, sweat beading on his forehead, when we (MCM+VN) first met him. Eli had terrible anxiety; his family told us that he had worn holes in the carpet at home. Anxiety prevented him from getting treatment for his cancer before he ended up in the hospital. The agitation and restlessness in the hospital unfortunately led to physical restraints which worsened the symptoms and required medications that only were partially effective. The staff was exhausted and there was no time to waste. “What kind of music do you listen to? Can we listen together?” A quick nod and high intensity music started (MCM), matching his thrashing: “Immigrant Song” followed by “Moby Dick” by Led Zeppelin. Repeat, repeat! This was about getting a net of sound around and in him and with the help of music, slowly and carefully pulling him into the rhythm and therefore regulation. He started to entrain to the rhythm; the music hooked him. Next came “White Room” by Deep Purple and he allowed himself to lay back against the bed. Carefully and slowly, the tempo and intensity of music decreased with The Who, Pink Floyd, and more Zeppelin until his eyes closed and his breathing slowed. Now everyone could breathe. The music therapy sessions continued over the next few days allowing for deescalation of chemical and physical restraints and leading to increased engagement of Eli with his family and providers (VN). The treatment plan was formulated with input from everyone, and Eli was home by the next week. Sound is a powerful sense. When sound is organized into music, it addresses the limbic system directly. Rhythm, tonality (the organization of pitches into melody), and timbre (the voice, color, or quality of a sound) fire up large-scale neural networks throughout the brain (1). By selectively using the elements of music to prime the neuro-circuitry of resilience, we can induce the relaxation response (2), create empathic social connections through increased oxytocin from singing and improvisation (3), organize cognition and behavior, orient attention, increase motivation, access memory and integrate positive resources and coping skills (4). Through music, we can bypass cognition and reach people in crisis, even with altered mental status and communication disorders. That is why, even within the loud hospital chorus of alarms, beeps, overhead pages, and human voices, music therapy is powerful and effective. Music therapy (MT) is a person-centered, evidence-based discipline in which board certified therapists use music pur-

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posefully within the therapeutic relationship. At UMass Memorial Medical Center, it is a collaborative therapy which utilizes the patient’s own positive resources, relationship with music, and healthy core-self in combination with the multifaceted elements and functions of music to achieve greater wellbeing. MT has been shown to help with cognition, mood and can reduce pain, dyspnea, and stress responses (5). Music therapists are specialized providers with extensive training in providing supportive care because music can open up vast landscapes of feeling, memory, and pain, but can cause harm if not used judiciously and cautiously in a therapy session. The open dialogue, mutual respect and deep listening between the therapist and patient informs the music selection. Selected music acts as a friend to the patient and is the co-therapist — someone familiar with whom they already have a relationship. The therapist’s job is to facilitate a safe space and be a witness many times to raw emotion where the patient has agency in deciding the pace and length of the journey. The sessions are sometimes hard, charged with deep meaning, and other times they are lighthearted and joyous. There are also sessions where the support is more subtle like during a terminal extubation where music is in the background, providing emotional support and nervous system regulation for patients, families, and even teams. Palliative care is team-based care of people living with serious illness and their families. It is beautiful and challenging at the same time, as we carefully step, for some amount of time, into people’s lives when they are at their most tender and vulnerable. The relationship of palliative care and MT makes sense, as together they enhance the patient’s quality of life through patient/family-centered care, increased patient engagement, better symptom control, and legacy work. Music therapy availability in the hospital setting is variable across the nation. At UMass Memorial Medical Center, MT has been available for palliative care and neurology patients at the University site since 2019. We used MT successfully for varied reasons during COVID-19 surges and we hope to further grow the program through continued support. It is an integral part of the treatment plan, whether through opening the relationship or through symptom management. When Colina* woke up panicked and confused after weeks of intubation and ventilatory support for acute respiratory failure, the first sound that registered to her and centered her was that of an ongoing music therapy session in her hospital room. Later she told the team that it made her feel safe; she did not know that the music therapist (MCM) had been working with her the last few weeks, but her brain, body, and heart knew it. Such can be the great power of music therapy! +

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Palliative Care Music Therapy in Palliative Care Continued *Patient names changed to maintain anonymity Mary-Carla MacDonald, MA, MT-BC, FAMI is the music therapist in the Palliative Care Division and in the Neurology Department at UMass Memorial Hospital in Worcester, MA. She is senior lecturer at Lesley University in the Expressive Therapies Department of the Graduate Schools for Arts and Social Sciences. Email: marycarla.macdonald@umassmemorial.org Vandana Nagpal, MD, FACP, FAAHPM is Associate Professor of Medicine at the UMass Chan Medical School, and Associate Chief for the Division of Palliative Care at UMass Memorial Medical Center in Worcester MA. Email: vandana.Nagpal@umassmemorial.org

REFERENCES

1. Alluri, V., Toiviainen, P., Jääskeläinen, I. P., Glerean, E., Sams, M., & Brattico, E. (2012). Large-scale brain networks emerge from dynamic processing of musical timbre, key and rhythm. NeuroImage, 59(4), 3677–3689. https://doi.org/10.1016/j.neuroimage.2011.11.019 2. Thoma, M. V., Marca, R. L., Brönnimann, R., Finkel, L., Ehlert, U., & Nater, U. M. (2013). The Effect of Music on the Human Stress Response. PLoS ONE, 8(8). doi:10.1371/journal.pone.0070156 3. Keeler, J. R., Roth, E. A., Neuser, B. L., Spitsbergen, J. M., Waters, D. J., & Vianney, J. (2015). The neurochemistry and social flow of singing: Bonding and oxytocin. Frontiers in Human Neuroscience, 9. doi:10.3389/fnhum.2015.00518 4. Olszewska, A. M., Gaca, M., Herman, A. M., Jednoróg, K., & Marchewka, A. (2021). How musical training shapes the adult brain: Predispositions and neuroplasticity. Frontiers in Neuroscience, 15. https://doi.org/10.3389/fnins.2021.630829 5. Reidy J, MacDonald MC. Use of Palliative Care Music Therapy in a Hospital Setting during COVID-19. J Palliat Med. 2021 11; 24(11):1603-1605. PMID: 34382835.

