pain managementmar./apr. 2008 worcester medicine| 3on the cover: pain management substance abuse...

MAR./APR. 2008 WORCESTER MEDICINE | 3

On the cover:Pain ManagementSubstance Abuse

contents Vol. 72, No. 2

MAR/APR 2008

4 President’s MessageBruce Karlin, MD

5 EditorialPaul M. Steen, MD

6 Why is Pain Management so Challenging?Mary Valliere, MD

8 Managing Pain at the End of LifeChristine McCluskey, RN

11 As I See ItBernadette V. Meade, DO

12 Science CornerMichele Matthews, PharmD

13 Legal ConsultPeter Martin, Esq.

15 Financial Advice for PhysiciansRuth R. Petty, MSFS

19 History of MedicineJohn Massarelli, MD

21 Off Call - Part OneMartin A. Lynch

25 In MemoriamJames M. Morrison, MD

Dr. Norio Higano

26 Society SnippetsMike Halloran

The WDMS Editorial Board and Publications Committee gratefully acknowledge the support of the following sponsors:

Saint Vincent Hospital

UMass Memorial Health Care

Fallon Clinic

Physicians Insurance Agency of Massachusetts (PIAM)

“Quality” is a most misunderstood term. The term“quality” is derived from the Latin ”qualitas,” whichmeans characteristic. To assure excellence in a prod-uct or service, the early quality engineers standardizedvarious qualities (characteristics) of that product orservice. They were so good at their job that ”quality”became equated with “excellence.” The current spateof insurance forays into quality engineering ignoresthe precepts of the original engineers. When you findyourself subjected to “quality improvement,” askyourself, “Which quality is being standardized?”Then ask yourself, “Will standardizing that character-istic provide a better product or service?”

For example, Blue Cross has subjected us to a Cultural Competency Exam. Whatcharacteristic has been standardized by the 2 hours or more spent working throughthat exercise? Putting aside all the problems of the inappropriateness of insurersadministering an academic test, the lack of reimbursement for our time, and the lackof testing of the measuring tool, I wonder how this exercise improves the excellenceof health care delivery. What was their measure of success?

As another example, controlling our prescribing practices with prior authorizationsdoes not improve care. We asked some members about prior authorizations: howmuch time did you and your staff spend? How many were rejected? What propor-tion of those rejected was reasonable? 24 answered that they had spent 10 minutesto 7 hours and that the lion’s share passed through (One commented that with“…enough time all would pass.”). Only a handful of rejections seemed reasonableto the respondents.

Where the insurance industry fails in quality engineering our medical society canshine. We can choose far better qualities to standardize. For example, we couldstandardize our information systems for recording immunizations. We could spenda little time now to assess our current sad state of affairs, implement a system, andthen test how much better the new system worked. While there is an enormousamount of work involved in implementing and designing such a system, I suspectyou, our members, would be more willing to waste two hours in pursuit of that goalthan two hours on a Cultural Competency exam.

In the coming months we will be looking for some adventuresome souls who mightjoin us as lab rats while we test existing measures (e.g., prior authorization) anddevelop new measures (e.g., office information networks). We will also look foryour ideas and comments. Your focus on our patients’ health will surely providemore appropriate quality improvement than do our insurers.

Bruce Karlin, MD

President

Worcester Medicine does not hold itself responsiblefor statements made by any contributor. Statementsor opinions expressed in Worcester Medicine reflectthe views of the author(s) and not the official policy ofthe Worcester District Medical Society unless so stat-ed. Although all advertising material is expected toconform to ethical standards, acceptance does notimply endorsement by Worcester Medicine unlessstated. Material printed in Worcester Medicine is cov-ered by copyright. No copyright is claimed to anywork of the U.S. government. No part of this publica-tion may be reproduced or transmitted in any formwithout written permission. For information on sub-scriptions, permissions, reprints and other servicescontact the Worcester District Medical Society.

WDMS OfficersBruce Karlin, PresidentJane Lochrie, Vice PresidentJoseph Cohen, SecretaryRobert Lebow, TreasurerJoyce Cariglia, Executive DirectorMelissa Boucher, Administrative AssistantFrancine Vakil, WDMS Alliance

WDMS Editorial BoardPaul Steen, MD, EditorGary Blanchard, MDCarol Bova, PhD, RN, ANPAnthony Esposito, MDMichael Hirsh, MDPeter Lindblad, MDJane Lochrie, MDMichael Malloy, PharmDThoru Pederson, PhDJoel Popkin, MDRobert Sorrenti, MD

WORCESTER

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4 | WORCESTER MEDICINE MAR./APR. 2008

president’s message

Bruce Karlin, MD


Chronic pain often resultsfrom conditions that are diffi-cult to diagnose and treat, ortake a long time to treat. Thepain itself is frequently man-aged separately from theunderlying condition andrequires a multi-disciplinaryapproach to treatment.Unfortunately, many practi-tioners are not adequatelytrained in the therapy for relief

of intense chronic pain. Even worse, the members of somestate medical boards are also unaware of the treatmentneeded and when they review physicians all they see isoveruse of controlled substances.

This led us to focus on pain management as a theme. Asthe articles came in, it became clear that this was going tobe a large, complicated subject. Therefore, we decided tosplit the topic into two issues, allowing us to have longerarticles to discuss what is new in this area and give it ade-quate coverage.

Also in this issue, we continue our History of Medicineseries by John Massarelli as it has been a popular additionto the publication.. To continue in this direction we addeda history article on the Irish in Worcester. I would inviteother ethnic groups to write similar articles for publica-tion. Before writing, please contact us to discuss thedetails, length and content.

Editorial

Pain Management IssuePaul M. Steen, MD

Paul M. Steen, MD

structure


substance abuse

What do we need to know to allow forappropriate pain relief while preventingmisuse and abuse of pain medications?

Pain is common.Pain is the number one reason that people seek medical atten-

tion. 45% of persons in the United States will visit a doctor for

pain at some point in their lives. In addition, approximately 75

million people live in “serious pain” and nearly 50 million are

partially or totally disabled by pain.i According to Dr. Carver

from the American College of Physicians (ACP) Online

Medicine, “Both acute and chronic pain are significant drivers of

increased utilization of health care resources. Persons with

chronic pain are five times as likely as those without chronic

pain to use health care services.”

