Worcester Medicine November/December 2020

medicine worcester

Volume 89 • Number 6

Published by Worcester District Medical Society November / December 2020

COVID-19 PART 3

Covid and a Vision for Wellness

The Covid-19 Vaccine Quest: A Unique Experiment in Both Immunology and Public Health

Palliative Care During the COVID-19 Surge

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Contents

NOVEMBER / DECEMBER 2020

Editorial 4

on the cover Backyard Social Distancing Photography by Dr. Joel Popkin

Diving Headfirst:Perspectives on entering the clinic in the time of COVID 15

Jane Lochrie, MD

Sheikh Moinul & Hannah Swartz

President’s Message 5

From the Archives

Spiro Spanakis, DO

Navigating Vaccination Controversy in a Tech-Savvy Population 17

COVID-19 Part 3

The Covid-19 Vaccine Quest: A Unique Experiment in Both Immunology and Public Health 5 Thoru Pederson, PhD

Dale Magee, MD, WDMS Curator

As I See It

A Pre-existing Condition in Medicine 18 Christine Runyan, PhD, ABPP

Covid and a Vision for Wellness 8 Steve Bird, MD, CXO

Lessons from Ruth Bader Ginsburg 19

Palliative Care During the COVID-19 Surge 9 Jennifer Reidy, MD, MS, FAAHPM

Michael Hirsh, MD

Legal Consult

Helping the Homeless During the Pandemic 11 Erik Garcia, MD

Supplemental Nutrition Assistance Program is Essential to Solving Food Insecurity 12

Psychosurgery – Qu’est-Ce Que C’est? 20 Peter Martin, Esq.

Society Snippets

Jean McMurray, CEO

The WDMS 29th Annual Women in Medicine Gathering 21

The Company of Birds in Social Isolation 14

Health Matters Update 22

Parul Sarwal, MD

Melissa Boucher

published by

wdms editorial board

produced by

Worcester District Medical Society

Jane Lochrie, MD, Editor Lisa Beittel, MBA Anthony Esposito, MD Heather Finlay-Morreale, MD Michael Hirsh, MD Anna Morin, PharmD Nancy S. Morris, PhD, ANP Thoru Pederson, PhD Joel Popkin, MD Alwyn Rapose, MD Robert Sorrenti, MD Paul Steen, MD Ram Upadhyay, MD Peter Zacharia, MD Alex Newbury, MD Resident Representative Parul Sarwal, MD Resident Representative Aly Rabin, Student Representative

Studio DiBella

321 Main Street, Worcester, MA 01608 wdms.org | mwwdms@massmed.org | 508-753-1579 wdms officers

President Spiro Spanakis, DO Vice President Giles Whalen, MD Secretary Marianne Felice, MD Treasurer Dale Magee, MD wdms administration

Martha Wright, MBA, Executive Director Melissa Boucher, Administrative Assistant

thank you to

The Reliant Medical Group, UMass Memorial Health Care, Music Worcester advertising

Inquiries to Martha Wright mwwdms@massmed.org 508-753-1579

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.

WORCESTER MEDICINE

Editorial Jane Lochrie, MD

T

HIS is the last issue of Worcester Medicine for 2020, the year that

brought us the worst pandemic in 100 years, the worst unemployment in 80 years, and the worst protests over racial injustice in 60 years, not to mention, murder hornets, giant jellyfish, wild fires, hurricanes, and droughts. (I am purposely not mentioning the political climate.)

I can’t imagine any one of us will be unhappy to say goodbye to 2020.

In addition to the enormous toll that COVID-19 has had on hospitals, nursing homes, and clinical offices, the virus has an immense personal effect. In this issue of Worcester Medicine, you will learn how the Central Massachusetts medical community has stepped up to help those in need.

In the first article, Dr. Thoru Pederson explains the process of the development of a vaccine against COVID-19. He describes four different approaches that the companies developing the vaccine are using. Despite the many advances being made, there are also many challenges. We do not know the duration of immunity as these are not challenge trials; production and distribution loom large; feasibility of shipping both as sheer capacity and the sustained ultra- low temperatures requirement both for shipping and storage.

Steve Bird, MD, defines secondary traumatic stress as a stress reaction that results from exposure to someone else’s traumatic experience resulting in a PTSD-like disorder. He states now during the pandemic physicians need to make personal well-being a priority. He gives us five suggestions how to promote personal mental health.

Jennifer Reidy, MD, focuses on the importance of palliative care during this crisis and the difficultly for providers including PPE shortage limiting direct patient contact; the no visitor policy for hospitalized patients and the moral distress for physicians who have been redeployed without training in serious illness communication and symptom management.

Many of us are familiar with Eric Garcia’s, MD, legendary commitment to the homeless in the Worcester area and his article reinforces this.

He describes the difficulty of socially distancing and voluntary self- quarantining for the homeless. Worcester only has one emergency shelter and can only house 23 people with no capacity for socially distancing and often lacking basic sanitation supplies. Even after opening three satellite shelters and a shelter for quarantining possible COVID-19 cases,

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there just was not enough capacity when 53 patients tested positive for COVID-19. Undiscouraged, Dr. Garcia opened a 60-bed shelter in the DCU center for COVID-19-positive homeless patients.

Another champion for the underserved in Central Massachusetts, Jean McMurray, tells us that the pandemic has triggered a public health crisis for food insecurity. Prior to the pandemic, 1 in 12 people and 1 in 10 children were food insecure. Those numbers are 1 in 8 people and 1 in 6 children. Food distribution has increased by 18%, and many of the people are seeking help for the first time. She is also advocating to increase the monthly benefit for the SNAP program.

Our resident article was written by Parul Sarwal, MD, a third-year resident at St. Vincent Hospital.

She opines that our social inclinations are mimicked by her favorite bird, the Indian silverbill. She has given several resources for nature centers and bird sanctuaries in the Worcester area. In addition, she relates how birding is similar to diagnostic medicine.

Two third-year medical students write about their experience during the pandemic. Sheikh Moinul tells us how the students’ lives have been turned upside down with the cancellation of STEP 1 exams, quarantine modifications, and clerkship changes. Students have expressed apprehension, uncertainty and confusion with so many changes in the curriculum.

Our second student, Hannah Swartz, relates that her first clinical experience made her much more appreciative of every moment that she can spend in person with a patient.

As always, I would encourage everyone to read the President’s Message, As I See It, Legal Consult, News from the Archives, and Society Snippets. +

“

I can’t imagine any one of us will be unhappy to say goodbye to 2020.

NOVEMBER / DECEMBER 2020

”

WORCESTER MEDICINE

President’s Message

COVID-19

The COVID-19 Vaccine Quest: A Unique Experiment in Both Immunology & Public Health

Spiro Spanakis, DO

A

Part 3

s we all adjust to living with the

pandemic in our professional lives and our personal lives, I can assure you that your district medical society has been focused on the same. The officers, Executive Committee, and other committee members have been diligently working to continue and advance the Society’s work. We are so fortunate to have such a dedicated, learned group of volunteers for these efforts. Personally, it is an honor to work with many of these district society members, since many of them have served as mentors over the years.

I hope you all enjoy this issue of Worcester Medicine, which is the third in a series focusing on the COVID-19 pandemic. Under the leadership of Dr. Jane Lochrie, the magazine quickly adapted its content to disseminate articles on important topics such as novel drug therapies to improve outcomes, while also shedding light on the personal aspects of providing care as a healthcare provider during these difficult times.

After many years of service as editor of the magazine, Dr. Lochrie will be retiring from this role. On behalf of the entire membership, I want to thank her for her tireless dedication to the publication of a high-quality magazine. The officers, Editorial Board, and Publications Committee, chaired by Dr. Robert Sorrenti, are exploring how to fill the role Dr. Lochrie excelled at for so many years.

Given that in-person meetings are not possible at this time, and that the district was forced to cancel some meetings in the spring due to the pandemic, we are revising our calendar of events using online platforms instead. Please keep an eye out for announcements relating to these events. I want to congratulate the organizers of the Women In Medicine online gathering that occurred recently, which was a success. +

Thoru Pederson, PhD

T

his

pa s t

ja n u a r y

collab orating

scientists in Beijing, Wuhan and Jinan, China identified the third severe acute respiratory virus affecting humans, SARS/CoV-2* (1) after an outbreak of such a disease had occurred in Wuhan a month before. Five days later another team in China published the virus’ RNA code (2) and within weeks, one U.S. company had designed a vaccine candidate based on this information. I open this article on this point in the context of concerns that U.S. science is vulnerable to illegal exploitation by China, as indeed has been confirmed in certain cases.

