Maryland Medicine Volume 14 Issue 1

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Features

Depar tments

Introduction: Global Health for Maryland Physicians: 7Why You Should Read These ArticlesTyler Cymet, DO

Why Practicing Physicians Should Care about Global Health 9Tyler Cymet, DO

Overview of International Emergency Medicine 11 Terrance Mulligan, DO

Transitioning from a Practicing Physician to a 13Mission Director: Addressing Safety IssuesEmily E. Tylski, OMS IV, & Gautam J. Desai, DO

Global Aging, Local Solutions: 15Maryland Physicians as the Agents of ChangeRoberto J. Fernandez, MPH, & Yogesh Shah, DO

The Global Challenge of Non-Communicable 17Diseases in the Age of AusterityAmber Hull

Reverse Aid to Maryland Revisited Again 18Timothy Baker, MD, and Ligia Paina

Resources Availability and Utilization: 19 Local vs. International NeedsAlan Schalscha, DO Tuberculosis in Maryland: Global and Historical Perspectives 21Sara Mixter, MD, Jesse X. Yang, and Joshua M. Sharfstein, MD 2012 Maryland Medicine Index 23

2012 MedChi Necrology 25

I n S I D E Volume 14 Number 1

Scan the code with your smart phone and download Maryland Medicine to your mobile device.

President’s Message 4Brian Avin, MD

CEO’s Message 5 Gene Ransom, III, Esq.

Editor’s Corner 6Bruce M. Smoller, MD

Historical Perspectives 22Susan A. Raskin

Word Rounds 26Barton J. Gershen, MD The Last Word 30

Amber Hull discusses primary prevention and patient education for patients worldwide.

Photographs from DOCARE International missions used on the cover and in “ The Last Word” used with permission from DOCARE with all rights reserved. DOCARE International is dedicated to pro-viding much needed healthcare to indigent and isolated people in remote areas around the world.

4 Vol. 14, Issue 1 Maryland Medicine

This issue of Maryland Medicine address-es global health and I thought it would be of interest to examine and compare the four basic healthcare delivery systems that have evolved in developed nations. The United States has the premier medical schools and research centers in the world, and the best trained physicians. nonetheless, the World Health Organization (WHO) believes that we perform poorly when compared to other developed nations in terms of health outcomes are measured such as maternal and infant mortality, life expectancy, preventable illnesses, drug abuse, avoidable accidents, mental health, nutrition and homicides. In addition, the per capita healthcare costs in the United States are at least double those of other developed nations.

The healthcare experience in the United States has deteriorated over the years, both for physicians and for patients. Healthcare is more fragmented than ever before, and there are an increasing num-ber of companies created to tell us what we can and cannot do, and how to do it. The unending notifications from pharma-cies and insurance companies informing us of potential drug interactions, drug substitutions, what not to use with the elderly, etc., end up in the trash because of their sheer volume. Referrals, step therapy, prepayment audits, postpayment audits, Recovery Audit Contractors (RACs) and pre-authorizations for medications, tests and procedures are time consuming and distracting, add to the cost of delivering healthcare and rob time that otherwise would be used to provide care to patients. Layer upon layer of wasteful processes make the delivery of healthcare inefficient and costly and reward companies that per-petuate this chaos. Approximately 15–20 cents of every dollar spent on health insurance premiums goes towards admin-istrative and marketing costs, and addi-tional costs cover the wasteful activities described above rather than being used to provide healthcare. Additional factors that

need to be addressed are the ever-growing disparities in our society that make it more difficult for patients to access and pay for healthcare. Individuals lose their health insurance when they lose their jobs, just when they need it the most. In the United States, we pay a great deal for medications that one can purchase for far less in other countries. Our country’s finances are in disarray and our government is unable to address the serious economic issues of the day. Our tax code is burdensome, costly and full of loopholes, thus diverting funds away from the treasury. These are the issues that make our healthcare system the most costly and inefficient system in the developed world and why we are having problems financing it.

Other developed nations have systems of insurance that cover individuals from cradle to grave. These individuals pay income taxes, value added taxes (VAT) and other fees until age 65, that supports government sponsored health insurance. Citizens do not lose their health insurance when they lose or change jobs. The governments set fees and may be involved further in the delivery of health care depending on the model discussed. no other country relies on for profit insurance companies to pay for basic healthcare services. Emphasis is placed on health promotions and healthy lifestyles so as to limit the need for expensive healthcare services. Medical students do not pay to go to medical school and graduate with-out financial commitments. Malpractice insurance costs a pittance. The government sets physician payments and physicians are able to establish private practices to provide services that are not provided or regulated by the government. Four major healthcare delivery models have evolved in the developed nations and all of them share the parameters outlined above – except for the United States. The other countries have made a moral decision to guarantee medi-cal care to anyone who gets sick. There are examples of each of these four models in the United States today.

The Bismarck Model can be found in Germany, Japan, Belgium, and Switzerland. Under this model health-care providers and insurance companies are private entities, financed jointly by employers and employees through payroll deduction. Insurance plans cover every-one, are not allowed to make a profit on basic healthcare services, and determine what services will be covered as well as their cost. The lure for insurance com-panies is that this is an entry for them to sell other insurance products. The govern-ment oversees and referees the process. The healthcare delivery system in the United States that most closely resembles this model is the system that insures indi-viduals 65 and under, although our system does not provide universal coverage, insur-ance is not portable and insurance com-panies profit on basic healthcare services.

The second model is Britain’s national Health Service (the Beveridge Model) in which healthcare is financed and provided by the government through tax payments. Hospitals and clinics are owned by the government and doctors can either be employed by the government or have a private practice, and either way they are paid by the government. The government controls what services can be provided and what they will cost. Other countries that use this model include Italy, Spain, and most of Scandinavia as well as Hong Kong. The healthcare delivery system in the United States that best exemplifies this model is the U.S. Department of Veterans Affairs.

The third model is the Canadian National Insurance Model which con-tains elements of the two above models. Healthcare providers are private and every citizen pays into the government run insurance program. The government controls costs by regulating fees and limiting the medical services they will cover. Other countries that utilize this

EdiTor’s cornErBrian H. Avin, MD

PrEsidEnT's MEssAGE

2013 Healthcare: The Rest of the Story

continued on page 8

Maryland Medicine Vol. 14, Issue 1 5

Insurance Reforms Needed to Curb Costs

Gene Ransom, III, Esq.cEo's MEssAGE

According to the World Bank, in 2010, the United States had the highest expenditure on healthcare of any country as a percent-age of gross domestic product (GDP). Currently, it is spending 17.9 percent of the GDP on healthcare. While we are paying more for healthcare than any other nation, we suffer ridiculous insurance rules such as prior authorization, retroactive denial, and fail first policies, to name a few. For years, MedChi, the Maryland State Medical Society, has fought to reform unfair insurance practices and level the playing field.

Insurers claim these procedures are needed for cost contain-ment, but if that is the case, why does healthcare cost so much in this country? Absent from the critical debate in Maryland over how to rein in healthcare spending has been a serious examina-tion of the dangerous and expensive policies that some Maryland health insurers have enacted in the name of cost containment, and their potentially deleterious impact on patient health.

MedChi focused on one particular insurance abuse during the 2013 Maryland General Assembly session—step therapy or fail first policies. In the name of controlling costs, some Maryland health insurers have enacted a set of onerous barriers to care that prevent patients from accessing timely and effective treatment, and place health insurers squarely in the middle of the physician-patient relationship.

Step therapy or fail first policies often require that patients try and fail on up to five less-effective treatments before an insurer will cover the treatment originally prescribed by their physicians. Patients are often forced to try and fail on these treatments even when they have already tried them in the past, and even when their doctors know that those treatments will not work. For Maryland patients living with a host of serious, often painful conditions including cancer, arthritis, or epilepsy, step therapy can mean days, weeks, or even months without the proper treatment. This unnecessary delay in the best healthcare is not only cruel but also jeopardizes the patient’s general health and well-being.

Step therapy policies unnecessarily prolong ineffective treat-ment, prevent patients from immediately receiving access to life-sustaining treatments already recommended by their physi-cians, and often exacerbate health problems, allowing manageable conditions to devolve into disease. By forcing patients to undergo cheaper, less-effective treatments that their physicians know will not work, insurance companies are driving up their profits on the backs of those who are ill.

When patients are denied access to treatment, it is not only their physical condition that suffers. Every time a patient is forced to unnecessarily return to the physician or pharmacist because of an insurer’s step therapy policy, it can mean additional transporta-tion and childcare costs and additional missed work time, all of which, in turn, drive up costs for Maryland businesses through lost productivity and increased insurance premiums. Step therapy can also drive up the direct costs to the Maryland healthcare system through unnecessary hospitalization or emergency room visits.

Maryland physicians are frustrated with current insurer poli-cies that prevent them from treating their patients with what they feel is the best care. A recent survey of MedChi member physi-cians found that 95 percent feel that health insurer protocols, like step therapy, have a “somewhat” or “very negative” impact on their ability to effectively treat patients. Many states around the country have already begun to re-evaluate health insurer step therapy protocols and their negative impact on patients, with many, including new York, Connecticut, and Louisiana, taking legislative action to help curb these insurer abuses. The Maryland General Assembly failed to address dangerous health insurer practices that prevent Maryland patients from accessing timely and effective healthcare in 2013.

Sen. Thomas “Mac” Middleton (D, District 28) and Del. Eric Bromwell (D, District 8) sponsored common sense legislation (SB746 and HB1015) that would address egregious step therapy

Editorial OfficesMontgomery County Medical Society

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All opinions and statements of supposed fact expressed by authors are their own, and not necessarily those of Maryland Medicine or MedChi. The Editorial Board reserves the right to edit all contributions, as well as to reject any material or advertisements submitted.

Copyright © 2013. Maryland Medicine, The Maryland Medical Journal. USPS 332080. ISSN 1538-2656 is published quarterly by the Medical and Chirurgical Faculty of Maryland, 1211 Cathedral Street, Baltimore, Maryland 21201, and is a membership benefit. All rights reserved. No portion of this journal may be reproduced, by any process or technique, without the express written consent of the

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DISCLAIMER: Some articles may contain infor-mation regarding general principles of law. They are not intended as legal advice and cannot be substituted for such. For advice regarding a specific legal situation, consult an attorney licensed in the applicable jurisdiction and with appropriate training and/or experience in the legal area in question.

EDITORIAL STATEMENT

continued on page 8


EdiTor’s cornErBruce M. Smoller, MD

EdiTor's cornEr

Communication and Myths

I read another column by another expert today. It began by parroting “facts” about the medical system which you and I have gotten used to hearing over and over. The context was the medical malpractice system and how the feds should stay out of it, but its topic is really not the point. In amongst the various nostrums proposed to fix, rem-edy or improve our medical system were several bromides of dubious significance, to wit: Physicians who adhere to best practices save enormous sums of money. If we do some-thing about the medical malpractice system, doctors will order far fewer tests and thus save the system “enormous” amounts of money.

You’ve seen these or similar state-ments from sources as diverse as the Institute of Medicine and the plaintiff ’s bar. Statements such as these usually carry the imprimatur of some official sound-ing body, such as The Institute for Setting Standards for Practically the Whole World. Such pronouncements are rapidly picked up by newspapers, politicians, journalists and hangers-on who haven’t the slightest idea what good medical care consists of but need to sound off on it anyway.

I want to get two things straight from the outset: One, as a country we must do better in providing access to good health care. Two, physicians are quite human and, at times, make judgment calls that some-times appear unsound and irrational to the medically unsophisticated.

I thought about this particular author’s statements (attribution upon request) and put together a list of myths which keep appearing in various outlets about the practice of medicine and its practitioners.

Myth #1: Physicians order too many tests and drive up the cost of medical care.

Of course, most physicians do nOT order tests to cover their backsides. It hap-pens sometimes, but most tests are ordered to rule out disease. That’s the business we’re in, consultants…ruling out disease, preventing illness, forestalling death and

morbidity. It requires clinical acumen and, yes, ordering tests. These are not ordered because a lawyer is in the waiting room. They are ordered to: (ready) …discover and fight disease. Wow, what a concept!!

no one…not consultants, politicians, journalists, economists or other cognoscenti, would tell their physician not to order a test on a loved one because it’s too expensive. How many times have you heard, “Gee, doc, don’t order that CT scan on my father to rule out a tumor…its too damn expensive for the medical system and would add to the burden of the country.” nEVER! You will never hear it uttered by any person ever. As all politics is local, so is all life and death decision making personal. So, because you would never hear it uttered by any sane per-son, bureaucrats and consultants who have no medical training whatsoever, would like to make that decision for you.

