Complementary Medicine - WDMSThe major types of complementary and alternative medicine include the...

JAN./FEB. 2008 WORCESTER MEDICINE | 3

On the cover:Complementary Medicine

contentsVol. 72, No. 1JAN/FEB 2008

4 President’s MessageBruce Karlin, MD

5 EditorialPeter C. Linblad, MD

6 Strong Medicine:the Origins of Patent RemediesPeter C. Linblad, MD

8 Is Research in Holistic Medicine Held to a Higher Standard?Jay Glaser, MD

10 The Value of Reiki andMassage TherapyJune Bessette, BSN, RN, LMT

11 A Review of Herbal ReferencesAnna K Morin, PharmD

& Michele Matthews, PharmD

13 Traditional Chinese Medicine ~ Can East Meet West?Richard DeSouza

15 As I See ItMarc Greenwald, MD

18 As I See ItJanet Letourneau

19 Science CornerDeepu A. Thomas MD,

George Abraham, MD, MPH,

and Anthony L. Esposito, MD

21 Legal ConsultPeter Martin, Esq.

23 Financial Advice for PhysiciansMike Halloran

25 Off CallHugh Silk, MD

29 In MemoriamRichard W. Aspen, MD

Paul H. Martin, MD

30 Society Snippets

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

Saint Vincent Hospital

UMass Memorial Health Care

Fallon Clinic

Physicians Insurance Agency of Massachusetts (PIAM)

I want to thank our members for their time and effort for

Community Immunity. We achieved a lot. Our exercise

was of great value to the Worcester MMRS which had an

opportunity to test its capacity for response with “live

ammo.” We were prepared for a true emergency. The

Department of Public Health learned about details that

would never be apparent absent a live test. Further, the

effort by the Medical School, bringing medical students

and nursing students into a training exercise, was stellar.

Thanks to Dr. Broadhurst and Robin Klar, we expect that

this exercise will continue to be a part of the Community

Medicine Clerkship. The Worcester Medical Reserve Corps

developed a major new recruiting tool. The medical students were given expert instruc-

tion in injection technique and then got to practice with real patients. The Nursing

School got to demonstrate its considerable expertise in preparing the injectors. The

WDMS Alliance was outstanding in planning and executing our publicity. We learned a

great deal about mounting a publicity campaign, and coordinating billboards, internet,

TV, newspaper and radio press in the run up to our final days. The City Council pro-

claimed 10/13/07 Community Immunity Day and all the mayoral candidates came for the

exercise. Dr. Suasn Lett, Director of the Immunization program for Massachusetts DPH,

visited as well. The glut of vaccine decreased the urgency of our effort and diminished

the turnout, but we learned that we could develop partnerships with private industry if

needed. Maxim stepped up to assure vaccine early in the process when the supply was

not clear. Wal-Mart again stepped forward with supplies and advertising. Fallon Clinic

supported us with advertising. The Worcester MRC was pleased with the exercise and I

am sure the Worcester DPH will try a similar one next year. The synergy among all the

healthcare professionals was exhilarating. We have shown the way and Worcester is bet-

ter prepared for emergencies because of our efforts.

On another front, our Partnership is making great progress in giving our physician com-

munity a common, secure e- mail. Dr. Abraham continues to astound us with his ability

to get disparate factions to row together. Stay tuned.

I am constantly amazed at how much we accomplish when WDMS leads the way. Thanks

again to all who have worked so hard.

Bruce Karlin, MD

President

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

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

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

WORCESTER

medicineWorcester Medicine is published bythe Worcester District Medical Society321 Main Street, Worcester, MA 01608 e-mail: [email protected]: www.wdms.orgphone: 508.753.1579

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4 | WORCESTER MEDICINE JAN./FEB. 2008

president’s message

Bruce Karlin, MD


Have you ever seen a patient’s condition improve through meth-ods that you can’t explain? We all have. That’s why it’s importantfor those of us practicing “conventional medicine” to have an openmind regarding therapies that are effective and not harmful, butfall into the categories of “alternative” or “complementary” medi-cine. If you are skeptical, consider this: non-traditional therapyin the U.S. today is a $39.5 billion industry.

The major types of complementary and alternative medicineinclude the following:

• Whole medical systems ~ naturopathic and homeopathic medi-cine, such as traditional Chinese medicine and Ayurveda, prac-ticed by millions in India, Nepal and Sri Lanka.

• Mind/body medicine ~ meditation and similar approaches

• Biologically-based therapies ~ herbal remediesand dietary supplements

• Manipulative and body-based practices ~including massage therapy

• Energy medicine ~ Reiki, therapeutic touch,magnets, etc.

No doubt we would all be surprised by how manyof our patients use ~ and see improvement with ~these therapies. Do we who practice “convention-al medicine” have all the answers? The answer isNO. What truly works, no matter what form ofmedicine you are practicing, is creating an engagedpatient ~ one who takes an interest in his or herown health.

In this issue, our authors examine variousapproaches to non- traditional medicine, how theyare currently being used, and how they potentiallycan make your patients improve and feel better. Ifan alternative therapy is not harmful, seems towork, and motivates your patients to become moreinvolved in their own health care, then why arguewith success? Patients are likely to seek out anduse alternative therapies anyway. Therefore, asphysicians shouldn’t we become better educated

about non-traditional approaches?

If you still think “traditional medicine” has all the answers, justremember: many conventional medical treatments in the 1800swould be viewed as malpractice today. One hundred years fromnow, will what we are doing today will be viewed the same way?

Many “non-traditional” therapies have been around for centuries,are harmless and truly seem to help patients. Can we say the sameof traditional medicine? If you’re wondering, just read theInstitute of Medicine’s book To Err is Human and you will haveyour answer.

But even if a non-traditional remedy is seemingly helpful and ishelping the patient improve and become engaged in his or herhealth care, it’s still important to evaluate each and every alterna-tive therapy based on the phrase we all uttered upon becoming

Editorial

Non-Traditional TherapiesFact or FictionPeter C. Linblad, MD


non-traditional therapies

Cocaine, morphine, alcohol, mar-

ijuana, turpentine, arsenic, mer-

cury, radium, organophosphates

and water. These were the most

common ingredients of many of

the patent medicines that enjoyed

phenomenal success in the 1800s

and early 1900s.

But there was one more important

“secret ingredient” in the patent

medicine mix - advertising. Not

only did patent medicine promot-

ers pioneer colorful product names and claims, they also pio-

neered the techniques of advertising their potions directly to con-

sumers.

Patent medicines, or “Nostrum Remedium,” Latin for “our reme-

dy,” started in Great Britain in the 1600s and became popular in

the United States in the mid 1800s. Amazingly, the only require-

ment to market these medications was that the formula be owned

by the maker. Proving a medication’s effectiveness and safety was

not required.

Popular medicines of the period included Mud-Wump (for venere-

al diseases), Obtundia (an opium lotion for itch), Dr. Thurston’s

Death to Pain, Clark Stanley’s Snake Oil Liniment, Mrs. Winslow’s

Soothing Syrup (containing morphine and used for colicky babies).

Even Shredded Wheat, which was manufactured in Worcester

from 1895-1900, was originally invented by Henry Perky to ease

his own chronic indigestion.

Probably the most successful of all patent medicines was Lydia

Pinkham’s Vegetable Compound, which is still on the market today.

Lydia Pinkham (1819-1883) began manufacturing her famous

compound for “ailments peculiar to women” in Lunenburg, MA.

using roots from the local Mulpus Brook. She later opened a fac-

tory in Lynn. The reason for Pinkham’s phenomenal success?

Smart marketing and the fact that her vegetable compound con-

tained 20 per cent alcohol.

Many patent medications contained even stronger ingredients like

opium for common, everyday maladies such as colic, diarrhea,

pain, and headache. Even radium was routinely used by injection,

tablet, suppository or inhalation as a cure for baldness, impo-

tence, and aging (I guess back then a positive review of systems

would have included the question, “Do your stools glow in the

dark?”).

Some of the patent medications did prove to be extraordinarily

useful. In 1890s Germany, the Bayer Company found a better way

to synthesize acetylsalicytic acid and started manufacturing Bayer

Aspirin in 1899. Of course today “aspirin” is a generic name ~

Bayer lost its rights to the trade name in 1919 as part of Germany’s

concession at the end of WWI.

Strong Medicine:the Origins of Patent RemediesPeter C. Linblad, MD

Peter C. Linbald, MD

Several U.S. inventors developed other

remedies as enduring as aspirin. Jordan

Lambert, who later founded Warner

Lambert Pharmaceuticals, marketed a

mouth wash for halitosis named after

Joseph Lister. Listerine is, of course, still a

top brand today. Charles Phillips devel-

oped a remedy combining that combined

water and magnesium hydroxide and

called it Milk of Magnesia. In North

Carolina, Lunsford Richardson developed

a salve cold remedy named after his broth-

er-in-law, Joshua Vick, and Vick’s VapoRub

endures today.