But with SARS/CoV-2, the Chinese infectious disease physicians and virologists operated with astonishing speed and complete openness.

The vaccine developments have been and are now moving very rapidly, and with ongoing shifts in testing strategies and anticipated approval and deployment timelines. This article was finalized on October 26.

Two hundred and thirteen COVID-19 vaccines are in development and a dozen are already in Phase 3 trials. Readers wishing more details are referred to an excellent database maintained by the Milken Institute: milkeninstitute.org > COVID-19-tracker.

To adjust Senator Howard Baker’s famous Watergate remark from the past to future verb tense: “What will we know and when will we know it?”

the four vaccine concepts

Most of the COVID-19 vaccines in development are “conventional” in that they deploy, in one format or

*The coronavirus that is the infectious agent is termed SARS/CoV-2 and the condition is termed Covid-19 (for “Coronavirus disease 2019”). Here, either term is used depending on whether the virus or the infection is being discussed.

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Part 3 The COVID-19 Vaccine Quest Continued

another, a particular protein that resides in the outer shell of the virus to hopefully trigger a subject’s immune system to make an antibody response.

Although there are numerous proteins in the SARS/CoV-2 virus that could be tried in this approach, the “poster child” is one that constitutes the “spikes” on the coat that gives this clade of respiratory viruses its “crown”based name. This protein has been purified and injected into animals to see if they produce antibodies against the protein. They do of course but how successful this approach will be as a protective vaccine is not yet clear.

In one variation of this approach, many copies of the spike protein are assembled in the lab into a “virus-like particle” (VLP), with the idea that these proteins will thus be “seen” by the animal or human subject’s immune system as more closely resembling how these proteins appear on the actual virus. When positioned in a VLP, the spike protein adopts the same shape and orientation it has in the actual coronavirus, whereas in the vaccines based on individual, free-floating copies of this protein it may adopt alternative shapes that are not as stimulatory to the immune system. One of the pioneers of this concept is Trudy Morrison, a professor at UMass Medical School, who has validated this vaccine concept for a different human respiratory virus and is now applying it to SARS/CoV-2.

Another coronavirus vaccine concept is to use the SARS/CoV-2 spike protein itself (vide supra). Hamster cells can be genetically engineered to make it and it can then be easily harvested and tested as a vaccine. In this strategy the protein is often combined with another entity to hopefully boost its antibody-generating activity.

Yet another strategy is to insert the genetic code of the spike protein into a human cold/respiratory virus called adenovirus. The track record of this type of vaccine for other viruses is not encouraging but each new virus on the scene is a distinct entity and we cannot predict how any given vaccine strategy tried before will or will not be promising.

A fourth type of coronavirus vaccine in development is based on using the genetic code of the spike protein not as DNA, as in the adenovirus-based vectors mentioned above, but in the form of the so-called messenger RNA that causes the protein to be made in the protein synthetic factories of the infected cell. In this strategy, the messenger RNA that codes for the spike protein is put into a capsule and then injected into subjects. It then causes the cells it reaches to make the spike protein which is then released into the bloodstream to thus elicit an antibody response.

There is yet a fifth vaccine strategy- using the virus itself. But the consensus of respiratory virus disease experts is that vaccines based or live or attenuated SARS/COV-2 virus should not be pursued. putting things into perspective

There are no solid bets with respect to the vaccine strategies described above although various experts “lean in” on one vs. others. I take a circumspect view because the history of vaccines is littered with failures, many of these involving such detailed knowledge of the virus that success seemed assured at the time. But knowing the virus in laboratory studies is one thing and knowing its lifestyle in the infected host is another. A good example is polio, where both the virus and the disease were well understood and yet the vaccine breakthrough came out of nowhere. There had been a widely accepted belief that the polio virus could not grow in non-nervous system tissue and thus could not be amplified at vaccine production

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scale, because nerve tissue cannot be readily expanded in cell culture. But this turned out to be wrong and it resulted in vaccines, and a Nobel Prize (1).

When we think about the advent of a vaccine, we of course mean a highly protective one and which can be administered very broadly as to production scale and breadth of distribution. By mid-late November the levels of coronavirus antibodies elicited in one or more of the ongoing Phase 3 trials may be known, not from the completed trials but from early indications that carry a degree of statistical meaning. But at such a time we will not know the degree of immunity as these are not challenge trials, i.e. ones in which vaccinated subjects are given the virus. Two such trials have been conducted in monkeys, one with an adenovirus-based vaccine and the other the messenger RNA type. Both demonstrated significant degrees of protection and this is, to me, one of the most encouraging signposts so far. In late September the British government announced it was considering the launch of a human challenge trial. But even if challenge trials were to be conducted in the coming months, the duration of immunity would need to be determined. The pediatric measles-mumps-rubella vaccine typically provides enduring immunity, often for life. No respiratory disease virus vaccine has ever achieved this.

Even if we are optimistic enough to think the early data on the vaccines now in Phase 3 trials will be encouraging, on October 6 the FDA issued updated safety standards requiring subjects to be followed for two months prior the companies seeking emergency approval. Thus, it is likely such approvals would not be granted until mid-late January.

There is another issue: mutation. 5,000 different single-mutation versions of SARS/CoV-2 were compiled in a report posted by a team of U.S. scientists in September, and a larger number were published earlier in a British study. Most of these were inconsequential as regards infectivity although one was associated with increased severity of infection. The various antibody strategies outlined earlier in this article are likely to have varying degrees of “breadth”, i.e. the extent to which a given vaccine elicits antibodies directed against different regions of the virus’ antigenic protein. Clearly, the more the better given the observed mutation rate. One particular vaccine approach involves so-called monoclonal antibodies against the virus’ spike protein but used as a combination (“cocktail”) of several for this reason.

Other biological parameters are in the picture.

One is a phenomenon called “antibody dependent enhancement”, or ADE, in which the antibodies in a vaccine paradoxically enhance the virus’ ability to

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The COVID-19 Vaccine Quest Continued enter the cells of subject. All the vaccine developers are watching signs of ADE. Another factor is the degree of human variation with respect to genes that elevate or reduce either the propensity for SARS/CoV-2 infection, or the severity of the disease. A private-government consortium in England is carrying out such a “genomics” study on 15,000 subjects who experienced mild COVID-19 disease vs. 20,000 who had intense symptoms.

Yet another parameter, perhaps the most important and yet somewhat vexing, is “herd immunity”, defined as the state at which the number of immune individuals in a given population has reached a level in which further transmission is negligible or even absent, due to an insufficiency of vulnerable individuals. Herd immunity is why we are still around, descendants of the survivors of even the most horrific plagues in history, eras that were of course pre-vaccines. It is thought that for most viral diseases herd immunity is attained when somewhere around 70% of the population is immune, either from vaccination or natural infection. But some infectious disease epidemiologists have come out with lower estimates in the case of COVID-19, in the range of 45-50%. This is based on modeling that takes into consideration the value called R0, which is the estimated number of people that become infected by a given individual. Variables such as the relative frequency of young vs. older people in a given population, or the density of people (urban, rural), have been meticulously weighed in these models using epidemiological data for COVID-19 already in hand. For example, a study conducted in Mumbai, India found that 51-58% of people living in the highest density areas of poverty had SARS/CoV-2 antibodies vs. only 11-17% in the more affluent areas. Two unpublished studies of SARS/CoV-2 natural immunity have yielded encouraging results. In one, patients having had mild cases displayed antibodies to the virus for at least three months and in some cases the antibody levels increased during this period, indicating the subjects’ immune systems were in an amplification state. The second study included mild vs. severe cases, as well as asymptomatic infected individuals. The more severe cases displayed higher levels of antibody but in all three groups, the duration of antibodies was two-three months. Of course, how such levels and duration would play out as to approaching herd immunity would depend on the population-based variables mentioned above. One other finding of interest in the second study was that the age and sex of the subjects played a lesser role in the antibody response than the severity of symptoms.

Production and distribution issues loom large. The capital investments being made in vaccine discovery and validation are indeed substantial but as we have all read in the media, there are questions about the cost and feasibility of shipping many of these various vaccines given current refrigerated transport modalities, both as sheer capacity and sustained ultra-low temperatures (in some cases requiring -110oF).