Myth #2: Physicians don’t learn about dis-ease prevention in school or in training. Allied health professionals know about prevention. Therefore, physicians can’t be trusted to pre-vent disease because they make money treat-ing disease. Physicians won’t entertain “alter-native” medical treatments because they have a strong union and the union keeps them “in gravy,”…something like that.

I don’t even know where to start with this one, except to say that if you allow this calumny to take root and flower not only we as a profession, but our patients as well, will reap a multiyear harvest of weeds.

Myth #3: The training of physicians takes too long. Thus, we not only can shorten the training, we can use substitutes to deliver care…. They are all the same anyway.

need I say more about this one? nurse Practitioners and others in the allied health fields can be wonderful deliverers of healthcare. They’re training, however, comes no where near that of physicians. In a health delivery

group where the physician is in a supervi-sory role, these allied health professional often function very, very well. ‘nuff said!

These myths and canards come readily to mind, but there are many more that need to be aired. I would like to ask our readers to contribute more myths about the practice of medicine…statements or concepts that should be exposed and refuted.

The purpose of all of this would be, at best, academic and effete if, as Mike Meyers intoned on Saturday Night Live, we only, “spoke amongst ourselves.” Myths such as these are intended to degrade. They serve the purpose of making their target less…less capable, less knowledgeable; less able, less caring…pick your poison. It is a classic tech-nique of organizational propaganda that we have witnessed throughout history and serves to inform the public that whatever group is the object of such propaganda, is, “less than” and needs to be changed by dint of force.

Again, I am not in the least suggesting that on some scale we don’t need to pay attention to how we serve the most patients with the best medicine. More efficient sys-tems of healthcare integration, such as Kaiser Permanente, can help the physician provide a more efficient health care. I am, however, sug-gesting that statements such as these often serve to provide an excuse to take the locus of control completely from us. That’s bad for us, but it’s worse for those whom we treat.

Your job, if you believe I am correct, is to counter the trite, the banal, the unproved conclusion, the belittling and infantalization of our profession. We must take every opportunity to communicate to others outside the profession that we phy-sicians will be an integral part of whatever changes truly benefit our patients. We should not tolerate others dictating the expedient, illogical and herd-like rush simply for the sake of change. We will be a part of helping those whom we serve here and abroad, but that help must be based on fact, not myth.


EditorBruce M. Smoller, MD

Editorial Board

Director of Publications Susan G. D’Antoni

Managing Editor Susan A. Raskin

Production nicole Legum Orders

MedChi, The Maryland State Medical Society

CEO

Gene M. Ransom, III, Esq.President

Brian H. Avin, MDPresident-Elect

H. Russell Wright, Jr, MDImmediate Past President

Harbhajan S. Ajrawat, MDSecretary

Ben Stallings, MDTreasurer

Stephen J. Rockower, MDSpeaker of the House

Ira D. Papel, MDVice Speaker of the House

Michele A. Manahan, MDAMA Delegation Representative

George S. Malouf, Sr., MDAnne Arundel County Trustee

James J. York, MDBaltimore City Trustee

Tyler C. Cymet, DOBaltimore County Trustee

Gary W. Pushkin, MDMontgomery County Trustee

Mark S. Seigel, MDPrince George’s County Trustee

Benjamin Z. Stallings, MDEastern Group Trustee

John J. LaFerla, MDSouthern Group Trustee

Howard M. Haft, MDWestern Group Trustee

J. Ramsay Farah, MD, MPHTrustee at Large

Stephen J. Rockower, MDTrustee at Large

Brooke Buckley, MDSpecialty Society Trustee

Benjamin H. Lowentritt, MDIMG Section Trustee

Jeffrey R. Kaplan, MDResident Section Trustee

Seth Flagg, MDMedical Student Section Trustee

Vacancy to be filledBylaws Council Co-Chairs

Joseph Snyder, MD and Shannon P. Pryor, MDCommunications Council Co-Chairs

Shital Desai, MD and Bruce M. Smoller, MDLegislative Council Co-Chairs

James J. York, MD and Brooke M. Buckley, MDMedical Economics Council Co-Chairs

Loralie Ma, MD and Richard Scholz, MDMedical Policy Council Co-Chairs

Ramani Peruvemba, MD and Robert P. Roca, MDOperations Council Co-Chairs

Anuradha Reddy, MD and David I. Safferman, MDMedical Student Section Trustee

Taylor DesRosiers

Timothy D. Baker, MD, MPH Steven Brotman, MD, JD John W. Buckley, MD Beverly A. Collins, MD, MBATyler Cymet, DO

Barton J. Gershen, MD (Editor Emeritus) Mark G. Jameson, MD, MPHStephen J. Rockower, MDAnne Sagalyn, MD

Being a participant in global health practice can be liberating for physicians. While rules and regulations about healthcare and health systems occur at the national level, there is no global health system or governance in global health.1 And global health is a great deal more than treating tribal people in primitive ways. Health risks and health resources vary widely among countries, various socioeconomic groups of patients, and their need to be addressed. Things are very different from when Albert Schweitzer, MD, first went to Africa.

Global health can be practiced by focusing on specific health issues, working on issues in a particular geographic area, or the interaction of health between and among different countries or areas. Looking at global health as another way to address issues that concern human health (or broader) makes it important to all physicians.

In this issue of Maryland Medicine, Roberto Fernandez, MPH, and Yogesh Shah, MD, talk about aging in a global health context while still focusing on Maryland. Dr. Shah is currently a Fulbright Fellow studying aging in Rwanda. Amber Hull’s article on non-communicable diseases addresses everyday issues, but with an “outsider on the inside” view of these conditions. Dr. Terry Mulligan looks at international emergency medicine and the benefit of this new field.

Dr. Alan Schalscha runs medical facilities in both the United States and Guatemala, and he writes about the differences in these two populations and systems of healthcare from a medical director’s perspective. And if you think you may want to look into global health further, Dr. Gautham Desai and Emily Tylski provide a step-by-step outline on how to run a service trip. Although there isn’t one accepted term for global healthcare trips, my feeling is that mission is no longer the term that should be used for these global health experiences. They are service trips, programs, or collaborations, and often do not have any spiritual or philosophical orientation.

Maryland Medicine has started to work with MedChi’s Center for a Healthy Maryland to highlight the rich medical history we have in Maryland and across the country, and Susan Raskin writes about Elizabeth Blackwell, MD, the first practicing female physician in the United States.

Maryland Medicine is also happy to welcome two new members of the editorial board, Beverly Collins, MD, and Anne Sagalyn, MD. Dr. Collins worked for CareFirst Blue Cross Blue Shield as a Vice-President and is now working in medical informatics and issues related to the patient-centered medical home. She is a past president of the Baltimore City Medical Society and has done an incredible amount of work with organized medicine. Dr. Sagalyn is a psychiatrist in Bethesda, Maryland, who teaches clinical assessment skills and the basics of the doctor-patient relationship, as well as the ethical, social and professional issues surrounding patient care to students at the George Washington University School of Medicine. We are excited to have both of them on the editorial board.

We hope you enjoy this issue of Maryland Medicine and that it gets you to think about what you do every day just a little bit differently.

Tyler Cymet, DO, is Associate Vice President for Medical Education for the American Association of Colleges of Osteopathic Medicine. He may be contacted at [email protected]. For a complete list of references, contact Susan Raskin at 301.921.4300 or [email protected].

Reference:

1. Frenk, J., and S. Moon. “Governance Challenges in Global Health.” NEJM 368 (10):936–42.

Introduction: Global Health for Maryland Physicians: Why You Should Read These ArticlesTyler Cymet, DO


model are Australia, Taiwan and South Korea. The healthcare delivery system in the United States that best exemplifies this model is Medicare.

The fourth model is the out of pocket model that exists in most poor countries. The rich are able to obtain medical care and the poor stay sick or die. Seventeen percent of healthcare costs in the United States are funded by out of pocket payments.

The two major reasons medical costs are so much higher in the United States, other than other developed nations, is that we allow health insurance companies to make a profit on basic healthcare services-the most expensive way to pay for a nation’s healthcare. Other countries allow health insurance companies to make a profit on supplemental policies but not on the universal basic coverage. The second reason medical costs are higher in the United States is that there are scores of private insurance plans, each with its dis-tinct rules concerning what services it will cover and how much it will pay. There are government programs that insure those over 65, veterans, other military personnel, poor children, poor adults and American Indians. The system is overly complex, inefficient, and costly, and does not provide universal coverage.

The Unites States provides the best healthcare in the world but is home to the most complex and costly healthcare delivery sys-tem. Physicians may need to reconsider what health care delivery model best works for them and their patients.

President's Message ...continued from page 4

CEO's Message ...continued from page 5

policies. The legislation had broad support from state provider and patient advocacy groups, including statewide groups repre-senting Marylanders living with cancer, arthritis, epilepsy, lupus, hemophilia, chronic pain, and mental health conditions, among many others. While the legislation failed to get a vote, and did not pass in 2013, it will be back, and MedChi was successful in getting a study on the issue that will result in a report prior to the 2013 General Assembly Session.

Decisions about how to treat patients should remain between the patient and physician, and patients should have reason-able, timely access to prescribed procedures and treatments. Advancements in science and medicine are yielding new medica-tions, procedures, and therapies that can more effectively treat patients and speed up their recovery. But these therapies will only work if insurers do not force patients to bear the unnecessary physical and emotional burdens of step therapy.

Gene Ransom is the chief executive off icer of MedChi, the Maryland State Medical Society. His email is [email protected] and he can be followed on twitter at @GeneRansom.

PHYSICIANS NEEDED

The Maryland Department of Human Resources (DHR) is actively recruiting physicians to conduct exams and tests needed for applicants of Medical Assistance who are claiming disabling medical conditions. Developing a relationship now with these applicants provides an opportunity for continuing care upon their approval for Medical Assistance.

DHR offers:• Competitive fee structure• Broken appointment fees• Rapid, direct state reimbursement

Providers are needed statewide. Particular specialties needed include: internal medicine, cardiology, pulmonary, orthopedic, neurology, audiology, ophthalmology, nephrology, rheumatology, oncology, gynecology, psychology and psychiatry.

To Perform Paid Exams for Maryland Medical Assistance Applicants

To register or learn more, visit us at www.dhr.maryland.gov/physicians

or call 410-767-5015

physicians ad.indd 1 3/25/2013 11:12:35 AM


Why Practicing Physicians Should Care about Global HealthTyler Cymet, DO, and Timothy D. Baker, MD, MPH

It is not the act of traveling that broadens our minds, but the mindset that travels along with us that will bring a person far in life. ~Margaret Mead

Physicians are busier than ever practicing medicine every day, and more physicians are choosing to specialize and sub-specialize and focus on smaller and smaller tasks. In this kind of environ-ment, global health could be looked at as a luxury that isn’t truly necessary. But instead of global health being pushed aside and ignored, interest in global health has never been greater.

Physicians are participating in more international health activities than ever before. The number of global health programs offered by universities and medical schools quadrupled between 2003 and 2009.1 Global health is now a 22 billion dollar indus-try.2 Maryland physicians are very active in the area.

Could the increasing interest and participation be linked to the modern global environment? Is it because American physi-cians are now thinking about diseases that could be brought to the United States from other areas around the globe? Is it the flattening of the world and the interconnectedness that makes the medical community’s knowledge and interest in global health seem more necessary now then it was in the past?

Could the staggering changes physicians are experiencing in the American healthcare system be one of the causes of the increased curiosity about foreign healthcare systems? Is it that physicians are seeking new relationships with healthcare provid-ers from other systems, or are physicians becoming more compas-sionate outside of their usual sphere of practice?3

Is this increased interest in global health a fad or just the suc-cessful re-packaging and marketing of preventive medicine and international health?

In the new interconnected environment of the 21st century, physicians are asking more questions about the goal and meaning of healthcare, and where healthcare fits into the bigger picture of society. The answers aren’t easily found while working only in our

own offices. The information required for the answers is more readily available when thinking and working outside of our own system and, perhaps, comfort zone.