Pain is individual.The very nature of pain defined as “…an unpleasant sensory and

emotional experience associated with actual or potential tissue

damage or described in terms of such damage”ii makes evalua-

tion and treatment complicated and sets pain apart from other

objective and more easily measurable complaints.

Pain evaluation takes time.In addition to being a significant issue alone, pain is also a

prominent feature of a number of complex, chronic illnesses.

Cancer, HIV\AIDS, arthritis, and sickle cell anemia are just a few

of the medical conditions that require complex disease manage-

ment in addition to the management of pain.

Pain medications carry risk of misuse,abuse or diversion.

“Misuse” is a common phenomenon related to 1 misunderstand-

ing the appropriate way to use pain medication or 2 using more

medication in response to under-treatment of pain. Misuse does

not constitute “abuse” and patients should not be labeled

abusers. “Abuse” is the use of medication for non-therapeutic

purpose or purposes other than those for which it was pre-

scribed. “Diversion” is a legal term that describes the illegal

procurement of prescription pain medication intended for

someone else or other illegal practices to obtain prescription

drugs. All physicians have legal and regulatory obligation to

prevent diversion and abuse of prescription pain medications.

What are the facts about misuse, abuse,and diversion of pain medications?

Abuse is uncommon.Abuse of prescription pain medication is uncommon among the

general patient population. Most patients who are prescribed

opioids for pain do not abuse these medications or become

addicted. While the National Institute on Drug Abuse (NIDA)

reports that more research is needed on the factors that predis-

pose patients to addiction, they clearly endorse the fact that the

risk of addiction is minimal in most cases, especially when

patients are treated on a short term basis3.

Risk of abuse is individual.The most reliable known risk factor for predicting abuse or

addiction to pain medication is a history of addiction. This neu-

robehavioral syndrome has genetic and environmental factors

and is manifested by compulsive use of a substance despite

harm. Addiction should not be confused with the phenomenon

of physical dependence, an expected consequence of legitimate

Why is Pain Management soChallenging?Mary Valliere, MD

In the world of clinical medicine, there is perhaps nothing more challenging for a patient or physician thanmanaging pain. Balancing the commitment to compassionately relieve suffering without causing harm canbe a confusing mixture of imperfect science, fear and miscommunication. While clinicians are always inter-ested in doing the best for their patients, concerns about a history of addiction, “drug-seeking” behaviors andthe potential for drug diversion weigh heavily on their minds. Even their vocabulary can be unclear andinconsistent when trying to communicate with colleagues as well as patients about these issues.

long term use of pain medication.

Physical dependence defined as the pres-

ence of tolerance and withdrawal can be

seen with cessation of either legitimate or

illegitimate pain medication use.

Addiction is not a contraindication to

prescribing pain medication, but it will

require a much more structured, individ-

ualized monitoring and follow-up treat-

ment plan.

Intervention in misuse,abuse, diversion and addic-tion takes time.Based on an assessment of a patient’s

inappropriate use of medication, a clini-

cian should determine whether the

behaviors represent misuse, repeated

misuse, likely abuse, or exacerbation of

an underlying addiction. Interventions

have been described for each category of

inappropriate useiv and physicians are

legally and ethically responsible for inter-

vening in the setting of problems with

prescription pain medications.

How can clinicians andpatients work together toimprove pain relief andprevent misuse and abuseof pain medications?

Patients: • Always give complete and accurate

information re: medical and drug use his-

tory

• Follow prescribing directions carefully

and ask questions to clarify instructions

• Do not escalate pain medication use

without consulting your clinician

• Never use another person’s prescrip-

tion or share yours with another person

Clinicians: • Always follow the guidelines of the

state medical board regarding the use of

controlled substances in the treatment of

pain5

• Aggressively manage pain according to

medical standards and document well

• Thoroughly screen all patients for a

history of substance use problems

• Identify any prescription misuse or

abuse issue and intervene as soon as it

occurs

• Set clear treatment goals & plan for

frequent reassessment & revision of the

treatment plan, including discontinua-

tion of treatment when indicated

In summary, the Massachusetts Board of

Registration in Medicine recognizes the

role that fear of legal and regulatory sanc-

tions may play in the problem of under-

treatment of pain by physicians and has

developed clear policy to alleviate physi-

cian uncertainty. The Board has clearly

stated that “…inappropriate treatment of

pain includes non-treatment, under-treat-

ment, over-treatment, and the continued

use of ineffective treatments”vi” and has

provided detailed guidelines for evalua-

tion of a physician’s treatment of pain

with controlled substances. Good pain

treatment based on a thorough knowl-

edge base applied in a fair and consistent

manner with sound clinical judgment

that has been meticulously documented

is the best way to ensure

References:1. Carver, Alan, 11 Neurology, XIV Pain, ACP MedicineOnline, Dale DC; Federman DD, Eds. WebMD Inc., NewYork, 2000

2. International Association for the Study of Pain, IASPPain Terminology www.iasp-pain.org

3. National Institute on Drug Abuse, Preventing and recog-nizing prescription drug abuse,www.drugabuse.gov/ResearchReports

4. Jl Harry Isaacson, MD, et al, Postgraduate Medicine, Vol118/No1/July 2005

5. Model Policy for the use of Controlled substances for theTreatment of Pain, Adopted by the Massachusetts Board ofRegistration in Medicine, December 15, 2004www.massmedboard.org

Mary A. Valliere, MD is Assistant Professor of Medicine atUMass Medical School, Chief of the Division of PalliativeMedicine at UMMMC is certified in Hospice & PalliativeMedicine and Addiction Medicine.



substance abuse

For many people, no fear isgreater than the prospect ofpain at the end of life ~ forsome, it is worse than thefear of death itself. This factwas illustrated in astatewide survey conductedthroughout MA in 2005 bythe Massachusetts End ofLife Commission and AARPof Massachusetts. In thatsurvey, eight out of tenrespondents said they werefearful of dying painfully,while only 40% said theywere afraid of dying.1

Despite this widespread concern, pain at the end of life is fre-quently under-managed or not managed at all. Two importantnational studies 2,3 have shown significant deficiencies in themanagement of pain for dying persons as reported by familymembers. Similarly in Worcester, the SODIUM study 4 revealedthat 20% of patients for whom pain management was importantas reported by next of kin were inadequately treated for pain asthey were dying. What accounts for this wide disparity betweenthe needs of patients and the care provided to them at this mostvulnerable time?

Why is pain under-treated at the end of life?