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The Role of the Pharmacist on the Palliative Care Team Symptom/Pain Management Anna K. Morin, PharmD

T

OXFORD DICTIONARY DEFINES TERM PALLIATIVE as “a medicine or medical treatment that reduces pain without curing its cause” (1). The World Health Organization further defines palliative care as a team-based approach that is patient-, family- and caregiver-centered and focuses on improving quality of life by providing relief from pain and addressing physical, psychosocial, emotional and spiritual needs (2). Palliative care has evolved significantly over the past several decades and can be provided as the main goal of care or in tandem with curative treatment. An interdisciplinary team is required to address the various needs of the patient receiving palliative care, and because medication therapy is usually a core part of a palliative care treatment plan, this team includes pharmacists in both inpatient and outpatient settings. Hospice care is an extension of palliative care that provides compassionate care for people in the last phases of incurable disease so that they may live as fully and comfortably as possible (3). The role of the pharmacist on the palliative care team, which may also include physicians, nurses, caregivers and spiritual counselors, is diverse and can encompass a number of different roles and responsibilities as part of all aspects of the medication use process. The American Society of Health-System Pharmacists has published guidelines that define the role of the pharmacist engaged in the practice of palliative and hospice care (3). In addition to ensuring the timely provision of medications, pharmacists can play a key role in policy and procedure development, formulary management, and medication therapy management services, including assessment of medication plans, education regarding possible side effects or drugdrug interactions, and the detection and management of drug-related problems. Specialized training or advanced degree programs and postgraduate year 2 (PGY2) residency opportunities are available to train pharmacists to develop, participate in and support comprehensive services for patients in pain and those with palliative care needs (3,4). Palliative care regimens are highly individualized to meet each patient’s needs. Working as a member of the palliative care team, pharmacists can support the development of individualized treatment regimens and help to optimize both pharmacologic and nonpharmacologic management to improve patient outcomes while reducing costs and unnecessary medications.3,5 As part of their training and responsibilities, pharmacists assess the appropriateness of medication orders and ensure that the patient receives safe and effective care in a timely manner. Many medications can pose administrative challenges for patients with an interruption in oral access, due to nausea and vomiting or other gastrointestinal issues that may develop secondary to many chronic conditions. Pharma-

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cists can assess and make recommendations for alternative routes of medication administration to improve adherence and overall bioavailability. If necessary, some drugs can be compounded into solutions, topical creams or ointments, or parenteral, rectal, or transdermal dosage formulations (3,5). A retrospective study evaluating pharmacist intervention and patient outcomes in the palliative care setting found that acceptance of the pharmacist’s recommendation was a significant predictor (p<.001) of desired clinical outcome.6 Recommendations made by pharmacists with experience and training in palliative care included change in dose, medication, route or time of administration and initiating new or discontinuing existing medication therapy. Overall, 90% of recommendations were accepted with 80% of patients achieving better management of symptoms such as anxiety, constipation, depression, nausea and vomiting, and pain (6). Improving patients’ quality of life and maintaining dignity and comfort during the transition into palliative care are at the center of any care plan. In collaboration with the interdisciplinary team, pharmacists, particularly those with special training or expertise in pain management or palliative care can play a vital role on the palliative care team by serving as patient advocates and managing and improving all aspects of the medication-use process in a variety of patient care settings. + Anna K. Morin, PharmD Associate provost – Worcester/Manchester Massachusetts College of Pharmacy and Health Sciences REFERENCES:

1. Oxford Dictionary. Palliative. Available at: https://www.oxfordlearnersdictionaries.com/us/ definition/american_english/palliative; accessed Mary 29, 2022 2. World Health Organization. WHO definition of palliative care. Available at: https://web.archive. org/web/20031004221126/http://www.who.int/ cancer/palliative/definition/en/; accessed March 29, 2022. 3. Herndon CM, Nee D, Atayee RS, et al. ASHP guidelines on the pharmacist’s role in palliative and hospice care. Am J Health Syst Pharm. 2016 Sept 1;73(17):1351-67. 4. Palliative Care Pharmacist. Resources: career development. Available at: https://www. palliativepharmacist.org/; accessed March 29, 2022. 5. Demler, TL. Pharmacist involvement in hospice and palliative care. US Pharmacist.2016;41(3):HS2-HS5. 6. Wilson S, Wahler R, Brown J, et al. Impact of pharmacist intervention on clinical outcomes in the palliative care setting. Am J Hosp Palliat Med. 2011;28:316-20.

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Palliative Care

Formalizing a Palliative Approach to Dialysis Care Ashley Rotella, BSN, MSN

T

HERE ARE APPROXIMATELY

786,000 individuals in the United States living with ESRD (1). The burden of this disease often has a profound impact on the patient and their family. Some of this burden is related to the symptoms of ESRD, the ESRD therapy, symptoms of the patient’s comorbidities, and side effects from medications. For the patient, these encumbrances significantly impact their quality of life including their independence, relationships, interests, and profession. Patients often experience a multitude of emotions and feelings throughout their disease process. In terms of long-term treatment, patients with ESRD require renal replacement therapy (RRT) to sustain life. While there are more options for RRT than ever before, each option has associated risks and benefits, and must be fitted to the individual. Patients disproportionately choose in-center hemodialysis requiring the patient to receive treatment at a center within their community. Unfortunately, the truth is that the dialysis schedule is demanding, and the patient will spend a minimum of ten hours per week connected to a dialysis machine to remove waste and extra fluid from their body. Following the in-center hemodialysis procedure patients often feel exhausted and will require several hours to recover. From initiation through the continuation of RRT, patients are faced with many challenges that can lead to decreased quality of life and depression. In fact, approximately 25% of the ESRD population suffers from depression (2). When patients require RRT, a strong nurse-patient relationship commences. Patients spend several hours a week with the nurse over many months to years while receiving dialysis. Upon initiation and continuation of RRT, patients often feel their quality of life has been negatively affected and fear expressing these feelings to their family could impact their relationships. The dialysis nurse bears witness to the discomfort patients experience, from the physical side effects of the procedure (nausea, hypotension, cramping, dizziness, tiredness) to the psychosocial challenges (relationships, transportation, finances, diet, lifestyle). Many dialysis nurses experience moral distress related to the burden dialysis places on very sick patients. The nurse often serves as a confidante to the patient while observing the patient’s burden and feels helpless as to how to sup-

