Worcester Medicine September/October 2021

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Volume 90 • Number 5 Published by Worcester District Medical Society Sept / Oct 2021

Students Then A Road Map of Change in Medical Education

& Now

Training the Next Generation of Physician Scientists Evolution of Nursing Education

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Contents

on the cover Then: The first UMMS graduating class, 1974.

Now: Modern medical students.

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Students Then And Now

From the Archive

Editorial 4

Medical Education and our Worcester District 15

Alexandra Rabin

Dale Magee, MD, Curator, WDMS

Legal Consult

Medical School: Then and Now 5 A Conversation Between Alexandra Rabin and Rebecca Kowaloff, DO, Harvey Kowaloff, MD, Joel Popkin, MD, Lynn Eckhert, MD, Peter Schneider, MD

A Roadmap of Change in Medical Education: Milestones Along the Journey, and a Preview of What’s To Come 7

Constitutional Haberdashery 16 Peter Martin, Esq.

Society Snippets Annual Business Meeting & Awards Ceremony 18

Michele Pugnaire, MD

Melissa Boucher

Training The Next Generation of Physician Scientists 9

Women in Medicine Leadership Forum 19

Sylvia Corvera, MD Philip Feinberg

Melissa Boucher

Nursing Education: A History and Future of the Dynamic Professional Pathways to Excellence in Care 10 Elizabeth DelSignore MS, RN Michelle Page, DNP, RN

Health Matters 20 Melissa Boucher Doctoring is All in the Family 22 Reprint from The Telegram & Gazette

My Journey Through the Match 12

Allison K. Jones

Kate Freeman, DO

Physician-Scientists, Nurse-Innovators and CommunityShapers: A Student Research Highlight 13 Compiled by Alexandra Rabin; Julia Sherman, Zachary Michaels, Jessica Ferreira, DNP, AGACNP-BC, Kevin Makhoul

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Editorial Alexandra Rabin

Clinicians from Different Eras Shine Their Lights on Medical Education

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t is an immense privilege to be a student.

Few other situations afford us the chance to explore fundamental topics while also forming our views on the world around us. In the realm of medical education, we are particularly lucky, knowing that our training contributes not only to our personal fund of knowledge but also to supporting our mission of ameliorating the world around us. The world of medical education has evolved drastically since the era of the Ether Dome, shaped by shifting standards in healthcare and teaching and by new technologies. This edition of Worcester Medicine seeks to highlight the forces that have shaped our medical educational system from the eyes of those participating in the system’s evolution.

I had the opportunity to speak with five Worcester-area physicians whose time in medical school ranged from the 1950s to the 2010s. It is easy to imagine how much our educational system has changed since 1959, when our most senior colleague graduated medical school. I’ve witnessed how profoundly my own education has been impacted by the COVID-19 pandemic and was curious to hear how events like the Vietnam War shaped medical school experiences in the 1970s. I encourage younger readers to pay particular heed to the evolution in our clinical experiences.

Dr. Lynn Eckhert, Class of 1970, writes about spinning her patients’ hematocrits and examining smears herself on overnight shifts. It’s fascinating to see how our responsibilities have shifted since then.

We are fortunate to hear from Dr. Michele Pugnaire, former senior associate dean for educational affairs at UMass Medical School, who expertly contextualizes the evolution in medical education since 1910. Dr. Pugnaire details the origins of the current “2x2 framework” of undergraduate medical education, paying particular attention to recent curricular reforms designed to promote healthcare quality, equity, and patient safety across all stages of learning. The future of medical education is bright, she notes, as innovations in curricula will serve to cultivate future generations of humanistic and quality-focused physicians.

Philip Feinberg and Dr. Silvia Corvera collaborate to highlight the distinctive skill set of physician scientists, particularly in the rapidly evolving world of COVID-19. Their article delivers an insight into the UMass Medical School MD/PhD program, which serves to train the next generation of research-oriented physicians. As the authors note, MD/ PhD students and faculty are integral to bridging the gap between the bench and the bedside. In fact, the MD/PhD program arranged campuswide physician scientist forums at the onset of the COVID-19 pandemic, helping to convey the findings of early basic science research on the virus to the UMass community.

The intricacies and objectives of nursing education are deftly summarized by Elizabeth Delsignore, MS, RN, and Michelle Paik Page, DNP, RN. The authors provide a well-referenced history of nursing education as early as 1872, as the need for formally trained nurses became apparent in the post-Civil War era. Since then, a number of avenues for nursing education have become available, including the associate degree of nursing (ADN) and bachelor of science in nursing (BSN). While the number of BSN-educated nurses has increased, the authors argue that

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augmenting the proportion of nurses with BSN degrees will encourage better healthcare outcomes.

Though medical and nursing school can be incredibly busy, many students set aside time for exciting research projects. I urge the reader to look at several innovative projects highlighted in this edition. To assess the effect of the COVID-19 pandemic on firearm-related violence, Julia Sherman and the Pediatric Surgery Research Group are examining factors associated with firearm-related hospital admissions and ED visits during the pandemic as compared to years prior. Zachary Michaels details his findings studying the association between chronic pain, mental illness, and suicidality in his patients. Jessica Ferreira, recent UMass nursing school graduate, initiated a program at Milford Regional Medical Center that enhanced nurse-led stroke screenings in the ED to hasten stroke detection. And Kevin Makhoul, always interested in history, describes his fascinating profile of Dr. Julia Gordon Arrowood, the first female anesthesia resident and department chief at Massachusetts General Hospital.

Dr. Kate Freeman, a third-year UMass Internal Medicine resident, offers an informative and personal insight into “the Match,” the process by which medical students secure spots in residency programs. Dr. Freeman depicts her own journey through medical school, interweaving information on the match process itself and the experiences of her peers. She shares her disappointment in matching to a residency program that would separate her geographically from her husband, a fear of many prospective residents understandably aspiring to their first-choice programs. Encouragingly, Dr. Freeman writes that she is now thriving, and would not have changed the outcome of her match. I encourage my peers, particularly other fourthyear medical students, to read Dr. Freeman’s story for a realistic and reassuring take on this daunting process.

A remarkable story about filial co-residents at St. Vincent Hospital, initially published in the Worcester Telegram & Gazette in 1992, highlights the unique challenges faced by a duo of international medical school graduates.

Drs. Andino and Andy Abril hail originally from Colombia, where Andino trained in tropical diseases before immigrating to the United States. Andy, his son, joined his father at St. Vincent hospital for their Internal Medicine residencies. This article provides a captivating glance into a one-of-a-kind family, and I urge the reader to take a look.

And last, please take a look at our exciting snippets, curator and legal columns.

I would like to thank the Editorial Board of Worcester Medicine for the opportunity to act as Guest Editor for the September/October 2021 edition. I am incredibly lucky to have attended medical school in Worcester, where medical education is unquestionably in good hands.

Alexandra Rabin is a fourth-year medical student at UMass Medical School.

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Students Then & Now Medical School: Then and Now

A Conversation Between Alexandra Rabin, University of Massachusetts Medical School Class of 2022, and: Rebecca Kowaloff, DO Touro New York College of Osteopathic Medicine Class of 2011 Harvey Kowaloff, MD Northwestern University Feinberg School of Medicine Class of 1975 Joel Popkin, MD SUNY Downstate Medical Center College of Medicine Class of 1974 Lynn Eckhert, MD SUNY Buffalo School of Medicine Class of 1970 Peter Schneider, MD Harvard Medical School Class of 1959 Certain core tenets of medical training have held true through the generations: the weight of basic science and physiology, the integration of medical students in the clinical system, and the fostering of professional identity. Medical education does not exist in a vacuum, however, and is shaped with the entire educational system by major world events, social and educational movements, and new technologies. Among many examples, our limitless access to the internet and the subsequent ease of conducting research, searching for therapies such as medication doseses, and understanding disease pathology are relatively new privileges for medical students compared to earlier generations. This is just one of countless advances that have reshaped medical education. I spoke with several Worcester-area physicians who graduated medical school between 1959 and 2011 to learn about their medical school experiences and understand the trends that shaped them.

Alexandra Rabin: While medical students may sometimes feel we operate in a closed system of studying and clinical work, our education has certainly not existed in a bubble. What was the zeitgeist of your time in medical school?

Harvey Kowaloff (’75): Entering medical school in 1971, my class was at the beginning of a transition in American medicine. We saw the first significant increase in women entering medical school and we were one of the first classes to enter medical school who had come of age during the Vietnam and civil rights eras. As a result, there was more social and political consciousness among my classmates than in most medical school classes in the preceding decades.

