BRIGHAM AND WOMEN´S HOSPITAL
Thomas S. Thornhill, MD
JOHN B. AND BUCKMINSTER BROWN PROFESSOR OF ORTHOPAEDIC SURGERY, HARVARD MEDICAL SCHOOL
CHAIRMAN, DEPARTMENT OF ORTHOPAEDICS, BRIGHAM AND WOMEN´S HOSPITAL, BOSTON MASSACHUSETTS







Introduction

A wise man once said, “Do not tell people your problems. Half of them do not care and the other half are actually glad you got them”. Health care in Boston continues to pose challenges similar to those probably experienced by each of you. I will not dwell on the problems, because I think they are far overshadowed by our progress. The academic medical centers have unique challenges due to decreased funding for research and education. It is still unclear path as to the impact of the Massachusetts Health Care reform bill. All of the academic medical centers have adapted a strategy of forming satellite facilities and we are no exception. While these are convenient for patients and can add efficiencies hard to reproduce in the academic Medical Center, they also cause both internal and external challenges. We are now on five different campuses and soon will increase to a sixth. Our Faulkner Hospital Unit continues to grow and, in fact, represents the greatest growth in our program. Dr. Michael Wilson continues to be chief of that program. We have opened four new operating rooms outfitted with state-of-the-art orthopedic arthroscopic cameras and video systems. We have also just moved into new operating room facilities at the main campus. For those of you who remember rooms 11 and 14 where a hip revision, major trauma or spine set up would take every square inch of the room, these new rooms are very spacious. As the Brigham has opened the Carl J. and Ruth Shapiro Cardiovascular Center with several new operating rooms, we have taken over the old cardiovascular suite. These rooms have been refitted for orthopedics and will give us an operating suite that is light years ahead of our old facilities.

One of the challenges of satellite facilities is not only moving surgeons and support staff around the Greater Boston area, but also interacting in a positive way with other colleagues at the local hospitals. It is clear that we will do best to integrate with and complement these hospitals and surgeons rather than try to compete. I am sure that these are similar problems faced throughout the country.

NEW RECRUITS

As our Hand Service has grown there has been a need for an additional surgeon. Following a national search we are pleased that Dr. George Dyer, a recent graduate of both the Harvard residency and the combined Harvard hand fellowship will be joining our staff. I have had the pleasure of knowing George since medical school and he has lived up to the high expectations that many of us had formed. George will also be working at the West Roxbury VA Hospital. This unit is led by our colleague, Dr. Tamara Martin, and George’s addition, both in hand, upper extremity and trauma will be invaluable.

George’s hiring is something that Barry Simmons and the rest of the hand group have been working on to mollify the increased demand. Unfortunately, this became even more acute with the illness of our colleague, Dr. Mark Koris. Many of you know about Mark’s illness. I am pleased to report that he is making good and steady progress. I spoke recently to his wife Francine and with their permission, I reporting that Mark is on medical leave due to problems stemming from longstanding hypertension. He has had an extensive rehabilitation and is now walking with a walker. His speech is much improved and his speech therapy is almost completed. Mark and family will spend the summer in Ipswich at their summer house as it is on a single floor. He will be there probably through the summer and early fall and then we will return to Brookline for continued therapy. I know that he would love to hear from his old friends, but we are not sure where he will be over the next several months. You can send your well wishes to the office. We all wish Mark a speedy recovery.

Our second recruit is Dr. Kimberly Thurmond. Dr. Thurmond will be working with Dr. James Ioli to help with the increased podiatric need in the department. She is also a great addition to the staff.

BWH ORTHOPAEDIC DEPARTMENT

As I review the various aspects of our clinical research and education programs, I will try to be brief and give you an overview. Our strategic plan over the next three years is to achieve a better balance of the three legs of the academic stool, namely, clinical activities, research activities and educational activities. I will discuss each as well as to define a restructuring of our administrative organization to help with this balance.

Administrative organization: Mr. Tom Gakis continues to be our administrative director, Jenny D’Isola as my executive assistant is the integrator and quarterback for the department. As I have assumed the additional role as Chairman of the Executive Committee for the Harvard Combined Orthopedic Residency Program, it also has added an additional burden to Jenny. As we have grown and restructured our divisions, there is growing responsibility at the Division Chief level. This includes resource allocation, fellowship and student training, resident education and budgetary issues.