port the patient in their very real distress. The moral distress of the nurse could be reduced with the addition of a palliative approach to dialysis care for the patient. To further validate the concept of moral distress among dialysis nurses, recently a patient with late-stage dementia and co-morbidities, including chronic respiratory failure with a permanent tracheostomy and a permanent percutaneous endoscopic gastrostomy tube, was initiated on hemodialysis. The patient had a central venous catheter as their primary access and experienced infections due to adherence issues with catheter care protocols. Due to baseline confusion, the patient required restraints around the clock to avoid dislodgement of devices. Upon arrival to dialysis, the staff would medicate the patient with benzodiazepines to safely and adequately perform the dialysis procedure. Additionally, the patient resided in a nursing home and had passive involvement from family. The dialysis nursing staff felt a significant amount of moral distress while caring for this patient as they felt continuation of dialysis was causing more harm due to concerns for the patient’s safety and malalignment with the patient’s goals of care. The dialysis nurses advocated for advanced care planning for this patient to reduce pain and suffering. In short order, a palliative care consult was placed and ultimately the decision was made to discontinue dialysis. This case is one of many that come through the dialysis department every year and is emblematic of the moral distress among nurses and demonstrates the nurse’s role as a patient advocate. Although the National Kidney Foundation (NKF) recognizes the need for board certified palliative care providers to be a part of the patient’s . this population. The rate of palliative care consults among patients diagnosed with CKD and ESRD is substantially lower than patients diagnosed with cancer or dementia (3). A board certified palliative care provider that is trained to care for individuals diagnosed with a serious chronic illness would be a tremendous addition to the patient’s care team by enhancing the patient’s quality of life and reducing suffering. The need to formalize a palliative approach to dialysis care has received recognition and endowment by many throughout the healthcare industry. The use of palliative care for patients with ESRD remains an area of opportunity to greatly improve quality of care. Healthcare organizations must work together to delineate resources, create processes, and substantiate expectations for advanced care planning and palliative care support for patients with ESRD. + Ashley Rotella, BSN, MSN is the Hemodialysis and IV Resource Nurse Manager at UMass Memorial Medical Center and a DNP student at UMass Chan Medical School, Tan Chingfen Graduate School of Nursing. REFERENCES

1. National Institute of Diabetes and Digestive and Kidney Disease. (2021, September). Kidney disease statistics for the United States. Kidney Disease Statistics for the United States | NIDDK (nih.gov) 2. Kimmel PL, Cukor D, Cohen SD, Peterson RA. Depression in endstage renal disease patients: a critical review. Adv Chronic Kidney Dis. 2007;14(4):328-334. doi: 10.1053/j.ackd.2007.07.007 3. Abdel-Rahman, E., Metzger, M., Blackhall, L., Asif, M., Mamdouhi, P., MacIntyre, K., Casimir, E., Ma, J., & Balofun, S. (2021). Association between palliative care consultation and advanced palliative care rates: A descriptive cohort study in patients at various stages in the continuum of chronic kidney disease. DOI: https://doi.org/10.1089/jpm.2020.0153 MAY / JUNE 2022

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Palliative Care

What Mrs. T Taught Me Pawina Subedi, MD

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AUGUST OF MY INTERN YEAR WHEN I FIRST MET with Mrs. T, a pleasant young female in her mid-50s with a history of alcohol use. She had been admitted overnight for severe abdominal pain. An upper GI endoscopy confirmed alcoholic gastritis. As she began feeling better, we started planning for her discharge. I discussed her results and my concerns about the effect alcohol was having on her health. She said I had given her a lot to think about and that she would avail herself of the provided resources when she was ready. It was about 7 a.m. on a cold December morning in the medical ICU when I met Mrs. T again. She had developed symptomatic hyponatremia, in part resulting from continued alcohol use. I was disappointed, but not terribly surprised. I shared my previous experience taking care of her with my ICU team. As her hyponatremia improved, she was transferred to the medical floor and subsequently discharged in stable condition after three days. About five months later I was conducting sign-out for a patient with cirrhosis and severe C. diff colitis. Yes, Mrs. T had returned. When, how and why had she developed cirrhosis? As I entered her room, I was stunned to see a now icteric Mrs. T with generalized edema, swollen parotids, and a clearly altered mental status in the throes of hepatic encephalopathy. It turned out that she had been admitted three times since our last encounter in the MICU. She had continued to drink and was no longer a candidate for liver transplant. Since her disease process was advanced and she did not have capacity for medical decision making, the palliative care team came onboard. We contacted her healthcare proxy — her best friend, Ms. V — who told us she had not seen or heard from Mrs. T in the past three months despite multiple attempts to get in touch. I was not prepared for what Ms. V had to say next. It turns out Mrs. T had been battling depression for a few years, but it had worsened over the months as marital turmoil had resurfaced. She had taken to heavy drinking as a coping mechanism. Her hospitalization in August had served as a wakeup call for Mrs. T and she had been determined to cut down on her drinking. Her father, who was her pillar of strength, had been helping her through this. Things spiraled downward quickly after his sudden death from a heart attack and she went back to drinking. The last time Ms. V had seen her best friend was during her father’s funeral. Things got even worse after her divorce was finalized, and she lost the custody of her three children. She had become homeless thereafter and later moved in with a friend. I could not believe how much she had been through. Her current medical issues seemed to be just the tip of the iceberg. It felt like we were putting a Band Aid on a bullet hole, so to speak. It struck me how little I really knew about Mrs. T, how unaware I was of her struggles and how in