But what happened to some of the disrep-

utable preparations? In 1905, Samuel

Hopkins Adams published the exposé “The

Great American Fraud” in Colliers Weekly

that eventually led to the first Pure Food

and Drug Act in 1906. Since then, patent

remedies became have become more tight-

ly controlled, driving many from the mar-

ket.

But notable exceptions have survived to

this day, although they may have changed

some of their original ingredients. They

include: Absorbine Jr., Bromo-Seltzer,

Fletcher’s Castoria, Geritol, BC Powder,

Carter’s Little Pills, Chlorodyne, Doan’s

Pills, Goody’s Powder, Luden’s Throat

Drops, and Smith Brothers’ Throat Drops.

Today, drug makers must disclose addic-

tive ingredients and harmful side effects.

But last year the pharmaceutical industry

spent a combined $2.5 billion advertising

directly to consumers. Just how far have

we come since the days of patent medi-

cines?

Peter LIndblad, MD, a WDMS Editorial Board Member, is a

board certified physician in Internal Medicine with Primary

Physician Partners, St. Vincent Hospital.




In 1971, when I returned to medical school from Zululand, hav-

ing witnessed that only breast-fed infants survived the infectious

and nutritional landmines of a Zulu baby’s life, I nearly flunked

a pediatric rotation, labeled a regressive hippie heretic for advo-

cating nursing over formula. The following year I found myself

staring at a pile of herbs a patient with tuberculosis was hiding

in his bedside stand at a prestigious Indian medical school and

thus discovered Ayurveda, the medical science of the Vedic cul-

ture of ancient India. I wondered whether a time-tested science

could survive the scrutiny of scientific inquiry and spent twen-

ty years wrestling with research designs to shed light on this

question. I have learned that such research is held to a higher

standard.

Traditional Ayurvedic practitioners feel that robust research

designs, examining one variable while keeping other conditions

the same, violate the spirit of their art. Ayurveda may be the

extreme example of a holistic medical science, targeting all

aspects of a patient’s life to effect affect the cure: mind, body,

behavior and environment. A proper Ayurvedic therapeutic pre-

scription for hypertension, for example, incorporates yoga,

meditation, weight control, exercise, a grain and dairy-based

diet low in salt and animal fats, “behavioral tonics” such as

singing and playing with children, and herbs (the first useful

“western” pharmaceutical for hypertension was rauwolfia, an

Ayurvedic tranquilizer). So how do you research the question,

“Can Ayurveda treat hypertension?” if the traditional interven-

tion is multifactorial? What foolish subject would submit to

sham yoga, meditation, exercise and herbs to function as a prop-

er control? Moreover, shouldn’t an ethical review board nix such

a study now that individually yoga, meditation, exercise, diet

and herbs have been found to improve blood pressure? You can

research the effect of an isolated herb, but that diminishes the

art of Ayurveda to herbal pill pushing, when its value lies in

altering the lifestyle and behavioral underpinnings of the dis-

ease. Studying only a part takes the Veda out of Ayurveda, mak-

ing this holistic science reductionistic, and moving both

Ayurvedic and western physicians to reject as poorly designed

the thousands of positive

studies. as poorly designed.

Meanwhile, in western med-

icine, we continue to kid

ourselves that our practice

is evidence-based while evi-

dence is lacking for most of

what we do. Reducing BP

has been shown in con-

trolled trials to reduce

stroke, CAD and mortality

only for a limited number of

agents, yet we extrapolate

the findings to any drug that

reduces blood pressure and are surprised when an agent turns

out to be harmful. Ditto for glucose reduction, cold medications

and others.i

Respected Ayurvedic masters focus on prescriptions affecting

consciousness, knowing the patient will adopt behaviors con-

ducive to her disorder. Indeed, research on Transcendental

Meditation has shown that practitioners, without encourage-

ment, reduce tobacco and normalize cholesterol, BP and weight,

but also reduce their risk of multifactorial pathological process-

es such as atherosclerosis. Inner city elderly blacks who started

TM had significantly reduced intimal thickening of the carotid

arteries after 6-9 months, compared to subjects who did progres-

sive relaxation, whose intima continued to accrue plaque.ii

Ayurveda is a Veda for ayu, the span of life, and includes within

its scope, yoga and meditation, also conceived for longevity and

spiritual growth. The research endpoint should therefore be

rejuvenation and freedom from disease. In a study of 1900 sub-

jects, long-term practitioners of TM and Ayurveda had higher

serum levels of DHEA-sulfate, which progressively declines with

age, that were comparable to non-practitioners 5-10 years

younger.iii Members of an Iowa corporate Blue Cross plan prac-

Is Research in Holistic MedicineHeld to a Higher Standard?Holistic research design: an oxymoron?Jay Glaser, MD

Jay Glaser, MD


ticing Ayurveda and TM had hospitalization

rates that were on average 60-70% lower

than similar Iowa BCBS plans in 17 disease

categories including cancer and heart dis-

ease (-87%). The only exception was obstet-

rics, showing that subscribers were using

health services when necessary ~ and that

these practices don’t make you celibate.iv

Elsewhere, analysis of Quebec Health

Insurance data showed that people begin-

ning TM had 2% yearly reductions in uti-

lization costs over fourteen years following

instruction compared to normative 12%

yearly increases. v Yet, these and other well-

designed studies showing we can change

health and its costs are ignored by clinicians

and by administrators planning health

budget priorities.

Is complementary medicine being held to a

higher standard of evidence? Or is it simply

easier to make token changes in our prac-

tice, like prescribing fish oil for coronary

risk reduction, rather than profoundly

affecting an unhealthy lifestyle? Like it or

not, yoga, like breast-feeding, has entered

the mainstream, and the radical, comple-

mentary medicine of a generation ago is

now the community standard. Good

research designs to document holistic med-

icine and the funding to carry studies out

will show us what we have to learn from

ancient physicians.

Jay Glaser, MD is a hospitalist at Leominster HealthAllianceHospital. Research on Ayurveda and its use in clinical practicecan be found on his web site, www.AyurvedaMed.com

References:i Nissen SE, Wolski K. Effect of rosiglitazone on the risk ofmyocardial infarction and death from cardiovascular causes.NEJM 356:2457-2471

ii Castillo-Richmond A, et al., Effects of stress reduction oncarotid atherosclerosis in hypertensive African Americans,Stroke: Journal of the American Heart Association. 2000;31:568-573.

iii Glaser JL et al. Elevated serum dehydroepiandrosterone sul-fate levels in practitioners of the Transcendental Meditation(TM) and TM-Sidhi Programs. Journal of Behavioral Medicine.1992;15:4, 327-341.

ivOrme-Johnson DW. Medical care utilization and theTranscendental Meditation program. Psychosomatic Medicine,1987;49:493-507.

v Herron R, Hillis S. The impact of the TranscendentalMeditation program on government payments to physicians inQuebec: an update. American Journal of Health Promotion.2000; 14(5):284-291.

Reiki is defined as universal spirit or ener-

gy which permeates all living forms.

Ancient civilizations understood that this

life force energy flows through the body

supporting optimal development and ful-

fillment ~ the mind body connection.

Reiki induces the relaxation response.

Studies show that this deep state of relax-

ation acts through the autonomic nervous

system to lower blood pressure and heart

rate and relieves tension and anxiety. This

deeper state of relaxation augments the

abilities of the immune system and stimu-

lates the production of endorphins to

decrease the perceptions of pain and create

a sense of well being.

Reiki has been incorporated into many

hospital and clinic settings throughout the

country in pre op, post op, labor and deliv-

ery and chronic care units. The general

public is increasingly interested in this and

other modalities of complementary health

care.

Reiki therapy is applied through an

attuned, trained practitioner to a willing

recipient by a series of hand placements on

or above the body. The practitioner acts as

a conduit for the energy to flow in a non-

invasive method.

Reiki is particularly helpful in the hospice

and palliative care settings. Reiki requires

the positioning of the therapist’s hands but

does not require any special positions of

the patient nor is it necessary to remove or

necessitate the removal of clothing; both

are advantages. This is a valuable tool for

the hospice population who may be

extremely debilitated. The Reiki energy

complements the clients’ medical regime

by enhancing the quality of life, a basic goal

of hospice care. It is an adjustment to the

medical treatment and has been found to

be helpful with end of life patients afflicted

with Alzheimer’s disease as well. Reiki

brings relaxation, peacefulness and a sense

of warmth.