CLINICAL PROGRAMS

Adult Arthroplast y Service:

After serving as head of the Adult Arthroplasty Service for many years, Dr. Richard Scott electively stepped down from this position though he maintains a very active clinical and teaching practice. He still runs a weekly conference for the residents and fellows and it continues to be one of the most popular of conferences. We also still have the Robert’s Conference on Thursday mornings, which is an interactive clinical case discussion. I usually run this conference and we would welcome any interesting cases submitted in PowerPoint presentation. We have often taken one specific case to add as a separate article to this journal.

The new Chief of the Arthroplasty Service is Dr. Daniel Estok. Dan continues to be a leader in revision surgery. During their exit interviews, the fellows find that their experience with Dan Estok assuages some of their fears in approaching difficult hip revision cases. Our current fellows will be going to great practice opportunities, Brandon Feeney will be returning to the Salt Lake area, Dr. Mike Laker will be going back to Detroit and Kathleen Hogan will be practicing nearby in Concord, New Hampshire. We continue to have an active international fellowship program, which is a complement to our educational process.

I am pleased that the Arthroplasty Service continues to be a mainstay of our program reflecting our history at the Robert Brigham Hospital.

Spine Service

With the addition of Dr. Christopher Bono as Chief of Spine our program with Chris, Mitch Harris and Greg Brick is extremely active. Moreover, they have been very active in clinical research and in integrating with our basic science departmental researchers. I have recently reviewed the nearly 20 papers written from that unit and our clinical program continues to grow. There is a Brigham based unit for complimentary medicine under the direction of Dr. David Eisenberg at our 850 Boylston campus. This is a well-funded, evidenced based program that includes complimentary therapies for the nonoperative management of patients with back pain. Moreover, we continue to have a nonoperative spine unit predominantly based in rheumatology and are working with our neurosurgery colleagues as they expand their program.

Dr. Bono reports ‘The Orthopaedic Spine Service at BWH has continued to have multi-faceted growth over the past year. In addition to its clinical productivity, which continues to increase at a steady pace, the Spine Research Division has witnessed remarkable achievements. Under the excellent coordination of Natalie Warholic, the Spine Division has six IRB protocols that are currently approved, in progress, or recently submitted. These research projects vary from multi-center prospective evaluations of spinal cord compression from metastatic disease, degenerative spine conditions, and spinal trauma to retrospective evaluations of C2 fractures in the elderly and a comparison of anterior cervical discectomy and fusion with a titanium cage versus allograft.

The past year has seem a number of projects completed, presented, and on the path to publication. Spearheaded by Dr. Michael Glotzbecker and guided by Dr. Bono, the Research Division has produced a series of extremely worthwhile studies regarding DVT prophylaxis after spinal surgery. In one study, a nationwide survey of spine surgeons DVT prophylaxis practices for high-risk tumor or trauma patients was performed, which has been presented both nationally and internationally and has been accepted by Spine. In another study, a systematic review of the world’s literature on this topic was performed. Also presented nationally and internationally, this paper has been selected to appear in a special issue of Spine focusing on highlights from the recent annual meeting of the International Society for the Study of the Lumbar Spine in Geneva, Switzerland. In the past year, Dr. Harris and the Spine Research Division completed an exquisitely important paper regarding mortality rates in elderly patients after cervical spine fractures. In its final stages of manuscript preparation, this work was awarded “Best Resident Research Study” at the last Cervical Spine Research Society annual meeting in San Francisco. Also under Dr. Harris’ guidance, Dr. Joe Simon has completed an important study assessing the differences in radiologists and spine surgeons’ “clearance” of the cervical spine using CT. This paper has already been submitted for publication. Now in the final stages of data analysis, Natalie Warholic and the Spine Research team have completed a multi-disciplinary PRIDE project, with critical participation from Drs. Jeff Katz and Elena Losina, nicknamed “PIPAC”, which assessed pain’s influence on patients’ acceptance of complications following lumbar spinal surgery for low back pain.