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my ignorance I had failed to see why her habits remained as so. Ms. V told us that the Mrs. T she knew, her best friend, would not have wanted anything heroic and her code status was changed to DNR/DNI. I asked Ms. V if Mrs. T would have wanted us to contact her family or friends. Perhaps they would want to know that Mrs. T was in the hospital. I was unable to find any phone numbers in the system apart from hers. But Ms. V said that her family did not want anything to do with her nor did her friends. I do not remember much about what I did that afternoon after our meeting concluded. I must have reached home somehow. I struggled trying to fall asleep that night as a myriad of thoughts occupied my mind. Had I known what she was going through, could I have intervened somehow? Would things have turned out any differently if all those times she had been admitted to the hospital, I had taken care of her and learned more about her? Maybe I could have asked psychiatry to see her. Maybe I could have requested our social worker to help with her disposition. Or, maybe — just maybe — she would have confided in me about what was going on in her life. I felt a very strong sense of guilt, as if I had failed her. How could I have not seen this coming? How could I have not anticipated this? As medical professionals, we are trained to save lives. Then, how did we fail her? How did I not see this sooner? Even with all these modern medicines and interventions, why is there still so little she could be offered? How could we be so helpless? I could not keep myself from imagining a scenario in which some intervention had happened and the outcome was different. Mrs. T went on to develop progressive renal failure and was discharged to home with hospice. To this day, I feel a strange sensation in my chest each time I pass by the room that she last occupied. Strangely, perhaps by some unknown forces, none of the patients that I have taken care of since has been assigned that room. But I take some solace in thinking that she was comfortable and with her beloved friend in the days that followed. Whenever I am faced with a patient’s demise, I feel like a part of me goes with them. Death is the inevitable truth that no one wants to necessarily think about. Working in the medical field, especially with the pandemic, I have come to respect the role of palliative care — the team faced with the daily challenges of providing comfort near the end of life. It was Mrs. T who introduced me to this indispensable medical field and for this I am forever grateful to her. + Pawina Subedi, MD, PGY3 Internal Medicine Residency, St. Vincent Hospital

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Palliative Care

Communicating in the ICU What a Medical Student Learned From Researching Clinician-Family Communication for Patients With Critical Illnesses Connie Ge, MS4

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URING MY FIRST OBSERVATION OF A GOALS-OF-CARE FAMILY

meeting as a first-year medical student, the conversation was so raw and honest that I still remember seeking refuge in the ICU supply closet afterward to collect my thoughts. I had never talked about the value of life or the understanding of death so openly, nor had I any personal experience with difficult health outcomes in family or friends. Rather, I was just there as part of a research project centered on examining clinician-family communication, and therefore found myself sitting on the sidelines of dozens of these meetings over the next few years. As part of our project, we wanted to explore the different ways clinicians lead family meetings. In my role, I was able to see how a variety of clinicians communicated and I gained insight into the answers that families responded best to and found helpful in decision-making for their loved ones. With this exposure to goals-of-care meetings, I started to define for myself what approaches were “good” or “bad.” “Good” meant that the clinician genuinely listened to family members’ questions and answered them directly. They responded with empathy. They explained the relevant clinical picture and left space for questions. They partnered with family members and treated them like decision-making equals by recognizing the family member’s expertise on and knowledge of the patient. In contrast, during “bad” encounters, clinicians steamrolled through the conversation or sometimes made insensitive comments. Other times, clinicians appeared uncomfortable and dodged difficult questions. I picked up on moments where the words spoken were not thoughtful and could have been improved. I promised myself that I would work to be a better communicator, to inspire confidence in my patients and their family members, and to support them through these tough decisions. Our formal analysis of the clinician and family conversations largely supported the anecdotal evidence I was starting to compile and internalize. During my clinical rotations, I drew on my research experiences to examine similar complicated conversations in other settings, hoping to learn how to lead these meetings myself. As my clinical year progressed, I took a more active role in conversing with patients and their families. I started to make some small strides: a patient thanking me for answering their questions; an attending complimenting my ability to relay information and explain medical concepts. I attributed this progress to my early exposure to goals-of-care meetings and I began to see how my actions could directly help patients and their families. Then, I met Anna (named changed for privacy). Anna was a young woman who was admitted for difficulty breathing. She was worried she had an infection or, worse, a heart attack like the one her father had recently suffered.

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I found out the following day that she had metastatic ovarian cancer. From the primary team, we knew that Anna’s workup would include a tissue biopsy and further imaging to stage her disease. I checked in with Anna later that morning. I asked if she understood the next steps and what questions she may have had. “I’m okay, thank you,” she said immediately. She paused, “Well… They told me this morning I have a mass in my stomach. I guess that this means it’s cancer and it’s spread to other places already.” I nodded as she continued. I tried to recall the specifics of her scan and the report, thinking that she may have wanted to know more details. “What I’m wondering is — and I know you might not have this answer — but what does that mean?” I stopped nodding. I knew I should have anticipated this question, but somehow, I didn’t. Anna didn’t seem to notice that I’d frozen. “Does it mean that it’s really bad?” She looked at me. “Am I going to die?” I can’t remember the specifics of what I said, other than telling her, “I don’t know” and “We’ll have more answers soon” before retreating from her room. I do, however, recall very vividly how ashamed I felt in that moment. I had seen so many serious illness conversations just like this one and knew the literature well in terms of what clinician responses are most helpful to patients. However, now confronted with these questions directly, I was unable to access that knowledge and instead failed to help a patient who was searching for answers in the face of terrible uncertainty. I have thought back to this interaction many times since. One conclusion I’ve drawn is that, in pushing myself to prove that I could be a great clinician communicator, I was building on an unstable foundation. In my early days of listening to family meetings, I had started identifying what made for empathetic communication, but I did not have enough practice leading this conversation myself. I’ve since realized that true knowledge comes from experience, and this experience takes time to develop. During my research, I’ve seen that even seasoned clinicians have moments when they may falter. For now, I am trying to approach these interactions with greater humility and empathy, knowing that the expert in what families or patients are looking for are the families and patients themselves. There is so much to be learned from them, and I know I have a lifetime to shape that experience. + Connie Ge, BA, is a 4th year medical student at the UMass Chan Medical School. Email: connie.ge@umassmed.edu

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From the Archives

Legal Consult

Terminal Care for Incurable Cancer Victims

Caretakers of the Elderly: Risk, Neglect and Injury

Worcester Medical News Vol. XII, No 5, Nov. 1947. Pg 8

Peter Martin, Esq.