Global health provides an experiential way of understanding the world. When we work in other systems of healthcare, our own system may make more sense. And the questions that matter are usually the same questions that we grapple with ourselves. How do we get care to those who can’t care for themselves? Whose responsibility is it to put it all together? How do we evaluate our success in healthcare? These are all questions that beg for answers no matter which system you work in, and they become more obvi-ous when a system is viewed with an outsider’s eyes.

Global health is a qualitative course on information and prac-tice that has a different rigor from basic medical science. It takes exposure and immersion in a new system for the system to be understood.

Understanding global health is one way physicians can explore issues of concern that they might have about their own practices and the system in which they work. A global health experience may be the only way for physicians to take a week off from their regular practices and look at how they have been practicing medicine in an objective manner. A global health experience often feels as if one has climbed to the top of a mountain in order to examine one’s own culture and healthcare system. This would help physicians gain an understanding of healthcare within our own system and lives.

The Value of Global Health

1. Personal growth of participants2. Global health value in public health3. Learn new ways of practicing medicine4. Learn about compassionate caring. 5. Advocacy of health issues


Gaining an understanding of how a civilization structures its society helps with understanding the values of a culture and can help physicians better provide their own patients with what they want and need.

Global health takes healing relation-ships outside of the formal classroom setting and transcends textbooks, labs, and lectures; it helps physicians understand where healthcare fits into our patients’ lives as well.

The benefits of a global health experi-ence include honing knowledge and skills in understanding the concepts of wellness and disease, learning alternative methods of treatment, understanding the barri-ers for caring for those in our culture as well as others, enhancing language abili-ties, and improving history and physical examinations skills.4

A global health experience can make medicine three dimensional. Global health makes a physician think outside of the box, and gives them an opportunity to work outside of that box as well.

Short-term exposure to other health-care systems will have a much different, and perhaps more meaningful, effect on

the traveling physician than on the vis-ited country and people who received the care.5 The broadening aspect of travel is often the realization that the collabora-tion with one’s peers in a global health experience and the partnering with those we are travelling to see can be the most illuminating part of the experience.

We live in a world with unlimited options to experience and learn from peo-ple all over the world. The battle against diseases that have never known borders has gotten to be a fairer fight. And, in the end, caring about health issues in Maryland requires us to look at Delaware, Virginia, Canada, Mexico, Guatemala, Cape Verde, and anywhere our patients have interactions. If we don’t think about global health, then we aren’t looking to win the battle for better health.

Tyler Cymet, DO, is Associate Vice President for Medical Education for the American Association of Colleges of Osteopathic Medicine. He may be contacted at [email protected]. Timothy D. Baker, MD, MPH, Professor of International Health, Health Policy and Management, is

at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. For a complete list of references, contact Susan Raskin at 301.921.4300 or [email protected].

References:

1. Merson, M., and A.C. Page. The Dramatic Expansion of University Engagement in Global Health. Implications for U.S. Policy. A Report of the CSIS Global Health Policy Center. 2009. http://www.ghdonline.org/uploads/Univ_Engagement_in_GH.pdf accessed March 2, 2013

2. http://seattletimes.com/html/thebusinessofgiving/2009356330_global_health_study.html accessed March 20, 2013

3. Peabody, J.W., and R.G. Feachem. “Why Global Health Matters to US Primary Care Physicians.” West J Med 2001 September; 175(3): 153–4.

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Overview of International Emergency MedicineTerrence Mulligan DO, MPH

Over the past 20 years, emergency physicians (EPs) have begun to examine the scope of emergency medicine (EM) and its exten-sion into the fields of public health and primary care. Specifically, EPs have increasingly looked beyond their borders to learn how emergency medicine is practiced in other parts of the world. The emerging field of international emergency medicine (IEM) is concerned with the development of emergency medicine and acute care systems development in countries and regions where EM development is needed, and can be viewed as a subspecialty of EM; it allows emergency physicians and other health profes-sionals who are involved in emergency medical care to learn from each other, and involves the educating and training of emergency care providers throughout the world.

As one of the youngest medical specialties worldwide, EM has not even reached its fullest potential in the United States, Canada, the United Kingdom, and the small number of other places where it currently is a mature, fully-functioning medical specialty. Indeed, EM is established as a fully mature specialty in only six countries worldwide, and approximately 45 other coun-tries are in early stages of development. The vast majority of the world does not yet enjoy the benefits of emergency medicine in all of its aspects, such as:

• EM as a profession/specialty, with governmental recogni-tion, board certification, national professional societies, and specialty journals

• EM is a mature profession/specialty in only six countries (Canada, UK, USA, Australia/new Zealand, Hong Kong, and Singapore), developing in 45+countries, and vastly underdeveloped in 120+ countries.

• The same socioeconomic, demographic, and epidemiolog-ic forces that enabled the genesis of EM in these countries are currently at play in nearly all communities worldwide, but at a much faster and critical pace.

EM Residency Programs

• EM residency programs are in development in 60+ coun-tries, with 30+ more countries in the earliest stages of development.

• The vast majority of physicians and health professionals practicing in hospitals worldwide have little or no formal training or experience in emergency aspects of their fields.

Trauma Systems

• Trauma is the leading cause of death in developing and underdeveloped countries and is among the top three or four causes of death in developed countries worldwide.

• Organized trauma systems and intra-hospital and inter-hospital trauma response systems are virtually nonexistent in all but a few developed countries.

• EM systems [ = pre-hospital/ambulance systems] and pre-hospital services development

• The considerable decrease in trauma morbidity and mor-tality in developed countries has been repeatedly shown to correlate with the state of development of EM systems.

• The overwhelming majority of EM systems worldwide are grossly underdeveloped, even in developed countries.

Many international public health policy makers have underes-timated the increasing need for science, engineering and health in developing communities. Historically, world health policy makers


have concentrated their time, money, and energy on maternal and child health issues, primary care development, infectious diseases, and other communicable disease models. Only research in the past 15 years has shown this concentration to be overestimated, and has revealed that non-communicable conditions such as trauma, cardiovascular diseases, diabetes, and cancer have over-shadowed earlier healthcare concerns—the exact healthcare areas that EM is specifically designed to address.

Conclusion

Emergency medicine is a fully-established medical specialty in only a handful of countries in the world, with 45+ countries in the early stages of development and with many countries with little or no EM or acute care systems development at all. Many of these countries are increasingly cooperating with the so-called “mature” or fully-developed EM systems, with their EM Societies and their EPs for advice, expertise, training, and consultation. Many emergency physicians have undertaken further training in international emergency medicine in IEM fellowships and

other IEM training programs in the United States and abroad, and these IEM fellowships and training programs have recently come together to form an IEM fellowship consortium. This IEMFC represents the 38+ U.S.-based IEM fellowships and the 5+ Fellowships outside of the United States. More information can be found at iemfellowships.com. The enormous and growing international community of emergency physicians and physicians working in the emergency setting has a tremendous amount of expertise and advice to offer each other, and should increase their cooperation and collaboration with one another through IEM activities, projects, conferences, the newly formed IEM fellowship consortium, and other regional, national, and international EM organizations.. IEM fellowships and the IEMFC help to provide the depth and breadth of expertise required to assist in compre-hensive national and international emergency medicine and acute care systems development.

Terrence Mulligan, DO, MPH, is Director, International Emergency Medicine Program, University of Maryland School of Medicine, Department of Emergency Medicine, and Executive Editor, EPI.


Transitioning from a Practicing Physician to a Mission Director: Addressing Safety IssuesEmily E. Tylski, OMS IV, and Gautam J. Desai, DO

In recent years, interest in internation-al medicine has dramatically increased, as reflected in the development of international rotation opportunities for medical students, residents, and volunteers. The Association of American Medical Colleges’ (AAMC) survey of matriculating medical students shows that approximately 64 percent of incoming students expect to participate in a global health program, and from 2008 to 2012, medical school graduate participation in international health electives has grown from 27.5 percent to 30.4 percent, compared to 6.2 percent in 1984.1,2,3 Though organi-zations such as Doctors Without Borders coordinate outreach missions, international health programs have increased in the arena of medical education and provide a chance for professional growth for students and physicians at all levels of experience.4

Individuals participate in global mis-sions for many reasons: improving clini-cal skills, developing cultural competence, or simply helping others. International medical outreach is a growing movement among physicians of all ages and special-ties.5 There are growing opportunities for practicing physicians to take the lead as mission directors—a task that requires extensive preparation. While it may be simple to hastily set out with plans to help an underserved population, it is of pri-mary importance that the mission director first ensure the safety of those volunteer-ing their time and expertise. This article will focus on some aspects of safety during a medical mission; it is not intended to be an exhaustive list.

Pre-travel vaccinations and infectious disease prevention are good places to begin when planning a mission. The Centers for Disease Control and Prevention (CDC) provides destination-specific guidelines, regularly releasing updates on health warnings/disease outbreaks, as well as publishing an extensive list of country-specific health information.6 Every two years, the CDC releases an updated ver-sion of the Yellow Book—a resource for health professionals that includes rec-ommended pre-travel vaccinations and travel-related risk assessment, common illnesses and their associated prevention and treatment methods, guidelines for counseling higher-risk travelers, and sug-gestions for assessing an ill patient upon returning home. There is also a smart-phone application for physicians.7

A survey of Voluntary Service Overseas volunteers showed that approximately 80 percent of mission volunteers experienced gastrointestinal distress while overseas, and approximately 40 percent report-ed cutaneous complaints.8 The mission director must be well acquainted with health risks at the destination in order to advise volunteers appropriately about prophylactic therapy, and to be prepared with medications for potential illnesses. It is also important to consider health insurance coverage while out of the coun-try, because many policies do not include international travel. Supplemental cover-age, including evacuation coverage in case of a medical emergency, may be acquired

through a travel agent or over the internet, or the Bureau of Consular Affairs website provides a list of coverage options.9

The most common cause of death for travelers is motor vehicle collisions, closely followed by cardiovascular events, cere-brovascular accidents, and drowning.5,10,11 Medical missionaries may find themselves in unsafe situations that they otherwise would have not have been vulnerable to, so it is crucial for the mission director to take any actions necessary to ensure the safety of volunteers.5 These include basic steps, such as wearing seatbelts whenever avail-able or hiring a driver who knows the area and local driving laws.

Mission directors should be aware of the U.S. State Department website that lists specific travel warnings by country as well as general information about other possible risks. The mission director must be famil-iar with the destination and should con-tinuously monitor for changes that develop relating to the stability of the intended location.6 It is important to register with the Smart Traveler Enrollment Program (STEP) before leaving the United States to permit the U.S. government to be aware of the team members’ location and alert them in case of emergency. Additionally, the website provides locations of embassies and consulates.12

Another often overlooked area to watch for with those working overseas is psycho-logical safety. Missionaries are at risk of witnessing or being involved in traumatic situations.


Providers may become emotionally engaged with their patients and affected by their heartbreaking stories. In a 2012 survey of Romanian medical students, those who pursued medicine out of altruism more frequently experienced this form of emotional dif-ficulty—known as secondary traumatic stress (STS). Physicians who closely interact with patients in traumatic situations may demonstrate symptoms similar to those of post-traumatic stress disorder (PTSD) without having experienced the event them-selves.13 Management of PTSD or STS during a medical mission is equally as complex as dealing with PTSD in any other setting. Some recommend psychological debriefing (PD), but the benefits are debated in the literature.14,15 PD is a post-exposure method of acknowledging a traumatic situation and discussing common cop-ing strategies. It is best done within two weeks following the inci-dent.15 Physical exercise and exercises in self-awareness/acceptance are key to handling the stressors most physicians endure daily.16 Mission directors should be prepared to provide volunteers with resources for handling stress, which may include pre-departure counseling in addition to a final debriefing session.17 Further, direc-tors should become role models in utilizing self-care practices in their own lives.

This is just an introduction to some of the aspects of mission planning. The medical director must take on the burden of being responsible for the safety of the team, and should prepare for any eventuality, especially any known dangers in specific regions. At best, the unprepared team will not be useful; at worst, it will be a burden to the very population it is trying to help.

