medicine worcester
Volume 89
• Number 5
Published by Worcester District Medical Society
September / October 2020
COVID-19 PART 2
Conquering COVID-19 at Saint Vincent Hospital The Impact of COVID-19 on Pediatrics Small Practice Adaptations to Healthcare in the Pandemic
COVID-19 – It’s Coming, It Came, It’s Here
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Contents
SEPTEMBER / OCTOBER 2020
on the cover Transmission electron microscopic image of an isolate from the first U.S. case of COVID-19
Source: Centers for Disease Control and Prevention
COVID-19 Editorial 4
The Role of Corticosteroids for the Treatment of COVID-19 14
Jane Lochrie, MD
Paul Belliveau, PharmD & Anna Morin, PharmD
Conquering COVID at Saint Vincent Hospital 5
Spanning the Patient-Provider Divide 16
Carolyn Jackson
Interview with Michelle Shabo by Alexandra Rabin
The Impact of COVID on Pediatrics 6
From the Archives The Practicing Physician in the Public Health 18
Heather Finlay-Morreale, MD
Dale Magee, MD, WDMS Curator
COVID-19 Pandemic Perspective From a COVID-Only Skilled Nursing Facility 7 Jessica Boatman Dray, MD, Randall Morse, MD, CMD, FACP,
Book Review Stalking the Doctors of the Full Moon 19
& Erika Zimmons DO, MS, CMD, AGSF
Joel H. Popkin, MD, MACP
Small Practice Adaptations to Healthcare In the Pandemic 9
Berlin Award Little Brown Bird 20
Peter T. Zacharia, MD
Peyton Morss-Walton
COVID-19 – It’s Coming, It Came, It’s Here 10
As I See It Engaging the Worcester Senior Community Throughout COVID 21
Zahra Sheik, MD
An Interventional Cardiology Fellowship and COVID STEMIs 11
Sara Carbone & Kristina Jakobson
Nirmal J. Kaur, MD, FACP, FACCh
Supporting Terminally Ill Patients with COVID-19: An ICU Nurse’s Perspective 13
Society Snippets Award Acknowledgements 22
Jennifer DiBenedetto, MSN, RN-BC
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
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WORCESTER MEDICINE
Editorial Jane Lochrie, MD
F
ive months after COVID-19 entered the United States, we are still unnecessarily struggling to contain the virus. The crisis is clearly spiraling out of control with 5,382,125 total cases and 169,350 deaths in the US as of today. In times of crisis we look to our top elected officials to provide accurate, reliable information and to lead by example, but unfortunately, we are presented with the exact opposite. We are receiving misinformation that is so egregious that Twitter, Facebook and YouTube have removed the content. Hospitals have been asked to circumvent the Centers for Disease Control (CDC), the backbone of the scientific community and the CDC’s reopening plan has been blocked by administration calling it “overly prescriptive.” When administration puts politics above public health, we all lose. We are so fortunate to live in the Greater Worcester area. We have seen the exact opposite from our leadership that we have seen on the national level. Very early on, the Worcester medical community, namely, UMass Memorial Health Care and St. Vincent Hospital presented a unified front. Though competing hospital systems, they agreed to share their experiences, knowledge and resources as hospitalizations increased. During the surge, the hospitals were able to stay open and were not overwhelmed; the curve was flattened and lives were saved. The city embraced mask requirement two weeks before the state mandate and this undoubtedly made an impact on community spread. I want to personally thank Ed Augustus, our City Manager, Dr. Eric Dickson, president of UMass Memorial Health Care, Carolyn Jackson, President and CEO of St. Vincent Hospital, Dr. Michael Hirsh, our city’s Medical Director and Dr. Matilde Castiel, Commissioner of Public Health, for their assiduous work during this crisis. In the first article, the CEO of St. Vincent Hospital, Carolyn Jackson states that the safety of her team, patients and the community was at the forefront of every decision that she made during this crisis. She rounded everyday with staff, sent daily communications to everyone in order to connect with staff, thank them for their dedication, and listen to their concerns and ideas. She celebrated the success stories of patients with a celebration as the patient was discharged, “Code Strong.” The impact of COVID-19 on pediatrics is discussed by Heather Finlay-Morreale, MD. Patient visits dropped off dramatically as parents were afraid to come to the office causing many pediatricians serious cash flow issues. Children visits are down 30-40% leading to deterioration of many indicators of child well-being. Vaccine orders are down 60%, lead screening is down 75%, and reports of child abuse and neglect are down 50%. Inpatient pediatricians have been deployed to care for adult COVID-19 units and adult patients were cared for in the pediatric units. Peter Zacharia, MD discusses how he adapted his outpatient specialty practice to care for patients during the pandemic. All elective surgery was cancelled, patient visits were 10% of his usual schedule, and office staff was furloughed. He found telehealth was not feasible as many patients require a physical exam, such as slit lamp exams, ocular pressure or fundus evaluations that cannot be completed remotely. In addition, he discusses the many positive changes to his office that he made, many that he intends to continue after the pandemic. We have two articles from physicians working in nursing homes, a venue that has been particularly hard-hit. Jessica Boatman Dray, MD et al.
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Approximately 75% of COVID-19-related deaths occur in patients over 65. Beaumont Rehabilitation and Skilled Nursing Facility in Worcester was the first dedicated COVID-19 recovery and rehabilitation center requiring 130 residents to be relocated to other facilities and many changes to the physical plant. Many of the staff struggled with continuing to work there due to personal health risks and risk to loved ones and concerns with lack of testing, viral spread and infection control supplies availability. There were many new interventions introduced for this endeavor including infection control education, increased calls to families and post-discharge follow-up calls. The second article from a geriatrician, Zahra Sheik, describes how difficult it was for her to transfer her long-term nursing home patients to another facility without saying goodbye in order to care for COVID-19 patients. This was followed by long and painful discussions with residents and their families to reevaluate the goals of care should they contract COVID-19. She explains seeing fear in the eyes of the staff and calls them “my heroes.” An Interventional Cardiology Fellow, Nirmal Kaur, relates her experience of completing a fellowship during the pandemic. The symptoms and electocaridiology changes of a myocardial infarction are very similar , making it difficult to decide if patients need a procedure. Paul Belliveau, PharmD and Anna Morin, PharmD review the current literature using steroids in COVID-19 patients. Though the guidelines from some of the professional societies vary slightly, available data suggest benefit for patients with severe disease and against using steroids in patients with less severe disease. Our student representative on the Editorial Board, Alexandra Rabin, interviewed a fourth-year medical student, Michele Shabo, who contracted severe COVID-19 disease. Michele opines that this made her think more before ordering invasive and painful tests for a patient. She advocates convincingly for mask wearing and other safe practices. This year the Berlin Award for creative writing was granted to Peyton Morss-Walton for her essay, “Little Brown Bird.” This was clearly written from her heart. She tells us that she chose a frail elderly patient with pancreatitis because her team more or less ignored her, and she felt that her presentation would not be scrutinized. She compares the patient to a tiny bird that she found when she was five years old that she could not touch because her mother feared that the bird might be infectious. Peyton develops a close relationship with the patient and was able to tell her something that she could not tell anyone else in the hospital (you’ll have to read the essay to find out). As always, I would encourage everyone to read the As I See It, Book Review, News from the Archives, and Society Snippets. +
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COVID-19 Conquering COVID-19 at Saint Vincent Hospital Carolyn Jackson
W
hen the COVID-19 pandemic hit Central Massachusetts, being nimble and making timely decisions was critical to effectively dealing with this crisis. The safety of our team, patients, and the community had to always be at the forefront of every decision. We had to make rapid decisions with imperfect information, and sometimes the solution that was right yesterday needed to be altered tomorrow because of new guidance or a situational change. Every day that I was at Saint Vincent during the height of COVID-19, I rounded on each patient care unit that had COVID19 positive patients or patients under investigation. My goal was to connect with staff, thank them for the great work they were doing, listen to their concerns and ideas, and make sure they had everything they needed to provide the best possible care. Rounding was probably one of the most important things I did during the height of COVID-19. Effective communication to everyone at Saint Vincent was also critical during this time. We communicated through multiple channels, and I started a daily email update to the entire house. It went to over 3500 people each day for over 100 consecutive days, and it is currently sent weekly. The email contains key statistics, PPE, safety and visitor updates, and most importantly, success stories and things to celebrate. Our leaders print each email to review it with their teams and ensure that it reaches as many people as possible. It has been a great way to ensure everyone stays informed and that everyone can see changes happening in real time. We all know the expression: “Necessity is the mother of invention.” I don’t think I ever used that phrase prior to the COVID-19 pandemic, but I found myself saying it frequently over those several months because there were so many novel challenges that resulted in wonderfully creative solutions. We found fairly quickly that people’s ears became sore from the constant tug of mask loops. Solutions to this ranged from 3-D printed hooks that go behind the wearer’s head to crocheted headbands with buttons on them.
Part 2
An open door to a patient room makes it easy to watch someone who may have mild confusion, but patient room doors needed to be closed for COVID-19 patients. Someone suggested baby monitors, and that turned out to be an excellent solution that provided monitoring and easy communication while keeping staff and patients safe. There are countless other examples of innovative solutions that helped make caring for COVID-19 patients a little easier. There were many difficult COVID-19 outcomes, so we decided to brighten our spirits by celebrating our successes. One of the best ways we did this was via our “Code Strong” discharges. When a COVID-19 positive patient was ready to go home, we would ask if they would like to have a special celebration as they headed out. Many of them did, and our team would line the halls and applaud as they were wheeled to meet their loved ones. We were left with tears in our eyes when we said goodbye to these success stories. Some of our Code Strong discharges included people who we never thought would survive, people whose loved ones knew our staff well from all of the calls and check-ins, and even one whose wish included a send-off from the Worcester Fire Department complete with a truck and sirens! Our team remains incredibly proud of the 300+ COVID-19 positive patients who we successfully discharged, and I am incredibly proud of how our team came together to overcome challenge after challenge this spring.