B. Dale Magee, MD, WDMS Curator

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“AUTUMN FEVER,” OUR president has, with characteristic clarity of thought and kind urge, touched upon needs and opportunities for constructive service as a society to the communities which support us and of which we are a part. The president nods to one of our members — who not only recognizes a problem but does something about it. Dr. Dunlap threw the weight of his influence and liberally gave his time to the April campaign in support of the American Cancer Society (Massachusetts Division) and it seems only fair that our society and the public should know something of what the raised money is doing for the incurables. An intelligent approach to the problem is on the horizon, although we’re still a far cry from “adequate terminal care.” Not many understand the extent of the problem, partly because of pride and sensitivity, and partly because in Massachusetts cancer is not yet a reportable disease. It seems that next to the doctors, social service workers and home nursing organizations would be as close to the problem as anyone. They were called into counsel and under rigid agreement to report their use of funds and tentative allotments were made on as nearly a statewide basis as could be attained through responsible groups willing to cooperate. It is now the third year this work has been under way; so far, some 500 cases have been aided according to their specific needs by home nursing, hospitalization, transportation for treatment, grants to supplement income, purchase of apparatus, food and medicines, and care in nursing homes. Funds have also been allotted to the only two institutions in the state dedicated to this type of case. Many such cases are helpless and impoverished, requiring aid in all facets. Others have relatively minor material needs, yet all deeply need the assurance of neighborly love and concern for their plight. How can the Medical Society help? Let us think it through and evolve a “Worcester County Plan.” I wholeheartedly believe that nursing homes and/or small sanatoria — supplemented by public support, if need be — are all part of the answer. + E. L. Hunt

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N HIS INITIAL EDITORIAL,

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OES PLACING A VULNERABLE ELDER AT HIGHER RISK OF

illness constitute an injury to that person, leading to criminal liability? Are administrators of long-term care facilities criminally liable if they make policy decisions that increase risks to residents of such facilities? Last year, a trial court decision regarding the Soldiers’ Home in Holyoke answered both questions in the negative. The decision, reached in the context of the Covid-19 pandemic, should reassure elder care providers and facilities that their efforts to render adequate patient care will not be considered criminally blameworthy, particularly when implementing infection control measures. The matter arose during the early weeks of the Covid-19 pandemic, when two administrators at the Soldiers’ Home decided in the face of staff shortages to merge two dementia housing units. The Commonwealth indicted the administrators on five counts of elder neglect and permitting serious bodily injury to an elder, in violation of Massachusetts General Laws chapter 265, sections 13K(d1/2) and (e). The administrators filed motions to dismiss the indictments. The Hampden County Superior Court heard the matter in November of 2021 and dismissed both indictments in their entirety. The defendants were the superintendent and the medical director of the Home, neither of whom directly provided medical care to the Home’s residents. As the pandemic developed in March of 2020, they adopted infection control measures to reduce residents’ risk of contracting Covid-19. A particularly difficult population was dementia care residents, who could not effectively comply with handwashing, social distancing, and masking requirements. These residents, including the five residents allegedly harmed by the two administrators’ decision to merge the dementia units, would commonly wander through the common areas of their unit, and go into other residents’ rooms. The Massachusetts Department of Public Health told staff at the Home that it was not appropriate to confine these residents with dementia to their rooms even as an infection control measure. Prior to the merger of the dementia units, all five of the dementia residents had already been exposed to one or more other resident who had tested positive for Covid-19. When nurses began to not show up for work due to fear of infection, and a request for National Guard staffing assistance was unsuccessful, the administrators ordered the merger of two units, with residents who had asymptomatic Covid-19 segregated into a dining room outfitted with beds. The five dementia residents were moved into this dining room, as they had already been exposed to Covid-19. Grand jury testimony did not establish that

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As I See It Caretakers of the Elderly Continued any of the five suffered from malnourishment or dehydration while in the merged unit. Grand juries must find probable cause that the defendants committed the applicable offense. This probable cause standard is less than that required to secure a conviction but is more than “mere suspicion.” The statutes in this matter made it unlawful for a “caretaker of an elder” to “wantonly or recklessly” permit serious bodily injury to an elder, or to wantonly or recklessly commit or permit another to commit abuse, neglect or mistreatment of an elder. The “serious bodily injury” alleged here were first, an increased risk of contracting Covid-19 and second, dehydration and malnutrition. The court quickly dismissed the notion that increased risk of contracting Covid-19 was a serious bodily injury: “there must be a discernible ‘bodily injury’ in the first instance.” Under standard canons of statutory interpretation, the Commonwealth’s position here would fail to give meaning to each word in the legislation and would render the “bodily injury” language superfluous. As to the alleged dehydration and malnutrition, the evidence presented to the grand jury did not create more than a mere suspicion that the five residents suffered from these conditions. The court found the neglect argument “less weak” because the statutory language provides that a substantial likelihood of harm created by a caretaker of the elderly by itself may constitute neglect. However, because prior to the merger of the units, the five residents had wandered throughout all of the units, they had already been exposed to Covid-19 positive residents, increasing the likelihood of harm to them. Therefore, the unit merger itself could not have created the substantial likelihood of harm. The court went on to rule that neither the superintendent nor the medical director were “caretakers” of an elder, as required by the statutes. Evidence presented to the grand jury did not establish that either individual rendered direct or substantial care to any of the five residents. The statute defining the Home’s superintendent and medical director states that the former is to be the administrative head of the Home with authority to appoint a medical director, who in turn has responsibility over the Home’s medical, surgical and outpatient facilities and makes recommendations to the superintendent regarding physician, nurse, and medical staff appointments at the Home. The court declined to adopt the Commonwealth’s argument that facility administrators rather than actual care providers could be held criminally liable under either statute cited in this case. This matter arose in the specific context of the Covid-19 pandemic and under specific state statutes, but it holds more general lessons for those providing elder care services. First, the decision reiterates the commonsense notion that administrative personnel are not direct care givers. Second, the decision provides yet another example of how causation in a complex medical institution can be difficult to prove. Third, it articulates the idea that increased risk is not itself bodily injury. All three notions support a realistic level of liability for those running health care facilities for the elderly. + Peter Martin, Esq. is a partner at Bowditch and Dewey.

