Family Medicine · Richard W. Besdine, MD, Chief Medical Officer Rhode Island Medical Society...

Volume 89 No. 8 August 2006

�Family Medicine

263VOLUME 89 NO. 8 AUGUST 2006

Medicine and Health/Rhode Island (USPS 464-820), a monthly publication, is owned and published by the Rhode Island Medical Society, 235Promenade St., Suite 500, Providence, RI 02908, Phone: (401) 331-3207. Single copies $5.00, individual subscriptions $50.00 per year, and $100per year for institutional subscriptions. Published articles represent opinions of the authors and do not necessarily reflect the official policy of the Rhode IslandMedical Society, unless clearly specified. Advertisements do not imply sponsorship or endorsement by the Rhode Island Medical Society. Periodicals postagepaid 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,phone: (401) 383-4711, fax: (401) 383-4477, e-mail: [email protected]. Production/Layout Design: John Teehan, e-mail: [email protected].

UNDER THE JOINTEDITORIAL SPONSORSHIP OF:

Brown Medical SchoolEli Y. Adashi, MD, Dean of Medicine& Biological Science

Rhode Island Department of HealthDavid R. Gifford, MD, MPH, Director

Quality Partners of Rhode IslandRichard W. Besdine, MD, ChiefMedical Officer

Rhode Island Medical SocietyKathleen Fitzgerald, MD, President

EDITORIAL STAFFJoseph H. Friedman, MD

Editor-in-ChiefJoan M. Retsinas, PhD

Managing EditorStanley M. Aronson, MD, MPH

Editor Emeritus

EDITORIAL BOARDStanley M. Aronson, MD, MPHJay S. Buechner, PhDJohn J. Cronan, MDJames P. Crowley, MDEdward R. Feller, MDJohn P. Fulton, PhDPeter A. Hollmann, MDSharon L. Marable, MD, MPHAnthony E. Mega, MDMarguerite A. Neill, MDFrank J. Schaberg, Jr., MDLawrence W. Vernaglia, JD, MPHNewell E. Warde, PhD

OFFICERSKathleen Fitzgerald, MD

PresidentBarry W. Wall, MD

President-ElectK. Nicholas Tsiongas, MD, MPH

Vice PresidentDiane R. Siedlecki, MD

SecretaryMark S. Ridlen, MD

TreasurerFredric V. Christian, MD

Immediate Past President

DISTRICT & COUNTY PRESIDENTSGeoffrey R. Hamilton, MD

Bristol County Medical SocietyHerbert J. Brennan, DO

Kent County Medical SocietyRafael E. Padilla, MD

Pawtucket Medical AssociationPatrick J. Sweeney, MD, MPH, PhD

Providence Medical AssociationNitin S. Damle, MD

Washington County Medical SocietyJacques L. Bonnet-Eymard, MD

Woonsocket District Medical Society

RHODE ISLANDPUBLICATION OF THE RHODE ISLAND MEDICAL SOCIETY

Medicine � Health VOLUME 89 NO. 8 August 2006

COMMENTARIES

264 Thanks for the Bad NewsJoseph H. Friedman, MD

265 A Craving for Sugar Hastens Slavery in the WestStanley M. Aronson, MD

FAMILY MEDICINEGuest Editor: Jeffrey Borkan, MD, PhD

CONTRIBUTIONS266 A Tribute to John Cunningham, MD

Arthur Frazzano, MD

267 Thirty Years of Academic Family Medicine in Rhode Island: Looking Back,Looking Forward

Jeffrey M. Borkan, MD, PhD

270 Family Medicine Residency Education: Staying on the Cutting EdgeMelissa Nothnagle, MD, and Rabin Chandran, MD

272 Brown Medical School Family Medicine at Thirty: Residents’ Views of Nowand Then

Paul F. George, MD, and Joanne M. Silvia, MD

274 Fellowship Training in Family Medicine at Brown: Adding Depth to BreadthRick Long, MD, Sean P. David, MD, SM, DPhil, Alicia Monroe, MD,and Jane Shaw, MS

276 History of the Predoctoral Division in the Department of Family Medicineat Brown Medical School

Julie Scott Taylor, MD, MSc, Stephen R. Smith, MD, MPH, Thomas T.Gilbert, MD, MPH, Timothy Empkie, MD, MPH, Charles B. Eaton, MD, MS,and Alicia D. Monroe, MD

281 Building a Successful Research Enterprise in Family Medicine: The BrownExperience

Sean P. David, MD, SM, DPhil, Charles B. Eaton, MD, MS,Larry Culpepper, MD, MPH, Roberta E. Goldman, PhD, Laura K. Lavallee,Emma M. Simmons, MD, MPH

284 Becoming a DoctorJoanne Wilkinson, MD, Msc

285 Rhode Island Academy of Family Physicians: Then and NowDavid P. Carter, MD, Michael D. Fine, MD, Alfred A. Arcand, MD,Robert P. Sarni, MD, Nancy G. Leggat

287 Improving Health Care Access for Uninsured Rhode IslandersMichael D. Fine, MD, and Emory E. Liscord

COLUMNS288 HEALTH BY NUMBERS: – Evidence of Increased Prostate Cancer Screening

in Rhode IslandJohn P. Fulton, PhD

291 QUALITY PARTNERS OF RHODE ISLAND – Rhode Island Health IE Project UpdateMary Ellen Casey, RN, BS, MEd, COS-C

292 PHYSICIAN’S LEXICON – Skin-Deep in WordsStanley M. Aronson, MD

292 Vital Statistics

294 August Heritage

Cover: “Jack Cunningham with Erin,”photograph by Bill Gallery, a Rhode Islandphotographer. This photograph was usedin a 1987 brochure from Memorial Hos-pital of Rhode Island. www.BillGallery.com

264MEDICINE & HEALTH/RHODE ISLAND

Thanks For the Bad News�

Commentaries

“Thank you so much.”“I didn’t do anything,” I replied,

mildly mystified. “I told you that Ididn’t know what the problem was.I really don’t know why your sonwalks the way he does, and I’m notsure I’m going to figure it out either.”

“But you told me that there wasa problem. You didn’t tell me notto worry, that it’s nothing. Thatmeans a lot to me.”

“Well, of course there’s somethingwrong. Your son used to walk fromCentral Falls to Foxboro and nowhe has trouble walking down thecorridor of my office.”

The son was a mildly retarded 40 year-old man. The mother was in her late sixties,very much intact. The son was labeled ashaving “cerebral palsy” at age 6, althoughno etiology had been identified. Now, 10years after walking to Foxboro, a walker wason the not too distant horizon.

So, why was the mother relieved?Thirty years before there had been twobrothers. The younger one started slowingdown, getting a bit clumsy; and the motherknew there was something wrong, but thedoctors identified the problem as themother, not a disorder in the child. Themother was sent to a psychiatrist. She didn’tthink she needed one, but she’d do anythingto help her son, so she went. After the boydied from his brain tumor, though, shenever had much confidence in doctors.

I cannot recall a story quite so bad, al-though it is not uncommon to hear aboutpediatricians who reassured the parents thattheir babies were quite normal and the childturned out to have some type of cerebral palsy.And the reasons for that are fairly obvious.Children develop at different rates, and mostinquiries by parents are because the currentnormal child is developing a bit slower thanthe older sib, or because the child isn’t ex-actly on the path charted in a popular bookon raising children. I’m quite certain that thevast bulk of reassurances are correct, but oc-

casionally there is something amiss. Were theparents hysterical? Was the doctor conde-scending and thoughtless?

I was taken off guard by the mother’sthankfulness for being taken seriously. I al-ways expect people to get upset with mewhen I say I don’t know what’s going on. Ithappens to me a lot. It got me to wonder-ing how often patients think they are be-ing “blown off.” A large percentage ofpeople getting care at all levels have non-physiological symptoms. A very prominentgastroenterologist friend of mine many yearsago told me that half the patients in the GIclinic at a major Midwestern medical schoolhad functional complaints (i.e., complaintswith no apparent tangible basis). About 5%of new referrals to movement disorder cen-ters have non-physiological disorders, eitherconversion disorders or malingering.

If one deals only with conversion dis-orders, neurological signs and symptoms ofpsychogenic origin, we have learned in re-cent years that the prognosis is usually dis-mal. If the problem has persisted for sixmonths or more the chances of cure ofminiscule. Since it takes at least that longfor most of these patients to see a sub-spe-cialist who can make the diagnosis, most ofthese patients don’t do well. So I take thisdiagnosis very seriously. And the field ofneurology has come to realize that “real”disorders and “psychogenic” disorders mayproduce similar disabilities. In fact, since thelatter don’t behave in as predictable a man-ner as organic disorders, responses to “stan-dard” treatments for the movements are alsounpredictable. One world expert opinedthat only psychogenic dystonia producesjoint deformities, which is, of course, theopposite of what most people would think.

It is important to identify the problemas “real” despite the underlying problem hav-ing no organic cause. The important pointfrom the doctor’s perspective is to identifythe problem and then the etiology. It tookme many years to develop an approach todiscussing non-organic movement disorders.As I have often encountered great resistance

to being told a disorder was a conversion dis-order rather than a small stroke missed onthe MRI, I have come to identify the prob-lem and then to discuss separately the po-tential etiologies, including the non-organic.I then focus on this. I point out that the move-ment disorder identification is crucial butno more so than identifying the cause, as thecause determines the therapy. If the etiologyis psychogenic, then the treatment must ad-dress those issues.

Many patients with psychogenic dis-orders have already heard the diagnosis andarrive almost spoiling for a fight. “You thinkI’m crazy? You think it’s all in my head?” Itis uncommon for me to encounter the op-posite behavior in a patient, expecting tobe taken too lightly, and being over-whelmed at being told there is a non-psy-chogenic problem, even though the diag-nosis is either unknown or not good. I havelearned over and over again that patientsneed to know the name of their disordereven when there is no treatment.

The issue in this case, less common forme than conversion disorder, is in distin-guishing functional from organic. Asidefrom patients who complain of memory dys-function, complaints which are usually re-lated to depression or anxiety, it is uncom-mon to see patients who think they have amovement disorder problem that othersdon’t easily perceive. It’s usually the otherway around, with the patient not perceiv-ing their slowness, their chorea, their stiff-ness. Some patients have a minor degree oftremor but are relieved to learn that it isnot Parkinson’s disease. Others are pleasedto learn that their imbalance might be nor-mal for people in their eighties. However,people do not like to learn that their per-ceived disability is not “real.” They like tolearn that it is “real” but not serious.

I felt like an impostor in dealing withthis patient and his mother. At least I admit-ted that I didn’t know what was wrong. Usu-ally that slows people down in their enthusi-asm, but this mother was so pleased that I notonly endorsed her own conception of theproblem but that I was interested and both-ered by the fact that I didn’t know what thiswas. And clearly this was a serious problem.

These are humbling experiences. It isalways humbling in not knowing an answer.It is even more humbling to be praised forone’s ignorance.

– JOSEPH H. FRIEDMAN, MD


A Craving For Sugar Hastens Slavery In the West�

A 17th Century couplet declared that young maidens weremade of “sugar and spice, and all that’s nice”. The anonymouspoet clearly selected exotic, rarely attainable items as metaphorsfor little girls. Certainly spices and sugar were then unknownto the western European cuisine except for a privileged few.Other than the occasional usage of honey, sweetening rarelyaccompanied the average occidental meal.

The extraction of sugar from a tall perennial grass was prob-ably first accomplished in southern India over two millenniaago. Arab entrepreneurs then brought the plant to the MiddleEast in succeeding centuries.

In the bloody siege of Antioch, in the year 1098, Crusad-ers became familiar with the cultivated sugar cane, learning tochew upon the raw cane to yield a sweet substance the Arabscalled sukkar. This translated in the Frankish tongue to zucra,and finally to English as sugar. And a taste for sugar was one ofmany novel customs that the Crusaders brought back to west-ern Europe.

Sugar cane was a fastidious crop requiring a warm, moistclimate; and while some sugar-cane fields were established inSicily and southern Italy, the annual yield remained modest.

The conquest and colonization of the Caribbean regionopened many possibilities for profitable investments. Venturecapitalists, particularly English, envisaged vast plantations ofsugar cane in the newly acquired territories. The island of Bar-bados, in the eastern West Indies, was selected and by 1627 aruthless campaign of deforestation was begun. The island, some500 square kilometers in area, was transformed into a series ofone-crop plantations.

The production of sugar is labor-intensive, requiring muchwork in the harvesting process as well as the milling, separationand refining of the canes. Fields had to be planted and neigh-boring mills constructed. The sugar content of the canes dete-riorated rapidly after harvesting; and to retain its sugar, thecanes had to be milled shortly after being cut down. For de-cades, much of this work was performed by indentured whiteBritons as well as by many who voluntarily sought employment,and perhaps adventure.

The need for more workers for the sugar plantation wasaccelerated by an expanding demand for sugar to satisfy theincreasingly discriminating European palate. Annual Britishsugar consumption was less than one pound per capita in 1620.By 1690 it had increased to 4.6 pounds; by 1720, to 11.1pounds; and to 16.2 pounds per capital by 1760. The French,and to a lesser degree, other European nations also developeda passion for sugar, particularly to sweeten two new beveragesintroduced from the East - coffee and tea.

Slavery, the consummate obscenity of the Second Millen-nium, was an entrenched global enterprise by the early 17th

Century. The Portuguese had developed numerous slavingports along Africa’s western coast; and Arab traders had a vir-tual monopoly in the sale of African slaves from the east coast.Soon afterward other European nations participated in the in-voluntary transport of captured Africans to South America [par-

ticularly Brazil], Meso-America, the Caribbean and the En-glish-speaking colonies of North America.

For a few decades, teams of European whites and Africanblacks worked the sugar plantations of Barbados. Workingconditions were barbaric and the inevitable attrition requiredconstant worker-replacement. England was no longer a reli-able source and so slavery became the dominant, if not exclu-sive, wellspring of field workers. The deforested island of Bar-bados, now with a resident population of about 40,000, be-came the most densely populated region of the Western Hemi-sphere.

The attrition of workers was increased by a new threat totheir survival. A disease which had been formerly confined tothe forests of western Africa had now achieved a firm footholdin the densely populated islands of the Caribbean. It was amuch feared, acute ailment characterized by hectic fevers, con-fusion, profound lassitude, anorexia, intense vomiting [oftenbloody], a yellowish discoloration of the skin and eyes and amortality rate exceeding 30%. It was called yellow fever.

Yellow fever was unlike pestilences such as smallpox. Thosein intimate contact with yellow fever victims, such as nurses orphysicians, rarely contracted the disease; and yet large num-bers in the community regularly were felled by the disease withno apparent pattern or explanation. It would require anotherthree centuries before physicians such as Carlos Findlay of Cubaand Walter Reed of the United States indicted the Aedes mos-quito as the carrier of the often-fatal virus of yellow fever.

Transforming Barbados from a sylvan paradise to a tree-less expanse of cultivated and irrigated fields provided themosquito vector of the disease with vast numbers of shallowpools to lay their eggs. Added to this was the densely popu-lated nature of the island.

By 1647, Barbados confronted its first yellow fever epi-demic, one of the first outbreaks to transform an occasionaldisease in Africa to a lethal epidemic in the Western Hemi-sphere. Within months, over 6,000 African slaves had suc-cumbed to the disease on Barbados; and for the next threecenturies, yellow fever devastated every Caribbean island whichventured into deforestation and a plantation economy basedon slavery. It was not until the Spanish-American War, at theend of the 19th Century, that mosquito-abatement programsfinally eradicated the disease.

Yellow fever, historically, has been a mosquito-borne dis-ease infecting the forest monkeys of West Africa and, only oc-casionally, natives living at the margins of these forests.