The Hospice program of the UMass

Memorial Medical Center has incorporated

Reiki into its Massage Therapy program.

These complimentary services are offered

not only to hospice patients but to children

in the newly established Pediatric Palliative

program.

Family evaluations strongly indicate that in

the adult population relief of anxiety is evi-

dent after a session of Reiki or massage

therapy. The promotion of peacefulness

and restful sleep after each session was well

noted.

The effects of the one to one energy touch

in hospice should not be underestimated in

providing quality in end of life care.

June Bessette is certified in Reflexology and Level I Reiki. Shehas worked for UMass Memorial Hospice for 10 years, the last5 years as a massage therapist. June still fills in as a nursewhen needed.

References:Barnett, L and Chambers, M, Reiki Energy MedicineHealing Press 1996

Bullock, M, RN, BSN “Reiki: A complimentary Therapy forLife,” The American Journal of Hospice and Palliative Care,Jan/Feb 1997

Rand, William Lee, Reiki - The Healing Touch, expandededition

Visions Publications, 2000

The Value of Reiki and Massage TherapyJune Bessette, BSN, RN, LMT




Self-medication with herbal products for preventative or thera-peutic purposes has greatly increased in recent years. Many peo-ple assume that because herbal products come from nature, theyare “natural” and safe to use. In fact, herbal products, like anyother exogenous chemicals (including medications), have thepotential to cause adverse effects and interact with foods and med-ications. In addition, a lack of product standardization, and thepotential for contamination and allergic reactions, pose inherentrisks associated with the use of herbal products. Herbal productsare medicines and should not be used without proper guidancefrom a healthcare professional. Many patients, however, believethat healthcare practitioners have negative attitudes toward or arenot well informed about dietary supplements. In turn, many prac-titioners are reluctant to discuss herbal therapies because they areunfamiliar with or skeptical of alternative treatments.

Under the Dietary Supplement and Health Education Act of 1994,herbal products are classified as dietary supplements (not asdrugs) and are not under the auspices of the FDA. As a result,herbal products are not regulated under federal drug laws; safetyand effectiveness need not be demonstrated before these productsare marketed. No legal standards are applied to their harvesting,processing, or packaging ~ so the possibilities of poor quality,adulteration, contamination and varying strengths must be kept inmind when evaluating them. Manufacturers of dietary supple-ments can make claims about the ability of the product to alterstructure or function but implied, as well as expressed, claimsregarding the treatment, cure, or prevention of disease cannot bemade. The FDA becomes involved in safety issues for herbal prod-ucts only after they are on the market and complaints are filed.Unlike a drug, which must establish efficacy and safety to be mar-keted, herbal products can be marketed until proven to be unsafe.

In recent years, there has been an explosion of references aboutnatural products. This review will assess the usefulness of some ofthe most common and most easily accessible tertiary references(Table 1) that healthcare professionals employ to answer questionsabout herbal products and dietary supplements. This informationis intended to assist healthcare professionals to more efficientlyselect a helpful collection of resources to handle requests concern-ing herbal products and dietary supplements in their practice set-ting.

Overall, AltMedDex, Natural Medicines Comprehensive Database,The Review of Natural Products, and The Natural Standard have con-sistently proven to be the most comprehensive and helpful refer-ences, but can be more expensive than more traditional hardcopyreferences (1, 2, 3, 4). The electronic format of these four databas-es allows for frequent updating (daily-monthly) and search byindividual ingredient or by product brand name. AltMedDex isavailable as part of Micromedex; the high cost, however, precludesindividual subscription (1). The Natural Medicines ComprehensiveDatabase, The Review of Natural Products and The Natural Standardprovide objective, comprehensive, and evidence-based clinicalinformation on natural medicines (2, 3, 4). Information regardinghistory, purported uses, safety, effectiveness, adverse effects, inter-actions, dosing, and use in pregnancy and breastfeeding is pre-sented in peer-reviewed monograph format. Information is refer-enced and rating scales (different for each database) are used toevaluate the quality of evidence.

Internet sites for use by healthcare professionals include TheAmerican Botanical Council (ABC) and the National Center forComprehensive and Alternative Medicine (NCCAM) (5, 6). TheABC is a non-profit organization and requires a yearly subscrip-tion that includes access to HerbGram (a quarterly, peer-reviewedjournal), continuing education materials for healthcare profes-sionals, and herbal information sheets for duplication and distri-bution patients and consumers (5). The NCCAM (a governmentalagency that is a part of the National Institutes of Health) sponsorsand conducts research using scientific methods and advancedtechnologies to study CAM (6). Information on this site is gearedtoward both the public and healthcare professionals.

Numerous herbal information resources are available as boundtextbooks. Publication dates vary considerably and some com-monly used resources do not provide the most updated informa-tion. The print versions of Natural Medicines ComprehensiveDatabase and The Review of Natural Products are updated annually(7, 8). In 1978, the German government established an expertcommittee, the Commission E, to evaluate the safety and efficacyof over 300 herbs and herb combinations sold in Germany.Published in 1998, the Complete German E CommissionMonographs provides information on the approved uses, con-traindications, side effects, dosage, drug interactions and othertherapeutic information for the use of herbs and phytomedicines

A Review of Herbal ReferencesAnna K Morin, PharmD & Michele Matthews, PharmD



(9). In 2000, Herbal Medicine: ExpandedCommission E Monographs was published toaddress deficiencies of the previous publi-cation with added overviews of clinicalresearch, expanded sections on chemistryand pharmacology, more on dosage andadministration, and a comparison chart ofleading herbal brands (10). Producedunder the direction of the RoyalPharmaceutical Society of Great Britain,Herbal Medicines: A Guide for HealthcareProfessionals is organized around 141monographs on individual medicinalplants and has a number of quick referencetables (11). Each monograph includesspecies, synonyms, plant parts used, legalcategory of product (in Great Britain), con-stituents, food use, herbal use, pharmaco-logical actions, side effects and toxicity,contraindications and warnings, and refer-ences (11). The Physician’s Desk Referencefor Herbal Medicines includes over 700monographs, compiled using the GermanCommission E indications, that have beenupdated to include recent scientific find-ings on efficacy, safety and potential inter-actions (12). There are also updated sec-tions on enhanced patient management

techniques and nutritional supplements(12). The well-known Tyler’s Honest Herbalincludes botanical information, folkloricbackground, plant sources, traditionaluses, evaluation of literature, and laws andregulations pertaining to greater than 100commonly used herbs (13). Tyler’s Herbs ofChoice augments Tyler’s Honest Herbal (butthe two texts do not need to be purchasedtogether) and discusses the practical thera-peutic application of herbal remedies forover 100 health problems with chaptersorganized by disease states or symptoms(14). An updated edition of Tyler’s Herbs ofChoice is expected in 2008.

Practitioners should be aware of the infor-mation regarding efficacy and safety ofherbal products so that they can provideguidance regarding herbals that may affecttheir patients’ health or current therapeuticregimens. Reviewing current medical liter-ature will provide limited information onherbal products. While some researchstudies have been published, most are inlanguages other than English. Data sup-porting safety and efficacy are weak due tostudies of few subjects, short duration of

treatment, and varying dosesand formulations of the prod-ucts. Due to rising consumeruse of herbal products, the lackof conclusive evidence forthese products, and theabsence of formal didactictraining in alternative medi-cines, practitioners must relyon herbal textbooks and data-bases as a source of primaryinformation. When selectingherbal references, practitionersshould evaluate the type ofquestions they expect toencounter, the format of theresource they would be mostlikely to use, the timeliness ofthe information presented, andthe cost.

Anna K Morin, PharmD is AssistantProfessor in the Department of PharmacyPractice at the Massachusetts College ofPharmacy and Health Sciences inWorcester, MA. Email:[email protected]

Michele Matthews, PharmD is AssistantProfessor in the Department of Pharmacy Practice at theMassachusetts College of Pharmacy and Health Sciences inWorcester, MA.