For a variety of reasons, pain management at the end of life canbe especially challenging. The reasons have to do with cultural,legal, and professional factors related to patients and families,institutions, and health care providers. Among physicians inparticular, a lack of formal training in the treatment of pain, dis-comfort in addressing end of life issues in general, and specificconcerns related to the prescribing of opioids all may contributeto poor pain management practices. Moreover, successful treat-ment of pain may be challenged by multiple and complex clini-cal, social and spiritual issues occurring at the end of life,including the presence of other concomitant symptoms. Lack ofattention to fear, anxiety, depression, and unresolved spiritualconcerns may contribute to an increase in pain intensity, and the

failure to attend to them can lead to devastating consequencesfor dying patients and their families.

A closer look at barriers among physicians

While some of the obstacles to good pain management amongphysicians may be grounded in the fear of potential legal rami-fications for prescribing large doses of narcotics, others are relat-ed to an incomplete understanding of the properties of opioidsand their effects, which has particular relevance for dyingpatients.

Concerns about addiction: Many physicians fear that patientswill become addicted to opioids and are reluctant to prescribethem for this reason. Studies have shown, however, that about4% of patients become addicted4. Because the overwhelmingmajority of patients do not become addicted, this concernshould not be an overriding one. In the unlikely event that trueaddiction should develop, there are resources that provide guid-ance in how to manage pain effectively in such patients (see arti-cle on addiction in this issue).

Fear of hastening death: Physicians as well as nurses and fami-ly members often have grave concerns about administering largedoses of opioids, fearing that they will hasten death. While alarge dose of a narcotic given to an opiate-naive person cancause respiratory arrest, increasing the dose incrementallyallows the patient to build tolerance to respiratory depressanteffects, thus providing a safer transition to more effective andhigher dosing.6; this should be explained to family memberswho may withhold larger doses of medication at home duringthe final stages for fear of administering an overdose.

Lack of skill in managing pain: The basics of pain managementare infrequently taught in medical schools, yet pain is a symp-tom that often causes patients to seek medical attention. As ill-ness progresses pain may escalate, and good pain assessment(and re-assessment) and other skills are crucial for successfulpain management. Additional competencies include:

• understanding the patho-physiology of pain and the selectionof analgesics based on the type of pain

• knowing actions of opioids and other analgesics and aggres-sively managing side effects

Managing Pain at the End of LifeChristine McCluskey, RN

Christine McCluskey, RN


• knowing the difference among addic-tion, pseudo-addiction, physical depend-ence, and tolerance

• practice of equi-analgesic dosing andtitration of opioids, management ofbreakthrough pain, and use of the WorldHealth Organization step ladder for painmanagement

• knowing indications for the use ofadjuvant analgesics such as antidepres-sants and corticosteroids, and co-anal-gesics such as non-steroidal anti-inflam-matory drugs

• familiarity with non-pharmacologicalmethods for the treatment of pain

In addition, examination of personal atti-tudes toward pain may help to uncoverbiases that could potentially interferewith successful pain management prac-tices.

Suggestions for improving the manage-ment of pain for patients

There are many resources and options foraccessing good information to assist thepracticing physician in pain treatment atthe end of life.

For more information go to www.bet-terending.org.

Consider the following:

Take advantage of local experts: consultwith palliative care physicians, hospicemedical directors, pain specialists, andhospice nurses.

Seek out pain management coursesonline and offerings through state anddistrict medical societies.

Expect hospice nurses to report the painstatus of patients; ask for and considertheir recommendations for specificpatients.

Provide written materials to patients andfamilies and encourage them to reporttheir pain status regularly.

Ask frequently about pain: consider it the“fifth vital sign.”

References:1. MA Commission on End of Life Care Survey Project,Executive Summary, September 2005.

2. A Controlled Trial to Improve Care for Seriously Ill IIIHospitalized patients: The Study to Understand Prognosesand Preferences for Outcomes and Risks of Treatments(SUPPORT): JAMA, Vol 274(20). November 22/29, 1995.1591-1598.

3. Teno J, Clarridge B, Casey V, Welch L, Wetle T, Shield R,Mor V. Family Perspectives on End-of-Life Care at the LastPlace of Care: JAMA, Vol 291(1). January 7, 2004. 88-93.

4. Snapshot of Dying in an Urban Milieu. Unpublisheddata. Better Ending Partnership, Worcester, MA.

5. Fleming MF, Balousek SL, Klessig CL, Mundt MP, BrownDD. Substance use disorders in a primary care samplereceiving daily opioids therapy. Journal of Pain. Vol 8(7).July 2007. 573-82.

6. Portenoy R, Sibirceva U, Smout R, Horn S, Connor S,Blum R, Spence C, Fine P. Opioid Use and Survival at theEnd of Life : A Survey of a Hospice Population. Journal ofPain and Symptom Management, Vol 32(6). December2006. 532-540.

Christine McCluskey, RN, a former hospice nurse andadministrator, is the Executive Director of Better EndingPartnership, a community coalition to improve end of lifecare in Central Massachusetts.

During a “Death and Dying“discussion in a highschool’s bioethics class, astudent queried, “As aphysician, how do you feelabout your own death?”What an appropriate andthought-provoking ques-tion. How does the “doc-tor” in me deal with my ownmortality? How would Ienvision my own dying?

I feel bittersweet about mydeath, yet I plan to die well.Death is a natural and

unique event for each person, but I know that I will have onlyone opportunity to try to do it right. First of all, I feel my deathshould be a celebration of my living. Secondly, I imagine that Iwill experience the varied emotions that dying usually evokes inmy patients. There will be my anticipatory grieving of leavingloved ones and knowing all my life dreams may not be a reality.There will be the fear of being dependent. There will be the fearthat my body, mind, and soul might suffer. And perhaps mostdifficult will be seeing the quiet reflections of sorrow in myfriends’ faces.