Talking to Patients: A Lecture Series in Moldova Paul L. Hart, MD

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HEALTHCARE INTERNATIONAL (JHI) was an outstanding Non-Governmental Organization (NGO) that would contact small medical communities and ask if they needed assistance with medical education. Then the JHI would send volunteers to present talks on the topics requested and clinics held with the local providers. Many of the missions were to countries in the former Soviet Union. A group of 30 physicians, nurses, and healthcare aides, working with JHI would present the lectures. The same lectures. would then be repeated, usually five to six times to different groups. Moldova was perhaps the poorest of the countries in the former Soviet Union, and the coordinator there had requested a lecture on patient communication. I was to be the presenter. My topic: “Talking to your patient.” The first time I gave this talk, I began by asking the question, “If a patient you knew had advanced cancer (and whose death was quite plausible) asked you, ‘doctor, do I have cancer, and will I die from it?’ how would you reply?” In the past, if I had asked the participants a simpler question such as, “What medication do you usually use first for hypertension?” I would get a few hands with a quiet room. But not this time. Once I posed the question and waited for replies, I noticed a change in the room. The participants were suddenly more alert, some seemed anxious, and others talked to their neighbors. The first response from the audience was, “No, I would tell them that they were going to be alright.” “If we revealed their chances, they would become more distressed and die sooner,” another observer replied. “Why should I make them feel uncomfortable?” someone else shouted out. The room was palpably energized. Not one of the participants wanted to let their patients know the actual status of their health. Some of the participants actually seemed angered by my question. I then asked another question: “If this was you, would you want to know?” “Yes” was a nearly universal answer. EWISH

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As I See It Talking to Patients Continued As I probed a bit more, none of the providers were aware of Kubler Ross and her work on stages of dying in terminally ill patients. It turned out to be common practice among these providers not to present the patient with the facts about their situation. I suggested that they may want to consider a change in their approach and gave some information about how this situation was approached in the U.S. I repeated this lecture a number of times. The next time I began by saying that what I was going to discuss was a little different from how medicine was practiced in their community. This did not work; I encountered the same reply and level of anxiety in the room. I went as far as to say my talk may be controversial, but please look at these ideas as just ideas and not a recommendation to change your practice pattern. Still, the response remained the same. I had always considered these replies wrong and not in the best interest of the patient, until I began writing this article. The rather uniform responses from our overseas colleagues demonstrated that not all doctors are following what is standard practice in the United States. Without categorizing different approaches as right or wrong, the differences do underline what our duty is to our patients facing the end of life, and why we would consider approaching our patients in a manner different from that we ourselves would prefer. + Paul L. Hart, MD, Retired Family Physician, Sterling, MA Email: paulhart46@yahoo.com

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Essay Contest EDITORIAL NOTE: The Meyers Health Care Institute is a joint endeavor between the UMass Chan Medical School, Reliant Medical Group and Fallon Health. Its mission, as noted on its website, is to conduct innovative, population-based research and education to generate and disseminate new knowledge and promote evidence-based healthcare across the lifespan for the benefit of our community and beyond. Part of its mission involves education of medical students, as described below. In collaboration with the Meyers Health Care Institute, Worcester Medicine is pleased to publish the entries submitted by the first and second place winners of this year’s essay contest for medical students. These essays provide us with the personal perspectives and opinions of two medical students at the start of their medical careers, providing us with insight into their solutions for the challenges we face in health care delivery.

The Meyers Health Care Institute Health Policy Essay Contest U.S. expenditures on healthcare now exceed $4 trillion per year, yet our health care system faces an expanding number of challenges. Understanding these challenges has become intrinsic to the practice of medicine. Incorporating health policy concepts into the medical student curriculum at the UMass Chan Medical School has long been a priority. In support of such efforts, over the past 25 years, the Meyers Health Care Institute has coordinated an educational program for all third-year students called, “Health Policy and the Practice of Medicine,” serving as an introduction to a broad range of topics, including health care coverage, financing, organization, delivery, quality, access, and equity. Students learn from national leaders in health policy and participate in small group discussions where they confront and debate real-life situations in which policy and the care of patients intersect and sometimes collide. Coinciding with the 25th anniversary of the Meyers Health Care Institute and the 25th year of this important health policy educational initiative, the Institute sponsored an essay contest for third year UMass Chan Medical School students focusing on personal experiences (clinical or otherwise) relating to a contemporary health policy issue. In this issue of Worcester Medicine, the essays of the first and second prize winners are published. In her essay entitled “A Fresh Start,” Megan Hansen shares an experience during a year of oncologic research at the National Institutes of Health. Megan describes why being able to provide not only free oncologic care but also wraparound services to stabilize an uninsured patient’s housing, support her mental health, and address her substance use, “feels a bit like a miracle to (her) — but it shouldn’t.” Shervin Rezaei was inspired to write his essay, “Reflections on the Cost of Statins,” by a quote from Canadian physician Norman Bethune: “Medicine, as we are practicing it, is a luxury trade. We are selling bread at the price of jewels.” We hope you enjoy these two essays chosen from many outstanding submissions. We are especially appreciative of the efforts of our Meyers Health Care Institute essay contest selection committee: Drs. Angela Beeler, David Brumley, Robert Kossack, and Linda Weinreb. + Jerry H. Gurwitz, MD Ron Adler, MD The Meyers Health Care Institute ( formerly Meyers Primary Care Institute) was established in 1996 by the UMass Chan Medical School, Reliant Medical Group, and Fallon Health as a joint endeavor with a mission to pursue research and educational activities to improve the health and health care of populations and communities.

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1st PLACE

Essay Contest Winners Health Policy and the Practice of Medicine Essay Contest UMass Chan Medical School and the Meyers Health Care Institute

A Fresh Start Megan Hansen

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WAS EXHAUSTED.

THE COVID-19 PANDEMIC HAD MADE my third year of medical school a more challenging experience than I had anticipated. Balancing my time between caring for patients and studying for standardized exams forced me to make decisions that did not sit well with me. I missed my family, and I worried about them. I felt trapped in a hospital while feeling pulled to work on climate change, or racial inequity, or any of the most pressing challenges of 2020. I felt inept and helpless. I was perhaps most exhausted with the U.S. healthcare payment system. I watched patients bargain over every CT, every blood draw, doing mental math, determining how much each test would set them back. I even passed an afternoon with a patient who was dying from cancer and spent his final days calculating how much medical debt he would be leaving behind. I felt the dollars and cents slowly draining the humanity from a field that would otherwise be so wonderfully human. Several months later, I was a few weeks into a year of oncologic clinical research at the National Institutes of Health (NIH). My sense of awe at the place had not yet waned — and really, it still hasn’t. As my attending and I walked to see a new patient in the oncology unit, I found myself taking it in: the state-of-theart facilities, the clean, light-filled atmosphere, and the large, spacious hospital rooms were a stark contrast to the noisy, overcrowded, understaffed hospital where I had completed my Internal Medicine rotation just a few months ago. We knocked on the door and introduced ourselves to Tanya. She was only 30, but she was gaunt, her face lined with premature signs of age. Her eyes darted frantically around the room, wide and unblinking. Her hands never stopped moving, nervously picking at her skin or tapping her leg. A bag of blood was hanging from an IV pole, slowly infusing into her arm. As we got closer, I could see several large, violaceous lesions on her face, arms, and thin legs. Tanya had HIV and Kaposi sarcoma, a cancer that can arise in persons with immunodeficiency. Kaposi is rare in women. It was, unfortunately, not the only unlucky thing to happen to Tanya. She had been homeless since age 14, in and out of shelters, and had trouble staying in one place due to schizophrenia and drug use. She had not spoken to her family in years and had no support system. She was hospitalized because she had been vomiting blood and was now symptomatically anemic and was referred to the NIH for potential participation in a Kaposi clinical trial.