In addition to the BWH collaborative projects described above, the Spine Research Division has seen a great many individual project achievements as well. In the 2008 calendar year thus far, Dr. Bono has published eight peer-reviewed articles in prestigious journals such as Spine, Journal of Bone and Joint Surgery American, and Journal of American Academy of Orthopaedic Surgeons on a variety of topics. Notwithstanding his publications about orthopaedic trauma, Dr. Harris thus far published four excellent peer-reviewed articles in 2008 on spinal topics in such journals as New England Journal of Medicine, Spine, JAMA, and Clinical Orthopaedics and Related Research. Beyond peer-reviewed projects, Dr. Bono has just launched production of a new textbook of spinal surgery entitled “Prove It”, which is a practical guide to evidence-based decision-making for common spinal conditions.

The combined BWH-MGH Spine Surgery Fellowship has just begun its second year, under the direction of Kirkham Wood, MD and Christopher Bono, MD. The fellowship celebrated the graduation of three outstanding fellows this past June. The new fellows have begun training as of August 1, 2008 and show equal, if not more, promise both clinically and academically. Above the excellent local reputation that the fellowship has gained since its inception, it is becoming increasingly recognized on a national basis as well.”

Musculos keletal Oncology

With the addition of John Abraham, the Sarcoma Program has experienced rapid growth. Division Chief Dr. John Ready continues to be active both in his oncology role and arthroplasty roles. The Dana-Farber recently prepared their semiannual report to the Brigham Chiefs and the musculoskeletal sarcoma program was one of its highlights. The strong relationship between the Brigham and Women’s Hospital and the Dana-Farber has been a great plus for both institutions.

Foot and Ankle Service

When Dr. Mike Wilson became Chairman of Orthopedics at our Faulkner Department, Dr. Chris Chiodo assumed the role as Division Chief of Foot and Ankle. Chris has also been president of the Massachusetts Orthopedic Association and is increasingly active in regional and national issues concerning foot and ankle.

The Foot and Ankle Division remains extremely productive. Patients are now seen at the main campus and all three satellites. With continued clinical growth, we are proud to announce the addition of two new members to the team. Dr. Eric Bluman, MD PhD, will be on board within the year. Eric comes from Tacoma Washington, where he is Chief of the Foot and Ankle Division at the Madigan Army Medical Center. Eric is very active in the American Orthopedic Foot and Ankle Society (AOFAS) and has a strong commitment to academic research. Also joining Dr. Jim Ioli in Podiatry is Dr. Kimberly Thurmond, DPM. Dr. Thurmond was previously with Healthdrive Medical in Newton and will be seeing patients at the main campus.

The Foot and Ankle Division also remains committed to our academic mission. Drs. Chiodo and Wilson have presented their exciting basic science research on the quality of autologous bone graft at both the AAOS and AOFAS annual meetings. Additionally, they have presented clinical research on peroneal groove deepening and have served as moderators for several scientific sessions and symposia. This fall, Dr. Chiodo will also serve as Chair of the AOFAS Complete Foot Care Course.

Hand Service

Dr. Barry Simmons as Chief of the Hand Service will be honored this year by the Massachusetts Arthritis Foundation with a Marion Ropes Award recognizing his many years of patient care and education in the field of arthritis. As I mentioned last year there was a successful 25th reunion of the Hand fellowship which has trained many outstanding graduates who have assumed leadership roles throughout the country. We are hoping that many of these individuals will be returning to honor Dr. Simmons this fall. Dr. Phil Blazar continues to run our Ethics and Quality Control programs. Dr. Brandon Earp is the orthopedic liaison to our Physician Assistant Program. We now have 12 physician’s assistants who are essential to our patient care activities.

Sports Service

The Sports Service is headed by Dr. Larry Higgins. He also heads the Brigham component of the Partners Shoulder Service. The Shoulder Service per se will be covered in a separate Partners section, as it is co-run by Dr. Higgins and Dr. J.P. Warner at the Massachusetts General Hospital.

One of the difficulties that we have had and continue to have is that some of our surgeons crossover amongst the divisions. Dr. Tom Minas has successfully maintained the sphere of influence in the prearthroplasty adult reconstructive arena. He still performs over a 100 osteotomies a year and has been doing unicompartmental, bicompartmental, tricompartmental and patellofemoral arthroplasty in younger patients with isolated osteoarthritis. As director of the Cartilage Repair Center he is one of the leaders in autologous chondrocyte implantation, OATS procedures and other forms of mosaicplasty. Their data registry is a source of numerous clinical papers and will enable us prospectively to ascertain the long-term efficacy of these procedures. Dr. Andreas Gomoll, who is a graduate of this laboratory, the Harvard Orthopedic Program, and a fellowship at Rush in Chicago has been a great addition to the Sports Program and the Cartilage Repair Center. He is busy clinically particularly in the knee and the shoulder and has taken an active role in cartilage repair. Dr. Gomoll has been very productive academically and is clearly one of the stars of the future.