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Lynn Eckhert (’70): The Vietnam War had a major impact on us all. In the evenings, night after night, we saw the carnage of war and we took to the streets and marched in protest. I recall leaving the medical school library to find the campus full of tear gas as police tried to quell an uprising. The male medical students were granted military deferments as a result of their studies and some were conscientious objectors. Female physicians did not have to serve. However, it impacted all of us. As a spouse of a physician assigned to the Indian Health Service, my GME years were spent at three different institutions as he was reassigned.

Peter Schneider (’59): I was in medical school 65 years ago, so I may have forgotten much of the zeitgeist. It was a relatively placid period but, importantly, it was the dawning of the space age with the launching of the Russian Sputnik I in 1957. However, my career path was not shaped by external events but by my own long-term interest in science. Perhaps, and somewhat unusual at the time, was that one-third of my class went into psychiatry.

Rebecca Kowaloff (’11): I was in the first class of a new osteopathic school opening in Harlem with a mission to increase the number of underserved groups in the medical profession. The fact that we were a new school was a blessing. There was ample room for us to step into leadership roles and establish clubs and such.

For instance, I was a student government president in my second year, something not normally in my nature.

Being the inaugural class was a curse, however, in that we often felt we had to advocate more than we should have for the support and resources we felt we needed.

Alexandra Rabin (’22): It has been a strange and exciting experience to attend medical school in the COVID-19 era. While we are privileged to experience medicine in an unprecedented age, with new innovations like the mRNA vaccine and the treatment of COVID-19 pneumonia, we have also suffered tremendous losses on the personal and global scale. Beyond COVID-19, movements like Black Lives Matter have also contributed to forming a more conscious group of students who are thoughtful about our role in reducing disparities and racism in health care.

AR: Did you have any particularly memorable interactions between yourself and a medical school attending?

Joel Popkin (’74): I still remember the day as a third-year clerk. We were to meet the chief of medi5

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Medical School: Then and Now Continued cine for teaching rounds. He was an intimidating figure and presenting a case to him seemed to be best avoided. But, he turned out to be every bit the wonderful teacher he was renowned to be and conducted rounds in a relaxed atmosphere, conducive to taking home some of the teaching points I actually remember today. But, things went less well if he found out a medical student was contemplating marriage or – heaven forbid – had actually done the deed. He felt very strongly that a career in medicine excluded marriage and any other significant distractions. I would almost invariably see him eating dinner alone in our cafeteria and, knowing no better, could only feel sorry for him.

Lynn Eckhert (’70): The most remarkable interaction I recall was with an attending who served as a supervising physician for me during a clinical rotation in Liberia. Dr. Franklin Keller was a remarkable physician and surgeon, a highly skilled and caring individual who devoted his life to caring for a vulnerable population in upcountry Liberia. Often, as the only physician in a 70-bed hospital, he was capable and comfortable in the full breadth of medicine and common surgeries. A highly principled man, he sought to bring out the best in his patients, his colleagues, his students and himself. He was a patient teacher who moved each of us to build on our talents and perform at the highest levels. From Dr. Keller, long before the social determinants of health were well defined, I learned how education, socioeconomic status, culture, and the environment impacted the health of individuals and families.

AR: What is the most salient difference between your medical school experience and that of current students?

Joel Popkin (’74): In our class of 205, five students were women. Horrifying to think of today, but standard in the early 1970s.

Lynn Eckhert (’70): Women were uncommon in medical school with the percentage in the single digits. Often we were referred to as “hen meds.” My senior resident on a medicine rotation during my third year of medicine announced, “I do not like women in medicine,” an inauspicious way to begin a six-week stint on his service. However, I had no such incidents from my classmates who felt we were all in this together.

Harvey Kowaloff (’75): We were in clinical training before limits were placed on residents’ hours. Consequently, a part of the medical student’s education was to experience the long hours that would be an integral feature of their training and practice lives.

Peter Schneider (’59): It’s almost obvious that the greatest change in medical school is the explosion of information and the means to access it. We all felt there was too much to learn. That feeling is probably even greater now. However, the second part of the information explosion is the computer which remembers almost everything for us. To look something up, we went to the library and its shelves of the “Index Medicus.”

That was a huge, printed resource, updated yearly, which covered most of the world’s medical publications. To find something, we would look up as many pertinent keywords as we could think of, find references, and search the library stacks for relevant articles. It was very time consuming, but it did demand a certain discipline to determine the best search strategies.

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Lynn Eckhert (’70): For better and worse, medical school was different. Simulations were upfront and personal as we practiced drawing blood, taking blood pressures and passing nasogastric tubes on our classmates. In the clinical settings during our third year, we were immersed in the care of our patients. Among our responsibilities, we carried out what is often referred to as “scut work.” This taught us much about clinical medicine and about the best use of the ancillary services of the hospital. If we needed to take our patient to radiology for a film, we did, and while there we learned how the department functioned.

Long before hospital accreditation required higher standards in laboratory techniques, we students, while on night duty, spun our patients’ hematocrits, stained and examined smears for red and white cell morphology, determined the specific gravity of urine, and checked for glucosuria. We performed lumbar punctures and trotted off to the lab to perform the cell counts in suspected cases of meningitis. Students were central to uncovering the diagnosis. What a pure joy it was to detect malaria parasite in the Giemsa stain slides I had prepared.

Joel Popkin (’74): Third- and fourth-year students had relatively little supervision compared to now. Getting data back then was incredibly more difficult, both in medical records and medical literature. But, we often provided the primary care for our patients and therefore learned the value and need for ownership. And, as crazy as the hours were, we devoted everything to learning and patient care, being very little bogged down by some of today’s needless documentation exercises. I believe this is the reason that the term “burnout” had not even been described until the year after my graduation. Perhaps from the few in my generation still hanging around training programs, where burnout has been rightly described as occurring in epidemic proportions, our perspectives might be of some relevance.

In speaking with these physicians, I perceive several important trends. Demographics have shifted; the concept of “hen meds,” as Dr. Eckhert writes, is now foreign, as medical school enrollment is evenly distributed between men and women. Second, global events like the Vietnam war and the COVID-19 pandemic drastically affected students’ social and political consciousness and showed that our experience is understandably susceptible to outside forces. And last, the responsibilities of medical students have evolved markedly since Drs. Schneider, Eckhert and Popkin were third-year clerks, though medical students continue to be highly engaged in patient care. The extent of change in medical education over the last half century is remarkable. But the common themes – a passion for constant learning and an excitement about science and clinical medicine – still define who and what we are. + Alexandra Rabin is a fourth-year medical student at UMass Medical School.

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Students Then & Now A Roadmap of Change in Medical Education: Milestones Along the Journey, and a Preview of What’s To Come Michele Pugnaire, MD

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n these pandemic times, change in medical education is ongoing

and ever-accelerating. In grappling with “change fatigue”, let’s recognize that medical education has evolved for over a century and consider how change has shaped medical education as we now know it. What follows is a roadmap of medical education with timelines and change milestones from the 1900s to now, offering perspective on changes past as we look ahead to future change yet to come.

Our roadmap begins with the 1910 Flexner Report. Commissioned by the Carnegie Foundation for the Advancement of Teaching to ensure quality in 20th century medical schools, Abraham Flexner’s report set revolutionary standards for his time (1). His “2x2” model prioritized acquiring scientific knowledge and rigorous clinical training through two years of classroom-based coursework and two years of clinical rotations in university-affiliated hospitals supervised by clinician faculty.

Designed for teaching medical students “to think like scientists,” Flexner established a clear dividing line between preclinical and clinical years (2). In 1942, accreditation standards adopted the 2x2 model as the medical education prototype. By 1967, students in 92 medical schools were being taught to think like scientists through arduous hours of coursework, for example, anatomy 556 hours (median, range 252-1257) and pathology 330 hours (median, range 108-706) (3).

From 1970 to 1990, complementary milestones emerged in the form of primary care workforce shortages and nationwide calls for “generalism.” Addressing workforce needs, generous federal and state funding expanded primary care education and residency training. By 1990, 22 new medical schools were accredited, with the University of Massachusetts among these state-sponsored “primary care schools” (4). Along with school expansion, primary care advocates, the Association of American Medical Colleges and the American Medical Association endorsed a general professional education preparing students with foundational skills and values required of all physicians, regardless of specialty (5).