The disease was brought to the Caribbean in the 17th Cen-tury where its mosquito-carriers found a much more conge-nial environment as well as a vast population of vulnerable souls.Yellow fever was one of the bitter accompaniments of slavery;and the induced craving for sugar, a needless dietary supple-ment, was a major impetus in bringing slavery to the West.

– STANLEY M. ARONSON, MD


A Tribute to John Cunningham, MDArthur Frazzano, MD

John J. Cunningham, MD, (“Jack”)pictured on the cover in a 1987 photo-graph with his granddaughter, Erin, wasone of the inspirational forces behind theestablishment of the fledgling trainingprogram in family medicine at the BrownMedical School. An icon in thePawtucket community, he brought hispractice to the Family Care Center atMemorial Hospital in 1975 to serve asthe seminal patient cohort for the firsteight residents in family medicine. A last-ing tribute to his compassionate, caringnature and to the loyalty he instilled inpeople is the fact that many of the pa-tients he brought with him are still theretoday.

Jack was born in Providence on Feb-ruary 21, 1924. His father, John Sr., diedwhen Jack was young; and he was raisedby his school teacher mom, Mary, andhis three sisters. Jack attended local schoolsand served a stint in the military. Aftergraduating from Providence College in1947, he graduated from Tufts MedicalSchool and completed a rotating intern-

ship at Memorial Hospital of Rhode Is-land (MHRI) in Pawtucket. He enteredan ob/gyn residency, but tuberculosis cutshort his training. He spent time in a sani-tarium, where he underwent treatment,including therapeutic lung collapse. Jackalways said this detour in his career madehim better able to understand the role ofillness in everyday life. It gave him aninsight to further underscore his compas-sionate empathy for those who have hadlives altered by illness. After leaving thesanitarium, he trained at the Veterans Ad-ministration Hospital in Rutland, Mas-sachusetts. Soon thereafter, he and hiswife Biruta, “Bert” to friends and family,settled in Pawtucket, where he estab-lished a general practice.

Much of the magic of Jack’s person-ality and uncanny ability to bond withchildren is captured in this photograph.One of many memories of Jack is his en-tering the room of a crying child, dul-cetly muttering, “Hi Tiger,” and gainingthe child’s attention without further tears.Truly, Jack embodied the wisdom of

�Aeschylus who understood twenty-fivehundred years ago, that “it is not the oaththat makes us believe the man, but theman the oath.” Today, 18 years after hisdeath, “Cunningham,” as Bert fondlyrefers to her husband, is still rememberedby patients, friends and colleagues for histireless efforts on behalf of the BlackstoneValley community. He is the closest thingto a “patron saint” that we have in RhodeIsland family medicine and his spirit ofhealing continues among those he taughtand inspired.

Arthur Frazzano, MD, is AssociateDean of Medicine (Clinical Faculty),Brown Medical School, and a member ofthe first class of Family Medicine residentsat Brown/MHRI, from 1975.

CORRESPONDENCE:Arthur Frazzano, MDBox G-A1Providence, RI 02912phone: (401) 863-3675E-mail: [email protected]


Thirty Years of Academic Family Medicine in Rhode Island:Looking Back, Looking Forward

Jeffrey M. Borkan, MD, PhD

Thirty years ago, a fledging medicalschool at an Ivy League university and atime-honored community hospital decidedto take a risk—opening a residency andlater a Department of Family Medicine.This specialty was established to provide in-dividuals, families, and communities withcontinuous and comprehensive high qual-ity health care throughout the lifecycle. Thegamble was large; although Rhode Islandhad historically been a general practice state,the medical school and the hospital weremoving into uncharted ground and break-ing tradition with both their larger com-petitors north and south (Harvard and Yale)and with the direction of some of the othernewly affiliated Brown hospitals. Accord-ing to its first Dean, Stanley Aronson,Brown Medical School (BMS), then justa “Program” in medicine, was ready to takea chance with this new field, especially sinceit seemed to hold significant potential forthe training of well-educated physicians tomeet the compelling needs of the RhodeIsland population. Also, like the Depart-ment of Community Health, where Fam-ily Medicine was originally located, it didnot require the investment in laboratory in-frastructure that the new school could littleafford. Memorial Hospital of RI (MHRI)was interested in sponsoring Family Medi-cine because, as the CEO both then andnow, Mr. Frank Dietz, observed, it was con-sistent with the hospital’s “history and philo-sophical bent of primary care, general in-ternal medicine, and prevention.” MHRIhad sponsored a general practice trainingprogram until the mid-1960s and wantedto re-enter medical education after its af-filiation with Brown. Family Medicine ap-peared to be a natural and logical develop-ment.

However, how could one start a Fam-ily Medicine residency and department inRhode Island? There were no faculty, noresidents, no teaching practices, and no ex-perience. Family Practice (FP) had begunas an approved specialty in 1969, andknowledge of the field in the Northeast wassparse. To gather data, the CEO, along witha leading faculty member from internal

medicine, traveled toone of the early FPsites in New Jersey.Meanwhile, the firstFamily Medicine Di-vision Head and laterDean, Dr. DavidGreer, visited theheartland to learnabout the new spe-cialty in Kansas Cityand upper Minne-sota. The zealousfounders of the field,the leaders of the newAmerican Academyof Family Physicians (AAFP), were eagerto help this Ivy League school make themove and imparted their wisdom duringvisits to Pawtucket.

Another step forward was catchingthe attention of a leading general practi-tioner in the Pawtucket area, Dr. John J.Cunningham (depicted on the cover).Though he may have originally beenskeptical, he jumped in wholeheartedly,becoming the first medical director, fac-ulty member, and role model. When hecame to MHRI to help start the resi-dency, he brought his long-standingpractice—including patients, staff, andrecords—transforming it into the firstFamily Care Center. Dr. Cunninghamalso brought his approach to care, pro-viding endless clinical pearls and helpingresidents distinguish between what wasimportant and what was not.

When the three-year residency openedon July 1, 1975, with seven trainees, thefull time faculty consisted of Drs. Greer andCunningham. Dr. Tom Scaramella, a psy-chiatrist who has been the residency direc-tor at Butler Hospital, Dr. Mary AnnPassero, a pediatrician, Dr. John Evrard, anOB-Gyn, and a psychologist, Dr. Ann DeLancey, joined soon afterward. A few localpreceptors filled out the first faculty —in-cluding Dr. Barry Weisman. who contin-ues to precept. The residency flourished andattracted top candidates from around theUS. The class size expanded to 12 by 1977,

and to 13 several years later. The first gradu-ates completed the program in 1978 andbegan a tradition that continues to thisday—most go into practice within an hour’sdrive of the residency.

The next step in the development ofFamily Medicine at Brown involved thegranting of Departmental status and thehiring of the first Department Chair. Bothmilestones occurred in 1978. The newDepartment, headed by Dr. LouisHochheiser, began to expand its range offaculty and activities. The Predoctoral di-vision, whose goal was to teach BrownMedical students the principles of medi-cal care and attract young physicians tothe specialty, began in 1979, led by thefirst Predoctoral director and later Associ-ate Dean for over twenty years, Dr.Stephen Smith. Although it took until1995 before a required six-week clinicalrotation in Family Medicine was mandatedat Brown, multiple courses, electives, andenrichment opportunities have alwaysbeen offered. The first researcher, Dr.Larry Culpepper arrived in 1981 andbegan the outstanding research traditionthat continues to this day. He was alsoinstrumental in starting the collaborativetraining relationship with the BlackstoneValley Community Health Center, a part-nership that lasted 14 years, and expandedto other community health centers in RI.This reflected the Department’s contin-ued commitment to underserved and vul-

�


nerable populations in our communities.International family medicine became

a focus with the arrival of the second Chair,Dr. Vincent Hunt, who led the Depart-ment to new heights during his tenure be-tween 1986 and 2000. International col-laborative educational and research projectshave taken place in Russia, Jordan, Qatar,Vietnam, Israel, Greece, Hungary andmore recently Honduras and the Domini-can Republic, among others. These projectshave involved everything from the estab-lishment of national family medicine train-ing, to health service planning, to provid-ing direct service to the underserved.

The Department has continued todevelop and mature, taking its placeamong the major Family Medicine de-partments and training programs in thecountry. Fellowship training was added,starting with Maternal and Child Healthin 1992, followed by the C. Everett KoopHealth Policy Fellowship in 2002 and theLeadership Fellowship in 2004. In a typeof budding process, several faculty andgraduates were instrumental in initiatinga Department of Family Medicine at Bos-ton University, starting in 1996. In 1999,the finishing touches were put on the newFamily Care Center (FCC) at MHRI, astate of the art family medicine trainingcenter. The new FCC replaced the “clinic”style facility, providing three model prac-tices that now house the 39 residents andover 20 faculty – as well as a base for in-novative programs such as open access,group visits, chronic care collaboratives,and integrated mental and physical health

care. It has become a technology test cen-ter for electronic health records, decisionsupport tools, and patient portals.

Health policy and advocacy has alsobeen a critical component of the missionof the Department, with faculty, residents,and staff taking leadership roles in innu-merable public forums, committees, andadvisory boards, and even helping draftlegislation to change state laws. Workingclosely with the Rhode Island Academyof Family Physicians (RIAFP) on its leg-islative initiatives, we have worked to makeour voice heard on issues of importanceto our patients and our discipline. This hasalso been demonstrated through the manyprojects related to COPC (communityoriented primary care) in which residentsleave the confines of the hospital and theFCC to engage in public health issues andendeavors.

Over the last five years, we have tried totake the Department to the “next step” in itsevolution. We have created integrated divi-sions within the Department that allow re-sources and efforts to be focused upon par-ticular areas, such as research, education, orinternational health, while remaining com-mitted to a unified vision. Academic pro-ductivity, in terms of grants, publications, pre-sentations, and programs, has expanded dra-matically. (See Figures 1 and 2). We havetried to break down traditional academic andclinical silos and promote transdisciplinaryefforts, throughout Memorial, Brown, theUS and the world. We have expanded ourclinical base, establishing clinical depart-ments at Rhode Island Hospital (2000) and

the Miriam Hospital (2004). We have alsoestablished research collaborations with othercenters as close as Brown and as far away asOxford. At the same time, we have reachedout to our home institutions – both Brownand Memorial, as well as the RIAFP – in aneffort to both remain “mission critical” andto link our professional fortunes, transform-ing the usual metaphor of “them and us” tojust “us”. Though family medicine is not thelargest department at Brown MedicalSchool, it has made a contribution far be-yond the confines of primary care. Five As-sociate Deans are family physicians, our fac-ulty lead or teach major portions of four-teen courses, and our researchers are someof the most productive at the University. Weare involved in the newest wave of curricu-lum reform at all levels. For example, thenew Doctoring program, one of the mostradical changes in the BMS curriculum inyears, is established on a strong primary carebase, led in large measure by family physi-cians.

In 2006, looking back, it is amazingto consider how much has been accom-plished in the space of one generation.Though the numbers are remarkable,whether it is the 349 residency graduates,the nearly 200 faculty members, the tensof millions of dollars of research grants,stacks of articles and books, or the thou-sands of students who have received edu-cation in family medicine, mere numbersdo not suffice. It is fair to say that the resi-dency graduates and family medicine fac-ulty, who now comprise nearly 85-90% ofall family physicians in Rhode Island, have

inalterably influenced the face of pri-mary care medicine in the State.Though family physicians representonly about 7% of the State’s physicians,they care for nearly a third of all RhodeIsland children and more than onethird of all Rhode Island adults. Ourgraduates are sought after for theirskills and prowess, and now enter ca-reer paths, in addition to clinical roles,of which their forebears could onlyhave dreamed—academia, television,info-matics, health insurance, and in-ternational health. The articles in thisspecial issue reflect some the excitingachievements of the last 30 years andthe directions for the future.

Family Medicine at Brown re-mains true to its roots. We care for

Figure 1: Grant Funding By Five-Year Cycles


individuals and families in their own com-munities, and treat men, women and chil-dren of all ages, ethnicities, and economiccircumstances. We look forward to thenext 30 years, and plan to continue ourcutting edge contributions in clinicalcare, research, education, and advocacy.Our partnerships span Rhode Island, thenation, and the globe, and we are com-

Figure 2: Research Scholarly Production: Publications and Presentations

mitted to work together to improve thehealth of our population at every oppor-tunity. Remarkable accomplishmentshave been achieved in the course of onegeneration and we look forward to thoseof the next. We take this opportunity tocelebrate and to thank all those who haveplayed a role, as we gather our strengthto meet the challenges ahead.

BIBLIOGRAPHY:RIAFP Website: http://www.riafp.org/

ACKNOWLEDGEMENTS:Thanks to the Scholarship Pro-

motion Forum of the Department ofFamily Medicine for providing help-ful comments on this manuscript andfor the historical contributions fromDeans Aronson and Greer, and Mr.Frank Dietz.

Jeffrey Borkan, MD, PhD, isChair and Professor of Department ofFamily Medicine, Brown MedicalSchool, and Chief at Memorial Hospi-tal of Rhode Island.

CORRESPONDENCE:Jeffrey M. Borkan, MD, PhDMemorial Hospital of RI111 Brewster StreetPawtucket, RI, 02860Phone: (401) 729-2256e-mail: [email protected]


Family Medicine Residency Education:Staying on the Cutting EdgeMelissa Nothnagle, MD, and Rabin Chandran, MD�

The 30th anniversary of the Brown Fam-ily Medicine Residency Program providesan opportunity to highlight recent devel-opments in residency education and to de-scribe our vision of the future. Thesechanges, ranging from competency-basedassessment to advanced-access scheduling,prepare the next generation of family phy-sicians for their roles in the community.Brown’s Family Medicine Residency Pro-gram aims to remain on the “cutting edge”of these advancements in training.

RECENT CHANGES IN FAMILYMEDICINE RESIDENCY EDUCATIONCompetency-Based Education

Since its inception in the late 1960s,family medicine residency training has beenorganized as a series of clinical rotations. Bycompleting blocks of educational experi-ences, residents were expected to acquirethe knowledge, skills, and attitudes to be-come effective family physicians.

However, practitioners in a variety ofdisciplines have questioned the assumptionthat residents will achieve the learning ob-jectives of residency programs by attend-ing the required rotations and passing glo-bal evaluations. In most fields, the focus ofresidency requirements is shifting from thecontent and process of education to edu-cational outcomes. To measure these out-comes, the Accreditation Council forGraduate Medical Education (ACGME)charged residency programs with imple-menting a competency-based model of as-sessment. Important early work in this areacomes from our own discipline; a groupfrom the Society of Teachers of FamilyMedicine provided early leadership thatforeshadowed the ACGME’s embrace ofcompetency-based education.1

The ACGME plan includes six com-petencies which organize graduate medi-cal curricula: Patient Care, Medical Knowl-edge, Interpersonal and CommunicationSkills, Professionalism, Systems-based Prac-tice, and Practice-based Learning and Im-provement.2 (Table 1) Residency programsuse this framework to develop learning ob-jectives for residents, instructional strategies,

and assessment tools. The assessment dataare used to improve the performance of in-dividual residents as well as to evaluate theeffectiveness of the program.

The Brown Family Medicine Resi-dency has implemented a number of com-petency-based assessments. For example, toappraise medical knowledge in pediatrics, ourpediatric faculty leadership has developedweb-based self-study modules on topics suchas asthma management, fluids and electro-lytes, evaluation of the febrile child, failureto thrive, sickle cell disease, and hyperbiliru-binemia. Residents’ responses to study-mod-ule questions are directed to the faculty su-pervisor for pediatric education, who pro-vides feedback to correct misconceptionsand direct residents to additional resources.Faculty who oversee our maternal and childhealth curriculum have improved residentassessment on labor and delivery by incor-porating several competencies, includingpatient care, as demonstrated by accurateinterpretation of non-stress testing and ba-sic ultrasound, and communication skills,which are measured using a 360 degreeevaluation [written feedback from multipleobservers, including supervisors, peers, nurs-ing staff, and patients]. In addition, severalcompetency-based assessments are used inthe residents’ continuity practices. In some

cases a focus on competency-based assess-ment has involved applying a measurementof success to an existing and successful com-ponent of the residency. For example, dur-ing review of videotaped patient encounters,behavioral science faculty use a validatedmedical interview skills inventory to providestructured feedback on residents’ communi-cation skills. In addition, ambulatory familyphysician preceptors complete competency-based written evaluations of resident perfor-mance after patient care sessions. Theseevaluations address several competencies; forexample, proficiency in outpatient billingand coding serves as a measure of compe-tency in systems-based practice. Multiple as-sessments will be integrated to include mea-sures of each of the six competencies through-out the three years of training, with increas-ing competence expected at each level.