I envision that the last month of my life might present somechallenges. I might need 24-hour care. My physical symptomsmight progressively and acutely get worse. I hope that I wouldbe moved to the VNA Care Network & Hospice’s Rose MonahanHospice Home. My death bed would see me looking out at thesunset over Coes Pond. My pain and dyspnea could be con-trolled with medications, either sublingually or, if needed, intra-venously. I would be surrounded by the support, care, andempathy of the hospice team. I would find comfort in knowingthat the hospice bereavement coordinator would console myfamily as they mourn in the months after my death. Part of mewould still will want to be immortal, yet I would be at peace. This vision of my own dying, though, begins long before the lastmonth of my life. If my physicians would not be surprised toread my obituary in the next six months, I hope that they wouldrequest hospice services. National Hospice and Palliative Care

Organization (NHPCO) estimates that only 36% of all deaths in2006 were under hospice care. NPHCO also relates in 2006 thatonly 44.1% of patients admitted to hospice had cancer; thisleaves 55.9% for non cancer diagnosis including heart disease,debility unspecified, dementia, and lung disease. I am not surewhat disease I would want to choose for myself ~ I think debil-ity unspecified from being 109! In 2006, the average length ofservice for hospice patients was 59 days, yet the more accuratemedian length of service declined from 26 days in 2005 to 20.6days in 2006.

In my own story, I would be a hospice patient for seven months,and I would live alone at home for the first six months. In 2006,NPHCO National Data Set revealed 74.1% of hospice care is inwhat the patient calls home, including nursing homes (22.5%)and assisted living (4.6%). During this time, the hospice nurs-es would continue treatment for symptoms of reversible diseaseas well as aggressive management of the consequences of myirreversible disease. Hospice pastoral care, volunteers, andsocial workers would counsel me and my family. And yes, Ilived longer than the six months and yet remained eligible dueto my continued decline amid disease progression. In March2007, a study published in the Journal of Pain and SymptomManagement reported that hospice care may actually prolongthe lives of some terminally ill patients. In the study, 4,493 ter-minally ill patients with either CHF or cancer of the breast,colon, lung, pancreas or prostate were selected and comparedfor difference in survival periods for those who received hospicecare and those who did not. The mean survival was 29 dayslonger for hospice patients.

As Medical Director of VNA Care Network & Hospice I have thehonor of caring for the dying. Each day, these patients and fam-ilies teach me about the art of dying. Thus, they help me answerthe question of my mortality. I know discussing death and hos-pice with our patients is difficult. I invite you to answer the stu-dent’s question ~ this exercise added to my perspective. Iencourage you to visit the Rose Monahan Hospice Home inWorcester. It is a special dwelling that will inspire your work.To arrange a visit or for any questions concerning hospice care,email me at [email protected].

Bernadette V. Meade is Medical Director of VNA Care Network& Hospice

Dying – A Physician’s AnswerBernadette V. Meade, DO


as i see it

Bernadette V. Meade, DO


Chronic pain is often intractable to

available pharmacotherapy. Opioid

analgesics are effective for the

treatment of moderate to severe

pain chronic pain; however, their

use is associated with several

adverse effects, including the risk

of addiction. Utilizing routes of

administration that allow for drug distribution to areas rich in

opioid receptors ~ such as in the spinal cord ~ may limit adverse

effects while producing significant analgesia. The intrathecal

administration of these agents has been shown to be more effec-

tive than systemic use1 but requires the use of an implantable

pump and catheter, thereby increasing the risk of infection and

other complications. Gene therapy, an experi-

mental technique that involves the administra-

tion of genes instead of medication for the

treatment of certain diseases, may be the future

of chronic pain management.

Researchers at the Department of Medicine

and Neuroscience at the Mount Sinai School of

Medicine have developed a therapeutic gene

called prepro-?-endorphin (pp?EP) that was

designed to induce secretion of the endoge-

nous opioid ?-endorphin. Previously, pp?EP

demonstrated the ability to produce analgesia

in a rat model for up to 2 weeks after adminis-

tration.2 The authors concluded that the anal-

gesic effect of pp?EP was short lived because

the vector used to administer the gene was rap-

idly neutralized by the immune system. With

new vector technology available, researchers

have once again evaluated the efficacy of

pp?EP in a rat chronic neuropathic pain model

and have found that a single injection of

intrathecal administration of pp?EP produced

significant reversal of exaggerated pain

responses (i.e. allodynia). This response

occurred within 15 to 30 days and lasted for ≥

3 months and was found to be

reversible with the adminis-

tration of naloxone.3

There are several barriers to

overcome before gene therapy

can be considered a viable

option for patients suffering

from various chronic pain syndromes. First, use of this gene has

yet to be tested in humans. Second, the pp?EP gene has demon-

strated efficacy in neuropathic pain models only and its benefit

in other pain disorders is unknown. Third, long-term efficacy of

the pp?EP gene and the safety of the vector used are also

unknown.

Gene Therapy for Chronic PainMichele Matthews, PharmD

science corner

Gene therapy, an experimentaltechnique that involves theadministration of genes

instead of medication for the treat-ment of certain diseases, may be thefuture of chronic pain management.

A physician prescribed sever-

al medications for an elderly,

chronically ill patient with-

out warning the patient

about the sedating side

effects of the drugs or advis-

ing the patient not to drive

while taking the medica-

tions. Two months after the

patient’s last visit with the

physician, he apparently lost

consciousness while driving;

his car left the road and

struck and killed a pedestrian on the sidewalk. The pedestrian’s

mother sued the doctor not for medical malpractice, but for neg-

ligence. Massachusetts’ highest court ruled late last year that the

suit could proceed, reversing a lower court’s ruling that the

physician could not be sued because he owed no duty of care to

anyone other than his patient.

This decision has some troubling implications for the physician-

patient relationship. The case stands for the proposition that

physicians owe a duty of care to anyone foreseeably put at risk

by the physician’s failure to warn the patient of the side effects

of treatment. Apparently, a physician can meet this broader duty

of care to others by fulfilling his specific duty to warn the

patient of such side effects, but the broader duty imports into

the physician-patient relationship extraneous considerations

about how the warning given to the patient meets the physi-

cian’s duty to unknown third parties.

The difficulties surrounding this apparent expansion of physi-

cians’ potential liability are underscored by the fact that only

two justices concurred with the opinion written by Justice

Ireland. Three other justices dissented in whole or in part from

that opinion. The arguments articulated by the justices on both

sides of this question contain characterizations of physicians’

treatment of patients and implications for how physicians com-

municate with their patients; both are troubling, to say the least.

