Volume 90 No. 9 September 2007

Medical Education

UNDER THE JOINT VOLUME 90 NO. 9 September 2007 EDITORIAL SPONSORSHIP OF: Medicine
Health The Warren Alpert Medical School of Brown University HODE SLAND Eli Y. Adashi, MD, Dean of Medicine R I & Biological Science PUBLICATION OF THE RHODE ISLAND MEDICAL SOCIETY Rhode Island Department of Health David R. Gifford, MD, MPH, Director COMMENTARIES Quality Partners of Rhode Island Richard W. Besdine, MD, Chief 262 Graybeards, Or Grayheads Medical Officer Joseph H. Friedman, MD Rhode Island Medical Society Barry W. Wall, MD, President 263 Drink To Me Only With Thine Eyes Stanley M. Aronson, MD EDITORIAL STAFF Joseph H. Friedman, MD Editor-in-Chief CONTRIBUTIONS Joan M. Retsinas, PhD Managing Editor SPECIAL ISSUE: Medical Education Stanley M. Aronson, MD, MPH Guest Editor: Philip A. Gruppuso, MD Editor Emeritus 264 Growing Into Our Vision For an Academic Health Center In Rhode EDITORIAL BOARD Stanley M. Aronson, MD, MPH Island: The Impetus of the Warren Alpert Foundation Gift Jay S. Buechner, PhD Eli Y. Adashi, MD John J. Cronan, MD James P. Crowley, MD 266 The Warren Alpert Medical School of Brown University: Class of 2007 Edward R. Feller, MD Philip A. Gruppuso, MD, Joanne MacConnell, and Janice Viticonte John P. Fulton, PhD Peter A. Hollmann, MD 272 Redesigning the Medical Science Curriculum at the Warren Alpert Sharon L. Marable, MD, MPH Medical School of Brown University Anthony E. Mega, MD Sonia Garg, Philip A. Gruppuso, MD, Luba Dumenco, MD Marguerite A. Neill, MD Frank J. Schaberg, Jr., MD 275 Educating the Next Generation of Leaders In Medicine: The Scholarly Lawrence W. Vernaglia, JD, MPH Concentrations Program at the Warren Alpert Medical School of Newell E. Warde, PhD Brown University OFFICERS Emily Rickards, MA, Jeffrey Borkan, MD, PhD, Philip A. Gruppuso, MD Barry W. Wall, MD President 283 Reducing the Public Health Burden of Low Vision In the Rhode Island K. Nicholas Tsiongas, MD, MPH Elderly President-Elect Christina S. Moon, Angela Turalba, MD, Kent L. Anderson, MD, PhD, Diane R. Siedlecki, MD Edward Feller, MD Vice President Margaret A. Sun, MD Secretary COLUMNS Mark S. Ridlen, MD Treasurer 287 IMAGES IN MEDICINE – Granulomatous Myositis in Association with Kathleen Fitzgerald, MD Chronic Graft vs. Host Disease Immediate Past President Robert Bagdasaryan, MD, and John E. Donahue, MD DISTRICT & COUNTY PRESIDENTS Geoffrey R. Hamilton, MD 289 HEALTH BY NUMBERS – Resident and Family Satisfaction with Nursing Bristol County Medical Society Home Care in Rhode Island: Differing Views of Performance Herbert J. Brennan, DO Margaret S. Richards, PhD, and Gwen C. Uman, RN, PhD Kent County Medical Society Rafael E. Padilla, MD 291 GERIATRICS FOR THE PRACTICING PHYSICIAN – Chronic Dizziness In Older Pawtucket Medical Association Persons Patrick J. Sweeney, MD, MPH, PhD Aman Nanda, MD, CMD Providence Medical Association Nitin S. Damle, MD 294 PHYSICIAN’S LEXICON – The Words of Fear Washington County Medical Society Jacques L. Bonnet-Eymard, MD Stanley M. Aronson, MD Woonsocket District Medical Society 294 Vital Statistics Cover: Photograph, “150 South 296 September Heritage Main Street” [as written in big let- ters above the entrance to the head- Medicine and Health/Rhode Island (USPS 464-820), a monthly publication, is owned and published by the Rhode Island Medical Society, 235 quarters of the RI Attorney Gen- Promenade St., Suite 500, Providence, RI 02908, Phone: (401) 331-3207. Single copies $5.00, individual subscriptions $50.00 per year, and $100 per year for institutional subscriptions. Published articles represent opinions of the authors and do not necessarily reflect the official policy of the Rhode Island eral] by Howard Schulman, MD, Medical Society, unless clearly specified. Advertisements do not imply sponsorship or endorsement by the Rhode Island Medical Society. Periodicals postage for his photography website, paid at Providence, Rhode Island. ISSN 1086-5462. POSTMASTER: Send address changes to Medicine and Health/Rhode Island, 235 Promenade St., Suite 500, Providence, RI 02908. Classified Information: RI Medical Journal Marketing Department, P.O. Box 91055, Johnston, RI 02919, www.MyRhodeIsland.org phone: (401) 383-4711, fax: (401) 383-4477, e-mail: [email protected]. Production/Layout Design: John Teehan, e-mail: [email protected]. 261 VOLUME 90 NO. 9 SEPTEMBER 2007 ment, that the two women were actually Commentaries younger than herself. I am unsure what conclusions she drew from this, but she did report her shock. There are several issues to consider. One is society’s devaluing of older women. Graybeards, Or Grayheads Another is the lag time it takes language to  catch up with changing mores. In some cases language precedes social change, It was not long ago that age was supposed ing glasses, is what has always connoted the which typically occurs when new words to bring wisdom rather than dementia, “wisdom” of age. Our old TV doctor he- enter the vocabulary. It takes longer to constipation and incontinence. Patients roes had white hair but few wrinkles. Our eliminate old, outdated words, and some- often sought second opinions from the doctor heroines have neither. times these don’t fall completely out of us- “graybeards,” the doctors with experi- What a comment on the society we age. In medicine we had “simian stoop” for ence, reflected, presumably, by the white- live in that where men get wiser with age, the flexed posture of Parkinson’s disease; ness of their hair and beards. Having which is a good thing, women simply get “reptilian stare” for the reduced blink rate achieved a partially white beard (Many old, which is a bad thing. Why are older and masked facial expression; the term years ago my daughter remarked, “Oh, women demeaned? Why is it that older “idiot” used initially to describe epileptics, daddy, that isn’t sugar in your beard, it’s men marry “trophy wives,” younger or the amentias of infancy, and later to de- white hair!”), and a largely white rim women; but older women don’t mirror note severe retardation. On the other hand, around a bare scalp, I now have a that behavior? How many older women we use the term “wise men” synonymously graybeard. In fact, one patient com- are on TV or in movies? How many older with “brain trust” or highly competent ad- mented on it. “My doctor referred me to women are seen as advisors in the public visors. Presumably as wise women join wise you for a second opinion because he said domain? And even these role models dye men in forming advisory panels the term you were a ‘graybeard.’ I see now that their hair. It seems impermissible for “wise men” will drop in its use. I think that you really do have a gray beard.” women to let their hair turn gray. the term “graybeard” has already lost its pa- Until recently there couldn’t be any The elimination of white hair in older nache and is little used, but it has not been female counterparts since few women were women has occurred with a blinding speed. replaced. It strikes me as a catchy phrase, allowed into medical schools. Now that Certainly many women have been dying based, as it is, in an older, more refined time, there are middle-aged women doctors, their hair for many years, but the develop- but it is clear that it is also based in a more and soon-to-be aged women doctors, there ment of “easy” to use dyes which are of near- discriminatory (in a pejorative sense) time. should be female wizened counterparts! professional quality, and the increasing use The main problem, as I see it, now Obviously there can’t be women of plastic surgery, has made the use of dyes that my hair is gray, is that aging confers “graybeards,” but there could be a virtual requirement for middle-aged, older different images when we describe men “grayheads” or something more catchy. and prematurely gray younger women. Re- and women. Women use “corrective” These days though, women no longer have cently a 60 year-old woman I know men- measures to erase the perceived negative white hair. It is experience and wisdom tioned that she saw two women with gray effects of age. They do not get the “boost” that distinguishes the graybeard from hair from a distance and wondered how that age presumably provides in the way “that old fool,” but the white hair, not the old they were. She slowly walked by their of perceived experience and judgment. wrinkled skin or the dependence on read- table, and concluded, with some amaze- It is surprising then that men are increasingly turning to measures to en- hance their youthful appearance as well, perhaps reflecting an increasing tendency to identify advancing age with weakness and incompetence.

– JOSEPH H. FRIEDMAN, MD

Disclosure of Financial Interests Joseph Friedman, MD, Consultant: Acarta Pharmacy, Ovation, Transoral; Grant Research Support: Cephalon, Teva, Novartis, Boehringer-Ingelheim, Sepracor, Glaxo; Speaker’s Bureau: Astra Zeneca, Teva,Novartis, Boehringer-Ingelheim, Glaxo Acadia; Boehringer-Ingelheim, Sepracor, Glaxo Smith Kline

262 MEDICINE & HEALTH/RHODE ISLAND Drink To Me Only With Thine Eyes

The early years of the 20th Century witnessed a surge of immigration development. They have problems with walking, deafness, poor to these shores. Many acclaimed this population growth as an coordination, sensory losses and frequent seizures. These neu- enrichment of the nation’s legendary heterogeneity; but others rological deficits are often accompanied by abnormalities of viewed it with horror, believing that these huddled masses were the heart and other organs, but the overwhelming damage is corrupting the native population with unwanted taints of within the nervous system. feeblemindedness while diverging from the ethnicity of the As these affected children age, their problems in adapting Founding Fathers. One eminent psychologist, H. H. Goddard, to society seem to increase. These newer problems include poor believed that feeblemindedness was solely a heredity quality memory retention, insuperable learning difficulties, impover- and he therefore advocated rigorous screening of immigrants ished problem-solving capabilities and impulsive and antiso- to prevent morons from entering the country. For those men- cial behavior. tally challenged already here, he recommended institutional- How much alcohol is needed to cause the fetal alcohol ization to prevent them from further breeding [since they “ . . syndrome? This threshold has not been determined since each would produce more feeble-minded children with which to woman processes the intake of alcohol differently; therefore it clog the wheels of human progress.”]. is recommended that pregnant women avoid any contact with To strengthen his case that mental defectiveness is virtu- beer, wine or liquor. Alcohol easily passes through the placen- ally always inherited, Goddard, a fervent eugenicist, traced an tal barrier, and the fetus has fewer metabolic means by which American family [which he renamed the Kallikaks] descend- to eliminate alcohol. Accordingly, alcohol lingers longer in the ing from a “feebleminded tavern wench” in the late 18th Cen- fetal body. tury. Many of her descendants were living in utter poverty in How common is this tragic syndrome? Epidemiologists now the Pine Barrens of New Jersey. He determined feeble- believe that it arises in about two newborns per 1,000 births, mindedness solely by visual inspection of the children. [“Three but that it is more frequent in the offspring of African-Ameri- children, scantily clad and with shoes that would barely hold can and Native-American parents, probably caused by a selec- together, stood about with drooping jaws and the unmistak- tive genetic fetal vulnerability to alcohol. able look of the feeble-minded.”] And he used these people, The relationship between maternal alcohol consumption beset by poverty and alcoholism, as proof of the hereditary and irreversible damage to the fetal nervous system has been nature of mental incompetence. amply verified in tests performed on experimental animals. The Decades later, a number of medical scientists reviewed the syndrome has also been observed before 1973 in isolated re- photographs of the Kallikak children and were impressed with ports. And even in classical documents from ancient Greece, their resemblance to a heretofore unrecognized perinatal syn- the advice was offered that husbands should avoid wines lest it drome described in 1873 by Kenneth Jones and David Smith will lead to the birth of a female child, an event considered to from the University of Washington. They called their newly be unfortunate. assembled group of signs and symptoms the “Fetal Alcohol The Bible first mentions wine in the story of Noah. While Syndrome.” the fruit of the vine is unabashedly celebrated, the Scriptures This new syndrome is characterized by the following clini- are not unaware of the dangers of alcoholic beverages. Gen- cal elements: stunted fetal growth, low birth weight, failure to esis, for example, is not shy in describing the effects of excessive thrive, characteristic facial stigmata, serious brain damage as- wine consumption by Noah. And Proverbs [20:1] declares: sociated with disorganization of neural architecture, and en- “Wine is a mocker, strong drink is raging; and whosoever is during mental, physical and behavioral abnormalities. This deceived thereby is not wise.” Indeed, Proverbs advocates that syndrome is a consequence of women drinking alcohol during strong drink be reserved solely for those about to die or those their pregnancy. Exposure of the fetus to alcohol is now re- with heavy hearts [31:6]. garded as the leading cause of mental retardation in the West- But does the Bible speak to the newly described fetal alco- ern world. In the words of one government brochure: “When hol syndrome? Perhaps yes. In the Book of Judges [13: 1-24] a pregnant woman drinks alcohol, so does her unborn baby.” we learn that the wife of a man named Mahoah was barren. The visual characteristics of these afflicted infants include An angel of the Lord appeared and spoke to the wife: “Now the following: the head is smaller in diameter than normal; the therefore beware, I pray thee, and drink not wine or strong width of the eyelids is marked reduced; the cheek bones are drink, and eat not any unclean thing.” And further, promised flattened, the groove between the nose and the upper lip is the angel, “Thou shalt conceive.” And later, “The woman bare smoothed or obliterated; and the upper lip is markedly thinned. a son, and called his name Samson. And the child grew and These children present dramatic retardation in growth and the Lord blessed him.”

