Fellows & Alumni

About Our Fellows

The Linde Fellowship aims to provide early and mid-career physician leaders with an opportunity to develop the expertise and skills needed to advance careers in primary care leadership, including practice management and innovation. Fellows are given the opportunity to imagine, design and execute a project aimed at changing and improving an aspect of their primary care practice.

To date, our fellows' projects address a range of primary care topics including teamwork and communication, disease management, and education initiatives.

Meet Our 2024-25 Fellows

Christine Pierre, MD

Christine Pierre, MD

Associate Medical Director

FELLOWSHIP
University of Massachusetts Chan Medical School
RESIDENCY
University of Massachusetts Chan Medical School
MEDICAL SCHOOL
Ross University School of Medicine in Dominica, West Indies
UNDERGRADUATE
Barnard College of Columbia University

Laura Reis, MD

Laura Reis, MD

Medical Director

RESIDENCY
Stanford-affiliated O’Connor Hospital Family Medicine Residency Program
MEDICAL SCHOOL
Dartmouth Medical School

Our Past Fellows

 

JBeach

Jennifer Beach, MD

Instructor in Medicine
Assistant Medical Director, Healthcare Associates (HCA)

Dr. Jennifer Beach came to BIDMC in 2000 after graduating from Virginia Commonwealth University School of Medicine. After completing her internal medicine residency at BIDMC, Dr. Beach joined the faculty in Healthcare Associates (HCA). An excellent teacher, Dr. Beach soon became a Rabkin Fellow in Medical Education. She became a Suite Director in HCA in 2011, a role that has since transitioned to Assistant Medical Director. Dr. Beach is working as a Team Leader in the Harvard Center for Primary Care’s Academic Collaborative, transforming HCA into a Patient Centered Medical Home. She actively teaches and mentors students and residents.

Dr. Beach’s project focused on a multidisciplinary approach to track and improve the management of hypertension in HCA. Affecting approximately 30 percent of adult patients, hypertension is one of the most common chronic medical conditions in the US and in HCA. Blood pressure is easily measured with clearly defined goals and outcomes, but achieving those outcomes is often challenging. With a nurse performing a counseling visits, and with concrete algorithm for medication escalation, patients in the combined nurse/physician clinic had a greater improvement in systolic blood pressure (21 mm Hg vs 5 mm Hg) and diastolic blood pressure (10 mm Hg vs. 0 mm Hg) than patients receiving standard care (5 mm Hg). Dr. Beach created a hypertension registry in HCA, to standardize her co-management format across the practice, and to incorporate students, residents, and specialists into the project.

DBrockmeyer

Diane Brockmeyer, MD

Assistant Professor of Medicine
Medical Director, Hospital Anticoagulation Service
BIDCO Pod Leader, Healthcare Associates

Dr. Diane Brockmeyer, a graduate of the University of California, Davis School of Medicine, completed her primary care internal medicine at Brigham and Women’s Hospital (BWH). She became a faculty member in BWH’s onsite primary care practice, with a focus on education. She quickly rose to be named the Resident Clinic Coordinator, overseeing the outpatient primary care experience for the medicine residents. Diane came to BIDMC in 2004. The recipient of a Curtis Prout Fellowship in Medical Education at Harvard Medical School in 2004-2005, Diane developed a teaching skills curriculum for internists and surgeons. In 2005 Diane assumed the role of resident practice director in HCA, an administrative and teaching leadership role similar to the role that she had held at BWH. In 2009, Diane began to shift her focus toward clinical leadership and became the BIDPO Pod leader for Healthcare Associates, focused on improving quality of care in the outpatient setting while controlling costs. Finally, in 2011, she became medical director of HCA’s anticoagulation service and has since expanded it into a hospital-wide service focusing on managing the complexity of chronically anti-coagulated patients across departments and practices.