For instance, the court’s opinion compared the failure to warn

situation described above to such “unreasonably dangerous” sit-

uations as the improper storage of firearms resulting in the gun

owner’s son killing a police officer, or a liquor store’s sale of beer

to a minor who subsequently killed a bicyclist while driving

drunk. In these other cases, the law extends a duty of reason-

able care to all those involved in a foreseeable accident, even

when the accident is caused by the criminal or negligent con-

duct of an intermediary. In this case, the court is saying the

physician’s failure to warn the patient about the sedating effects

of the medications created an unreasonably dangerous situation

in which an automobile accident was foreseeable.

Consequently, the physician owed a duty of care to all those

harmed in such an accident, even if the accident were directly

caused not by the physician, but by the patient.

Even one of the concurring justices described this line of rea-

soning as “an immoderate and indefensible characterization of

the medical profession, and one that . . . impermissibly intrudes

on the traditional physician-patient relationship held virtually

inviolate since the time of Hippocrates.” This justice went on:

“A physician should not, in ordinary circumstances, be held

legally responsible for the safety of others on the highway, or

elsewhere, based on medical treatment afforded a patient. To a

physician, it is the patient (and not a third party with whom the

physician has no direct contact) who must always come first.”

Nevertheless, this justice reasoned that since the risk of danger

faced by the patient when the physician failed to warn him of his

medications’ adverse side effects ~ harm from an automobile

accident ~ is the same risk posed to third parties, “…there can

arise no conflict of professional interest.”

Other justices questioned whether the court’s decision necessar-

ily creates such conflicts. Chief Justice Marshall noted that the

New Interpretations in thePhysician-Patient Relationship!Peter Martin, Esquire

legal consult

Peter Martin, Esq.


scope of a physician’s duty to warn his

patient of side effects was limited to those

side effects the physician determined

were necessary and relevant for that

patient to make an informed decision,

after considering that patient’s history

and needs and the nature of the drugs

prescribed. She was concerned that the

court was now requiring physicians to

warn the patient not only of all side

effects that are relevant to that patient,

but also of all side effects and dangers that

might lead to harm to a possible future

plaintiff.

Dissenting Justice Cordy noted that prior

Massachusetts case law supported the

autonomy of the physician-patient rela-

tionship. For example, a prior decision

held that the physician, not the pharmacy,

was the appropriate person to warn the

patient about a medication’s side effects,

and that to hold otherwise would inter-

fere with the physician-patient relation-

ship. This earlier decision “confirmed a

strong policy of maintaining that relation-

ship as autonomous, free from the influ-

ence of concerns beyond the patient’s

well-being.”

Justice Cordy contended this new deci-

sion would act to undermine that “strong

policy,” noting “[a] nuanced communica-

tion between doctor and patient works

well (and is presumably highly prefer-

able) where a doctor’s concern is focused

solely on what, in his or her judgment,

the patient’s own situation requires. With

his or her attention now, necessarily, also

directed elsewhere, however, the doctor

may, understandably, become less con-

cerned about the particular requirements

of any given patient, and more concerned

with protecting himself or herself from

lawsuits by the potentially vast number of

persons who will interact with and may

fall victim to that patient’s conduct out-

side of the treatment setting. The sub-

stance and extent of the doctor’s advice

and judgment about ‘warnings’ will nec-

essarily be affected.”

As these remarks, and the non-majority

nature of the opinion, indicate, there is

considerable concern about the parame-

ters of a physician’s duty of care to non-

patients established by this recent court

decision. Subsequent decisions may fur-

ther define the limits of this expanded

duty of care. In the meantime, physicians

should be extremely cautious in advising

patients about taking medications with

side effects that may compromise the

patient’s ability to drive and in document-

ing the warnings given to such patients.


financial advice for physicians

In many ways, how you

invest is more important

than where you invest. If

you invest in more than a

handful of stocks, bonds or

mutual funds, you are bound

to have some winners and

some losers ~ and today’s

winners may be tomorrow’s

losers. Over time, if you

invest carefully, the winners

should outweigh the losers

and help you achieve your

financial goals.

How you invest, though, can either produce

long-term dividends or cost you plenty. Investors

frequently do the wrong thing. They sell the

stocks they should keep and keep the stocks they

should sell. They run up credit card debt and pay

high interest rates while they’re getting low

returns on their investments. They invest in the

market when prices are high and bail out when

prices are low.

Knowing what not to do is, for most investors,

the first step toward improving long-term invest-

ment performance. So what are some of the most

common investment mistakes?

1. Gambling instead ofinvesting.Some investors try to “time” the market, buying

stocks when they think prices are going to rise

and selling when they think prices are going to

fall. That’s a quick way to go broke. The world’s

best, most seasoned professionals cannot accu-

rately time the market with any consistency.

Neither can you.

Other investors act on hunches, half-truths and tips from their

Uncle Raymond, who heard from a friend of a friend whose

neighbor is a broker that Acme PCs is introducing new comput-

ers for pets and that’s going to open a new market and send the

company’s stock soaring.

Ask yourself, “If Uncle Raymond knows so much, why isn’t he

rich?”

2. Not diversifying sufficiently. You may recall hearing about employees of Enron losing all of

their retirement savings when the company went broke.

Financial fraud, bad business decisions, market changes, new

regulations, increased competition, lawsuits and many other

Avoiding Common Investing ErrorsCan Produce Long-Term DividendsRuth R. Petty, MSFS

Ruth R. Petty, MSFS


factors can cause a business to suffer a

reversal of fortune. If all of your money is

invested in that company’s stock, you will

suffer when the company does.

If, conversely, only a small amount of

your money is invested in a company

whose stock implodes, you will barely

notice the loss.

Investing in many different stocks is not

enough, either. At the least, your portfo-

lio should be diversified to include

stocks, bonds and cash equivalents such

as money market funds. Your stock and

bond holdings should also be diversified.

Stock investments, for example, may be

in large-cap, mid-cap and small-cap

stocks, value and growth stocks, and

domestic and international stocks.

Mutual funds provide added diversifica-

tion because the average mutual fund typ-

ically is invested in many stocks or bonds

at any given time.

3. Not owning stocks.Some people refuse to invest in stocks

because they think they are too risky. Not

investing in stocks can be much riskier,

because your portfolio will not be proper-

ly diversified. Past performance is no

guarantee of future returns, but histori-

cally stocks have provided the best long-

term returns of any investment.

4. Failing to plan. Wealth doesn’t come naturally. You have

to plan for it. Start by identifying your

financial goals. How much do you need

to save for retirement? How many chil-

dren do you have (or expect to have) and

do you expect to pay for their college

education?