The Future of Family Medicine’sNew Model of Practice

The Future of Family MedicineProject,3 initiated in 2002, created a planfor transforming family medicine. The re-sults include a vision of a “New Model ofPractice.” The Brown Family Medicine Resi-dency has integrated several elements of thenew model into our resident and facultypractice. First, to incorporate advanced in-

Table 1: ACGME Competencies2

• Patient care that is compassionate, appropriate and effective for the treat-ment of health problems and in the promotion of health.

• Medical knowledge about established and evolving biomedical, clinical andcognate sciences as well as the application of this knowledge to patient care.

• Practice-based learning and improvement that involves the investigation andevaluation of care for their patients, the appraisal and assimilation of scientificevidence and improvement in patient care.

• Interpersonal and communication skills that result in the effective exchangeof information in collaboration with patients, their families, and other healthprofessionals.

• Professionalism, as manifested though a commitment to carrying out profes-sional responsibilities, adherence to ethical principles, and sensitivity to pa-tients of diverse backgrounds.

• Systems-based practice, as manifested by actions that demonstrate an aware-ness of and a responsiveness to the larger context and system of healthcare, as well as the ability to call effectively on other resources in the systemto provide optimal health care.


formation systems, we have implemented anelectronic health record (EHR) and examroom computers which provide access to theEHR, laboratory and imaging reports, hos-pital records, and internet access for pointof care information retrieval and patient edu-cation. Second, to reduce barriers to access,we adopted an advanced-access schedulingsystem with the goal of “doing today’s worktoday.” Third, to focus on quality of care,the practice is implementing the ChronicCare Model for patients with diabetes.4 Fi-nally, we model multidisciplinary team man-agement of patients in our Diabetic GroupVisits Program.

Resident Work Hour LimitsResponding to the data on the effects

of sleep deprivation on clinical perfor-mance and public attention to excessiveresident work hours, the ACGME beganto enforce limits on resident work hoursin July 2003, with the goal of prioritizingpatient safety and resident education overservice obligations.5 Residents in all spe-cialties are now limited to 80 work hoursper week, no more than 24 consecutivehours on duty (with an additional 6 hoursfor educational activities or continuity ofcare), a maximum on-call frequency ofevery third night, and at least one day offper week. While this may not seem gen-erous to those outside the medical profes-sion, most practicing physicians recall hos-pital shifts longer than 36 hours.

Three years after implementation ofthe duty-hour limits, controversy remainsover whether patients truly benefit fromthese changes, and research findings onpatient safety and educational outcomesafter implementation are conflicting. Amajor concern is that shorter resident shiftsresult in more frequent sign-outs, whichhave been associated with delays in careand increased medical errors.6, 7 To im-prove continuity of care on the inpatientmedicine service, our residents have de-veloped an electronic sign-out system tostreamline communication with cross-cov-ering residents.

THE FUTURE OF FAMILY MEDICINEEDUCATION

As these recent changes are reshap-ing the landscape in family medicine edu-cation, additional changes are close ontheir heels.

Learner-Centered ResidencyEducation

One of the attractions of a career infamily medicine remains the variability andchoice in scope of practice, from rural prac-tice to hospitalist medicine, urbanunderserved care, academic medicine andresearch, and a host of other options. Thedebate within our specialty about whetherall family physicians should be trained inobstetric care rages, although the nationalorganizations have reiterated their commit-ment to full-spectrum training. How-ever, training residents for this wide rangeof choices will require more emphasis onindividual learning plans. We envision asystem in which residents, in collaborationwith their advisors, will develop concentra-tions. We offer residents a road map toidentify mentors and educational resourcesin several areas of concentration, includingmaternal and child health, health policy andadvocacy, sports medicine, internationalhealth and reproductive health.

Beyond the CompetenciesThis era of residency education will be

marked by competency-based assessment.However, in many areas of medicine, atten-tion is shifting from measuring physician orresident behaviors to assessing patient out-comes, as exemplified by pay-for-perfor-mance initiatives by private insurers and gov-ernment agencies. Leaders in medical edu-cation research have called for a focus on pa-tient-centered outcomes, linking medicaleducation to quality of care rather than justphysician competency.8 Medical educatorshave also emphasized using data on healthoutcomes to guide the content of graduatemedical curricula and continuing medicaleducation.9 Such “evidence-guided educa-tion” should prepare physicians to amelio-rate the health problems of greatest signifi-cance to our patients and communities.

Evidence-Based EducationFinally, we envision a future in graduate

medical education in which educators applyscientific evidence to teaching, learning andassessment. Informed by research in educa-tional psychology on how medical traineeslearn best, we are providing opportunities foractive and collaborative learning, teachingclinical skills in authentic contexts, and usingassessment tools to improve resident learningas well as to provide feedback on the effec-tiveness of the educational program. 10-12

CONCLUSIONBuilding on our 30-year tradition of ex-

cellence, the Brown Family Medicine Resi-dency will continue to innovate, in an effortto constantly improve the educational expe-rience of our residents and the quality of carefor our patients. Methods are changing, butthe goal remains the same—to train compe-tent, humanistic physicians who provide ex-cellent care and leadership to their com-munities.

REFERENCES1. Bell H, Kozakowski S, Winter R. Competency-based

education in family practice. Fam Med1997;29:701-4.

2. Accreditation Council on Graduate Medical Educa-tion. Outcomes Project: General Competencies[website]. Available at: http://www.acgme.org/out-come/comp/compFull.asp. Accessed April 15, 2006.

3. Future of Family Medicine Project Leadership Com-mittee. The Future of Family Medicine: a collabora-tive project of the family medicine community. An-nals Fam Med 2004;2:S3-32.

4. Wagner E. Chronic disease management. EffectiveClin Practice 1998;1:2-4.

5. Accreditation Council on Graduate Medical Edu-cation. Statement of justification/impact for the finalapproval of common standards related to resident dutyhours. Chicago September 2002.

6. Petersen L, Brennan T, et al. Does housestaff discon-tinuity of care increase the risk for preventable ad-verse events? Ann Intern Med 1994;121:866-72.

7. Laine C, Goldman L, et al. The impact of a regulationrestricting medical house staff working hours on thequality of patient care. JAMA 1993;269:374-8.

8. Chen F, Bauchner H, Burstin H. A call for outcomesresearch in medical education. Acad Med2004;79:955-60.

9. Glick T. Evidence-guided education. Acad Med2005;80:147-51.

10. Spencer J. ABC of learning and teaching in medi-cine. BMJ 2003;326:564-7.

11. Irby D. Teaching and learning in ambulatory caresettings. Acad Med 1995;70:898-931.

12. van der Vleuten C, Schuwirth L. Med Educat2005;39:309-17.

Melissa Nothnagle, MD, is Assistant Resi-dency Director, Department of Family Medi-cine, Memorial Hospital of Rhode Island, andAssistant Professor of Family Medicine, BrownMedical School.

Rabin Chandran, MD, is ResidencyDirector, Department of Family Medicine,Memorial Hospital of Rhode Island, and Clini-cal Associate Professor, Brown Medical School.

CORRESPONDENCE:Melissa Nothnagle, MDMemorial Hospital of RI111 Brewster St.Pawtucket, RI 02860Phone: (40) 729-2236e-mail: [email protected]


Brown Medical School Family Medicine at Thirty:Residents’ Views of Now and Then

Paul F. George, MD, and Joanne M. Silvia, MD

The Brown Family Medicine Resi-dency turns thirty this year. Over thisperiod, our residency and the residentsthat populate it, like medicine in general,have evolved. Our talented and diversegroup of trainees faces challenges muchdifferent than those that presented them-selves to the first residency class threedecades ago. Thirty-six hour shifts nolonger exist. The challenge now is learn-ing the perpetually expanding breadthof family medicine within three yearswhile obeying new work hour rules. Yet,like our predecessors, we remain stead-fast in our mission to provide healthcareto individuals, families, and communitiesin the Blackstone Valley.

Today, as in the past, our residentsare engaged in an intense and vibrantmedical practice at the Family Care Cen-ter (FCC), now a modern facility openedin 1999 with three semi-independentpractices. Thirty years ago, Dr. JohnCunningham, a local family physician,moved his practice to Memorial Hospi-tal, slowly introducing his patients to theresidents who became their primary careproviders. Over the decades the popula-tion served by the FCC has expanded,and three generations of Pawtucket resi-dents have come to trust us with theirmedical care. Each of us carries our ownpanel of patients. Many we “adopt” fromgraduating residents, while other newpatients are consistently drawn to theunique atmosphere of our practice. Ourrange of practice is broad, providing con-tinuity through the outpatient and inpa-tient settings, and through the lifecycle.We see adults for preventive care; womenfor gynecologic and obstetrical care; chil-dren for well visits and sick visits. Wegraduate from the residency knowingthat we are capable and confident physi-cians, having become competent in thecare of patients because of our time spentat the FCC.

We also spend time outside the FCCperforming primary care for patientsboth in nursing homes and during homevisits for home-bound FCC patients.

Both these experiences are rewarding andoften thought-provoking for resident andpatient alike. One of our residents re-cently followed a patient at the FCC forover a year. The patient was reluctant todiscuss much of her social situation andthe reasons behind her deep depression,which complicated her care. A sched-uled home visit, as part of the geriatricscurriculum where residents assess a pa-tient in the patient’s home environment,revealed in minutes that the patient hadlost a son to suicide and was strugglingwith associated guilt. The patient was alsounder financial stress, supporting bothherself and a handicapped adult child.On return visits to the FCC, the patienthas been more open and willing to dis-cuss her emotions, and her depression hasgreatly improved. Similar experiences arerepeated during our many home visitsand demonstrate that returning to a morepersonal model of medicine, reminiscentof the past, augments our ability to carefor our patients.

Our inpatient hospital responsibili-ties are also wide-ranging and often feelimmense—even if they may appear lessdaunting than those thirty years ago. Theoriginal residents were not only respon-sible for floor patients during their medi-cine months, but at times those in theIntensive Care Unit as well. During ourthree years, we spend almost one full yeardoing inpatient medicine, beginning asinterns where we learn to manage pa-tients on the floor and ending as thirdyears where we rotate for two months asacting attendings (with attending super-

vision, of course). The intensity of inpa-tient care has increased, particularly aslengths-of-stay decreased, but thankfully,ICU patients and floor patients are nowcovered by different teams.

Our founding residents were alsonot bound by the eighty-hour work weekregulations that began three years ago.While we are shielded by laws governingthe number of work-hours in a shift andin a week, no such laws existed thirty yearsago. On medicine, we admit six patientsduring a call day and carry no more thantwelve at a time. The original familymedicine residents at Memorial carriedup to twenty-four patients at a time andworked thirty-six hour shifts every thirdday. The challenge for us today is not somuch working with sleep deprivation.Instead, we must learn an abundance ofmedical knowledge and new technolo-gies, in less time than our predecessors.

The Obstetrics service and the Pe-diatric service have also changed. Bothare less busy now—pediatrics becausemany diseases treated as inpatients in thepast are now managed on an outpatientbasis; obstetrics because of the high costof malpractice and the decline in obste-tricians and family doctors performingdeliveries at Memorial. The original resi-dents learned deliveries from obstetriciansand pediatrics from pediatricians. A largemajority of our expectant moms comefrom the FCC where they are managedthroughout pregnancy by the residentswho then deliver them under the super-vision of a Family Medicine attending.The same is true for pediatrics—a ma-jority of our pediatric in-patients are nowalso patients at the Family Care Centeralthough we still admit many patientsfrom private pediatricians.

Our Obstetrics and Pediatric cur-riculum is unique in that we take care ofmoms and babies from conception. Prac-tically, this means we know a baby’s birthhistory and mom’s prenatal course beforea newborn visits FCC. Even more so, weare situated to take care of a mom’s psy-chosocial needs should a newborn need

�

“…“…“…“…“…we know ababy’s birth history

and mom’sprenatal course

before a newbornvisits FCC.”


special care. For example, a resident re-cently delivered one of her prenatal pa-tients from the FCC. Shortly thereafter,the newborn became septic and requiredparenteral feeding and antibiotics. Natu-rally, the new mom was frightened withthe prospect of her sick newborn. Yet,because of the trust the resident devel-oped with the mom throughout her pre-natal course, the resident could allaymom’s concerns and gently explain to herthe natural course of her newborn’s ill-ness, all while taking care of the medicalneeds of the mom and baby pair. Noother specialty allows this type of conti-nuity and trust-building that familymedicine offers from conception to babyand beyond to the family unit.

Just like the diversity of the serviceson which we rotate, the Family Medicineresidents at Memorial are a diversegroup, and have been since the incep-tion of the Residency. Our residentsspan all ethnic backgrounds. We comefrom as close as Rhode Island and as faraway as Ghana. Our current residentshave gone to medical school at some ofthis nation’s top institutions such as Yale,Stanford and Brown. Doctors of osteo-pathic medicine now comprise approxi-mately one-third of the residency, and areincluded among the best teachers andchief residents. We are involved in basicscience, clinical and anthropologic re-search, as well as the teaching of Brownmedical students, and of each other. Wetestify about important issues in our Stategovernment and participate in localhealth fairs. As third years, we all do com-munity-oriented projects that benefit ourlocal neighborhoods. For example, oneof our residents opened up a homelessshelter for her project while anothertaught about various health problems ina local middle school. Most importantly,we share the desire to improve the medi-cal and social well-being for the citizensof the Blackstone Valley.

The patients we serve are also di-verse. The original panel of patients Dr.Cunningham brought to Memorial waslargely middle class background. Today,many of our clinic and hospital patientsspeak Spanish. We have a large West Af-rican population who speak French andAfrican dialects. We still have a smatter-ing of middle class patients, but most ofour patients are in the lower socioeco-

nomic classes. We have patients with pri-vate insurance, others who are enrolledin Medicaid or Rite Care, and some whohave no insurance. And the challengesof our system necessitate that we be notonly physicians but also mental healthworkers, pharmacists and social workers.We diligently engage in multiple tasks,diagnosing diabetes at one moment thenworking with pharmaceutical programsat the next to procure medications for ourindigent patients.

An increasing and different chal-lenge than our predecessors faced is thatof balancing newer technologies and spe-cialties with meaningful and complete in-teractions with our patients. We havecomputers in each of our exam rooms;laboratory values are within the click of amouse. Handouts on any disease can befound in less time than it would take toactually describe the disease. However,navigating insurers is difficult and frus-trating. Patients often demand specialistcare for common ailments that we as fam-ily physicians can treat easily. Yet we, likethe original residents, know our patientsand their families. We are there for themregardless of whether they have a cold orlung cancer. We counsel our patients onsexually transmitted diseases and risk fac-tors for heart disease. We deliver theirbabies and then take care of them as theygrow. We remain a safe haven for ourpatients where we take care of medicalconditions and so much more even astechnologies advance and specialties be-come narrower.