“
We want to stress ... they should not delay care.” While we anticipate more COVID-19 patients at Saint Vincent Hospital, our numbers have significantly decreased, and we are finding our new normal. We have put policies and procedures in place in accordance with Massachusetts reopening guidance to ensure that our team, our patients, and our community remain safe as we resume all different types of care. It is critical that we ensure everyone feels safe upon entering our doors, as people need to receive all the care that they put aside during COVID-19. Our visitor polices, masking and cleaning protocols, and hand hygiene stations are all designed with safety in mind. We want to stress to the community that they should not delay care. Whether it is a routine screening, diagnostic imaging test, surgical procedure, urgent or emergent care, your health is important. Saint Vincent Hospital is ready to safely deliver the care you need when you need it. Experts say there will be a second wave in the fall. If that is true, we are well positioned to care for the wave of COVID-19 patients while continuing to deliver all of the other needed care that is required by our community. + Carolyn Jackson is the Chief Executive Officer of Saint Vincent Hospital. Email: Carolyn.jackson@stvincenthospital.com
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Part 2
The Impact of COVID-19 on Pediatrics Heather Finlay-Morreale, MD
C
OVID-19 is having a major impact on pediatrics. During March, April, and part of May, parents simply stopped bringing their children to the pediatrician. In my own office, visits dropped off dramatically. Infants were more likely to come in, but many parents kept older children, especially those not needing vaccines, at home. The administrators of my group decided in March to postpone routine visits and only bring in those needing vaccines. Due to the drop off in visits, some of my colleagues with small private practices have had serious issues with cash flow. Some were able to obtain federal Paycheck Protection Programs loans and there is another federal payout for those seeing Medicaidcovered children. At the same time visits dropped, pediatricians needed to purchase scarce and expensive PPE and change workflows and practices. Some pediatrician friends of mine have had their hours and salaries cut. There was a partial rebound in patient visits after the state opened up. The Massachusetts Health Policy Commission reports that visits by children remained 30-40% down depending on age. A survey in Orlando found that two thirds of parents were afraid to go to the pediatrician. Now, Florida’s rates are different than Massachusetts’ but this illustrates the perception. Children’s visits have not rebounded to the same degree that adults have. Perhaps adults are more willing to risk an exposure for themselves than for their child. All pediatric practices are feeling the effects of this reduced patient volume. As you’d expect, preventative care benchmarks are low. According to the Communications Office at the Massachusetts Department of Public Health, pediatric vaccine orders were down 60% for the month of April and down 40% for the month of May. The American Academy of Pediatrics and others are concerned about a coming wave of vaccine-preventable illnesses. Lead screening in the state (which is done at ages 1, 2, and 3) was down 75%. Sadly, cases of lead poisoning went up as children are spending more time at home and more people are remodeling. In another example of child health being impacted, reports to the Department of Children’s and Fami-
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lies for abuse or neglect went down 50% during the pandemic. Overall, many indicators of child well-being have worsened during the pandemic. Testing children for COVID-19 posed some challenges. Multiple times I interacted with parents whose children had COVID-19 symptoms and who refused to have their child tested. Some didn’t want their child “labeled” COVID-19, others perhaps didn’t want to be quarantined out of work for 10 days, some were afraid the testing was too “traumatic,” and others didn’t believe that their child might have COVID-19. Many testing sites only test adults so young children have less access to testing. People are waiting 1-4 hours in a hot car for a test which is especially challenging for a sick young child. There is a deluge of calls for people wanting COVID-19 testing either due to having symptoms, due to travel, due to exposures in sports teams, for work, or the return to college. Overall, there are more people clamoring for tests than capacity for testing allows, and access for children is more difficult compared to adults. In-patient pediatrics was also affected by COVID-19. There was a smaller census. Some in-patient providers were deployed to adult COVID-19 units. Some young adult patients were cared for on the pediatric floor and the ICU. One report I heard from a resident was that the young adults loved being on the pediatric floor as it has ice cream and gaming systems and is a generally pleasant place to spend a hospitalization.
“
All pediatric practices are feeling the effects of this reduced patient volume.” Telehealth has really taken off in many practices. For myself, most urgent problem-oriented visits are now done by telehealth. Also, most mental health visits that I provide are via telehealth. I actually like telehealth for mental health visits in particular as you get to see the child and the parent in their home environment. You can see the general household interactions as other family members come into the video. For rashes, I usually have the family take well-lit photos and send via portal and then do a video visit because I find the video feed is often too grainy to get a good view of a rash. I did learn not to book telehealth with teenagers before noon as most of my patients over the age of 13 are on a vampire sleep schedule at this time. I was quite impressed that the medical community went from minimal telehealth to widespread use of telehealth in weeks. There were some technical issues initially but for the most part I feel it is working well. The executives for the community practices where I work have decided that they will not see potential COVID-19 patients. People are screened for symptoms over the phone before they come in. Anyone with a cough, fever, GI symptoms, nasal symptoms, sore throat, etc. are booked for a telehealth visit. During the telehealth, it is decided if the patient just
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The Impact of COVID on Pediatrics Continued
needs a COVID-19 test, then they are referred to the testing tent. If they need a COVID-19 test plus other testing or IV fluids or an in-person exam, they are referred to the ER or urgent care. Other local organizations are focusing sick visits into respiratory clinics seeing only sick patients. Keeping well children and sick children separate seems like a good plan. Some of the groups with respiratory clinics have them setup outdoors so that will need some modifying as the weather gets cold. It is unknown how this might change as fall and winter approaches and respiratory illnesses pick up. The capacity of these “sick” sites to handle all the sick visits of winter is an unknown. I also work in the pediatric emergency room and visits there dropped dramatically as well. Parents were petrified to come to a medical setting — especially the ER. On more than one occasion answering calls for the primary office, I had parents whose children had serious non-COVID-19 symptoms needing urgent care who simply refused to go to a medical setting. Rather than having all the rooms full in the ER, at times there were only a few children there. At times, adults were seen in the pediatric area instead, and at other times, there were more adults than children. The children who were coming in were, on average, of a higher acuity — fractures, large lacerations, and appendicitis. Fortunately, few children have been testing positive for COVID-19 and fewer have had serious illnesses. Several children are presenting with several days of fever and GI symptoms that are concerning for MIS-C. So far, there have been a few admits for potential MIS-C at UMass. By June 5th, 2020, the state had reports of 33 total cases of MIS-C in the state and no deaths. Fortunately, although the children can have multisystem organ failure, most recover and very few die. Overall, pediatrics has changed across all settings with COVID-19. Some changes, like telehealth, are welcomed by many. Other effects, such as a drop off in visits, are challenging financial stability. Hopefully, as fall and winter approach and respiratory season starts, the demand for testing, evaluation, and treatment will not be greater than the capacity. +
Heather Finlay-Morreale, MD is Assistant Professor of Pediatrics for UMass Medical School with an office in Sterling, MA. Twitter: @finlaymorreale
Part 2
COVID-19 Pandemic Perspective From a COVID-Only Skilled Nursing Facility Jessica Boatman Dray, MD Randall Morse, MD, CMD, FACP Erika Zimmons, DO, MS, CMD, AGSF
A
Coronavirus 2019 (COVID-19, or COVID) has affected people through the entire spectrum of ages and living environments, older adults and those in nursing homes have been disproportionately affected. Approximately 75% of COVID-related deaths occur in patients ≥651 with over 60% of COVID-related deaths in Massachusetts occurring in nursing facilities.2 Weinberger et al. estimated deaths in the US from March to May 2020 not attributed to COVID were 28% higher when compared to the previous year, which may be related to undercounting of COVID deaths and patients not seeking timely care for routine and urgent medical issues due to the pandemic.3 Consistent with a recommendation by the American Medical Directors Association (AMDA)4, an initiative by the Commonwealth of Massachusetts selected Beaumont Rehabilitation and Skilled Nursing Facility - Worcester Campus to become the first dedicated COVID recovery and rehabilitation center. A rapid transition, with over 130 residents needing relocation to other facilities, was required due to the anticipated imminent spread of COVID. This transition presented not only a logistical challenge, but also a strain on families, caregivers, and the residents, many of whom had cognitive impairment. Several alterations were made to the physical plant of the building; some patient rooms were converted into dedicated personal protective equipment (PPE) donning and doffing rooms, and a mini gym including a dedicated area with rehabilitation equipment, was created. When Beaumont-Worcester Campus converted to a COVID-only facility, diagnosed cases were just starting to rise in the area. Due to potential personal health risks and the health of loved ones, many staff members grappled with continuing in their current roles at Beaumont and upwards of 70% of staff initially stepped away, although many ended up returning to work at Beaumont. Many providers have identified challenges to the care of older adults in a skilled nursing facility during the pandemic, including concerns with testing, virus spread, infection control resources (e.g., PPE), and discharge disposition. Test kit availability issues and prolonged turnaround time for results led to delays in diagnosis and has infection control implications. Another factor includes virus spread within the facility, which includes the primary mode of virus transmission, the prevalence of asymptomatic spread, and close interactions between residents lthough