Air shipment will be extensive given that the production of any vaccine will be at one or only a few sites around the world and dry ice sublimation on-flight is a serious concern for cargo airlines and must be controlled, at substantial cost, to say nothing of the energy balance sheet for manufacturing amounts of dry ice never before achieved. The anticipated levels of glass and/or plastic manufacturing for vials and syringes has been predicted to stretch current world capacity. (As a 7-year old boy I toured the Corning Glass plant in southern New York and marveled at the masters making “Steuben glass” of scintillating beauty. The descendent

Part 3

of that company is among the contractors for the COVID-19 vaccine effort).

Finally, we must face yet another challenge and this is the disturbing degree of vaccine skepticism that abounds in many parts the world. It turns out the roots of this are more complex than many might assume and although they parallel to some degree an anti-science stance or science illiteracy (4), in some quarters the skepticism is more focal and less irrational, e.g. a suspicion of corner-cutting by pharmaceutical companies. These are formidable issues that could reduce the levels of vaccination. Nonetheless, it is likely that eventually (I suspect by the fall of 2021), there will be sufficiently potent vaccines in amounts for widespread deployment with willing subjects that these levels of immunity together with that from natural infections will combine effectively.

The science of SARS/CoV-2 is still a frontier, and we may have surprises that are setbacks. Or we may see successes that mirror what vaccinology has done in the past at its most heroic moments (5,6). I predict the latter. + disclosure: I own stock in one company that is working on a COVID-19 vaccine. For this reason, I have not mentioned any companies in this article.

The categories of vaccines described, and the companies working on them, can be readily found on the Milken Institute site. references:

1. Zhu, N. et al. A novel coronavirus from patients with pneumonia in China, 2019. New Engl. J. Med. 382: 727-733, 2020.

2. Lu, R. et al. Genomic characterization and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. The Lancet 395: 565-574, 2020.

3. Pederson, T. Turning on a dime: the 75th anniversary of America’s march against polio.

The FASEB J. 27:2533-2535,2013.

4. Pederson, T. How Americans see science: what’s in a poll? FASEB J. 34:14059-14060, 2020.

5. Kinch, M. “Between Hope and Fear: A History of Vaccines and Human Immunity”. 2018, Pegasus.

6. Wadman, M. “The Vaccine Race: Science, Politics and the Human Costs of Defeating Disease”. 2018, Penguin Books.

Thoru Pederson, PhD is Arnett Professor of Cell Biology, Professor of Biochemistry and Molecular Pharmacology, University of Massachusetts Medical School. E-mail: thoru.pederson@umassmed.edu

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Part 3

COVID-19 and a Vision for Wellness

1. know that what you’re feeling is a normal stress response

Steve Bird, MD

A

fter

more

than

six

months

of

uncertainty, w e a r e beginning to see light at the end of the tun-nel of the COVID-19 pandemic. But during this time (and likely for the foreseeable future), healthcare professionals have faced increased stress and risk of burnout. The continued well-being of all healthcare professionals is paramount to ensure the health and well-being of our patients, all staff, and our healthcare institutions.

Burnout can be defined as a syndrome of emotional exhaustion, depersonalization, and a re-duced feeling of personal or professional accomplishment. But one does not need to exhibit symptoms in all three domains to be burned out. A 2017 Medscape study found that 50% of all physicians experienced burnout, with some specialties having burnout rates of greater than 70%. While signs and symptoms of burnout are varied, they often include irritability, frustra-tion, increased interpersonal conflicts, depression, social isolation, and decreased job satisfaction.

What is also now clear is that physicians and other healthcare professionals are also at higher risk for secondary traumatic stress during the pandemic.

Secondary traumatic stress is a stress reaction that results from exposure to someone else’s traumatic experiences, rather than from direct exposure to a traumatic event. Signs of secondary traumatic stress mimic those of PTSD, but the most common are excessive fear or worry, an exaggerated startle response, persistent ruminations about the traumatic event, as well as sleep disturbances.

It is well known that physicians are not great at self-care. Our medical education system has conditioned us to prioritize the needs and care of patients over our own. Now, more than ever, it is important to make personal well-being a priority and to manage the various stresses we experience in check. Below are a few ideas and suggestions for managing stress and promot-ing your own well-being. For your own wellness is important not only for you (and your family), but also for your patients.

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Physicians are encountering stressors that may include direct exposure to COVID-19 while treating patients; the death of patients from COVID19 (or other disease) without the benefit of the presence of families; working in more difficult situations with PPE and the lack of personal contact; and the fear of bringing COVID-19 home to their families. We know from the UMass-Memorial Peer Support Network that physicians are experiencing more stress than is typical. So, allowing yourself some self-compassion and acknowledging what you are feeling (and that it’s normal), is a good first step.

2. personal wellness check-in Take a few moments at different points throughout the day for a personal wellness check-in. Although time pressure is felt by all of us, and perhaps even more now as there is a rush to make up RVUs lost during the height of the pandemic, taking the time for self-care is an im-portant aspect of managing stress. Some emotional signs of stress include the persistence of fear or anxiety, irritability, anger, or perhaps a feeling of hopelessness.

Some cognitive or men-tal signs of stress include an inability to concentrate, an inability to make decisions, and mental exhaustion.

To help with this stress, you can add some well-validated breathing exercises to your personal wellness check-in. Try the 4-7-8 breathing method: close your mouth and inhale through your nose for a count of four. Hold your breath for a count of seven. Exhale completely through your mouth for a count of eight.

3. prioritize your own needs Physicians are generally not good about prioritizing their own needs in normal times, let alone during a pandemic. Try as best as possible to eat at least three healthy meals every day, while avoiding food high in sugar and fats. To make this easier, I have taken to making a spinach and frozen fruit smoothy each morning and bringing it to work in a hydroflask.

It’s also important to take some breaks during the day to rest and reset your mind and body. Short walks of just 10 minutes have been shown to have valuable mental and physical benefits. If, as the weather turns colder you can’t realistically go for a quick walk during the day, identi-fying a quiet space where no one can bother you for a short duration and doing the 4-7-8 breathing or other mindfulness technique might be just what you need.

4. maintain supportive connections with your colleagues

Check in with your colleagues and be open to receiving reciprocal help.

One program that we initiated at UMass was the Check You, Check Two. That is, check in with yourself and then brief-ly check in with two colleagues each day. This can be a simple text, email, or call. Let them know

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COVID-19 and a Vision for Wellness Continued that you’re thinking of them and acknowledge the unprecedented experiences of today. Such validation will help normalize the feelings that both you and they are experiencing. Fur-thermore, nonstop media coverage of the pandemic can overshadow the bright spots of your daily work. So talk about the positive things that are occurring in your life, with your family, and with your institution or place of work.

5. seek professional help to cope with moral distress

Symptoms of moral distress may include self-criticism or feelings of shame, guilt, and regret. This moral distress and the anticipatory grief that often co-exists is likely something with which you are unaccustomed. Coping with such novelty may be difficult. Therefore, additional help and support may be needed to address their insidious and harmful effects.

Although physicians are generally reluctant to seek help, seeking early help is important to ad-dressing the trauma from moral distress. Peers have been found to be valuable when coping with moral distress. If you have access to an employee assistance program (EAP), you can often receive free and confidential help as well as referrals to help you cope with moral distress. You can also contact your health insurance provider for referrals to mental health professionals who provide telemedicine therapy, or contact the Physician Health Services (http:// www.massmed.org/Physician_Health_Services /About/About_Physician_Health_Services/#.

X2O6QJNKhp8). + Steve Bird, MD, is professor of emergency medicine and the Clinician Experience Officer (CXO) at UmassMemorial Healthcare and the University of Massachusetts Medical School.

Email: Ste-ven.bird@umassmemorial.org

Part 3

Palliative Care During the COVID-19 Surge Jennifer Reidy, MD, MS, FAAHPM

T

he global pandemic has been described as

a “powerful amplifier of suffering,”(1) and the field of palliative care has mobilized onto the frontlines in emergency rooms, hospital wards, and intensive care units during the COVID-19 crisis.

In general, palliative care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness – whatever the diagnosis.

The goal is to improve quality of life for both the patient and the family. Palliative care is appropriate at any age and at any stage in a serious, life-threatening illness and can be provided together with curative treatment.

During the pandemic, palliative care providers have faced multiple barriers to their usual hightouch, relationship-based care, including PPE shortages limiting direct patient contact; a no-visitors policy for hospitalized patients which separates loved ones and prevents in-person family meetings; and the moral distress of redeployed clinicians without training in serious illness communication and symptom management.