– STANLEY M. ARONSON, MD

Add: Disclosure of Financial Interests Stanley M. Aronson, MD, has no financial interests to disclose. 263 VOLUME 90 NO. 9 SEPTEMBER 2007 Growing Into Our Vision For an Academic Health Center in Rhode Island: The Impetus of the Warren Alpert Foundation Gift Eli Y. Adashi, MD

You will become…as great as your Warren Alpert Foundation brought many and teaching. Our unified faculty teaches dominant aspiration. of our most critical goals into closer reach. students on all levels, in the undergradu- – William James This influx of support, which will be ate College and the Medical School, as awarded incrementally over the next sev- well as in other graduate programs, so skill Three years ago, the Division of Biol- eral years, has already increased the momen- and devotion to teaching are essential in ogy and Medicine at Brown committed tum of our efforts, and dramatically so. those we hire. We are very pleased with its energies and resources to a comprehen- our success to date in attracting new fac- sive plan for growth designed to strengthen A NEW NAME, A NEW HOME ulty members who bring the requisite medical education, expand our programs A change of designation to The mix of commitment to teaching and ac- in biology and public health, and revital- Warren Alpert Medical School of Brown complishment in research. ize our crucial relationships with our teach- University was made to permanently ac- As we expand faculty numbers and ing hospital partners, all by 2010. knowledge the magnitude of Mr. Alpert’s provide increasingly effective faculty sup- The overarching purpose of this in- gift and its anticipated impact on the fu- port, we keep our commitment to diver- vestment was for the University and the ture strength and stature of our program. sity in sharp focus. We remain commit- Medical School to play a more effective A new Medical School logo was intro- ted to gender equity and to promoting the role than ever in the education of scien- duced this summer to reflect the new academic advancement of our women fac- tists and physicians of outstanding abil- name, to perpetuate the proud history, ulty to the highest senior ranks and lead- ity and potential, to augment focus and and to represent the certain potential of ership positions. Our Office of Women depth in the local research environment, academic medicine at Brown. in Medicine helps advance the mission of and to contribute increasingly to the na- The most visible result of the gift of fostering the academic progress of women ture and quality of clinical practice lo- the Warren Alpert Foundation will be a faculty, residents, fellows and students cally and globally. A natural corollary of new home and campus for the Medical through education, advocacy, mentoring this vision was the goal of propelling the School, for the first time providing a uni- and networking. In the course of the past Medical School into the top twenty-fifth fying center around which our hospital- year, we collaborated with our colleagues percentile of the nation’s institutions of based initiatives can revolve. The build- at Women & Infants Hospital to present academic medicine. ing will physically represent the Warren a highly regarded professional develop- By the end of 2006, we could claim Alpert Medical School in the eyes of the ment series and conference addressing considerable progress toward realizing community. In the new building’s class- such themes as leadership and institutional the ambitious goals of the comprehen- rooms and laboratory facilities, which will transformation. In the coming year, we sive plan. We had been steadily expand- include an anatomy lab and perhaps a plan to launch the Dean’s Award for the ing our biomedical faculty, had begun simulation center, forward-looking tech- Advancement of Women Faculty to rec- increasing the size of our medical school nologies will support innovative ap- ognize a leader within the Medical School classes, had secured a new home for our proaches to teaching. The building will who has demonstrated a commitment to burgeoning Program in Public Health, bring administrative offices together with the recruitment, retention and advance- had inaugurated new research and teach- a variety of purposefully designed in- ment of women faculty. ing facilities in Sidney Frank Hall for Life structional spaces under one roof to bet- We also remain committed to racial Sciences on our campus and opened the ter meet the needs and consolidate the and ethnic diversity among our students. Laboratories for Molecular Medicine in focus of the Medical School community, The Program in Liberal Medical Edu- the Jewelry District; we were seeing an from first-years to residents, fellows, and cation (PLME), our 8-year combined acceleration in the development of faculty. undergraduate/medical education pro- multidisciplinary collaborations both on gram, has had exceptional success in our campus and beyond it, and we had GROWTH IN FACULTY AND STUDENT bringing a diverse population of students begun restructuring our agreements with BODY to the medical school. While striving to our hospital partners to support closer The Alpert gift is accelerating our continue the success of the PLME in this and more fruitful relationships in re- efforts to recruit and retain outstanding area, we are committed to augmenting search, teaching, and clinical care. faculty members, both directly, by mak- the diversity of our student body as we As 2007 began, our efforts were cata- ing more positions and better research pursue the standard admissions route as lyzed by an extraordinary act of philan- support available, and indirectly, by en- a primary means of attracting students thropy. A gift of $100 million from the hancing the environment for research to the Warren Alpert Medical School. 264 MEDICINE & HEALTH/RHODE ISLAND In the next three years, our medical policy issues, with its appeal to students The Alpert gift is, without doubt, a student body is slated to increase by one increasingly interested in social change, tremendous catalyst. Together with our third. Today, several years after the inau- and with its competitiveness in the arena traditional funding sources, including the guration of a need-blind admission policy, of research funding—has been growing gifts of alumni and friends, and growing 75% of our medical students receive fi- rapidly. It is so robust, in fact, that we external funding for our increasingly fo- nancial aid. As class sizes increase, and we are making plans to establish an accred- cused research programs, this extraordi- seek to engage the most talented students ited Brown school of public health. nary gift can position our Medical among our applicants, we anticipate wel- The sequencing of the human ge- School, and the medical community that coming still greater numbers students with nome has swept computational molecu- gives it context and continuity, for un- financial need. The Alpert gift has already lar biology, genomics and proteomics into precedented achievement in the years begun to increase the number of scholar- prominence. At Brown, we have made and decades ahead. ships we can make available. significant investments in building exper- We are well on our way. This spring, tise in these areas and in providing facili- our Medical School’s research ranking in INNOVATION IN TEACHING ties to support investigation into the mo- U.S. News and World Report rose nine Curricular change is another area in lecular basis of disease. Faculty, graduate points, to place us at 34th in the nation, which the pace of the work we had begun students and postdoctoral trainees are all just two points away from breaking into is increasing thanks to Alpert Foundation partners in this enterprise. The Division’s the top 25%. I have every confidence support. Brown has prided itself for de- unique meld of basic science and medi- that all the important indicators will bear cades on placing responsibility for planning cine facilitates innovative and out our progress as we move forward. their undergraduate programs directly into multidisciplinary approaches and collabo- We have a great deal to anticipate the hands of students. Our new medical rations between basic scientists and physi- and to experience together. I consider it curriculum is putting this concept into prac- cians. We anticipate a growing presence a privilege to participate in this unique tice to a degree unprecedented in our medi- of Brown researchers in the emerging field moment of growth and promise. cal school’s history, opening the way for stu- of personalized medicine, as molecular dents to focus on their areas of interest ear- analysis enters the medical mainstream. Eli Y. Adashi, MD, is Dean of Medi- lier and more intensively than ever. cine and Biological Sciences. Among recent innovations is the HIGHER PURPOSES new scholarly concentrations program, All these changes are designed to en- CORRESPONDENCE which offers students the opportunity to courage the development of physicians Eli Y. Adashi, MD pursue intellectual interests beyond core who can function brilliantly in clinical The Warren Alpert Medical School of medical studies through independent and research settings, who are enlight- Brown University cross-disciplinary research projects of sig- ened scientists and fully-realized human Box G-A1 nificant scholarly value. Nearly a dozen beings, who are skilled in the Providence, RI 02912 concentration areas are now available to bioinformatics technologies of the our medical students, from Advocacy and present and prepared to adopt those that DISCLOSURE OF FINANCIAL Activism to Informatics, and from Con- are continually emerging, familiar with INTERESTS templative Studies to Women’s Reproduc- complementary healing traditions, fo- Eli Y. Adashi, MD, has no financial tive Health, Freedom and Rights. cused on patients and committed to ser- interests to disclose. The Doctoring Program we initiated vice, equipped to navigate the nation’s last year engages first and second-year health care system, and willing and able medical students in community practice to advocate for health care quality and with faculty mentors in clinics, emer- patient safety. gency rooms, and private offices. The This goal is a lofty one, but the War- program has made a wonderfully pro- ren Alpert Medical School is making great ductive and encouraging start, thanks efforts to put it within reach of every stu- largely to the many physician volunteers dent who trains with us. These efforts in- who have introduced our students to the clude a wave of construction of new labo- world of clinical medicine with such care- ratories and classroom buildings, burgeon- ful attention and capable guidance. ing support for research, re-designed col- laborations with our seven teaching hos- NEW DIRECTIONS pital partners, and the introduction of new A number of initiatives that have academic and research programs. The important implications for research and latter category includes a number of new practice locally and globally are flourish- centers and programs designed to coordi- ing on campus. Our Program in Public nate and advance both longstanding and Health—with its focus on crossing the emerging efforts in areas such as AIDS borders of disciplines to address crucial research, children at risk, vision research, national and international health and and recovery from trauma. 265 VOLUME 90 NO. 9 SEPTEMBER 2007 The Warren Alpert Medical School of Brown University: Class of 2007 Philip A. Gruppuso, MD, Joanne MacConnell, and Janice Viticonte On May 27, 2007, 93 men and women Shortly after the PLME was inaugu- grams decided upon a career in medi- received the Doctor of Medicine degree rated, the medical school entered into cine only after completing college. Stu- from Brown University: the 33rd class of special agreements with dents have typically been engaged in physicians graduated from that institu- postbaccalaureate premedical programs other careers for several years. The goals tion since 1975. Of the 2,577 physician at Bryn Mawr College and Columbia in establishing this new route of admis- graduates of previous classes, approxi- University. Students from these pro- sion were to maintain a rich diversity in mately 15% are currently licensed to practice medicine in Rhode Island. The purpose of this article is to introduce the graduates of the Warren Alpert Medical School Class of 2007 to the physician community in Rhode Island, as many will be your professional colleagues.

A PORTRAIT OF THE CLASS OF 2007 Of the 93 graduates, 33 were men (35%) and 60 were women (65%). The demographic characteristics and racial/ ethnic composition of the MD Class of 2007 are shown in Table 1. The propor- tion of students from Caucasian Ameri- can and Asian American backgrounds is the same as in the previous year (47% and Figure 1. Recent trends in residency matching. The percentage of students matching in 27%, respectively). Nineteen percent of combined primary care disciplines is shown for graduates of the Alpert Medical School (filled circles) and for all U.S. medical school graduates (unfilled circles). Similarly, data the graduates are members of minority for combined surgery plus surgical specialties are shown for graduates of the Alpert groups underrepresented in medicine (15 Medical School (filled squares) and for all U.S. medical school graduates (unfilled squares). African Americans and 3 Mexican Ameri- cans) as defined by the Association of American Medical Colleges (AAMC). This number is the same as the 19% underrepresented minorities (URM) re- ported for last year’s graduates. The pro- portion of URM students among all four years of Brown medical students is 19%. Seventeen graduates are residents of Rhode Island. They came from eleven different communities in the state, with

four students from Providence. Ranking/Rating The largest proportion of students in the MD Class of 2007 continues to come from Brown’s Program in Liberal Medical Education (PLME): 50 of the graduates (54%) came through that route. Another cohort (sixteen graduates; 17%) came through the combined Brown-Dartmouth Medical Education Figure 2. An assessment of the quality of residency programs at which Alpert Medical School Program in which students spend their graduates have matched. All students at Brown and selected other institutions who matched with first two years of medical school at programs affiliated with U.S. medical schools were included in the analysis. “Ranking” refers to Dartmouth, and transfer to Brown for the place in the U.S. News 2007 rank order list. Rating refers to the scale applied to these same the final two years. medical schools (maximum of 100). Data are shown as mean + 1 standard deviation. 266 MEDICINE & HEALTH/RHODE ISLAND Table 1. Demographic Characteristics of the Alpert Medical Table 2. Specialty Choices for the Warren Alpert Medical School Classes School Class of 2007. of 2002–2007. the student body by admitting older stu- major (48%) among the class members dents). There was a marked increase in dents who had different academic and was biology (including subdisciplines pediatrics, 13 students. The increase in life experiences as well as rounding out such as biochemistry, neural sciences, and students choosing primary care disci- the total class size to compensate for the microbiology). Science majors taken to- plines was associated with a modest de- expected attrition from the PLME. Nine gether (including psychology) accounted crease in those choosing surgery and the members (10%) of the class were for 19% of all majors, while 15% of ma- surgical specialties. However, this decline postbaccalaureate students: three from jors were in the humanities and 18% in in the latter was not sufficient to explain Bryn Mawr College and six from Colum- the social sciences. Among the humani- the change in primary care. Rather, the bia University. ties majors, religious studies was the most increase was largely accounted for by a Among the remainder of the class, common choice, while sociology and eco- decrease in the number of students six students were part of the Early Iden- nomics were the most popular choices choosing to delay residency. The change tification Program (EIP): three from among those majoring in the social sci- in primary care could not be attributed Tougaloo College, and three from the ences. Nine students double-majored. to any curricular or advising/mentoring University of Rhode Island. EIP students changes in the medical school. are offered provisional admission to the WHERE THEY ARE GOING Table 2 shows the number of stu- medical school during their sophomore The career choices made by the Class dents selecting the various categories of year at their respective undergraduate of 2007 showed an unexpected but grati- residency programs. colleges. Of the remaining graduates, fying trend in that selection of primary Table 3 lists the Class of 2007 gradu- two entered medical school through the care disciplines, which had been declin- ates and their residency programs. Of MD/PhD program, and two through ing over the past four years, neared the the 93 graduates who will enter residency advanced transfer. same level achieved in 2002. (Figure 1) training next year (2 are delaying their Brown University was the most com- The proportion of students matching in residencies, 13 graduates matched with mon undergraduate college (62 gradu- the primary care areas (internal medicine, Brown-affiliated programs and will be ates). The University of Rhode Island pediatrics, med/peds, family medicine, and staying in the state. Massachusetts is the came next with five class members, fol- obstetrics/gynecology) totaled 50%,, ap- most popular state for residency, becom- lowed by Tougaloo (3 graduates) and the proximating the national figure.1 ing home for 18 graduates next year. The University of Pennsylvania (2 graduates). Internal medicine remained the second most popular state for residency The most common undergraduate most frequently selected specialty (19 stu- is tied between Rhode Island and New 267 VOLUME 90 NO. 9 SEPTEMBER 2007 Table 3. Residency positions for members of the Warren Alpert Medical School Class of 2007. (Continued on next two pages.)