The 2x2 framework accommodated generalism teaching, by replacing basic science time with longitudinal preceptorships and patient-focused small group teaching, including patient interviewing, clinical problem solving and humanistic values in patient care. In clinical years, hospital-based clerkships carved out time for ambulatory and primary care rotations in physician offices. By 1988, accreditation standards required generalism teaching across preclinical and clinical years. Students being taught to think like scientists would graduate with a general professional education required for all physicians (5). Despite these advances, Flexner’s 2x2 dividing line between preclinical and clinical years held firm, with limited flexibility in year three, dominated by six- to 12-week rotations in medicine, surgery, obstetrics and gynecology, psychiatry, and pediatrics – much like the 1960s (6).

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With the new millennium, 2010-2020 soon became a decade of curricular reform with three milestones transforming medical education beyond prior periods of curriculum change. Leading the way, companion reports from the Institute of Medicine, “To Err is Human” and “Crossing the Quality Chasm,” focused public attention on medical errors as a leading cause of death in the United States (7), while endorsing two major reforms to promote health care quality: competency-based standards across the learning continuum (student, resident, physician) and patient safety and health care quality training in all stages of learning (8). By 2008, core competencies were defined for each learner level, unifying the educational continuum through a competency-based framework. One hundred years after Flexner, his model of teaching students to think like scientists was redesigned to prepare students as competent graduates, “residency-ready” for their next phase of GME training.

Building on competency reform, the Carnegie Foundation issued a second report in 2010, “A Call for Reform in Medical Education,” reappraising and dismantling the Flexner model through comprehensive reform. It features: • Enhanced curriculum flexibility to individualize student learning • Integration connecting basic, clinical and social sciences across years • Fostering inquiry and continuous life-

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A Roadmap of Change in Medical Education Continued long learning in diverse settings, including community and population-based experiences focused on health care quality and equity • Continuous professional development emphasizing student wellness and self-care (2) Coinciding with Carnegie’s call for reform, a second workforce shortage emerged nationwide across all medical specialties. From 2010-2020, 24 new schools were established (4), many with pioneering innovations. For example, Kaiser Permanente Tyson School of Medicine was established in part to “prepare students for future-facing clinical practice and health system leadership” (9).

Spearheaded by newcomer innovations, medical schools nationwide comprehensively redesigned their curricula by dismantling Flexner’s 2x2 model.

Common trends featured integrated systems-based courses replacing basic sciences; more time for small group interactive learning and independent study displacing lecture time; diversification of learning venues in community settings outside the hospital; earlier start to the clerkships in year two by shortening the “preclinical” years, and six- to 12-month longitudinally integrated clerkships replacing “stand-alone” clerkship blocks. To enhance individualization, parallel tracks, scholarly concentrations and expanded electives across all years offered students choice and customization of their learning experience (10).

And then came the pandemic in March 2020.

In just weeks, in-person classes became remote and clinical rotations were comprehensively redesigned for student and patient safety. In this time of curricular redesign, how else did medical education respond to pandemic-driven change? Some early, impressive trends emerged, including: • Fourth year “residency-ready” medical students joined the COVID-19 workforce through early graduation, licensure and deployment in school-affiliated health care systems at UMass (11) and in schools nationwide.

• Interest in medical school soared, with record numbers of applicants in 2020 and 2021 (12).

• Students became change agents and valued pandemic partners in communities and health care systems locally and nationwide.

In June 2021, Academic Medicine compiled publications from 2020-2021 addressing pandemic-related changes in medical education. Of these, 56 publications (38%) included student authors, showcasing

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student activism spanning systemic racism; racial and ethnic disparities; student diversity in medical schools; interprofessional partnerships; social justice reform; student wellness; and humanism; as examples (13).

Looking ahead, what future change is anticipated for post-pandemic medical education? While uncertain, we know medical education is now more adaptable than ever, without Flexnerian constraints and with cutting-edge innovations underway. Student interest in medicine is stronger than ever, undeterred by pandemic-related change. And, today’s students are competency-prepared, socially conscious and ready to advocate for and contribute to much needed forward-facing change, particularly targeting socio-demographic barriers to health care equity, access and quality. Come what may, post-pandemic, future change in medical education rests in the very best of caring and competent hands.+ references

1. A. Flexner, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching 1910 reprinted Science and Health Publications: 1960 2. Irby, David M et al. “Calls for Reform of Medical Education by the Carnegie Foundation for the Advancement of Teaching”: 1910 and 2010”, Academic Medicine: February 2010 - Volume 85 - Issue 2 - p 220-227 doi: 10.1097/ ACM.0b013e3181c88449 3. Undergraduate Medical Education. JAMA. 1972;222(8):965–991. doi:10.1001/jama.1972.03210080045014 4. https://lcme.org/directory/ 5. Muller, S. (chair) Physicians for the Twenty-first century: Report of the Project Panel for the General Professional Education of the Physician and College Preparation for Medicine J.Med Educ.59 part2 (November 1984).

6. Jonas HS, Etzel SI. Undergraduate Medical Education. JAMA. 1988;260(8):1063–1071. doi:10.1001/jama.1988.03410080033005 7. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press, 2000.

8. Crossing the Quality Chasm: A New Health System for the 21st Century.

Washington, D.C.: National Academy Press, 2001.

9. https://medschool.kp.org/about/mission-vision-and-values . accessed 10. Novak, Daniel A. et al “Continuum of Innovation: Curricular Renewal Strategies in Undergraduate Medical Education”: 2010–2018, Academic Medicine: November 2019 - Volume 94 - Issue 11S - p S79-S85 doi: 10.1097/ ACM.0000000000002909 11. Flotte, Terence R et al. “Accelerated Graduation and the Deployment of New Physicians During the COVID-19 Pandemic.” Academic medicine : journal of the Association of American Medical Colleges vol. 95,10 (2020): 1492-1494. doi:10.1097/ACM.0000000000003540 12. https://www.aamc.org/media/37816/download 13. https://journals.lww.com/academicmedicine/pages/collectiondetails.aspx?TopicalCollectionId=68

Michele P. Pugnaire, M.D. Professor Emeritus Office of Educational Affairs Department of Family Medicine and Community Health University of Massachusetts Medical School SEPT / OCT 2021

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Students Then & Now Training The Next Generation of Physician Scientists Sylvia Corvera, MD Philip Feinberg

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ultidisciplinary and collaborative research

aimed at ameliorating human disease has been pursued by physicians and scientists for many years. The COVID-19 pandemic has raised awareness of the value of these collaborative efforts; we’ve all seen firsthand what rigorous collaborations across the health care ecosystem can do. They resulted in the rapid identification of the pathogenic virus, established diagnostic tests, developed and improved standards of patient care, guided resource allocation, and paved the way for the development of several highly effective vaccines. We have seen how necessary it is to have experts that understand clinical medicine and have the research skills to identify and move evidence-based practices forward. And, we have seen how important this was, and remains, to patient and public safety. At the intersection of medicine and research sits the physician scientist, a professional with focused training in both areas and uniquely suited to bridge the divide between bench and bedside.

While many avenues to become a physician scientist exist, the dual degree MD/PhD program is one that combines medical and scientific training for a continuous, on average, eight-year period. At the University of Massachusetts Medical School, MD/PhD students are enrolled in both the School of Medicine and the Graduate School of Biomedical Sciences, learning alongside traditional single-degree students, while integrating medical and research knowledge. The National Institutes of Health awards a competitive Medical Scientist Training Program grant to the most successful MD/PhD programs in the United States, which are trusted to “develop and implement effective, evidence-informed approaches to integrated dual-degree training.” The UMMS MD/ PhD program successfully competed for MSTP status in 2013, a clear testament to how the quality of our program is perceived nationally. The growth of the program is another testament to its relevance. In 2004, when the program opened its enrollment for the first time to applicants from outside the Commonwealth, it received 43 applications. In 2021, the program received 263 applications, from which 11 applicants were selected to join a robust program of 76 students.