With the integration of the Cartilage Repair and Partners Shoulder Service in the Sports Medicine Division, this has become one of our largest groups. Dr. Scott Martin runs a very active program in sports medicine. As he is dually trained in sports medicine and arthroplasty, he has a unique perspective in dealing with the transition in the ageing athlete.

The Sports Program has become actively involved in the area of High School Athletic programs and we are increasing this program to care for an ever increasing demographic.

Trauma

The prototypic success model of the Partners integration has been the Partners Trauma Service under the direction of Mark Vrahas as the Partners chief, Dr. Mitch Harris as the BWH Trauma Chief and Dr. Malcolm Smith as the MGH Trauma Chief. As this is a truly integrated unit, it will be presented in a separate section of this report.

Educational Activities

The BWH Orthopedic Department continues to be active in both fellowship and resident education. As you will see from Dr. Herndon’s report there are many changes going on in the Residency Program including a change in residency director. The executive committee has a shortlist of candidates who each has significant experience at the level of the RRC, as a program director and/or a director of a residency training program. We feel that any of these candidates will be capable of carrying on the positive changes made under the tenure of Jim Herndon.

Dr. Herndon will have reviewed, in his section, the results of resident survey and a retreat that has led to significant changes in the program. The major change is that we have lengthened rotations so that there will be more continuity between resident and attending. This has been facilitated by the growth at the institutions that allows parity in training. While there is a downside of the fact that not every resident is able to work with every attending, it is the resident’s council and the executive committee’s feeling that the educational experiences will be similar. The other challenge at all of our institutions is the fact that we are all going to satellite units. This poses logistical problems in resident education. Finally, it is essential that we comply with the resident work hour restriction and be certain that it does not diminish from the educational opportunities for each resident.

A manifestation of the success at the Brigham and Women’s Hospital has been that five of the last six Golden Apple awards have been given to individuals affiliated with the Brigham. The Golden Apple is an award given each year by the residents to an attending, who they feel has been outstanding in their education. Our other challenge is to maintain a balance between resident and fellowship education. We think that it can be synergistic but must be careful that the requisites of each of these training programs are met. Finally, we still have an active program in medical student training both from our Harvard students and visiting students. While, as at most institutions, this is most intense prior to the deadline for residency application, we are actively pursuing students at earlier levels to ignite an interest in orthopedics. The leadership of the early medical student education has been assumed by Dr. Charles Day at the BIDMC with active participation from all members of the Combined Program Orthopedic Departments.

Many of the old graduates remember fondly the six month chief residency and felt that its demise would be a long term determent to the program. I was one of those skeptics but it has evolved to be even better. The PGY-5 trauma service is akin to the old chiefship. Each institution has an administrative chief resident whose role is integral in the training program.

RESEARCH

The orthopedic research continues to be stratified into specific areas. We are integrated as the musculoskeletal line in the Brigham Research Institute and there are many opportunities for interdepartmental and translational studies.

Skeletal Biology Research Laboratory

The Skeletal Biology Research Laboratory studies basic, clinical, and translational aspects of skeletal pathophysiology, skeletal cell differentiation, effects of age and vitamin D status on bone physiology, mechanisms of chondro/osteoinduction, and tissue engineering approaches for skeletal regeneration. The group’s original basic research publications in the past year include reports on a new model in which nicotine is used to impair distraction osteogenesis in rats, intrinsic effects of age on human marrow cells and their differentiation to osteoblasts, and uses of porous collagen scaffolds for tissue engineering. Clinical research publications concern the importance of vitamin D in fracture care pathways and the finding that hip fracture patients with greatest deficiency of vitamin D showed significantly more falls and poorer muscle function in the year following the fracture than did patients with better vitamin D status.