268 MEDICINE & HEALTH/RHODE ISLAND 269 VOLUME 90 NO. 9 SEPTEMBER 2007 York, each with 15 graduates. affiliated with medical schools. The Pennsylvania is the third top U.S.News & World Report ranking of Top choice for residency with 7 Medical Schools offers a potential metric graduates. to assess the quality of residency matches. Table 4 lists those states Results of such an analysis (Figure 2) indi- where the graduates will be go- cate that the Warren Alpert Medical ing for their first year of resi- School graduates matched at programs dency training. Seventy-two that are comparable in quality to those of percent of the class will stay in students at a number of peer institutions, the Northeast, a 37% increase including Boston University, the Univer- from the previous class. Eight sity of Massachusetts, Dartmouth and the percent of graduates will go to University of Rochester. Yale University, the West Coast, down 15% also included for comparison, shows stu- from last year. dents matching at programs affiliated with We were interested in ana- higher ranking and higher rated medical lyzing the quality of the resi- schools. While the analysis should be in- dency programs that our stu- terpreted with great caution, it seems to dents will be entering. Such an demonstrate that our medical students are analysis is difficult to perform ranking at residency programs that are of since graduate medical educa- high quality. In a related analysis (not tion programs are not ranked. shown), we found that no significant lon- However, most of the programs gitudinal changes in the metric for the Table 4. Where graduates are going for PGY1 our students will be entering are 2004 through 2007 graduating classes. residency positions. 270 MEDICINE & HEALTH/RHODE ISLAND CONCLUSION REFERENCES Disclosure of Financial Interests The proportion of Brown medical 1. National Resident Matching Program, 2007 Match Philip A. Gruppuso, MD, Joanne graduates entering primary care residen- Data (obtained at http://www.nrmp.org/. Ac- MacConnell, and Janice Viticonte have cessed June 19, 2007.) cies showed a marked but unexplained 2. U.S. News & World Report, Top Medical Schools (at no financial interests to disclose. increase this past year. Other trends were http://www.usnews.com/usnews/edu/grad/ similar to those demonstrated by recent rankings/med/brief/mdprank_brief.php.) CORRESPONDENCE: past graduating classes. An analysis of the Philip A. Gruppuso, MD quality of the programs in which our stu- Philip A. Gruppuso, MD, is the Asso- The Warren Alpert Medical School of dents matched, one that should be inter- ciate Dean for Medical Education and Brown University preted cautiously, indicates quality con- Professor of Pediatrics. Box G-A218 sistent with a number of our peer insti- Joanne MacConnell is Executive As- Providence, RI 02912 tutions. sistant to the Associate Dean for Medical phone: (401) 863-1618 Education. e-mail: [email protected] Janice Viticonte is the Medical Stu- dent Residency Program Coordinator. All are with the Warren Alpert Medi- cal School of Brown University.

271 VOLUME 90 NO. 9 SEPTEMBER 2007 Redesigning the Medical Science Curriculum at the Warren Alpert Medical School of Brown University Sonia Garg, Philip A. Gruppuso, MD, Luba Dumenco, MD

The story of medical education at Brown THE CURRICULUM University is one of striving for innova- Prior to the 2006-2007 academic Section 1. Scientific Foundations of tion, promoting scientific discovery to year, the two-year preclinical curriculum Medicine (an amalgam of Cell improve health, and preparing physicians consisted of a traditional model of “nor- Physiology, Nutritional Science, Bio- to improve the world. In planning for mal,” taught in Year I, and “abnormal” chemistry, Introductory Immunol- the arrival of the Class of 2010, Brown (pathophysiology, pathology, and pharma- ogy and Genetics) launched a major redesign of the pre- cology) taught in a systems-based manner Section 2. Histology clerkship curriculum with the goal of in Year II. Year I was organized on a disci- Section 3. Human Anatomy achieving an integrated, contemporary pline-based, department-based model Section 4. General Pathology course of study that would be consistent (separate courses in biochemistry, anatomy, with these guiding principles. The rede- pathology, etc., with minimal integration). Throughout the semester, lectures sign process began with a review of the In the new curriculum, we sought to intro- from each of the different sections are co- existing content as well as an examina- duce fundamental concepts that underlie ordinated by topic area. For example, the tion of the curricula at other medical mechanisms of disease in an integrated fash- anatomy of the GI tract is taught in con- schools. By encouraging collaboration ion during Semester I, followed by systems- junction with GI histology and nutrition between students, faculty and adminis- based study starting in Semester II of Year science. Moreover, integrated examinations tration, we undertook the potentially con- I. This not only creates focused modules of are scheduled for 2-3 week intervals on the tentious process of redesign while taking study, but also allows students to finish their topics covered during this time period. This advantage of the great student initiative pre-clerkship coursework earlier. As a re- approach, as opposed to having separate and interest that exists here at Brown. sult, students will begin their clerkships six exams for each subject (biochemistry, pa- Curricular changes have been aimed weeks earlier and will be better positioned thology, etc.) scheduled as a block of mid- at promoting intellectual integration of to complete their core clerkships prior to terms or finals, further helps students con- the basic sciences with clinical medicine. applying to and interviewing with residency solidate what they are learning and draw At the center of the initial effort was re- programs. parallels across subject areas. The effort aligning curricular content in a logical, towards integration is ongoing and has sequential fashion, based on educational YEAR I REDESIGN required the cooperative input of course goals rather than departmental logistics. Semester I leaders, faculty, and students. Because this An important aspect of this goal was Recognizing that students enter model was well-received in Fall ‘06, we will early clinical exposure afforded to stu- medical school with varying levels of ex- maintain this general schematic with fur- dents via a newly developed two-year pre- pertise and knowledge of different fields, ther integration in Fall ’07. clerkship course called Doctoring.1 The the first semester is largely comprised of didactic sessions and community a course focused on providing a founda- Semester II mentoring components of this course tion in the basic science building blocks. Starting in the second semester, In- were specifically designed to further en- The course, Integrated Medical Sciences tegrated Medical Sciences II (IMS-II) courage students to make meaningful I (IMS-I), includes 4 sections: includes separate blocks organized by connections between the ba- sic sciences and clinical medi- cine. Finally, in addition to content integration, the planned design aimed to in- corporate flexibility that would foster individualism. Students have the opportu- nity to delve deeply into a cross-disciplinary Scholarly Concentration2 of their choice during their four years of medical school. A conceptual schematic of the intended 4-year continuum Figure 1. A schematic representation of the goal of achieving curriculum redesign in which basic medical is shown in Figure 1. science content, clinical training and scholarship are integrated across a 4-year medical curriculum. 272 MEDICINE & HEALTH/RHODE ISLAND Figure 2. Organization of the previous and redesigned medical curricula. 273 VOLUME 90 NO. 9 SEPTEMBER 2007 “system.” In the redesigned curriculum, integration and changes in the new cur- CONCLUSION each block incorporates teaching of nor- riculum. Examination scores were not With the redesign of the Warren mal physiology with the pathophysiology, significantly different than in past years. Alpert Medical School pre-clerkship pharmacology and systemic pathology for Given that the content had been signifi- curriculum still underway, and in antici- each system. Between January and cantly condensed and thoroughly reor- pation of students entering Year II of the March, students engage in the study of ganized, this was seen in a positive light. new curriculum, enthusiasm from both Brain Sciences – a combination of neu- Planning for further development of the faculty and students continues to grow. robiology, behavioral science (our former first semester curriculum was taken un- Many of the original design goals have “Brain and Behavior” course), neuropa- der consideration during two well-at- been implemented and student and fac- thology and neuropathophysiology. Af- tended retreats with first semester course ulty feedback have been positive. The ter a one-week Spring break, students leaders. curriculum is integrated across content return to study a 4 week block of Endo- areas, and the succession of content ar- crine Sciences consisting of Endocrine YEAR II REDESIGN eas is rationally designed rather than be- physiology, pathophysiology, pathology, There are several changes envisioned ing dependent on a traditional course- and pharmacology. Year I ends with a 6- for the new Year II curriculum, to begin based and discipline-based approach. week block in which microbiology and in August 2007. They can be briefly The faculty from diverse disciplines have infectious diseases are covered. During outlined: come together to create new educational this Micro/ID block, students also study structures, such as the Integrated Brain epidemiology and quantitative reasoning. 1. Year II will be shorter than in the Sciences section and the Micro/ID sec- By dedicating segments of time dur- traditional curriculum, since three tion. In addition, dedicated time in the ing the year to specific systemic topics, systems were shifted to Year I – schedule in Year II has been allotted for students are able to better focus their neuropathophysiology, endocrine Scholarly Concentration and indepen- study efforts on mastering the topics pre- (pathophysiology, pathology and dent study work. While the process to sented in class. For example, during the pharmacology), and infectious dis- date is by no means complete, the imple- Brain Sciences block, the anatomy team eases. Classes will end earlier mentation of the redesigned first-year teaches head and neck anatomy along- (March 17, 2008, as opposed to curriculum marks a significant step for- side neurobiology. Students are intro- May 3 this year). The completion ward for the medical education pro- duced to pathways and structures in class- of classes will be followed by 6- gram. room sessions which are revisited in a dif- weeks of USMLE Step 1 prepara- ferent format in the anatomy lab. This tion. Clerkship orientation will be- REFERENCES configuration encourages reinforcement gin on May 5, and Core clerkships 1. Monroe AD. Doctoring. Medicine & Health RI of material learned in different disci- will begin on May 12, 2008. 2006;89: 304-6. 2. Rickards E, Borkan J, Gruppuso PA. Educating plines, but with less unintentional and the next generation of leaders in medicine. Medi- ineffective redundancy. 2. Each system block will incorporate cine & Health RI [CURRENT ISSUE], 2007. Students from the Class of 2010 normal physiology, pathophysiol- completed Year I of this new curriculum ogy, pharmacology and pathology. Sonia Garg is a member of the Class on June 8, 2007. All measures indicate The information is presented in class of 2009. that students are overall satisfied with the lectures and then reinforced with Philip A. Gruppuso, MD, is the Asso- cases in multiple small group ses- ciate Dean for Medical Education and sions during each week. Figure 2 Professor of Pediatrics. shows an overview of the Year II Luba Dumenco is the Director for curriculum design. Pre-Clinical Curriculum. All are with the Warren Alpert Medi- 3. Students will have time devoted spe- cal School of Brown University. cifically to their Scholarly Concen- tration, if they have chosen to pur- Financial Disclosure sue one. There will be minimal Sonia Garg, Philip A. Gruppuso, scheduling of classes on Wednes- MD, and Luba Dumenco, MD, have days, which will be reserved for self- no financial interests to disclose. directed learning and work on Scholarly Concentrations. CORRESPONDENCE Luba Dumenco, MD The Warren Alpert Medical School of Brown University Box G-B2 Providence, RI 02912 phone: (401) 863-2913 e-mail: [email protected] 274 MEDICINE & HEALTH/RHODE ISLAND Educating the Next Generation of Leaders In Medicine: The Scholarly Concentrations Program at the Warren Alpert Medical School of Brown University Emily Rickards, MA, Jeffrey Borkan, MD, PhD, Philip A. Gruppuso, MD