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Part 2 COVID-19 Pandemic Perspective from a COVID-Only Skilled Nursing Facility Continued during communal dining and other group activities. In addition, there was difficulty in procuring and maintaining PPE supplies. Finally, discharge disposition brought up challenges as accepting facilities had differing criteria for re-admission and some individuals required a higher level of care after having COVID. Several early interventions targeted anticipated challenges when caring for patients with COVID. Given the relationship between Beaumont and UMass Medical Center, staff underwent extensive infection control education as it relates to COVID by a disaster specialist, which included information about caring for patients with COVID and appropriate use of PPE. To address concerns from patients and families exacerbated by visitor restrictions, we increased calls to loved ones, provided informational handouts regarding COVID, and conducted post-discharge follow-up calls for those returning to the community to identify any issues for those discharged. A partnership with Ava Robotics allowed for staff to utilize a robot to interact with patients, thus decreasing PPE utilization and the risk of in-person exposure to staff. Strong lines of communication between administration and clinicians enabled efficient development and updating of workflows as the pandemic evolved. During the past several months, we’ve cared for over 250 new patients with COVID, mostly for rehabilitation but also a significant number at the end of their lives. We often hear of the pulmonary impact of COVID with hypoxia and the potential development of cytokine storm in the acute care setting. We observed, however, that anorexia, dehydration, and a non-specific decline were common further along the disease course. Additionally, a number of patients have continued to experience persistent symptoms months after their initial illness, as has been reported recently.5 Most notably, we have observed a number of cases of persistent cognitive dysfunction and functional decline months after diagnosis. Lastly, we have noted depression symptoms exacerbated by the social isolation due to the pandemic. Regional COVID recovery centers may be feasible in the future, although several challenges and questions require exploration. Ideally, future facilities should not require relocating residents. Rather, previously empty facilities could be renovated and staffed to fill this role. Variable reports and guidance about potential duration of infectivity and inconsistent workflows for clearing patients from precautions can lead to bed capacity issues. A clear and unified workflow, with buy-in from both sending and
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receiving facilities, could help manage expectations and improve patient flow. It would be important to design the facility to care for the patient populations most in need, including nursing home patients and community dwelling patients needing rehabilitation. The pandemic has uniquely affected patients and providers at all levels of care, from the ambulatory setting to facilities and hospitals. Although we have learned many things along the way, there remain immensely important unknowns, including the future availability of tests and PPE, interpretation of tests in previously positive patients with concerns about the potential for reinfection, the role and effectiveness of a potential vaccination, and the impact of persistent symptoms on function and quality of life. This information would help provide a better understanding of the duration, size, and number of future COVID recovery centers, should the need arise. Our hope is that specialized COVID recovery centers could mitigate the impact COVID has upon this vulnerable population by decreasing the exposures both in the community and other facilities and providing specialized care to those with COVID. + Randall Morse, MD, CMD, FACP, Assistant Professor of Medicine, UMass Medical School and Medical Director at Beaumont Rehabilitation and Skilled Nursing Facility Jessica Boatman Dray, MD Assistant Professor of Family Medicine and Community Health, UMass Medical School, Worcester Campus Erika Zimmons, DO, MS, CMD, AGSF, Assistant Professor of Family Medicine and Community Health, UMass Medical School and Medical Director at Beaumont Rehabilitation and Skilled Nursing Facility, Worcester Campus 1. Characteristics of Persons Who Died with COVID-19 – United States, February 12-May18, 2020. MMWR weekly report, July 17, 2020 / 69(28);923-929. https://www.cdc.gov/mmwr/volumes/69/wr/ mm6928e1.htm#T1_down 2. Massachusetts DPH COVID-19 Dashboard, Weekly COVID-19 Public Health Report. https://www.mass.gov/ 3. Weinberger DM, et al. Estimation of Excess Deaths Associated with the COVID-19 Pandemic in the United States, March to My 2020. JAMA Internal Medicine. Doi:10.1001/jamainternmed.2020.3391 4. AMDA Executive Committee. Resolution on COVID-19. March 19,2020. https://paltc.org/sites/default/files/Approved%20Resolution%20on%20COVID-19%2019MAR2020.pdf 5. Carfi A, Bernabei R, Landi F, et al. Persistent Symptoms in Patients After Acute COVID-19. JAMA July 9, 2020. DOI:10.1001/ jama.2020.12603. https://jamanetwork.com/journals/jama/fullarticle/2768351
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COVID-19 Small Practice Adaptations to Healthcare In the Pandemic Peter T. Zacharia, MD
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hanges to my practice occurred rapidly
starting the first two weeks of March 2020 as I followed daily advisories from national and state medical societies. I cancelled all elective surgery and non-urgent patient appointments while keeping appointments in cases such as uncontrolled glaucoma, active uveitis, ocular surface infections, or patients calling to report eye pain, sudden visual loss, or symptoms of threatened retinal detachment. My staff removed waiting room magazines and more than half of the chairs, spreading the remaining chairs several feet apart. We kept open all doors within the office through which patients travelled to eliminate contact with doorknobs. Less than 10% of my usual office patient schedule remained, forcing me to cut back to one morning a week of temporally distanced patients on my schedule. I furloughed six staff members until the Payroll Protection Program allowed me to restore staffing six weeks later with strategies of mask wearing, physical distancing, and meticulous cleaning of office surfaces. While most of my staff was out, I personally inspected our patient schedule each day, reviewed each chart, and called that patient to postpone appointments for more than 90% of our patients. I implemented CMS telehealth guidelines and adapted my EHR templates to accommodate documentation and coding requirements. Using the free Doximity app, I made audio and video contact with patients, however quickly realized telehealth shortcomings as several patients required an office exam which revealed patients with uncontrolled intraocular pressures, another patient whose new onset uveitis was not “pink eye,� and yet another misdiagnosed by telehealth elsewhere for whom an office slit-lamp exam revealed an infectious corneal ulcer. I have found telehealth helpful mostly for maintaining contact with patients for whom I prescribe maintenance medication to verify correct medication usage and compliance and ask about adverse effects. I can counsel patients with certain symptoms and visually inspect some external eye conditions such as chalazia, and can even roughly measure visual acuity by having patients read from publications of known
Part 2
print size or download apps which allow this. There are important components of an ophthalmic exam that I cannot employ, such as slit lamp evaluations of the anterior segment of the eye, tonometry to check intraocular pressure, or do a good fundus exam from a home setting. Adversity forces us to evaluate how we do things and make changes which we sometimes wish we had done years ago. I made several changes with the main goal of providing care for patients during the pandemic while keeping patients, staff, and myself safe, including best strategies for disinfecting equipment and patient flow. I was pleasantly surprised to find that these changes also made my practice more efficient and increased patient satisfaction. The first change utilizing remote communications technology was primarily intended to enable me to communicate with my technicians while keeping them outside of the exam room to reduce the overall number of inter-individual contacts by restricting the individuals in the exam room to only the patient and myself. I accomplished this with the purchase of full-duplex intercom headsets for me and staff and immediately realized additional unforeseen benefits. I no longer have to share the exam room computer workstation with the scribe and this allows me to use a scribe more efficiently than before. This facilitates my review and documentation of interpretations of testing which I view on the exam room workstation as I dictate to the scribing technician who can also write medication instructions for each patient and coordinate follow-up care and referrals while listening to me and the patient at an outside workstation. Now my scribe can also give me important chief complaint and historical information as I walk between exam rooms so that I no longer have to open the chart and read these myself before seeing my patient, thereby saving me additional time. I am now also able to communicate with any relatives waiting in outside cars (we don’t allow any relatives to accompany patients into the office), while examining the patient, since my headset communicates with my telephone using Bluetooth, while I simultaneously maintain a connection with the scribe. Fortunately, the headset that I selected connects to a support bridging the two sides of the headset which fits around the back of my neck, an overlooked advantage for an ophthalmologist since we use an indirect ophthalmoscope, for fundus exams, which fits on top of our heads. I bring this up only to illustrate the small details we can overlook when envisioning solutions for problems which can sometimes conflict with other requirements. A second change involved my patient scheduling format which eliminated double booking, incorporated appropriate spacing after every three patients on the schedule, and placed more time-consuming patient slots, such as new patients, later in each of the morning and afternoon sessions so that if a delay results it affects fewer subsequent patients. We extended the hours during which patients arrive which has actually not extended my days since patients who will be examined later in the day will just arrive later and be taken in without the previous wait. We have almost eliminated use of our waiting room, bring about 90% of patients directly into an exam room, and discharge the patient from the appointment directly from that exam room at the end of the encounter. A third modification was to my own work habits. Completing complex patient notes and contemplating complex care plans at the end of each
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Part 2 Small Practice Adaptations to Healthcare in the Pandemic Continued day allows me to minimize the time spent by the patient in the office and also the waiting time for the following patient. I accomplished this by jotting in quick reminders in my impression and plan for later completion. Sometimes, I ask a patient to go home and expect a call from me later after I have reviewed additional history and testing data, and to discuss the care plan or surgical plan in greater detail. A fourth change involved having my technicians call new patients in advance to preload patients’ histories, medication lists, and allergies. We have also asked new patients to download registration forms or enter items electronically in advance to reduce the amount of time in the office. As another improvement, my reception staff now calls patients both two weeks in advance and three days in advance of their appointments to make sure they are symptom-free and well enough to keep the appointment. This reduces the number of no-shows which also enables us to move later patients into earlier empty appointment slots instead of wasting slots on unexpected no-shows. The COVID-19 pandemic has brought unforeseen suffering and tragedy to our society and has changed our lives in ways we have not expected. However, our human race has thrived, expanded, and advanced throughout the millennia because of our resilience and ability to use innovation to survive setbacks. Public health concerns will mandate that some things will not operate as they did before the pandemic, and I have reacted by making changes to my practice which I am confident will offer an advantage over the way we did things before the pandemic.+ Peter T. Zacharia, MD Glaucoma, Cataract, and Anterior Segment Disease Ophthalmology, Worcester Eye Consultants
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COVID-19 – It’s Coming, It Came, It’s Here
Zahra Sheik, MD
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ll spring , friends and family texted and called me