Dr. Brockmeyer’s project sought to improve the safety, efficacy and communication about transitions in care for anticoagulated patients when they undergo procedures, specifically in gastroenterology. The goal is safer care, with fewer errors and near misses, and fewer cancelled outpatient procedures, for the cohort of patients. Due to the success of this pilot project, the program will be expanded Beth Israel Deaconess Milton Hospital GI procedures.

JFogg

Jane Fogg, MD, MPH

Instructor in Medicine
Medical Director of Care Redesign, APG
Medical Director for Primary Care, BIDCO

Dr. Jane Fogg came to BIDMC as a primary care internal medicine resident in 1993, and she has not left the extended BIDMC family since. A graduate of the Columbia's School of Public Health and School of Medicine, Jane has been a leader and an innovator in primary care practice since completing her residency. In her initial position as a practicing physician at Dimock Community Health Center in Roxbury, Dr. Fogg quickly became the director of adult medicine, of residency training, and of the Diabetes Collaborative project there funded by the Bureau of the Health Professions. In 2004, Jane moved to BIDMC’s APG and founded a practice in Needham as their medical director. She became involved in BIDCO as a Pod Leader and served on the BIDPO board as well. In 2010 she assumed leadership roles in APG and BIDCO as the Medical Director of Care Redesign, and of Primary Care, respectively. She designed, implemented and directed the first centralized urgent care facility for BIDMC community owned practices, called After Hours Care. Her current work focuses on primary care redesign and strategies to improve population health across the network.

Dr. Fogg’s project implemented practice redesign in four APG practices as well as develop metrics to evaluate success. She used a framework she developed in her own practice based on core values of continuous population health work flows, consistent availability and responsiveness to patients, and teamwork. She created a curriculum for medical assistants and practice nurses as they shift core work duties including population health pre-visit work flows and outreach protocols for patients in need. Focusing on practice culture and provider satisfaction in redesign, she wrote and conducted provider and staff surveys aimed at understanding the driving forces and dynamics in the change process. Her work continues at APG as the Practice Excellence Department with goals to spread her redesign framework across the organization.

Cohen

Marc Cohen, MD

Instructor in Medicine
Assistant Medical Director, Healthcare Associates (HCA)

Dr. Marc Cohen trained in primary care internal medicine at the Hospital of the University of Pennsylvania. He was awarded the C. William Hanson II Prize for Outstanding Primary Care Resident at his residency graduation. Dr. Cohen joined the faculty at BIDMC in 2007 as a primary care physician in Healthcare Associates. An excellent teacher, Dr. Cohen completed a Rabkin Fellowship in Medical Education in 2009. In 2012, Dr. Cohen became an assistant medical director in Healthcare Associates. Dr. Cohen is Co-Chair of the Narcotics Committee and actively teaches and mentors students and residents in his practice.

During the Linde Family Fellowship, Dr. Cohen seeks to develop a comprehensive plan for standardizing and implementing universal care team huddles within Healthcare Associates as part of the practice’s ongoing transition to a Patient-Centered Medical Home model of care. His main goals include increasing ownership and buy-in from all HCA care team members, developing a structured checklist for care team huddles, increasing effectiveness by providing data reports that can be accessed and utilized during huddles, and decrease barriers by providing coaching and role play opportunities. He hopes to measure success by analyzing qualitative and quantitative measures including provider & staff surveys, documentation of team huddle occurrences, and measures of population health and quality of care.

Ford

Kelly Ford, MD

Assistant Professor in Medicine
Resident Practice Director, Healthcare Associates (HCA)

Dr. Kelly Ford came to Beth Israel Hospital as a medical intern in 1993. After completing her internal medicine residency at Beth Israel Hospital, Dr. Ford joined the faculty at Rush Medical College and served as an attending physician at Cook County Hospital and Woodlawn Community Clinic. There she held several leadership roles, including director of the Breast and Cervical Cancer Screening Program. In 1999, Dr. Ford returned to BIDMC and joined the faculty at Healthcare Associates (HCA). Dr. Ford became the HCA Resident Practice Director in 2012. She is actively involved in improving the resident outpatient curriculum, ensuring an outstanding clinical education for the residents, and helping residents achieve excellent clinical outcomes for their patient panels.