Generations of physicians have been trained search. The program’s emphasis on self- identity while at the same time retaining in the traditional medical school model. directed learning and scholarly rigor has the institutional values of Brown Univer- This model, while comprehensive, takes the potential to contribute greatly to the sity. The decision to make the SC Pro- a one-size-fits-all approach to medical education of modern medical students gram elective rather than required was education. Current medical students are and to the creation of the next genera- based on institutional values of student at the forefront of Generation Y (also tion of leaders in medicine. This article choice and self-directed learning, and on known as Generation Why and the Mil- provides an overview of the SC Program the desire that students not perceive the lennium Generation),1 a generation that and compares it to similar programs program as an additional “hoop” to jump is technologically savvy, socially conscious across the country. through. The SC Program is ideal for and interconnected to an unprecedented students who have, or wish to develop, degree. A contemporary model of medi- PROGRAM OVERVIEW an involvement in a subject, activity or cal education must harness the passions Setting the Stage cause related to their future as physicians. of today’s medical students, and through The curriculum reform efforts at the Academic rigor is a central tenet of the its programs and initiatives help students Alpert Medical School have provided new program, and only students in good translate their interests into scholarship. fertile ground for development of the standing at the time of application will Such programs would bring a new level new SC Program. Conversations about be permitted to participate. of excellence to medical education. The students’ professional development and Scholarly Concentrations (SC) Program the need for a cross-disciplinary approach Goals at the Warren Alpert Medical School of to biomedical content were already well The goals of the Scholarly Concen- Brown University does just that. underway in academic year 2007 when tration Program are: The SC Program is an elective ini- the SC Program was launched. More • To promote scholarly excellence tiative through which students may pur- broadly, the curricular reform and other sue cross-disciplinary academic interests institutional changes occurring at the • To produce scholarly leaders in medi- that extend beyond the conventional Alpert Medical School represent an ef- cine, research, education, and advocacy curriculum. Scholarly Concentrations fort to build a distinct medical school are designed to create opportunities for professional growth, depth of knowledge Table 1. Program Timeline and academic excellence. Students who participate in a Scholarly Concentration Process undertake rigorous independent schol- Year I • Students identify an area of interest and a faculty mentor. arship in a field related to medicine, pub- • Together, students and faculty mentors develop a summer expe- rience, investigate summer funding opportunities, and outline a lic health, engineering, or a bio-medically four-year plan to complete the concentration requirements. relevant topic in the sciences, arts, or • Concentration Directors review applications for project merit and humanities. In collaboration with their determine program acceptance. concentration area mentors, students will Summer • Students engage in in-depth summer experiences (8-10 weeks). produce an academic product, such as a • This summer work provides the scaffolding upon which the four- manuscript of publication quality, a cur- year concentration, and the final scholarly product, will be built. riculum project, or an equivalent prod- Year II • Students continue their participation in the concentration through uct. Additionally, the array of concentra- the utilization of self-directed learning time (half-day of self-di- rected learning time on Wednesdays). tion areas lets students increase their skills • Students attend courses/seminars as required by the particular in the medical school’s defined compe- concentration area. tency areas, the “Nine Abilities.” Year III • Students continue their participation in the concentration through The SC Program at the Alpert Medi- the choice of electives related to their chosen concentration area. cal School aligns with Brown University’s • Students continue independent project work. core institutional values of curricular flex- Year IV • Students continue their participation in the concentration through ibility and self-directed learning. The the choice of electives related to the concentration area. program takes a broad view of “scholar- • Students complete independent project work. ship” that includes, but is not limited to, • Students present their scholarly product for evaluation in Febru- ary/March of Year IV as required by the concentration area. traditional basic science or clinical re- 275 VOLUME 90 NO. 9 SEPTEMBER 2007 Table 2. Comparable Programs

Required vs. School Program Elective Program Requirements Alpert Medical School Scholarly Elective • Cross-disciplinary exploration of Brown University Concentrations • In-depth summer experience • Longitudinal faculty-student mentorship • Presentation of scholarly product in Year IV Baylor College of Elective Tracks Elective • Presentation of scholarly product in Year IV Medicine Case Western Reserve Research Block Required • 4 month research block University School of • Research focus Medicine • Thesis Duke University School Scholarly Experience Required • 10-12 months in duration of Medicine • Research focus • Thesis Harvard Medical School Areas of Concentration N/A • Program has been proposed and is in development as part of curriculum reform Stanford University School Scholarly Concentrations Required • Cross-disciplinary exploration of Medicine • Annual Progress Report final Scholars Paper • Presentation of on-line learning portfolio UCSF School of Medicine Areas of Concentration Elective • Cross-disciplinary exploration • Required courses within each area of concentration • Presentation of scholarly product in Year IV University of Pennsylvania Scholarly Study Elective • 3 months to 1 year duration School of Medicine • Research focus • Final written report or publication • Poster presentation at Research Day University of Pittsburgh Areas of Concentration Elective • Presentation of scholarly product in Year IV School of Medicine required for all students (regardless of participation in an area of concentration) Yale University School Thesis requirement Required • Focus on original basic science or clinical of Medicine research • Thesis

• To enrich the student experience, central to the Concentrations Program. As ditional “scholarship of discovery” that en- the Alpert Medical School commu- a result, the program necessarily involves a compasses original research. “Scholarship nity, and the greater society. high level of faculty participation. Faculty of integration” refers to interdisciplinary are involved as concentration area Directors work in which connections are made Essential elements of the Scholarly and as mentors. In the Director role, faculty across research fields, and to the ground- Concentrations experience include: design and deliver curricula for individual ing of discovery in wider contexts. “Schol- concentration areas, and facilitate the evalu- arship of application” refers to the bidi- • Rigorous independent scholarship ation of student projects. In the role of medi- rectional feedback loop between theory • Cross-disciplinary study cal student mentor, faculty provide students and practice, and is particularly relevant with guidance and support throughout their to service aspects of academic life. Finally, • Mentored relationships four years of medical school. The willing- “scholarship of teaching” refers to effec- • Group seminars/courses ness of faculty to participate in this new pro- tive communication of knowledge to learn- gram has been gratifying and reflects their ers, and to the creation and sharing of • Scholarly work across Years I-IV of dedication to medical student education. knowledge about the practice of teaching. medical school The SC Program incorporates ele- • Completion of an academic product SCHOLARSHIP ments from each of these domains. First Defining Scholarship and foremost, each concentration area is The Scholarly Concentrations offer stu- The promotion of “scholarship” re- explicitly designed to cross traditional bio- dents “real world” educational experiences quires a shared understanding of the term. medical disciplines (scholarship of inte- and the opportunity to apply their biomedi- In 1990, Ernest Boyer2 expanded the defi- gration). Additionally, a student’s expe- cal knowledge in new and exciting ways. Ad- nition to include the full scope of aca- rience within a concentration area might ditionally, students benefit from the longi- demic work. He proposed three addi- include work that falls within other schol- tudinal faculty mentor relationship that is tional areas of scholarship beyond the tra- arship domains. 276 MEDICINE & HEALTH/RHODE ISLAND 277 VOLUME 90 NO. 9 SEPTEMBER 2007 278 MEDICINE & HEALTH/RHODE ISLAND 279 VOLUME 90 NO. 9 SEPTEMBER 2007 For example, a student concentrating in Medical Technol- • Creation of a bioengineering tool or biomedical software ogy and Innovation might develop a biotechnology tool that product; spans the disciplines of engineering and medicine (scholarship • Development of new clinical protocols. of integration). The student then focuses her efforts on docu- menting the uses of that tool and its effect on patient outcomes PROCESS AND TIMELINE (scholarship of application). Another student might choose a Information about the program has been made available for concentration in Medical Education, allowing him to extend potential medical school applicants on the BMS website (http:// his bench research by writing a curriculum for a preclinical course bms.brown.edu/students/curriculum/concentrations). Alpert that incorporates his research findings (scholarship of integra- Medical School applicants will also be informed about the pro- tion). During his concentration he might solicit peer review of gram during admission interviews. Once students have matricu- his lecturing and presentation skills (scholarship of teaching). lated, they will be exposed to the program and to all of the concen- tration areas during Orientation and a fall information session. Scholarly Products Formal application to the SC program is completed in the In addition to meeting general concentration require- spring of Year I (Table 1). Participants will develop a summer ments such as attending didactic sessions and discussion groups, project to be completed between Years I and II. In Year II they students must produce a final “scholarly product.” will attend didactic sessions and continue their project work. (One Although not all will be based on traditional basic science aspect of curriculum reform included a rearrangement of Year II or clinical research, these products must be characterized by clear courses. As a result, one day per week was freed up to be dedi- goals, adequate preparation, appropriate methodology, signifi- cated to self-directed learning. Second year students participat- cant results, effective presentation and reflective critique. Schol- ing in the SC Program will be able to dedicate approximately arly projects may include the following but are not limited to: half of this time to their concentration area projects.) In Years III • Development of a new curriculum component or module; and IV students will complete clinical electives related to their concentration. Additionally, each student must produce a “Schol- • Evaluation of an outreach program; arly Product” in Year IV. • Publication in a peer-reviewed journal; Fulfillment of the requirements of a concentration area is fea- sible within four years, although students may choose to extend • Medical creative writing; their studies for an additional year of research or project develop- ment. Through this process of mentoring, submission and review, students ultimately achieve recognition for scholarly excellence, and YOUR OWN the University contributes to the development of leaders in the PERSONAL OASIS bio-medical sciences. NATIONAL TRENDS AND COMPARABLE PROGRAMS AT OTHER MEDICAL SCHOOL

THE 903 RESIDENCES IN DOWNTOWN The development of programmatic tracks providing students PROVIDENCE ALLOW YOU TO ENJOY with additional academic opportunities represents a national trend THE BEST OF EVERYTHING: in medical education. A number of medical schools across the country have established similar concentrations or “Areas of Excel- Stylish Interiors lence” programs (Table 2). Some programs focus exclusively on Resort Style Swimming Pool traditional research and provide students with dedicated time to Full-Service Concierge pursue research projects.3 Perhaps the oldest such program is that State-of-the-art Gym of Yale, which has required students to complete a basic science or Gated Parking clinical research thesis since 1839. Other programs more loosely Media Room define “scholarship” and emphasize cross-disciplinary inquiry. The Close to Dining & Entertainment establishment of both required and elective programs reflects an Convenient to all Major Hospitals understanding of the importance of providing students with self- Studios: $187,900-$224,900 directed learning time to explore biomedical content beyond the SEPTEMBER INCENTIVE One Bedroom:$262,900-$305,900 traditional medical school curriculum. Ask about our: Though not the first of its kind, the Alpert Medical School’s Two Bedroom: $344,900-$462,900 Special Financing SC Program is unique in its level of student and faculty involve- for Licensed Sales office open daily 11-6 Medical Sales By: BFC ment. A comparable elective program at the University of Pitts- Professionals Call for details. burgh School of Medicine reported an enrollment of 5 students in its initial year, and an average of 22 students (approximately 15% of the class) participating in seven Areas of Concentration in subsequent years.4 In the initial year of the SC Program, 41 students of the Alpert Medical School class of 2010 (45% of the 401-831-0903 • 903 Providence Place • Providence RI • the903.com class) are participating in 10 concentration areas (Tables 3 & 4). 280 MEDICINE & HEALTH/RHODE ISLAND Table 3. Student Participation, Class of 2010

Total # Students Concentration Area Enrolled Examples of Student Projects Advocacy and Activism 4 Breaking the Silence- Cambodian Refugees and the Role of Health Advocacy as a Voice for Displaced Populations Nutrition Indicators in the Homeless Population of Providence, RI Aging 6 Integration of End-of-Life Care into the Medical School Curriculum Current Research in Cellular Senescence: The Biology of Aging Contemplative Studies 2 A Study of Consciousness: A First and Third-Person Approach Global Health 10 Women’s Health Initiatives in Rural Honduras: Analyzing Barriers to Care Utilization and Improving Interventions Highly Active Anti-Retroviral Therapy in Pregnant and Breast Feeding Women in Rural Zimbabwe Risk Factors for Mortality in Hospitalized Adults with Tuberculosis at Komfo Anokye Informatics 1 The FreeCRF Project Medical Education 3 Curriculum Development in the Doctoring and Anatomy Courses (Anatomy lab curriculum redesign) Medical Ethics 2 Comparative Medical Ethics Medical Humanities 5 Art Therapy: A Study of its Effects on Anxiety and Depression Levels among Psychiatric Inpatients Exploring Music, Communication and Pain in Medicine Medical Technology 4 Breast Cancer Screening & Diagnosis and Innovation with Optical Spectroscopy Women’s Reproductive 4 A survey-based multi-faceted study of risky behaviors of female sex workers in Health, Freedom and Rights China (Role of Migration, mental health and knowledge) Creating Prenatal Care Provider Prompts for an Electronic Medical Record

TOTAL 41* *Scholarly Concentration participation = 45% of the Class of 2010 (92 students)

The elective nature of the program en- • Medical Education municate biomedical information to pa- sures that students are motivated by the tients or through scientific writing (Con- • Medical Ethics internal factors of intellectual curiosity, centration in Medical Humanities). Stu- dedication to social issues, and a desire to • Medical Humanities dents interested in mainstream biomedi- take an active role in their own education. • Medical Technology and Innovation cal research are encouraged to think cre- Broad faculty and student interest in the atively about how to apply the timeline program indicate that the SC Program • Women’s Reproductive Health, and requirements of the Concentrations fulfills a curricular need. Freedom and Rights Program to their experience.