My attending explained to Tanya that she had a type of cancer that can affect the skin and internal organs (including the GI tract, causing bleeding) and that her cancer was due to her HIV. We explained that it was curable with appropriate treatment, but that she would need chemotherapy and antiretrovirals. In addition, she would need to take antipsychotics and we would refer her for a drug treatment program if she was interested. As my attending outlined the steps ahead — including inpatient hospitalization, chemotherapy, medications, psychiatry consults, social work consults, scans, blood draws, paperwork — Tanya looked increasingly panicked. “I have to go,” she said, and moved to take the IV out of her arm. My attending placed her hand on Tanya’s arm and smiled reassuringly. “Hold on — I haven’t gotten to the good part,” she explained. She proceeded to tell Tanya that medical care — and all related services — at the NIH are completely free of charge. Not only would she not receive any bills for her hospital stay, but her chemotherapy, antiretrovirals, antipsychotics, and every outpatient clinic visit for as long as she needed care would have no associated costs. She did not relax entirely, but I saw Tanya’s face change as she realized the magnitude of what this could mean for her. Over the subsequent weeks, I saw Tanya slowly begin to improve. The lesions faded as the chemotherapy took effect, her hemoglobin stabilized, her paranoia waned as her new antipsychotic regimen took effect, and we began to build trust. She even, with social work’s help, made plans to reconnect with her family when she left the hospital. She was discharged a few weeks later, optimistic about her plans to live with her sister. I often think about the stark contrast between medical care at most institutions in the U.S. and medical care in a place in which patients know they will not have to pay. For Tanya, a woman for whom the system had often been unkind, her cancer diagnosis gave her a second chance and allowed her to begin to trust the medical system. She will need more than free medical care, and it will be too easy for her to fall through the cracks in a country without a strong social safety net. However, a diagnosis that would have surely been a bankruptcy sentence for her — as it is for over 860,000 people in the U.S. annually (1) — became a chance for her to make contact with an institution able to lift her up. Yet, most people in this country do not have access to government-run clinical trials that make such care a reality at the NIH, and there are millions of patients a year who are in dire need of payment reform. A transition to a single payer system would diminish overhead costs — savings that could be passed on to patients — re-

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Essay Contest Winners Health Policy and the Practice of Medicine Essay Contest UMass Chan Medical School and the Meyers Health Care Institute

A Fresh Start Continued duce medical bankruptcies, improve health outcomes, and make healthcare financing more equitable (1). This would have profound impacts in the field of oncology, where patients have an estimated 2.65 times higher rate of bankruptcy than patients without cancer (2). Further, uninsured patients with cancer are 1.5 times more likely to die within five years compared to their insured counterparts (3). This stratification of access to care and clinical outcomes by income is an astounding injustice and an indictment of the fractured, profit-driven payment system in the U.S. I saw Tanya in clinic last week. She has been taking her medication consistently, is participating in outpatient rehabilitation, has stable housing, and is working to find employment. I cannot say for certain what will happen to her. The world is not designed for her to succeed, and if one thing goes wrong, her entire house of cards could come crashing down. While substantial payment reform has the potential to move our healthcare system toward equitable health promotion, it will also be important to pair such reform with a strong social safety net; patients like Tanya cannot be healthy if they lack stable housing, clean air and water, nutritious food, and strong communities. Being able to offer Tanya not only free oncologic care but also wraparound services to stabilize her housing, support her mental health, and address her substance use feels a bit like a miracle to me — but it shouldn’t. Every single patient deserves to have their health promoted at every level, and every provider deserves the joy of having a field centered on facts and figures become one not only about science, but also about compassion and love — the way it should have been all along. + Megan Hansen UMass Chan Medical School Class of 2023 Email: megan.hansen@umassmed.edu REFERENCES

1. Drasga RE, Einhorn LH. Why Oncologists Should Support Single-Payer National Health Insurance. Journal of Oncology Practice. 2014;10(1):7-11. 2. Ramsey S, Blough D, Kirchhoff A, Kreizenbeck K, Fedorenko C, Snell K, et al. Washington State Cancer Patients Found To Be At Greater Risk For Bankruptcy Than People Without A Cancer Diagnosis. Health Affairs. 2013;32(6):1143-52. 3. Ward E, Halpern M, Schrag N, Cokkinides V, Desantis C, Bandi P, et al. Association of Insurance with Cancer Care Utilization and Outcomes. CA: A Cancer Journal for Clinicians. 2008;58(1):9-31.

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2nd PLACE

Reflections on the Cost of Statins Of Bread and Jewels Shervin Rezaei

O

I DON ’ T KNOW. YOU’LL HAVE TO CALL YOUR insurance about that.” The resident I was following gave this final disclosure to Mr. Jones before making a prompt exit from the room. It was well past mid-day on a busy afternoon clinic, and we were already three patients behind schedule. While the resident feverishly filled a template for her notes, I entered the next room, greeted the patient, and set up interpretation by phone. Now on my third week of my Family Medicine clerkship, I started to grow accustomed to the rapid flow of a full clinic. With this patient set up, I left the room to gather a brief H&P for the patient two doors down. But as I am crossing from one hall to the next, I see the patient who we advised to call their insurance. He stood in the waiting room, shuffling in place with impatience. As I continue to rush by hurriedly, I take in the rest of his body’s expression: his brow furrowed, one hand with his phone to his ear, the other with some cash wrinkled and poking out between his taut fingers. As I continue past, find the next room, and read the patient’s intake form, I ask myself: does Mr. Jones have insurance? By the end of the day, the resident and I finally get a chance to grab a bite to eat. I think back to Mr. Jones and what I could have done differently. I open his chart, and indeed he is uninsured. I open his most recent lipid panel results and plug away on the ASCVD risk calculator on my phone. With an LDL-C of 230, maximally tolerated highintensity statins are recommended. From earlier in our clerkship, I recall the Walmart $4 prescription list, an essential service to ensuring Mr. Jones not only starts his necessary treatment but continues it long enough to sustain lower LDL-C levels and reduce his cardiovascular risk. I repeat under my breath “rosuvastatin 20 to 40 mgs, atorvastatin 40 to 80 mgs” as I search the list and scroll down to cholesterol-related medications. Rosuvastatin is not there, but atorvastatin 40 mg is! I call our local Walmart pharmacy, but lo and behold, they are out of stock. The medication is in high demand, they say. While my resident continues to tap away at her keyboard, I tell her, “Our patient earlier, Mr. Jones, with the high LDL, it turns out he’s