Dr. Ford’s Linde Family Fellowship project seeks to enhance the educational content of the patient panels that residents manage in their outpatient clinic over three years. In order to increase the size, diversity and continuity of care of the housestaff panels, Dr. Ford has identified three core objectives of her project. The first is to develop a panel initiation plan that would enable interns to more rapidly and completely connect with their new clinic panel. The second phase is to create standardized quantitative and qualitative tools to evaluate housestaff panels in terms of gender, age, complexity and educational opportunity. Lastly, Dr. Ford hopes to develop an integrated panel transfer process that would help faculty, housestaff, patients and clinical support teams with the transition at the time of a resident’s graduation.

Molina

Elizabeth Molina Ortiz, MD, MPH, CDE

Medical Director, Joseph M. Smith CHC

Dr. Elizabeth Molina received her medical degree and MPH from Tufts. She trained in family medicine at the Beth Israel Hospital Residency in Urban Family Practice in New York. After her residency graduation in 2007, Elizabeth joined the Institute for Family Health in New York, a network of 17 federally qualified health centers. She practiced in an underserved area of the Bronx and became the diabetes medical director of the Institute’s 70 primary care providers, supervising the care of 6700 diabetic patients while working with her team of seven certified diabetes educators and four diabetes case managers. In 2013, Dr. Molina moved to Boston and joined the Joseph M. Smith Community Health Center in Allston where she was associate medical director before her promotion to medical director.

Dr. Molina’s Linde Family Fellowship project seeks to develop actionable chronic disease registries for diabetes, hypertension and asthma. Joseph M. Smith Community Health Center currently has the beginnings of these registries, but Dr. Molina’s project would refine the registries by establishing clinically appropriate process and outcome targets, developing a workflow for identifying and targeting at-risk patients, and enhancing existing education visits associated with these populations. Dr. Molina hopes to develop a work plan with the IT department to perform quality assessment on existing databases. She also plans to create and train a multidisciplinary team to help develop a systemic approach to outreach and target those most at risk. Lastly, Dr. Molina aims to improve existing nursing education visits by developing policies and procedures to help transform nursing visits to provide education on crucial management of asthma, diabetes and hypertension.

NBasu

Nisha Basu, MD, MPH

Instructor in Medicine
Director of Population Management, Healthcare Associates BIDCO Pod Leader, Healthcare Associates


Dr. Nisha Basu, a graduate of Tulane University and the Tufts School of Medicine, trained in primary care internal medicine at BIDMC. She has been an primary care physician in the Atrium clinic since 2008. As a two-year fellow in the HMS Center for Primary Care Innovation Fellows Program, she directed a registry-based outreach pilot and started a program with our Pulmonary Division to screen patients who have diabetes for obstructive sleep apnea. This year, she served as the faculty advisor for a nurse practitioner-led Diabetes Intensive Management and Education (DIME) clinic in HCA. This multidisciplinary clinic, aimed at those patients with poorly controlled diabetes, demonstrated an average 1.1 percent reduction in A1C. Recently, Dr. Basu was named the clinic’s first director of population management. Her role as the BIDCO Pod leader dovetails with these goals.

Dr. Basu’s Linde Family Fellowship project is to design a system that balances the tension inherent in the Triple Aim - improving the health of the HCA patient population, improving the experience of care and promoting high-value care. There are six areas she will focus interventions for quality goals: comprehensive visit-based care; integrated between-visit care; patient engagement; physician, team, resident engagement; information technology tools and infrastructure; and actionable data. Her success will be measured by the development of infrastructure and interventions to impact pre-defined quality and cost metrics.