In addition to identifying your financial

goals, you’ll need to determine what it

will cost to achieve them. Based on your

investments, and what you plan to save in

the future, what rate of return will you

need to achieve your goals?

glickman



Adjust your investments over time based

on your changing needs and financial sta-

tus. It is best to project conservatively.

Having more money than you need dur-

ing retirement is better than not having

enough.

5. Investing short-term. It takes time for investments to grow in

value. Investment professionals typically

advise that investors have at least a five to

seven year time frame when they invest in

stocks, based on the assumption that it

may take that long for the stock market to

run through a typical cycle during which

the market goes up and down. Building

wealth is a long-term process that

requires patience and discipline. Because

of the cost of trading, investing short-

term is also expensive.

6. Failing to invest regularly. Unless you invest a set amount regularly,

you will likely put off investing altogeth-

er. You’ll find some other use for your

money. You’ll wait until next year, then

the year after that, then the year after that.

Then you won’t have enough to live off of

when you want to retire.

Saving a set amount every week or every

month can help you achieve your finan-

cial goals and is also a smart way to

invest. Let’s say you invest $100 a month

into Up and Down Technology stock.

This month, the price is $20 a share, so

your $100 buys five shares. Next month,

the price rises to $25 a share, so your

$100 buys only four shares. Note that

you are buying more when the price is

low and less when the price is high.

This practice is called “dollar cost averag-

ing.” Dollar cost averaging requires con-

tinuous investment in securities, regard-

less of fluctuating prices. Investors

should consider their ability to continue

to make purchases through periods of

high and low price levels. Dollar cost

averaging does not ensure a profit and

does not protect against loss.

7. Failing to take advantageof tax-advantaged invest-ing. Employees today can invest more than

ever in tax-advantaged retirement plans,

such as 401(k) plans, which allow taxpay-

ers to defer paying taxes until retirement.

They can also invest in IRAs, which are

tax-deferred, or Roth IRAs, which allow

investments to grow on a tax-free basis.

Parents can also save for their children’s

college education on a tax-advantaged

basis. Contributions to Section 529

plans, for example, are made with after-

tax dollars, but any growth in investment

values is tax-free.

Tax-advantaged investment allows more

of your money to work for you because

there is no taxation until withdrawals are

made. Investors should take advantage of the opportunity to

the extent that they can.

8. Buying “hot” stocks. “Hot” stocks can be found anywhere ~ in financial newsletters

and on television, in your e-mail and in your fax machine.

However, by the time you read them, they may no longer be

“hot.” The market reacts to information. If a company is

expected to perform exceptionally well or particularly poorly, its

stock price will adjust accordingly before you hear about it.

9. Not cutting your losses. It’s good to invest long-term, but that doesn’t mean holding onto

a bad investment indefinitely. If an investment turns out to have

been ill advised, sell it and move on.

It is more difficult to recover your losses than it is to protect

your money. For example, if a stock declines in value by 50%,

it will have to double in value just for you to break even. Don’t

wait to recover your loses before selling. You may never recov-

er.

10. Failing to seek professional help. If you don’t invest for a living, you are probably not aware of

everything happening in the market that is affecting your invest-

ments. You are likely unaware of failed drug tests, recalled auto-

mobiles, class-action lawsuits, changes in money managers, and

the various other factors that can affect the value of your invest-

ments.

Letting a professional handle your investments and help you

plan your finances may save you a lot of money long-term.

Over time, investors are likely to make many mistakes, no mat-

ter how careful they are. Perhaps the worst mistake they can

make, though, is not learning from other people’s mistakes.

Ruth R. Petty, MSFS is a Senior Financial Consultant with Centinel Financial Group, LLC,John Hancock Financial Network, 16 Laurel Ave., Wellesley Hills, MA 02481 and can bereached at 781-446-5031 or [email protected].

Insurance products offered through John Hancock Life Insurance Company, Boston, MA02117.Registered Representative/Securities and Investment Advisory Services offered throughSignator Investors, Inc., Member NASD, SIPC, a Registered Investment Advisor.

The information presented is for informational purposes only. It is not intended to replacethe need for independent tax, accounting, or legal review. Individuals are advised to seekthe counsel of such licensed professionals to review their personal situation.



history of medicine

Last July, a column in theWorcester SundayTelegram with the head-line “How Worcester WonBattle for Med School”told the story in a well-written, accurate fashion.But it didn’t include thedrama of the ballotingprocess which secured thesite for the Heart of theCommonwealth.

After World War II, the rise in population (the “babyboom”) and the growth of health insurance resulted in anincreased demand for medical services. In response, theGeneral Court of Massachusetts established the Universityof Massachusetts Medical School in October 1962. Itslocation would be decided by the university’s trustees inconjunction with the dean whom the trustees selected.

The school would be a boon for the chosen area, promis-ing first hundreds of construction jobs then thousands ofstaff jobs once the bricks-and-mortarphase was over, as well as homes foraffluent doctors and other professionalpersonnel. Proposed candidates for thesite included Cape Cod, Boston, theNorth Shore, Worcester, Springfield,Amherst (where the UMass campuswas), and it seems the home of everypolitician in the state.The decision came down to Boston, aBoston suburb, Worcester, Springfield,and Amherst. Voting for the site tookplace on Friday, June 11, 1965. A major-

ity of the 22 votes was required for the selection; in theabsence of a majority, the last-place finisher would beeliminated and another vote taken. Springfield, Boston,and the Boston suburb were eliminated on the first threevotes, the last two places probably because of the tacit dis-approval of the three established medical schools in theBoston area that didn’t see the need for another “col-league” (the academic word for “competitor”). This leftWorcester and Amherst. On the fourth round the vote dra-matically split at eleven apiece. A fifth vote would be nec-essary.

One of the two trustees from Worcester, General Maginnis,was later quoted as saying the following:

“There was this fellow on the board I didn’t know. Wechatted before the final vote. I said to him, ‘You’re going tovote for Amherst, of course.’ And he said, ’I hate like hellto vote for it.’ Then he described his displeasure with theuniversity over some personal matter. So I took him asideand said, ‘Now’s your chance to get even!’ On the fifth bal-lot the result was Worcester 12 and Amherst 10. It was assimple as that.”