regularly to ask how my family and I were doing and how we were holding up during the early months of the COVID-19 outbreak. My response evolved from “good,” to “stressed,” to “anticipating,” to “sad.” Yes... sadness is what describes my feelings most of the time these days. As a Geriatrician providing care to older adults in the Worcester community over the past 13 years, I have created a second family; my work family. This family includes the group of wonderfully empathetic people I work with at UMass Geriatric Medicine and the staff and residents at two nursing homes where I provide medical care. Working with the residents and their families for many year, I know their stories. Not only do I know their medical conditions but over time they share highlights of family events, new grandchildren, graduations, marriages, milestone birthdays, and key aspects of their lives. When the decision was made by the city of Worcester to turn one of “my” nursing homes into a facility limited to patients positive for COVID-19, all the long-term residents were transferred to other facilities. I felt like I was losing a part of my family. People — real people, not just room numbers, who I have come to know over the years. My colleagues and I wrote short summaries about each person, hoping to ease the transition to the new medical teams. It wasn’t easy emotionally to wrap up their individual stories and share the nuances I knew about each one in five lines in the Electronic Medical Record. It wasn’t easy to part ways, to say goodbye without even seeing them. This was a radical step being taken by the city of Worcester in preparation for an anticipated surge of patients with COVID-19 who would need a place to receive care. This transition happened over a span of five days and it was a draining experience for all us involved in preparing to part and send off our patients. It was hard for the health care providers, the residents, and their families. But it was a needed step in the wake of preparing for a potential onslaught of patients with COVID-19. During the ensuing few weeks, we all spent time on the computer, learning about the unseen devil that was called coronavirus. We read about the ever-evolving nature of the disease, and we had several daily Zoom meetings to prepare to provide the best possible care to our patients when COVID-19 attacks. I regularly reached out to colleagues in New York to learn how they were handling the surge and was awed by the courage they had in managing this disaster without any preparation or forewarnings. These days were followed by long, painful and touching phone calls and conversations with nursing home residents and their families to re-evaluate and discuss their goals of care if and when COVID-19 strikes. Most of the elderly patients and their families wanted to be able to die a comfortable death within the nursing homes where they resided. They didn’t want to be in a hospital and risk not only isolation and delirium, but also the potential irreversibility of intubation should it be necessary. And then the most dreaded day arrived. One of my residents on the dementia unit at the nursing home tested positive for COVID-19. The first conversation with the family lead to many, many other conver-
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COVID-19 – It’s Coming, It Came, It’s Here Continued sations with family members of other residents who tested positive. The count just kept going up. As I spoke to family members whose loved ones were not doing well, they wanted to come in but because of risk, they primarily visited through a window. They were grateful to see their dying parent through the window, often leaving flowers, cards and special messages outside the window. One daughter had permission to visit her dying father and despite donning personal protective equipment (PPE), she was still very apprehensive. Others, however, were afraid to come - they didn’t want to risk bringing the virus home to their families. The days were busy as we made and revised guidelines and protocols as new information became available. The dedicated staff at the nursing home have fear in their eyes peering out above their masks. They are afraid not only for their own health but also that of their families. One nurse had an infant at home and was afraid of bringing the virus to him. The physical therapist moved into the trailer outside her home to try and protect her teenager with asthma. The full-term pregnant nurse who worked on the dementia unit hoped her unborn baby would be immune to COVID-19. The administrator at the nursing home was ever inspiring with her multi-tasking skills of accepting our recommendations and not letting cost be an obstacle to doing what needed to be done, despite the financial constraints that the facilities were facing in this environment. The staff developer evolved into much needed infection control and unit manager roles very professionally. Then, the staff start falling sick. One, two, three, and now several more nurses and aides are out sick with COVID-19. As the virus spread within the facility, the nurses worked short staffed and extra hours, often extending their shifts from eight to twelve hours. Despite the use of PPE, they were still afraid and tired. But, they are dedicated, and they care about the residents. They are all my heroes. When friends and family ask me how I am doing, my answer is that my family at home is well, but my nursing home family is not, and I worry about them. I worry about them all day and wake up each morning and wish this was all a dream... but it is not. My three kids are home from school, but I have no space in my brain to worry about their studies, or lack of. I have bigger worries at this time. I wish this pandemic to be over not today or tomorrow, but yesterday. Until then, however, I wear my mask, face shield, gown, and gloves and tend to those in need.+ Zahra Sheik, MD, Assistant Professor of Medicine, Division of Medicine, University of Massachusetts
Part 2
An Interventional Cardiology Fellowship and COVID-19 STEMIs* Nirmal J. Kaur, MD, FACP, FACC
R
eading the ekg in the er ’ s st - elevation myocardial
Infarction (STEMI) bay, I was emotionally taken back to the start of my interventional cardiology fellowship nine months earlier. Yumi, our structural fellow, and Tony, my co-resident, and I had planned out the exciting fellowship year ahead, assigning ourselves targets for procedures and skills, to emerge as confident and competent interventional cardiologists. With these strategies, we had mostly cheerfully undergone the expected growing pains of the first three quarters. We had painstakingly learned STEMI triage including: when to give a heads-up to the staff for more than just a regular STEMI setup, how catheters of our choice behaved and the physics behind them, which wire would work best under individual circumstances, and when to choose thrombectomy catheters vs. atherectomy devices. Most importantly, we had learned how to keep calm when things didn’t go our way during meticulously run codes on the table. Over these months, we watched pride emerge on our mentors’ faces, as we began to ease into piecing art into science. With the establishment of deepening rapport with our attendings and their granting of progressive independence, we were comfortably – and maybe naively – heading for the final stretch. We were starting to feel we were now trained for our futures. But then – overnight, it seems – the crushing debacle of COVID-19 imposed a herculean unlearning and adaptation curve. None of our disciplined plans readied us to promptly differentiate a true STEMI from COVID-19 myopericarditis. We were certainly not trained for handling scenarios during a pandemic, and this was as steep a learning curve for our teachers as it was for us. Suddenly, mentors and mentees alike were transformed into pandemic trainees. During this dynamic situation, we made rules and protocols on the fly, awaiting the evolving science for evidence-based guidance. It soon dawned on us that we would be robbed of the excitement of a traditional finish to our fellowship. Tony and my “curriculum” had not accounted for instant contagion. Nor had we anticipated that the by now imprinted race to achieve the shortest door to balloon time (DTBT) possible would be abruptly jolted by COVID-19’s mimicry of STEMI EKGs, the time accounted for donning the PPE, and performing procedures with its hindrances. As I stood there analyzing the EKG of my 40-year-old non-English speaking patient experiencing what seemed like an inferior STEMI, the first three quarters of training were prompting me to reflexively rush the patient to the catheterization laboratory. But this time, I found myself pondering over ethical what-if scenarios – fear of spreading a pandemic virus and potentially risking further lives versus potentially saving one
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Part 2
An Interventional Cardiology Fellowship and COVID STEMIs Continued
COVID-19“imposed a
herculean unlearning and adaptation curve” from a STEMI. And my pattern recognition-trained brain couldn’t help but revisit the inferior STEMI EKG from two days earlier of a woman with nearly an identical EKG that turned out to be a fatal myopericarditis from a possible COVID-19 infection. I can’t help but wonder how long it would take me to comfortably switch gears from DTBT sprints to safe-survival marathons. These days neuroplasticity needs an accelerator. Further delving into his history suggests this 40-year-old patient with an inferior STEMI is very high on our suspicion list for COVID-19 infection, and we take him to the catheterization laboratory. Despite continual drills to minimize DTBT – “time is muscle” – the mantra has gone for a tailspin. Here we are having to unlearn this fundamental rule for STEMIs. The meticulously measured OCT/IVUS guided PCIs for stent sizing decisions have been reverted to angiography-based decisions, in order to shift the paradigm in favor of minimizing exposure times and brevity for safety. Our training has also consequently taken a hit in frequency of procedures being performed and now seems to be limping towards the finish line. Our lab stopped doing elective cases in mid-March, with the dramatic decline potentially stunting our training. Should fellowships such as interventional cardiology have plans in place going forward for such unforeseen calamities? In terms of timing, our class did receive robust training in the first three quarters of the year, meeting our graduating numbers and skills criteria. Were this to have happened earlier in the year, compromised confidence and skills would have shaken our venture into practice as attendings. Should this therefore make us think about artificially simulated cases or other teaching to keep up our competencies if scenarios like these were to arise again? Alternatives such as live cases that we could watch in a nationally telecast training program from any lab would greatly benefit trainees. Needless to say, our first year out in the real world as attendings will not include the normal curve that junior attendings have thus far enjoyed. The kinds of cases that we do see will also probably be different,
12
depending on COVID-19’s long-term impact on the cardiovascular risks of the population. After this strange and frightening fourth quarter, when we are burnishing our attending badges, we will not have had the luxury of walking a known path. Uncertainties are many: What jobs will be available? Will we be sufficiently adapted to a new way of decision-making that accounts for a pandemic? Will we still be racing in an attempt to compensate for the non-system delays in DTBT caused by this illness? Will we see an adverse cardiovascular effect on the endothelium from the virus? Will our caseloads return to the BC (Before COVID-19) era or will we have to manage complications from cardiovascular disease that may have gone unaddressed? Or is it that this last quarter will have actually prepared us better for the role of a new kind of interventional attendings, if this viral situation continues into the beginnings of our junior attending year? It’s time for Tony and I to sit back and restructure our last quarter plans. Our catheterization laboratory staff was planning a trip to New York City for our farewell celebration. Quite ironically, we sent off our structural fellow Yumi to New York City, as she truncated her structural fellowship to aid her hometown in desperate need. With the promise to each other to celebrate our graduation some day when all this is behind us, for now we soldier on.+ *STEMI stands for ST-Elevation Myocardial Infarction – a major type of heat attack caused by blockage of arteries and requiring urgent treatment. Nirmal J. Kaur, MD, FACP, FACC, recent graduate of the SVH Internal Medicine Residency and Cardiology Fellowship and an Interventional Cardiology Fellowship at UMass Medical School, is now an interventional cardiologist at Alliance Health, Durant, Oklahoma
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SEPTEMBER / OCTOBER 2020
WORCESTER MEDICINE
COVID-19 Supporting Terminally Ill Patients with COVID-19: An ICU Nurse’s Perspective Jennifer DiBenedetto, MSN, RN-BC
C
aring for patients who are terminally ill