EBrackett

Ethan Brackett, MD, MPA

Instructor in Medicine
Site Medical Director of Fenway: South End

Dr. Ethan Brackett studied at the University of Massachusetts Medical School then helped bring family medicine to Boston Medical Center as a member of the first residency class in 1999. While in residency, Dr. Brackett headed up the residents’ union and improved his knowledge of Boston’s immigrant populations by working in Brazil, Haiti and Cape Verde. He worked for 10 years at Codman Square Health Center in Dorchester, MA, where he supervised residents and students, pioneered group prenatal and well-child visits, championed PCMH transformation and managed the Family Medicine Department. In 2008, Dr. Brackett attended the Kennedy School of Government at Harvard University with a Zuckerman Fellowship from the Center for Public Leadership and earned a Master of Public Administration with a concentration in health policy. He came to Fenway Health in 2013 with the aim of expanding the breadth of LGBT healthcare through community outreach, added services and new levels of advocacy.

During the Linde Family Fellowship Dr. Brackett seeks to continue leading Fenway Health’s transition into a full-service family health center. Fenway is an FQHC that has functioned as an adult-only, LGBT-focused practice. Fenway leadership has identified expansion to pediatrics as a logical and necessary next step for 2015-16. Dr. Brackett has already facilitated cross-departmental coordination and planning to lay the groundwork for this transformation. He will spend his fellowship year focusing on staff training, new protocol implementation/refinement and the roll-out of new clinical services. To guide this work, he intends to follow patient and staff satisfaction, service delivery supply and demand, and pediatric clinical outcome measures. Dr. Brackett is eager to do this within the existing structure of Fenway’s Patient-Centered Medical Home (PCMH) initiative, and its behavioral health integration in the primary care setting.

ASeth

Arshiya Seth, MD

Instructor in Medicine
Primary Care Physician, Cambridge Health Alliance

Dr. Arshiya Seth trained in primary care internal medicine at Cambridge Health Alliance (CHA), Harvard University. After completing her internal medicine residency, Dr. Seth joined the faculty at Cambridge Health Alliance, Somerville Hospital Primary Care. Dr. Seth is also an Innovations Fellow, Center for Primary Care. She is leading Patient Experience of Care and Staff Experience of Care project at her site, conducting workshops for staff focused on "AIDET (Acknowledge—Introduce—Duration—Explanation—Thank you), "keywords at key times," techniques for reducing patient anxiety and implementing Service Recovery. She has had several institutional leadership roles at CHA, including Principal Investigator for Academic Innovations Collaborative HMS Grant, Physician Lead Practice Improvement Team, Tobacco Cessation group, diabetes shared medical appointments and organizing Weight Watchers for hospital staff.

Dr. Seth’s Linde Family Fellowship project seeks to scale up and introduce the workshops at other sites within CHA, creating a sustainable and replicable model of improving patient and staff experience of care. The first phase of the project involved designing and conducting 14 hours of workshops on “Patient Experience of Care” and “Staff Experience of Care” at Somerville Hospital Primary Care. In the next year workshops will spread across Cambridge Health Alliance and will be part of an ongoing training for new as well as old employees of CHA including medical students who rotate at CHA. Gradually, this workshop will take the form of a “Service Academy” at Cambridge Health Alliance thus creating customer loyalty, patient retention, satisfied employees and improvement in financial stability of the institution.

AWeinStein

Amy R. Weinstein, MD, MPH

Assistant Professor in Medicine
Clerkship Director, BIDMC Core I Medicine
Faculty Director, BIDMC Crimson Care Collaborative

Dr. Weinstein is a general internist at Healthcare Associates (HCA), the BIDMC academic faculty practice. She is a leader in medical student education in the Division of General Medicine at BIDMC. Through her role as the BIDMC Core I Medicine Clerkship director, she leads Harvard medical students’ education in internal medicine during their core clinical year. Guiding a core group of faculty and Harvard Medical School students, Dr. Weinstein led efforts to develop the BIDMC-Crimson Care Collaborative Student-Faculty Practice based at Healthcare Associates, where she now serves as faculty director. As the Interprofessional Education faculty lead for the HMS-wide Crimson Care Collaborative organization, she coordinates efforts to bring and advance interprofessional teams in the student-faculty practices. She is a member of the HMS Academy of Medical Educators and a senior member of the BIDMC Academy of Medical Educators. Dr. Weinstein received formal training in medical education through the selective Rabkin Fellowship for Medical Education in 2007-2008.