SCHOLARLY CONCENTRATION AREAS The identification of these areas is not FUNDING AND RESOURCES Concentration areas have been de- meant to detract from the more tradi- The Scholarly Concentrations Program veloped through the dedication of inter- tional basic or clinical research experience was undertaken with considerable resources ested faculty from across the University that some students will undoubtedly con- already in place, and more are being sought. and affiliated hospitals. The following tinue to choose. While no concentra- The Hind Endowment supports between ten concentration areas are offered in tion area specifically focuses on traditional twenty and twenty-five summer assistant- Academic Year 2007 (Table 4): research, the cross-disciplinary nature of ships each year. Tuition derived from the the concentrations lends itself to the in- Visiting International Medical Student pro- • Advocacy and Activism corporation of traditional research. A gram contributes to support for interna- • Aging student pursuing traditional research tional travel for our students. Gifts and re- might extend his or her investigation to • Contemplative Studies stricted funds are available to support pro- the application of findings to a geriatric grams in Women’s Reproductive Health, • Global Health population (Concentration in Aging). Freedom and Rights and Humanism in • Informatics Another student might become inter- Medicine. A grant from the Donald W. ested in how physician-researchers com- Reynolds Foundation to the Alpert Medi- 281 VOLUME 90 NO. 9 SEPTEMBER 2007 cal School supports multiple geriatrics-re- to the education of medical students. This REFERENCES lated curriculum innovations and summer initiative has great potential to create 1. http://en.wikipedia.org/wiki/Generation_Y stipends for students. Going forward, it is knowledge and develop future leaders, 2. Boyer EL. Scholarship Reconsidered: Priorities of the Professoriate. Princeton, MJ: The Carnegie Foun- thought that the SC Program will be ideal and we look forward to its growth and dation for the Advancement of Teaching, 1990. for future development efforts. evolution. We anticipate that the SC Pro- 3. Schor NF, Troen P, et al. The Scholarly Project gram will raise the profile of the Alpert Initiative. Acad Med 2005;80: 824-31. SUMMARY Medical School of Brown University na- 4. Kanter SL, Wimmers PF, Levine AS. In-depth learning. Acad Med 2007;82: 405-9. The establishment of the Scholarly tionally, and ultimately carve a distinctive Concentrations Program represents an place for the school among the top medi- Emily Rickards, MA, is the Manager important aspect of overall curriculum re- cal education programs in the country. of the Scholarly Concentrations Program. form, and of the institution’s commitment Jeffrey Borkan, MD, PhD, is Profes- sor and Chair, Department of Family Table 4. Concentration Areas and Directors Medicine. Concentration Area Director(s) Philip A. Gruppuso, MD, is the Asso- ciate Dean for Medical Education and Advocacy and Activism Patricia Flanagan, MD Professor of Pediatrics. Associate Professor of Pediatrics All are with the Warren Alpert Medi- Aging Lynn McNicoll, MD cal School of Brown University. Assistant Professor of Medicine Renée Shield, PhD Disclosure of Financial Insterests Director, Resource Center for Geriatrics Emily Rickards, MA, Jeffrey Borkan, Education MD, PhD, and Philip Gruppuso, MD, Contemplative Studies Harold D. Roth have no financial interests to disclose. Professor of Religious Studies and East Asian Studies CORRESPONDENCE Gary Epstein-Lubow, MD Emily Rickards, MA Instructor, Department of Psychiatry and The Warren Alpert Medical School of Human Behavior Brown University Global Health Stephen T. McGarvey, PhD, MPH Box G-B203 Professor of Community Health and Anthropology, Providence, RI 02912 Director, International Health Institute phone: (401) 863-9139 Timothy P. Flanigan, MD e-mail: [email protected] Professor of Medicine Timothy Empkie, MD, MPH Assistant Dean of Medicine (Advising) Informatics Cedric J. Priebe III, MD Chief Medical Information Officer, Care New England Reid Coleman, MD Medical Informatics Officer, Lifespan Medical Education Richard Dollase, EdD Director, Office of Curriculum Affairs Medical Ethics Jay Baruch, MD Assistant Professor of Emergency Medicine Tom Bledsoe, MD Director, Center for Biomedical Ethics Medical Humanities Michael Steinberg, PhD Professor of History Medical Technology and Gregory Crawford, PhD Innovation Dean and Professor of Engineering Eric Suuberg, PhD Professor of Engineering Women’s Reproductive Lori A. Boardman, MD, ScM, Health, Freedom and Rights Associate Professor Obstetrics and Gynecology Melissa Nothnagle, MD Assistant Professor of Family Medicine 282 MEDICINE & HEALTH/RHODE ISLAND Reducing the Public Health Burden of Low Vision in the Rhode Island Elderly Christina S. Moon, Angela Turalba, MD, Kent L. Anderson, MD, PhD, Edward Feller, MD In the US, low vision is defined as having 0.78% are estimated to be blind and light following exposure to much less than 20/40 best-corrected acuity (not 1.98% are estimated to have low vision.1 brighter light, is also markedly decreased correctable with glasses, contact lenses, or This data on visual acuity impair- in the aged eye. In one study, after mea- surgical intervention); blindness is defined ment, although based on a criteria com- suring visual acuity in ambient light, par- as having a best-corrected acuity less than monly applied in the USA, underestimates ticipants exposed to a bright light source 20/200 as measured using a standard the spectrum, prevalence, and impact of for one minute were timed to determine Snellen eye chart.1 A 2002 National Eye low vision under diverse viewing condi- how much time subjects required to re- Institute study estimates that there are 3.4 tions. In older individuals, visual acuity cover pretest visual acuity; 25% of those million individuals with low vision and measured as 20/30 under standard con- 75-79 years old required 1 minute, and blindness in the US.2 The definition of ditions can deteriorate to as low as 20/120 25% of those 85 and older required more visual impairment, which determines who in conditions of low contrast, glare, and than 2.5 minutes.7 Under the same con- can receive provided services and tax-ben- low luminance. (Figure 1) Under the ditions, a young adult would be predicted efits, varies from state to state. In Rhode same conditions, a young person with an to recover in less than 10 seconds. Im- Island (RI), visual impairment is defined acuity of 20/20 would only be expected paired glare recovery has practical impli- as an acuity better than 20/200, but not to drop to an acuity 20/30 or 20/40.6 cations, potentially rendering an older better than 20/60. More than 16,000 person functionally blind while adjust- Rhode Islanders are estimated to be visu- Standard visual ing to indoor lighting after being out- ally impaired or blind.2 Health profes- doors on a bright day or entering a dim sionals must be aware that visual acuity as acuity testing is an tunnel while driving in the daylight. determined by the Snellen chart does not incomplete Older individuals who have good acuity encompass the range of visual limitations by standard measures may experience low that affect daily living. measure of low vision in common, every-day situations. Age-related ocular diseases such as vision in older macular degeneration, diabetic retinopa- CONSEQUENCES OF VISUAL thy, cataract, and glaucoma cause the adults. IMPAIRMENT majority of severe visual impairment. Data suggest that visual impairment Therapeutic options exist, although some THE AGING EYE is an independent predictor of mortality, forms and stages are less amenable to The dramatic deterioration of sight 8, 9 a risk factor for falls in the elderly,10 treatment. Aging itself is also associated in the elderly is thought to be a result of and a factor in as many as 40% of hip with ocular changes that result in re- the aging of the eye. A decline in stere- fractures.11 Impaired vision is thought to duced visual function. Many older indi- opsis, the ability to see objects in depth contribute to depression12 and cognitive viduals have reduced acuity, loss of cen- based on the disparity of the images in decline.13 Vision loss is the third most tral or peripheral visual fields, loss of color the two eyes, also occurs. Decreased pu- common chronic condition, after arthri- or contrast sensitivity, light scatter, image pil diameter and yellowing of the lens tis and heart disease, that causes individu- distortion, and sensitivity to glare. reduce and tint the amount of light als over 70 to require assistance in activi- Much of the irreversible damage reaching the retina of the older patient, ties of daily living.14 Vision loss is also as- associated with ocular disease can be pre- creating a retinal image that is dimmer sociated with emotional distress,15 dimin- vented or slowed with appropriate eye and yellowed. In addition, increased scat- ished quality of life, and an increased re- care. Data indicate that elderly persons ter of light occurs in the cornea, lens, and liance upon community services16 who have regular eye examinations ex- vitreous.6 Consequently, glare reduces perience less decline in vision and func- and exacerbates the intensity of light and SOCIALIZATION-BEHAVIORAL tional status.3 However, regular eye ex- effective contrast of visual targets. As a ASPECTS aminations are not common practice. As result of miosis and decreased ocular Vision loss significantly increases the few as 11% of nursing home residents transmittance, the effective intensity of risk that a person will have difficulty with have received an eye exam in the last two white light in the 80 year-old eye is re- daily tasks such as reading a telephone years.4 Blindness and visual impairment duced to only 10% of that appreciated book or newspaper, watching television, are common among nursing home resi- by the 25-year old eye.7 Loss of color dis- and recognizing faces.17 The ability to dents. In a Johns Hopkins study of nurs- crimination results from the smaller pu- recognize faces and emotional expressions ing home residents, 17 % of the residents pil diameter and reduced light transmit- is key to successful social interactions; were blind and 18.8% were found to be tance through the lens.6 Glare recovery, even in elders without severe eye disease, visually impaired.5 In US adults over 40, the ability to recover vision in moderate face recognition is reduced with age7 283 VOLUME 90 NO. 9 SEPTEMBER 2007 284 MEDICINE & HEALTH/RHODE ISLAND dence through assistive technology. The Table 2. Low Vision Resources. organization holds monthly public dem- Rhode Island (RI) Resources onstrations to provide general informa- Services for the Blind and Visually Impaired 401-222-2300 tion regarding low vision devices that are http://www.ors.ri.gov/copied/SBVI.htm available from multiple vendors; e.g., IN-SIGHT: http://www.in-sight.org 401-941-3322 (Table 2) closed circuit televisions TechACCESS: http://TechACCESS-ri.org/ 401-463-0202 (CCTVs) with cameras that one can use Ocean State Center for Independent Living 401-738-1013 RI Vision Education and Services Program for Children 401-456-8910 to access printed material or a classroom blackboard, hand-held magnifiers, talk- National Resources ing calculators and watches, and software http://www.afb.org (American Foundation of the Blind) programs that magnify computer text, http://www.medem.com read out loud what is on the computer Vendors of Low Vision Aids screen, or scan printed material. Patients http://www.visiondynamics.com (local) can test devices. A loan library lets indi- http://www.adaptivetech.net (local) viduals try out equipment. During pub- http://www.maxiaids.com (national) lic demonstrations, TechACCESS also http://www.tsbvi.edu/technology/manufacture.htm- a useful guide to different low reviews community resources such as vision devices (Texas School for the Blind) online libraries and memberships to or- ganizations that provide digital text or Reading is essential for maintaining in- curbs, trip, or bump into things? Can audio materials. Individuals can pay a dependence, as it allows an individual to the patient read the mail and the news- fee to receive an assistive technology pay bills, read labels on food packages, paper? Can the patient read a clock or evaluation to formally identify specific medications, and signs. Patients who are dial a phone number? For patients who technology that would suit their needs. visually impaired may experience a loss encounter difficulties, physicians can of- The center offers an “after school tech of independence, autonomy, and control, fer simple strategies to improve quality of time” where students can make appoint- poor self-esteem, and strained social re- life, including improving contrast, reduc- ments to try out different devices. lationships.18 Reduced visual acuity has ing glare, using non-visual cues to orient INSIGHT has similar vision-enhanc- also been shown to reduce participation oneself, and organizing the home envi- ing devices that people can test before in religious and social activities, 19 in ad- ronment. (Table 1). If PCPs suspect low purchasing. In addition, the organization dition to limiting one’s ability to indepen- vision or a patient complains of low vi- offers rehabilitation programs where in- dently perform activities of daily living sion, referral to an eye care provider is dividuals can learn to use new skills to navi- such as dressing and bathing.20 Older necessary. An ophthalmologist referral gate a “virtual home” complete with a individuals may have negative stereotypes is often necessary to qualify these patients kitchen, dining room, bedroom, and liv- associated with visual impairment such for specific assessments and services. ing room. During classes, participants de- as increased helplessness, increased vul- velop daily living skills such as personal nerability to crime, the stigma of inhab- RHODE ISLAND RESOURCES grooming, safety in cooking, travel tech- iting a world of darkness, or the percep- In RI, several resources (Table 2) aid niques, handwriting, brailling, use of tion that using visual-assistive devices those with visual difficulties. As many as assistive devices, and organization of sur- mark them as different or as an object of 90% of individuals with low vision still roundings so that they are easier to navi- pity. Some of the aged may attempt to maintain useful vision that could be used gate. INSIGHT can visit a client’s home pass as fully sighted individuals in order to increase functional capacity when ap- and adjust the environment to be more to avoid having others project these ste- propriate rehabilitation services, vision- accessible and safe. INSIGHT also offers reotypes onto them.6 enhancing techniques, and adaptive skills professional social work services to provide are available.21 Though the state of RI will help with the adjustment to vision loss. REDUCING THE PUBLIC HEALTH provide services free of charge to eligible INSIGHT has a radio station specially BURDEN OF LOW VISION individuals, low vision aids and rehabilita- geared to the RI community unable to use Primary care physicians (PCPs) can tion are not covered under Medicare. print media independently. The station play a major role in reducing the public Medicare will cover the cost of a low vi- has daily broadcasts of newspapers, books, health burden of low vision. Annual eye sion evaluation performed by an eye care magazines, and specialty programs that can exams for screening and prompt referral specialist. The RI Services for the Blind be listened to with a radio set obtained free if low vision is suspected are vital. An and Visually Impaired, a state agency, as- of charge at INSIGHT. INSIGHT’s oral history will identify patients who ex- sesses individuals’ need for services and technology center provides instruction on perience low vision under conditions of makes referrals to several in-state organi- assistive software that can be used to ac- glare, low-contrast, and low-illumination. zations. INSIGHT and TechACCESS are cess the internet, email, and common com- Can the patient see traffic signals at in- two non-profit groups in Warwick that puter programs. Both INSIGHT and tersections? Can the patient pour her also offer helpful programs. TechACCESS also perform low vision as- own coffee or see dials on kitchen appli- TechACCESS specifically helps in- sessments, but an ophthalmologist must ances? Does the patient miss steps or dividuals with disabilities gain indepen- refer the patients for these services. In RI, 285 VOLUME 90 NO. 9 SEPTEMBER 2007 MEDICARE will cover the cost of a low REFERENCES 14. LaPlante MP. Prevalence of conditions causing vision evaluation performed by an eye care 1. Congdon N, O’Colmain B, et al. Arch Ophthalmol need for assistance in activities of daily living. In: LaPlante MP, ed. Data on disability from the Na- specialist, but low vision aids and rehabili- 2004;122:477-85. 2. Shoemaker JA, Friedman DS, et al. Vision prob- tional Health Interview Survey, 1983-85. Wash- tation are currently not covered. lems in the US: Prevalence of adult vision impair- ington, DC: National Institute on Disability and ment and age-related eye disease in America. Rehabilitation Research; 1988:1-12. CONCLUSION Bethesda, MD: National Eye Institute: 15. Williams RA, Brody BL, et al. Arch Ophthalmol 1998;116:514-20. Standard visual acuity testing is an Schaumburg, Ill; 2002. 3. Sloan FA, Picone G, J Am Geriatr Soc 16. Wang JJ, Mitchell P, et al. Invest Ophthalmol Vis incomplete measure of low vision in older 2005;53:1867-74. Sci 1999;40:12-9. adults. Specialized testing by a low vision 4. Newell SW, Walser JJ. Ann Ophthalmol 17. Vu HT, Keeffe JE, McCarty CA, Taylor HR. Im- specialist assessing for vision dysfunction 1985;17:186-9. pact of unilateral and bilateral vision loss on qual- 5. Tielsch JM, Javitt JC, et al. NEJM ity of life. Br J Ophthalmol 2005;8:360-3. in everyday conditions of glare, dim light, 1995;332:1205-9. 18. Leinhaas MA, Hedstrom NJ. Geriatrics and reduced contrast may reveal clinically 6. Watson GR. J Am Geriatr Soc 2001;49:317-30. 1994;49:53-6. important visual difficulties. For patients 7. Schneck ME, Haegerstrom-Portnoy G. 19. West SK, Munoz B, et al. Invest Ophthalmol Vis Sci 1997;38:72-82. with visual impairment not correctable by Ophthalmol Clin North Am 2003;16:269-87. 8. Knudtson MD, Klein BE, Klein R. Arch 20. Jacobs JM, Hammerman-Rozenberg R, et al. Ag- glasses, medication, or surgery, referral to Ophthalmol. Feb 2006;124(2):243-249. ing Clin Exp Res 2005;17:281-6. an appropriate eye care provider can di- 9. McCarty CA, Nanjan MB, Taylor HR. Br J 21. Scott IU, Smiddy WE, et al. Am J Ophthalmol rect them to a combination of visual ser- Ophthalmol. Mar 2001;85:322-6. 1999;128:54-62. 22. American Academy of Ophthalmology. Vision vices, rehabilitation, and environmental 10. Tinetti ME. NEJM 2003;348:42-49. 11. Ivers RQ, Norton R, et al. Am J Epidemiol Rehabilitation for Adults, Preferred Practice Pattern. measures that can improve or maintain 2000;152:633-9. San Francisco: American Academy of Ophthal- function and quality of life. 12. Ip SP, Leung YF, Mak WP. Depression in mology; 2001 institutionalised older people with impaired vi- sion. Int J Geriatr Psychiatry 2000;15:1120-4. Christina S. Moon is a medical stu- 13. Lin MY, Gutierrez PR, et al. J Am Geriatr Soc dent at the Warren Alpert Medical School 2004;52:1996-2002. of Brown University. Angela Turalba, MD, is a resident in Ophthalmology at the Massachusetts Eye and Ear Infirmary, Harvard Medical School. Kent L. Anderson, MD, PhD, is a Clinical Assistant Professor of Surgery (Oph- thalmology), Brown University. Edward Feller, MD, is a Clinical Pro- fessor of Medicine, Brown University. He is Co-director of the Community Health clerkship and Director, Division of Gas- troenterology, Miriam Hospital.