Our thirtieth birthday is both a timeof joy and reflection. From our humblebeginnings, we have changed much. Nolonger is family medicine an outlier in thefield of medicine—we are physicians first,but also teachers and researchers. We arephysicians for adults and children; for ex-pectant moms and nervous dads; for one-day old newborns and one hundred yearold grandparents. Our reach extendsthrough all socioeconomic levels, yet weremain advocates for those who are mostvulnerable and whom society most oftenforgets; the poor, the uninsured and thementally disabled. And through it all,we have remained steadfastly loyal tothose we serve—the people of Pawtucketand the Blackstone Valley.

ACKNOWLEDGEMENTS:The authors wish to thank Gilbert

Altongy, MD and Donald Derolf, MD,original residents at Memorial Hospitalin the Family Medicine Department fortheir assistance in writing this article.

Paul F. George, MD, is a second-yearresident, Department of Family Medicine,Memorial Hospital of RI.

Joanne M. Silvia, MD, is a third-yearresident, Department of Family Medicine,Memorial Hospital of RI.

CORRESPONDENCE:Paul F. George, MDMemorial Hospital of RI111 Brewster St.Pawtucket, RI 02860e-mail: [email protected]


Fellowship Training In Family Medicine At Brown:Adding Depth to Breadth

Rick Long, MD, Sean P. David, MD, SM, DPhil, Alicia Monroe, MD, and Jane Shaw, MS�While Family Medicine is a specialtymost notable for its breadth of knowl-edge and scope of practice, the goal ofadvanced fellowship training is to in-crease the depth of knowledge and ex-pand a defined skill set rather than fo-cus on sub-specialization. After comple-tion of a Family Medicine residency, afamily physician can enter into fellow-ship training for a period of usually 1-2years. The Department of Family Medi-cine at Brown Medical School and Me-morial Hospital of Rhode Island offersthree post-residency fellowships: Ma-ternal and Child Health, Health Policy,and Leadership.

MATERNAL AND CHILD HEALTHFELLOWSHIP (MCH)

The Maternal and Child Health fel-lowship (MCH) is the oldest of the fel-lowship programs in Family Medicine atBrown, initiated and designated as aBrown University-affiliated program in1991. The Department of Family Medi-cine at Memorial Hospital of Rhode Is-land worked with local, federally funded,and non-federally funded communityhealth centers to organize and restruc-ture maternal and child health care de-livery systems for women and children insurrounding, underserved communities.This followed recognition that infantmortality, prematurity, low birth weightand disparities in health care in theUnited States reflected a complex inter-action between social factors, publichealth, technical innovation, and accessto clinical services. Developing a pro-gram of care which is easily accessible andresponsive to the needs of underservedfamilies is a major undertaking and re-quires clinical and administrative leader-ship not present in many areas. OurMCH Fellowship was developed to pro-duce clinical leaders in MCH care. Itwas structured to provide both advancedclinical skills and the public health skillsrequired to develop, coordinate, and or-ganize community-oriented MCH pro-grams. From its inception, fellowship

goals have remained the same: 1) to trainfamily physicians to provide direct careto women and children at high psycho-social and medical risk, 2) to train spe-cialists in caring for underserved and vul-nerable populations, and 3) to train lead-ers capable of developing, organizing anddirecting collaborative, community-based MCH programs.

Fellows receive one or two years ofadvanced clinical training in obstetrics,care of the newborn, and community/public health. Fellows in our two-yearprogram concomitantly pursue either aMPH or a MSc in epidemiology throughBrown Medical School’s Department ofCommunity Health. Table 1 lists asample of scholarly works completed aspart of fellowship training. Twenty-twograduate-fellows practice in such diversesettings as inner-city Chicago, ruralAlaska, Nepal, Guam and Ecuador.Former fellows provide an entire scopeof maternity care from prenatal care androutine vaginal delivery, to complicated,high-risk care, cesarean sections.

Fellows also gain experience ineducation through the didactic andhands-on clinical teaching of our Fam-ily Medicine residents and medical stu-dents in maternal and child health.Half of graduates have joined familymedicine residency programs as MCHfaculty.

Over the last decade and a half, theMCH fellowship has contributed to astable provider base within the BrownFamily Medicine Residency by provid-ing role models for family physicians intraining at a hospital where the major-ity of deliveries are managed by familydoctors. Additionally, the fellowshipencourages and fosters cooperation andexchange with our nursing, midwife,pediatric, and obstetrical colleagues.Lastly, the MCH fellowship has pro-vided the foundation for promotion offamily-centered maternity care for vul-nerable and underserved women andchildren in a supportive, collaborativecommunity hospital setting.

THE C. EVERETT KOOP HEALTHPOLICY FELLOWSHIP

As a response to the need for train-ing future leaders in the re-design of fam-ily medicine and to inform the process ofhealth services policy formulation at a timewhen the US health care system is argu-ably in crisis, our Department sought todevelop a training mechanism for primarycare physicians seeking health policy ca-reers. The C. Everett Koop Health PolicyFellowship (http://bms.brown.edu/pcgl/ceverettkoop.htm) was established in 2002when former Surgeon General Koop en-dorsed and authorized use of his archives,now available online through the NationalLibrary of Medicine (http://profiles.nlm.gov/QQ), as a resource fortraining health policy professionals. Thegoals of the Koop Fellowship are for learn-ers to 1) develop the requisite knowledgebase and skill set in political and policystrategies to promote health, 2) applyknowledge and skills to specific health pro-motion issues, 3) conduct scholarly analy-sis of policy strategy, and to 4) preparenetwork in policy making circles provid-ing access to decision makers and commu-nication venues to advance future healthpolicy initiatives. Koop fellows have com-pleted masters in public health degrees atBrown Medical School and undergo amentored health advocacy program in-volving an internship in Washington,D.C., analysis of national health servicesdata, and interviews with policy makersand opinion leaders. Projects completedby Koop fellows are shown in Table 1.

THE FACULTY DEVELOPMENTLEADERSHIP FELLOWSHIP

The Faculty Development Leader-ship Fellowship was established in Au-gust, 2004. It seeks to cultivate a genera-tion of visionary leaders and changeagents who will model and teach patient-centered, high quality health care forunderserved and vulnerable populations,improve healthcare processes and systemsthrough redesign, and foster individualand organizational change.


The 18-month program, geared foractively practicing family physicians, pro-motes personal and professional growthin leadership, skills in systems-based prac-tice, scholarship and advocacy. The fel-lowship faculty represents medicine, an-thropology, psychology, business admin-istration, hospital administration andpublic health. The program includes aweekly seminar series, weekly clinicalpractica, scheduled mentoring sessions,and clinical teaching. With the assistanceof mentors each fellow designs and com-pletes a “keystone” project that synthe-sizes the core content areas. The weeklyseminars incorporate cutting edge knowl-edge and resources needed to improvechronic illness management, advocate forvulnerable populations, and provide stateof the art primary care. The practicumenables fellows to integrate new knowl-edge in their practice sites and developtheir office-based team. Individualmentoring sessions help fellows define in-dividual leadership and career goals andmonitor progress on the “keystone”project.

The fellowship graduated 5 fellowsin the first cohort, and is now trainingthe second cohort of 4 fellows. All fel-lows to date have been women, with arange of experience from 0 to 15 yearspost residency. Their practice settingshave been diverse including communityhealth centers, private practice, and aresidency clinic. Most fellows have astrong interest in underserved popula-tions. The keystone projects of the firstcohort of fellows are listed in Table 1.

Future directions for the Faculty De-velopment Leadership Fellowship in-clude: program adaptation to activelyelicited feedback; a component to teachcoaching skills; continued support andmentoring of graduated fellows pursuingsystems redesign; finding creative ap-proaches to secure future funding; andredesigning the program to enable dis-semination to other sites.

SUMMARYThe Brown Family Medicine fellow-

ship programs share a common goal ofnurturing the future leaders of our spe-

Table 1. Representative description of scholarly projects byfellowship graduates

Fellowship Representative Scholarly Projects Maternal and Child Disparities in emergency department utilization byHealthFellowship pregnant women in Rhode Island’s Rite Care

program

Predictors and prevention of teen pregnancy

Predictors of unintended pregnancy

The effects of continuity of care on pregnancyoutcome

Barriers to appropriate contraceptive use

Koop Fellowship Promotion of international tobacco control

Medicaid coverage of smoking cessation services

Childhood obesity prevention

International physician training for HIV management

Leadership Demographics and characteristics of uninsuredFellowship pregnant women in RI

Qualitative study of resident physicians’ educationalneeds for chronic disease management

A walking program supporting exercise in self-management of depression

Implementing the chronic care model to improvediabetes care in a private practice setting

A practice-based intervention to improve screeningfor osteoporosis

cialty. In a complex and demanding prac-tice environment our fellowships havecontributed to the development andpropagation of an adept Family Medi-cine specialist. These fellowships endorseour specialty’s broad approach tohealthcare through addressing primarycare and prevention, but also enhance thefuture of our field through melding thebreadth of our discipline with the depthof expertise and the stewardship of re-sponsible leadership.

Rick Long, MD, is Clinical AssociateProfessor and Director, Maternal andChild Health Fellowship, Department ofFamily Medicine, Brown Medical School.

Sean P. David, MD. SM, DPhil, isAssistant Professor and Director of Re-search, Department of Family Medicine,Brown Medical School.

Alicia Monroe, MD, is Professor andAssociate Dean of Medicine (Minority Af-fairs), Department of Family Medicine,Brown Medical School.

Jane Shaw, MS, is Assistant Educa-tion Coordinator, Department of FamilyMedicine, Memorial Hospital of RhodeIsland.

CORRESPONDENCE:Rick Long, MDMemorial Hospital of RI111 Brewster StreetPawtucket, RI 02860Phone: (401) 729 -2235e-mail: [email protected]


Since its inception in 1979, thePredoctoral Division of the Departmentof Family Medicine has had two majorgoals: to inspire medical students to chooseFamily Medicine as a specialty and to edu-cate all students on basic medical principlesand practices. Whether students chooseour specialty or not, we aim to familiarizethem with primary care to prepare themfor their roles in the health care system.

Over 27 years, the division has grownfrom a single faculty member to two corefamily physicians, two support staff and62 local sites. In 14 different courses, thedivision works with more than 100 stu-dents each year. The division is involvedin several pre-clinical courses and pro-grams during the first two years of medi-cal school, the 6-week required FamilyMedicine clerkship, multiple electives, andan integrated advising and mentoring pro-gram for clinical students in their third andfourth years of medical school.

Stephen Smith, MD, the original Di-rector of Predoctoral Education (1979-1981), developed a full curriculum for anew Community Health Clerkship, com-plete with standardized patients, videotap-ing of students’ actual student-patient en-counters, lectures, workshops, and projects.He introduced one of the first computersimulations of clinical decision-making anda national award-winning board game onhealth insurance coverage to the curricu-lum.1-3 In 1980 Dr. Smith developed asummer preceptorship program, followedby a Family Medicine Interest Group(FMIG). He increased family medicinefaculty involvement in the preclinical medi-cal interviewing and physical diagnosiscourses, and began to offer family medi-cine electives. He received the division’s firstfederally-funded medical educationPredoctoral Training Grant (a Title VIIgrant from the Health Resources and Ser-vice Administration (HRSA).

Dr. Thomas Gilbert (1981-1984) di-rected the newly established division, fo-cusing primarily on the six-week Commu-nity Health Clerkship for third-year and

History of the Predoctoral Division In the Department ofFamily Medicine at Brown Medical School

Julie Scott Taylor, MD, MSc, Stephen R. Smith, MD, MPH, Thomas T. Gilbert, MD, MPH, Timothy Empkie, MD, MPH,Charles B. Eaton, MD, MS, and Alicia D. Monroe, MD

�early fourth-year students. Students spentthe first and last week of the rotation atMemorial Hospital of RI (MHRI) work-ing with actors from the Trinity RepertoryCompany as standardized patients andfour weeks in the middle seeing patientswith doctors in their own practices.

Timothy Empkie, MD, (1984 to 1993)not only expanded the Community HealthClerkship, but was involved in two newprojects: the establishment of a maternal-child health elective at MHRI and a medi-cal student exchange program with the thenWilhelm Pieck University in the former Ger-man Democratic Republic (East Germany).In addition to running this Brown-wide ex-change program, he arranged for East Ger-

man students to spend time at the MHRIFamily Care Center.

Charles Eaton, MD, (1993 to 2001)received three HRSA Title VII grants dur-ing his tenure: one in 1994-1997 to de-velop a six-week required clerkship in Fam-ily Medicine; a second from 1997-2000to develop a 3-generation standardized pa-tient family as part of the clerkship; and athird from 2001-2004 to develop a cur-riculum on health care disparities. Theoriginal Family Medicine Clerkship, whichhas been offered continuously since 1995,consisted of six clinical sessions, two to threehalf days of community health each week,and a Community Health project. The firstcurriculum included lectures on epidemi-ology and alcoholism and workshops oncasting and management of pharyngitis.

Julie Taylor, MD, joined the depart-ment in 2001. Since then, the four-per-son predoctoral team has utilized twoHRSA Title VII grants, as well as othersmaller medical education grants, to re-vise the clerkship, expand the division’s par-ticipation in multiple other required andelective courses, and become a presencein the national medical education arena.

The current predoctoral division is in-volved in 14 courses at the medical school,six in the first two years and eight in the

Table 1: Family Medicine Predoctoral Education Leaders atBrown Medical School

Directors of Predoctoral EducationStephen Smith, MD, MPH 1979-1981Thomas Gilbert, MD, MPH 1981-1984Timothy Empkie, MD, MPH 1984-1993Charles Eaton, MD, MS 1993-2001Julie Taylor, MD, MSc 2001-present

Assistant Directors of Predoctoral EducationRobert Reinhardt, MD 1980-1983Timothy Empkie, MD, MPH 1984-1985Meredith Goodwin, MD 1994-2000Sean David, MD, MS, DPhil 2000-2002Judith Nudelman, MD 1998-2002Melissa Nothnagle, MD 2002-2003David Anthony, MD, MSc 2003-present

Brown MedicalSchool has

consistently had thehighest percentageof students applyingto Family Medicineresidencies of anyIvy League school.





third and fourth years of medical school.Some are solely Family Medicine efforts,while others involve collaborations betweenmultiple departments and individuals atBrown. For example, the Doctoring courseis a new two-year, longitudinal, requiredcourse for first- and second-year medicalstudents that replaces the medical interview-ing and physical diagnosis courses and isdesigned to teach the knowledge, skills, at-titudes and behaviors of the competent,ethical and humane physician. This inno-vative course was initiated in September2005 and is the first step of a major revi-sion of the curriculum at Brown MedicalSchool. Family medicine faculty membersserve as course leaders (Dr. Alicia Monroe),small group leaders, and community men-tors. The revitalized Family Medicine In-terest Group runs under the guidance ofDr. David Anthony in conjunction with theRI Academy of Family Practice. StudentExperiences And Rotations in CommunityHealth (SEARCH) is a summer programthat exposes students to underserved pa-tients. Funded primarily by Title 7 grants,SEARCH has run continuously from1993, in partnership with the Departmentof Health. Dr. Taylor has been the facultyadvisor for the student-led preclinicalMedical Students Outreach to MotherS-to-be Program (MOMS) since its incep-tion in 2001. This elective pairs first-yearstudents with prenatal patients (fromWomen & Infants prenatal clinic and TeamB in the Family Care Center) for a conti-nuity and advocacy experience.