The core components of physician-scientist training at the UMMS campus take place in basic science laboratories, clinical research labs, and inpatient and outpatient settings – all of which give students access to a rich environment in which they can develop their skills as physician scientists. A strength of the UMMS MD/PhD program is the recognition by program leadership and students of the changing needs in society and of the fast evolution of medical research technologies which must be met by a dynamic training model. We therefore work together to constantly refine the program to meet the distinct career goals, motivations, academic identity and preparedness of aspiring physician scientists. This involves addressing areas not included in the traditional single degree programs, such as simultaneously learning how to use best-practice guidelines to diagnose and treat a disease while remaining open to posing further questions and designing research studies to answer them. We have developed a specific program, the Physician Scientist Forum, to help students identify knowledge gaps in our understanding of diseases and the most current research tools and concepts that can be leveraged to fill these gaps.

The COVID-19 pandemic demonstrated just how activities such as the Physician Scientist Forum can rapidly help address an emerging health crisis. In the early weeks of the pandemic, when case and mortality numbers were on the rise in our community, a significant volume of COVID-19 research had not yet undergone the normal and trusted peer-review process. There was confusion about what it all meant for treating patients or protecting ourselves, our loved ones and our community. The MD/PhD program arranged three 90-minute campus-wide virtual Physician Scientist Forums to address what we knew in five primary areas, each fundamental to understanding the nature of the pandemic. We refer to these areas as “pillars of disease”, and they are: clinical presentation; epidemiology; molecular pathophysiology; mitigation, which includes treatment and prevention; and justice, which includes impact of health disparities. Current students, with related expertise derived from their clinical and research focus were selected to present in these forums. Additionally, basic science and clinical faculty experts were available to provide their own insights and to answer audience questions.

Through this experience, we helped educate our community during an emerging health crisis and gave our students an opportunity to further their skills in communicating science to general audiences. Moreover, several of our students rapidly pivoted their efforts into developing tools and clinical research strategies specifically to help mitigate COVID-19.

Our community was rocked by more than just COVID-19 in 2020 and 2021. In the aftermath of George Floyd’s murder, and a national conversation about racism in America, we began our own reckoning as an MD/PhD program asking what role physician scientists have in achieving healthcare equity. By pursuing both medical and scientific training, we are committed to

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Training The Next Generation of Physician Scientists Continued

Nursing Education: A History and Future of the Dynamic Professional Pathways to Excellence in Care

providing our patients of today with the best possible care while remaining steadfast in our goal to provide patients of tomorrow with better outcomes through collaborative research and innovation. As such, we agreed that we have a duty to understand the broad impact that racism has on various aspects of health and began an initiative to incorporate discussions on racism and justice into our Physician Scientist Forums. Over this past year, we held four 90-minute sessions on racism in medicine and focused each session on specific minority populations in the U.S. We discuss the diverse ways that racism and injustice exist within the health care field, how we can be better providers to patients from minority communities and what role research plays in either perpetuating or correcting health disparities. We believe that learning about how racism contributes to medical injustice, we can contribute to eradicating it through our collective careers by applying best practices at the bench and bedside.

As we look to the future, our goal remains to provide the next generation of physician scientists with the tools required to make a mark on healthcare discovery and innovation. We welcome any members of the Worcester medical community to contact us if interested in collaborating on local projects or participating in our Physician Scientist Forums. +

Elizabeth DelSignore MS, RN Michelle Page, DNP, RN

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when there was a need to care for wounded soldiers during the Civil War. The first school of nurse training in the United States opened at the New England Hospital for Women and Children in Boston in 1872. Student nurses completed apprenticeship-style training which included long hours on the hospital wards caring for patients followed by physician lectures in the evenings.

Nursing education transitioned into the university setting in the early part of the 20th century and the National League for Nursing (NLN) developed one of the first sets of curriculum guidelines.

By the 1950s, the associate degree of nursing (ADN) at community colleges was piloted to provide “technical” practitioners during a nursing shortage (1). The advent of intensive care units in the 1960s required a broader range of skills, and the application of clinical reasoning became a vital part of the role. The NLN and the American Nurses Association (ANA) called for baccalaureate prepared Registered Nurses (RNs) in the mid-1960s, but the social climate at that time discouraged the advancement in the education of women and progress was hindered. Although there has been an increase in the percentage of baccalaureate prepared nurses for initial RN licensure since 2013, 37.7% of registered nurses in 2020 report the ADN as their highest degree at initial licensure (2).

Silvia Corvera, MD, is professor of molecular medicine, endowed chair in diabetes research and director of the MD/PhD program at the University of Massachusetts Medical School.

Email: silvia.corvera@umassmed.edu.

Philip A. Feinberg is a student in the MD/PhD program at the University of Massachusetts Medical School working on understanding and treating neuropsychiatric disorders.

Email: Philip.feinberg@umassmed.edu. references:

academic pathways and the need for

1. Medical Scientist Training Program. Accessed July 27, 2021. https://www.nigms.nih.gov/training/ instpredoc/pages/predocoverview-mstp.aspx

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he need for formal nurse training arose

baccalaureate-prepared nurses

There are educational options a student may consider for initial licensure as a RN, including the diploma, the associate degree, and the baccalaureate degree (BSN) however, many stakeholders encourage the BSN as the minimum educational preparation for entry into professional nursing practice (3,4).

Many schools have bridge programs for nurses with a licensed practical nursing (LPN) certificate, diploma,

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Students Then & Now

Nursing Education Continued

or ADN to obtain a BSN or a master’s degree in nursing (MSN). There is solid research linking the educational level of a nurse with patient outcomes, including a decreased risk of patient mortality and adverse events when nurses are prepared with a BSN or higher (5,6).

Despite the IOM recommendation that 80% of the nursing workforce be BSN prepared by 2020 (4), as of 2018 only 57% of RNs were prepared with a BSN or higher (7) with projections that only 66% of nurses will have a BSN or higher by 2025 (8). In response to the IOM recommendation, the Robert Wood Johnson Foundation, the Tri-Council for Nursing, and the American Organization for Nurse Executives spearheaded the Academic Progression in Nursing (APIN) task force. The APIN program provided grant funding and resources to nine U.S. states, including Massachusetts, to help fulfill the goal of more BSN-prepared nurses at the bedside (3). academic progression model best practices

Massachusetts developed a statewide curriculum model designed to facilitate ADN to BSN transition, the Massachusetts Nurse of the Future Core Competencies © (9). The most recent update of the competencies was influenced by feedback from local practice partners to address the needs of the organizations hiring newly licensed nurses (3). This curriculum model, when used in conjunction with articulation agreements between community colleges and universities, allows students to obtain their BSN within 15 months of completing an ADN (2).

Preliminary findings from the four-year APIN project revealed that curricular integration and overlapping curricula, overlapping admission or dual enrollment in community colleges and universities, and having excellent relationships with practice partners in the community were some of the keys to successful academic progression and increasing the number of BSN-prepared nurses (3). Every state involved in the APIN project successfully decreased the length of time for students to progress from the ADN to the BSN, with 80% of students who completed the ADN continuing their education in a BSN program (3). Findings from academic progression programs highlight similar themes in best practices including a curriculum design that eliminated redundancies, dual admission models that created seamless progression through simultaneous curriculums, and intentional advising practices which also eliminated and identified redundancies in program course work (10). One of the most integral policies developed as part of the Massachusetts APIN initiative was the Nurse Educator Transfer Compact (NETC). The compact directly addressed the seamless progression for Massachusetts ADN students allowing for participating nursing programs to accept and apply 72 transfer credits for a BSN degree completion. Massachusetts programs that have applied the NETC in Massachusetts can be found at: https://www.mass.gov/service-details/about-board-approved-prelicensure-nursing-programs. future considerations for academic progression

With the need for a standardized curriculum across all levels of nursing practice and with a consistent eye on the dynamic changes in the healthcare environment, the American Association of Colleges of Nursing (AACN) recently updated their nursing curriculum guidelines (The

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Essentials of Professional Nursing Practice) which outline ten domains and associated competencies and concepts that “represent the essence of professional nursing practice” (11). The competencies are designed to be met throughout four spheres of caredisease prevention and health promotion; chronic disease care; restorative or regenerative care; and hospice, palliative, and supportive care; and integrated in each level of the nursing program of study (11). These components of practice are not new to nursing; however they are re-framed as integral competencies that thread throughout all care areas as key to the holistic support of patients. As nurse educators plan to meet the next set of evidence-based benchmarks to achieve the goal of the BSN for entry to practice for all registered nurses, competency-based educational models will be a key component in the future considerations of curricular design for academic progression pathways. As educators continue to provide seamless professional pathways for academic progression, RNs at any point of practice will have the opportunity to continue to excel in the care provided to our patients. + Elizabeth DelSignore MS, RN Instructor Worcester State University, Staff Nurse Massachusetts General Hospital Michelle Page, DNP, RN, Nursing Program Administrator at Worcester State University references:

1. Keating, S. B. (2015). Curriculum Development and Evaluation in Nursing. Springer Publishing Company 2. Smiley, R. A., Ruttinger, C., Oliveira, C. M., Hudson, L. R., Allgeyer, R., Reneau, K. A., Silvestre, J. H., & Alexander, M. (2021). The 2020 National Nursing Workforce Survey. Journal of Nursing Regulation, 12 (1), S1-S96. https://doi.org/10.1016/S2155-8256(21)00027-2 3. Farmer, P., Gerardi, T., Thompson, P., & Hoffman, B. (2018). Academic Progression in Nursing (APIN): Final program summary and outcomes. https://nepincollaborative.org/wp-content/uploads/2018/03/FINAL-APIN-REPORT.pdf 4. Institute of Medicine. (2011). The Future of Nursing: Leading Change, Advancing Health. The National Academies Press. https://doi.org/10.17226/12956 5. Aiken, L. H., Cimiotti, J. P., Sloane, D. S., Smith, H. L., Flynn, L., & Neff, D. F. (2012). Effects of nurse staffing and nurse education on patient deaths in hospitals with different work environments. Journal of Nursing Administration 42 (10 supplement), S10-S16. https://www.ncbi. nlm.nih.gov/pmc/articles/PMC6764437/

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Nursing Education Continued

6. Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality.

Journal of the American Medical Association, 290 (12), 1617-1623. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3077115/ 7. Campaign for Action (2020).

Welcome to the Future of Nursing: Campaign for Action Dashboard. https://campaignforaction.org/ wp-content/uploads/2019/07/r2_ CCNA-0029_2019-Dashboard-Indicator-Updates_1-29-20.pdf 8. Spetz, J. (2018). Projections of progress toward the 80% Bachelor of Science in Nursing recommendation and strategies to accelerate change. Nursing Outlook, 66 (4), 394-400. https://doi.org/10.1016/j. outlook.2018.04.012 9. Massachusetts Department of Higher Education Nursing Initiative.

(2016). Massachusetts Nurse of the Future Nursing Core Competencies©: Registered Nurse. https://www.mass. edu/nahi/documents/nofrncompetencies_updated_march2016.pdf 10. Angel, L. (2020). Best practices and lessons learned in academic progression in nursing: A scoping review. Journal of Professional Nursing, 36, 628-634. https://doi. org/10.1016/j.profnurs.2020.08.017 11. American Association of Colleges of Nursing. (2021). The Essentials: Core Competencies for Professional Nursing Education. American Association of Colleges of Nursing. https://www.aacnnursing.org/ Portals/42/AcademicNursing/pdf/ Essentials-2021.pdf

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My Journey Through the Match Kate Freeman, DO

T

he process through which fourth-year medical students

gain entry into residency programs — referred to as “the match”— initially filled me with trepidation and anxiety. Now, years down the line, I see it as a gateway into the next exciting opportunity. Residency is when freshly minted doctors finally get to test their mettle and develop their own identities as physicians — and the match is how they get there. So, whether you are a mentor to medical students or a medical student yourself, I hope you will gain some advice and encouragement from my story.

I am a third-year internal medicine resident at UMass Memorial Medical Center and I will be going into hospital medicine at the end of this academic year. I went to medical school at the University of New England College of Osteopathic Medicine. I enjoy going on adventures with my husband, puttering in my garden and scuba diving. I am from Maine and I would like to remain in New England long term.

When I was eight years old, I read a book about a nurse who rode through the Appalachian Mountains giving medical care to the impoverished families of the region. This inspiring story set me on the path toward medical school because I wanted to spend my life taking care of those in need. This dream solidified when my sister was diagnosed with breast cancer while I was in college. Thankfully she is now cancer-free, although the physical and emotional scars remain. Her journey, and my small part in it, was the final motivation I needed to enter medical school.

Like all medical students, I completed two years of classroom learning and passed my first of four board exams before finally entering the world of clinical medicine. I completed my third-year clerkships at Eastern Maine Medical Center, now Northern Light, in Bangor, Maine. There, I saw the gamut of what medical subspecialties have to offer — from openheart surgery to inpatient child psychiatry to rare medical illnesses like autoimmune meningitis and primary CNS lymphoma. Ultimately, I chose internal medicine because I liked the variety of cases, the excitement of building and narrowing a list of differential diagnoses, and the relationships one forms with patients both in and out of the hospital.

Finally, after about 18 months of clinical work and two more board exams, I was ready to enter the match process. On a fundamental level, the match has remained the same for decades. Each fall, all fourth-year medical students submit applications to a national governing body. They interview through the winter and submit a rank list in early spring. Then, the preferences of applicants and programs are entered into a proprietary algorithm designed to put as many applicants into as many spots as possible. Finally, every applicant finds out where they matched during the same week in March.

That said, the landscape of the match is now shifting. When I applied in 2018, the osteopathic and allopathic matches were two distinct processes with different applications and deadlines. While I participated in the allopathic match successfully, I had to eschew the safer option of the osteopathic match to do so. This meant I had to apply to more programs than the average medical student. In the end, I applied to roughly thirty.

Now that the matches are combined, the field has become more

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Students Then & Now

My Journey Through the Match Continued

competitive. There are also more applicants entering the pool each year as it has become increasingly popular for graduates of foreign medical schools to come to the U.S. for residency. However, this may change in the coming years because the USMLE Step 1, an allopathic board exam, has become pass/fail. The COMLEX, the osteopathic equivalent, will remain a scored exam.

The match process itself, and the unknown element introduced by all these changes, puts a lot of pressure on applicants. I certainly shed lots of tears over the process because it felt like my whole life had led to something over which I had no control. I want to reassure any applicants reading this, it truly is not as bad as it seems. My advice is this: choose one factor that is most important and use that as a framework.

For me, this was location. My husband would remain in Maine during my residency so I limited myself to programs between Maine and New Jersey. Those applying to a more competitive specialty, like dermatology or ophthalmology, will need to be flexible and apply more broadly.

My own match day was bittersweet. UMass was not my first choice and matching here meant that I had to move away from my then fiancé. At first, I was upset and it felt like the end of the world. However, I am thriving here at UMass and have no regrets about matching. I fit in incredibly well with my co-residents and I have made life-long personal and professional relationships. I have gotten married and weathered a global pandemic. My training here has broadened my horizons and challenged me in ways that will ultimately make me a better, more independent, and skilled physician.

If you do not match, all is not lost. A medical school classmate of mine failed to match, waited a year, got married, and couples-matched with his wife. One of my best friends also did not match and had to scramble into a residency in a specialty she did not intend. Now, three years later, she has found her calling in critical care and could not picture herself doing OBGYN as she had originally thought.

All this is to say that you can trust the process.

Even though it did not feel like it at the time, I matched into the program that was best for me and, if I had it to do over again, I would not change the outcome. It simply takes a little strategy and a little resilience for young doctors to end up exactly where they are supposed to be. + Kate Freeman, DO, is a third-year Internal Medicine resident at UMass Memorial Medical Center.

Email: catherine.freeman@umassmemorial.org

Physician-Scientists, Nurse-Innovators and Community-Shapers: A Student Research Highlight Compiled by Alexandra Rabin, University of Massachusetts Medical School Class of 2022

T

hough the primary focus of medical and nursing

school is the acquisition of knowledge and clinical training, many students make time for exciting research projects. Medical and nursing students have historically contributed avidly to research. The Islets of Langerhans, the cells within the pancreas that produce insulin, were discovered

by Paul Langerhans in 1869 while still a medical student.

The availability and diversity of student research has grown exponentially since, as students participate not only in basic science research, but also in community-oriented and public health projects. At UMass, students are privileged to conduct research with formal faculty mentors and are supported by residents, fellows, basic scientists and more. This section highlighting student research displays the breadth of subject matter and applicability — both to the clinical setting and to the community at large — of several such projects.