Emily E. Tylski, OMS IV, is currently an Undergraduate Osteopathic Medicine Fellow at Kansas City University of Medicine and Biosciences College of Osteopathic Medicine. She recently returned from a medical mission to the Dominican Republic, where she served as the Student Team Leader. Gautam J. Desai, DO, FACOFP, is Associate Professor, Department of Family Medicine, at KCUMB. He is currently the Vice-President, Board of Trustees, of DOCARE International, NFP. Dr. Desai may be contacted at [email protected].

For a complete list of references, contact Susan Raskin at 301.921.4300 or [email protected].

1. Association of American Medical Colleges. Matriculating Student Questionnaire: 2012 All Schools Summary Report. December 2012. https://www.aamc.org/down-load/323378/data/msq2012report.pdf.

2. Association of American Medical Colleges. Medical School Graduation Questionnaire: 2012 All Schools Summary Report. July 2012. https://www.aamc.org/down-load/300448/data/2012gqallschoolssummaryreport.pdf.

3. Evert, J., A. Bazemore, A. Hixon, and K. Withy. “Going Global: Considerations for Introducing Global Health into Family Medicine Training Programs.” Family Medicine 2007 Oct; 39(9): 659–65.

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Global Aging, Local Solutions: Maryland Physicians as the Agents of ChangeRoberto J. Fernandez, MPH, and Yogesh Shah, MD

We all have anecdotes. Medicine is rich with opportunities to learn about the struggles our patients and their families endure. When it comes to caring for an aging population, the stories are all too familiar. Several examples in recent memory come to mind: a 79-year-old male with multiple myeloma who cannot afford adequate homecare; a 69-year-old widowed female who was forced into retirement and now suffers from ongoing alcoholism and depression with suicidal ideation; or the 74-year-old female with multiple co-morbidities who was nonadherent because she could not afford to buy her medicine and purchase Christmas gifts for her grandchildren. The anecdotes are many, and they touch us on an emotional level. Indeed, population aging is an issue that concerns everyone.

Global Aging: The Next Public Health Challenge Has Arrived

People throughout the world are living longer than at any other time in history. Globalization, urbanization, and steady economic growth have contributed to country development and improved living conditions. The demographic and epi-demiologic trends that have begun to unfold reveal profound societal challenges. The world is indeed entering an unprec-edented transformation. Dubbed the “Silver Tsunami,” popu-lations in every region are growing older, while fertility rates decline. The number of people aged 60 and over is double what it was in 1980, and longevity has increased to a global average of 69 years of life.12 In 1900, the leading causes of death were due to infectious etiologies, while today mortality among all countries stems primarily from chronic, non-communicable diseases.3 The future implications of this global transforma-tion are complex and uncertain. It is essential for the global community to recognize and understand the issues, and to seize the opportunity to make positive changes for their aging populations on a local level.

Toward Solutions: Making a Local Impact

With myriad challenges that face the world, it may seem daunting for individual clinicians to appreciate their role. Understanding the local issues can inform our collective action on both an individual and a community level. For instance, of the 5.3 million residents in Maryland in 2000, 15 percent (801,036) were over the age of 60.4 The percentage is expected to increase to 25 percent of Maryland's projected population of 6.7 million by 2030. Furthermore, a large proportion includes people with dis-abilities or low income, the highest concentration of which reside in the Baltimore metropolitan area.5 As this trend unfolds, the state will increasingly need to improve its services for older adults.

In an effort to ensure that older citizens are treated with dignity and respect, the Maryland Department of Aging has worked with community leaders to establish four goals aimed at empowering older adults statewide.6 Consistent with the United nations Principles for Older Persons, these goals can guide fur-ther progress.7 In addition, cities within Maryland may consider joining the World Health Organization’s (WHO) Age-Friendly Cities Initiative.8 This initiative builds upon the WHO’s life-course approach for healthy and active aging. It encourages local governments to make improvements that affect living conditions for older adults. As deficiencies are identified, cities take steps toward earning an “age-friendly” status. Physicians should con-sider learning more and becoming advocates by approaching their city council members who may be receptive to participating.

Maryland physicians are already serving as agents of change within their communities. Yet many struggle with how to make a direct patient impact. The WHO has identified three core areas of intervention in the field of aging for health providers.9 The first two concern health promotion and disease prevention. As non-communicable diseases increasingly threaten our way of life, nowhere is the opportunity greater for physicians to effect positive change than within primary care. In a recent issue of The Lancet, results were published from the Global Burden of


Disease Study 2010. Of the 235 causes of death and 67 risk fac-tors evaluated, high blood pressure was identified as the greatest global risk factor, ahead of tobacco, alcohol, and poor diet.10 We must be proactive in screening and counseling our patients, and striving for blood pressure control can help our patients avoid premature death.

Mental health is another area of particular relevance to aging populations. nearly eight million Americans over the age of 65 currently have a mental illness or substance-use condition, many of them undiagnosed or undertreated.11 Those with mental illness have a higher risk of experiencing disability from physical insults, worse health outcomes, and increased hospitalization rates.12 These patients have increased rates of suicide, and it is well-known that major depression is among the greatest contributors to morbidity globally.13 As physicians, we owe it to our patients to screen for mental illness and substance use disorders.

Conclusion

Population aging is a global transformation with sweeping epidemiologic and demographic transitions. The issues are com-plex, yet failure to act will result in an unsustainable scenario. By practicing preventive medicine, we can work to achieve improved patient health outcomes. On a broader level, progress requires input from multiple key stakeholders. Maryland physicians should support the Department of Aging and consider raising awareness of relevant initiatives that may prove beneficial, such as WHO’s Age-Friendly Cities Initiative. Physicians are in a unique position to make a difference on individual and community levels. The next public health challenge has arrived. We must respond.

Roberto J. Fernandez, MPH, is a fourth-year medical student at Des Moines University, College of Osteopathic Medicine. Pursuing interests in global health and health policy, he interned at the WHO in the Department of Aging and Lifecourse and will soon complete an eight-week internship in health policy at the American Association of Colleges of Osteopathic Medicine (AACOM) in Washington, D.C. He will begin his residency training this summer in internal medicine. Yogesh Shah, MD, is Associate Dean of Global Health and Medical Director of Des Moines University’s Memory Clinic. Triple-board-certif ied in family medicine, geriatrics, and hospice and palliative care, he was recently awarded a Fulbright scholarship, where he will work to develop a palliative care program in Rwanda. For a complete list of references, please contact Susan Raskin at 301.921.4300 or [email protected].

References:

1. U.S. national Institutes of Health. Global Health and Aging. 2011.

2. World Health Organization. Global Status Report on Non-Communicable Diseases. 2011.

3. Maryland Department of Aging. http://www.aging.mary-land.gov/index.html. 2013.


The Global Challenge of Non-Communicable Diseases in an Age of Austerity: Why Physicians Should Contribute to the Global Policy DiscussionAmber Hull

In September 2011, the United nations General Assembly held a high-level meet-ing to address the growing burden of non-communicable diseases (nCDs). “According to World Health Organization (WHO) estimates, deaths from cardio-vascular disease, cancer, chronic respira-tory disease, and diabetes accounted for 63 percent of global mortality in 2008, of which 80 percent was in Lower and Middle Income Countries (LMICs).”1 The consensus was to focus on these four primary disease categories and begin to address their common underlying risk fac-tors: smoking cessation, increased physical activity, healthy diet, and reduced excessive use of alcohol. While these policymaking guidelines currently represent a significant step forward in a collective battle against nCDs, there are a variety of country-level issues and provider-level initiatives that should factor into a comprehensive plan.

As physicians in the United States know, patients who are being followed for diabetes or hypertension have very different needs from people who seek care for infectious diseases. Simple initial steps, such as cali-bration and consistent use of blood pressure cuffs, glucometers, and scales allow the tracking of measures that physicians use to screen for risk factors and tailor optimal care to individuals’ needs. As the global health community and local physicians begin to take action on nCDs, there may be a need for additional training in some countries to ensure the proper use of these tools and

documentation of the measurements. In response to the need for the training of local practitioners in healthcare shortage areas, the Global Health Service Partnership was launched in March 2012. Although not a direct response to nCDs, the program is an example of a public-private partnership upon which sustainable program devel-opment will rely in the years ahead. The alliance between the Peace Corps and the Global Health Service Corps recruits U.S. academic physicians and nurses to practice and train local providers with respect to the needs expressed by the host country.

Likewise, clinicians providing care with-in the United States or abroad must be engaged in partnerships with local govern-ments and international policymakers to best serve the interests of patients. At the country level, national policies to discourage smoking, inactivity, or excessive alcohol use can be tailored to the cultural concerns of the local populace. Such policies may take the form of smoke-free public areas, taxes on the sale of cigarettes and alcohol, or public service messages on the health risks associ-ated with sedentary lifestyle. Public-private partnerships and negotiations with industry may also encourage food and beverage mak-ers to offer healthier options in their product lines. In addition, many medications used in the treatment of chronic diseases are on the WHO’s Model List of Essential Medicines. Advocacy for increased access to medica-tions and other essential resources may be the next step in making real progress in the

fight against chronic disease. Physicians are uniquely positioned to serve as experts on the dangers of lifestyle factors in chronic disease development and to advocate for public policies that expand access to life-saving medications.

Primary prevention and patient educa-tion will play crucial roles in curtailing the rising tide of nCDs both domestically and abroad. In a January 2013 Lancet article, a strong case is made for integrating nCD education into existing maternal-child health and nutrition programs.2 There is a growing body of evidence supporting the role of maternal exposures and epigenetics in the development of chronic disease in children. Providing a foundational educa-tion for women and girls about proper nutrition and avoidance of environmental pollutants may prove pivotal in attain-ing healthy pregnancies and incremental reductions in nCD risks for future genera-tions. Programs such as these are consis-tent with the Millennium Development Goals of Empowering Women, Reducing Child Mortality, and Improving Maternal Health, while offering a cost-effective means of integrating nCD prevention into existing education and treatment programs.

As the framework for post-2015 Millennium Development Goals is being established and the conversation surround-ing the control of nCDs continues to evolve, it is imperative that U.S. physicians participate in the discussion. In May 2012, the World Health Assembly agreed to


work toward the goal of 25 percent reduction in nCD mortal-ity by 2025.3 While policymakers and public health officials do exceptional work with respect to health diplomacy and program development, physicians are at the heart of patient care and can bring a practical perspective to the daily challenges of implement-ing those programs. The people who provide direct patient care are best positioned to address barriers to compliance such as cost, time requirements, and socio-cultural traditions, which influence per-sonal healthcare decisions. By participating in global health policy discussions, we can have an impact on the lives of our patients here at home and on the lives of countless others around the world.

Amber Hull is a third-year medical student at Midwestern University-Arizona College of Osteopathic Medicine. She is the National Global Health Representative for the Council of Osteopathic Student Government Presidents and served as an intern at the U.S. Department of State’s Office of International Health and Biodefense.4

References:

1. Robinson, H.M., and K. Hort. “non-Communicable Diseases and Health Systems Reform in Low- and Middle-Income Countries.” Pac Health Dialog 2012 Apr;18(1):179–90.

2. Balbus, J.M., R. Barouki, L.S. Birnbaum, R.A. Etzel, P.D. Gluckman Sr., P. Grandjean, C. Hancock, M.A. Hanson, J.J. Heindel, K. Hoffman, G.K. Jensen, A. Keeling, M. neira, C. Rabadán-Diehl, J. Ralston, and K.C. Tang. “Early-Life Prevention of non-Communicable Diseases.” The Lancet 2013 Jan 5;381(9860):3–4.

3. World Health Organization. 65th World Health Assembly Closes with New Global Health Measures. Geneva: World Health Assembly, 2012. http://www.who.int/mediacen-tre/news/releases/2012/wha65_closes_20120526/en/ (Accessed 03/05/2013).

Note: Further information on non-communicable disease as a global health policy issue can be found in the following series of articles in The Lancet:

• Improving Responsiveness of Health Systems to non-Communicable Disease: http://www.thelancet.com/jour-nals/lancet/article/PIIS0140-6736(13)60063-X/fulltext

• Inequalities in non-Communicable Diseases and Effective Responses: http://www.ncbi.nlm.nih.gov/pubmed/23410608

• non-Communicable Diseases: 2015 to 2025: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60100-2/fulltext

• nCDs: A Challenge to Sustainable Human Development: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60058-6/fulltext

• Independent Global Accountability for nCDs: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60101-4/fulltext

• Country Actions to Meet Un Commitments on non-Communicable Diseases: A Stepwise Approach: http://www.ncbi.nlm.nih.gov/pubmed/23410607

International medical graduates (IMGs), primarily from low- and middle-income countries, are an essential part of Maryland’s physician workforce. Below we present infor-mation on the countries of origin of IMGs working in Maryland and changes in the total number and countries of origin over the past decades.