The six-week Family Medicine Clerk-ship, a required rotation, runs eight timesper year with six to fifteen students per block.Each student is placed at one of 33 outpa-tient sites for seven half days of clinical time

weekly. Students spend all day Wednesdaysparticipating in a didactic curriculum whichconsists of a lecture and small group discus-sions of cases from the original three-gen-eration family in the morning taught by com-munity faculty followed by workshops in theafternoon taught by core faculty. Over thecourse of the block, there is birth and deathand lots of “bread and butter” family medi-cine in between. The final half day of theclerkship is allotted for “Social and Commu-nity Context of Health” projects. Since early2005, approximately half of the studentshave completed this requirement by work-ing on Service Learning projects at ProgresoLatino, a local social service agency. Underthe supervision of Dr. Teresita Hamilton, stu-dents have created and implemented severalprojects relating to nutrition and obesity andmaternal-child health. The predoctoral teamhas also implemented an iterative patienttracking system that documents clinical en-counters using personal digital assistants(PDAs). Members of the division have pre-sented at regional and national meetings andpublished on medical education topics, of-ten with students as collaborators.4-10

Brown Medical School has consistentlyhad the highest percentage of students ap-plying to Family Medicine residencies of anyIvy League school. Over the last five years,10 to 14% of the graduating class have ap-plied to Family Medicine residency programseach year. Virtually all our students havematched at their first choice program.

Looking forward, we envision contin-ued participation in many of the core aspectsof medical school teaching such as Doctor-ing, the Family Medicine Clerkship, key elec-tives, and advising. While the medical schoolhas begun to phase out the Dartmouth-Brown Program, there are plans to expand

the student body by 33% over the next sev-eral years. We will continue to recruit newcommunity faculty, a critical component ofour program. We are prepared for and wel-come the inevitable increase in student in-terest in family medicine.

REFERENCES1. Smith SR. MacLeod N. An innovative family medi-

cine clerkship. J Fam Practice 1981; 13:687-92.2. Smith SR. Evaluation of a telephone management

training exercise, J Fam Practice 1982; 24:22-4.3. Smith SR. An evaluation of a computer exercise in

teaching cost consciousness. J Med Educ 58:146-8.4. Taylor JS, Friedman RH, et al. Fellowship training

and career outcomes for primary care physician-fac-ulty. Acad Med 2001;76:366-72.

5. Taylor JS, Dube C, et al. Teaching the testicularexam. Fam Med 2004;36:209-13.

6. Taylor JS, Kacmar JE, et al. Breast versus bottle.Med Health RI 2004;87:142-5.

7. David SP, Taylor JS, et al. Evaluation of an edu-cational intervention for medical students to pro-mote competency in social and community de-terminants of health. Annal Behavior Science MedEduc 2004;10:68-73.

8. Frew J, Taylor JS. First Steps. Med Health RI2005;88:48-50.

9. Taylor JS, Anthony D, et al. A manageable ap-proach to integrating personal digital assistantsinto a family medicine clerkship. Med Teach2006;28:283-7.

10. Schoenfeld E, Caro-Bruce E, et al. Addressing gapsin abortion education. Med Teach 2006;28:244-7.

Julie Scott Taylor, MD, MSc, is Assis-tant Professor of Family Medicine, BrownMedical School.

Stephen R. Smith, MD, MPH, is As-sociate Dean of Medicine and Professor ofFamily Medicine, Brown Medical School.

Thomas T. Gilbert, MD, MPH, is re-tired and is a Peer Visitor for SpauldingRehabilitation Hospital.

Timothy Empkie, MD, MPH, is As-sistant Dean of Medicine (Advising) andClinical Associate Professor of Family Medi-cine, Brown Medical School.

Charles B. Eaton MD, MS, is Director,Center for Primary Care and Prevention, Me-morial Hospital of Rhode Island, and Professorof Family Medicine, Brown Medical School.

Alicia D. Monroe, MD, is Professor ofFamily Medicine, Brown Medical School.

CORRESPONDENCE:Julie Scott Taylor, MD, MScMemorial Hospital of RI111 Brewster St.Pawtucket, RI 02860Phone: (401) 729-2980 e-mail: [email protected]

Table 2: Timeline of critical predoctoral events

1975: Brown Medical School granted full 4-year accreditation; 1st graduat-ing class, and Family Medicine started as a Division of CommunityHealth

1978: Inception of the Department of Family Medicine1979: Community Health Clerkship commenced as 1st course in the

department1980: 1st Title VII Predoctoral Training Grant received1981: Dartmouth-Brown Program started1991: Longitudinal Ambulatory Clerkship began1993: 1st SEARCH Program1995: Family Medicine Clerkship initiated2002: MOMS Program came to the Family Care Center, Team B2005: Doctoring course launched


BACKGROUNDBoth the “Future of Family Medicine

Project” and the National Institutes ofHealth “Roadmap” seek to advance thestate of evidence-based primary care by cre-ating multidisciplinary “research teams ofthe future” and “advancing research thatsupports the clinical decision making offamily physicians and other primary carephysicians.”1 Two of the recommendationsfrom the October 2000 Keystone III Con-ference2 were that generalist physiciansshould be “expanding the infrastructure forpractice-based research” and “developinga multi-method, trans-disciplinary, partici-patory research paradigm.”3 Advancing thediscipline’s broader agenda of health for alland a well-trained, patient-centered, evi-dence-based workforce requires a major in-vestment in the research enterprise andtranslation of “bench to bedside” researchinto practice. Several “translational blocks,”or barriers to the successful translation ofbasic research into clinical research andfrom clinical research to practice, impedethis vision. (Table 1)4

This article traces the development ofa family medicine research division overthree generations of faculty members. Acommon pattern emerges from the growthof the research enterprise in the Depart-ment of Family Medicine; successful re-search ventures took root when precededby expansion of clinical capacity and com-munity outreach, development of under-graduate and graduate medical education,and leveraging of resources across the localhospital and university, and with nationaland international collaborators. By focus-ing on the history of research endeavors thathave been successful, effective approachesto overcoming barriers to building researchcapacity emerge and inform the next stepin advancing generalist research.

THE EARLY YEARSIn 1975, shortly after the founding of

Brown Medical School, the Departmentof Family Medicine was established, with abroad mission of promoting primary care

Building a Successful Research Enterprise In FamilyMedicine: The Brown Experience

Sean P. David, MD, SM, DPhil, Charles B. Eaton, MD, MS, Larry Culpepper, MD, MPH, Roberta E. Goldman, PhD,Laura K. Lavallee, Emma M. Simmons, MD, MPH

�and prevention through community-basedresearch. The first Chair (Louis Hochheiser,MD) and (later to become) Research Di-rector (Lawrence Culpepper, MD) were re-cruited in 1976 and 1981, respectively, andthe Department’s clinical division (establish-ment and growth of a Family Care Centerand linkage with a federally-designatedCommunity Health Center in 1975) andeducational division (establishment of theFamily Medicine Residency in 1975, Com-munity Health Clerkship in 1978) grew.

The first major research endeavors tookplace in the mid 1980s. Clinical effective-ness and quality improvement efforts in thelocal teaching hospital ultimately resultedin an examination of cesarean section rates,contributing to the national debate.5

The subsequent broadly-based pro-gram of research included a national sur-vey evaluating the status of family medicineresearch capacity and impediments.6,7 ge-riatrics education,8 spirituality in medicineeducation,9,10 and prenatal care.11 In ad-dition, some of the early departmental re-search focused on educational outcomes,including the first quasi-experimental re-search design studies of the effect of com-puterized clinical decision-making exerciseson cost consciousness.12

THE PAWTUCKET HEART HEALTHPROGRAM

From 1981 to 1993, the Departmentsof Medicine and Community Health atBrown conducted a major community-based multiple risk factor reduction trial intwo southern New England cities. ThePawtucket Heart Health Program was a 12-year research and demonstration projectfunded by the National Heart, Lung, andBlood Institute (NHLBI), based on ablend of social learning theory, communityorganization models, community psychol-ogy tenets, and diffusion research for theprimary prevention of coronary heart dis-ease. Members of the Department of Fam-ily Medicine, including a pharmacist,worked with the investigators of this land-mark study which led over the decades to

many fruitful collaborations including theWomen’s Health Initiative, a Nutrition Aca-demic award, an Osteoarthritis Initiative,and the development of a collaborative re-search enterprise, the Center for PrimaryCare and Prevention.

INTERNATIONAL FAMILY MEDICINEVincent Hunt, MD, Chair from 1986-

2000, brought a focus on international familymedicine. With federal funding, Hunt es-tablished family medicine residency pro-grams in Jordan, Russia, Nicaragua, Bahrain,and South Korea, and laid the groundworkfor a program of international family medi-cine education, health policy research andwork with the World Health Organization.Hunt introduced a mechanism permittingfunded researchers to collaborate on-site in-ternationally through brief but frequentmini-sabbaticals; as a result, the departmentdeveloped a collaboration with the CancerResearch UK General Practice ResearchGroup and the Department of PrimaryHealth Care at the University of Oxford.With laboratory-based genetics fellowshiptraining for one of the junior research fac-ulty members, the Department developed amolecular genetics laboratory.

ESTABLISHING A PRACTICE-BASEDRESEARCH NETWORK

The department has always used its clini-cal site as a research laboratory. Early work byDrs. Culpepper, Jack, Eaton, Davis and Mon-roe used the billing system to track diagnosesand audited charts to assess the quality of care.In 1993, the Department established a fam-ily medicine clerkship under Dr. Eaton’s lead-ership. With the support of the Rhode IslandAcademy of Family Physician’s Donya Pow-ers, Stephen Davis and Charles Eaton, familymedicine clerkship sites throughout RhodeIsland and Southeastern Massachusetts wererecruited and later formed the backbone of aprimary care-based research network: theNew England Research Network (NERN).This network conducted several outcomes re-search studies including a survey of patients’perspectives on antibiotic resistance, smoking


cessation counseling, exercise prescription andthe natural history of anxiety and depressionin primary care. This network expanded toinclude general internists and, in recent years,cholesterol management, cancer prevention(working with Quality Partners), and improv-ing diabetes care as part of a CDC grant withthe Rhode Island Department of Health.

GERIATRICSDuring the 1980s and 1990s, the De-

partment developed a program of geriatriceducation and research. Germinal researchincluded secondary data analysis in collabo-ration with the Center for Gerontology, re-search into the efficacy of growth hor-mones, improving rehabilitative care in frailelders,15 and educational research.16

BEST PRACTICE TECHNOLOGY TESTCENTER

As part of the quality improvement re-search and DHHS funding, the departmentsecured an electronic health record (EHR)and has performed studies aimed at improv-ing the quality of care using technology; e.g.,NHLBI-funded programs that developed (1)a computerized evidence-based decision sup-port program for congestive heart failure pre-vention (HeartMetric) and (2) a cholesterolmanagement guideline (National CholesterolEducation Program-Adult Treatment PanelIII, ATPIII) decision aid through integrationof patient and physician recommendationswith the EHR. Recently, Dr. Arnold Goldbergwith the support of a Robert Wood Johnsongrant has been researching improvement inpatient satisfaction and the process of care mea-sures for diabetic patients when the patient isinvolved in developing self-management goalsand an EHR tracks progress.

MATERNAL AND CHILD HEALTHFrom the early years of the Depart-

ment, educational research was performedin prenatal care/obstetrical care17 and pre-conception care.18 Building upon thislegacy and the infrastructure of an estab-lished maternal and child health (MCH)clinical fellowship and a clinical outreachprogram, educational and clinical researchemerged particularly in the area ofbreastfeeding. The work combined educa-tional research from the family medicinecore clerkship and studies of maternal andchild health outcomes resulting from in-terventions to improve maternal knowledgeand skills around nursing.19,20

HEALTH DISPARITIESA local research endeavor beginning

in 1990, driven by a faculty anthropolo-gist, explored pregnancy, prenatal care, de-livery, and early childhood parentingamong Cape Verdean immigrants inPawtucket. The findings were used to de-velop cross-cultural medicine curricula forresidents and medical students.21 Studies inthe 1990s examined disparities by race andsocioeconomic status with regard to cancerscreening, substance abuse, and health careaccess. Additionally, an anthropologicalstudy analyzed perceptions and behaviorsaround cancer prevention and screeningamong Dominicans and Puerto Ricans liv-ing in RI; other studies aimed at reducingdisparities in cancer prevention amongworking class populations of varying eth-nic backgrounds, and, more recently, stud-ies examined menopause among Latinas inRI, including ethnographic data collectionand a participant-driven educational inter-vention via the Internet.22

Health disparities research in the De-partment now includes the prevention, earlymanagement and treatment of HIV andAIDS in the primary care setting. In collabo-ration with a local infectious disease researchcenter, this research is concerned primarilywith the continued spread of HIV/AIDS inthe African American and Latino commu-nities and aims to reduce the barriers to HIVtesting and treatment among primary careproviders and patients.23,24

QUALITATIVE AND MIXED METHODSRESEARCH

Jeffrey Borkan, MD, PhD, (Chair,2001-present) brought research expertisein medical anthropology and emphasis onmixed-methods research. This new direc-tion involves focus groups, direct observa-tion of primary care, participant observa-tion, and integration of these methods withepidemiological and clinical trial data.25 Forexample, a NHLBI-funded program aimedat increasing physician and patient adher-ence to the ATPIII guidelines. Other stud-ies examined educational interventions forteaching alternative medicine, early clini-cal exposure for medical students, physicianpractice patterns with regard to managinglow back pain, and the impact of electronictechnology on physician-patient commu-nication and practice patterns in a familymedicine clinic.

PRIMARY CARE GENETICS ANDPHARMACOGENETICS

Two new investigators joined the fac-ulty during 2000-2002, bringing exper-tise in molecular genetics and physiciancommunication of cancer risk. This researchincluded examination of the influence ofgenotype for dopamine-related and sero-tonergic genes on smoking cessation treat-ment response to bupropion and nicotinepatch therapy 26,27 and acceptability of phar-macogenetic tailoring to primary care phy-sicians. Additional studies used functionalmagnetic resonance imaging of the brainand positron emission tomography to ex-amine genetic influences on neurologicalphenotypes of nicotine addiction.28 In ad-dition, studies examined translational ques-tions around physician knowledge, beliefsand communication skills of cancer risk.29,30

With funding from the National In-stitute on Drug Abuse, the National Can-cer Institute, the Health Resources and Ser-vices Administration, and the Robert WoodJohnson Foundation, the department estab-lished The Primary Care Genetics Labora-tory and Translational Research Center(http://bms.brown.edu/pcgl/) with a mis-sion to promote bench-to-bedside geneticsresearch in primary care and to integrategenetic medicine into the family medicineresidency curriculum. A grant from the Na-tional Cancer Institute and National Hu-man Genome Research Institute supportedan international video-teleconference in-cluding a link to the Royal College of Gen-eral Practitioners Virtual Genetics Groupin London. The center is currently con-ducting a randomized clinical trial ofbupropion that is examining genetic influ-ences on bupropion response for tobaccocraving, neurophysiological measures, andsmoking cessation.

HEALTH POLICY RESEARCHIn 2002, the Department established a

Health Policy and Advocacy Division, headedby Arthur Frazzano, MD, and the C. EverettKoop Health Policy Fellowship. This divisionestablished a policy track for family medicineresidents, a health policy seminar series, andan academic vehicle for health care advocacyat the state and federal levels.

One example of successful advocacyis the collaborative lobbying effort that re-sulted in a Rhode Island smoke-free work-place law (2003).32


CONCLUSIONResearch in Brown’s Department of

Family Medicine has spanned multiple dis-ciplines, diseases, and methods. The port-folio represents three generations of inves-tigators and thirty years of effort involvinggrant generation, development of clinicaldatabases, local, regional and internationalcollaborations, and deep investments in re-search career development. In most cases,a common pattern emerged that beganwith expansion of clinical services and out-reach to the community and family medi-cine education. Clinical and educational in-frastructure were the substrates for virtu-ally every successful and sustainable researcheffort in the Department, and all came as aresult of effort by investigators and depart-mental support in the context of busy clini-cal and teaching schedules.

Many of the challenges facing primarycare researchers today have been navigatedby our department’s investigators. For ex-ample (Table 1), when the research divisionwas first established, there was a lack of studyparticipants. Not until a large clinical basewas established was there a steady stream ofwilling participants. The paucity of well-trained investigators in the early years wasaddressed by recruiting junior clinical inves-tigators with masters in public health andfellowship instruction who were successfulin obtaining career development grants.