A Medical School for WorcesterJohn Massarelli, MD

John Massarelli, MD

off call - part one

The Irish first came to Worcester in 1826

to build the Blackstone Canal. Many were

skilled laborers who had worked on the

Erie Canal in New York. They were called

“wide backs” for the obvious reason that

they moved 2.5 yards of earth per hour

for 10 to 12 hours a day with shovel and

pick. An Irishman named Tobias Boland

supervised the construction of the 46.5

mile canal, which started at Thomas

Street in Worcester and ended in

Providence and later was called the

“Seaport of Narragansett Bay.”

While working on the canal, these men

set up camp on the east side of Worcester

in the Shrewsbury Street section and

called it “The Meadows” or “Pine

Meadows.” The locals called it “Shanty

Town.” The Irish workers were not

allowed in Worcester without a pass.

They could not even bury their dead in

Worcester and had to take them by barge

to Rhode Island. When the canal was

completed, many of these laborers stayed

in Worcester. By late 1830s, 500-600 Irish

canalers had established a small commu-

nity in Worcester’s east side.

Three additional Irish settlement areas

followed. The next settlement, called

“Scalpintown,” was created in the 1840s

on the east side of the canal. Here, Christ

Church, the first Catholic church, was

built in 1834, replaced in 1846 by St.

John’s Church on Temple Street. East

Worcester was an extension of

Scalpintown and was located downtown

near the railroad yards. The Island ~ or

“Green Island” ~ ran along Millbury and

Harding Streets. It was called The Island

because the canal intersected several

small streams and separated the area from

the rest of the city. Two new neighbor-

hoods emerged in the mid 1800s ~ the

North End, obviously on the north side of

the city, was also called Messenger Hill or

Fairmont Hill, and the South End, where

my father’s family came from, was an

extension of The Island along Cambridge

Street.

Churches were important social as well as

religious centers for the Irish in

Worcester. Each Irish district was served

by a Catholic church: Immaculate

Conception - North End, St. Anne’s - East

Side, St. John’s - The Island, and Sacred

Heart - South Worcester. Father John

Power established a small hospital at St.

Anne’s parish in the 1860s because the

impoverished sick members of his parish

had nowhere else to go. Monsignor

Thomas Griffin, an immigrant from

County Cork and pastor at St. John’s

church, was instrumental in the founding

of St. Vincent’s Hospital in the 1890s. Two

thirds of the trustees were Irish and the

Sisters of Providence provided most of

the nursing staff. St. Vincent’s was known

for treating all ethnic and religious back-

grounds the same.

The second wave of Irish came to

Worcester because of an Gorta Mor ~

“The Great Hunger.” The famine in

Ireland is estimated to have caused 1 mil-

lion deaths due to malnutrition and dis-

ease. It also caused over a million people

to immigrate to the United States. By

1870, there were 8,589 Irish in the city,

one fifth of Worcester’s 41,000 people.

The Irish in WorcesterMartin A. Lynch


1936 St. Vincents School of Nursing graduating class


These Irish immigrants, coming from an

agrarian society, were not skilled like the

first wave nor accustomed to working in

industry. Worcester had become primarily

a center for the heavy industries of wire,

iron and machinery. By 1890, Worcester

was the thirteenth largest manufacturing

city in America and many of the Irish

worked in those factories that would in

fact accept Irish workers.

Patriotism was shown by the Irish in the

Civil War as well as in wars to follow. Two

Worcester Irish received the

Congressional Medal of Honor during the

Civil War. Sergeant William Plunkett ~

who lost both arms saving the colors at

Fredericksburg ~ and Captain Thomas

O’Neill, for his service at Cold Harbor.

During World War II, two more

Worcester Irish received the Medal of

Honor: John V. Powers, a Holy Cross

graduate and Marine whose life was lost

during fighting in the Pacific (a statue of

him was erected on the right side of City

Hall), and Father Joseph T. O’Callahan,

who taught at Holy Cross and was

acknowledged for his actions as a chap-

lain aboard the aircraft carrier U.S.S.

Franklin.

The Irish faced significant prejudice from

groups like the Know-Nothings in the

1850s and the Klu Klux Klan, who met in

Mechanics Hall in 1920s. Politics became

a way to help the Irish move forward and

by 1885 over 2,800 Irish-born males

became citizens and voters. Phillip J.

O’Connell, a second-generation Irish-

American, became the first Irish mayor in

1901 (he was later appointed a judge in

1915).

By the turn of the century, many Irish

attended the College of the Holy Cross.

Francis J. McGrath, City Manager in

1951, graduated from Holy Cross and

went on to guide the city for many years.

Phillip K. Kenny “The Cobra” O’Donnell

received the Distinguished Service Cross

and became Robert Kennedy’s best friend.

He would later become Chief of Staff for

Presidents John F. Kennedy and Lyndon

Johnson. He also worked with Robert

Kennedy until the Senator’s death. The

movie Thirteen Days was based on

Worcester’s own Kenneth O’Donnell.

Irish women in Worcester made great

strides in entering the professional ranks

and by 1910 over half of the teachers in

the Worcester Public Schools were sec-

ond-generation Irish women. One of

these women, Mary O’Callaghan, after

teaching for ten years in Worcester, went

on to medical school and became one of

the most respected physicians in the city.

This tradition is carried on today by the

likes of Mary Hawthorne, an Irish-

American physician.

References:Shannon, William V. The American Irish A political andSocial Portrait 1963 The Macmillan CompanyWay, Peter Common Labor Workers and the Digging ofNorth American Canals 1780-1860 1993 CambridgeUniversity Press

O’Donnell, Helen A Common Good: The Friendship ofRobert F. Kennedy and Kenneth P. O’Donnell 1998 WilliamMorrow and Company Inc.

Miller, Kerby A. Emigrants and Exiles Ireland and the IrishExodus to North America 1985 Oxford University PressWoodham-Smith, Cecil The Great Hunger Ireland 1845-1849 1962 Old Town Books

Meagher, Timothy J. Inventing Irish America Generation,Class, and Ethnic Identity in a New England City, 1880-1928 2001 University of Notre dame Press

Southwick, Albert B. More Once told Tales of WorcesterCounty 1994 DataBooks

Rooney, Thomas L. Tobey Boland and the Blackstone Canal2005 Ambassador Books

McGratty John J. The Life of Very Reverent John J. Power,D.D.,V. G. “Father John” Pastor of St. Paul’s ChurchWorcester Press of T. J. Hurley Front St. 1902

Martin A. Lynch is a CMR Senior Therapeutic Consultantwith Pfizer, Inc. He can be reached [email protected].