Drs. Chris Bono, Chris Chiodo, Mitch Harris, Larry Higgins, Tom Thornhill, Mike Wilson, and John Wright are active surgeon members of the Skeletal Biology Research Laboratory. Current research is funded by NIH grants, BWH Biospecimens Pilot Awards, and the OREF. Ongoing basic science work concerns the mechanisms of skeletal aging, effects of age on cell signaling, bone cell differentiation with post-mortem biospecimens, effects of vitamin D status on marrow cell differentiation, and vitamin D metabolism by human marrow cells. Tissue engineering research involves the regulation of chondrocyte and osteoblast differentiation, optimization of the Mizuno tissue bioreactor, and mechanisms of actions with differentiation agents to enhance histogenesis. Translational and clinical research continues our multidisciplinary program to improve follow-up management of osteoporosis in fragility fracture patients, expand fracture pathways with other in-hospital caregivers, the effect of fracture on circulating pre-osteoblasts, regional differences in quality of bone grafts, the natural history of osteoporosis in patients with osteoarthritis, the pathophysiology of rotator cuff arthropathy, and impact of medications in vivo on marrow biology in vitro.

Joe (Shuanhu) Zhou, Ph.D. received two competitive, prestigious honors this year. He was selected as one of the very few young scholars invited to participate in the weeklong Buck Institute Summer Training Course in Experimental Aging Research in Seattle. He was also selected to participate in the highly-competitive National Institute on Aging Summer Institute on Aging Research, held for one week at the Aspen Wye River Conference Center in Queenstown, MD. Each of these intensive programs identifies outstanding young investigators with interest in modern biogerontology and exposes them to the breadth and depth of knowledge needed for developing successful careers in clinical, basic, and translational research in aging. Joe was able to network and share his recent discoveries about human skeletal aging during those programs.

Dr. Glowacki continues to serve the department as representative to the BWH Biomedical Research Institute’s Research Oversight Committee, Co-Chair of the BWH Musculoskeletal Research Center of Excellence, and as Professional Standards Officer for BWH Research Staff. She is a member of the NIH review panel for Musculoskeletal Tissue Engineering, advises NASA and the FDA, and is on the Ethics Advisory Committee of the American Society for Bone and Mineral Research, after serving as its co-founder and chair for 4 years.

Center for Molecular Orthopedics

Dr. Keith Crawford reports “Since the establishment of the Center for Molecular Orthopedics (CMO) in 2000, the Chairman has continued fostering cutting-edge research, which improves our understanding of Orthopedic diseases. The CMO focuses on gaining a better understanding of the molecular mechanisms associated with Osteoarthritis and the development of gene and cell-based therapeutics for the repair and regeneration of damaged tissues. Our research, focusing on the joint milieu, has uncovered a small population of mononuclear cells in Osteoarthritic patients. Within these cells exist subsets possessing regenerative properties. Molecular analysis of these subsets has enabled us to identify dominant molecular pathways, modulating during disease progression. These finding have allowed us to identify an inflammatory cytokine profile unique to Osteoarthritis. In addition, these studies have uncovered a number of proteins, which may be of interest for therapeutic modulation of Osteoarthritis.”

Biomechanics, Biomaterials and Nanotechnology

Dr. Anuj Bellare reports “In this academic year, our laboratory has developed several new processes to fabricate joint replacement prostheses from ultra-high molecular weight polyethylene, with high resistance to wear and oxidation, while retaining high mechanical properties. These processes utilize several novel approaches to optimize the performance of joint replacement prostheses such as: (1) high pressure annealing of irradiated polyethylene to induce wear & oxidation resistance (2) utilizing shape memory characteristics of polyethylene to increase its ductility, (3) confining crosslinks in polyethylene components to articular regions to preserve bulk mechanical properties and (4) developing “rubber-like” polyethylene by blending with elastomeric polyethylene copolymers to prevent catastrophic failure. Each of these technologies is being tested in the laboratory to measure wear resistance, oxidation resistance and clinically relevant mechanical properties.”

Anuj is productive on many areas. There are several patented processes registered through CSRL at Partners, which may prove to enhance the mechanical and biological properties of implant materials.

Optical Coherent Tomography

Dr. Mark Brezinski as chief of this research unit is well funded in this very difficult period of time of obtaining research grants. His collaborative work with Dr. Scott Martin promises to give us greater insight in both the degeneration and regeneration of cartilage. In an attempt to keep this report within its limits, I will not reiterate the many publications from this unit over the past year.