The fragmented clinical infrastructureand limitations to conducting clinical trialsin office practices often experienced in pri-mary care-based research, was integratedinto an educational and research networkand the introduction of EHRs and the highcosts of establishing research infrastructurewere overcome by leveraging resourcesthroughout the University.

Finally, a new paradigm oftransdisciplinary, translational researchbrought investigators together from mul-tiple disciplines, departments, and institu-tions, making possible otherwise cost- andtime-prohibitive research. A major lessonlearned from three generations of familymedicine research is that it is possible anddesirable to develop research that spans thetranslational continuum (basic biomedicalresearch to clinical knowledge and clinicalstudies to clinical practice and policy), butthat a comprehensive translational researchenterprise by family medicine departmentsrequires leveraging of finite resources. Astrong clinical and educational foundationproved to be crucial for developing capac-ity. Furthermore, synergistic collaborationsacross disciplines and institutions wereequally as important in bringing about pro-grams of research that provided local infra-structure, expertise and mentors for juniorfaculty.

ACKNOWLEDGEMENTSWe would like to acknowledge Jeffrey

Borkan, John Murphy, and Stephen Smithfor critique and content contributions tothe first draft of the manuscript.

REFERENCES1. Martin JC, Avant RF, et al. Ann Fam Med 2004; 2

Suppl 1: S3-32.2. Green LA, Graham R, et al. (The Keystone III Quar-

tet). Fam Med 2001; 33: 230-1.3. Eaton CB, Goodwin MA. Stange KC. Am J Prev Med

2002; 23:174-9.4. Sung NS, Crowley WF Jr, et al. JAMA 2003;

289:1278-87.5. Culpepper L. Fam Med 1989; 21: 333-5.6. Culpepper L, Franks P. JAMA 1983; 249: 63-8.7. Culpepper L. Fam Med 1991; 23: 10-4.8. Culpepper L., Murphy J., Fretwell M. Clin Geriatr

Med 1986; 2: 37-51.9. Anandarajah G. Stumpff J. Fam Med 2004; 36:160-

1.10. Anandarajah G. J Fam Pract 1999; 48:389..11. Jack BW, Culpepper L. J Am Board Fam Pract 1990;

3: 228-9.12. Smith SR. J Med Educ 1983; 58: 146-8.13. Hunt VR. RI Med 1993; 76: 351-60.14. WONCA. WHO AND WONCA UNITE ON

“TOWARDS UNITY FOR HEALTH”.Globalfamilydoctor.com News 2001 [cited 2006April 20]; http://www.ulb.ac.be/esp/wicc/icpc_2001.html.

15. Murphy JB. RI Med J 1991; 74: 211-9.16. Coletta EM, Murphy JB.. Acad Med 1993; 68: 901-

2.17. Jack B. Culpepper L, et al. RI Med 1993; 76:285-9.18. Jack BW, Culpepper L. J Fam Pract 1991. 32: 306-

15.19. Taylor JS, Kacmar, J, et al. Med Health RI 2004. 87:142-

5.20. Taylor JSV, Dugan L,et al. Med Health RI 2004; 87:

331-2.

Table 1. Translational Blocks and Strategies for Overcoming ThemBarrier Strategy

Translational Research from Basic Science to Human Studies

Translation of New Knowledge into Clinical Practice and Health Decision Making

• Lack of Willing Participants

• Regulatory Burden

• Fragmented Infrastructure• Incompatible Databases• Lack of Qualified Investigators

• Establishment of Rhode Island Academy of Family Physicians Practice-Based Research Network (PBRN)

• “Clinical laboratories”: cardiovascular disease prevention, diabetes, smok-ing cessation, maternal child health clinics

• Research administrative support• Human Subjects and HIPPA Training• Electronic Health Record and PBRN• Integrated EHR with physician support and patient education• NIH K Awards• NIH Training Grants• Collaborative funding with other departments• Faculty Development Fellowship• Mentoring• Funded mini-sabbaticals

• Career Disincentives• Practice Limitations• High Research Costs• Lack of Funding

• Career incentives for research success• PBRN and electronic decision tools• Leverage existing research infrastructure and economies of scale• Research administrative core support• Monthly investigator internal review of grant specific aims and method


21. Goldman R., Hunt MK, et al. Health Educ Behav 2003;30:564-81.

22. Hunt MK, Stoddard AM, et al. Cancer Causes Control2003. 14: 749-60.

23. Simmons EM, Roberts M, et al. AIDS Patient Careand STDs 2006; 20: 79-83. PMID: 16475888

24. Simmons EM, Rogers M, et al. J Nat Med Assoc 2005;97: 46-52.

25. Borkan JM, Ann Fam Med 2004; 2: 4-6.26. David, S, Niaura, R. et al. Nicotine Tob Res 2003; 5:

935-42.27. David, SP. Prim Care 2004; 31: 543-59.28. David SP, Munafo, MR, et al. Biol Psychiat 2005; 58:

488-94.29. Gramling R, Trask, P, et al. Fam Med 2004. 36: 691-2.30. Gramling R., Anthony D, et al. Genet Med 2005.

7:640-5.31. Uiterwyk S, Smith M., Lavallee L. Med Health RI 2004.

87: 341-4.

Sean David, MD, SM, DPhil, is Assis-tant Professor of Family Medicine, BrownMedical School, and Director and Founder,C. Everett Koop Health Policy Fellowship,

Charles Buckley Eaton, MD, MS, is Di-rector, Center for Primary Care and Preven-tion, and Professor of Family Medicine,Brown Medical School.

Larry Culpepper, MD, MPH, is Chief,Department of Family Medicine, BostonMedical Center; Adjunct Professor of FamilyMedicine, Brown Medical School; and Pro-fessor and Chairman of Family Medicine,Boston University Medical Center.

Roberta E. Goldman, PhD, is Direc-tor, Program in Community Oriented Pri-mary Care, Family Medicine Residency, and

The way you become a doctor is like theway you grow up, like a beetle creeping acrossa green leaf in the summertime, when youwatch it and watch it and it seems to justhurry in place, scratching its little legs tryingto get across one tiny section of leaf, and thenthe screen door slams and you look up to seewho’s there, your other hand going up toblock the sun from frying your eyes, and youswear it’s only a second but when you lookback down the beetle has made it all the wayacross and jumped down into the tall grass,safely hidden again from view.

It’s how you’re thirteen, dying to befourteen so you can be in high school, orsixteen so you can drive, and the first timeyou drive the car alone you can barely seethe road ahead of you, it’s so exciting to be atthe wheel, and the next thing you know driv-ing is like breathing, and you’re on your thirdcar and you’re thinking of trading it in, ifyou can get a decent deal, and if not, thenyou’ll wait till the end of the model year. It’show you’re reading college catalogues, dream-ing of walking across a quadrangle strewnwith autumn leaves and living in a dorm andyou can’t wait to leave home, senior year istaking way too long, and the next thing youknow you’re walking under your college’swrought-iron gates in a black gown, think-ing: wait, but wait, wasn’t there more stuff Iwas supposed to learn?

It’s how you’re twenty-two, coming outof anatomy lab on a fall afternoon stinking

Becoming a DoctorJoanne Wilkinson, MD, Msc�

of formaldehyde and thinking that somedayin the future, you’ll know all this stuff, you’lljust know it, the untapped forces in yourbrain will open wide to admit all this newinformation and you’ll be a doctor whoknows whether the flexor carpi radialis is nextto the…and the next thing you know you’rean intern cutting corners on your H&P soyou can get six of them done before mid-night and when your medical student asksyou a technical question about electrolytesyou snap, “I don’t know. All I know is, weneed to get some potassium into this guy sowe can get to the cafeteria before they close.”And how you’re twenty-five, a senior medi-cal student desperately trying to rememberthe number of joules it takes to shock some-one out of ventricular fibrillation, becauseyou know you won’t have time to look it up,when the time comes, and the next thingyou know you’re the senior resident, runningthe code in the middle of the afternoon withpeople streaming in and out of the room,and you hear your voice, strong and calmand decisive saying things like, “Only essen-tial personnel in the room please, and turn itup to three-sixty please, so we can shock himagain”, and people are actually doing whatyou say.

It’s how you’re twenty-seven, a residentin the middle of the night in the ICU, look-ing out the window at the highway lightsshining through the rain, your pale face re-flected in the pane, and thinking someday

you’ll be an attending, you’ll sleep at nightand still be able to get your patients into CTscan first thing the next morning, and thenext thing you know you’re wearing a blackwool suit and trying not to spill coffee on thesleeve, and the nurse is asking what she cando to help you, doctor, and she really meansit. And how you’re thirty-three, driving homefrom your patient’s memorial service andwondering when you are finally going to bea good enough doctor that you won’t cry,and the next thing you know you’re in thatchurch again, but getting married this time,by the minister who knows the husband ofyour patient who died and still, after all theseyears, remembers your tears, and says that’show he knew that you really cared.

Joanne Wilkinson, MD, Msc, a residentin the Department of Family Medicine 1995-8, is Clinical Assistant Professor, Departmentof Family Medicine, Brown Medical School,and Instructor, Boston University MedicalSchool.

CORRESPONDENCEJoanne Wilkinson, MD, MscDepartment of Family MedicineBoston University School of MedicineDowling 5 SouthOne Boston Medical Center PlaceBoston, MA 02118-2393Phone: (617) 414-6198e-mail: [email protected]

Clinical Associate Professor of Family Medi-cine, Brown Medical School.

Laura K. Lavallee is Education Coor-dinator, Family Medicine Residency, andClinical Teaching Associate in Family Medi-cine, Brown Medical School.

Emma Mariah Simmons, MD, MPH,is Assistant Professor of Family Medicine,Brown Medical School.

CORRESPONDENCESean P. David, MD, SM, DPhilCenter for Primary Care & Prevention111 Brewster StreetPawtucket, RI 02860phone: (401) 729-2071E-mail: [email protected]


The Rhode Island Academy of Fam-ily Physicians (RIAFP) was establishedon May 26, 1972, by five family doctors:Alfred A. Arcand, MD, John E. Murphy,MD, Jean M. Maynard, MD, Robert P.Sarni, MD, and Charles E. Millard, MD.The official “Rhode Island Chapter,American Academy of Family Physicians,Inc,” grew out of the Rhode IslandChapter, American Academy of GeneralPractice. The original Purposes of the Or-ganization are just as important today asthey were 34 years ago:

1.To promote and maintain highstandards in the general practice ofmedicine and surgery.

2.To encourage and assist young menand women in preparing, qualify-ing, and establishing their skills infamily practice.

3.To preserve the right of the familypractitioner to engage in medicaland surgical procedures for whichhe is qualified.

4.To assist in providing post-gradu-ate study courses for family practi-tioners.

5.To advance medical science andprivate and pubic health.

To fulfill these goals, the RIAFP, overthe past 34 years, has held regular Board,Committee and Annual Meetings, col-laborated with the American Academyof Family Physicians (AAFP), and in-volved itself in political action. Since itsinception, the organization has grownunder the leadership of its Officers andExecutive Secretaries. (Table 1)

The crowning event of the year hasbeen the Annual Meeting, featuring lo-cal and national speakers. At each meet-ing, AAFP CME credit has been awardedto the participants; and the officers havebeen elected. For the first 16 years, theannual meeting agenda was a half-day ofbusiness and education, followed by anevening’s social gathering with spousesand significant others. A daunting chal-lenge that the RIAFP faced early on was

Rhode Island Academy of Physicians:Then and Now

David P. Carter, MD, Michael D. Fine, MD, Alfred A. Arcand, MD, Robert P. Sarni, MD, Nancy G. Leggat�

to recruit enough physicians to join theAcademy and to attend meetings. To at-tract local physicians, the RIAFP heldmeetings at noon (to accommodatemorning house calls, hospital rounds and

afternoon office hours) at various localesincluding country clubs and hospital staffrooms, from Newport to Warwick,Pawtucket, and Providence. Success wasvariable. In fact, one year the Annual

Table 1. PRESIDENTS/EXECUTIVESRhode Island Chapter, American Academy of General Practice, RhodeIsland Chapter, American Academy of Family Physicians, and Rhode IslandAcademy of Family Physicians

1949-1951 Charles E. Millard, MD1951-1952 A. Lloyd Lagerquist, MD1952-1953 Peter C. H. Erinakes, MD1953-1954 Charles E. Byran, MD1954-1956 Samuel D. Clark, MD1956-1957 Gustavo A. Motta, MD1957-1958 Edmund T. Hackman, MD1958-1959 Alphonse R. Cardi, MD1959-1960 Walter E. Hayes, MD1960-1961 Frank C. Jadosz, MD Madeline Flanigan (1960-1962)1961-1962 Charles L. Farrell, MD1962-1963 Mary M. Tyszkowski, MD1963-1964 Raul Nordarse, MD1964-1965 Richard J. Kraemer, MD1965-1966 Jose Ramos, MD1966-1967 Robert C. Hayes, MD James E. Miller (1966-1980)1967-1968 George C. Charon, MD1968-1969 Paul E. Barber, MD1969-1970 R. Bruno Angelli, MD1970-1971 Raul M. Nordarse, MD1971-1972 Robert P. Sarni, MD1972-1973 Alfred A. Arcand, MD1973-1974 John E. Murphy, MD1974-1975 Joseph L. C. Ruisi, MD1975-1976 Simon L. Blumen, MD1976-1977 Daniel S. Harropp, Jr., MD1977-1978 Jaroslaw Koropey, MD1978-1979 Daniel S. Magiera, DO1979-1980 Nathan Sonkin, MD1980-1981 Jaroslav Struminsky, MD Mary M. Davies1981-1983 Charles E. Millard, MD1983-1985 Barrie Weisman, MD Alberta Procaccini, Susan

Guralnick, Nancy Leggat (1985-2004)1985-1987 David P. Carter, MD1987-1989 Edward F. Asprinio, MD1989-1991 Arthur A. Frazzano, MD1991-1993 Ira G. Warshaw, MD1993-1995 David P. Carter, MD1995-1997 Colleen A. Cleary, MD1997-1998 Thomas T. Gilbert, MD1998-2000 Donya Ann Powers, MD2000-2002 Michael D. Fine, MD2002-2004 Arnold Goldberg, MD Susanna Rhodes (2002-2006)2004-2006 John O. Bossian, DO Susanna Rhodes,

Jennifer Bianco2006- Margaret Sun, MD Kim McHale


Meeting was cancelled due to insufficientattendance. Even the business meetings,attended by the officers and the execu-tive secretary, were uncertain.

The “modern era” of the RIAFPbegan as graduates of Family MedicineResidencies, particularly that of BrownMedical School at Memorial Hospital ofRhode Island, joined the medical com-munity and the RIAFP. After 1989 allof the succeeding presidents of the Acad-emy have been residency-trained. Dur-ing this time the educational program atthe Annual Meeting expanded to cover2 days, with social gatherings in theevening. During the past 10 years, theBrown Medical School Residency in Fam-ily Medicine has co-hosted with theRIAFP these annual educational pro-grams, and attendance has been high.

The RIAFP has established close tieswith the AAFP. Delegates from the RIAFPhave attended all of the national meetingsand many regional cluster meetings of theAAFP. Members of the RIAFP have beenappointed to positions with the AAFP in-cluding Members and Membership Ser-vices Committee, Annual Scientific Assem-bly Planning Committee, Urban FamilyMedicine Task Force among others, andSergeant at Arms. In 1980, the RIAFPhelped to elect Morris B. Mellion (bornand raised in RI) as President of the AAFP.

On multiple occasions, the RIAFP wasawarded plaques and citations for in-creased enrollment of family doctors, resi-dents and medical student members.Numerous RIAFP resolutions have beenintroduced and accepted by the AAFPCongress of Delegates.