Effects of the COVID-19 Pandemic on Firearm Injuries and Community Firearm Ownership Julia Sherman, University of Massachusetts Medical School, Class of 2022 Drs. Michael Hirsh (Principal Investigator, Pediatric Surgery Research Group) and Max Hazeltine (Pediatric Surgery Research Fellow)

B

eyond the enormous human toll of COVID-19, we have yet to fully grasp the social and economic consequences of the pandemic. Our study aims to assess the effect of the COVID-19 pandemic on firearm-related violence. It will do so by comparing the sales of firearms, rates of firearm-related injuries and fatalities, and turnout for the Goods for Guns program during the pandemic compared to years prior to the pandemic. Since 2002, the Goods for Guns program has allowed participants to anonymously surrender firearms to various community sites in exchange for gift cards, with the aim of eliminating unwanted firearms from homes and raising community awareness about gun safety. This study will also assess demographic and clinical factors associated with firearm-related hospital admissions and emergency department visits during the pandemic compared to prior years.

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Physician-Scientists, Nurse-Innovators and Community-Shapers Continued The findings of this study may ultimately have important public health implications, furthering our understanding of the determinants that underlie firearm-related violence and how these can be addressed through injury prevention programs.

The Role of Mental Illness in the Association Between Chronic Pain and Suicidality Zachary Michaels, University of Massachusetts Medical School, Class of 2022 Celine Larkin, Ph.D.; April Sawko, MPH, CHES; Joseph Davenport, B.A.; Rachel Davis-Martin, Ph.D.; Bo Wang, Ph.D.; and Edwin D. Boudreaux, Ph.D.

U

sing survey data from a study about mental health and suicide risk, I found patients who reported experiencing chronic pain were not necessarily more likely to report suicidal ideation or behavior, despite a well-documented interaction between the two variables in the literature. However, patients struggling with daily chronic pain were more likely to have mental illness affecting their daily life and mental illness had a significant association with recent passive suicidal ideation. It is my hope that this impacts patient care, particularly in the need to continue to be vigilant in assessing suicide risk in acute and outpatient settings, especially in populations experiencing chronic pain and mental illness. As a result, in addition to other suicidality-facing research, I have dedicated time to training in different forms of suicide risk assessment and management such as Collaborative Assessment and Management of Suicidality, or CAMS, and Counseling for Access to Lethal Means, or CALM, and encourage other clinicians to do the same if at all possible.

Reducing Inter-Stroke Center Transfer Time Through Utilization of the VAN Tool Jessica Ferreira, DNP, AGACNP-BC; University of Massachusetts Graduate School of Nursing, Class of 2021 Henry Ellis DNP, AGACNP-BC

E

mergent Large Vessel Occlusions, or ELVOs, are life-threatening ischemic strokes associated with the highest rates of morbidity, mortality and long-term disability among all strokes. They require rapid identification in order to initiate the multiple time-sensitive interventions necessary to maximize the likelihood of positive patient outcomes. Poor recognition of ELVOs in the emergency department leads to prolonged inpatient hospitalizations, increased risk of mortality and higher incidence and cost of long-term disability. Our quality improvement project aimed to improve nursing recognition of ELVOs through an educational module introducing the Vision, Aphasia and Neglect, or VAN, tool.

Used as an adjunct to the clinical neurologic assessment, this tool was designed to enhance rapid identification of ELVOs. Our results proved that implementation of this tool improved nurse recognition of ELVOs in emergency departments. The results of this quality improvement

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study have led to a change in Milford Regional Medical Center’s emergency-department stroke algorithm. Now, when potential stroke patients arrive, nurses will complete a VAN assessment and communicate their findings to an MD, prior to the patient being transferred to CT, so that the MD can decide whether a CT angiogram (CTA) is warranted and can be done at the same time as the CT head. This new step in completing the VAN assessment could lead to a decrease in door-to-CTA and subsequent door-totransfer times for ELVO patients.

Julia Gordon Arrowood (1900-1984): A Brilliant Anesthesiologist and a Woman of Many Firsts in Medicine Kevin Makhoul, University of Massachusetts Medical School, Class of 2023

I

n my first year of medical school, I came across a prospective request by my mentor, Dr. Desai. She was looking for a student to work on a history project about a notable anesthesiologist. I have always been something of a history buff, but I had never imagined I could incorporate two of my great interests in this way. Medical history is a field of research whose impact is easily underestimated.

When we delve into these stories, we often unearth important events and ideas that predict and contextualize present realities of our fields of study. History is taught to be rigid and unchanging because we need reliable references to justify current practices, but many of our histories are altered, abridged or missing from our collective memory. Many professionals who have contributed so much to medicine are underrepresented due to social biases, and their stories deserve to be told. Julia Gordon Arrowood is one such professional. During a time when the proportion of female physicians was in steep decline due to a patriarchal backlash, she rose through the ranks to become the first female resident of anesthesiology in Massachusetts — as well as the first female chief of a department at Massachusetts General Hospital, in addition to other distinctions. She contributed much to the field through her research on local anesthesia, spinal block and muscle relaxants. While her male colleagues have received much attention, her story is only now being told in full. Not only does her story contribute to our medical knowledge and inform future studies, it also demonstrates the importance of diversity in leadership as a lasting bulwark against institutionalized discrimination in medicine and beyond. +

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From the Archive Medical Education and our Worcester District Dale Magee, MD, WDMS Curator

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ducation

and

credentialing

are

foundational for the Worcester District Medical Society. When 41 physicians met at the U. S. Arms Hotel on Main Street in Worcester on December 18, 1794 it was out of concern that education was not standardized, lectures not readily available and experience varied depending on who was a student’s preceptor. The minutes of that first meeting state: “Since the business of the Physician is of such importance to mankind and since the science of Physick with the best opportunities for improvement can never be perfectly attained by any individual in the short compass of human life, it becomes the duty of every practitioner of this Divine Art to adopt the best methods for his own improvement and also to make his knowledge as useful as possible. Confident of this truth and influenced by motives of friendship and philanthropy, we, whose names are subjoined, agree to form ourselves into a fraternity by the title of the Worcester Medical Society…” The Society at that time sought to credential physicians by having censors examine them on a list of topics. There was a list of what would be examined as well as suggested books. The credentialing issue (with a charter from the State providing authority) was at the heart of a decade long conflict with the Massachusetts Medical Society. The MMS wanted all of the authority for the state (even though they had limited their membership to 70…) and Worcester wanted local authority.

This was resolved in 1804 with the merger of the two Societies with Worcester becoming a District with authority west of Framingham.

A career in medicine was basically training by apprenticeship. Keep in mind that this was when the only medical school in the state was what would later be called the Harvard Medical School. Over a decade after its founding it had graduated less than a dozen doctors. Nonetheless, the founders of the WDMS did encourage attendance at the medical school to those seeking admittance to the Society.

But, until the mid 19th century most physicians had not graduated from medical school. States had not adopted licensing requirements (Massachusetts would establish the Board of Registration in Medicine in 1894). Those who attended medical school

routinely graduated without laying eyes on a patient! It seems that one either apprenticed without academic training or went to medical school without clinical exposure. Courses were often taken one at a time with cards issued certifying completion. Instructors were paid when their pupils passed. Pupils often were not literate and exams were oral. Those who chose would commonly go to Europe to further their training.

Although education was poor by today’s standards, medicine itself was not considered a science. Prior to the mid 19th century there was no knowledge of infections, appreciation for the benefits of hygiene, ability to perform any but the most crude operations (without anesthesia!) and medicines were not standardized. Some felt that the theories that were being taught may have done more harm than good.

Besides credentialing physicians, and having the certificate acting as a defacto license, the Society became a prime source for books with the library being the central function well into the twentieth century.

As the mid 19th century approached, medicine began to change. John Snow’s revelations regarding epidemiology and hygiene, the discovery of anesthesia, Pasteur’s exposure of the world of infectious disease and Lister’s development of antiseptic technique all advanced the potential of medicine. Now there was something important to be gained with a good education.

Although there were numerous breakthroughs in advancing medical education in this time span, I will quickly review a few.

Elizabeth Blackwell is best known for being the first female graduate of a medical school in the U.S. Less well known is the fact that she felt that medical education was not only not accessible to women, but that medical education in general was deficient. She and her sister Emily instituted a Women’s Medical College of the N.Y. Infirmary for Women and Children in 1868. Besides actually having some educational requirements for entering students, they expanded the curriculum from 2 years to 3, provided a graduated curriculum (prior to this courses were simply repeated from 1 year to the next) and connected the medical school to their hospital to provide clinical experience.

At about the same time, at Harvard, Dean Charles Eliot advocated for a 3 year graded curriculum, expansion of the year from 4 to 9 months and written exams. He was warned by faculty that given the low literacy among students that this would be a disaster for the school. He persisted and, in 1870, Harvard instituted the new structure…with 40% fewer students.