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Essay Contest Winners Reflections on the Cost of Statins Continued uninsured.” I explain about Walmart and the statin situation. The price jumped from a $9 30-day supply at Walmart to $236 for brand name statins, a 2,600% increase for the same effective formulation. “Good work checking on that,” she says with a light smile, “but there is only so much we can do with 15 minutes. We can set up a tele-health appointment, or chat with him when we see him next.” I left the clinic that day with my own brow furrowed and fingers taut, reflecting on the 15 minutes of counseling with Mr. Jones today, and how its impact would differ from the next 15 minutes we have with him. As a newcomer to the day-to-day workings of medicine, I had witnessed a cardinal problem that continues to muddle healthcare delivery; before us we have the impossible dichotomy to provide both the best, most advanced care, and the most widely accessible to treat the most people. There are many in our field who would feel at home claiming to treat patients on one side of this coin or the other, but others who may feel they are able to provide both. On these extreme ends, one could consider an academic physician at a quaternary care center, performing experimental treatments and specialized surgeries. On the other end, one can imagine a primary care physician in a rural setting, the only doctor for miles and tasked with everything from physical exams and trauma to delivering babies. I do not mean to argue as to whether funds are best channeled toward advancing the most refined treatments, or toward delivering the current gold standard to the most people. Both, in their own right, hold merits, and likely a rebalancing of this funding is needed to advance healthcare delivery. My contention is with economic profit incentives and influences on all sides (insurance companies, administrative redundancies, pharmaceutical ventures) because in combination, this leads to the exorbitant bloated healthcare spending in our nation. Just like the patient excerpt above, the stark overspending within U.S. healthcare has become the accepted status quo of our current system. Expenditures from the top 11 Organization for Economic Co-operation and Development (OECD) countries in 2018 revealed that the U.S. spends 16.9% of its GDP on healthcare, doubling the OECD average of 8.8% (1). When dissecting U.S. total per-capita spending by public vs. private sector, per-capita spending from private sources exceeds that of any other top 11 OECD country. In the U.S., private spending, including both voluntary payment of health insurance premiums and employer-sponsored healthcare plans, exceeded the next highest country in private sector spending (Canada) by more than five times (1). One could argue that such private sector spending allows for our healthcare system to continue to become one of the most advanced in the world. However, rates of mortality due to preventable and treatable causes (e.g., diabetes, cardiovascular disease, certain cancers) are also the highest in the

U.S. (2). Many OECD countries use this metric as a measure of overall health system performance (3). Recent global health systems data continue to demonstrate what we have all come to accept: we pay the most, with the largest chunk toward our private sector, for worse outcomes. While I continue my training in medicine, healthcare delivery, policy, and an entire world of data, pathology, and evidence-based practices, I turn toward the world of philosophy to guide my moral compass. I think of the late Canadian thoracic surgeon and humanitarian, Norman Bethune. A prolific surgeon in his youth, Dr. Bethune contributed to the development of numerous tools, including the Bethune Rib Shears still in use in operating rooms today. Over the course of his career, he became disillusioned with his colleagues, and increasingly concerned with the socioeconomic state of medicine. On his humanitarian vision for medicine, he stated: “Medicine, as we are practising it, is a luxury trade. We are selling bread at the price of jewels. ... Let us take the profit, the private economic profit, out of medicine, and purify our profession of rapacious individualism ... Let us say to the people not 'How much have you got?' but 'How best can we serve you?’” (4) If Mr. Jones lived in a country with a different healthcare system, perhaps he would have had the “bread” needed to lessen his treatable ailment. Instead, we have normalized this undue financial burden on our patients. Shifting blame from ourselves contributes to the perpetuation of this status quo. Perhaps our next 15-minute visit could be spent discussing his lifestyle, his family life, and the things that bring him joy. It is on us, current and future healthcare providers, to ensure our healthcare activities exist more so to serve our patients than to serve private economic interests which may interfere with the provision of optimal care. + Shervin Rezaei UMass Chan Medical School Class of 2023 Email: shervin.rezaei@umassmed.edu REFERENCES

1. Tikkanen R, Abrams MK. U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes? Commonwealth Fund. Published online Jan. 2020. 2. Gay JG, et al. Mortality Amenable to Health Care in 31 OECD Countries: Estimates and Methodological Issues, OECD Health Working Papers, no. 55 (Organisation for Economic Co-operation and Development, Jan. 2011) 3. Anderson GF, Hussey P, Petrosyan V. It’s Still the Prices, Stupid: Why the U.S. Spends So Much on Health Care, and a Tribute to Uwe Reinhardt. Health Affairs. Jan 2019; 39(1):87–95. 4. Patterson R. Norman Bethune: his contributions to medicine and to CMAJ. CMAJ. 1989;141(9):947-953.

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Society Snippets Worcester District Medical Society 226th Annual Oration “What’s The Future of Healthcare Quality and Safety?” Held on February 16, 2022

Orator: Kimiyoshi Kobayashi, MD, MBA, SFHM Chief Quality Officer for UMass Memorial Group and Medical Center 2022 Annual Business Meeting Held on April 13, 2022 Keynote Speaker Senate President Emerita Harriette L. Chandler

WDMS/MMS Community Clinician of the Year Award

WDMS Editor’s Award

WDMS President’s Award

Anniversary Members 50 Year Member

Peter S. Chen, MD 25 Year Members

Recipient: June R. O’Connor, MD

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Recipient: Robert W. Sorrenti, MD

Recipient: Robert W. Finberg, MD (Posthumously)

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Michael W. Potter, MD Richard A. Rosiello, MD Karen F. Rothman, MD