The most recent American Medical Association (AMA) data indicate that there are 7,262 IMGs in Maryland; this is 27 percent of all Maryland physicians. Over the past decade, more than 300 IMGs per year have joined the work force in our state.

In 1970, the countries providing the largest number of physicians to Maryland were:

The Philippines 385 India 129 Iran 115 Cuba 113 Korea 108

By 1988, the major contributing countries were:

India 756 The Philippines 562 Mexico 225 Iran 200 Korea 197

Thus, low-income countries contribute approximately $90 million per year to Maryland’s economy.

Similarly, international nursing graduates comprise a significant percentage of Maryland registered nurses: 3–5 percent were classified as “foreign” licensed practical nurses and 1–2 percent were classified as “foreign” registered nurses.

For readers with a special interest in this topic, we recom-mend referring to Maryland Medicine, The Maryland State Medical Journal, Summer 2007 pp. 7–9.

Disclaimer: We note that there are major discrepan-cies between the figures for IMGs offered by MedChi, the Maryland State Medical Society, and the AMA figures.

Timothy D. Baker, MD, MPH, Professor of International Health, Health Policy and Management, and Ligia Paina, an Albert Schweitzer fellow, are at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland.

Reverse Foreign Aid to Maryland Revisited AgainTimothy D. Baker, MD, MPH, and Ligia Paina

Resource Availability and Utilization: Local Versus International Needs

Alan Schalscha, DO

How is the treatment of American patients different from that in the rest of the world? Do the resources we have here in the United States translate into patients receiving better medical care here than patients abroad where resources may be limited? As a physician working in Scottsdale, Arizona, and the Medical Director of the DOCARE International Continuity Clinic in San Andreas Itzapa, Guatemala, I have many questions about resource utilization. Overseeing health-care delivery in both the United States and Guatemala, I see many similarities in the issues that people face in obtaining the resources they need for their health.

By reputation, Scottsdale, Arizona, is an area of higher socioeconomic status than many cities, but the city still suffers from critical healthcare needs that are not being adequately addressed. A recent health needs assessment reported that the mortal-ity rate is higher in Scottsdale than in other cities in Maricopa County, Arizona.1

The city of Scottsdale has a higher prevalence of diabetes, high blood pres-sure, and heart disease than other cities in Maricopa County and in the state of Arizona.2 Two of the three sites where county residents get their healthcare are located within the Scottsdale area and half of the population is uninsured and not receiving the healthcare they should.

The health centers that I oversee in Scottsdale are designated as Federally Qualified Health Center Look Alikes,

and they offer care for all patients who want to use the facility, regardless of whether a patient has health insurance

or the ability to pay for their healthcare. The health centers strive to serve as medical homes for all of these patients and provide the comprehensive medical, behavioral health, and dental care, as well as health education programs, that we feel are appropriate.

The health center coordinates the care of our patients through disease manage-ment systems. The staff strive to improve each patient’s health in order to optimize care and prevent patients from deterio-rating to the point of needing emergency care. This improves both patient care and, we hope, reduces episodic emer-gency care costs. All patients are able to access care at each of the three centers; however, there is a significant differ-ence in the resources that are available to those who have health insurance and those who are not as fortunate.

Regulations governing referrals for spe-cialty care, diagnostic testing, and other procedures are increasingly complex for

patients who do have insurance. And the availability and affordability of diagnos-tic testing and specialty care for them is substantially greater than it is for those with no medical insurance coverage. Availability does not always translate into the ability to use those resources.

For the uninsured, referrals for specialty care present a greater challenge. Although there are a few federally funded entities that help uninsured patients obtain the care that they have been prescribed, for the uninsured there still remain limited appointments and competition for the limited resources we allot to them. A referral for a first appointment to a spe-cialist may not occur for several months.

Waiting for such a lengthy time for needed care obviously has a negative effect on the patient. It also means that the health centers are working on alternative

The health center coordinates the care of our patients through disease management systems. The staff strive to improve each patient’s health in order to optimize care and prevent patients from deteriorating to the point of needing emergency care. This improves both patient care and, we hope, reduces episodic emergency care costs.

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methods of care for these people while they wait for specialty care. The clinics work with individual specialists who will consider offering their services on a sliding fee scale to a certain number of uninsured patients per month. This agreement occurs on a provider-by-provider basis. The clinics have also negotiated basic lab and imaging services for uninsured patients who meet basic financial criteria. Though these costs are reduced, they are often still cost-prohibitive, creating a barrier in improving healthcare for these patients.

Disease management for uninsured patients, in order to ensure appropriate medications and medication compliance, is also chal-lenging. For example, long-acting insulin is cost-prohibitive for many of our patients without insurance. Many do not qualify for an assistance program and need to be prescribed the less expen-sive multidose forms of insulin. This decreases compliance and many of these patients are not able to have their diabetes controlled with the limited options available. In Scottsdale, we need significantly more resources to optimally serve our under-resourced population.

Compare Scottsdale, Arizona, USA, and San Andres Itzapa, Guatemala. San Andreas Itzapa is a community known for its agriculture and friendly people. The town is made up of nine vil-lages with 30,000 inhabitants, and multiple languages are spoken; the two most common are Spanish and Kaqchiquel. There is little professional or formal healthcare available for this popula-tion. Though the Guatemalan Department of Health has a few clinics in the villages, they are often unstaffed and/or have no resources. After a 15-year history of working with this commu-nity, DOCARE International established a clinic in the heart of San Andres Itzapa. It partnered with a local not-for-profit, which

funded the building of the clinic and appropriately equipped it. The clinic then hired a Guatemalan nurse and physician to care for the patients. It funded the acquisition of disease-specific medications in an attempt to increase the tools available for the clinic personnel to care for patients. Clinic personnel felt that certain resources were needed in order to improve the health and well-being of this population and they went about obtaining the resources in the form of donations. Patients soon began visit-ing the clinic more frequently. Often, patients seemed reluctant to have their visits with a physician, and chose to make their appointments with the nurse instead. Soon the clinic was able to dispense medications with limited charges to the patients.

Patients seemed to be satisfied with their care as long as they received a “parting gift” (a medication) after their examina-tion. Though all types of medications were available, they were initially given to patients with little regard for evidence-based practices. Diagnoses were made and the need for specialty referrals was noted, though none was available. Staff have since learned that in rural areas of Guatemala, medical personnel and resources are limited and are concentrated in more urban areas. Physicians are utilized for emergency and/or hospital care only and are mostly seen in hospital settings or when patients are in critical health. Preventive care in this town is a luxury and a unique concept for this population. Diagnosing a patient is only the first step in preparing the patient for care. Resources, whether medication, the use of specialists, or cultural medi-cal education, needs to be provided appropriately in order to increase the chance to improve health.

Health clinics in both Arizona and Guatamala help patients obtain the appropriate care, and resources may be needed even in the most affluent areas within the United States. In Scottsdale, the patient needs to be at the center of the healthcare team even when the population is similar to that in Guatemala in terms ofits ability to access resources. In the United States, we are a society with greater resources, but sometimes access to care depends on socioeconomic status.

In addition, resources alone do not improve population health. If the environment is not conducive to using those resources appropriately, the health and improvement of that health for a population may not be possible. The appropriate resources and the education on utilization of those resources both need to be provided to patients and their care teams. This is an elemental but critical point to improving community health no matter where in the world it is being offered.

Alan Schalscha, DO, currently serves as the Medical Director for the Federally Qualif ied Health Center Look Alike-LA NOAH Clinics (in association with Scottsdale Healthcare), Associate Professor at Midwestern University, and Clinic Director for the DOCARE Clinic in San Andres Itzapa, Guatemala.

References:

1. Maricopa County Department of Public Health, Office of Epidemiology. Health Status Report for Cities and Towns in Maricopa County, 2007–2009. Phoenix, Arizona. 2011.

2. Arizona Health Survey. www.arizonahealthsurvey.org. 2010.


Tuberculosis in Maryland: Global and Historical PerspectivesMArYLAnd dEPArTMEnT oF HEALTH And MEnTAL HYGiEnE

In January 1904, physicians, scientists and public health officials from around the country and the world came to Baltimore for the week-long Maryland Tuberculosis Exposition. Speakers ranging from the Governor to Sir William Osler gave presentations to a crowd of over 1,200 on the pathogenesis, epidemiology and control of tuberculosis (TB), and attendees toured exhibits like models of sanatoria from around the world.1 It was the first conference of its kind in the U.S., and can be considered to mark the beginning of the modern anti-tuberculosis movement in America.

From the Tuberculosis Exposition to passing the first universal reporting laws for TB, the turn of the 20th century saw Maryland at the fore of the fight against one of history’s greatest health threats. At the time of the exposition, death rates from TB in Maryland and across the country were in fact on the decline and had been for some 50 years, most likely due to improvements in sanitation and working conditions. But TB was still responsible for nearly 10 percent of all mortality for whites, and 15 percent of all mortality for African Americans; Osler himself estimated that a staggering 90 percent of the population was infected with tuber-culosis.2 (For comparison, it is estimated that at its height in the 1800s, TB was responsible for about a quarter of all deaths in the U.S. and Western Europe.3) With ongoing hygiene campaigns and improving living standards, these rates continued to fall nationwide, and the introduction of streptomycin, the first anti-tubercular antibiotic, in 1946 ushered in a new era in TB control.

However, once TB became treatable, the socio-economic dis-parities that already drove its transmission continued to manifest themselves in poor access to care, and the remaining disease bur-den was more and more shifted to cities. nowhere was this truer than in Baltimore, which by 1966 had the highest TB infection rate of any U.S. city. In the end, though, it was this dubious honor that allowed the city to become a proving ground for one of the greatest advances in tuberculosis treatment and control, directly observed therapy (DOT). DOT, in which all therapy is taken under direct supervision, was initially conceptualized as a way to treat non-adherent patients. However, after his hiring in 1973, Baltimore Health Commissioner Dr. David Glasser introduced DOT for the treatment of all TB patients at city clinics. Under this treatment regimen, disease rates fell from 75/100,000 before DOT to 36/100,000 in 1981. After switching to community-based DOT in 1981, cases fell even further, to 17/100,000 in 1992, and Baltimore’s ranking in incidence of tuberculosis among large cities fell once again, from 6th highest in 1981 to 28th in 1992.4 Most significantly, this occurred while incidence rates were actually increasing in many cities. DOT is now the standard of care for tuberculosis treatment around the globe.

The success of DOT notwithstanding, there are still chal-lenges to TB treatment and control in Maryland. In the most recent available data from 2012, Maryland continued to have a

rate of TB just above the national average (3.8/100,000 versus 3.4 nationally), even as rates for both the state as a whole and Baltimore City decreased.5 In fact, the incidence rate of TB in Baltimore City (3.5/100,000) is now lower than the state aver-age. Instead of a marked disparity between the city and counties, the greatest disparity in the disease rates now is for foreign-born Maryland residents, who had an incidence of 21.1/100,000, over five times the state rate. In the counties, foreign-born residents account for nearly 80 percent of all tuberculosis diagnoses, and in the city it is over 36 percent. Several counties with high immigrant populations now have rates of tuberculosis incidence that well surpass the state and city rates; for example, for 2012 Montgomery County reported an incidence rate of 8.7/100,000, and Prince Georges County a rate of 5.7/100,000.6

The incidence of TB among Maryland’s foreign-born resi-dents is a direct reflection not only of the state’s increasingly international population, but also the massive global burden of the disease. The World Health Organization (WHO) estimates that one-third of the world’s population has latent infection with TB. Asia has the highest burden of disease, and within Asia, India and China account for nearly 40 percent of the world’s TB cases. Africa, with its high rate of HIV co-infection, has the highest rates of new cases and deaths per capita; 24 percent of the world’s TB cases are in Africa. 7 Currently, it is estimated that only two-thirds of people infected with TB each year are diagnosed, and access to treatment is limited in many populations. Untreated, sputum smear-positive TB kills 70 percent of those infected within 10 years. 8

Despite these statistics, the news is not all dire. TB is still the second leading cause of death from an infectious disease world-wide after HIV/AIDS, and the leading infectious disease cause of death among women.9 However, with increased testing and implementation of DOT, global mortality from TB has decreased by 41 percent since 1990. Infection rates have been falling since 2006, and declined by 2.2 percent in 2011.7 But there are two major challenges that threaten to derail what global progress has been made against TB: the emergence of drug-resistant TB and TB/HIV co-infection.10

Currently, the best treatment for TB is the four-drug regimen of isoniazid, rifampin, ethambutol, and pyrazinamide for six months. Multi-drug resistant tuberculosis (MDR-TB), which is defined by resistance to isoniazid and rifampin, requires creative and some-times toxic drug regimens and extended courses of treatment. MDR-TB has been reported in all countries, but is most prevalent in Eastern Europe and Central Asia. More threatening still is the emergence of extensively drug-resistant TB (XDR-TB), or exten-sively drug-resistant TB, which has been found in 84 countries and accounts for 9 percent of all MDR-TB.7 XDR-TB requires

Sara Mixter, MD, Jesse X. Yang, and Joshua M. Sharfstein, MD

continued on page 29


The Changing Face of MedicineHisToricAL PErsPEcTivEs

It is not easy to be a pioneer – but oh, it is fascinating! I would not trade one moment, even the worst moment, for all the riches in the world.