Possibly the most significant breakthrough in medical education in the 19th century came with the design and opening of Johns Hopkins.

Beginning with Daniel Coit Gilman in 1876, adding John Shaw Billings (who had previously founded what later became the National Library of Medicine), a faculty was recruited from the best in the country. This included: William Osler in Medicine, Howard Kelly in Gynecology, John Whitridge Williams in Obstetrics, William Halsted in Surgery and William Welch in Pathology. Designed with the intent of revolutionizing medical education it instituted a requirement for a bachelor’s degree for admission, and a medical school curriculum including 2 years of basic science training and 2 years of clinical training at a hospital designed to be part of the educational system. The school opened in 1893.

The influence of Johns Hopkins cannot be overstated. As concern grew that the science of medicine was advancing but degree mills were SEPT / OCT 2021

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Legal Consult Constitutional Haberdashery

turning out unqualified-and dangerousdoctors, the American Medical Association and the Carnegie Foundation sponsored a comprehensive review of all medical schools in the US and Canada. Published in 1910, the Flexner Report (named for the lead investigator, Abraham Flexner, a Johns Hopkins professor) applied the Johns Hopkins framework to the schools reviewed. He rated resources and structure of schools and summed things up in very compact, direct language.

At the time the report received tremendous publicity. As a result, over the following decade, about half of the medical schools in the US either closed or merged with others to strengthen their curriculum.

As medical education moved to medical schools and teaching hospitals and licensing to the Board of Registration, the Worcester District Medical Society continued to offer library resources until this was taken over by the UMass Medical School in 1971. We continue to offer medical education in niche areas such as health policy, quality and public health. The “motives of friendship and philanthropy” stated in the minutes of that first meeting carry through to the present to assure that the next generations of our profession remain connected to those values that brought us together as an organization and them to the dream of a career in medicine.+ further reading:

1. A History of the Worcester District Medical Society. Paul Bergin, MD. 1954. WDMS. 2. From Humors to Medical Science.

John Duffy. 1993. Univ of Illinois Press.

3. Carnigie Foundation Bulletin No. 4 Abraham Flexner, Herman Weiskotten. 1910.

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Peter Martin, Esq.

A

recent U nited S tates S upreme C ourt decision sought to put limits on the government’s ability to compel the disclosure of donors’ personal information in order to regulate charities. The Supreme Court decided a compelled disclosure regime must be narrowly tailored to the government’s asserted interest in the information. On the one side is a government’s legitimate interest in investigating fraud and other misconduct; on the other side is a donor’s right to privately associate with a charity.

For Massachusetts health care providers, many of which are tax-exempt organizations, this decision merits attention due to its possible effects on donor support for charitable health care institutions.

The case arose out of the California Attorney General’s Office’s efforts to require California charities to disclose the names and addresses of significant charitable donors as a condition of the, legally required, annual registration renewals in California. That information is found on Schedule B of the Internal Revenue Form 990 (The Internal Revenue Service redacts donors’ information from this schedule when the Form 990 is publicly disclosed). The attorney general’s office argued collection of donor information is critical to their efforts to combat fraud and misconduct – and that donors’ privacy interests are protected because the information is not disclosed to the public.

The plaintiffs in the case, two politically conservative charities, argued compelling disclosure of donor information interfered with the charities’ First Amendment right to free association and the rights of their donors, whose fear of reprisal would make them less willing to make donations. When they refused to turn over donor information, the attorney general’s office threatened to suspend their registrations and fine their directors and officers. Although the attorney general’s disclosure scheme did not include public disclosure, but only internal use in investigations, that office’s case was adversely affected by the discovery during trial of nearly 2,000 Schedule Bs which had been inadvertently posted to the attorney general’s website. Also unhelpful to the attorney general’s case was the fact the trial court credited testimony from California officials that Schedule Bs were rarely used to audit or investigate charities.

The original trial court issued an order preventing the attorney general from collecting Schedule-B information. The case then wound its way up to the Ninth Circuit Court of Appeals and then back to the trial court on remand.

Eventually, the Ninth Circuit ruled in favor of the attorney general, holding that the trial court had imposed too strict of a test requiring “narrow tailoring,” that the disclosure regime was supported by the need for the up-front collection of information to promote investigative efficiency and effectiveness, and that disclosure would not unduly burden plaintiffs’ associational rights because the attorney general had taken remedial measures to fix the identified confidentiality breaches. The U.S. Supreme Court granted certiorari.

Constitutional analysis of the matter begins with the implicit right under the First Amendment to associate with others. Government action may “chill” the exercise of that right by, for example, forcing a group to take in members it does not want, punishing individuals for their political affiliation or denying benefits to an organization based on the organization’s message. In NAACP v. Alabama ex rel. Patterson, 357 U.S. 449 (1958), an attempt by the Alabama attorney general to compel the NAACP to disclose its membership lists was rejected because of the demonstrated danger that such disclosure would subject

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Legal Consult Continued NAACP members to reprisal for the group’s advocacy efforts. In Shelton v. Tucker, 364 U.S. 479 (1960), an Arkansas statute required public school teachers to disclose every organization to which they belonged, in order to assess their competence and fitness. That statute was struck down because even a substantial governmental interest “cannot be pursued by means that broadly stifle fundamental personal liberties when the end can be more narrowly achieved.” In the present case, the Supreme Court stated: “Shelton stands for the proposition that a substantial relation to an important interest is not enough to save a disclosure regime that is insufficiently tailored. This requirement makes sense. Narrow tailoring is crucial where First Amendment activity is chilled – even if indirectly – ‘[b]ecause First Amendment freedoms need breathing space to survive.’ [citation omitted].”

The crucial issue in the present case was the appropriate standard of scrutiny to apply to the attorney general’s disclosure requirement. Plaintiffs sought either the “exacting scrutiny” test, which requires a substantial relation between the disclosure requirement and a sufficiently important governmental interest; or the “strict scrutiny” test, which requires the least restrictive means of achieving a compelling governmental interest. The Supreme Court settled on a compromise which might be called exacting scrutiny plus, in requiring a disclosure requirement have a substantial relation with a sufficiently important governmental interest and that the requirement be narrowly tailored to the government’s asserted interest.

In applying this test, the Supreme Court noted what it called a “dramatic mismatch” between the state’s interest in preventing wrongdoing by charitable organizations and a disclosure regime calling for universal production of information from all charities rather than, for example, relying upon targeted audits of suspect charities. It called California’s true interest here one of administrative convenience and not one of investigating fraud. The Supreme Court stated: “We have no trouble concluding here that the attorney general’s disclosure requirement is overbroad. The lack of tailoring to the state’s investigative goals is categorical – present in every case – as is the weakness of the state’s interest in administrative convenience. Every demand that might chill association therefore fails exacting scrutiny.” This is the case, the Supreme Court reasoned, even where the information disclosed is not re-disclosed to the public.

It is at this latter point – that governmental collection of information, without publication, can unduly chill associational rights – where the Supreme Court majority differs from the dissenters’ position as artic-

ulated by Justice Sonia Sotomayor’s dissenting opinion. In the dissenters’ view, the plaintiffs did not show an actual burden resulting from the disclosure of information, and without that showing of burden, tailoring cannot match governmental means to Constitutional ends. (Note that the dissenters’ tailoring is tied to the burdens imposed by disclosure on donors, while the majority’s tailoring is tied to the nature and scope of the governmental interest furthered by disclosure.) In Associate Justice Sotomayor’s words: “the Supreme Court requires plaintiffs to demonstrate that a requirement is likely to expose their supporters to concrete repercussions in order to establish an actual burden. It then applies a level of means-end tailoring proportional to that burden.” The mere fact that the California attorney general’s office has the donor information, without public re-disclosure or evidence of actual harm to donors, is in the dissenters’ view insufficiently chilly to violate associational rights.

The dissent then asks whether the Supreme Court is now saying that all disclosure requirements impose associational burdens. Would the Supreme Court’s decision support invalidation of the normal IRS collection of significant donor information in the Schedule B? The dissent also notes that no evidence was brought to light suggesting the government would use the disclosed information to retaliate against any donor, in contrast to the NAACP members or the teachers in the earlier cases. In the present case, the dissent argues, this relatively modest burden on donors’ associational rights requires a correspondingly modest level of constitutional scrutiny.