References:

AltMedDex® system. Greenwood Village, CO:Micromedex. Available at http://micromedex.com/prod-ucts/altmeddexTherapeutic Research Center. Natural MedicinesComprehensive Database. Available at: http://naturaldata-base.comFacts and Comparisons 4.0. The Review of NaturalProducts. Available at: http://factsandcomparisons.comUlbricht C, Basch E, eds. The Natural Standard. Availableat: http://naturalstandard.comThe American Botanical Society. Available at:http://abc.herbalgram.orgNational Center for Complementary Alternative Medicine.Available at: http://nccam.nih.govJellin JM, ed. Natural Medicines Comprehensive Database.Stockton, CA: Therapeutic Research Center; 2007.Dermarderosian A, ed. The Review of Natural Products: TheMost Complete Source of Natural Product Information, 4thed; St. Louis, MO: Facts and Comparisons; 2005.Blumenthal M, Busse WR, Goldberg A, et al. eds. TheComplete German Commission E Monographs:Therapeutic Guide to Herbal Medicine. Austin, TX:American Botanical Council; 1998.Blumenthal M, Goldberg A, Brinckmann J, eds. HerbalMedicine: Expanded Commission E Monographs. Newton,MA: Integrative Medicine Communications; 2000.Barnes J, Anderson LA, Phillipson JD, eds. HerbalMedicines: A Guide for Healthcare Professionals, 2nd ed.London, UK: Pharmaceutical Press; 2002.Physician’s Desk Reference for Herbal Medicines, 4th ed.Thompson Healthcare; 2007.Foster S, Tyler VE. Tyler’s Honest Herbal: A Sensible Guideto the Use of Herbs and Related Remedies, 4th ed. NewYork, NY: The Hawthorn Herbal Press; 1999.Robbers JE, Tyler VE. Tyler’s Herbal Choice: TheTherapeutic Use of Phytomedicinals. Binghamtom, NY:Hawthorn Press; 1999.


Oh, east is east, and west is west, and never the twain shall meet,till earth and sky stand presently at God’s great judgment seat.

Rudyard Kipling (1865 – 1936)

The times have proven Mr. Kipling to be wrong. Visit any partof the world and the power of globalization is evident, the worldbecoming a happy blend of east and west. But medicine may bethe exception, where “western medicine” has become dominant.China is the exception in that Traditional Chinese Medicine(TCM) is still very active. But frankly speaking, physicians inthe United States know little of TCM and TCM has not integrat-ed the contributions of western science. Both are reluctant totake into account the other, each quite content to do its ownthing.

Though acupuncture and other forms of treatment in TCM arestill controversial, there is strong reason to believe that, for atleast some patients, these treatments may be a good option.Considering that each year in America over 2 million patientssuffer from serious adverse drug effects, TCM may provide a safeand effective alternative or complement. While acupuncture isnot without some risk, with cases of serious complicationsreported, overall TCM is a natural form of therapy, workingthrough enhancing the body’s own self-healing capabilitiesrather than vigorously attacking the disease agent, and thereforeis relatively safe if performed correctly.

I have seen first-hand its effectiveness. This was while I was atthe Longhua Hospital in Shanghai, where I went as a medicalstudent for a 3 month acupuncture training program at theShanghai University of Traditional Chinese Medicine. Manypatients swore by it. For example, one patient had been smok-ing for several years and had tried to quit numerous times butnothing seemed to work for him, including the patch; however,after just that one acupuncture treatment he’d been able to cutback from 2 packs per day to just 2 cigarettes daily.

Perhaps the greatest testament to acupuncture’s efficacy is itswidespread use in China for over 2000 years. Currently, over200 million patients are seen each year in the over 2,500 TCMhospitals in China. There are over 350,000 full-time TCM doc-tors in China, each of which whom has undergone a rigorous 5year training. TCM is also rapidly spreading throughout the

world, with more than 120 regions having set up TCM clinics.America is no exception to this popularity, with over 8 millionAmericans having tried acupuncture.

Despite this increasing popularity, many westerners remainsceptical about TCM. So where do we go from here? We firstneed to more convincingly answer the question, “Does acupunc-ture work?” Global and U.S. organizations, like WHO and theNIH, have “softly” endorsed acupuncture, listing a variety ofconditions for which acupuncture may be indicated based onthe clinical evidence. Strictly speaking, however, the evidenceto date is spotty, with a paucity of trials involving “sham”acupuncture controls, making it difficult to decipher psychoso-matic effects from true therapeutic benefit.

Second, we need to answer “Why does acupuncture work?”With regard to relief of pain we do have some ideas, with grow-ing evidence of an effect through the nervous system anddemonstration that endorphins, the “pleasure chemicals” in thebrain, are released in response to acupuncture. Our understand-ing of how acupuncture works for other ailments, however, isvery limited, and more controlled trials with measurements ofobjective parameters are needed.

Third, TCM theories and treatments, which have remainedlargely unchanged for thousands of years, need to be updated.For instance, acupuncture is believed to work in TCM throughan invisible energy, an idea that arose based on ancient Chinesereligious beliefs rather than science. Descriptions of certainorgan functions, which have bearings on which points are cho-sen for puncturing, are also clearly contradicted by what is nowknown in medical science.

My experience in China impressed me and has made me enthu-siastic, as I have personally seen many of the patients I workedon improve. Some of my classmates have treated themselves(e.g., for migraine headaches) and found relief. Acupunctureappears to work for pain-relief and other conditions and is asafer and more pleasant therapy than drugs or surgery. Butacupuncture today appears not to have incorporated theadvances that western medicine can offer. More collaborationbetween acupuncture and western medicine can result in a treat-ment that is more effective, better understood and more widelyused.

Traditional Chinese Medicine ~Can East Meet West?Richard DeSouza, M.D., University of Massachusetts MS1V


as i see it

Pay for performance has

been implemented by CMS

on a pilot basis and by multi-

ple insurers because our cur-

rent payment system and

incentives are not aligned

with the IOM's six quality

aims.1 The goal of the P4P

pilot was to create incentives

to better performance by evi-

dence based medicine for

selected disease states.

CMS selected ten group prac-

tices and launched the Medicare Group Practice Demonstration

in April 2005. It measured the ten groups on their performance

in diabetic management: HbA1c management, HbA1c control,

LDL levels, testing for urine protein, pneumococcal vaccination,

lipid measurement, diabetic eye exams, foot exams, influenza

vaccination and blood pressure management.

My concern, shared by many, was that CMS would measure cost

savings, not quality of care. It linked quality care to immediate

cost savings ~ which it would allegedly share with the groups,

giving back some of the savings as a bonus.

The first year results are in! If you read the AMA News2, you'd

know that two of the ten groups hit all ten targets. All groups

met at least seven of the ten clinical quality measures. Yet only

two groups got bonuses and that included only one of the two

groups hitting all the quality measures! Why did eight group

practices actually lose money (they invested in systems and

processes) rather than get bonuses? They did not save Medicare

enough money to trigger payouts based on Medicare's mid-

stream rule change. CMS says that more practices could get

bonuses the second year and onward by learning lessons from

the first year. I think the lesson learned is not to trust CMS's

promises. Apparently saving money trumped improving quali-

ty as the real goal and the trigger for payouts.

This was a high profile year, with much attention and focus. I

shudder to think what might happen in future years, when the

concept is routinely operational rather than a small-scale high

visibility pilot.

The espoused goal of P4P is to improve health care and reduce

spending cost. Some up front programs can be very effective in

creating incentives for physicians to operate under best prac-

tices. We saw that in the results of the CMS pilot project. The

problem is that while we can be more effective where there are

clearly defined best practices, those areas are small compared to

those where there are none. If we divide medical procedures

into three groups3 ~ effective care (with best practices), prefer-

ence sensitive care (which may include trade offs on quality and

duration of life), and supply sensitive care (how many visits

should a patient with congestive heart failure have?) ~

Wennberg estimates 50% of all medical spending is in the third

group!

Then there is the potential for the moral hazard in P4P. First is

the huge focus on the first group of patients. Here we have a

shift in resources to “perfect” care of certain aspects of some

patients from other aspects of those patients and patients with

other problems. We spend much time and energy and develop

systems specifically to address those aspects of best practices

that will result in payoffs. Maybe. Second, as a recent survey

showed, roughly one quarter of our basis for best practices (the

“evidence base”) changes and goes out of date every two years.

Anyone think CMS (or other insurers) will keep up that quick-

ly? Can you see yourself changing your practice to a new best

practices and getting penalized? Third, the guidelines that

insurers (and we) use are imperfect. While there are nearly

2000 clinical practice guidelines listed in the National Guideline

Clearinghouse, there are at least two issues: we have to make

clinical decisions on living patients, not a dataset fitting into a

cubbyhole, and many studies on which these guidelines are

based included too few patients of the set most often evaluated

and treated!4 (The example cited is congestive heart failure,

wherein many trials included few older patients ~ those we treat

P4P ~ The Moral Hazard or theMoral High Ground?Marc Greenwald, MD

Mark Greenwald, MD



most often for heart failure. Are the

guidelines right despite that?)