James M. Morrison, MD 1915-2007

With the exception of time away from Worcester to study medicine and servicein the military, Dr. James M. Morrison was a lifelong resident of the city of hisbirth. A member of the Medical Staffs of St. Vincent and Fairlawn Hospitals, hepracticed primary care Internal Medicine for 52 years, retiring in 2001. He exem-plified the type of physician everyone proclaims we need more of, but presentlytoo few elect to become. He loved Worcester, and Worcester loved him.

He was educated at St. John’s High School and the College of the Holy Crossbefore entering St. Louis University School of Medicine. Early in his career, beforethe specialty of addictionology existed, he extended himself to patients sufferingfrom alcoholism and advocated for the creation of an inpatient treatment facilityat St. Vincent Hospital. It became a haven for the treatment of acute withdrawaland guidance for recovery. Dr. Morrison was a Charter Member of the AmericanMedical Society of Alcoholism and Drug Addiction and served as Chairman of theState Committee on Alcoholism and Addiction. His compassion and empathy forafflicted individuals led him to serve on the Massachusetts Medical Society’sImpaired Physicians’ Committee, the forerunner of the Physicians’ HealthService, now recognized as a national model. In 1954, he co-founded the St.Vincent Hospital Alcoholic Clinic and founded Faith House, a half-way house forwomen addicted to alcohol and drugs.

Midway in his career, Dr. Morrison moved his office into his home across thestreet from Worcester State College. The plantings and grooming of the grounds~ designed and maintained by his late wife Dorcas, a talented landscape andflower designer ~ complimented the neighborhood. For many years, Dr. Morrisonserved as the Director of Health Services at Worcester State College, and theschool demonstrated its appreciation by presenting him with the Good SamaritanAward and the Alumni Association honored him at the Annual Scholarship Tea in2005.

Dr. Morrison was an excellent athlete. He was a four-sport letterman at St. John’sHigh School and was inducted in the school’s Hall of Fame. In 1990, he receivedthe Distinguished Alumnus Award from St. John’s. He played golf in college andthroughout his adult life. Characteristically Jim would boast about others but wasalways very modest about himself and his athletic prowess. His interest in sportsfound its way to the professional boxing arena, where he served on behalf of theMassachusetts Boxing Commission over-seeing pugilist safety.

Jim Morrison was an active member of the Worcester District Medical Society andunofficially is thought to be one of its most loyal meeting attendees. Jim was quietbut always very attentive and most fair and kind when offering opinions. He wasa member of the American Medical Association and the Massachusetts MedicalSociety. In 1997, he received the Volunteer Physician of the Year award from theMMS. If the world were comprised of people like Jim Morrison, the entireDefense Budget could be directed to medical research and humanitarian relief.

Five children, four grandchildren, two great grandchildren, and a most gratefulgreater Worcester community survives Dr. James Morrison.

Leonard Morse

Dr. Norio Higano 1927 – 2007

Dr. Norio Higano died June 16, 2007, at his home inWestborough. He was 86 years old. He was my teacher,colleague, and friend for over 40 years. He was born inSeattle, Washington, and graduated from the University ofWashington in 1943 magna cum laude. He received hisM.D. degree from the St. Louis University School ofMedicine in 1945. He was very fortunate to have escapedthe craze of being sent into one of the detention camps cre-ated for Japanese Americans during World War II. Heexcelled academically and was elected to both Phi BetaKappa and Alpha Omega Alpha honor societies.

Following a straight medical internship at MaimonidesHospital in Brooklyn, NY, he moved to Boston (Cambridge)for his medical residency at Mount Auburn Hospital. Hethen completed a research fellowship at Harvard University.In 1952, he came to Memorial Hospital as the Director ofthe Hospital Research Laboratory. He was a born teacher,full of knowledge that he loved to share with the housestaffand his peers. His fastidiousness was exemplified by hismeticulous physical examinations. He surprised youngresidents with the correct diagnosis derived from historyand physical examination much before the laboratoryresults returned with the answer. His enthusiasm to mas-ter clinical problems stimulated many house officers tobecome endocrinologists.

I remember with pleasure the house officer parties that heand his wife Dorothy put on for the interns and residents.It is hard to believe that the “little people” present at theparty (daughters Celestia and Priscilla and son Stuart) havegrown and become substantial adults with children.

Norio loved to drive fast and there are a goodly number ofresidents who can attest to that fact because he took manyof us to the Atlantic City “young turks meetings.” He wasproud to own a German car ~ a Hansa ~ that, unfortunate-ly, turned out to be a dud.

Norio introduced the nuclear medicine era to the MemorialHospital by way of applying radioactive iodine in the diag-nosis and management of thyroid disorders.

As the years passed, we covered for one another. We alllearned from him about how to address certain clinicalproblems, but most of all he strengthened our belief thatpatients always come first.

Guenter L. Spanknebel, MD

in memoriam

WDMS Remembers its Colleagues


society snippets

The Guenter L. Spanknebel,MD Medical Education Grant

The Worcester District Medical Society was pre-sented with a $10,000 Medical Education Grantfrom The Health Foundation of CentralMassachusetts in honor of Guenter L.Spanknebel, MD, upon his retirement from serv-ice as a founding Director of the Foundation.

Dr. Spanknebel served on the board since theFoundation's inception in 1999 and with otherretiring directors oversaw the Foundation's assetsof about $65 million and awarded grants to agen-cies and projects dedicated to improving thehealth of Central Massachusetts residents, espe-cially those considered particularly vulnerable.

WDMS 2008Annual Business Meeting

Wednesday, April 9th, 5:30pm

at the Beechwood HotelWorcester, Ma

BETTERSpeaker: Dale Magee, MD, President,

Massachusetts Medical Society

This activity meets the criteria of the Massachusetts Board ofRegistration in Medicine for risk management study.

For more information or to register contact Joyce Cariglia, 508-753-1579, [email protected]

Sahdev R. Passey, MD, 2008 Worcester District Medical Society,

Massachusetts Medical Society Clinician ofthe Year Award recipient

left to right - Joyce Cariglia, WDMS Executive Director, Guenter L. Spankenbel, MD,honoree, and Bruce Karlin, MD, President

Dale Magee, MD, President,Massachusetts Medical Society

pain managementmar./apr. 2008 worcester medicine| 3on the cover: pain management substance abuse...

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