This decision has generated a great deal of debate across the country – and not just among tax-exempt organizations. Some have noted if a donor is concerned about the disclosure of personal information to the attorney general’s office, an easy expedient lies in the use of a donor-advised fund to anonymously support the charity. Others have argued that if the attorney general’s office wants to investigate a charity, it can always issue a subpoena for the donor information. Some commentators have contrasted the IRS’ tax compliance regulatory role, as to which donor information is crucial, to the states’ function of regulating fundraising and charitable asset use, for which donor information is irrelevant. Still others have made the point that the opinion’s uncompromising stance – “every demand that might chill association therefore fails exacting scrutiny” – is hostile to the notion that in the tax-exempt world, transparency is the price charities pay for tax exemption and tax-deductible contributions.

What is most striking, is the majority opinion in this case focuses on the danger of governmental bodies holding personal information, not on the danger that such information is publicly disclosed. It is the distrust of the government and how government may use personal information that seems to have motivated this decision. (Similar concerns do not appear to attach, at least not yet, to the collection and manipulation of personal information by large, powerful private actors such as social media platforms.) Given the fundamental, constitutional right of association involved in this case The Supreme Court was right to acknowledge the exercise of that right requires “breathing space to survive.” Roomy accommodation for free association is fostered by narrowly tailoring government intrusions on that right. In a government clothed only with limited and conferred powers, that cut seems to be the right fit. + Peter Martin, Esq. is a partner at Bowditch and Dewey.

SEPT / OCT 2021

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WORCESTER MEDICINE

Society Snippets ANNUAL BUSINESS MEETING & AWARDS CEREMONY Held on April 18, 2021 “Medicine for Madness: The Rise and Fall of Moral Treatment at Worcester State”

Speaker

Madeline Kearin Ryan, PhD Project Development Librarian Worcester Historical Museum

AWARD PRESENTATIONS Editor’s Award (Formerly the Wisteria Award)

MMS/WDMS Community Clicician of the Year

Peter J. Martin, Esq.

Nancy W. Detora, MD

WDMS President’s Awards

Edward M. Augustus Worcester, City Manager

Dr. Michael P. Hirsh Medical Director of WDPH

Joseph M. Petty Mayor, City of Worcester

ANNIVERSARY MEMBERS 50 Year Members Charles A. Birbara, MD Hannes J. Scheffel, MD Imre G. Toth, MD

25+ Year Members Vasanthi Arakali, MD Frederic Baker, MD Patricia D. Chernosky, MD

Lisa B. Noble, MD Sara G. Shields, MD Paul M. Steen, MD

TO VIEW THIS EVENT Click: https://www.youtube.com/watch?v=NMzDEKXBZX4 18

You can also, visit our website: www.wdms.org go to Event Calendar/Past Events SEPT / OCT 2021

WORCESTER MEDICINE

Society Snippets

Women In Medicine Leadership Forum

Held on May 27, 2021

“From Burnout to Thriving: One Physician’s Bundle for Personal Resilience” SPEAKER Heather S. Lipkind, MD, MS

Associate Professor, Section of Maternal Fetal Medicine Department of Obstetrics, Gynecology, and Reproductive Sciences Yale School of Medicine Associate Program Director, Meternal Fetal Medicine Fellowship TO VIEW THIS EVENT Click: https://youtu.be/mzl_F1DW3eI You may also, visit our website: www.wdms.org and to go Event Calendar/Past Events

SEPT / OCT 2021

19

WORCESTER MEDICINE

Society Snippets Health Matters

Health 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 visit our Website: www.wdms.org Or Click the Links to view the episodes

Show Number 209 "The New Arms Race-Vaccination in the Time of COVID-19 Pandemic" Host: Dr. Bruce Karlin, Guests: Dr. Michael Hirsh and Karyn Clark

Link: https://www.wccatv.com/video/health-matters/healthmatters-209

Show Number 210 "COVID-10 and Pregnancy"

Host: Dr. Michael Hirsh, Guest: Dr. Julianne Lauring Link: https://www.wccatv.com/video/health-matters/healthmatters-210

Show Number 211 "Vaccine Response"

Host: Dr. Michael Hirsh, Guests: Chancellor Dr. Michael Collins and Dr. Jillian Terrien Link: https://www.wccatv.com/video/health-matters/healthmatters-211

Show Number 212 "2021-New Frontiers in Bladder Cancer"

Host: Dr. Lynda Young and Guests: Drs. Kriti Mittal and Jennifer Yates Link: https://www.wccatv.com/video/health-matters/healthmatters-212

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

20

SEPT / OCT 2021

WORCESTER MEDICINE

Society Snippets Doctoring is All in the Family: Father-Son Team Turning Heads at St. Vincent Reprint with permission from the T&G, Publication date: 6/26/1992

Allison K. Jones

W

as it his brother or his son?

Only the family knew for sure when Dr. Andy Abril joined Dr. Andino I. Abril in the internship-residency program at St. Vincent Hospital earlier this month. Andino Abril was just finishing the program when Andy - his son, not his brother - came on board.

The pairing made for a lot of jokes and occasional confusion at St. Vincent, where the father-son team marked an all-in-the-family first for the hospital training program.

“Sometimes my beeper sounds and it’s not for me,” said Andy, 24, a soft-spoken man with a stethoscope slung around his neck. “It’s for the other Dr. Abril.”

“Sometimes I feel a little bit embarrassed,” added his 49-year-old father, who looks more like former Surgeon General C. Everett Koop than his son. “Sometimes my fellow residents don’t believe it’s my son. Most didn’t believe I was that old. So that made me feel a little better.”

Andino holds dual U.S. and Columbian citizenship. He was born in New York City and moved to Columbia with his family when he was 5. He was a doctor there 20 years.

He obtained his medical degree at The People’s Friendship University in Moscow in the 1960s under a Soviet scholarship routinely offered to natives of Third World countries. studied tropical diseases

When his training was completed, he returned to Colombia. He moved to the remote town of Villavicencio in the Orinoco Amazon basin, a region of vast grasslands and jungle, to work in a regional hospital and conduct epidemiological studies on tropical diseases. There, he married a doctor, Lillia Ramirez, and raised a family.

“Those were my Albert Schweitzer years,” he said with a grin.

Two of his sons, Andy and Ivan, 22, eventually entered medical school.

Andino, his wife and two younger children, Diana, now 14, and Juan, 13, moved to the United States three years ago to escape the escalating violence of the drug cartels. The guerrilla movement had taken over the region where he lived.

“There were continuous explosions and car bombs,” Andino said.

“These things were happening in shopping malls all the time. You could be walking down the street and get shot. It’s very dangerous.”

The rural area Andino once frequented to study yellow fever and malaria became closed to him because of the violence.

“When I was in Medellin, in medical school, even the windows on my apartment were broken by car bombs,” Andy said.

“We thought it was a good time to leave and get a foothold in the United States,” Andino said. had to pass exam

With Andino’s joint U.S. citizenship, it was not a difficult move. In order

22

SEPT / OCT 2021

to obtain a U.S. medical license, Andino had to pass an exam, then complete a two-year residency program here. To be recertified in internal medicine, he spent an additional year at St. Vincent.

“I wish I didn’t have to start all over again, but if that’s what it takes, I guess we all have to do it,” he said.

The training proved valuable “to learn how the American hospital system works, the type of pathology available here and legal issues.”

Although the family hopes eventually to return to Colombia, Andino will begin work in the emergency room at Clinton Hospital in July. His expertise in tropical diseases, for now, will be limited to treating mosquito bites.

In the meantime, his wife, clinical supervisor at Centro Las Americas on Sycamore Street, has completed a three-year master’s program in public health administration at Framingham State College.

In Colombia, she was assistant director of the regional hospital. next, son no.

2

Andy arrived in the United States a year ago and last summer passed the certifying exam for foreign medical school graduates. St. Vincent was one of three residency programs to which he was accepted.

His younger brother will complete his training in Colombia in a year. The family expects Ivan will come to the United States for his residency. The family’s two youngest children are in the eighth-grade in Shrewsbury, where the family lives.

Andy said his father already has been a valuable resource during his training. “I ask him a lot of questions.” But sometimes Dad’s presence adds to the pressure of a rigorous program.

“He has a good name with his workmates,” Andy said. “Sometimes they expect me to know as much as he does.”

But Andy’s not the only one feeling pressure.

“I tell my fellow residents I better clear out of here quick before a grandson has to work with his grandpa,” Andino quipped. +

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