Dr. Weinstein has also played a role in primary care innovation at BIDMC and HCA. She developed and led a Shared Medical Appointment Program with the pharmacy team and medical residents. Through her work on shared medical appointments she was selected to be a HMS Center for Primary Care Innovation Fellow (2011-2012). She led efforts to integrate students into the HCA patient centered medical home primary care redesign, including a summer internship program, as a part of the Center for Primary Care’s Academic Innovations Collaborative. Based on Dr. Weinstein’s work with medical students on primary care redesign and through the Crimson Care Collaborative, she was awarded the HMS Center for Primary Care Excellence in Mentoring Award in 2013.

Dr. Weinstein’s Linde Family Fellowship project will focus on engaging medical students to improve transitions in care. Through this project students will help patients transition from the inpatient to the outpatient setting, easing the process for patients and facilitating communication among providers. Success of the project will be measured by patient follow-up rates, and the quality of communication and patient follow-up. The process will be developed and evaluated and successes will be shared across the network.

Carr

Jayson C. Carr, MD, FACP

Instructor in Medicine

Dr. Jayson Carr graduated from Brown University and Brown Medical School under the Air Force Health Professions Scholarship Program. He completed residency training at David Grant USAF Medical Center, California and UC Davis Medical Center. He spent two years on the medical staff and residency faculty at David Grant/UC Davis and completed his seven years of active duty service at the 92nd Medical Group Fairchild AFB, WA. Returning to his native Rhode Island, he was site medical director for a community hospital practice, medical director at Care New England Wellness Center, and medical director at a rehab/skilled nursing facility while teaching medical students at his alma mater. He also served on the RI Medical Society’s Physician Review Committee.

Since joining Beth Israel Deaconess Healthcare, Brookline, Dr. Carr has served on the BIDCO Pharmacy and Therapeutics Committee and BIDHC’s Physician Advisory Board. He has taught third year HMS students in the core medicine clerkship for the past eight years, winning both the BIDHC Excellence in Teaching Award and he BIDMC Department of Medicine Award for Excellence in Ambulatory Student Teaching in Primary Care Medicine.

In his Linde Family Fellowship project, Dr. Carr will design a program to reduce primary care physician use of high cost radiology in the evaluation of acute low back pain. He plans to collaborate with BIDCO and the BIDMC Spine Center to obtain baseline imaging rates and design a program of education and incentives for primary care physicians to improve adherence to accepted guidelines. He hopes to use this project to investigate the larger topic of how to help physicians provide high-value care in a way consistent not only with payer and organizational goals but also with our professional ethic, in which our first duty is always to our patients.

Heckman

James Heckman, MD

Instructor in Medicine

Dr. James Heckman is a 2010 graduate of the University of Virginia School of Medicine and a 2013 graduate of the BIDMC Internal Medicine Residency Program. After completing his training, he accepted a position as a full-time clinician educator at Healthcare Associates at BIDMC. Since then he has faithfully served his patients while assuming several leadership positions within the practice. As South Suite Medical Team Leader, Dr. Heckman has propelled forward several projects aimed at improving patient care, including placing visual way finders to help patients navigate the suite and a bundled intervention to improve return rates of completed health care proxy forms. He has also fostered a culture of collaboration and communication that has been vital to practice improvement. As a content leader of the Physical Diagnosis Curriculum, Dr. Heckman co-designed a series of 90-minute evidence-based interactive workshops supported by interactive web-based algorithms and embedded short video clips demonstrating physical diagnosis maneuvers. These have been well received by house staff and are one focus of curriculum redesign within the residency program. Dr. Heckman is also a member of the BIDMC Academy of Medical Educators and the Arnold P Gold Foundation, Gold Humanism in Medicine Society.