And then there is the potential for adverse

selection. If you create the best systems

for dealing with (for example) diabetic

patients, you'll attract more, including the

ones whom you may never be able to

“control.” Remember the No Child Left

Behind Act?5 Texas did very well ~ by

making the very students who were more

likely to fail and drop out disappear into

thin air! In some school districts, up to

40% of students vanished. The Texas

Commissioner of Education decided to

disregard unilaterally the NCLB require-

ments for testing students with learning

disabilities.6

Tufts-NEMC found that they had the low-

est mortality for stroke patients admitted

to academic institutions in 2003, but the

second worst in 2004.7 The low rate was

statistically significant, but the high rate

did not statistically differ from the cohort

for 2004. Their procedures had not

changed year to year. The explanation?

The insurer focused on the difference in

mortality rate and translated that into a

quality issue. Yet there was no attempt to

understand that the DRG encompasses

diagnoses that have significant variations

in severity: ischemic stroke, hemorrhagic

stroke, acute subdural hemorrhages and

subarachnoid hemorrhages. An intensive

review failed to find quality of care issues

but did find a significant increase in

patients with a diagnosis of cerebral hem-

orrhage, accounting for most of the mor-

tality difference. I suspect this kind of

problem is not isolated.

One of the most ambitious P4P projects is

between general practitioners and the

United Kingdom's National Health

Service. Doctors who can satisfy 76 qual-

ity indicators in ten clinical domains of

care can receive 50% more in government

compensation. But by gaming the hyper-

tension management criteria, each prac-

tice could get an additional $1800 annu-

ally. How? While there is a penalty for

not recording blood pressure at least once

every nine months, a practice could

exclude that value for patients who do

not meet the trigger BP level and instead

record the BP more often on an equal

number of well controlled patients!

We have high ethical standards. Yet I sus-

pect there are practices that might termi-

nate relationships with the very patients

who need them the most because the

patients' lack of control or compliance

would compromise the practices' chances

of getting the P4P reward. Then CMS and

other insurers will add a whole new over-

lay of rules and regulations on terminat-

ing patients, and we'll be faced with

another set of problems. And “we,” as

usual, generally applies to those who fol-

low the rules in the first place.

How do financial rewards for P4P stack

up? There are many reports across the


country. One model is Hill Physicians

Medical Group, a 2100 physician group

with headquarters in Ramon, California.

They have an internal system that rewards

physicians based on individual quality

performance (HEDIS and other targets)

up to 30%, with an average bonus payout

of 15% (or $10,500 quarterly). At the

same time, nevertheless, the external P4P

bonuses reached only 1% of gross rev-

enues. Most group practices do not

reward performance to the extent that

Hill does. Even at Hill, one out seven

physicians gets no bonus.8 For the

amounts most practices bonus, the indi-

vidual physician financial incentive is an

order of magnitude less.

So where do we go from here? How do

we take the best care of patients we can,

avoid penalties, and avoid adding work

onto the backs of already overworked pri-

mary care physicians to meet best prac-

tices (where they exist)? I suggest we

redefine P4P as “Perform for Patients.”

We need to do the right thing for all our

patients, where “right thing” is well-

defined by high quality evidence from

appropriate patient populations, and do

the right thing as physicians and decision-

making partners for those for whom

“right thing” may be partially or wholly

subjective and a matter of personal

choice. We need to delegate to our lead-

ers (physicians and administrators) and

lobbyists the task of defining quality for

government and insurers as it truly relates

to the practice of medicine and getting us

rewarded properly; in the meantime,

though, we should take the high road and

work for our patients. We should task

our leaders to go beyond current EHR

systems (for which there is painfully little

evidence of intrinsic improvement in

care) to systems that actually help us do

all the things patients need when those

interventions are proven and defined. We

need systems that are flexible in order to

keep up with the rapid changes in evi-

dence-based medicine. And we need

leaders who recognize that we should

supply “everything each patient needs in

a timely fashion and nothing each patient

doesn't need.”

Marc Greenwald, M.D., Chief of Medicine at BrocktonHospital, is also president of MLM Consulting, focusing onquality assurance and outcomes systems for hospitals andon patient service training for physicians. The opinions inthis article do not necessarily reflect those of BrocktonHospital or the Worcester District Medical Society.

References:1 Crossing the Quality Chasm, 20012 August 6, 20073 John Wennberg, Dartmouth Medical School4 Krumholz, Harlan. Guideline Recommendations andResults: The Importance of the Linkage. Annals of InternalMedicine, vol. 147, No. 5, September 4, 2007.5 20016 Stateline.org, July 7, 20057 Hwang, et al. A Review of Stroke DRG Mortality Rate asa Quality of Care Measure. AANS Bulletin, vol.16, No. 2,2007.8 Weber, David Ollier, The Physician Executive, May - June2004


as i see it

The phone call from the doctor confirmed that the source of thepain in my left hip was cancer. I had first gone to the doctorcomplaining of a slight pain in my left hip in February 2001 andhere it was July. I had been to the recommended chiropractor,had numerous x-rays which revealed nothing, and had spentcountless hours in physical therapy until the pain had becomeso intense that I could no longer endure it.

This was my second cancer experience; the first was in 1993.Then it was a small lump (no surrounding tissue involvementand all lymph nodes were clean) in my left breast. The treat-ment that time was a lumpectomy, radiation, and Tamoxifen. Ihad my concerns about Tamoxifen because I had read that onepotential side effect might be uterine cancer. I was, however,declared cancer free.

In 1995, my annual pap smear and exam revealed that myuterus walls were thickening. My gynecologist recommended abiopsy; it showed I had endometrial hyperplasia, which I wastold could be the early stages of uterine cancer. Several monthslater, heavy bleeding confirmed that the condition had worsenedand at that point, a complete hysterectomy was recommended.

It was then that my daughter suggested I see a naturopathic doc-tor. I did, and she recommended 3 homeopathic remedies. Iimmediately followed her advice and informed my gynecologistthat I had decided against a hysterectomy; she thought I wasmaking a poor decision and asked that I consent to a D&C andhysteroscopy in 2 months. I agreed. When the procedure wasdone, my gynecologist happily informed me that there was nosign of endometrial hyperplasia and that my uterus looked per-fectly normal. This news was followed up with several biopsiesat 3 month intervals which proved that my uterus had indeedreturned to a completely normal state.

I was totally devastated with the second cancer diagnosis. Howcould my body have betrayed me again? I was told that thetumor on my hip, another breast cancer, was attached to bone,tissue, and muscle. Surgery was out of the question. I was toldthat I had approximately 3 years to live and that those yearswould be, most likely, dedicated to treating my cancer. Onceagain, I agreed to radiation. I also contacted the naturopathic

doctor who had cured the endometrial hyperplasia. She referredme to another naturopathic doctor who had successfully beentreating breast cancer for over 20 years.

This was a huge step for me to take but I felt strongly that Ineeded to pursue another course of action. I started on a verystrict regiment of holistic remedies, including monthly REIKIand body works therapy, in September of 2001. The naturo-pathic doctor explained to me that everyone has cancer cells.The critical issue then becomes what each person’s immune sys-tem does with those cells. A well working immune system willnot allow these cancer cells to grow into tumors while a com-promised immune system like mine cannot stop the process.I’ve had both Crohn’s Disease and Graves’ Disease.

Now, more than 6 years after I started with naturopathic medi-cine, I am cancer free and living a perfectly normal and healthylife, aside from all the extracts and supplements that I take eachday. I have no aches, no pains, no ailments. As a result of myongoing experience with naturopathic medicine, I have recom-mended the same for many people with all types of problemsfrom dry skin and cracked nails to ALS to cancer to high bloodpressure to thyroid disease to arthritis and so much more. Theone thing that they all have in common is that their ailmentshave been arrested with naturopathic medicine.

I have also altered the way I eat to exclude all meats and farmraised fish. The rationale behind this decision was simply thatfarmers will feed their livestock hormones in order to increasethe size and, consequently, the monetary value of their product.My cancers were both hormone receptor positive. I have no ideaif the hormones used by farmers contain either estrogen or prog-esterone, but I’d rather be safe than sorry. I am also very carefulwith the produce and diary products that I eat and always seekout the organic varieties.

I thank God every day for my life, the quality of it, and the won-derful people in it who supported and cared for me throughhard times. I hope they know that they have made a difference.

Cancer ~ Choices and DecisionsA Patient's PerspectiveJanet Letourneau


science corner

A probiotic is a live microbe that, whenadministered in adequate amounts, con-fers a health benefit to the host. Anincreasing awareness of the importance ofprobiotics in the United States has fol-lowed the publication of studies reportingremedial effects on a variety of gastroin-testinal (GI) disorders, allergic condi-tions, and vaginal infections. Mostresearch has focused on the potential roleof probiotics in disorders of the GI tract.