Based on reports from the epicenter in New York City, our palliative care team at UMass Memorial Medical Center quickly developed strategies to plan for the patient surge in central Massachusetts last spring, including: • Expand in-person consults from 5 to 7 days per week at University and Memorial campuses as well as telephone support for outpatient clinicians and the DCU Field Hospital; • Partner with outpatient providers to proactively reach out to their highest-risk patients about their goals and medical wishes if they contracted COVID-19; • Collaborate with local hospices and skilled nursing facilities to anticipate barriers to providing end-of-life care in the community for people dying of COVID-19; and • Promote the use of video technology to connect isolated patients with their loved ones.

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Part 3 Palliative Care During the COVID-19 Surge Continued

We codified these strategies as a best-practice guideline and distributed it throughout the health system via virtual town halls, department meetings, grand rounds and the intranet. We provided at-theelbow coaching for providers in the hospital and quick, focused trainings on serious illness conversations for critical care and ED physicians. Our team distributed 200 laminated pocket cards to hospitalists, nurses, and trainees on symptom management, communication tips and how to reach us. Already a scarce resource before the pandemic, palliative care also closely involved in “crisis standards of care” preparations of local health care systems – including hospice agencies – were overwhelmed.(2) When the COVID-19 surge hit, our inpatient team saw its daily consult volume nearly double and an unprecedented number of patient deaths from April through May 2020. Across the hospital, providers experienced severe levels of stress related to deployment in areas outside their discipline with unfamiliar colleagues, caring for very sick and dying patients, and long hours of donning/doffing PPE, with fears of contracting COVID-19 and/or transmitting the virus to loved ones.

“

...we used music therapy to engage a patient recovering from COVID-19 which improved his alertness and ability to wean from a ventilator.

”

In response, our team developed creative strategies to maintain humanism in a frightening, hectic health care environment. First, we implemented an art intervention, “PPE Portraits” or postcard-sized face portraits printed on stickers and affixed to PPE. Artist Mary Beth Heffernan, a professor at Occidental College, had created and piloted PPE Portraits during the Ebola epidemic in 2015.

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During the COVID-19 surge, PPE Portraits helped reassure scared patients and enhanced patient and team interactions, according to a recent survey of 170 UMMMC providers.(3) Simultaneously, we expanded our music therapy program to help with direct patient care and staff support. For example, we used music therapy to engage a patient recovering from COVID-19, which improved his alertness and ability to wean from a ventilator. For patients dying from COVID-19, we instituted a ritual of pausing at the bedside to reflect after a patient’s death, which was widely embraced throughout the medical center. Our music therapist created “heartsongs,” or heartbeat recordings fused with a person’s favorite music as legacy gifts for families. For hospital staff, our palliative care team members reached out to individuals and COVID-19 units needing emotional support, and our music therapist developed a popular “music for resilience” session available via Zoom for all health care providers once a week.

Meanwhile in clinic, the outpatient palliative care team conducted video telehealth visits side-by-side with primary care providers and their patients at home, assisted living, and skilled nursing facilities to navigate COVID-19 and non-COVID-19 related serious illness. We found these planning conversations were met with relief and gratitude, and ensured people received care tailored to their own values and goals.(4) Many frail patients, who have trouble getting to the clinic and/or a multitude of appointments, appreciated the new telehealth capability, which will improve access to palliative care both now and in the future.

Personally, the experience of the pandemic so far has helped me appreciate the existential stress and anxiety of patients living every day with serious illness and their families. Like a life-threatening diagnosis, the pandemic clarifies what is most important in life. For my team and I, this experience only fuels our efforts and passion to grow “palliative care everywhere,” both during the pandemic and beyond. + references:

1. The Lancet. Palliative care and the COVID-19 pandemic.

The Lancet. 2020;395(10231):1168. doi:10.1016/S01406736(20)30822-9 2. 2. Abbott J, Johnson D, Wynia M. Ensuring Adequate Palliative and Hospice Care During COVID-19 Surges. JAMA Published online - September 21, 2020. doi:10.1001/jama.2020.16843 3. Reidy J, Brown-Johnson C, McCool N, Steadman S, Heffernan MB, Nagpal V, Provider perceptions of a humanizing intervention for healthcare workers – a survey study of PPE Portraits, Journal of Pain and Symptom Management (2020), doi: https://doi. org/10.1016/ j.jpainsymman.2020.08.038.

4. Gracey K, Martin S, Reidy J. Palliative Care During Public Health Emergencies: Examples from the COVID-19 Pandemic. American Family Physician (September 1, 2020) Vol 102(5):312-315 Jennifer Reidy, MD, MS, FAAHPM, is chief of the Division of Palliative Care at UMass Memorial Medical Center and associate professor at UMass Medical School. Email: Jennifer.reidy@umassmemorial.org

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Helping the Homeless During the Pandemic Erik Garcia, MD

T

o be homeless is to be vulnerable and that’s never been

starkly demonstrated than during COVID-19 times. Social distancing and voluntary self-quarantine – now familiar methods for protecting self and others (1) – are often not possible when you have no place to call your own. Homeless people face a choice: exposure to the virus or exposure to the elements.

In early March, I was struck by the contrary observation that COVID-19 began as a disease of relative social privilege, infecting those who travelled internationally (2) or interacted with those who had. The Biogen Conference in Boston resulted in the first “superspreading” event in Massachusetts, resulting in over 90 documented cases. Before long, virus bearing the same genetic markers would enter Boston’s homeless shelter population and become linked to 40% of all COVID-19 infections in the Boston area. (3). It was during this window of time in early March that Worcester chose to act.

Worcester’s response to COVID-19 and homelessness focused on the SMOC shelter at 25 Queen Street, the only open access emergency shelter in Worcester. Built as a 23-bed rapid rehousing facility in 2013, the population swells to five times that capacity in the winter and spring, frequently topping 130 individuals plus staff. The resultant overcrowding puts residents at particular risk for COVID-19 infection – with no capacity for social distancing and often lacking basic sanitation supplies. To address this threat, Dr. Mattie Castile and City Manager Ed Augustus brought together leadership from UMass Memorial, St. Vincent’s and the Family Health Center in a collaborative effort I haven’t seen in my nearly 30 years as a physician in Worcester.

The response was two-fold: Open three satellite shelters – each with a 25-bed capacity – to limit overcrowding at the SMOC shelter, and open a COVID-19 shelter to house patients under investigation and to quarantine COVID-19 positive homeless persons. Family Health Center’s Adam Bliss NP and I ran the shelter with a group of amazing volunteers, providing food, shelter and medical respite 24/7 throughout the month of April. The crucial support has to be credited to the Worcester EMS, though. Under the leadership of John Broach MD, they performed weekly testing of all shelter residents on site and established a transportation “hot line” helping me shuttle those who tested positive to the shelter. We initially housed patients at the vocational high school but had to scramble to move into the DCU in week two, when 53 patients tested positive, far outstripping capacity there. In three hours, we dismantled half of the field hospital set up in the DCU by the Army Corp of Engineers and converted it into a 60-bed capacity shelter with separate housing for men and women, a dining and common area and a medical station.

That month would see a total of 99 residents – 45% of the SMOC shelter population – test positive and stay with us and our volunteers. more

Part 3

We would have three overdoses (all revived), one wall collapse (no injuries), two COVID-19 negative “guests” who heard that we ran a nice shelter and snuck in, and one COVID-19-related death. Adam would gain 30 lbs (which he has since lost) and I would develop GERD, which is finally resolving. No volunteer would get infected, and we would all come to appreciate the importance of strong city leadership and its role in fostering collaboration among the Medical Community of Worcester.

We also learned and reinforced some difficult lessons throughout this process. The burden of transporting patients fell entirely on the Worcester EMS as the private ambulance services found no profit in the task. We were constantly pushing back against efforts to legally enforce mandatory quarantines directed solely at homeless persons. And most importantly, we saw the need to providing safe, accessible housing options for homeless individuals, as nearly half of the shelter population would become infected with COVID-19 despite all of our efforts. As fall’s approach becomes more evident on my early morning jogs, I see the need to change our current reliance on a single 23-bed facility to house hundreds of Worcester’s homeless residents without having to rely on emergency measures, but I am warmed by the knowledge that our city’s health is in the hands of organizations that will rise to meet the needs of our most vulnerable citizens. + references:

1. Physical distancing, face masks and eye protection to prevent person to person transmission of SARS-CoV-2 and COVID-19: a systemic review and meta-analysis. Chu DK, Akl EA, Duda S, et al. Lancet, 2020.