is a core component of nursing practice. The nursing profession prides itself on how well it attends to the needs of patients and their families. When a patient’s code status is changed to “do not resuscitate/intubate” (DNR/DNI) and subsequently to “comfort measures only” (CMO), the nature of nursing care is also altered. The focus of care transitions from lifesaving to supportive. However, during the peak phase of COVID-19, the shared decision-making process regarding code status was greatly disrupted. What were once lengthy and frequent conversations are now limited to a single phone call made by a resident to the patients’ family member. The critical care team had to adapt to a new way of managing, communicating, and discussing the health care needs of our patients; yet another challenge in addition to the those associated with understanding the trajectory of COVID-19 While nurses are accustomed to providing comfort to patients and their families when a patient has a serious condition or is terminally ill, care during the novel coronavirus pandemic was different. Early in the pandemic, we did not feel we had the knowledge and ability to help our patients with COVID-19. It was one of the most powerless experiences many of us had ever endured in our nursing practice. We told families we would call once their loved one had passed, which we recognized was not an adequate way to help them grieve and heal. But as time went on, we improved. We learned signs and symptoms, came to understand a common trajectory, and could often anticipate the sequence of events. We became accustomed to wearing masks, gowns, and face shields every day and we came to appreciate our role in supporting the patient and their family throughout the hospitalization; especially when the family could not be present. The uncertainty and contagiousness of COVID-19 created obstacles to our usual mode of communication with patients, their families, and even our co-workers. One of the many challenges centered on our inability to discuss a patient’s condition in person with the family. We had to become creative, using virtual methods such as “FaceTime” on an iPad designated to the ICU. We found the iPad to be very helpful when connecting with families, facilitating important conversations,
Part 2
and processing the patient’s condition; this form of communication became essential when families were making code status changes or when the patient was intubated. However, some families did not have access to Apple products. At times, a nurse who had an Android phone would offer to use it to connect with families. This worked to relieve some of the stress and burden from family members, but it was not a reliable way for families to communicate on a daily basis. Many of us found virtual communication lacking, as it did not truly satisfy the desire for a physical connection between the patient and their family during end of life. This created emotional turmoil for the nurses, especially when the family members’ visits were discontinued, and they would plea for us to save their loved one from COVID-19. We were accustomed to an environment that encouraged visitors, with family members frequently entering and exiting the unit. The need to physically distance left us all feeling pained and empty. We wished that families could be with their loved ones during their final moments, but we understood the implications and risk of transmission associated with ignoring the social distancing guidelines. These restrictions intrinsically altered how we provided support to patients and their families. Nursing’s role shifted during the early stages of this pandemic when we began to provide a more intensely supportive service to patients experiencing end of life and their families. Many patients with COVID-19 did not recover, and this weighed heavily on our unit. Our goal is always to provide the best care for our patients. One patient was well acquainted with the nurses in our ICU because he had been frequently admitted to our unit. Upon admission this time, however, he chose CMO and requested to see his family. His immediate family members, permitted to visit from outside his room while wearing face masks, were given 15 minutes to say their goodbyes. As the family exited, I watched them mourn and acknowledged their request that we “take good care of him.” The next morning, though he smiled when I entered his room, the patient was restless. He relaxed after being medicated, and I sat next to him and took his hand as he drifted more deeply into sleep. Completely clothed in full personal protective equipment, another nurse, a respiratory therapist, and I alternated sitting with him so he would not be alone when he died. It was challenging to be consistently present for someone while managing multiple patients with COVID-19, but I was humbled to be the person at his bedside during his final moments. After his passing, we washed him, placed him in a special shroud for patients with COVID-19, and brought him to a truck outside of the hospital, as the morgue was overwhelmed. This experience highlighted the mortality of COVID-19 and the significance it played in our community. Nurses are committed to meeting the needs of patients and their families despite the challenges presented by COVID-19. Working with terminally ill patients who have COVID-19 has significantly impacted the way nursing provides end of life care, which has made us depend on each other more than ever before. We always strive to provide excellent supportive care, and we have adjusted to recent challenges so that we can continue to provide the love, care, and support we would want for our own families. As a nurse during the COVID-19 pandemic, I am honored to be a valuable support for patients and their families.+ Jennifer DiBenedetto, MSN, RN-BC is an ICU nurse at Saint Vincent Hospital in Worcester, MA and a PhD candidate at the University of Massachusetts Medical School GSN. Email: Jennifer.dibenedetto@umassmed.edu
SEPTEMBER / OCTOBER 2020
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The Role of Corticosteroids for the Treatment of COVID-19 Paul Belliveau, PharmD Anna Morin, PharmD
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SARSCoV-2, COVID-19 has two phases:in the first phase, the virus enters the body and replicates, followed by the production of antibodies and inflammatory reactions to the virus approximately 10-14 days later.1 Patients with COVID-19 typically report onset of symptoms such as fatigue, chills, fever, and dry cough three to five days after exposure. In severe cases, COVID-19 can lead to pneumonia and acute respiratory distress syndrome (ARDS). Postmortem evidence from severely ill COVID-19 patients confirms the presence of highly activated immune cells in blood, lung tissue, heart tissue, and other organs.1 Anti-inflammatory corticosteroid treatment for other severe non-COVID-19 related lung conditions, such as ARDS, has been associated with a decrease in mortality and duration of mechanical ventilation (MV).2 This suggests that drugs such as corticosteroids might also be of benefit for COVID-19 infection. Published experiences with corticosteroids in patients with severe COVID-19 pneumonia provide some support for this approach. Initial publications related to corticosteroid treatment for SARS-CoV-2 are from experiences with this infection in China. Investigators reported that methylprednisolone reduced the need for supplemental oxygen (8 versus 14 days, P < 0.001) and MV (11.5% versus 35%, P = 0.05) and decreased intensive care unit (ICU) (8 versus 15 days, P < 0.001) and overall hospital length of stay (14 versus 22 days, P < 0.001).3 Another group of investigators reported that, among patients with COVID-19 pneumonia with ARDS, there was a lower frequency of death (46% versus 61.8%).4 However, other investigators have provided contrasting observations. Lu et al. observed no association between corticosteroid therapy and 28-day mortality in critically-ill COVID-19 patients; increased corticosteroid dosage was significantly
14
aused by the novel coronavirus
associated with mortality risk.5 Zha et al. reported no association between corticosteroid therapy and virus clearance time, hospital length of stay, or symptom duration in patients with mild COVID-19 disease.6 The initial experiences outside of China involved patients in Spain, Italy, and the United States (US). In Spain, patients receiving corticosteroid therapy for severe COVID-19 infection had lower in-hospital mortality (13.9% versus 23.9%).7 In Italy, researchers reported that the composite endpoint (admission to ICU, need for invasive MV, 28-day all-cause mortality) occurred less frequently (22.9% versus 44.4%, P = 0.003) among patients receiving methylprednisolone.8 In the US, early methylprednisolone treatment in patients with moderate-severe COVID-19 pneumonia resulted in the composite endpoint (progression to ICU admission or MV or in-hospital all-cause mortality) occurring less frequently (34.9% versus 54.3%, P = 0.005).9 While most experiences to date have been retrospective, there are currently two trials in which investigators have employed varying degrees of prospective randomization. Corral-Guidino et al. performed a partially randomized, open-label trial in adults with COVID-19 pneumonia, impaired gas exchange, and biochemical evidence of hyper-inflammation.10 The partial randomization was the result of patients being administered corticosteroid therapy if the clinical team had a strong preference for initiating this therapy; all other patients were randomized to standard of care (SOC) or SOC plus methylprednisolone (40 mg intravenously every 12 hours x 3 days, then 20 mg every 12 hours for 3 days). Methylprednisolone treatment was associated with a reduced risk of the composite endpoint (death, ICU admission, or requirement for non-invasive ventilation).10 The RECOVERY Collaborative Group provides the largest randomized experience to date.11 In this trial, 6,425 patients hospitalized with SARS-CoV-2 infection were randomized to SOC or SOC plus dexamethasone (6 mg once daily for up to 10 days). Twenty-eight day mortality was lower among the dexamethasone recipients (22.9% versus 25.7%). In the dexamethasone group, the incidence of death was lower among patients receiving invasive MV (29.3% versus 41.4%) and oxygen without invasive MV (23.3% versus 26.2%). However, this was not observed in patients who were not receiving respiratory support (17.8% versus 14.0%).11 professional organization statements/recommendations
The Surviving Sepsis Campaign COVID-19 panel provides guidelines for management of adults who are critically ill due to SARS-CoV-2 infection. The authors suggest the use of systemic corticosteroid therapy for adults with COVID-19 and refractory shock or mechanically ventilated adults with COVID-19 and ARDS.12 In the absence of these conditions, the panel suggests against the use of corticosteroids in patients with SARS-CoV-2 infection. When reviewing these recommendations, clinicians should consider that they have not been updated to include recent data such as that reported by the RECOVERY Collaborative Group.11 The National Institutes of Health COVID-19 Treatment Guidelines provide its highest recommendations for the use of dexamethasone (6 mg per day for up to 10 days) in mechanically ventilated patients.13 They also recommend this treatment in patients requiring supplemental
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The Role of Corticosteroids for the Treatment of COVID-19 Continued
oxygen but who are not mechanically ventilated. The Infectious Diseases Society of America suggests use of corticosteroids (dexamethasone 6 mg per day for 10 days) for patients hospitalized with severe illness (oxygen saturation ≤94% and those requiring supplemental oxygen or ventilation support).14 In the absence of hypoxemia requiring supplemental oxygen, both groups suggest against the use of corticosteroids.13,14 conclusion
There are still limited rigorous clinical trial data to support specific recommendations for use of corticosteroids for treatment of SARS-CoV-2 infection. However, the pathophysiology of the disease and data describing corticosteroid use in other inflammatory lung processes suggest these drugs may have a role in the treatment of these patients. Available randomized trials and current guidelines suggest benefits for patients with severe disease. Dexamethasone (6 mg per day for 10 days) is the treatment regimen with the most robust data and guideline support. Given recommendations against this treatment in patients with less severe disease, it would be prudent to properly identify the best candidates for such treatment. + Paul Belliveau, PharmD, Associate Dean, School of Pharmacy Worcester/Manchester & Professor of Pharmacy Practice Anna Morin, PharmD, Dean, School of Pharmacy-Worcester/ Manchester & Professor of Pharmacy Practice 1. Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020;382:1708-20. 2. Mammen MJ, Aryal K, Alhazzani W, Alexander PE. Corticosteroids for patients with acute respiratory distress syndrome: a systematic review and meta-analysis of randomized trials. Pol Arch Intern Med. 2020;130(4):276-86. 3. Wang Y, Jiang W, He Q, et al. A retrospective cohort study of methylprednisolone therapy in severe patients with COVID-19 pneumonia. Signal Transduct Target Ther. 2020;5(1):57.