Probiotics occur naturally in fermentedfoods such as yogurt, kefir, sauerkraut,kimchi, and soybean-based miso and

natto. The most common commerciallyavailable forms of probiotics are dairyproducts and probiotic-fortified foods.However, tablets and capsules containingthe bacteria in freeze-dried forms are alsoavailable. Genetically engineeredmicrobes designed to deliver specificproducts to the GI tract are being devel-oped.

The precise mechanisms of probioticaction have not yet been fully established.However, based on the standard defini-tion, a probiotic is understood to be non-pathogenic and viable at the time of con-

sumption and following contact with gas-tric acid and bile salts. After overcomingchemical barriers, probiotics adhere tothe intestinal surfaces where they com-pete with pathogenic agents and modu-late the host’s inflammatory and immuneresponses. Probiotics do not multiplyquickly and therefore, they do not perma-nently colonize the digestive tract. Inaddition to inhibiting the growth of othermicrobes by increasing intestinal acidity,producing metabolically active proteins(i.e., bacteriocins) and competing fornutrients and intestinal adhesion recep-tors, probiotics promote digestion.

Probiotics Microbes to the RescueDeepu A. Thomas MD, George Abraham, MD, MPH, and Anthony L. Esposito, MD

~


Probiotics also have the potential to stim-ulate the immune function of the gutassociated lymphoid tissues, enhancemucosal barrier function, and induce T-cell apoptosis in the lamina propria.

The impact of different probiotics on aparticular disorder varies. Moreover,alternate strains of the same species mayexert different probiotic functions. Suchresults are typical among divergent strainsof Lactobacillus. Mechanisms that lead tospecific health effects are often notknown. When these are better under-stood, it may be possible to predict func-tionality in vivo. Thus, clinical trialresults from one probiotic in one popula-tion cannot be generalized to other strainsor to different populations.

Although a listing of all studied probioticsis beyond the scope of this article, an out-line of agents demonstrating promise inspecific conditions is noted below.

1. Prevention and treatment of GI infec-tions:• Saccharomyces boulardii• Lactobacillus casei DNA-001• Bifidobacterium lactis BB12

2. Lactose intolerance:• Lactobacillus acidophilus NCFM

3. Helicobacter pylori infection:• Lactobacillus johnsonii La1 (Lj1)

4. Gastrointestinal inflammatory dis-eases:• VSL#3 - inflammatory bowel disease,pouchitis • Lactobacillus salivarius UCC118 -active Crohn’s disease • Escherichia coli Nissle 1917- mainte-nance of remission in ulcerative colitis

5. Irritable bowel syndrome:• Lactobacillus plantarum 299V • Bifidobacterium infantis 35624

6. Hepatic encephalopathy:• Lactobacillus acidophilus

7. Allergy symptoms:• Bifidobacterium longum BB536• Lactobacillus reuteri

8. Vaginal infections (candidiasis andbacterial vaginosis):• Lactobacillus rhamnosus GR-1 (LGG)and Lactobacillus reuteri RC-14

Antibiotic associated disease due toClostridium difficile (C. difficile) is aprevalent, serious and costly problem inhealthcare facilities. Central to the patho-genesis of the disorder is the disruption ofthe normal colonic flora by antimicrobialsand the overgrowth of institutionallyacquired and toxin producing C. difficile.The concept that an innocuous microbemight prevent or treat disease due to C.difficile has appeal. Indeed, studies haveshown that probiotics given prophylacti-cally (Lactobacillus casei, Lactobacillusbulgaricus and Saccharomyces ther-mophilus) can reduce attack rates of C.difficile in adults receiving antibiotics.Other probiotics (Saccharomycesboulardii) enhance the response rates ofpatients with C. difficile who are treatedwith vancomycin or metronidazole.However, the available data remain limit-ed and as a result, a firm role for probi-otics in disease due to C. difficile has notyet been established. Similarly, promisingdata in support of probiotics for simpleantibiotic-induced diarrhea need to besupplemented with larger studies.

Probiotics have been widely used in foodproducts for the past several years andhave an excellent safety record. However,there have been several case reports sug-gesting that their use in high-risk individ-uals, especially premature infants anddebilitated or immunocompromisedadults, might cause sepsis. For example,S. boulardii has been associated withfungemia, and Lactobacillus rhamnosusand other lactobacilli have caused bac-teremia in patients with severe underlyingillnesses.

In summary, probiotics have been shownto be effective in managing a wide range

of clinical conditions in both children andadults. Although there is a mounting listof health benefits provided by the con-sumption of probiotics, their precisemechanism of action remains largelyunknown. Current guidelines suggestthat strain specific probiotics are to beadministered only for clinically provenconditions and in appropriate doses basedon the levels found to be efficacious inhuman studies. Further research will benecessary to define the conditions forwhich probiotics might prove beneficialand to expand knowledge regarding theirtherapeutic actions.

Drs. Deepu A. Thomas, George Abraham and Anthony

L.Esposito are with the Department of Medicine, St. Vincent

Hospital.

SELECTED READING

Bai AP and Ouyang Q. Probiotics and inflammatory boweldiseases. Postgrad Med J 2006; 82:376.

Boyle RJ, Robins RM, et al. Probiotic use in clinical prac-tice: what are the risks? Am J Clin Nutr 2006; 83:1256.

Chen CC and Walker WA. Probiotics and prebiotics: role inclinical disease states. Adv Pediatr 2005; 52:77.

Falagas ME, Betsi GI, and Athanasiou S. Probiotics for pre-vention of recurrent vulvovaginal candidiasis: a review. JAntimicrob Chemother 2006; 58:266.

Floch MH, Madsen KK, et al. Recommendations for probi-otic use. J Clin Gastroenterol 2006; 40:275.

Guandalini S. Probiotics for children: use in diarrhea. JClin Gastroenterol 2006; 40:244.

Hammerman C and Kaplan M. Probiotics and neonatalintestinal infection. Current Opin Infect Dis 2006; 19:277.

Katz JA. Probiotics for the prevention of antibiotic-associ-ated diarrhea and Clostridium difficile diarrhea. J ClinGastroenterol 2006; 40:249.

Madsen K. Probiotics and the immune response. J ClinGastroenterol 2006; 40:232.

Marco ML, Pavan S, and Kleerebezam M. Towards anunderstanding of molecular modes of probiotic action.Curr Opin Biotechnol 2006; 17:204.

Nichols AW. Probiotics and athletic performance: a system-atic review. Current Sports Med Rep 2007:6:269.

Probiotics. Have they been shown to be effective? MedicalLetter 2007;49:66.

Riordan SM and Kim R. Bacterial overgrowth as a cause ofirritable bowel syndrome. Current Opin Gastroenterol2006; 22:669.

Rioux KP and Fedorak RN. Probiotics in the treatment ofinflammatory bowel disease. J Clin Gastroenterol 2006;40:260.

Szajewska H, Setty M, et al. Probiotics in gastrointestinaldiseases in children: hard and not-so-hard evidence of effi-cacy.

legal consult

This summer, the Governorsigned into law a newstatute, Chapter 93H of theGeneral Statutes, that, effec-tive October 31 of this year,imposes notice requirementson entities that maintain,store, own or license “per-sonal information.”Although the new state lawis intended to be consistentwith federal requirements,such as the HIPAA securitystandards, it goes far beyondHIPAA in its scope and prac-

tical consequences for health care providers.

The HIPAA security standard applies only to protected healthinformation that is electronically stored or transmitted; the statelaw is much broader. It covers personal information, which is aperson’s name plus one of that person’s Social Security number,driver’s license number or personal identification number orpassword. A breach of security that triggers the law’s require-ments is an unauthorized acquisition or use of unencrypteddata: “data,” for purposes of the state law, includes “…anymaterial upon which written, drawn, spoken, visual, or electro-magnetic information or images are recorded or preserved,regardless of physical form or characteristics.” Thus, the statelaw can apply to the protected health information covered byHIPAA but also to many kinds of other data, such as includingemployment records, that may be maintained by a health careprovider.

Not only does the state law apply to a larger set of data held byhealth care providers, but it is also written in such a vague wayas to make it difficult to know if a given incident triggers thelaw’s notice requirements. The state law requires holders of per-sonal information to issue notices in the event of a “breach ofsecurity,” which is an unauthorized acquisition or use of suchinformation “…that creates a substantial risk of identity theft orfraud” against a Massachusetts resident. An unauthorizedacquisition of personal information in good faith is not a secu-rity breach unless the personal information is used in an unau-

thorized manner or thereby becomes subject to further unau-thorized disclosure. It may be difficult for a holder of personalinformation to know, first, whether such a breach of security hasin fact occurred, and, second, whether the unauthorized disclo-sure has created the “substantial risk” required by the statute. Itmay therefore be difficult for holders of such information toknow whether the law’s notice requirements are triggered.