2. Evidence for Limited Early Spread of Covid-19 Within the United States, January-February 2020. Morbidity and Mortality Weekly Report, June 5, 2020/69(22)680-684 3. Phylogenetic Analysis of SARS CoV-2 in the Boston Area. Prepublication release, August 25,2020.

Erik Garcia, MD, Assistant Professor in the UMass department of Family Medicine and Community Health and the Medical Director of the Homeless Outreach and Advocacy Project, Family Health Center

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COVID-19

Part 3

Supplemental Nutrition Assistance Program is Essential to Solving Food Insecurity Jean McMurray

O

n march 24th, shortly after governor Baker ordered all public and private schools closed, issued his stay at home advisory, and closed all non-essential businesses due to the COVID-19 pandemic, calls and visits to Worcester County Food Bank (WCFB) increased dramatically from people looking for food assistance. One person who called was Marie, the panic evident in her voice when she told me, “I have three children and was laid off due to the Governor’s order. I never needed help with feeding my family before and I’m not sure where to go or who to turn to. I’m scrambling to cover my bills while I wait for unemployment to be approved.”

I gave Marie information on applying for Supplemental Nutrition Assistance Program (SNAP) benefits and where take-out school meals were available for her kids. Because her local food pantry wasn’t open until the next day, Marie came to WCFB to pick up food. As co-workers and I brought boxes with a variety of fresh, frozen, and nonperishable food items out to her car, Marie met us with a smile and told us her tears were tears of relief.

The speed at which the pandemic triggered a public health crisis and unemployment crisis was unprecedented as is the impact on our community.

The pandemic has disproportionately affected our neighbors and communities of color and exacerbated a food insecurity problem that already affected far too many of our neighbors – yours and mine – living next door, around the corner, and across town.

WCFB and its network of food pantries mostly run by volunteers went from helping an average of 30,320 people every month to an average of 36,630 people.

Prior to the pandemic, 1 in 12 people and 1 in 10 children in Worcester County were food insecure. Those numbers are now 1 in 8 people and 1 in 6 children.

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In addition to children, these neighbors are seniors, college students, parents and grandparents, working adults, people who are unemployed or underemployed, people with disabilities, veterans, and people of all races, backgrounds, and life experiences from all 60 cities and towns in Worcester County. Some have been struggling for a long while.

For others, circumstances changed just recently (sometimes unexpectedly) resulting in a first visit to a food pantry.

In April, WCFB and our food pantries assisted 10,300 people asking for help for the first time; an extraordinary number and a 205 percent increase compared to April 2019. This was not surprising given it was the first full month of the pandemic and people turned to food pantries as their first source of help while waiting to receive their SNAP benefits and unemployment assistance.

In May and June, the number of people going to food pantries decreased. Those were the same months people received additional SNAP benefits, Pandemic EBT benefits for children, and $600 a week in federal pandemic unemployment compensation. These additional resources supported them in meeting their needs.

At the end of our fiscal year on June 30, 2020, WCFB distributed enough food for 6 million meals, an 18 percent increase from last year. WCFB’s loyal supporters provide the food and financial resources that enable us to respond to people needing help.

Food donations are steady from the state funded MA Emergency Food Assistance Program (MEFAP) and from the United States Department of Agriculture (USDA). Thanks to the incredible outpouring of kindness from our community of donors: individuals, businesses, organizations, and foundations,

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COVID-19

SNAP Is Essential to Solving Food Insecurity Continued

Part 3

“

The current average SNAP benefit of $1. 40 per person per meal per day is inadequate...

WCFB is purchasing food for the first time to supplement our donated food resources to ensure we remain a consistent and reliable supplier of food to our network of food pantries during this challenging time of so much uncertainty.

Although food banks such as WCFB provide an essential service, the reality is that we could not solve the hunger problem before the pandemic, and we cannot solve the crisis now. This is a crucial reminder that our advocacy at local, state, and federal levels is more important than ever for policies and programs that decrease hunger by improving people’s access to healthy food. Programs such as SNAP. SNAP effectively and sustainably scales up to meet the needs of the number of people who are food insecure.

According to Feeding America, the national network of food banks, for every one meal provided by food from a food bank, SNAP provides nine.

SNAP is targeted to help our most vulnerable neighbors, predominantly serving households that include children, seniors, people with disabilities, and adults earning low wages. SNAP benefits phase out as people get back on their feet, with the average person staying on the program for about one year.

SNAP is also a highly efficient program with one of the lowest fraud rates of any benefit program.

As our nation’s most effective anti-hunger program, SNAP provides the purchasing power people need to buy their own food and it stimulates the economy. Each $1 spent in SNAP benefits during an economic downturn generates $1.80 in economic activity as families pay for food at grocery stores and farmers’ markets. The impact is felt throughout the food chain, from farmers and food producers to truckers, food retailers, and store employees.

The current average SNAP benefit of $1.40 per person per meal per day is inadequate to meet people’s nutritional needs. The monthly benefit needs to be increased to reflect the actual cost of feeding a family with healthy food. In May, the U.S. House of Representatives passed the HEROES Act,

”

a COVID-19 relief package, that languished for months in the U.S. Senate. If passed, it would boost maximum benefit levels by 15 percent, increase the minimum monthly benefit from $16 to $30, and suspend SNAP time limits and rule changes that would cut SNAP benefits. It would also extend Pandemic-EBT benefits through the 2020-2021 school year, a critical new program that expands access to meals for school children. As we move through this pandemic together, WCFB’s efforts will continue and we ask everyone to call on Congress to do its part to solve food insecurity. + Jean G. McMurray is Chief Executive Officer of Worcester County Food Bank, Shrewsbury, MA. She may be reached at jean@foodbank.org.

Learn more at foodbank.org.

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COVID-19

Part 3

The Company of Birds in Social Isolation Parul Sarwal, MD

M

y acquaintance

with birding was a happy accident.

I had just graduated from medical school and moved back into my family home in Chandigarh, India, to work part-time as a research associate. My evenings were reserved for studying in preparation for residency and frequently punctuated by spells of gazing out the window. It was during one of these interludes that I spotted something on our peach tree that I had never seen before – a strange bird with a red crown. Hastily grabbing my camera, I stole a shot just in time. The remainder of the evening was spent describing to Google what I saw – until I established that this intriguing visitor was the black-rumped flameback (Dinopium benghalense), a common woodpecker. Well, that was it. I had found myself in possession of what seemed to be yet another fleeting hobby. But as the year went on, this was what helped keep my wits about me as I spent most of it by myself, working on my research or studying. By the end of it, I had a species list of thirty-eight birds, all in my backyard alone.

Social isolation could be the maxim for the year 2020 and has changed the meaning of life and living as we knew it. Having spent the entirety of “the surge” from April through June as a resident in COVID-19 units, and the majority of it in critical care, I have been fortunate to be able to keep myself engaged during this time. Friends outside of medicine have shared with me the challenges of a hiatus from either work or workplace. It is something I can empathize with, as would most of my colleagues. The average physician has spent a more-than-average amount of time in some variety of social isolation at some stage of their career. Some of us find it easier to bear— even find solace in— the solitude, while others may feel the brunt of being left in the company of their own reflections. Regardless, the disruption of a work routine, however mundane it may have seemed before, has insidious consequences on the mind. In this pandemic, I imagine, children have probably had it harder than adults. Their sense of self is yet to develop, and their lives revolve much more around their social axes. In such times, they may find a welcome distraction in

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scouring their surroundings for some of our winged companions and, in the process, spending quality time with their families.

Our social tendencies are replicated closely, even comically, in the anthropomorphic behavior of my personal favorite, the Indian silverbill (Euodice malabarica). They are small and gregarious birds with short, cheeping calls. I first encountered them as they passed through Chandigarh on their way south at the end of winter that year. I would find the peach tree flocked with these effervescent creatures late in the afternoons.

They started staying around longer once they discovered the buffet of birdseed on the balcony. They would arrive on time every day for supper and, once content, take off in quick succession. If one of them decided to stay back for an extra helping, you would find their mate waiting for them on the balcony rails. It was their courting behavior that I found particularly endearing. The female would park herself beside the male on a branch.