Disclosure of Financial Interests Christina S. Moon, Angela Turalba, MD, Kent L. Anderson MD, PhD, Ed- ward Feller, MD, have no financial in- terests to disclose.

CORRESPONDENCE Edward Feller, MD Box G-S121, Brown University Providence, RI 02912 e-mail: [email protected] Phone: (401) 863-6149

Ms. Moon submitted an earlier ver- sion of this manuscript to partially satisfy requirements of the Commu- nity Health clerkship

286 MEDICINE & HEALTH/RHODE ISLAND Images In Medicine Granulomatous Myositis in Association with Chronic Graft vs. Host Disease Robert Bagdasaryan, MD, and John E. Donahue, MD

A 34-year old woman with a history of acute myelomonocytic leukemia, S/P autologous bone marrow transplantation, fol- lowed by allogeneic transplantation from her brother one year later, developed graft-versus-host disease (GVHD) three months after the second transplantation. There was no evi- dence for GVHD outside the GI tract. Further immunosup- pression was initiated with cyclosporine and prednisone, but she developed a second bout of GVHD 7 months later. A taper of cyclosporine and prednisone was underway while an immunosuppressant, mycophenolate mofetil, was introduced. One year later, the patient developed a fever of 101° and com- plained of muscle soreness and other flu-like symptoms, with profound proximal upper and lower extremity muscle weak- ness manifested by difficulty getting out of chairs, climbing stairs, and lifting her arms above her head. Neurologic exami- nation revealed a decrease in strength in her proximal muscles (3/5) and tenderness to palpation in both proximal and distal Granulomatous myositis. There is widespread destruction of skeletal muscle groups. Creatinine kinase was 3,826 IU/L, and a myo- muscle fibers associated with an extensive inflammatory infiltrate and globin assay revealed 1.59 micrograms/ml of free serum myo- numerous multinucleated giant cells (arrows). H&E stain, x200. globin. Muscle biopsy revealed an extensive inflammatory in- filtrate with granuloma formation and numerous multinucle- REFERENCE ated giant cells (see figure). At this point, the prednisone was 1. Kaushik S, Flagg E, et al. Granulomatous myositis. Skeletal Radiol 2002; increased to 15 mg/day, and she was kept on mycophenolate 31:226-9. mofetil. Clinically, she improved somewhat but not to baseline. Granulomatous myositis has been reported once previously in Robert Bagdasaryan, MD, formerly a fellow in neuropathol- association with chronic GVHD.1 ogy, at Rhode Island Hospital, is an attending pathologist at Kent. John Donahue, MD, is a neuropathologist at RI Hospital.

Disclosure of Financial Interests Robert Bagdasaryan, MD, has no financial interests to disclose. John Donahue, MD, Grant Support: NIH/NIA.

CORRESPONDENCE John Donahue, MD e-mail: [email protected]

287 VOLUME 90 NO. 9 SEPTEMBER 2007 Information for Contributors Medicine & Health/Rhode Island Medicine & Health/Rhode Island is a peer-reviewed publication, listed in the Index Medicus. We welcome submissions in the following categories.

CONTRIBUTIONS For the above articles: Please submit 4 hard Contributions report on an issue of inter- copies and an electronic version (Microsoft est to clinicians in Rhode Island: new re- Word or Text) with the author’s name, search, treatment options, collaborative mailing address, phone, fax, e-mail address, interventions, review of controversies. and clinical and/or academic positions to Maximum length: 2500 words. Maximum the managing editor, Joan Retsinas, PhD, number of references: 15. Tables, charts and 344 Taber Avenue, Providence, RI 02906. figures should be camera-ready, or as sepa- phone: (401) 272-0422; fax: (401) 272- rate files (jpg, tif, pdf). Photographs should 4946; e-mail: [email protected] be saved as separate files. Powerpoint files and slides are not accepted. IMAGES IN MEDICINE We encourage submissions from all medi- CREATIVE CLINICIAN cal disciplines. Image(s) should capture the Clinicians are invited to describe cases that essence of how a diagnosis is established, defy textbook analysis. Maximum length: and include a brief discussion of the disease 1200 words. Maximum number of refer- process. Maximum length: 250 words. The ences: 6. Photographs, charts and figures submission should include one reference. may accompany the case. Please submit the manuscript and one or two clearly labelled cropped files with the POINT OF VIEW author’s name, degree, institution and e- Readers share their perspective on any issue mail address to: John Pezzullo, MD, De- facing clinicians (e.g., ethics, health care partment of Radiology, Rhode Island Hos- policy, relationships with patients). Maxi- pital, 593 Eddy St., Providence, RI 02903. mum length: 1200 words. Please send an electronic version of the text and image to: [email protected]. ADVANCES IN PHARMACOLOGY Authors discuss new treatments. Maximum FINANCIAL DISCLOSURE FORMS length: 1200 words. All authors must submit a financial disclo- sure statement of possible conflicts. The ADVANCES IN LABORATORY MEDICINE form is available from the managing editor, Authors discuss a new laboratory technique. or the Rhode Island Medical Society web- Maximum length: 1200 words. site (www.rimed.org).

288 MEDICINE & HEALTH/RHODE ISLAND RHODE ISLAND DEPARTMENT OF HEALTH • DAVID GIFFORD, MD, MPH, DIRECTOR OF HEALTH EDITED BY JAY S. BUECHNER, PHD Resident and Family Satisfaction with Nursing Home Care in Rhode Island: Differing Views of Performance Margaret S. Richards, PhD, and Gwen C. Uman, RN, PhD

The publication of family and resident satisfaction with nursing members surveyed (as a group) in that home. A total of 3,057 home care in late 2006 was the first report of its kind for Rhode residents completed interviews, and 4,082 family members or Island’s 92 nursing homes.1 The two-year project, conducted friends returned completed surveys. The level of agreement with Quality Partners of Rhode Island and Vital Research, LLC, across 92 homes within each survey domain and for total satis- of California, consisted of self-administered surveys mailed to faction was tested with a prevalence and bias-adjusted Kappa family members or friends of residents and face-to-face inter- (PABAK) statistic.5 The Kappa statistic compares observed agree- views with residents, including residents with mild-to-moder- ment versus expected agreement, taking into account the fact ate cognitive impairment. The family and resident surveys were that two observers, or two groups of observers, will sometimes nearly identical in terms of dimensions of satisfaction (“do- agree or disagree simply by chance. A Kappa of 0.00 or lower mains”) assessed and methods for scoring performance.2 In an indicates poor agreement between residents and families, whereas earlier publication, we presented information from the surveys a Kappa near 1.00 suggests near-perfect agreement.6 Because on priority indices developed to guide quality improvement the satisfaction score is a continuous variable ranging from 1.00 (QI) efforts in the state’s nursing homes and found that the points (low) to 4.00 points (high) but the Kappa statistic is based high priority domains for QI efforts identified by residents and on a categorical outcome, we dichotomized all scores as less than their families differed.3 Here we present more specific infor- 3.70 (out of 4.00) versus greater than or equal to 3.70. (Note: mation on the nature and extent of those differences. Because of the de-identified nature of the survey results, we were Survey research in the long-term care setting can be chal- unable to examine agreement for resident-family pairs, which lenging, particularly when residents are cognitively or physically might provide more accurate analysis of agreement than our impaired and need assistance in reading or answering the ques- group analysis at the nursing home level. Moreover, our deci- tions. The cost of conducting a cognitively adapted face-to-face sion to dichotomize the scores as above or below 3.70 does not interview can be prohibitive, however, so patient satisfaction sur- take advantage of a weighted Kappa, in which partial credit for vey organizations often default to a mailed survey for residents as agreement is given when ordinal responses are in adjacent rather well as family members. These organizations are keenly aware of than extreme categories of performance. Such weighting is be- the potential for loss of information from the impaired residents yond the scope of this inquiry.) and for introduction of bias from staff persons, family members, or other residents who may provide assistance in filling out the RESULTS survey. Rhode Island’s nursing homes accepted the additional Overall, family and residents were more likely to agree (K > 0) than expense of a cognitively adapted face-to-face resident interview to disagree (K < 0). (Table 1) However, reasonable agreement, de- in order to include the broadest possible group of residents. Here fined as a Kappa of 0.50 or higher between family members and we examine whether or not these two populations generally residents, existed in only two of twelve scores. There was substantial agreed or disagreed on the quality of care delivered in order to agreement with respect to Meals and Dining (K = 0.674) and mod- determine if future survey ef- forts might reasonably be lim- ited to more cost-effective mailed surveys for residents or to surveys of family members only.

METHODS The family and resident surveys, adapted from surveys developed for use in Ohio,4 assess satisfaction with care in eleven common domains or topics. On a home-by-home basis, we looked at the level of agreement between the resi- dents surveyed (as a group) in that home versus the family 289 VOLUME 90 NO. 9 SEPTEMBER 2007 a large sum. For the Meals and Dining domain, for example, in 77 of 92 homes the family respondents as a group and the resident respondents as a group were in agreement in rating satisfaction with the homes’ food services either high or low.