In addition to the Officers and theBoard of Directors, the functions of theRIAFP have been carried out by theStanding Committees, including: Mem-bership, Legislative, students and Resi-dents, and Research. The RIAFP has awebsite (www.riafp.org), and a members-list serve.

The RIAFP has been politically ac-tive, particularly since the late 1990s, onlocal, state, and national issues. MultipleGovernors and many local and state leg-islators have sought its guidance. Start-ing in 2001, the Governor Lucius GarvinAward was established to honor legisla-tors who exemplify the values of Dr.Garvin – Family Physician and Governorof the State of Rhode Island (1902-03).Recipients have been CongressmanPatrick Kennedy, Lt. Governor CharlesFogarty, State Senator Elizabeth Roberts,and State Representative Peter Ginaitt.

Growth of the RIAFP has been pro-gressive, rapidly at first but then slowly,until a resurgence has brought the cur-rent membership to 174. Today the

RIAFP is an expanding, energetic andrespected organization still dedicated tothe principles established by the found-ing fathers of promoting the well beingof our patients and our members.

David Carter, MD, is Clinical Asso-ciate Professor of Family Medicine. BrownMedical School.

Michael Fine, MD, is Chairman ofthe Department of Family Medicine at theRhode Island and The Miriam Hospitalsand Clinical Assistant Professor of FamilyMedicine, Brown Medical School,

Alfred A. Arcand, MD, a former presi-dent of the American Academy of FamilyPhysicians, is a Clinical Assistant Professorof Family Medicine, Brown MedicalSchool.

Robert P. Sarni, MD, is a former presi-dent of the American Academy of FamilyPhysicians.

Nancy G. Leggat is a forner executivesecretary of the Rhode Island Academy ofFamily Physicians.

CORRESPONDENCE:David Carter, MD174 Armistice Blvd.Pawtucket, RI 02860Phone: (401) 723-7578E-Mail: DRDPCMD@aol

Class of 2006.


Health care access, defined as “thetimely use of personal health services to achievethe best health outcomes,”1 is the sine quanon of health services. Without access, nei-ther the character nor quality of services hasany bearing on health outcomes.2 More than40 million Americans do not have a specificand/or continuous source of health care.3 Pri-mary care, calculated as the statewide num-ber of primary care physicians per 10000population, is the only medical service that iscorrelated with improvements in populationhealth.4 Having a primary care physician asone’s standard source of care also leads to lowerlong-term health care costs.5

Those without health care coverage nowcomprise 15.7 % of the national population- a substantial increase from 1991 the percentof persons uninsured was between 14.1% and14.6% depending the reporting source.6 7

For a number of years, Rhode Island wasamong the best-insured states in the nation,but today, fewer Rhode Islanders have healthinsurance than at any time in the last 15 years.7

Rhode is now ranked 11th nationallyin the percentage growth of uninsured.6

According to the Centers for DiseaseControl and Prevention (CDC) in 2004,11.9% Rhode Island adults age 18 and olderreported not having any health care coverage.7

Minorities and people of a lower so-cioeconomic status, both in Rhode Islandand nationally, are less likely to have healthcoverage or a constant source of primaryhealth care.2 According to the Center forDisease Control’s Behavioral Risk FactorSurveillance System Survey, 9.2% of whiteRhode Islanders 18 and older lack health carecoverage versus 14.3% of Blacks and 35.5%of Hispanics. Only 5% of Rhode Islanders18 and older earning over $50,000 lackedhealth insurance, compared to 11.6% ofthose earning $35,000 – $49,999, or 24.4%of those earning less than $15,000.7

Educational attainment correlates withhealth care coverage. College graduates are lesslikely to lack coverage (6.4%) than those hold-ing only a high school degree or GraduateEquivalence Degree (GED) (14.3%) orwith less than a high school education (27.1%).7

An uninsured person is unlikely tohave a continuous source of health care and,therefore, unlikely to receive all needed ser-vices.8 Twenty percent of uninsured Ameri-cans, versus 3% of insured Americans, usethe emergency room for most of their

Improving Health Care Access for Uninsured Rhode IslandersMichael D. Fine, MD, and Emory E. Liscord�

health care needs.9 In many instances thepatient visits the hospital for conditionsthat could have been prevented if s/he hadbeen receiving regular primary care.10

In 2004, 25% of Rhode Island’s un-insured utilized Rhode Island’s Health Cen-ters.11 The number of uninsured seen bythe Health Centers increased by 29% from2003 to 2004, while the number of insuredpatients treated increased by 1.5%. Clearly,additional solutions are needed.

The Rhode Island Family Physicians Ac-cess Alliance is an evolving network of primarycare physicians that provides reduced fee-for-service primary care for people without em-ployer-provided health insurance, and for thosewith defined contribution plans and health sav-ings accounts. Three Rhode Island family prac-tices, beginning in 2002, pioneered this newfinancial model. At present, approximately 300patients have purchased primary care in this way,paying a monthly fee. Anyone who can payfor a cell phone, basic cable television, or highspeed internet access can afford to purchase pri-mary care this way. Alliance Primary care prac-tices often provide same-day access for peoplewho need it, provide 24-hour telephone cov-erage, and often care for their own patients oncethey are admitted to the hospital. The prac-tices receive no grant subsidies for their servicesto the uninsured. (The bulk of the practicesconsist of patients with insurance.)

The original members of the Alliancehave attracted national attention, with anumber of primary care practices around thecountry duplicating the Alliance structure.One of these practices, Hillside Avenue Fam-ily and Community Medicine, received the2005 Healthcare Leadership Council HonorRoll for Coverage Award, an award that high-lights new and promising approaches to thecare of the uninsured, for this work.

By making primary care available for alow monthly fee, these Rhode Island familypractices have done what most state and theUS Federal governments have failed to do:make basic health care available to all. Evenmore, they have suggested a pathway for a newway of thinking about primary health care, sug-gesting that the financing of primary care canbe effectively done without health insurancecompanies or big government intervention.

The Access Alliance process has triggereda new look at primary care, and primary carefunding. Could we remove primary care fund-ing from the fee for service, health insurance

world, and, instead, pay for primary care witha combination of capitation and patient de-rived fee for service? Policy makers in RhodeIsland are now rethinking the funding of pri-mary care part of the health care system.

The Rhode Island of Family Medicine isbeta-testing computer software that will sim-plify tracking and billing. Look for a statewidenetwork of primary care practices providing thiskind of reduced fee for service, monthly fee pri-mary care easily available to all Rhode Islanders;and look to Rhode Island to keep it in place as anational leader in making quality primary careservices available and accessible to all.

REFERENCES1. Millman Michael (ed.). Access to Health Care in America.

Washington, DC: National Academy Press, 1993.2. U.S Department of Health and Human Services,

Agency for Healthcare Research and Quality. Na-tional Healthcare Disparities, 2003

3. U.S. Department of Health and Human Services.“Healthy People 2010: Understanding and Improv-ing health.” Conference Edition, Volume 1. Wash-ington DC: January 2000:45

4. Starfield B, et al. Primary care, income inequality, andhealth indicators. J Fam Practice. 1999;48:275-84.

5. Institute of Medicine. (1996). Primary care: American’shealth in a new era. Washington, DC: National Acad-emy Press. 1996.

6. DeNavas-Walt, Carmen, Proctor B, et al. Income Pov-erty, and Health Insurance Coverage in the U.S.: 2004.

7. Centers for Disease Control and Prevention (CDC). Be-havioral Risk Factor Surveillance System Survey Data. Atlanta,Georgia: U.S. Department of Health and Human Ser-vices, Centers for Disease Control and Prevention, 2004.

8. National Coalition on Health Care. Facts on HealthInsurance. Accessed online on April 28, at:www.nchc.org/facts/coverage.shtml

9. Center on Budget and Policy Priorities. Number ofAmericans Without Health Insurance Reaches High-est Level on Record. 26 August 2004

10. The Henry J. Kaiser Family Foundation. Access to Carefor the Uninsured: An Update. 29 September 2003.

11. Rhode Island Health Center Association. Toward aHealthier Rhode Island: The Vital Role of Commu-nity Health Centers in Improving Public Health, 2004

Michael D. Fine, MD, is Physician Oper-ating Officer, Hillside Avenue Family and Com-munity Medicine LLC, and Physician-in-Chief,Department of Family and Community Medi-cine, Rhode Island Hospital and the MiriamHospitals.

Emory E. Liscord is a student atDartmouth Medical School.

CORRESPONDENCEMichael D. Fine, MDThe Miriam Hospital164 Summit AvenueProvidence, Rhode Island 02906Phone: (401) 793-5610e-mail: [email protected]


Evidence of Increased Prostate CancerScreening in Rhode Island

John P. Fulton, PhD

Screening for cancer of the prostate is controversial. Usedtogether, the digital rectal examination (DRE) and the pros-tate-specific antigen (PSA) blood test may be used to detectprostate cancer at early stages of disease, and clinical studies haverevealed promising outcomes from prompt, state-of-the-art treat-ment following positive screening results. Additionally, since theintroduction of the PSA test in 1986, mortality from prostatecancer has declined in the United States.1 However, the contri-bution of screening to mortality decline is unproven, and willremain so until a major clinical trial is completed in 2017.2

Until that time, recommendations for prostate cancerscreening will continue to be inconsistent, as follows:

• American Cancer Society [Recommended]: Both the PSAtest and digital rectal examination (DRE) should be of-fered annually, beginning at age 50, to men who have atleast a 10-year life expectancy. Men at high risk (African-American men and men with a strong family of one ormore first-degree relatives [father, brothers] diagnosedbefore age 65) should begin testing at age 45. Men ateven higher risk, due to multiple first-degree relatives af-fected at an early age, could begin testing at age 40. De-pending on the results of this initial test, no further testingmight be needed until age 45. Information should beprovided to all men about what is known and what is un-

certain about the benefits, limitations, and harmsof early detection and treatment of prostate can-cer so that they can make an informed decisionabout testing. Men who ask their doctor to makethe decision on their behalf should be tested. Dis-couraging testing is not appropriate. Also, notoffering testing is not appropriate.3

• National Cancer Institute [No recommenda-tion]: Benefits - The evidence is insufficient todetermine whether screening for prostate can-cer with PSA or DRE reduces mortality fromprostate cancer. Screening tests are able to de-tect prostate cancer at an early stage, but it isnot clear whether this earlier detection and con-sequent earlier treatment leads to any changein the natural history and outcome of the dis-ease. Epidemiological evidence shows a trendtoward lower mortality for prostate cancer insome countries, but the relationship betweenthese trends and intensity of screening is notclear, and associations with screening patternsare inconsistent. The observed trends may bedue to screening, or to other factors such asimproved treatment. Harms - Based on goodevidence, screening with PSA and/or DRE de-tects some prostate cancers that would neverhave caused important clinical problems. Thus,screening leads to some degree of overtreatment.Based on good evidence, current prostate can-cer treatments, including radical prostatectomyand radiation therapy, result in permanent sideeffects in many men. The most common ofthese side effects are erectile dysfunction andurinary incontinence.4

RHODE ISLAND DEPARTMENT OF HEALTH • DAVID GIFFORD, MD, MPH, DIRECTOR OF HEALTH EDITED BY JAY S. BUECHNER, PHD

Figure 1. Incidence of prostate cancer per 100,000 population, by age group,White males of all ethnicities, Rhode Island, 1987-1995 and 1996-2003.

Figure 2. Incidence of prostate cancer per 100,000 population, by age group,Black males of all ethnicities, Rhode Island, 1987-1995 and 1996-2003.


• U.S. Clinical Preventive Services Task Force [No rec-ommendation]: The evidence is insufficient to recom-mend for or against routine screening for prostate can-cer using PSA testing or DRE. There is good evidencethat PSA screening can detect early-stage prostate can-cer but mixed and inconclusive evidence that early de-tection improves health outcomes. Screening is associ-ated with important harms, including frequent false-posi-tive results and unnecessary anxiety, biopsies, and poten-tial complications of treatment of some cancers that maynever have affected a patient’s health. The current evi-dence is insufficient to determine whether the benefitsoutweigh the harms for a screened population.5

Because screening for prostate cancer has not been a cancercontrol priority in the United States, surveillance for prostate can-cer screening has begun only recently. For example, the Behav-ioral Risk Factor Surveillance System (BRFSS) of the Centers forDisease Control and Prevention began collecting informationabout use of the PSA test in 2002, and collected additional infor-

mation in 2004. At the time of the latter survey, themedian state value for the proportion of men ages40 and over who “had a PSA test in the past twoyears” was 52%, revealing widespread use despitelukewarm recommendations. Use varies by age, vary-ing from 25% for men ages 40-49 to 75% for menages 65 and over. The corresponding proportionsfor Rhode Island are statistically equivalent.6

Trends in incidence rates may also be used toassess the use of screening in a population. Of thetwo screening tests for prostate cancer, DRE has beena standard part of the complete physical examina-tions for decades. There is no reason to believe thatDRE use has changed substantially of late. The PSAtest, however, was introduced in 1986, and its rapidintroduction may increase incidence rates in twoways: first, by detecting some tumors that are unde-tectable with the DRE (because they are out of reach),and second, by detecting some tumors sooner thanthey would be detectable with the DRE, thus “heap-ing” several future years’ diagnoses in the current year.When PSA screening for prostate cancer becomesroutine, the heaping effect, which is not an effect ofscreening but rather of its rapid introduction, canbe expected to subside.

An examination of prostate cancer incidencerates in Rhode Island by age, race, and ethnicity(Hispanic origin) was undertaken to look for evi-dence of the rapid introduction of the PSA in sub-sets of the population of resident men, ages 40and over.

METHODSAge-specific prostate cancer incidence rates

were constructed from prostate cancer case reportsmade to the Rhode Island Cancer Registry between1 January 1987 and 31 December 2003 for menliving in Rhode Island (numerator data) and esti-

mates of the population of men living in Rhode Island duringthat period, based on US census reports for 1990 and 2000(denominator data). Age-specific rates were calculated for Whitemen of all ethnicities, Black men of all ethnicities, and Hispanicmen of all races, dividing the seventeen years of observation intoearly (1987-1995) and late (1996-2003) periods. The resultswere plotted by age group and period, controlling for race orethnicity, to examine changes for evidence of the rapid intro-duction of prostate cancer screening.

Note on Classifying Prostate Cancer Cases as Hispanic:Data on resident prostate cancer cases identified as Hispanic wereextracted from Rhode Island Cancer Registry case reports for theyears 1987-2003 and aggregated by age group and year of event.Alternative counts of resident prostate cancer cases for Hispanicswere estimated using a validated US Census technique for identi-fying Hispanics by surname.7 Synthetic aggregates of prostate can-cer cases for Hispanics were created by adding the additional casesclassified as Hispanic on the basis of the name analysis to thosecases identified as Hispanic in case reports.

Figure 3. Incidence of prostate cancer per 100,000 population, by age group,Hispanic males of all races, Rhode Island, 1987-1995 and 1996-2003.

Figure 4. Incidence of prostate cancer per 100,000 population, by age group andrace/ethnicity, males, Rhode Island, 1996-2003.


RESULTSFigure 1 reveals a shift to the left in age-specific rates of pros-

tate cancer incidence among White men of all ethnicities betweenthe two periods, with increased incidence in younger age groups(through ages 65-69), and decreased incidence in older age groups(ages 70-74 and higher). The same is true of Black men of allethnicities (Figure 2) and Hispanic men of all races. (Figure 3) InRhode Island, Blacks and Hispanics have small numbers of menin the oldest age groups, accounting for the jagged shape of inci-dence rates by age among Black and Hispanic elders.