He would coyly slide away and she would chase him, both bouncing sideways towards the far end of the branch (I may or may not have reversed the gender roles here). Once out of branch, they would both fly off, either together or apart, depending on which way the wind blew…

The time I spent watching the birds would probably amount to several days in totality. I used an online database of bird calls, xenocanto, to guide my little foragers to the birdseed when they were new to our backyard. (One must employ caution and consideration with such resources, as exposure to artificial calls can sometimes stress or confuse birds.) The Merlin Bird ID app by the Cornell Lab is a brilliant resource for identifying birds. Worcester and the surrounding region have an abundance of nature centers and sanctuaries, making it the perfect haven for birdwatching. New England’s largest urban wildlife sanctuary is right here at Broad Meadow Brook in Worcester. In addition to over 160 species of birds, it welcomes about half as many butterflies who star in the Annual Butterfly Festival (this year, virtually). The Wachusett Meadow Wildlife Sanctuary in Princeton is another such reserve with a nature center. It has been developed around an erstwhile farmstead with barns and rustic constructions lending to its character. It is connected

above The crimson-breasted barbet (Psilopogon haemacephalus) and the peach tree in bloom.

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COVID-19 Part 3 The Company of Birds in Social Isolation Continued to the Wachusett Mountain and trails. The Burncoat Pond in Spencer and the Eagle Lake in Holden are among the other sanctuaries in this region that host migratory waterfowl during spring and fall. The Mass Audubon Society frequently organizes bird walks and programs to observe ongoing research such as banding techniques used to study the migration of birds.

Amidst this wealth of birding opportunities, you can imagine my excitement when I found out about my residency mentor’s (Dr. Joel Popkin) fervor for birding. I have especially enjoyed his lectures due to our shared interest in the humanities and one of my favorite parts is the pictures from his birding expeditions he often includes. When I expressed my interest in writing this piece, he shared with me Dr. Joshua Schor’s perspective* in the New England Journal of Medicine on fighting burnout with birding. Dr. Schor beautifully articulates my own long-harbored opinion – how birding is much akin to the art of diagnostic medicine. Both require an unwearied observation of the physical and the behavioral in discerning the answer, be it the bird’s beak or the bird-beak sign. It is thus no wonder that a good number of birding enthusiasts happen to be physicians, as my interactions with the birding community have revealed, both back home in India and over the digital sphere.

Within or outside of medicine, the pandemic has given us a chance to rediscover the outdoors. It has left nature cleaner and clearer, inviting wildlife to venture out in areas previously considered hostile territory. Whether it is the domestic turkey (Meleagris gallopavo) out on a saunter in the neighborhood, or the dapper cedar waxwing (Bombycilla cedrorum) berry-hunting in the local park, the company of birds can be a stimulating way to socially isolate. + *Joshua Schor. When Sparks Fly — Or How Birding Beat My Burnout. N Engl J Med 380;11. March 14, 2019:997-999 Parul Sarwal, MD is a final-year internal medicine resident at Saint Vincent Hospital. After graduating from Kasturba Medical College in India in 2015, she completed a research fellowship at Mass General Hospital before moving to Worcester for residency.

She is looking to pursue a career in gastroenterology and medical editing. Having led editorial ventures in high school, medical school, and then her research training, she is excited to continue her commitment to writing through Worcester Medicine as a resident representative.

COVID-19

Part 3

Diving Headfirst: Perspectives on Entering the Clinic in the Time of COVID-19 Sheikh Moinul Hannah Swartz

sheikh moinul:

E

arly May marked a period of great uncertainty for many rising third-year medical students at UMass. The COVID-19 pandemic ensured that a rapidly evolving set of rules were being delineated on an almost-daily basis, leaving many students to refresh their Outlook inboxes at the same frequency as their Reddit feeds. With STEP 1 exam cancellations, quarantine modifications, and clerkship start date changes happening at what could only be described as warp speed, life as it was once known had been completely upended.

So, when the email announcing that clerkship experiences were set to start on June 1st, weeks before many other programs around the country were planning on doing the same, students expressed apprehension, uncertainty, and confusion. Every reassurance was made that extensive measures had been taken to maximize safety, but many students could still not fathom the prospect of being in a hospital during the throes of a global pandemic.

However, many expressed excitement at the prospect of continuing education, fervently exhausted by the severe cabin fever that quarantine had brought to daily life.

The revamped COVID-19 clerkship experience was, in many ways, as strange as one could imagine.

For starters, medical students were not allowed to participate in the care of any COVID-19-positive patients, which was to be expected. What were once weekly roundtable case seminars had become Zoom sessions, final examinations had become anxiety-inducers at home, and OSCEs

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Part 3

Diving Headfirst: Perspectives on Entering the Clinic in the Time of COVID-19 Continued

had transformed living rooms into virtual clinics.

Students were urged to socially distance as much as reasonably possible by Zooming into conferences, eating lunch separately from residents, and avoiding congregation in already-packed lounges.

Most patient encounters were carried out with face shields, surgical masks, and gloves, making students resemble makeshift astronauts as they visited their bewildered patients.

Despite all of this, the freshly revised clerkships still carried many characteristics that kept them familiar. The amount of immersion that they provide is still second-to-none; no online module can simulate the experience of building a bond with a 7-year-old receiving chemotherapy for metastatic renal cancer, nor can any textbook adequately replicate real interviews with acutely psychotic patients.

Even learning how to coordinate care between treatment teams at UMass and elsewhere is a vital skill best learned in-person. The very real experience of being educated by a seasoned cardiologist on the risks and benefits of anticoagulation makes for a much more vivid lesson than those found in online flashcard decks. These conversations are essential components in the training of young doctors, and even during a pandemic their value makes them worth hazarding the risk.

For third-year medical students, this has become the new normal, and a life without masks, social distancing, and weekly nasal swabs has become unimaginable. Despite being mildly inconvenient, the numerous safety measures taken at UMass have ensured that clerkships remain safe overall. Moreover, clerkships have brought back a semblance of normalcy to a life that was once filled with uncertainty; they have given medical students the opportunity to continue their training in a feasible, immersive, and rewarding manner. hannah swartz:

O

ur third-year medical school class started clinical rotations in June, just one month delayed from the planned start. With coronavirus cases declining, and in an attempt to not have unnecessary delays in our training, our school made arrangements for us to reenter the clinical setting. I started on the adult general medicine unit

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at our main hospital. Students were not allowed to see COVID-19 patients, but the residents and attendings we work with on our teams were. Every day we would discuss a patient who is admitted for two months, sick with COVID-19 and met with an incredibly unfortunate set of complications. I pass his room daily, unable to see him behind the sets of doors which isolate him from other patients. His wife only calls by phone, not allowed to visit due to strict protocols in place for COVID-19-positive patients.

A few weeks into my rotation, he finally tests negative for COVID-19; the doors open, and the warning signs outside his room come down. We visit him as a team the next morning. Lying in bed, he is just a fraction of what he used to weigh. He is sad, he is lonely, and he is sick.

As medical students, we follow at most a handful of patients, learning the intricacies of their cases and spending more time with the patients because we do not have the same time constraints and responsibilities that the residents and attending physicians have. Because we are able to spend so much time with patients normally, being restricted from seeing certain patients – let alone ones without visitors – made me so much more appreciative of every moment I could spend in person with patients.

Starting clinical rotations during a pandemic goes outside the confines of what any of us as students imagined during our clinical years. The years of studying we put in to prepare are over, the nervous excitement we feel remains, but there is a hyperawareness of the ways in which the pandemic has changed the hospital environment. However, as students, we still have the ability to visit with patients longer and more frequently. We are able to give time and companionship, a listening ear in person rather than on the phone, a hand on the shoulder — even if gloved — and a warm smile behind a mask, one just big enough so that the patients can see the crinkle in our eyes. The learning opportunities are endless, and although some are different than what we expected, we are pushing ahead just the same, absorbing all the information we can as we rotate through different specialties, all hit by the pandemic in different ways. + Sheikh Moinul and Hannah Swartz are third-year medical students at UMass Medical School

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From the Archives Curator Dale Magee, MD Worcester Medicine; 2013, Vol. 77(3), 20.

Navigating Vaccination Controversy in a TechSavvy Population Elizabeth Butler, MS4, University of Massachusetts Medical School

T

he use of the Internet to do research for any number of things has exploded over the past decade. With tools like Google, WebMD and UpToDate, it is no wonder that people first turn to their computers when faced with a health issue. This increase in readily available information is part blessing, part curse, especially when the information arrives from nebulous sources. This phenomenon is compounded when thinking about vaccinations, which have proven to be a hot topic on the Internet. There are countless websites dedicated to the discussion of pro- versus anti-vaccination, some legitimate and others with no scientific basis whatsoever. Knowing that there is so much information out there means that doctors must act accordingly.