~Elizabeth Blackwell

In 2013, there are more females receiving undergraduate degrees than males. Today, over 50 percent of those graduating from medi-cal school are women, and 54 percent of primary care residents are currently women. (The American Medical Association did not elect its first female board member until 1989.)1

This was not always the case. Elizabeth Blackwell, MD, was the first woman to graduate from medical school in the United States. She was also the first woman on the U.K. Medical Register, which notes those physicians registered to practice medicine through the United Kingdom.2

Born in 1821 in Bristol, England, Dr. Blackwell graduated from Hobart and William Smith College and, after being rejected for admittance to 29 medical schools, was accepted to and gradu-ated from Geneva Medical School.

I had not the slightest idea of the commotion created by my appearance as a medical student in the very small town. Very slowly I perceived that a doctor’s wife at the table avoided any communi-cation with me, and that as I walked backwards and forwards to college the ladies stopped to stare at me, as at a curious animal. I afterwards found that I had so shocked the Geneva propriety that the theory was fully established either that I was a bad woman, whose designs would gradually become evident, or that, being insane, an outbreak of insanity would soon be apparent.3

Her father, always opposed to slavery, became involved in Abolitionist activities when the family moved to the U.S. This greatly influenced Elizabeth’s attitudes on slavery, the treatment of the poor and underserved and, of course, because of her own expe-riences, the treatment of women. Originally a teacher—an accepted profession for women at the time—she turned to the study of medicine after a friend who was ill and dying suggested that she turn to the medical field in order to assist women dealing with disease, pain, and suffering who were being poorly treated by male physicians. Originally Dr. Blackwell had accepted a teaching posi-tion in Henderson, Kentucky. She left after a year because of her strong abolitionist views, which clashed with local racial attitudes.4

Upon applying to Geneva Medical School, the all-male student body voted for her admission as a joke. She graduated first in her class in 1849. Upon her graduation, Charles Lee, Dean of the medi-cal college, stated that he supported the medical education of quali-fied women and noted, “inconveniences attending the admissions of females to all the lectures in a medical school, are so great, that I feel compelled on future occasions to oppose such a practice….”5

Dr. Blackwell then worked in clinics in London and Paris and stud-ied midwifery at La Maternité. During her time there, she contracted purulent ophthalmia (an inflammation of the eye) from a baby she was treating, and lost sight in one eye. Upon returning to new York City,

recognizing that she would be unable to perform surgery and having been refused employment at other city hospitals, she opened her own clinic in the city’s slums, seeing patients three days a week.

Eventually, Dr. Blackwell moved her small clinic to a home where she, her sister Emily, who also became a physician, and Dr. Marie Zarsewska opened the new York Infirmary for Women and Children in 1857. The clinic expanded and, by 1867, became the Women’s Medical College, providing training and experience for women studying to become physicians. The college, whose main purpose was to give medical care to the poor, was devel-oped in conjunction with Florence nightingale, with whom Dr. Blackwell had developed a friendship while living in England.

During the Civil War, the Blackwell sisters helped organize the Women’s Central Association for Relief (WCAR) and trained nurses for service. The WCAR helped lead to the development of the U.S. Sanitary Commission.6

Although Dr. Blackwell never married, she adopted and raised an orphan, Katherine Barry (“Kitty”). Throughout her life, she was a strong advocate of both the women’s medical movement and the study and practice of holistic, or mind and body, medicine.

Her publications include:7

Blackwell, E. “Ship Fever. An Inaugural Thesis,” submitted for the degree of M.D., at Geneva Medical College, Jan. 1849. Buffalo Medical Journal 4(9):523–31. See, also, page 584 for notice of her graduation.

Blackwell, E. The Laws of Life with Special Reference to the Physical Education of Girls. London: S. Low. 1859.

Blackwell, E., and E. Blackwell. Address on the Medical Education of Women. new York: Baptist & Taylor, book and job printers. 1864. new York Infirmary for Women and Children and E. Blackwell. Address delivered at the Opening of the Woman's Medical College of the New York Infirmary, 126 Second Avenue. new York: Edward O. Jenkins, 20 north William Street. 1869.

Blackwell, E. The religion of health: A lecture. London: Partridge. 1869?.

Blackwell, E. How to Keep a Household in Health: An Address Delivered Before the Working Woman's College. London: Printed by W.W. Head. 1870.

Blackwell, E. Counsel to Parents on the Moral Education of Their Children. new York: Brentano's Literary Emporium. 1879. Blackwell, E. Christian Socialism: Thoughts Suggested by the Easter Season. Hastings: sold by D. Williams, the Library. 1882.

Blackwell, E. Wrong and Right Methods of Dealing with Social Evil: As Shown by English Parliamentary Evidence. new York: A. Brentano. 1883.

Susan A. Raskin

continued on page 28


VOLUME 13, Issue 1THE EVOLUTION OF MEDICAL EDUCATIONAlso Inside: Also Inside: Personal Perspectives: 5 Generations of Maryland PhysiciansBook Review: The Better End President’s Message: United We Stand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Harbhajan S. (Harry) Ajrawat, MDEditor’s Corner: How We Learn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Bruce M. Smoller, MDLetters to the EditorIntroduction: Medical Education: A Look With new Eyes and iPads . . . . . . . . . . . . . . . . . . .Tyler Cymet, DOEvidenced-Based Medicine: How is it Different from What We Have Always Done? . . . . . . Tyler Cymet, DOInformation Technology in the Medical Curriculum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Claudia n. Abras, PhDLearning Communities: A new Twist to Medical Education . . . . . . . . . . . . . . . . . . . . . . . . . . . .Robert B. Shochet, MDWhat’s new in Medical Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . David B. Mallott, MD, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Richard Colgan, MD, & . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Linda Lewin, MDResponding to a Changing Landscape: Medical School Curricular Change . . . . . . . . . . . . . . . Patricia A. Thomas, MDWhat is PBL and What is Case-Based Learning and How do They Differ? . . . . . . . . . . . . . . Stephen Davis, PhDTrends in Medical Education: Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Julianna Jung, MDThe Emergence of eHealth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .nancy K. Glaser, MS, RD, CDEUnderstanding the Outcome of Medical Education: Creating a Competent Physician . . . . . .Robert Dobbin Chow, MD, MBA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . & Tyler Cymet, DOThe Informationist’s Role in 21st Century Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Margaret Gross, MA, MLIS,

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AHIP & Victoria H. Goode, MLISVirtual Clinical Experience in Medical Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Cole A. Zanetti, D.O., Owen D.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Vincent, DO & Matthew Stull, MDThe Globalization of Medical Education: Sending American Medical Students Overseas . . . . . . . .Kelli Glaser, DOMedical Students Learn from Afar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Lisa Chun, MDLifelong Learning in Medicine: Physicians Following Plato’s Counsel . . . . . . . . . . . . . . . . . . .Ambadas Pathak, MD, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Steven F. Crawford, MD & . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Frank C. Berry, CCMEPPersonal Perspectives: Medical School Fifty Years Ago . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Bart Gershen, MDMedicine is in This Family’s Blood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Harry C. Knipp, MD & . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . David E. KnippHistorical Perspectives: Historical Vignettes of Medical Education in Maryland . . . . . . . . . . . .Sandra Rowland, MS, MABook Review: The Better End: Surviving (and Dying) on Your Own Terms in Today’s Modern Medical World, Dan Morhaim, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .John W. Buckley, MDWord Rounds: Potpourri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Bart Gershen, MDThe Last Word: The Changing Face of Medical School Graduation

VOLUME 13, Issue 2 THE DEVELOPMENT OF ACOS IN MARYLAND: STRATEGIC ALIGNMENT OF CARE, HEALTH & COSTAlso Inside: MedChi Accomplishments During the 2012 Maryland Legislative & Special SessionPresident’s Message: MedChi: Upholding the Standard of Medical Care for More than 200 Years . .Harbhajan S. (Harry) Ajrawat, MDEditor’s Corner: That Old College Try . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bruce M. Smoller, MDMedChi CEO Message: Maryland Medicaid: MedChi Works to Strengthen the Infrastructure . Gene Ransom, Esq.Letter to the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Delegate Bonnie CullisonIntroduction: “The Times, They are A’Changin” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stephen Rockower, MDA Physician’s Guide to Forming and Operating an ACO . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sarah E. Swank, Esq.Accountable Care Organizations in Maryland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Harbhajan (Harry) Ajrawat, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . & Craig Behm, MBAImplementation through Collaboration: The Brookings-Dartmouth ACO Learning network . . . Mark McClellan, MD, PhDThe Patient-Centered Medical Home in Maryland: Another Maryland Payment Reform Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Laura Herrera, MD, MPHA Curriculum on Health Policy for Medical Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Dora Ann Mills, MD, MPH,

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Peter Dane, DO & Tyler Cymet, DO

Index of Maryland Medicine Articles (2012-2013)


MedChi Accomplishments during the 2012 Maryland Legislative Session & Special Session . . Stephen Rockower, MDHistorical Perspectives: Medical Licensure: Setting the Standards in Maryland . . . . . . . . . . . . . . Sandra Rowland, MS, MA Word Rounds: Microbe Hunters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Barton J. Gershen, MDThe Last Word: The new Yorker Cartoon

VOLUME 13, Issue 3 MEDICINE AND THE MILITARYAlso Inside: MedChi CEO discusses the Loan Assistance Repayment Program for PhysiciansPresident’s Message: Leadership by Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Brian H. Avin, MDEditor’s Corner: Daisy and the Duke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bruce M. Smoller, MDMedChi CEO Message: Paying for Medical School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Gene Ransom, Esq.Letter to the EditorIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tyler Cymet, DOPost-Traumatic Stress Disorder and Other Trauma Disorders . . . . . . . . . . . . . . . . . . . . . . . . . .Robert J. Ursano, MDTrauma-Related Amputations: Treating the Whole Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . .Francisco Ward, MDMilitary Medicine and Civilian Medicine: A Comparison . . . . . . . . . . . . . . . . . . . . . . . . . . . .Murray R. Berkowitz, DO, MA,

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MS, MPHDomestic Violence in Military Families: non-Fatal Strangulation . . . . . . . . . . . . . . . . . . . . . .Audrey Bergin, MA & Rosalyn

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Berkowitz, Rn, BSnA Motor Vehicle Collision Involving a Veteran: A Teaching Case for the Joining Forces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Murray Berkowitz, DO, MA, MS,

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MPH;, Des Anges Cruser, PhD, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MPA, Alan Podawiltz, DO, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Charles E. Henley, DO, MPH, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Andrew Yuan, DO, Anita M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . navarro, Med, & Tyler Cymet, DO.