Figure 4 allows a closer comparison of incidence rates acrosssub-populations of resident Rhode Island men in the latter pe-riod of observation, 1996-2003. White men of all ethnicitiesand Hispanic men of all races (most of whom in Rhode Islandare White), have almost identical age-specific incidence ratesthrough ages 70-74. At older ages the small numbers of His-panic men and of prostate cancer cases among Hispanic menobscure rate comparisons. In contrast to these two sub-popu-lations of resident Rhode Island men, Black men of allethnicities have higher age-specific rates throughout the lifespan(again, partially obscured by small numbers of Black men andof prostate cancer cases among Black men at older ages.)

DISCUSSIONRhode Island prostate cancer incidence data are consistent

with rapid introduction of the PSA test in the late period of obser-vation, 1996-2003, relative to PSA use in the early period of ob-

servation, 1987-1995. The data are also consistent with a “natu-ral” increase in prostate cancer incidence, but several observationsargue against the latter explanation as the only explanation. First,the PSA test is now being administered to about half of all RhodeIsland men over the age of 40, enough for a substantial “screeningeffect.” Second, prostate cancer incidence rates for the UnitedStates as a whole clearly reveal the heaping attributable to the rapidintroduction of a screening test, superimposed on a mildly up-ward trend in “natural” prostate cancer incidence.

If it is indeed true that some substantial proportion of theobserved shift to the left in age-specific rates is attributable to therapid introduction of the PSA test, it is notable that Black menand Hispanic men under age 65 seem to have experienced theeffects of screening as well as White men, because on average,Black and Hispanic Rhode Island men are less likely to have aregular source of primary care than White Rhode Island men.8

Finally, Hispanic Rhode Island men of all races (most ofwhom are White) appear to have the same age-specific pros-tate cancer incidence rates as White Rhode Island men of allethnicities (of whom only about 10% are Hispanic), even afterapplying the Hispanic name algorithm to the data, which mayerr on the side of over-estimating Hispanic cancer incidencerates. In short, relative to White Rhode Island men of allethnicities, Hispanic Rhode Island men of all races do not ap-pear to be at higher risk of developing prostate cancer.

Screening for prostate cancer remains controversial. Al-though screening with the DRE and PSA is useful in detectingprostate cancer at early stages of disease, the net benefit of earlyintervention is unclear, and may not be determined for an-other decade. Yet, over half of Rhode Island men ages 40 andover have had a PSA test in the past two years, and screeninghas gained sufficient momentum, apparently, to have contrib-uted to higher prostate cancer incidence rates at earlier ages.Careful local monitoring of screening outcomes is indicated,as is constant monitoring of the scientific literature on the ef-fectiveness of prostate cancer screening.

REFERENCES1. Ries LAG, Harkins D, et al. (eds). SEER Cancer Statistics Review, 1975-2003,

National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2003/, based on November 2005 SEER data submission, posted tothe SEER web site, 2006.

2. National Cancer Institute: http://www.cancer.gov/3. American Cancer Society. American Cancer Society Guidelines for the Early De-

tection of Cancer. http://www.cancer.org/4. National Cancer Institute: http://www.cancer.gov/5. Agency for Healthcare Research and Quality: http://www.ahrq.gov/clinic/

3rduspstf/prostatescr/prostaterr.htm6. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Sur-

veillance System Survey Data. Atlanta, Georgia: U.S. Department of Health andHuman Services, Centers for Disease Control and Prevention, 2002 and 2004.

7. NAACCR Latino Research Work Group. NAACCR Guideline for EnhancingHispanic/Latino Identification: Revised NAACCR Hispanic/Latino Identifica-tion Algorithm [NHIA v2]. Springfield (IL):North American Association ofCentral Cancer Registries. September 2005.

8. Center for Health Data and Analysis. Rhode Island Department of Health. Behav-ioral Risk Factor Surveillance System: http://www.health.ri.gov/chic/statistics/brfss.php.

John P. Fulton, PhD, is Associate Director of Health, RhodeIsland Department of Health, and Clinical Associate Professor ofCommunity Health, Brown Medical School.


The Rhode Island Health IT e-Newsletter Project Update�

The Rhode Island Health Information Exchange projectcontinues to gain momentum. Most recently, RTI Internationalawarded the RI Department of Health a $344,000, 11-monthcontract to participate in the Health Information Security andPrivacy Collaboration. The money will be primarily used to funda business analyst, legal counsel, and project management forthe project to meet the required deliverables.

Rhode Island is one of 34 states participating in this col-laboration. Each state will:

• Assess variations in organization-level business policies andstate laws that affect health information exchange in itsstate or territory

• Work closely with Research Triangle Institute (RTI) In-ternational, National Governors Association (NGA), andother states and territories to share information and expe-riences regarding interoperable health information ex-change (HIE) barriers and best practices

• Identify and propose practical solutions that protect pri-vacy and security of health information and permitinteroperable health information exchange

• Develop plans to implement solutions in its state, and, ifapplicable, at the federal level

The Department of Health will be working with existingworkgroups, as well as committees organized by the Rhode Is-land Quality Institute, to gather broad stakeholder input dur-ing the assessment, solution development, and implementationplanning phases of the collaboration.

The timeline for this project is May 2006 – March 2007. The State and Regional Demonstration in Health Infor-

mation Technology Project, also known as the AHRQ HealthIT Project is a 5 year, $5 million dollar demonstration projectthat was awarded to the Rhode Island Health Department bythe Agency for Healthcare Research and Quality in 2004 andwill continue until 2009. Rhode Island is one of 6 states to bepart of this demonstration project. The contract will plan, de-velop, implement, and evaluate an electronic “backbone” to fa-cilitate interoperability and sharing of patient data between hos-pitals, physician offices, labs and other healthcare.

STATES CHOSEN TO PARTICIPATE IN RHIO BESTPRACTICES

The American Health Information Management Associa-tion (AHIMA) reports that its Foundation of Research andEducation (FORE) has chosen nine state-level regional healthinformation organizations to participate in developing consen-sus on best practices for state-level RHIOs. The project, undercontract with HHS’s Office of the National Coordinator forHealth Information Technology (ONCHIT), will producepublic information on best practices in the areas of governance,

structure, financing, operations and health information exchangepolicies, AHIMA reports.

The nine states selected are: California, Colorado, Florida,Indiana, Maine, Massachusetts, Rhode Island, Tennessee andUtah. Under the terms of the contract, AHIMA says, the se-lected RHIOs are required to have a form of public-private gov-ernance and operate at the state-level, either as a single organiza-tion or in a coordinating role bringing together multiple localhealth information exchanges. The organization adds that pri-ority was given to RHIOs that exchange health care data to somedegree. Other factors for consideration include geographic cov-erage, state population and longevity, AHIMA adds.

According to the organization, the project will include sitevisits and interviews and will be guided by a steering committeecomprised of representatives from the RHIOs. The steering com-mittee will develop a framework for describing and disseminat-ing best practices and models and encouraging adoption andcoordination among state-level RHIOs. For more informationvisit: www.ahima.org

CCHIT CHAIR PLEASED WITH CERTIFICATIONRESPONSE

Certification Commission for Healthcare Information Tech-nology Chair Dr. Mark Leavitt said he is pleased with theindustry’s response to the first certification round and added thatmore than two dozen electronic health record vendors have ap-plied to have their products tested for certification. For MoreInformation visit www.govhealthit.com

RHODE ISLAND LEADS NATION IN ELECTRONICPRESCRIPTIONS

When it comes to the number of doctors sending prescrip-tions to pharmacists electronically, Rhode Island leads the na-tion, according to electronic prescription network companySureScripts. About 20% of doctors in Rhode Island have con-nected to the system, however, more than 90% of prescriptionsin the state still are handwritten and given to patients who mustfill them at pharmacies. To learn more visit:www.getRXConnected.com /RI.

THE ANALYSES UPON WHICH THIS PUBLICATION is based were performedunder Contract Number 500-02-RI02, funded by the Centers for Medicare &Medicaid Services, an agency of the U.S. Department of Health and HumanServices. The content of this publication does not necessarily reflect the views orpolicies of the Department of Health and Human Services, nor does mention oftrade names, commercial products, or organizations imply endorsement by theU.S. Government. The author assumes full responsibility for the accuracy andcompleteness of the ideas presented.

To subscribe to the Quality Partners of Rhode IslandHealth IT e-Newsletter

contact Mary Ellen Casey: [email protected]


Skin-Deep In Words�

Physician’s Lexicon

The skin is the largest and certainly themost visible organ in the mammalian body.The volume of medical terms pertaining tothe skin is equally extensive.

As with so many other vertebrate or-gan systems, three Classical languages con-tribute materially to its vocabulary: Greek,often for terms of pathological relevance;Latin, primarily for anatomic names but alsofor some disease states; and Old HighGerman [OHG] for the more vernacularterminology.

Dermis [as in epidermis] is of Greek ori-gin and not to be confused with derma, a Yid-dish word meaning intestine, or dharma, aSanskrit word meaning natural law; integumentis from the Latin, integere, meaning to cover;cutis [as in cutaneous or cuticle] is from theLatin cutis ; corium is from the Latin meaningbark or leather; and skin is from OHG.

Intertrigo, meaning a cutaneous inflam-

mation due to friction between adjacent skinsurfaces, is from the Latin, inter-, meaningamong or between, and terere, meaning torub. Prurigo, skin inflammation associatedwith itching, is derived from the Latin mean-ing itching [also the root of the word, pruri-ent, meaning lewd.] Lentigo, meaning a len-til-shaped skin discoloration is from the Latin,lentis [as in words such as lens, lentil and len-ticula, a term describing freckles.] Lent, the 40weekdays preceding Easter, however, stemsfrom an OHG word meaning Spring. Impe-tigo, a pustular skin eruption, is from the Latin,impetere, meaning to attack or rush as in wordssuch as petition or competition.

Many medically oriented nouns of Latinorigin end with the letter ‘o’ [see above para-graph as well as words such as libido, ego, andvertigo.]

Pityriasis, a dermatosis characterized byexcessive desquamation in the form of bran-

like fragments is from the Greek meaning branor dandruff [OHG]. And the Greek noun-suffix, -iasis, is used to define any conditionmarked by pathological excessiveness [such ascholelithiasis or psoriasis.] This suffix is alsoemployed to describe many parasitic diseasessuch as giardiasis, helminthiasis and filariasis.

Psoriasis, a chronic skin disorder, is de-rived from a Greek root, psora, meaning torub or itch. This word, psora, stands alone asan English synonym for scabies. Scabies, inturn, is from the Latin, scabere, meaning toscratch or scrape. The word scab has come tomean the incrustation over a healing sore; andalso as a pejorative term describing a workerwho takes the place of one who is on strike.

A further dermatological lexicon will ap-pear in next month’s issue of Medicine &Health/Rhode Island.

– STANLEY M. ARONSON, MD

Diseases of the HeartMalignant Neoplasms

Cerebrovascular DiseasesInjuries (Accidents/Suicide/Homicde)

COPD

Number (a)192192

404134

Number (a) Rates (b) YPLL (c)3,005 280.9 4,737.52,403 224.6 6,495.0**

515 48.1 850.0423 39.5 6,751.5551 51.5 497.5

Reporting Period

12 Months Ending with August 2005August2005

UnderlyingCause of Death

Live BirthsDeaths

Infant DeathsNeonatal Deaths

MarriagesDivorces

Induced TerminationsSpontaneous Fetal Deaths

Under 20 weeks gestation20+ weeks gestation

Number Number Rates986 13,275 12.4*773 9,686 9.1*(10) (99) 7.5#(10) (82) 6.2#271 7,368 6.9*276 3,145 2.9*338 4,905 369.5#

74 999 75.3#(68) (924) 69.6#

(6) (75) 5.6#

Reporting Period12 Months Ending with

February 2006February

2006Vital Events

Rhode Island MonthlyVital Statistics Report

Provisional OccurrenceData from the

Division of Vital Records

(a) Cause of death statistics were derived fromthe underlying cause of death reported byphysicians on death certificates.

(b) Rates per 100,000 estimated population of1,069,725

(c) Years of Potential Life Lost (YPLL)

Note: Totals represent vital events which occurred in RhodeIsland for the reporting periods listed above. Monthly pro-visional totals should be analyzed with caution because thenumbers may be small and subject to seasonal variation.

* Rates per 1,000 estimated population# Rates per 1,000 live births** Excludes 1 death of unknown age

RHODE ISLAND DEPARTMENT OF HEALTH

DAVID GIFFORD, MD, MPHDIRECTOR OF HEALTH EDITED BY ROBERTA A. CHEVOYA, STATE REGISTRAR

V ITAL STATISTICS


a d v e r t i s e m e n t


To find out more, or to speak to an Army Health CareRecruiter, call 800-784-8867 or visithealthcare.goarmy.com/hct/50

NINETY YEARS AGO, AUGUST 1916An Editorial, “Using the Abnormal Mind,” suggested “that

we should put to practical use the output of the abnormalmind.” Since “genius is first cousin to insanity,” the conclu-sion was clear: “If it is true then that many valuable ideas aregoing to waste in our insane hospitals, is it not possible to availourselves of this material and put it to some profitable use?”

Peter Pineo Chase, MD, in “Nitrous Oxide Anesthesia andAnalgesia in Obstetrics,” discounted the past use of chloro-form and ether. As for scopolamine and morphine, “large ob-stetrical clinics of the country have given it a thorough trialand have decided against it.” In the last 2 years a group ofphysicians in Chicago praised nitrous oxide, combined withoxygen. “Consensus of opinion seems to be that it is like thelittle girl with the curl on her forehead: ‘ When it is good, it isvery very good, and when it is bad it is horrid!’”

Harold E. Smiley, ScM, contributed “Report on 20000Wassermann Tests Made at the Providence City Hospital Dur-ing 1914 and 1915, Together with a Study of the Compara-tive Value of the Antigens Used.” In 1914 the City Hospitalstarted doing the tests free for Providence physicians. Of the2,000 tests, 1,113 were negative. The 2 antigens – acetoneand choletserin - used together were most effective.

FIFTY YEARS AGO, AUGUST 1956This issued featured three faculty from Harvard Medical

School.George W. Thorn, MD, Hersey Professor of Medical

Theory and Practice of Physic, Harvard Medical School, de-livered the 15th Charles Value Chapin Oration, “Advances inthe Diagnosis and Treatment of Adrenal Disorders.”

Jack R. Ewalt, MD, Clinical Professor of Psychiatry,Harvard Medical School, and Commissioner, MassachusettsDepartment of Mental Health, contributed “Correlation ofPublic and Private Agencies Serving Mental Health Needs.”

Arthur L. Watkins, MD, Assistant Clinical Professor ofMedicine, Harvard Medical School, and Chief, Physical Medi-cine Department, Massachusetts General Hospital, contrib-uted “Medical Rehabilitation in a General Hospital.”

In “It Can Happen: Case Report at a Clinico-Pathologi-cal Conference at Woonsocket Hospital,” Francis King, MD,ACS, and George A. Keegan, MD, reported on a 38 year-oldwoman admitted “for what was thought to be a prematureseparation of the placenta with intra-uterine hemorrhage.”Eventually, after an operation, the pathological diagnosis washydatiform mole, probably malignant. The woman recovered.

TWENTY-FIVE YEARS AGO, AUGUST 1981Tom J. Wachtel, MD, in “The Less Common Etiologies

of Hyperthyroidism, An Algorithmic Approach,” cautioned:“Conditions other than Graves’ Disease or toxic disorder cancause the disorder.”

John L. Ferruolo, from the Division of OccupationalHealth Radiation Control, Rhode Island Department ofHealth, contributed “Mammographic Exposures in RhodeIsland: A Report on the BENT Study.” He reassured readersthat the current tests reduced patients’ exposure without less-ening the quality of the image.

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�VOLUME 1 PER YEAR $2.00NUMBER 1 SINGLE COPY, 25 CENTSPROVIDENCE, R.I., JANUARY, 1917

The Official Organ of the Rhode Island Medical SocietyIssued Monthly under the direction of the Publications Committee

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