We must realize that patients will enter appointments with their own set of ideas about what is happening, and we should be prepared to deal with this.

On one hand, it is wonderful that patients are taking the initiative to learn more about health and their bodies, and this behavior should be lauded. On the other hand, the Internet is rife with false and modified information and there is much opportunity for misinterpretation. This aspect is what makes it difficult for clinicians to fully appreciate how the Internet can help their patients. Rather than demonizing the Internet and deciding that it will never be useful to the patient-doctor relationship, I propose that we instead embrace the possibility that the Internet can, in fact, add to the relationship by acting as a conduit of medical information between patient and provider. Using the Internet can promote health literacy and a greater interest in one’s body and health.

Furthermore, using the Internet to learn about medical issues is not a phenomenon that will disappear anytime soon. Embracing this practice will help us develop a better relationship with our patients.

To return to the original point about parents choosing to not vaccinate their children based upon information found online, it would be beneficial to have a better understanding of what anti-vaccination websites promulgate. It can be challenging to understand where patients get their information about this issue, but glancing at the websites shows that there is often advice couched in pseudo-science that can be quite persuasive. Knowing this background gives us a better foundation to offer education and discuss how these theories are not evidence-based or scientifically sound. As a budding pediatrician, I know that many of my future patients and their parents will turn to the Internet when they have questions about vaccinations. Rather than feeling threatened, I know I need to accept this and learn more about the information they will find there. One way to do this is to survey the information available and use this as a starting point for our continuing conversation. + Dr. Butler currently practices Pediatrics in Rhode Island

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As I See It

A Pre-existing Condition in Medicine Christine Runyan, PhD, ABPP

C

OVID-19 shined a light on a pre-existing condition in medicine – our healthcare system has been failing to tend to the well-being of its workforce.

Physicians and advanced practice clinicians are mostly a privileged population. But, the process of becoming a doctor involves extensive and expensive training, repeated trauma exposures, geographical relocation and sometimes isolation, poor access to one’s own healthcare, fear about seeking help due to licensing, consent to disrupted sleep and 80-hour work weeks, as well as chronic stress in order to meet the demands of a culture that expects perfection and tireless self-sacrifice. Doctors do not lack resilience. The rigorous training paradigm ensures they

“

...trying to be resilient in the face of chronic stress with a mindset of perfectionism allows the voice of self-criticism to flourish.

”

have the ability to “bounce back in the face of adversity.” So why do over 400 physicians die by suicide every year and rates of burnout are well over 50%?

Because trying to be resilient in the face of chronic stress with a mindset of perfectionism allows the voice of self-criticism to flourish. Clinicians achieve excellence, in part, by repeatedly bowing at the altar of self-criticism and demanding more and better for themselves. This behavior is rewarded throughout training. Once training ends, however, this welloiled mechanism is extremely hard to turn off simply because the evaluations, feedback, and grading have stopped. The cognitive and behavioral habit loops have been formed. My clinical practice has been exclusively with physicians for the past few years and

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the most pernicious threat I try to defuse is a negative internalized voice - the voice of not being and doing (good) enough.

No amount of sophisticated technology can do what health professionals have done these past few months - offered care with uncertain evidence, sat with the dying, comforted family members from afar, held one another in fear and grief, celebrated unexpected recoveries, and simply showed up. We have asked and expected clinicians to show up in ways they were never trained to do. No one has been trained in how to emotionally manage months of mass casualties. No one has been trained on how to keep showing up despite feeling feckless on the job.

No one has been trained how to keep regular life afloat at home and anxiety at bay, while working day after day with a little known biohazard.

A fortuitous side effect of COVID-19 are the writings, videos, and social media outcries by healthcare professionals coalescing into one common message: pay attention to our needs. So how can we pay attention to the needs of healthcare professionals? Access to high quality, private, low barrier, and expert mental health care is needed but we also need to move beyond a model of providing care only after people are suffering. Even with the financial strain facing most healthcare organizations, there remains an ethical and moral imperative to address workforce well-being by offering protected time to learn and practice skills such as emotional intelligence, managing secondary trauma, compassionate communication, presence, conflict mitigation, self-compassion, emotional regulation, opportunities to process various events in the community, and skills to regulate one’s own nervous system. These are all the things that buoyed me over these past months, helped my patients, and ultimately will improve the healthcare any of us receive. + Christine Runyan, PhD, ABPP is Professor, Dept. of Family Medicine and Community Health, University of Massachusetts Medical School, UMMHC and Co-Founder, Tend Health, LLC

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As I See It

Lessons from Justice Ruth Bader Ginsburg Michael Hirsh, MD

W

e live in a time of great conflict and controversy. Passions are high on every side of every issue. Consensus is near impossible under these current conditions. We have heard a lot about the dying wishes of Ruth Bader Ginsburg wanting to have her replacement picked after the November third election. Of course, I would love to see this wish honored, but that may be out of our hands. I would prefer to honor her memory differently. I think the

best way to honor her is to mirror her behavior and embrace her philosophy of debate.

We have to channel the inner spirit of RBG. Justice Ginsburg always had strong opinions and frequently argued with people to which she was diametrically opposed. She was iconic in so many ways. What made her unique and so admirable was that she engaged in these legal debates with a gentility that did not lessen her laser focus or ferocity.

She knew she was frequently the odds-on favorite to lose her argument.

It’s her dissenting or opposition opinions that probably had the most influence. Whether she was in the minority or majority side she did not insist that the other justices leave the court and be canceled.

Instead, you can find photographic evidence that shows her lunching, exercising, and communing with Justices Scalia, Alito, Thomas, and, more recently, Gorsuch and Kavanaugh.

Her legacy will be one of fierce liberalism but also of civility and respect for opposing opinion — even if it was anathema to her. That’s what has been missing in our current discourse on so many issues from wearing masks to BLM issues.

Opposition and conflict should not mean ouster and ostracism.

Moving forward, let’s make this our take home life lesson gifted to us by this diminutive GIANT. + Michael P. Hirsh, MD, Chief of Pediatric Trauma and Assistant Vice Provost for Health and Wellness Promotion, UMass Medical School

left Ruth Bader Ginsburg (March 15, 1933 – September 18, 2020) was an associate justice of the Supreme Court of the United States from 1993 until her death in September 2020.

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Legal Consult

Psychosurgery – Qu’est-Ce Que C’est?

Peter Martin, Esq.

A

nne Vacca had been depressed for many years. She had tried various medications, psychotherapy, and electroconvulsive therapy, without relief. Her psychiatrist, Dr. Jane Erb, recommended deep brain stimulation, a treatment approved for Parkinson’s disease but not for depression. Implanting a DBS device in Vacca’s brain would cost about $150,000, which Vacca could not afford. Dr. Erb was the clinical director of the depression center at Brigham and Women’s Hospital, and she secured the hospital’s agreement to provide Vacca with free DBS treatment. Erb informed Vacca that the hospital agreed “to perform the surgery, provide the aftercare or the postoperative care, which included battery replacements, programming the device, and cover the costs as long as [Vacca] needed that.” Details of Vacca’s postoperative care, the type of battery to be used, and who would program the device were never specified and the parties never entered into a written agreement.

This is the point in the story at which the lawyer wags his finger and predicts doom. Sure enough, although Vacca found the initial results of the treatment to be very helpful, within three years she became concerned about the use of a standard rather than a rechargeable battery for the DBS device, the frequency with which the DBS battery required replacement, the fact that the most recent battery replacement caused her sleep problems, and the lack of a psychiatrist to program the device. She asked that her care be transferred to another hospital, and asked that her agreement with BWH be documented in writing. The hospital provided a letter agreement, but Vacca objected to this document, in part because it permitted either party to terminate upon written notice. Even after all this, BWH replaced another battery for Vacca and expressed a willingness to continue to treat her.

The story now becomes a tale of litigation. Vacca filed a complaint in Superior Court claiming BWH breached a contract, among other claims.

Vacca did not bring a medical malpractice claim because she asserted the treatment was experimental and she was challenging the hospital’s financial decision to not pay for elements of her care, not the medical judgment of her caregivers. At trial, evidence was presented suggesting BWH wanted to treat Vacca, in part in order to expand its psychosurgery program, and that the hospital had featured Vacca’s case in promotional materials about that program. Ultimately, BWH’s motion for summary judgment was allowed on all claims, with the trial judge noting that Vacca should have pleaded her claims as malpractice claims. Vacca appealed.