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8. Salton F, Confalonieri P, Santus P, et al. Prolonged low-dose methylprednisolone in patients with severe COVID-19 pneumonia. medRxiv 2020.06.17.20134031. 9. Fadel R, Morrison AR, Vahia A, et al. Early Short Course Corticosteroids in Hospitalized Patients with COVID-19 [published online ahead of print, 2020 May 19]. Clin Infect Dis. 2020;ciaa601. 10. Corral-Gudino L, Bahamonde A, Arnaiz-Revillas F, et al. GLUCOCOVID: A controlled trial of methylprednisolone in adults hospitalized with COVID-19 pneumonia. medRxiv 2020.06.17.20133579. 11. RECOVERY Collaborative Group, Horby P, Lim WS, et al. Dexamethasone in Hospitalized Patients with Covid-19 - Preliminary Report [published online ahead of print, 2020 Jul 17]. N Engl J Med. 2020; NEJMoa2021436. 12. Alhazzani W, Moller MH, Arabi YM, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med. 2020;48(6):e440-69. 13. COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Available at https://www.covid19treatmentguidelines.nih.gov/. Accessed 8.3.20. 14. Infectious Disease Society of America. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-andmanagement/. Accessed August 3, 2020.
4. Wu C, Chen X, Cai Y, et al. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med. 2020;180(7):1-11. 5. Lu X, Chen T, Wang Y, Wang J, Yan F. Adjuvant corticosteroid therapy for critically ill patients with COVID-19. Crit Care. 2020;24(1): article 241. 6. Zha L, Li S, Pan L, et al. Corticosteroid treatment of patients with coronavirus disease 2019 (COVID-19). Med J Aust. 2020;212(9):416-20. 7. Fernández Cruz A, Ruiz-Antorán B, Muñoz Gómez A, et al. Impact of glucocorticoid treatment in SARS-COV-2 infection mortality: a retrospective controlled cohort study [published online ahead of print, 2020 Jun 22]. Antimicrob Agents Chemother. 2020;AAC.01168-20. SEPTEMBER / OCTOBER 2020
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Part 2
Spanning the Patient- Provider Divide: A Conversation with Michelle Shabo, UMass Medical School Class of 2021 Interview with Michelle Shabo by Alexandra Rabin
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ichelle shabo, 28, was born and raised in worcester, ma. She received a degree from UMass Amherst in Biochemistry and Molecular Biology. She is a fourth-year medical student at UMass Medical School and hopes to specialize in Urology after graduating in 2021. Michelle was diagnosed with COVID-19 in early March. After experiencing a fever, chills, and worsening respiratory symptoms at home for two weeks, she was hospitalized and was found to have a superimposed bacterial pneumonia. She narrowly avoided the need for intubation and spent one week battling the illness in the hospital. When she fully recovered after several more weeks at home, Michelle took part in an emergency medicine clinical rotation at the Worcester DCU Center COVID-19 field hospital. what was your mindset transitioning from the patient to the caregiver role?
Being a hospitalized COVID-19 patient was one of the most impactful experiences for me as a clinician. As a medical student, it can be challenging to understand what certain procedures or orders mean for patients. UMass does a really good job of teaching that to students, but you can be really detached when you are placing orders for subcutaneous heparin every eight hours or drawing frequent labs. What that means for the patient is that every eight hours someone comes in the room and they stick them with a needle, and if they are a “hard stick,” it’s this traumatic thing that happens to them three times a day. I left the hospital with bruises all over my body because of the frequent injections. It’s things like that that have made me think more before ordering something invasive or painful for a patient. When I was in the hospital, it was scary for people to come in the room. I was one of the first people in Worcester to have COVID-19, and I was the first COVID-19-positive patient for every clinician that came into the room to care for me. The doctors and nurses were rightfully scared. Acknowledging the fear and being honest and transparent with your patients is so important. When I’m deployed as an intern, I am going to make a conscious effort to acknowledge that. But being alone in the hospital room for that long of a time was really hard. I think it provided me such a different perspective. As a physician or student, your time with patients is fairly brief – once or twice a day. I always tried to be mindfully present with patients before this experience, but I think I am now more than ever. I think – I hope – it made me a better clinician.
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is there anything unique about covid-19
patients that will inform the way you’ll practice medicine in the future?
Caring for COVID-19 patients, especially in the DCU field hospital, has really enlightened me to the resilience of the human spirit. In the field hospital, people are sleeping on cots, in makeshift rooms, with curtains between them. There’s not much humanity to it. But when you get to tell a patient – who may have been there for weeks on end – that they’re going home, it is an incredible feeling. In medicine, you don’t often get to see immediate payoffs for the work you do. I think that contributes to the high burnout rate. You have to hold onto those good experiences with patients when they have a positive outcome, and that motivates your persistence. what should be the role of medical providers in helping to prevent
community spread of covid-19? what else can we do to help?
I think we definitely have a responsibility to advocate for mask wearing and safe practices, because at the end of the day we’re the ones that care for these people when they’re sick. We spend years of our lives dedicating ourselves to health and public health, and this is no different. If anything, this is our call to serve. But beyond that, I don’t want anyone to go through what I went through. I think that’s one of the reasons why I was willing, as a more introverted person, to do those interviews on the news, to be an example for people. I’m young and healthy, and this almost killed me. Please, learn from me; this is serious. I donated my plasma many times, not just for life-saving purposes, but also for a clinical study that’s looking into antibodies. That was similarly why I chose to work at the field hospital, because I felt, operating on the assumption that I have some sort of temporary immunity, it makes the most sense for me to be the one working there, and taking care of people. It just made the most sense. +
Alexandra Rabin, UMass Medical School Class of 2022 and student representative to Worcester Medicine Michelle Shabo, UMass Medical School Class of 2021
SEPTEMBER / OCTOBER 2020
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From the Archives Curator B. Dale Magee, MD Boston Medical and Surgical Journal Vol. CLXXVI, 24; 840. 1917
The Practicing Physician in the Public Health Merrill Champion, MD, CPH
L
et us consider the place of the practicing physician in the
scheme of public health protection. For all practical purposes, we have four factors to deal with: the people, their private physicians, the local boards of health, and the State Department of Health. …Let us briefly outline the part the various factors should play. The public- the most important part of all naturally- determine who shall be their physicians, their boards of health and, ultimately, their state department of health. Local boards of health are entrusted by the people with the power to make and enforce reasonable regulations for the protection of the public health and these regulations are binding on laymen and physicians alike. The state department of health plays the role of expert adviser. It accomplishes it results, as a rule, by persuasion and argument, rather than through coercion. The practicing physician, however, is at present the all important factor in the protection of the public health. All others have to rely on him for great measure of their results. How has he met this responsibility? On the whole, I fear, the answer to this question must be made that he has not risen to the full measure of his opportunities. The physician is, by training, an individualist and something of an autocrat. He thinks in terms of family rather than of community. .. The many details of private practice tend to concentrate his attention on the cure of the ailments of his own clientele and he takes for granted that his brother practitioner is doing the same for his clientele. This attitude too often results in a certain the narrowness of outlook; the foreground is so sharply defined that the background is lost sight of. It means a vast number of units working independently of each other and with very little correlation. .. He’s apt to forget that his doctor neighbor’s patient, in the larger point of view, is of equal importance. This attitude of mind makes it possible for tremendous pressure to be brought to bear under certain circumstances, as, for instance in the matter of release from quarantine. I have known a physician to yield many times to such pressure and to certify that his patient was ready to be released from quarantine when his best judgment could not approve such a step. … Adequate isolation and quarantine are not enforced and foci of disease are established, to stamp out which may take much time and money, and which may even result in the loss of valuable lives. Examples of this are easy to find. One instance may be mentioned where a grown man was suffering from an eruptive disease. He was seen by his physician on the street; the physician made an offhand diagnosis of chickenpox and did not even report it. The sequel of it all was an epidemic of smallpox. In what way can the local board of health in the State Department of Health help the practicing physician and his fight against disease and in his attempts to protect the public health? Many ways come to
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mind at once. The local board of health, by authority conferred upon it by law, can render much easier the task of the family physician and maintaining proper control over communicable diseases. The local board of health can render possible for him to get his patients, rich and poor, into the proper communicable disease hospitals… It should also be able to furnish him with invaluable information regarding the prevalence of disease in the community. In many instances it does furnish him with laboratory service for the diagnosis of communicable disease. The State Department of Health, on the other hand, can likewise for furnish him with much assistance. It is the duty of the state to furnish expert advice at all matters which have to do with the life and health of citizens of the Commonwealth. .. It shall furnish him with diagnostic assistance in communicable diseases at no cost to himself or to his patient and with laboratory assistance such as examinations for diphtheria typhoid fever and malaria, etc. What does the state ask in return for these things which she furnishes to her citizens free? In the first place, she asks that the physicians report promptly all cases of communicable disease, births and deaths within their knowledge. She asks these things, but she does not always get them. Physicians are often very careless about reporting births, sore eyes in babies, and communicable diseases in older children or adults, yet the health authorities of both town and State are powerless to control disease, the existence of which they are unable to ascertain. Finally the State has a right to ask that the physicians be the first to support all matters which tend to promote the health and happiness of the citizens of the Commonwealth. How can this be done? The physician should be adviser of his families, not merely in times of sickness but in times of health... We all know in what a state of flux the public mind is at present in medical matters. Many people are becoming distrustful of the old measures of treatment and they are taking more interest in prophylaxis. They read in the newspapers articles on the cause and prevention of disease- information they too often do not get from their family physician. To sum up the gist of our subject, the family physician should be the strongest ally which the board of health has… He should learn to think in terms of community as well in terms of family. +