DISCUSSION Survey researchers have noted pre- viously that visitors—even regular visi- tors—are not good substitutes for assess- ment of elderly patient satisfaction with nursing home care.7 In our previous re- port, we noted that Rhode Island’s nurs- ing home residents and families have dis- tinctly different improvement priorities for nursing home care.3 It appears that Figure 1. Level of agreement (Kappa statistic) between nursing home residents and the additional resources needed to mea- families on satisfaction with care, by satisfaction domain, Rhode Island, 2006. sure the satisfaction of the nursing home erate agreement with respect to Activities (K = 0.544). (Figure 1) residents were warranted in this state, for residents and their The two groups surveyed were in least agreement regarding Facility families have unique expectations of and experiences with long- Environment (K = -0.413) and Laundry services (K = -0.033), where term care. family members appear to be less satisfied than the residents. Rhode Island’s nursing home administrators understood The numbers in the columns in Table 1 labeled A, B, C, the fundamental differences in family and resident expecta- and D correspond to the nursing home cell counts of the 2x2 tions of long term care, and committed in January 2007 to matrix with which each Kappa is calculated. Rating a domain follow up with and address each group’s concerns in both sepa- ‘high’ indicates that the respondent group (family or resident) rate and joint learning circles. We applaud their diligence and scored that domain a 3.70 (out of 4.00) or higher, on average; sensitivity in so doing. a low rating corresponds to an average score of less than 3.70. With the exception of the Social Services (n=74), Therapy Margaret S. Richards, PhD, is former Senior Scientist at (n=77), and Laundry (n=91) domains, cell counts added up to Quality Partners of Rhode Island. 92, the total number of participating nursing homes, for each Gwen C. Uman, RN, PhD, is Partner at Vital Research, row of Table 1. (The Social Services and Therapy questions LLC, Los Angeles, CA. were not answered by all residents, so that the numbers of re- sponses were too few to yield domain scores at the smaller nurs- Disclosure of Financial Interests ing homes.) Note that the highest Kappa—or highest level of Margaret S. Richards, PhD, and Gwen C. Uman, RN, agreement—tends to occur where columns A and D produce PhD, have no financial interests to disclose.

REFERENCES 1. http://www.health.ri.gov/chic/performance/quality/quality27pdf. 2. http://www.health.ri.gov/chic/performance/quality/quality27tech.pdf. 3. Richards MS, Uman GC. Resident and family satisfaction with nursing home care in Rhode Island: prioritizing improvement. Medicine & Health/RI 2007 90:223-4 4. Scripps Gerontology Center and The Margaret Blenkner Research Institute (under contract with the Ohio Department of Aging). 5. See http://www.mhri.edu.au/biostats/DAG_Stat/. 6. Viera AJ, Garrett JM. Understanding interobserver agreement. Family Med 2005 37:360-3. 7. Gasquet I, Dehé S, et al. Regular visitors are not good substitutes for assessment of elderly patient satisfaction with nursing home care and services. J Gerontol Series A: Biological Med Sciences 2003 58:M1036-M1041.

290 MEDICINE & HEALTH/RHODE ISLAND THE WARREN ALPERT MEDICAL SCHOOL OF BROWN UNIVERSITY GERIATRICS FOR THE Division of Geriatrics PRACTICING PHYSICIAN Quality Partners of RI Department of Medicine EDITED BY ANA C. TUYA, MD Chronic Dizziness In Older Persons Aman Nanda, MD, CMD

DS, an 85- year-old woman, complains of intermittent or disease in multiple systems.6,7,8 dizziness, and three falls over 6 months. She lives with her son, who witnessed the falls, which occurred in the home. There TYPES OF DIZZINESS has been no loss of consciousness or serious injury. She has hy- Dizziness is classically categorized into four subtypes: ver- pertension, coronary artery disease, mild bilateral cataracts, tigo, pre-syncope, disequilibrium, and other.9 A fifth category chronic backache, diabetes mellitus, impaired hearing, and mild is ‘mixed dizziness’. cognitive impairment. She has been using a cane for 7-8 1. Vertigo is a spinning sensation, either of the patient with months. Mrs. S says sometimes she feels woozy and light-headed, respect to the environment (subjective vertigo) or of the other times she feels the room is spinning. The episodes usually environment with respect to the patient (objective ver- occur when she tries to stand from sitting or lying down. She tigo). Vertigo, often sudden in onset, is episodic, and when denies nausea or vomiting. Medications include gilipizide xl 5 severe may be associated with nausea and vomiting. mg daily, metformin 500 mg twice daily, baby aspirin, metoprolol 12.5 mg. twice a day, nifedipine XL 60 mg. daily, 2. Pre-syncope is a feeling of impending or imminent faint- ranitidine 150 mg. twice daily, acetaminophen prn, multivita- ness or, lightheadedness. It is thought to result from min tablet, and calcium plus vitamin D twice a day. hypoperfusion of the brain; e.g., cardiovascular conditions. Dizziness is the subjective sensation of instability of pos- 3. Dysequilibrium is a feeling of unsteadiness not associated ture or of illusory motion. A nonspecific term, it includes with any abnormal head sensations. Dysequilibrium usually lightheadedness, vertigo, dysequilibrium, spinning, giddiness, results from abnormalities in the proprioceptive system. faintness, and other sensations. Dizziness is often classified, as acute (present for less than one or two months), or chronic 4. Other includes vague feelings other than vertigo, (present for more than one or two months). The causes of acute presyncope or dysequilibrium. The patient may describe, dizziness are usually similar for patients of all ages. Therefore, “floating,” “wooziness,” “spaciness,” “whirling” or other this discussion will be limited to chronic dizziness. non-specific sensations. Dizziness is one of the most common presenting complaints 5. Mixed includes combinations of two or more of the above in primary care practice for persons aged 65 years and older.1 types, and is the most common type of dizziness reported The overall prevalence ranges from four to 30%, and it is more by older adults.10 It is felt to result from the presence of common in women.2,3 The complaint increases by 10% for combinations of diseases affecting multiple systems. every 5 years of increasing age. Chronic dizziness has been as- sociated with increased risk for falls, increased fear of falling, CAUSES OF DIZZINESS orthostatic hypotension, syncope, stroke, and disability, and has Dizziness results from either discrete or combined effects a negative effect on quality of life among older persons, as well of impairments or disorders of the multiple systems respon- as worsening of depressive symptoms.4,5 sible for maintaining balance. Discrete causes of chronic dizzi- ness can be divided into vestibular disorders, central nervous CHRONIC DIZZINESS AS A GERIATRICS SYNDROME system disorders (CNS), disorders causing orthostatic hypoten- Most clinicians assume that dizziness is a symptom of one sion, psychogenic causes, systemic causes, medications and mis- or more discrete diseases. Because multiple systems maintain cellaneous. Common vestibular diseases causing chronic dizzi- balance, multiple conditions usually contribute to chronic diz- ness in older persons include benign paroxysmal positional ver- ziness in elderly persons. Chronic dizziness has been associated tigo, recurrent vestibulopathy, and ototoxic medications. The with multiple risk factors, including angina, myocardial inf- CNS disorders include cerebrovascular disease and parkin- arction, stroke, arthritis, diabetes, syncope, anxiety, depressive sonism. Two important other entities are postural dizziness with- symptoms, impaired hearing, alcohol consumption, smoking, out orthostatic changes and postprandial hypotension. The most nervousness and use of several classes of medications. In one common psychogenic conditions in older persons are depres- study, 51% of older adults with four or more of the following sive and anxiety disorders. Benign Paroxysmal Positional Ver- problems reported dizziness: depressive symptoms, cataracts, tigo (BPPV) is characterized by brief bouts (seconds) of sud- abnormal gait, postural hypotension, diabetes, past myocar- den vertigo provoked by changes in the head position (e.g., dial infarction, and three or more medications. Thus, chronic rolling over in bed into a lateral position, gazing upward or dizziness is best considered a geriatrics syndrome; a combina- leaning forward). Rotational nystagmus and nausea and vom- tion of symptoms and signs that often result from impairment iting are common. Patients typically experience recurrent bouts 291 VOLUME 90 NO. 9 SEPTEMBER 2007 of positional vertigo over days to months, with quiescent peri- ing loss, tinnitus or ear fullness suggest Meniere’s disease. Pre- ods between episodes. cipitating or provocative factors, such as standing, rolling over The pathophysiologic mechanism of BPPV is believed to in bed or changing the position of the head or neck should be be free-floating particulate matter, most likely dislodged oto- sought. Comorbid conditions (e.g., anemia, cardiac diseases, conia secondary to degenerative changes (tiny calciferous gran- diabetes, renal disorders, anxiety, depression) can predispose ules that form part of the receptor mechanism in the otolith to or exacerbate dizziness. A careful review of all medications, apparatus) in the endolymph of the posterior semicircular ca- including over-the-counter drugs, is essential. nal. The exact mechanism causing vertigo is unknown, but Physical examination should include orthostatic blood thought to result from movement of debris causing alterations pressure measurement. Ear wax should be removed. Hearing, in endolymphatic pressure. Postural Dizziness without orthostasis and near and distant vision should be tested. occurs in some older persons - dizziness on standing, but blood Spontaneous nystagmus may be present. The nystagmus pressure changes do not meet criteria of postural hypotension.11 in central lesions is vertical and is not suppressed by visual A postural drop in blood pressure is not always symptomatic, fixation, while that in peripheral vestibular lesions it is usu- and, conversely, all dizziness with postural change is not due to ally horizontal or rotatory, and is suppressed by visual fixa- blood pressure changes. tion. The head thrust test also tests vestibular function. The Postprandial hypotension is usually defined as an orthos- patient fixates on the examiner’s nose, and the head is moved tatic change in blood pressure after rising within one to two rapidly by the examiner about 10 degrees to the left or right. hours of eating a meal; dizziness is common, as are falls and In a normally functioning vestibular system, the eyes will re- syncope. main fixed on the target. With vestibular disease, the eyes Medications: Several classes of medications, such as nar- move with the head away from the target, followed by a cor- cotics, anxiolytics, antidepressants, antihypertensives, rective saccade back to the target. aminoglycoside antibiotics, chemotherapy, and NSAIDs pro- Cranial nerves should be examined for diplopia, dysar- duce dizziness as a side effect. Medications may cause dizziness thria, and facial weakness, along with cerebellar signs; e.g., gait through various mechanisms; e.g., antihistamines and tricyclic ataxia, truncal ataxia, or dysmetria, which suggest etiologies such antidepressants can cause dizziness through their anticholin- as a cerebellar stroke or cerbellopontine angle tumors. Gait ergic side effects. Aminoglycosides, NSAIDs, quinine and loop and balance examinations should be done. A positive Romberg’s diuretics can have ototoxic effects if used in high dosages or for sign suggests a vestibular or proprioceptive etiology. long periods. Over-the-counter cold preparations can cause One should also check for range of neck motion. A de- dizziness because of their anticholinergic effects. crease in the range of motion, with or without symptoms of In older persons, other contributors to dizziness include dizziness, may be due to a cervical process or, secondarily, to vision impairment, hearing loss, cervical arthritis and anemia. vestibular dysfunction. Apart from the history and physical That dizziness can be a geriatric syndrome does not preclude examination, certain provocative tests can be done at bedside the possibility that a single disease may sometimes be respon- to evaluate the vestibular system. sible. Rather, it acknowledges that many symptoms, such as In addition to head-thrust, Dynamic visual acuity test- dizziness, falls, delirium in older persons cannot be explained ing can be done. The patient reads a fixed eye chart while the solely by a single disease. examiner moves the head horizontally at a frequency of 1-2 Hz. A drop in acuity of two rows or more from baseline sug- EVALUATION gests abnormal vestibule-ocular reflex. Dix-Hallpike test can The goal is to identify and eliminate the cause of dizziness. If confirm BPPV.12 not possible, the goal should then be to minimize dizziness and to A small battery of laboratory tests should be performed avoid consequences, such as falls, injury, functional disability and on all patients with chronic dizziness - hematocrit, glucose, re- increased depressive symptoms. A stepwise approach to the evalu- nal function, electrolytes, thyroid function, and vitamin B12 ation of chronic dizziness is recommended. Careful history, physi- and RBC folate levels. EKG should be done, if a cardiovascu- cal examination and routine laboratory evaluation often can iden- lar etiology is suspected; not every dizzy patient needs holter tify possible diseases or contributing factors to dizziness. Rarely monitoring and tilt table test. Audiometry should be done if does a discrete cause require extensive further evaluation. Meniere’s disease or acoustic neuroma is suspected. The history should seek a precise characterization of the Specialized tests like vestibular function tests sensation of dizziness, although sometimes difficult and frus- (electronystagmography, caloric test, rotational chair tests, com- trating. Is the dizziness is episodic or continuous? In BPPV, puterized posturography) are indicated only if vestibular dys- Meniere’s disease or CNS disorders, dizziness is episodic, while function is high on list. Neuroimaging (CT or MRI) is only psychogenic or drug-induced dizziness is usually continuous. indicated if history and physical examination suggests stroke or Psychological dizziness typically begin insidiously, but acoustic cerebellopontine angle tumor. neuroma should be ruled out. Duration and frequency of dizziness, and any associated TREATMENT symptoms (tinnitus, diplopia, hearing loss, ear fullness, dysar- Treatment should be directed toward a specific cause, but thria, syncope) are all important. Recurrent episodes of dizzi- if evaluation is uninformative, a therapeutic trial can be help- ness lasting less than one minute are common in BPPV, while ful. The most effective treatment approach is to ameliorate one recurrent episodes of dizziness associated with fluctuating hear- or more potential etiological or contributor factors. 292 MEDICINE & HEALTH/RHODE ISLAND Vision and hearing should be corrected. Dizziness second- REFERENCES ary to medication usually responds to dosage adjustment or to 1. Sloane PD. Dizziness in primary care. J Fam Prac 1989;29:33-8. withdrawal of medication. Vestibular suppressants like antihis- 2. Sloane P, Blazer D, George LK. Dizziness in a community elderly population. J Am Geriatr Soc 1989:37:101-8. tamines (e.g., meclizine) are commonly used for symptomatic 3. Colledge NR, Wilson JA, et al. The prevalence and characteristics of dizziness relief, but effectiveness in chronic dizziness is not documented. in an elderly community. Age Aging 1994:23;117-20. Long-term use is not indicated because of CNS side effects 4. Grimby A, Rosenthall U. Health related quality of life and dizziness in old age. and because they suppress central and vestibular adaptation Gerontology. 1995:41;286-298. 5. Tinetti ME, Mendes de Leon CF, et al. Fear of falling and fall related efficacy and thus may worsen chronic dizziness. in relationship to functioning among community-living elders. J Gerontol Vestibular rehabilitation is an important and effective 1994:49;M140-7. management strategy for patients with peripheral and central 6. Tinetti ME, Williams CS, Gill TM. Dizziness among older adults. Ann Intern Med 2000.132:337-44. vestibular causes of dizziness. Combinations of exercises involv- 7. Kao AC, Nanda A, et al. Validation of dizziness as a possible geriatric syn- ing head and eye movements designed to provoke dizziness are drome. J Am Geriatr Soc 2001;49:72-5. used. Initially, the exercises may exacerbate dizziness, but over 8. Sloane PD, et al. Dizziness. Ann Intern Med 2001; 134:823. time (weeks to months) movement-related dizziness improves, 9. Drachman DA, Hart CW. An approach to the dizzy patient. Neurol 1972;22:323-34. likely because of central adaptation. The Epley’s Canalith re- 10. Sloane PD, Baloh RW. Persistent dizziness in geriatric patients. J Am Geriatr positioning procedure, and Brandt’s exercises are currently Soc. 1989;37:1031-1038. recommended treatments for benign positional vertigo. These 11. Ensrud KE, Nevitt MC, et al.. Postural hypotension and postural dizziness in bedside maneuvers, by the effects of gravity move free-floating elderly women. Arch Intern Med 1992;152:1058-64. 12. Furman JM, Cass SP. Benign paroxysmal positional vertigo (Review article). debris from the posterior semicircular canal into the utricle of NEJM 1999; 341:1590-6. vestibule, where it will no longer alter endolymphatic pressure in the semicircular canals.12 Aman Nanda, MD, CMD, is Assistant Professor of Medi- Surgical therapy is rarely needed, and is limited to exci- cine, The Warren Alpert Medical School of Brown University. sion of cerebellopontine angle tumors; ablative procedures (transmastoid labyrinthectomy and partial vestibular neurec- Disclosure of Financial Interests tomy for uncontrolled Meniere’s Disease or peripheral Aman Nanda, MD, MCD, Grant Research: Amgen; vestibulopathy); and non-ablative endolymphatic sac decom- Speakers’ Bureau: Forrest pression. Patient Education: Patients can modify activities; e.g., for 8SOW-RI-GERIATRICS -092007 postural dizziness, patients should rise slowly from sitting or THE ANALYSES UPON WHICH THIS PUBLICATION IS BASED were supine positions. They should avoid looking up, reaching up, performed under Contract Number 500-02-RI02, funded by or bending down, but should be cautioned not to habitually the Centers for Medicare & Medicaid Services, an agency of avoid other movements, such as head turning so as not to com- the U.S. Department of Health and Human Services. The con- promise central adaptation, thereby worsening dizziness. Above tent of this publication does not necessarily reflect the views all, patients should avoid over the counter drugs that may ex- or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or acerbate dizziness. organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented.