Contrast the state law’s language with the HIPAA security stan-dard, which requires that the holder of the information takesteps to “…mitigate, to the extent practicable, harmful effects ofsecurity incidents that are known” to that holder. The federalstandard is both more limited in its applicability to a carefullydefined set of data and more realistic in requiring the holder ofthe information to take only practicable steps and only inresponse to known security incidents. The state law is so vaguethat it is hard to know whether its application will result in toomuch compliance (that is, notification of affected individualswhere the unauthorized access to data does not really present a“substantial risk” of theft or fraud) or too little compliance (afailure to notify affected individuals because the holder of theinformation may not be aware of the fact that a security breachhas occurred).

What is not unclear is what the statute requires if the breach ofsecurity actually takes place. Any owner or licensee of person-al information who knows or has reason to know of a breach ofsecurity will notify the Massachusetts Attorney General, theDirector of Consumer Affairs and Business Regulation and theaffected individuals. “Notice” here means written notice, elec-tronic notice in certain circumstances or “substitute notice” ifthe holder demonstrates that the cost of providing writtennotice would exceed $250,000, that it involves more than500,000 Massachusetts residents, or that the holder does nothave sufficient contact information to provide notice.“Substitute notice” under the statute means all of the following:electronic mail notice to those with e-mail addresses, plus post-ing of the notice on the holder’s home page, if any, plus publica-tion in statewide broadcast or print media. Failure to meet thenotice requirements of the statute can lead to a consumer pro-tection enforcement action against the holder of information bythe Attorney General.

New Security Breach LawPeter Martin, Esquire

Peter Martin, Esq.



The notice must be forwarded by the holderof the information to such consumer report-ing agencies and state agencies as identifiedby the Director of Consumer Affairs andBusiness Regulation. The notice to theaffected individuals must include informa-tion on the individual’s right to obtain apolice report, how to request a securityfreeze and what fees must be paid to con-sumer reporting agencies. The notice maynot, however, disclose the nature of thesecurity breach.

Health care providers subject to this statelaw can only hope that promised regulationsfurther explaining how to comply with thelaw will indeed, as the statute says, take intoaccount the size, scope and type of businessand resources available to the provider, plusthe amount of data involved. In the mean-time, providers should review their securityarrangements of all personal data they hold,not just patient records, in order to avoid theextreme, and now mandated, hassles of deal-ing with a breach of security.

Peter J. Martin, Esq. is a partner in the Worcesteroffice of Bowditch & Dewey, LLP, whose practiceconcentrates on health care and non-profit law.

financial advice for physicians

Wouldn’t it be nice to have

a monthly income stream

for retirement which lasts

forever? In your case, this

means until “the day you

die.” Your parents, if they

worked for large corpora-

tions, had a shared com-

mitment with their

employer. They worked

hard for the company for

many years and at retire-

ment the company would provide a fixed monthly income for

life. Usually, the company hired an insurance carrier to do the

actuarial calculations, to manage the pool of retirement assets,

and to make the fixed monthly payments to

your parents. At retirement, your father chose

whether to receive a fixed monthly income

for life or a lesser monthly amount for both

his and your mother’s life. At death, the

monthly payments stopped. There was no

inheritance for the children or grand-chil-

dren. Both the employer and the employees

were only interested in the employee’s finan-

cial well-being in retirement. Unfortunately,

today the government has allowed employers

to end their financial obligations to their

employees at retirement. Perpetual inflation

combined with greater life expectancy has

made these traditional pension plans too

expensive for companies to provide for

employees. These plans became too expen-

sive for companies and too good a deal for

employees.

For retirement income you are on your own!!

Today’s employees and self-employed profes-

sionals must provide their own retirement

funds by diverting some W-2 earnings into

Qualified Plans. Government sponsored “Defined

Contribution” plans like 401(k) plans are very poor substitutes

for guaranteed retirement income programs. The money must

come from the workers themselves. The tax incentives, the

actual government share of citizens’ retirement programs, are

really very minimal. For successful people, accounts funded

with annual 401(k) contributions of $15,500 do not come close

to providing adequate retirement income. We are discussing

retirements which will last 20 to 35 years. “Where’s the beef?”

in the government sponsored retirement programs? Resources

well beyond your Defined Contribution Plan balances are going

to be needed to maintain your retirement lifestyle. Building

large retirement fund balances is Phase I of a comfortable retire-

ment. Winston Churchill was right when he said, “Savings is a

wonderful thing.”

“Until You Die”Mike Halloran

Mike Halloran



Consuming your retirement assets judi-

ciously is the Phase II of your successful

retirement. You and your financial plan-

ning advisor need to project your income

needs throughout your retirement. Your

income generating portfolio will change

over time. Since your longevity is uncer-

tain, a portion of your monthly income

should be guaranteed for life. While

businesses have stopped paying the tradi-

tional pension “Until You Die,” the life

insurance companies still offer Lifetime

Guaranteed Monthly Income products

called Immediate Annuities. You can buy

your own guaranteed monthly income

stream which you can not outlive. This

should be part of all retirees’ income

planning programs. The older you are,

the higher monthly income an immediate

annuity generates. Since males die before

females actuarially, a male will receive a

higher monthly income than a female the

same age. In today’s financial markets,

Treasury Bonds pay about 4% and bank

CDs pay about 5%. A 70 year old male

will get 8.9% lifetime income while his

female peer will get 8.2% from Immediate

Annuities. An 80 year old male will get

11.8% lifetime income and his female

peer will get 11.1%. That additional

income is the consumption of principal

in an organized fashion which cannot be

outlived. These Immediate Annuities can

be phased into your portfolio over time

depending upon your circumstances. For

instance, 10% of your investment assets

can be annuitized at age 70, another 10%

at age 75, and another 10% at age 80. In

this scenario, 30% of your investment

assets would have been turned into a life-

time monthly income stream paying over

10% monthly income on the funds so

committed. Your beneficiaries and your

advisors may object to your purchasing

these immediate annuities. These imme-

diate annuities will maximize your

monthly income but will not benefit any-

one else. With immediate annuities, at

your death, the income ends and there is

no asset to be inherited. Some beneficiar-

ies will not like this arrangement. Also,

many of your advisors earn fees from the

management of your assets and once the

assets are transferred to the insurance

company, there are no assets to manage

any longer. Like the old traditional pen-

sion plans, the monthly payments are for

you and for you alone. However, that

really isn’t so bad. After all, it is your

money, so enjoy your retirement.

Mike Halloran, PIAM RepresentativeHalloran Financial, LLC8 Grove St., Suite 300Wellesley, MA [email protected]


off call

This summer I visited the Museum of Fine Arts exhibit featur-ing Edward Hopper’s artwork.

Fifteen years ago I was introduced to Edward Hopper whileteaching a course at Harvard University with Robert Coles enti-tled, “The Literature of Social Reflection.” In an attempt to offera visual perspective on that social examination, Coles showedslides of Hopper’s paintings. I was moved by them. I had spentsummers trying to make connections with the world around meto give my privileged life some meaning. I worked on an assem-bly line making cars, worked road construction, and worked ona farm.

In that Harvard auditorium, upon the screen, were the images of“real” people. We were linking them to the stories of RaymondCarver and James Agee.

There I was this summer,immersed in those imagesagain, this time as a physician.I was thinking of the ways weget our medical learners tolearn about where ourpatients are “calling from.”Sometimes the link is made byvolunteering in a free clinic,doing an overseas elective, ormaking a home visit. TheHumanities in Medicine com-mittee at UMASS MedicalSchool would argue ~ what about through the arts? Stories,poems and paintings can take us to places about which we don’tknow very much.

Edward Hopper Offering a window into the lives of our patientsHugh Silk, MD

Hugh Silk, MD


In Hopper’s paintings, he offersus a chance to peer into thelives of the lonely, the desper-ate, and those looking forhuman connection.

Hotel Room (Figure 1) is afamiliar image for Hopper: awoman, half dressed, sitting ona bed, lost in thought. Herfocus is on a book; her expres-sion is flat. There are bags ~ isshe coming or going? Who elseis with her? As I think about

patients of mine who describehaving few people in their lives,few interests, and few opportu-nities, I think of this woman,finding solace in a story per-haps. As I look into the paint-ing I can feel her loneliness.

Other Hopper characters ven-ture out into the world but con-tinue to be lonely. In Automat(Figure 2), a woman is in themidst of a busy city and yetHopper hones his lens to showher alone. She has only a cup ofcoffee to cling to; she is so closeto others and still so far.Perhaps she suffers from anxi-ety or social phobia. Hopperlets us sit with her and under-stand the feeling of not havingsomeone to talk to.