SEPTEMBER / OCTOBER 2020
WORCESTER MEDICINE
Book Review Stalking the Doctors of the Full Moon By Sande Bishop Reviewed by Joel H. Popkin, MD, MACP
M
any years ago sande bishop began sharing with
me and some other friends a propagating series of “chapters” of central Massachusetts medical history, much of which emerged from the contents of a cryptic, dusty box marked “U.M.A.” – the Union Medical Association. This mysterious wooden case from the innards of the Worcester District Medical Society – the third oldest medical society in the nation – housed some 400 medical entries from meetings between the U.M.A.’s inception in 1834 until 1845. The U.M.A. was organized by six learned doctors in the Blackstone Valley, who restrictively granted membership to their select and erudite professional group. Since in those days anyone could declare himself a doctor, the U.M.A. was intent on establishing high standards. These monthly meetings of the Union Medical Association, by the way, took place “at 2 o’clock P.M. on every Monday next preceding the full of the Moon.” And thus, the title of Ms. Bishop’s new book, Stalking the Doctors of the Full Moon, was born. What stories she has uncovered! And despite the assiduous impartiality of a reporter’s narratives, what story telling! It’s hard for us, nearly two centuries later, to avoid feeling at least a bit smug when we see how these elite doctors “obviously” sickened and killed many of their patients. But we almost forget that the state-of-the-art medicine in the 1840s was essentially based on the teachings of Galen from 1800 years earlier and Hippocrates 700 years before that. The four humors of the human body – blood, phlegm, yellow bile, and black bile – were definitively considered the prime regulators of our well-being. Health is enjoyed when these substances are in correct proportion, while disease occurs with their divergence. Bleeding, purging, blistering, and horrific medicinals were confidently used to restore humoral balance. In fact, doctors’ decisions did sicken and kill many of their patients, as they still sometimes do today. But these doctors met regularly, discussed and anguished over their cases, sought advice, and did all that medicine had available at the time. Fortunately, they left their stories for Ms. Bishop to bring to us. To put this in perspective, Louis Pasteur’s revolution in understanding microbes was still 30 years away. Ms. Bishop’s assiduously impartial reporting doesn’t allow us arrogant judgment, nor by implication, allow (my interpretation) how primitively our own current brand of medicine will be judged a century from now. As she so astutely points out, “Holding the Union Medical Association to contemporary standards of belief, knowledge, and behavior would be the utmost injustice.” Doesn’t that say so much about all kinds of bias – medical and otherwise?
What Ms. Bishop ingeniously culled and interweaved from the documents are the bona fide lives that each of her doctors experienced – and they were indeed her doctors, as over time her friendship with them flourished. During her years of study, Ms. Bishop even found practice standards that were not so different from today. For example, there was little reimbursement for an all-night vigil at a bedside, while application of tortuous and deadly blistering agents (procedures) earned the physician much more income. Needless to say, this labor of love took years of enormous effort and detective work – and a “cult” of followers who pushed her mercilessly to paste the chapters together and publish. But more than this, Ms. Bishop is a scholar of Worcester medicine. Her expertise in the history of the hospitals and society of that era frame her investigations with authenticity and perspective. Thus, we are treated to chapters including, among many, humoral therapy, midwifery, homeopathy, mental disease, opium, and, yes, even contagion. As to the last, one of Ms. Bishop’s doctors, Augustine Taft, wrote: “When we know who, what, and where our foe is we can then the more readily select our weapons, choose our mode of attack, and beset him so valiantly as to compel him forthwith to beat a retreat.” Apologies for another interjection, but might our non-medical directors of today’s contagion management read these words before wildly and recklessly denouncing COVID-19 testing? While Worcester natives may especially appreciate name recognition and even some common ancestry, the reader quickly realizes that Ms. Bishop’s documentation of her doctors and their environment are generalizable to that era’s medical community at large. And so here we are with a major work. This most readable book is in no way limited to physicians or others in the medical field. Sande Bishop and her doctors have chronicled a study of vital historical significance – not only of the 1840 medical world, but of a society that tells us much about our modern-day selves. + Joel Popkin is the Director of Special Services at St. Vincent Hospital and Professor of Medicine at the University of Massachusetts Medical School. He can be reached at joel.popkin@stvincenthospital.com.
SEPTEMBER / OCTOBER 2020
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WORCESTER MEDICINE
The Gerald F. Berlin Creative Writing Award Little Brown Bird Peyton Morss-Walton The Gerald F. Berlin Creative Writing Award at the University of Massachusetts Medical School honors the poetry, fiction and essays of medical students, physicians, in training (interns, residents and fellows), graduate students and nursing students from the medical school. The award was established to encourage creative writing by health professionals-in-training and to honor the father of Richard M. Berlin, MD, who sponsors the award.
S
he is a middle-aged to older woman in the
hospital for chronic pancreatitis, and I cannot decide how much sympathy to feel for her. My team largely ignores her. Apart from continued missives for her to remain NPO and receive IV pain medication, she seems not to trouble them. My attending shrugs at her name during rounds – she needs to get on PO medication if we want to discharge her – and I decide to take her as my patient, largely because it seems my presentations will be minimally scrutinized. I go to see her in the morning before our rounds begin, and I ask her if she would be willing to be an example patient during our medical student teaching rounds. I am constantly surprised by the cheery willingness of patients to be exploited for my own gain, and she again defies my expectations by eagerly agreeing – I have often been a model before. She shows me her severe dextroscoliosis, which has no bearing on her current admission, and my sympathy for her begins to creep around the edges of my team’s disdain. She is tiny and wrinkled, like the bird I found on the sidewalk outside the dry cleaner when I was five. My mom told me I wasn’t allowed to touch it, because it might have diseases, so we picked it up using an old ACE bandage that we found in the footwell of our 1990 Ford Explorer. We brought the bird home to our house on the edge of the conservation land and dug worms from the dirt near a tree. The bird was nearly transparent. It could only swallow the smallest worms, and we watched them slip away, the throat muscles peristalsing as the worms slid slowly down. This lady feels transparent too, if only because she is so small and malnourished. She has an ex-smoker’s lines across her face, and her skin is so wizened that if her hair hadn’t been blonde, I would assume she had grandchildren. Instead, her yellow
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hair peeks anachronistically around a hair tie, and I wonder if I can even touch her without causing her pain. Her abdomen is so tender from this pancreatitis flare that I cannot – I barely dare to press my fingers against it before retrieving my unruly hand. She thanks me for not pressing too hard, and we agree to show her scoliosis on my teaching rounds, rather than her abdominal tenderness. I feel so tall and large, towering over her, but I have not yet reached the level of fluidity with patients where I feel entitled to sit on the edge of their beds as we speak. Instead, I stammer through a few more questions about her medications, her supplementary enzymes, and her history of pancreatitis. She sits upright, eyes bright and alert despite the opiates, and she tells me about her boyfriend, who after twenty-five years is still not allowed to live with her – it’s better to have your own space. She worked in a police force for years, so she’s accustomed to being the only woman in a room full of men, and she likes my shoes. Actually, she likes my whole outfit. I look cute today. She wore a uniform all her life, as an officer, so she’s always enjoyed looking at other people’s outfits. She likes seeing a woman’s face in medicine. I have forgotten completely what I’m wearing today, choosing clothes at random from the drawer reserved for dressy casual, whatever that means, and I stare down at my feet to find the black shoes from eBay that pinch my toes, the too-short pants from Gap that won’t quite sit on my waist, and a patterned shirt that I would never have picked for myself, so it must have been a gift. It surprises me so much that I laugh and a spout of authenticity pours out the frustrations of dressing nicely at 5:30 in the morning, with stubbornly long limbs that refuse to adhere to affordable style. She tells me she had the opposite problem, shopping for petite clothing, and I see her swallowed whole by a uniform, the image of the baby bird wrapped in an ACE bandaged superimposed alongside it. We called a lady in our town about the baby bird because we wanted to see if we could put it back in the nest. She told us that the mother birds sometimes kick out babies that don’t smell right and that even though we had been careful not to touch the bird, after living for a while at our house the mother would never accept it again. So we drove to this lady’s house and gave the bird to her. She held out her hands, and we placed it into her hands without any protective wrapping. Someone explained to me that it was because the bird was never going home to its nest. Far from her home, my patient is clearly lonely. The next day she explains that she doesn’t allow her boyfriend to visit her in the hospital, as she doesn’t want him to see her like this. She keeps only one thing by her bedside, a bouquet of artificial flowers from a close friend’s daughter. She says that after they visited, she gave them her credit card so the friend could take her daughter to Chili’s for lunch. The friend was struggling financially, and the daughter had been surprised and thrilled. She doesn’t have any children, this new little brown bird of mine, but she is still a mother. She compliments my outfits every day and we lightly discuss her life, sexism in medicine, and whether or not she should allow her boyfriend to visit her. Her stay is prolonged and her pain lingers. On the fifth day