293 VOLUME 90 NO. 9 SEPTEMBER 2007 Physician’s Lexicon The Words of Fear

Fear is a pervasive emotional response to grammed his queen with the terse victory fear of darkness, is based on the Latin, nictare, a bewildering variety of perceived external message, “Peccavi”, meaning, I have sinned meaning to blink or close one’s eyes. The threats. To most, a mild threat will evoke a [Sindh]. nictitating membrane uses the same root. mild degree of fear; yet in others, that same Cypridophobia, the fear of sex, is based Fear of aliens is called xenophobia. The mild threat may summon up an overwhelm- upon the root, Cypris, another name for Greek root, xeno-, meaning stranger or guest, ing, irrational fear, a phobia. One man’s joy Aphrodite and her home island, Cyprus. A appears in English words such as xenon and may be another man’s phobia. And indeed fear of nudity, gymnophobia, is derived from xenogamy, defining botanical cross-fertili- the numberless variety of human phobias just the Greek root, gymnos, as in English words zation. about equals the number of items that pro- such as gymnasium, gymnosperm [a plant The phobias are endless in number. Just vide rapture to others. with naked seeds] and gymnocyte. those beginning with the letter ‘a’ include: ac- The Greek word, phobos, meaning fear Thanatophobia, the fear of death, stems arophobia, acrophobia, agoraphobia, or panic, has given rise to two noun forms in from a Greek root meaning to be extin- aichmophobia, algophobia, ailurophobia, an- English: the specific clinical state of the fear guished or to be dead, as in English words drophobia, anthophobia, anuptaphobia, itself [e.g., claustrophobia] and those who such as euthanasia and thanatoid. apiphobia, aquaphobia and arachibutyrophobia are afflicted by that specific fear [e.g., Nosophobia, fear of disease, appears also in [fear of peanut butter sticking to one’s palate.] arachnophobes]. the word, nosology, the classification of dis- With so many diverse fears of things The fear of sin [peccatophobia] employs eases. A fear of darkness is called scotophobia. both common and uncommon, there is little a Latin word, peccare [to sin] as in English English words with the same Greek root in- left to fear except [in the immortal words of words such as impeccable [meaning faultless, clude: Scotoma [a blind spot], scotograph [an F. D. Roosevelt] fear itself; and for this the without sin], and peccadillo, a minor sin. The instrument for writing in the dark] and sc- Greeks indeed have a word: phobophobia. 19th Century English general who captured otodinia [vertigo associated with dimness of the city of Sindh [in current Pakistan], cable- vision.] Nictophobia is yet another term for – STANLEY M. ARONSON, MD

RHODE ISLAND DEPARTMENT OF HEALTH VITAL STATISTICS DAVID GIFFORD, MD, MPH DIRECTOR OF HEALTH EDITED BY COLLEEN FONTANA, STATE REGISTRAR

Underlying Reporting Period Rhode Island Monthly September Cause of Death 12 Months Ending with September 2006 Vital Statistics Report 2006 Number (a) Number (a) Rates (b) YPLL (c) Provisional Occurrence Diseases of the Heart 207 2,720 254.3 3,109.5 Malignant Neoplasms 194 2,276 212.8 6,114.5 Data from the Cerebrovascular Diseases 27 407 38.0 457.5 Division of Vital Records Injuries (Accidents/Suicide/Homicde) 44 463 43.3 6,838.0 COPD 36 475 44.4 440.0

Reporting Period (a) Cause of death statistics were derived from the underlying cause of death reported by Vital Events March 12 Months Ending with physicians on death certificates. 2007 March 2007 (b) Rates per 100,000 estimated population of Number Number Rates 1,067,610 Live Births 1,048 13,169 12.3* Deaths 833 10,072 9.4* (c) Years of Potential Life Lost (YPLL) Infant Deaths (9) (87) 6.6# Neonatal Deaths (7) (59) 4.5# Note: Totals represent vital events which occurred in Rhode Marriages 273 6,923 6.5* Island for the reporting periods listed above. Monthly pro- Divorces 196 3,029 2.8* visional totals should be analyzed with caution because the numbers may be small and subject to seasonal variation. Induced Terminations 637 4,814 365.6# Spontaneous Fetal Deaths 74 799 60.7# * Rates per 1,000 estimated population Under 20 weeks gestation (70) (736) 55.9# # Rates per 1,000 live births 20+ weeks gestation (4) (63) 4.8# 294 MEDICINE & HEALTH/RHODE ISLAND advertisement

295 VOLUME 90 NO. 9 SEPTEMBER 2007  

The Official Organ of the Rhode Island Medical Society

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VOLUME 1 PER YEAR $2.00

  NUMBER 1PROVIDENCE, R.I., JANUARY, 1917 SINGLE COPY, 25 CENTS

NINETY YEARS AGO, SEPTEMBER 1917 FIFTY YEARS AGO, SEPTEMBER 1957 Charles D. Cooke, AM, MD, in “The Acute Abdomen, This issue advertised assorted drugs; e.g., preludin (“just 1 with Report of [Eight] Cases,” urged readers to find the cause, specific therapeutic purpose – to curb the appetite of the over- e.g.; acute gangrenous and perforative appendicitis; twisting weight patient’), pavartine with phenobarbitol (for “spasticity of the pedicule of an ovarian cyst; rupture of an ulcer (includ- of the GI tract”), decholin (for “sluggish” older patients), ing typhoid ulcer); thrombosis of the mesenteric vessels; stran- neohydrin (an organomercurial diruetic), norlutin (an oral gulated hernia; renal crises; pneumonia (especially in children). progestational agent), floraquin (for vaginal parasites). He stressed early diagnosis: “Much valuable time will be saved J. Murray Beardsley, MD, in “Surgery of the Esophagus,” in the operation if the diagnosis can be accurately established described 9 cases from his operations at Rhode Island Hospi- beforehand. Morphine should not be given to mask tal. symptoms…Cathartics should not be given…If doubt exists as Donald L.DeNyse, MD, in “Clinical Observations with to whether the acute abdomen is present or not, that doubt Phenaglycodol in Hypertension with Anxiety Status,” selected should be cleared up by operation and not by delay. The mor- 75 patients with mild hypertension and 36 with severe hyper- tality of the acute abdomen is the mortality of delay, ignorance tension from a random sample seen over 10 months at Roger and neglect.” Williams Hospital. He found a “favorable” response with 92 Otto M. Faust, MD, in “Observation on Diastolic Blood patients, and found it “ideal in the 35 to 60 age group who Pressure,” noted that 13 years previously Richard Cabot (of showed mild to severe anxiety from the stress of modern life.” Boston) had written the first paper on human blood pressure. Domenic L. Coppolino, MD, and Francis P. Catanzaro, Since then, there had been thousands of articles on the topic, MD, in “Ingestion of Multiple Foreign Bodies,” described a but most focused on systolic, not diastolic, readings. Dr. Faust 55 year-old married woman admitted to St. Joseph’s with a reviewed 61 cases [from 1822 admissions, from January 1 – “chief complaint of repeated episodes of crampy abdominal December 1, 1916] at Rhode Island Hospital. He looked at pain.” Tests revealed pieces of broken glass, as well as broken patients with chronic nephropathies and cardiopathies “on razor blades. She had a laparotomy, enterotomy and colostomy, whom at least 1 blood pressure reading and 1 phthalein renal and 1 piece of glass was removed manually from her rectum. test was made.” He included 9 cases of aortic regurgitation as When asked to explain, she said “I don’t know,” and also ex- well. He found “a definite relationship between diastolic pres- pressed anger at her husband. sure and functional capacity of the kidney, except in cases of aortic regurgitation.” TWENTY-FIVE YEARS AGO, SEPTEMBER 1982 An “Honor Roll” listed the Rhode Island physicians thus Stanley M. Aronson, MD, and Renee R. Shield, MA, in far to accept commissions in the Medical Reserve Corps, US “The Domain of the Elderly,” explained: “The demographic Army, in the US Naval Reserve Force, or in the RI National data presented suggest numerous questions upon which re- Guard. search can be focused.” The authors cited dependency ratios An Editorial, “Abrogate Patent on Salvarsan,” reprinted a from different countries (ratio of people ages 15-64 to people JAMA editorial (April 21, 1917), calling for abrogation, largely ages 75 and older). In the United States and Western Europe, because “people who are supplying this product are charging the ratio was 31 (the Rhode Island ratio was 23.1). In Asia the prices that are exorbitant compared to the price at which oth- ratio was 75. ers in this country can supply it.” The cost for salvarsan was Alexander Leaf, MD, the Ridley Watts Professor of Pre- $4.50; for an equivalent amount of arsenobenzol, $2.00; and ventive Medicine and Professor of Medicine, Harvard Medi- producers expected to drop the price to $1.00 after the War. cal School, delivered “Aging, Longevity, Prevention and Cure: Our Professional Failures,” the 1981 Nathan J. Kiven MD Oration at The Miriam Hospital. John W. McClain, PhD, David S. Greer, MD, and Donald L. Spence, PhD, contributed “The Promise of the Partnership,” spelling out the role of the Gerontology Center at integrating the resources of the Brown Medical Program and several other agencies.

296 MEDICINE & HEALTH/RHODE ISLAND

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