Cartilage Repair Center

I have discussed the integration of the Cartilage Repair Center in the section on the Sports Medicine Program. With the addition of Dr. Gomoll to the unit and the additional year of data, we are and will continue to see prospective evidence based reports on the efficacies of these technologies. As an extension of this center Tom Minas, Wolfgang Fitz, Phil Lang of radiology and I have been working with a small company to develop custom implants capable of resurfacing single and dual compartments in arthritic knees.

Orthopedic and Arthritis Center for Outcom es Research (OrACORe)

The establishment of this center under the direction of Dr. Jeffrey Katz and Dr. Elena Losina has been a major advance in the Orthopedic Department and integration with Rheumatology. The program had worked to consolidate various joint registries within the group to permit more retrospective and prospective studies. Moreover, they will work through the critical process of obtaining IRB approval and in complying with conflict of interest regulations both at Partners and the medical school. This group works actively with our clinicians in study design, power analysis, data analysis, and manuscript preparation.

Rather then give you an exhausted list of their achievements of the past year let me give a significant yet representative example. The METEOR project is now operational. It is a multicenter study headed by Jeff Katz at the Brigham, which includes the Brigham and Women’s Hospital, the Hospital for Special Surgery, Cleveland Clinic, Mayo Clinic, and Vanderbilt University. There are lead investigators in each group and the goal is to ascertain the role of arthroscopy in early osteoarthritis. This has been a very controversial subject and as a scientific advisory to this group, I have learned more about study design and the control of confounding variables as I watch this study unfold.

The enthusiasm and expertise of OrACORe group is incredible, and it has provided great opportunities for residents, fellows, attendings, and medical students to participate in important orthopedic research.

OPERATION WALK

In 1995 Dr. Lawrence Dorr established the program of Operation Walk to realize his vision of bringing state of the art total joint arthroplasty to patients in international locations who would otherwise be unserved or underserved. After the early success of his Operation Walk group in Los Angeles, he recruited Orthopaedic Surgeons from other parts of the Country to establish chapters and organize trips to serve people in other parts of the world. Over the next 12 years, Operation Walk grew to 8 chapters and missions have been performed across the globe including Cuba, China, Nepal, the Philippines, Nicaragua, Guatemala, Peru, El Salvador, Mexico, Kenya and Panama.

Two years ago, I had the pleasure of traveling with my friend, Dr. Doug Dennis of Denver on an Operation Walk Denver program to Panama. Participating in this trip solidified for me my commitment to the mission of Operation Walk. This year, I made my second trip - this time to the Dominican Republic as a combined Operation Walk Boston/Operation Walk Denver group. The trip was a great success. There were approximately 30 volunteers from the Brigham that went on this mission and were joined by a group from Denver. Together, this dedicated group of volunteers performed 47 total joint replacements on 37 patients who would otherwise have never had these surger- ies that they greatly needed. I will quote from an article that appeared recently in a Brigham and Women’s publication that reported on this trip: “The day after a total knee replacement, 50-year-old Isabela didn’t just get out of bed and walk. She did steps for the Merengue by her bed and continued to progress so much that she was dancing through the halls of the Plaza de la Salud Hospital in the Dominican Republic within a week.”

With the help of the Operation Walk Denver and the Operation Walk Los Angeles. groups, we are now officially established as Operation Walk Boston and plan to return to the Dominican Republic in 2009. We have worked closely with surgeons, physicians and administrators in the Dominican Republic and are excited about this association and being part of Operation Walk.

SUMMARY

This has been a brief synopsis of the year’s activity. I apologize for many omissions. There is not much news from our past mentors. I have spoken with Dr. Clement Sledge, who spends much of his time in Maine. Dr. Fred Ewald and Sarah divide their time between Colorado and the Boston area. Dick Scott said that he saw him recently and that Fred is extremely fit and both are very active. I had the pleasure of seeing Dr. Bill Thomas at the resident graduation. The William Thomas award, which we established several years ago, has become a mainstay of the graduation program. It is to signify the excellence in teaching, patient care, and collegiality that were the hallmarks of Bill’s practice for many years. Finally, I did speak recently to Dr. Bob Poss, and he and Anita are still in Marblehead. He seems fine and has done an outstanding job working with Dr. Jim Heckman at JBJS. I wish you all the best and look forward to seeing you at the Academy, especially at the Harvard Combined Residency Program alumni reception.





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