Loneliness can happen evenwhen we are with people weknow well. In A Room In NewYork (Figure 3), Hopper showsus how people disconnect.How many people do we hearfrom in our busy practices whotell us they need more from

Fig. 1

Fig. 2

their partner? Here is a well-to-do woman waiting for her well-to-do husband to put down thatpaper. “What about my needs?What about my day?” her bodycalls out as she mindlessly tapsat the piano. These are two peo-ple so close physically and yetso far emotionally. Hopperoffers us glimpses of relation-ships that lack hope. You canfeel the quiet in the room andfear for the fight that is coming.

One of Hopper’s most famous paintings,Nighthawks (Figure 4), was also on dis-play this summer. Witness the other sideof Hopper: hope. There are fragile con-nections that spring from the faintestthread of similar interest. Late at night, aman, a woman, a diner operator ~ perhapsthe topic is baseball, or politics, or theweather. We are all human; we eat andsleep and love. We live in places that rallyaround teams or national holidays ortragedy. And in the quiet of the night, thesilence is broken by conversation over acup of coffee and a slice of pie. RaymondCarver would call it “a small, good thing,”a chance to leave loneliness behind, achance to share with another humanbeing who may be very different and yetvery interesting and colorful in his or herown way. These people are sharing some-thing. Hopper reminds us medical typesthat we too can connect with our patients.It is only a painted image and yet it speaksvolumes of how we hand one anotheralong, day by day, hour by hour.

Hopper’s world is a celebration of people.He gives us the gift of relationships ~good and bad ~ and reminds us what aprivilege it is to be let into their lives eachand every day. Williams Carlos Williamswrote, “Outside, Outside myself there is aworld;” Hopper and medicine help us toexplore it.

Hugh Silk, MD, is Assistant Professor of Family Medicine

and Community Health at UMass Medical School and

Family Medicine Residency.


Fig. 3

Fig. 4


Richard W. Aspen, MD1920-2007

Richard W. Aspen of Barre, MA, died peacefully in his homeSunday, July 8th, 2007 at the age of 87. He leaves a daughter,Deborah A. Aspen, a son, Richard V. Aspen, a sister, Anita J.Aspen, and five nieces and nephews. His wife, Dorothy B.Aspen, to whom he was married in 1948, predeceased him in1989.

Dr. Aspen was born in Hubbardston, MA, May 1, 1920. He grad-uated from Gardner High School and then went on to HarvardUniversity, taking additional classes at Yale University. He grad-uated from Harvard in 1944 and then entered Tufts UniversitySchool of Medicine, graduating in 1948. He completed hisGeneral Rotating Internship at Memorial Hospital in Worcesterin 1949.

Dr. Aspen served in the U.S. Army Medical Corps during WWIIand was a Captain in the Army Medical Corps during theKorean War, receiving a medal of commendation for outstand-ing and meritorious medical services and care.

He was in general practice as a primary care physician in Barre,MA for over twenty-five years and later served as a house physi-cian at Youville Hospital in Cambridge where he practiced inter-nal medicine.

Dr. Aspen was a Federal Aviation Medical Examiner for 25years, the medical examiner in the 10th Worcester District for 8years, a police surgeon in Barre, MA for 12 years, and a deputysheriff in Worcester County for over ten years.

He was a member of the U.S. Coast Guard Auxiliary for 30 years,a member of the American Legion for 58 years, and was a 32nd

degree Mason and member of the Mt. Zion Lodge of Masons forover fifty years.

Dr. Aspen was additionally a past Vice-President and Member ofthe Board of Governors for the Massachusetts Federation ofPhysicians and a Diplomate of the National Board of MedicalExaminers. He was a member of the Massachusetts MedicalSociety and the AMA, and was a member of the WorcesterDistrict Medical Society for over fifty years. He was also a mem-ber or on the board of numerous town committees in Barre andwas on the Board of the Worcester Regional Transit Authorityfor over a decade.

An avid fisherman and sportsman, he had hobbies that includedfly-fishing and boating. He also enjoyed maintaining his prop-erty and was particularly fond of riding his garden tractor evenwhen he was no longer able to walk. In his memory, donationsmay be made to The Leukemia and Lymphoma Society DonorServices, P.O. Box 4072, Pittsfield, MA 01202.

Deborah A. Aspen, PhD Anita J. Aspen, PhD

Paul H. Martin, MD 1925-2007

Paul Martin died on August 3rd, 2007. He was born into a work-ing class family in Biddeford, Maine in 1925. In 1942, upongraduation from high school, he could have entered the priest-hood as many of his friends did, but instead opted to join theArmy of the United States Army. He was stationed in Panama.Upon discharge at the end of WWII, he decided to continue hiseducation with the help of the GI bill. He chose the College ofthe Holy Cross. Following commencement, he did graduatework at Boston College before entering Laval University MedicalSchool in Quebec. He had to hone his language skills as all ofhis courses were taught in French.

He returned to Worcester to begin his post graduate studies atSt. Vincent Hospital then underwent specialty training inrheumatology at Tufts - New England Medical Center. Paul thenembarked upon medical practice in Worcester. He became a veryrespected physician and spokesperson for private medical prac-tice. He convinced St. Vincent Hospital to sell him a parcel ofland for one dollar and upon it he directed the construction ofthe Vernon Medical Center. At age 67, he retired and promptlyenrolled in a three year Master’s Degree program in the com-bined disciplines of philosophy, theology and science atAssumption College. He graduated with honors and was therecipient of the prestigious John Templeton grant. For the nextseveral years, he also served as a consultant for the Unum-Provident Co., becoming an authority on fibromyalgia whilecontinuing to manage the expanded responsibilities of theVernon Medical Center, known as “the house that Paul built.”

Paul Martin was a renaissance man. He had a joie de vivre ~ azest for the finer things in life. He was an unabashed romanticunafraid to cry when truly moved, whether during an operaticperformance or a movie like “La Vie En Rose.” He taught us toappreciate fine food and wine. He took us on trips to far awayplaces during which we learned to appreciate other cultures andwhat they contributed to the world in the form of, amongstother things, art, music and architecture. He opened our eyesand broadened our horizons. Every interaction with him was anenriching experience. He was a tireless seeker of knowledge andgrappled with the big questions in life.

Paul Martin’s patients, colleagues and friends respectively havelost a great doctor, knowledgeable confrere, and sincere confi-dant. Collectively they join the greater Greater Worcester com-munity in extending their sympathy to his wife Margaret, hischildren Denise, Susan, James, David and John, and his stepchildren Dawn and Darlene and their families.

Arthur A. Church, MD

in memoriam

WDMS Remembers its Colleagues


Worcester District Medical Society 17th Annual Dr. A. Jane Fitzpatrick Community Service Award

Wayne B. Glazier, MD(3rd from left)

Chairman of the Board, Health Foundation of Central MAPresident, Central MA Independent Physician Association

Medical Staff Member, Fairlawn Regional Hospital, Hubbard RegionalHospital, Saint Vincent Hospital and UMass Memorial HospitalBoard of Directors, American Red Cross, Central MA Chapter

Urologist, Independent Practice, Worcester

This annual award commemorates the life-long community contributions and exemplary efforts of Dr. Fitzpatrick in theWorcester community. The award emphasizes the main purpose of WDMS: to promote the health, benefit, and welfare of our citi-zens, to highlight contributions that have been made to the global community, to encourage others to seek similar opportunitiesand to publicly recognize the role of a health professional for outstanding contributions made beyond his or her professionalduties to improve the health and well-being of others.

2007 Worcester District Medical Society Career Achievement Award

Guenter L. Spanknebel, MD(3rd from left)

Director, Continuing Medical EducationUMass Memorial Medical Center - Memorial Campus

Assistant Dean for Continuing EducationAssociate Professor of Internal Medicine

University of Massachusetts Medical SchoolAssociate Director, Division of Digestive Disease & Nutrition

UMass Memorial Medical Center

This annual award was established to honor a member of the Worcester District Medical Society who has demonstrated compas-sion and dedication to the medical needs of patients and/or the public and has made significant contributions to the practice ofmedicine.

society snippets

WDMS is the recipient of the 2007 BetterEnding “Making a Difference Award.”

Worcester District Medical Society received the 2007 Better Ending Partnership Bill

Densmore and Brownie Wheeler "Making a Difference Award" for promoting the vision

and work of Better Ending since its inception in 2002 through numerous end of life

educational initiatives for physician members.

2007 WDMS Awardspresented at the Fall District Meeting on November 14, 2007

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