Emergency Open Heart Surgery Under World War II Combat Conditions: The Remarkable Experience of Douglas H. Stone, MD- A Young Baltimore Surgeon . . .Douglas H. Stone, MDPersonal Perspectives: MedChi Members Share Their Experiences of Military ServiceHistorical Perspectives: Dr. William Beanes, Treating Enemy Combatants and the “Star Spangled Banner.” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sandra Rowland, MS, MA

Teaching Curriculum for Medical StudentsPhysicians Leading Change: Towards What End? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alice G. Gosfield, Esq.In Sickness and in Health: Physicians as Captains of the Ship . . . . . . . . . . . . . . . . . . . . . . . . . . Joshua Sharfstein, MD, Secretary,

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maryland Dept. of Health & . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Hygiene

About Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . James L. Madara, MDWord Rounds: Black and White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Barton J. Gershen, MDThe Last Word: Chart: Growth of Physicians and Administrators 1970-2009

VOLUME 13, Issue 4 KEY MARYLAND HEALTHCARE STAKEHOLDEERS DISCUSS THE FUTURE OF MEDICINEAlso Inside: Maryland CEO Discusses the 2013 Legislative Agenda Restoring a Sense of Safety in the Aftermath of a Mass Shooting: Tips for Parents and ProfessionalsPresident’s Message: To Lead in Times of Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Brian Avin, MDMedChi CEO Message 2013 Session Shaping Up to be Challenging for Physicians . . . . . . . . . . . . . . Gene Ransom III, Esq.Editor’s Corner: The Road More or Less Travelled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Bruce M. Smoller, MDLetter to the EditorIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Mark Jameson, MD, MPHKey Maryland Healthcare Stakeholders Discuss the Future of Medicine . . . . . . . . . . . . . . . . .

1. Carmela Coyle, President and CEO of the Maryland Hospital Assoc.2. Majority Leader Rob Garagiola, Chair- Health Subcommittee in Finance Committee, Maryland Legislature

Index of Maryland Medicine Articles 2012...continued from page 23


Anne Arundel County

Joseph Taler, MD

BAltImore CIty

BAltImore County

CArroll County

Nathaniel Sharp, MD

William A. Dear, Jr., MDKonstantinos G. Dritsas, MD James R. Duke, MDFranklin T. Evans, MDTimothy B. Gilbert, MDDeha Gursey-Owens, MDIrvin B. Kaplan, MD

Gerhard Schmeisser, MDCarlton L. Sexton, MDEdward L. Suarez-Murias, MD Frances H. Trimble, MDHenry Wagner, MDSheila A. Walker, MDJose M. Yosuico, MD

John Adams, MDMartino Almogela, MDLeonard Berger, MDMichael Edelstein, MDFrank Faraino, MDPhilip Ferris, MDJohn Krejci, MDRaymond Markley, MDArnold, Michael, MD

John A. Mitchell, MDAlfred Nelson, MDThomas Provost, MDMorris Rainess, MDAnderson Renick, MDVernon Smith, MDDonald Somerville, MDHoward Williams, MD

3. David Horrocks, President of CRISP4. Gene Ransom III, Esq., Executive Director of MedChi5. Patrick Redmon, PhD, Executive Director of Maryland’s Health Services Cost Review Committee6. E. Albert Reece, MD, Vice-President for Medical Affairs of the University System of Maryland7. Joshua Sharfstein, MD, Pediatrician and Sec’y of the Maryland Dept. of Health and Mental Hygiene8. Ben Steffen, Exec. Dir. Of the Maryland Health Care Commission

The Questions for our “Stakeholders in Medicine”:

• In your experience, are the current changes to medical practice benefitting patients?• How can medical practices be changed to improve patient care?• What can physicians do to improve health care delivery?• Is the “medical home” a valid concept?• What do you think healthcare in this country will look like in 2020?• From your perspective, what are the three most important factors driving this transition?• What non-clinical skills do physicians need to remain viable in the next 3-5 years?• How can physicians effectively advocate for their patients, with payors, legislators and regulators in this post-reform era?

Bookends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Mark Jameson, MD, MPHEnergy Drinks and the Unwanted Buzz: A Case Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Tom noff, MD & Jerald Insel, MDPlanning for Change: The Implementation of the Patient Protection And Affordable Care ActWord Rounds: The Odyssey of Words . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Barton J. Gershen, MDThe Last Word: Restoring a Sense of Safety in the Aftermath of a Mass Shooting: Tips for Parents and Professionals

Index of Maryland Medicine Articles 2012...continued from page 24

ChArles County

Chinnadurai Devadason, MD

hArford County

Alberto S. Barretto, MD

montgomery County

st. mAry's County

Leon W. Berube, MD

WAshIngton County

AffIlIAte

Joseph J. Noya, MD

Jere J. Daum, MDStephen P. Ginsberg, MDRobert Gruber, MDLawrence Y. Kline, MDJames P. McCarrick, MD

Joseph M. O’Neil, MDJulius S. Piver, MDJorge H. Reisin, MDGeoffrey M. Wilner, MD

medChI neCrology 2012

Rizalito Amarillo, MDEvaristo Lardizabal, MDMichael Nemir, MD


Award names are not often explained – we simply accept them and move on. But every once in a while we think: “Where did that name come from?” In this edition of “Word Rounds” I’ll try to cover some common ones, and possibly evoke an “aha!” from some of you.

The awards that first come to mind are the Oscars, given each year by the Academy of Motion Picture Arts and Sciences (AMPAS). They are the origi-nal concept of Louis B. Mayer of MGM (Metro Goldwyn Mayer) studios, and were first presented in 1929. The origin of the name has produced two different pos-sible explanations. In the first, the execu-tive secretary to the president of AMPAS is alleged to have looked at the original statuette and said: “It looks just like my uncle Oscar!” The second claims that Bette Davis named it after her first hus-band Harmon Oscar nelson. Whatever the truth might be, the first academy award for best picture went to Wings, the best actor award to Emil Jannings, and the best actress award to Janet Gaynor – which only goes to prove the ancient Roman adage: sic transit Gloria mundi.

not to be outdone by Hollywood, Broadway developed its own celebrated trophy. In 1939, a group of Broadway actresses led by Antoinette Perry and Rachel Crothers created the American Theater Wing to honor the plays, the directors and the actors of the Broadway Theater. Perry, an actress and director, was perhaps most noted for having directed the play Harvey initially starring Frank Fay, and later Jimmy Stewart. Crothers was a playwright as well as a director. In 1947, the American Theater Wing introduced their version of the Oscar, which they named the Tony Award, for Antoinette (“Tony”) Perry who sadly had died the year before. (The first actors to receive a Tony were José Ferrer and Frederic March; the first actresses were Ingrid Bergman and Helen Hayes.)

It might also interest you to know that during WWII the American Theater Wing developed the Stage Door Canteen, a place where soldiers could go for relax-ation, refreshments, and the chance to dance and socialize with actresses who volunteered their time. The original stage door canteen was located in new York City, but others were soon established in Washington, Boston, Philadelphia, San Francisco and several other major cit-ies. In admiration for the work of these generous women, RKO produced a film, oddly enough titled “Stage Door Canteen” (1943) with numerous cameo appearances by Jack Benny, Harpo Marx, Katherine Hepburn and dozens of other stars.

Believing that off Broadway produc-tions deserved as much respect as those on Broadway, the Village Voice newspaper developed a ceremony to honor those pro-ductions. 1956 was the first year of that ceremony, and borrowing the initial letters from Off Broadway, the award became known as the Obie Award.

Keeping pace with Hollywood and Broadway, in 1949 the Academy of Television Arts and Sciences (ATAS) established their prize for excellence in television productions. This award also has multiple divisions, and was parti-tioned into Daytime Television and Primetime Television categories. The statuette awarded to each winner was named for the image orthicon tube, the recording element of early video cam-eras. “Immy” was the common diminu-

tive term for this device, and that’s what they named the statuette. However the name was soon changed to Emmy, in deference to the fact that the statue is that of a woman. The first awards were only given to shows and performers in the local Los Angeles area, but in 1950 it became a national event. That year the best actress was Gertrude Berg, best actor Alan Young, most outstanding TV per-sonality was Groucho Marx, and the best audience participation show was “Truth or Consequences.”

The man credited with 1,093 U.S. patents was Thomas Alva Edison, the “Wizard of Menlo Park.” His first patent was for an electrical vote recorder, but he also invented many other devices that have improved our lives, among which were long-lasting light bulbs, motion pictures, a stock ticker, electric power plants, the two way telegraph, the Vitascope to project motion pictures, an improved fluoroscope, and the carbon microphone (used in tele-phones until the mid 1980s). Perhaps his most startling invention was the ability to record sound and play it back. Using his carbon microphone and a needle which was deflected by the electrical variations caused by sound waves, etchings were made onto a rotating cylinder covered in tin foil. When the marked cylinder was then rotated at the same speed, a needle impelled by the etched grooves, turned mechanical movement back into sound. What had been recorded was enhanced by a trumpet-like device that increased the

Awards

Word roUndsBarton J. Gershen, MD Editor Emeritus

Believing that off Broadway productions deserved as much respect as those on Broadway, the Village Voice newspaper developed a ceremony to honor those productions. 1956 was the first year of that ceremony, and borrowing the initial letters from Off Broadway, the award became known as the Obie Award.{ }


sound volume. Edison called his invention a phonograph (from Greek phone: “sound or voice” plus gramma: “something written” as in grammar).

Inventor Emil Berliner improved Edison’s work by introduc-ing a wax-coated flat disc which enhanced sound reproduction. Berliner did not call his improvement a phonograph. Instead he reversed the syllables and called it a gramophone. In 1959, the national Academy of Recording Arts and Sciences, not to be surpassed by Hollywood, Broadway, or television, introduced their own ceremony to honor musical recording artists. Borrowing from the gramophone – they abridged the name and called the award the Grammy. It is, in fact, a gilded replica of the original gramophone, and some of the first winners included Ella Fitzgerald, Perry Como, Henry Mancini, the Kingston Trio and Count Basie.

A Swedish inventor with over 300 patents to his credit is responsible for an award that now has global recognition. nitroglycerin, a highly unstable explosive, was the basis for this inventor’s greatest innovation. He discovered that blending it with diatomaceous earth resulted in a much more stable product that became known as dynamite (from Greek dynamis: “power” or “something potentially dangerous”).

The inventor’s name was, of course, Alfred nobel. Following his death in 1896, and complying with directions specified in his will, the bulk of nobel’s estate was dedicated to the establishment of the Nobel Prize. His will specified five categories: physics, chemistry, medicine/physiology, literature and peace. In 1968, the Swedish national bank made a substantial donation to the nobel Foundation in order to establish a 6th prize in the field of eco-nomics. These awards are international in scope, and honor those recipients who have made outstanding contributions to their field.

The first nobel prizes were awarded in 1901, and the laure-ate in the field of medicine was Emil von Behring who had developed an antitoxin to treat diphtheria. William Röntgen won the initial prize in physics for his discovery of X-rays – a serendipitous occurrence. Röntgen had been experimenting with a Crooke’s tube – a tube with a partial vacuum and an electrically energized filament that emitted electrons. (Today it is known as a cathode ray tube.) Röntgen had covered the tube, thus blocking the emission of electrons. Despite impeding electron discharge, a piece of cardboard across the room, which had been treated with barium platinocyanide, began to fluoresce. Puzzled by this new and mysterious electromagnetic emission, Röntgen called it an “x-ray”, since “X” was always the unknown in mathematics.

The sports world may well boast the largest number of awards. John Heisman had been an outstanding college football player, and later became head football coach at several universities, most notably Georgia Tech where his teams put together 16 con-secutive winning seasons and a national championship. After his death, the Downtown Athletic Club of Manhattan created a trophy in his honor. The Heisman Trophy is awarded to the outstanding collegiate football player of the year, and has been awarded to such excellent players as Glenn Davis, Doak Walker, Roger Staubach, Tony Dorsett, Vinny Testaverde, Tim Tebow, and Robert Griffin III, to name just a few of the 77 players who have won to date.

In 1890, a 23-year-old pitcher entered the major leagues. His name was Denton True Young, and he continued to play in the major leagues for the next 22 years. Several years earlier, while try-ing out for a semiprofessional baseball team, some of his fast balls were not handled well by the catcher, and flew into the wooden

backstop, splintering the slats. Onlookers alleged that the fence looked like a cyclone had hit it, so they nicknamed the young pitcher “Cyclone” Young. It was later shortened to “Cy” Young, a nickname that remained with him throughout his life.