At this point in the story, we need to pause and ask some fundamental questions that were considered by the Appeals Court. Did the hospital and Vacca actually have an agreement here? Despite the lack of a written document, Massachusetts law recognizes oral agreements if they meet the

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three characteristics of offer, acceptance, and consideration. The Appeals Court considered this question in the light most favorable to Vacca, as it must in an appeal of a summary judgment where the moving party, here the hospital, would if the appeal fails to be entitled to judgment as a matter of law. That court did find that the parties had a sufficient “meeting of the minds” even though the oral agreement was indefinite in some of its terms. The court also found the required element of consideration in the fact that “BWH benefited from the arrangement because it hoped to establish a DBS program for the treatment of depression.”

However, the Appeals Court found that BWH did not breach the oral agreement, crucially because BWH continued to treat Vacca at no cost until after Vacca filed her action. Vacca alleged various breaches that did not form part of the oral arrangement – use of a standard, not a rechargeable battery, BWH’s refusal to pay for Vacca’s care at another hospital, the hospital’s failure to provide independent ethical oversight of her care, or the provision of the letter agreement. The Appeals Court found there was no “meeting of the minds” on these topics between Vacca and the hospital, and that the oral contract on other aspects of her arrangement with the hospital was not too vague as to be unenforceable. The Appeals Court affirmed the trial court’s summary judgment in favor of the hospital.

Having avoided the predicted doom, the hospital would then be told by the lawyer that the lesson here is that although having a written agreement might not have avoided litigation, not having a written agreement did not prevent the creation of a contract that is legally enforceable through litigation. The lawyer might counsel the hospital that next time it engages in a private-pay or uncompensated patient arrangement involving experimental treatments or significant financial and other obligations, it would be better off manifesting that arrangement in a written document that adequately specifies all of its material terms.

Another question that could be asked at this point is: why is this a contract breach matter and not a medical malpractice action? In bringing a contract action, Vacca may have wanted to avoid certain procedural steps required for medical malpractice claims, such as the initial review of the case by a pre-trial tribunal, and the statutory $100,000 cap on malpractice damages involving a nonprofit provider.

In doing so, she was obliged to find a reason other than poor clinical judgment or incompetent care for the harm she alleged, such as the hospital’s desire to exploit her case for the purposes of promoting its psychosurgery program. In a footnote to the Appeals

NOVEMBER / DECEMBER 2020

WORCESTER MEDICINE

Society Snippets

Psychosurgery – Qu’est-Ce Que C’est? Continued

Court decision, the Court states: “Vacca cites no authority for the proposition that a health care provider loses the protection of the medical malpractice statutory regime if it takes financial considerations into account when making treatment decisions.” The Court basically advises Vacca that “most of the alleged breaches she raised sound in medical malpractice and, as a matter of law, cannot be disguised or recast as a breach of contract claim.”

The distinction between business-related claims that may found a contract action and clinically based claims that constitute grounds for medical malpractice is worth noting here. The Appeals Court in the Vacca case cited two relatively recent decisions that draw similar distinctions. One case (Morgan v. Laboratory Corporation of America (2006)) involved the late reporting by a clinical lab of “panic results” that did not involve “deliberated judgment in the particular case on the part of a physician or other skilled staff,” but a decision by a non-clinical administrator. In that case, the matter would be considered under common-law negligence standards and procedures, not as a medical malpractice case.

The second case (Darviris v. Petros (2004)) involved a dispute between a patient and a physician as to the adequacy of informed consent, in which the plaintiff claimed the physician’s actions violated MGL Chapter 93A, the consumer protection statute. (Chapter 93A provides the potential for both treble damages and payment for reasonable attorney’s fees, neither of which is available in a medical malpractice action.) In the Darviris decision, the claim was denied because the physician’s behavior was not unfair or deceptive, though the court noted in an aside that “consumer protection statutes may be applied to the entrepreneurial and business aspects of providing medical services, for example, advertising and billing.”

Both cases seek to draw boundaries between medical malpractice and other types of legal actions, but the second case seems to have potential applicability to the situation of a future Anne Vacca , receiving health care not as a matter of charity, but in the normal course of a medical practice. Could the “entrepreneurial and business aspects” of promoting a new clinical service or treatment cause a physician’s decision to recommend that service or treatment to a patient, with a resultant bad outcome, be considered not just negligent but unfair or deceptive? Mixing business and clinical imperatives increases the risk of expanding disgruntled patients’ litigation options beyond that of the medical malpractice action, with unpredictable and potentially disastrous consequences.

At this point in the story, we may be entitled to conclude that caregivers are better off memorializing any unusual agreements they may have with patients in a carefully considered and drafted document. We may also want to emphasize that relationships with patients are best founded on and governed exclusively by clinical considerations. To do otherwise may result in bad litigation outcomes for providers and, ultimately, accounts of such cases written by lawyers, including bad puns. + Peter Martin, Esq.,is a partner at Bowditch and Dewey. He concentrates his practice on health care law, representing hospitals, long-term care facilities, physicians and other facilities and providers facing complex regulatory and contractual issues throughout Massachusetts and beyond.

The WDMS 29th Annual Women in Medicine Gathering September 24, 2020

speaker: Dr.

Lynn Eckhert

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n the heels of the 100th anniversary of the Women’s Suffrage Movement and the ratification of the 19th Amendment, Dr. Lynn Eckhert presented our first virtual presentation of 2020. Those who attended had the chance to win a prize for taking a short quiz to test your knowledge on the subject.

Congratulations to our winner Dr. Marjorie Saffron!

Dr. Eckhert’s lecture can be viewed from our website: WDMS.org under the Events Calendar/Past Events

physicians & suffrage quiz with results:

1. Who was the first woman to become a member of the Massachusetts Medical Society? Emma Louise Call 2. Who was the MMS member who advocated for women to join the MMS? Henry Bowditch 3. Which was the first state to offer women the right to vote? New Jersey 4. Which woman suffragist was a surgeon in the Civil War? Mary Walker 5. What mountain is associated with the struggle for woman suffrage? Mount Rainer 6. Name the woman physician who was President of the National American Woman Suffrage Association? Ruth Howard Shaw 7. Who was the first woman to become a physician who was rejected by Harvard Medical School? Harriott Kezia Hunt 8. Who were the Silent Sentinels of suffrage?

Protesters outside the White House 9. Why were the Mormons important in the woman suffrage movement? Mormon women had the right to vote 10. Who wrote “Common Sense” Applied to Woman Suffrage? Mary Putnam Jacobi +

NOVEMBER / DECEMBER 2020

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WORCESTER MEDICINE

Society Snippets

Health Matters

H

ealth Matters is a television program produced in collaboration with The Worcester District Medical Society and WCCA TV in Worcester. Offering valuable information on disease prevention, treatment options, current public health issues and more, Health Matters is produced in a ½ hour interview format and the program airs on WCCA TV Cable Channel 194: Wednesday- Noon and 7:30 pm, Thursday– 7:00 pm and Friday – 9:30 am.

To view episodes of Health Matters please visit: www.wdms.org +

show

200: Worcester Healthy Baby Collaborative

If you have an idea for a topic or guest, or wish to be a guest, please contact wordmsa@massmed.org or call 508-753-1579.

host:

Dr. Michael Hirsh, right guests:

Vanessa Villamarin, left Dr. Sara Shields, center

show

201: Surviving COVID-19: A Medical Student’s Point of View

host:

Dr. Bruce Karlin, right guests:

Michelle Shabo, left

We are honored to present a new Host, Michelle Shabo, MS4 UMass show

202: Improving Inpatient Sleep Quality at UMMHC Campus

host:

Michelle Shabo, center guests:

Katherine Sadaniantz, left Ezequiel De Leon, RN, right

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NOVEMBER / DECEMBER 2020

Introducing our new IVF Center.

Complete infertility care now offered locally.

The path to pregnancy can be overwhelming. Your patients need an expert team with the right experience and capabilities. That’s why we’re pleased to announce the addition of our on-site IVF Center to round out our robust fertility services — ensuring convenient, state-of-the-art care, close to home.

Call 508-334-1345 to speak to one of our infertility specialists.

For referrals, call Physician Concierge Services at 800-431-5151.