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As I See It
Berlin Award Continued that I see her, she asks me about my medical school trajectory, and I explain some of my interests and motivations. Your parents must be very proud of you, she says, and I nod, knowing they are. It is seven weeks after my dad died in a car crash, and I have spoken of it to no one in this hospital. I assume the other medical students know, but the faceless rotating teams of residents and attendings that switch weekly are a wall I haven’t thought to breach. My sisters attend grief groups at their colleges and get extensions on papers and exams. I pick my clothes out in the dark and start my car and drive to the hospital, where I pick patients that are overlooked, hoping to be so myself. My dad died recently, I tell her, and she takes my hand. He cried when I got into medical school, I tell her, and she nods. I think of the worms we fed the little bird and being so worried the whole time that it would choke. I was so afraid of the bird with its frailty and its diseases, and I was afraid for the bird because I wanted it to be happy and to find its nest again. I realize I am scared for this delicate old lady, who seems elderly before her time. I hope that her illness does not define her life and that she can leave this hospital and spend years with her friend’s daughter. She has shown me so much kindness when I did not even realize I was so desperate for it. I have chosen her for the wrong reasons – in grief, seeking a patient I thought would be “easy” to care for, and I am afraid for myself, too; of my sadness and my pain and the way I’ve changed since the crash. On her last morning in the hospital, I wear my favorite dress. Sitting on the side of the bed, I hold her hand and tell her that I hope she continues to improve and that I will remember her often and that I will write about her. In my mind’s eye, I hold the baby bird in my hand, instead of giving it away. We had tried to take the safe option, not touching it and not holding it, but it hadn’t mattered in the end. My dad’s crash also seems unpreventable. I hope that we are making a difference for this patient. And I wonder if this will be my life in anecdotes, the cradling of fragile things, and if it will bring me happiness or suffering. I think of all this and I return to my team to run the list. She is leaving the hospital, so it is time to add a new patient to my load. +
Engaging the Worcester Senior Community Throughout COVID Sara Carbone & Kristina Jakobson
W
hile most aspects of life during the covid-19 pandemic have been marked by uncertainty, one thing has been made abundantly clear; the dedication of the UMass student body to support the Worcester community. One effort we are particularly proud to spearhead is the Worcester Senior Center Outreach initiative. When the Worcester Senior Center was forced to close in March due to social distancing measures, approximately 4,000 elders in the Worcester area lost a significant source of community and social interaction. This vulnerable and isolated population had an immediate need for additional support. Within a short time, over 100 students from UMass Medical School, Nursing School, and GSBS volunteered to make weekly phone calls to this elderly population to check on their well-being and provide companionship. As of mid-August, 40 seniors have been paired with students and 230 phone calls have been made, with 19 languages offered. This outreach has since been expanded to a senior center in the Springfield area. Thanks to the continued dedication of our student volunteers, the program is popular with the senior citizens and currently has no end in sight. We have been inspired by the kindness, creativity, and collaboration of our fellow classmates during these past five months. It is heartwarming to see connections forged in our community that may not otherwise have been made. As much as the elders may benefit from this service, we as student volunteers have gained much from this experience as well. We are reminded of the importance of caring for our neighbors, and of the human connection that drew us to medicine in the first place. Special thanks to Dr. Michael Hirsh of UMMS, Amy Waters of WSC, and all of the student volunteers who have dedicated their time to this outreach. +
Sara Carbone is an MD candidate in the Class of 2022 at the University of Massachusetts Medical School and co-founder of the Worcester Senior Center Outreach Initiative. sara.carbone@umassmed.edu Kristina Jakobson is an MD candidate in the Class of 2023 at the University of Massachusetts Medical School and co-founder of the Worcester Senior Center Outreach Initiative.
Peyton Morss-Walton is a fourth-year medical student at the University of Massachusetts Medical School. Email: peyton.morss@umassmed.edu
SEPTEMBER / OCTOBER 2020
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WORCESTER MEDICINE
Society Snippets: Congratulations to Our Members 2020 MMS/WDMS Community Clinician of the Year: Timothy B. Hopkins, MD, FACS After graduating from Harvard Medical School, Dr. Hopkins pursued his residency in Surgery/Urology at Children’s Hospital Medical Center and subsequently trained as a Fellow in Urology at Peter Brent Brigham Hospital. From there he practiced at UMass Medical Center as an Attending Physician and Associate Professor. Dr. Hopkins has authored countless publications, has given presentations at local, regional and national meetings, has held dozens of faculty and committee titles, and has received multiple honors and awards, including being selected as the “Top Doctor” by his peers each year since 2001. For over 40 years, Dr. Hopkins has been extremely dedicated to his patients, to the “craft of urology,” and to teaching residents and students, where he has devoted his life to medicine and the “betterment of his patients.” He has actively participated in several organizations including WDMS since 1977. +
2020 WDMS Editor’s Award: Paul M. Steen, MD Dr. Steen graduated from Downstate Medical Center, SUNY in Brooklyn in 1965. He completed his residency in Internal Medicine and was Chief Medical Resident at Kings County Hospital before he completed two years in the Navy in Guam. He served fifteen years in private practice of Internal Medicine in Southbridge, MA. Following this, he worked in the corporate world at MediQual Systems and McKesson HBOC as VP of Clinical Development until retirement in 2005. For the Worcester District Medical Society, Dr. Steen served as President in 1992 and Editor of Worcester Medicine from 2005-2012. In retirement, Paul has become a Master Gardener for the Massachusetts Horticultural Society and Docent at the Worcester Art Museum. +
MMS Senior Volunteer Physician of the Year: Jane A. Lochrie, MD Dr. Jane Lochrie began her medical career as a staff nurse at mass General and advanced to the ranks of Pedicatric Nurse Practioner. She earned her Medical Degree from UMass Medical School, and completed her residency at St. Vincent Hospital Hospital. Dr. Lochrie Practiced as a General Internist for the Fallon Clinic/Reliant Medical Group from 1986-2017. In addition, she had many teaching postitions including Program Driector for the Internal Medicine Residency Program for St. Vincent Hospital. Dr. Lochrie served as the President for WDMS from 2008-2010. In addition to participating in and chairing
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many committees, she is the Chief Editor for Worcester Medicine. Dr. Lochrie is the recipient of multiple honors and awards, including the 2018 Leonard Tow Humanism in Medicine Award. She was cofounder of the Women’s Clinic for then Fallon Clinic, and is the Medical Director for St. Anne’s Free Clinic in Shrewsbury where she volunteers weekly. In an effort to maintain her passion and fulfill her personal goals of serving the underprivileged, Dr. Lochrie has participated in mission trips to Haiti and Gautemala, where she continues to help educate and care for those in great need. +
MMS Grant V. Rodkey, MD Award for Outstanding Contributions to Medical Education: Mary Callery O’Brien, MD Dr. Mary Callery O’Brien, an assistant professor of medicine at the University of Massachusetts Medical School, has been honored by the Massachusetts Medical Society as the 2020 recipient of the Grant V. Rodkey Award, an honor recognizing a Massachusetts physician for outstanding contributions to medical education and medical students. A longtime member of the Massachusetts Medical Society (MMS) and the Worcester District Medical Society (WDMS), Dr. O’Brien was the 2015 winner of UMass Medical School’s most prestigious award for educators, the Lamar Souter Excellence in Undergraduate Medical Education Award. She was the inaugural director of the medical school’s Longitudinal Preceptor Program and held that position from 19952005. She has directed the Physical Diagnosis program and for the last 10 years has led one of the
SEPTEMBER / OCTOBER 2020
school’s multidisciplinary learner centered first year courses taught by both basic scientists and clinicians. Dr. O’Brien also currently chairs the WDMS Committee on Education. +
Chair, Massachusetts Board of Registration in Medicine: George M. Abraham, MD, MPH, FACP, FIDSA Congratulations to George Abraham, MD, MPH, on his appointment of Chair of the Massachusetts Board of Registration in Medicine. In this role he will be responsible for ensuring that only competent physicians of good moral character are licensed to practice in the state of Massachusetts. Dr. Abraham earned his medical degrees from the Christian Medical College, Ludhiana, India. He completed his residency and chief residency at Saint Vincent Hospital and received his Master’s degree in public health from the Johns Hopkins Bloomberg School of Public Health. Additionally, Dr. Abraham is board certified in internal medicine and infectious disease. He is the President-Elect and a Regent of the American College of Physicians (ACP). He is an Emeritus Chair of the Board of Governors of the ACP. Dr. Abraham is also the Chair of the Infectious Disease Board of the American Board of Internal Medicine. He has served as the Governor of the Massachusetts Chapter of the American College of Physicians, as a trustee of the Massachusetts Medical Society, as President of the Worcester District Medical Society, as the Chief Medical Officer of the Central Massachusetts Independent Physician Association and Chair of the Board of Directors of the Health Foundation of Central Massachusetts. +
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