Cy Young pitched for 22 years before retiring in 1911. He still holds the major league records for most wins (511), most games started (815), most complete games (749), and most innings pitched (7,356). He also pitched three no-hitters, including a perfect game. In 1937, Young was inducted into baseball’s Hall of Fame. He died in 1955 and one year later major league base-ball created the Cy Young Award, given to the best pitcher in each league. (Don newcombe of the Brooklyn Dodgers was the first national League recipient and Bob Turley of the new York Yankees was the first American League winner.)

Other awards in the sports world include the Davis Cup in tennis (Harvard student Dwight Davis purchased the initial silver cup in 1899, to be awarded to the winner of a yearly U.S. – Great Britain match. In recent years the tournament has been expanded to include many nations.) In basketball there is the Naismith Award given annually to the best collegiate male and female basketball players, and named for Dr. James naismith who is credited with inventing the game. Hockey seems to have garnered the most trophies of any sport. Starting with the famous Stanley Cup, named in honor of Lord Stanley of Preston who was Governor-General of Canada at the time, and proceeding through the Calder Cup, Lady Byng Trophy, Conn-Smythe Award, and Grey Cup – all of which you will have to investigate for yourselves since space no longer permits.

I have not mentioned the Pulitzer Prize, the Clio Award, the Peabody Award, and dozens of others, which you again must delve into on your own. But as you do, remember that etymology not only involves ordinary words, it encompasses names, places, events – and even awards.

Barton J. Gershen, MD, Editor Emeritus of Maryland Medicine, retired from medical practice in December 2003. He specialized in cardiology and internal medicine in Rockville, Maryland. If you are interested in purchasing a copy of Word Rounds: A History of Words (Both Medical and non-Medical) and Their Relationship to One Another by Dr. Gershen, please contact Flower Valley Press, P.O. Box 83925, Gaithersburg, Md. 20883, or www.amazon.com.


Blackwell, E. The Influence of Women in the Profession of Medicine: Address Given at the Opening of the Winter Session of the London School of Medicine for Women. London: George Bell and Sons, York Street, Covent Garden. 1889.

Blackwell, E. On the Humane Prevention of Rabies. London: J.F. nock, printer, St. Leonards. 1891.

Blackwell, E. Pioneer Work in Opening the Medical Profession to Women. London and new York: Longmans, Green, and Co. 1895.

Blackwell, E. Scientif ic Method in Biology. London: E. Stock. 1898.

Maryland Medicine honors the contri-butions of Dr. Elizabeth Blackwell and the women and men who have followed in her footsteps.

Susan A. Raskin is Managing Editor of Maryland Medicine, the Maryland State Medical Journal. For a complete list of refer-ences, please contact her at 301.921.4300 or [email protected].

References:

1. http://www.aao.org/yo/newslet-ter/200806/article04.cfm

2. http://www.spartacus.schoolnet.co.uk/USACWblackwell.htm

3. http://www.nlm.nih.gov/exhibi-tion/blackwell/index.html

C L A S S I F I E D SInternAl medICIne: Call Sharing. Solo physician in Olney, MD, looking to share call with other physician(s) in nearby area. Flexible. Call 301.768.2169.

BethesdA: Attractive office space for rent in physician’s practice w/private office, exam rooms, and shared waiting room ready for use. Walking distance to Metro, parking garage, or on street and county garage across street. Please call Avelene at 301.656.0220.forest hIll: Office space available in a quiet professional building. Includes utilities, phone, copy, fax machine, recep-tionist area, waiting room, and parking. Two examination rooms and all other necessary accommodations for an MD (sink, closets, file areas, etc.). Part-time availability (1-3 days a week). Please con-tact Dr. Schmitt at 443.617.0682 or Dr. Legum at 410.852.0582.frederICK: Office space to share. Approx. 2000 sq.ft. bright & modern office on Guildford Dr. available to share (with some PT equipment). Waiting room and front desk. Perfect for inter-nal medicine/family practice looking to expand to Frederick area. Hours and rent negotiable. Inquiries to [email protected]. germAntoWn: Medical office space for lease in Germantown. 4000 sq.ft., Lots of Free Parking, Easy Terms.

One block to New Holy Cross near Montgomery College, Germantown. Call 301.502.1833 or 301.515.6971 after 6 pm. germAntoWn: Ambulatory Surgery Center in Germantown approved by Medicare, AAAASF for Lease, Partnership, or Sale. Multi-speciality, GI, PM, Urology, Surgery. One Block to New Holy Cross near Montgomery College, Germantown. Call 301.502.1833 or 301.515.6971 after 6 pm. roCKVIlle: 1,200 sq. ft. office next to Shady Grove Hospital. Available after-noons and weekends. 301.424.1904.sIlVer sPrIng, doCtors medICAl PArK: Georgia Ave. and Medical Park Drive. Close to Holy Cross Hosp., ½ mile north of #495. 3 building medical campus totaling 95,000 sq. ft. with over 100 medical practitioners and Clinical Radiology’s HQ. 2 suites 1400-2750 sq.ft. avail. immediately. Call Steve Berlin at Berlin Real Estate, 301.983.2344 or [email protected] sPrIng/WheAton: Lower your overhead expenses by sub-leasing or sharing medical office space. Luxurious penthouse suite with 3200 square feet, 7 treatment rooms, surgery center, equipment and staff available. All medical specialties welcome. Call: 301.949.3668.toWson: 2,087 square feet of second floor medical space available for lease at 660 Kenilworth Drive (directly across from Towson BMW). Suite is fitted for medical professional and landlord will build out to suit tenant’s needs. Lease rate includes full utility and janitorial service. Attractive two

story professional building with convenient and ample free parking. Caring on-site ownership and management. Excellent access to I-695, I-83, Timonium and down-town Baltimore. To discuss or see, call David Miller at 410.321.9558.WhIte mArsh: Office to share. 5 exam rooms incl. procedure rm. Nicely furnished. Call 443.690.4062.WhIte mArsh: Make me an Offer! Sublet my nice 2150 sq ft doctor’s office on Belair Road in White Marsh. 5-6 exam rooms, lots of parking and easy access. Call 443.690.4062.

ClInICAl trIAls: We are recruit-ing motivated, detail-oriented physicians as sub-investigators for diabetes-related clinical trials. If interested, please contact 301.770.7373.

medICAl eQuIPment: Two examination tables, EKG machine, com-puterized Burdick holter moniter with computer, printer, portable spirometer and autoclave. All in good condition. Asking price for all $7000. Price nego-tiable. Contact [email protected] eQuIPment: Diomed ∆15 Laser (for vein closure), with angio-dynamic kits and pump, and Ritter-230 exam table. If interested, call 301.325.3212.

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The Changing Face of Medicine...continued from page 28


even more challenging drug regimens. Though new rapid testing modalities have been introduced and novel drugs for MDR-TB regimens are on the horizon, current estimates are that only one in five individuals with MDR-TB is properly diagnosed.10

More progress has been made on the challenge of tuberculosis/HIV co-infection. Without treatment, 90 percent of those with HIV who contract TB will die within months, and tuberculosis causes about 25 percent of deaths in people with HIV. Thus, TB/HIV col-laboration is a major goal of the WHO’s Stop TB campaign. The increased availability of rapid testing for tuberculosis and HIV has resulted in significant gains, in testing at the very least. In 2011, 69 percent of those diagnosed with TB in Africa were simultaneously tested for HIV, up from 3 percent in 2004.7 The rate of TB screen-ing among HIV patients has also increased dramatically, though there is still significant room for improvement; less than half of all co-infected patients are receiving HIV therapy.

The global TB problem dwarfs Maryland’s annual incidence, just 226 cases in 2012. But as the TB patient population in Maryland becomes increasingly international, these global challenges to TB treatment and control have become our own. Once, the world came to Maryland to learn about tuberculosis control. now, controlling it in Maryland depends, in part, upon progress around the world.

Sara Mixter, MD, is a third-year resident in Internal Medicine and Pediatrics at Johns Hopkins Hospital. Jesse X. Yang is a fourth-year medical student at The Johns Hopkins School of Medicine who will be graduating this year and entering residency in Internal Medicine. Joshua M. Sharfstein, MD, is Secretary of the Maryland Department of Health and Mental Hygiene. We appreciate the assistance of Wendy Cronin, Nancy Baruch, and David Blythe, MD, of the state’s Center for Tuberculosis Control and Prevention and Office of Infectious Disease Epidemiology and Emergency Response in the preparation of this article. Dr. Sharfstein may be contacted at [email protected]. For a complete list of references contact Susan Raskin at 301.921.4300 or [email protected].

References:

1. Hurty, JR. The Maryland Tuberculosis Exposition. Sanitarian. 1904:52(414):385-396.

2. Roberts, SR Jr. Infectious Fear: Politics, Disease, and the Health Effects of Segregation. 2009: University of north Carolina Press, Chapel Hill.

3. Murray, JF. A Century of Tuberculosis. American Journal of Respiratory and Critical Care Medicine. 2004:169(11):1181-1186.

Tuberculosis in Maryland...continued from page 21

Actively screen for and report TB: Physicians should con-tinue to screen patients for signs and symptoms of tuberculo-sis, especially high-risk patients such as refugees, immigrants and migrants, as well as the homeless, HIV-infected patients, drug and alcohol abusers, and those who have been incarcer-ated.11 Confirmed or suspected active TB should be reported immediately to the local health department, which will then coordinate DOT where appropriate and, in cases of active TB, contact tracing and treatment. Physicians should also contact local health departments regarding screening or treatment options for patients at high risk for latent TB infection.

Be aware of MDR-TB: In Maryland, nearly all Isoniazid (InH)-resistant TB and all MDR-TB have been report-ed among foreign-born patients.6 As of February 2013, Maryland had not diagnosed one patient with XDR-TB. However, this could well change as its prevalence increases globally, and M/XDR-TB should be suspected in patients who come from high-risk areas (especially Eastern Europe and Central Asia), but also in those who fail to clear their cultures on traditional therapy.

Consider alternate testing for latent tuberculosis infection: Many patients at risk for TB come from endemic countries that employ the Bacillus Calmette-Guérin (BCG) vaccina-tion, and false positive tuberculin skin tests (PPD) can occur in patients who have received BCG. Recently, two interferon-gamma release assays (Quantiferon Gold-in-Tube® [QFT-GIT], Qiagen nV, netherlands, and TB T-SPOT®, Oxford Immunotec Ltd, Memphis, Tn, USA) have become available. These blood tests measure cellular immunity to tuberculosis, are not affected by BCG status, and are recommended by the CDC for latent infection screening among patients who have received BCG (though tuberculin skin testing is still preferred in children under 5).12 Both tests are commercially available in Maryland, and QFT-GIT is provided by the Maryland State Laboratories Administration for several local health depart-ments. In two Maryland jurisdictions, piloting QFT-GIT testing among foreign-born patients has reduced diagnoses of latent infection by 30-40 percent, thereby saving the costs and risks of months of therapy.6

What Physicians Need to Know About Screening for TB


L A S T W O R DTHE

Interesting Facts from the World Health Organization (WHO)

The WHO defines health as, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

WHO has a strong focus on public health (a.k.a. social health, social medicine and population health) with the assumption that society as a whole should attempt to boost the health of its population through:

1. Accessible healthcare (physicians, nurses, hospitals, clinics, diagnostic equipment, medicines, etc.)2. Healthy environments (clean air, sufficient food and water, etc.)3. Good individual and collective lifestyle choices (eating fruits and vegetables, not smoking, getting

exercise, etc.)4. 80 percent of women do not deliver their babies in a hospital setting. 5. Pregnancy complications account for 15 percent of deaths in women of reproductive age.6. Population aging is a significant contributor to the rise in cancer and heart disease.7. The average life expectancy for both men and women is just 44 years old.8. U.S. healthcare rates poorly in comparison with the health care systems of other countries due, in

part, to higher homicide rates than other countries, and death and disability due to car accidents.9. Seven million children under the age of five die each year. The cause of death in one third of the

children is due to nutritional needs.10. Half of all mental disorders begin before the age of 14. Regions around the world with the highest

percentage of population under the age of 19 have the poorest levels of mental health.11. A third of global disease relates to behaviors during adolescence, such as tobacco use, inactivity, obe-

sity and exposure to violence.

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