Dr. Heckman’s Linde Project seeks to improve communication between primary care and specialty providers through the design and implementation of an electronic consultation system. Current literature estimates that an average PCP coordinates care with over 200 specialists in over 100 different practices. This is accomplished through an informal system of emails, phone calls and pages with obvious shortcomings in terms of accountability, standardization and reimbursement. Dr. Heckman hopes to build upon pre-existing relationships with specialist peers as he co-designs a system to address these issues while at the same time improving patient access to specialty care. His hope is that this new system will facilitate relationships between primary care practices and their specialist neighbors and strengthen the BIDMC network as a whole.

Lindenburg

Julia Lindenberg, MD

Instructor in Medicine
Assistant Medical Director, Healthcare Associates (HCA)

Dr. Julia Lindenberg received her medical degree from Mt. Sinai School of Medicine and trained in primary care internal medicine at BIDMC. During her last year of residency in 2006, she was awarded Best Teaching Resident at the Harvard Medical School graduation. Following residency, she joined the faculty at BIDMC as a primary care physician and clinician-educator at Healthcare Associates. Dr. Lindenberg has had a longstanding career interest in addiction and co-directed the Behavioral Medicine ambulatory course for the internal medicine residents from 2008-2012. In 2010, she became director of the Atrium Suite in HCA and in 2012, this role transitioned to her current role as assistant medical director in Healthcare Associates. Dr. Lindenberg also co-chairs the HCA Narcotics Committee. She continues to actively teach residents and Harvard medical students.

During the Linde Family Fellowship, Julia will continue her work around addiction and will be focused particularly in developing supports in HCA for patients with opioid addiction. The state of Massachusetts is in the middle of an epidemic of opioid overdose deaths that reflects nationwide trends. Working in conjunction with other hospital departments, particularly psychiatry, Julia will aim to develop HCA’s first office-based opioid treatment program using buprenorphine, a medication approved to treat opioid dependence by licensed physicians. She will lead a small team of physicians as well as work with nursing and social work to coordinate this program and plans to integrate this clinic into the primary care residency training program in order to further the education of residents in HCA about the treatment of addiction. The hospital sees this program in HCA as a pilot as it works to also create a “bridge clinic” to treat inpatients with opioid addiction who are not patients at HCA.

Nguyen

Nicolas Nguyen, MD

Associate Professor in Family Medicine
Medical Director, BIDMC Family Medicine

Dr. Nic Nguyen graduated from Tufts School of Medicine and did his residency training at Cambridge Health Alliance, the first family medicine program situated at a Harvard-affiliated hospital. Upon completion, he became a core faculty member at the Tufts Family Medicine residency program and was appointment director of inpatient training. In 2013, he was named medical director of Beth Israel Deaconess Family Medicine at 1101 Beacon. He currently serves on the Future of Health Care and Vaccination Optimization Committees. At Harvard Medical School, he is a preceptor for the Foundations and Clerkship courses, and also serves as a principle clinical experience advisor. At the core however, “Dr. Nic” is a family doctor. With the exception of obstetrics, he practices full scope medicine for the whole family and believes in comprehensive and compassionate care.

During the Linde Fellowship, Dr. Nguyen will aim to create more cohesion amongst family medicine providers within the BI-APG network. These current 35 physicians (a growing number) practice at separate, isolated sites, yet under the same BI umbrella. There is increasing evidence on the benefits of creating stronger connections and cohesion between primary care physicians. In contrast, there is also data suggesting that isolation tends to increase burnout rates, reveal a lack of resources and education, and cause an absence of community and partnership amongst clinicians. The project will start with survey assessment of the level of connectivity, cohesion and communications among APG family medicine providers practicing out in the community. Through creation of stronger communication forums, promotion of department-wide meetings and organization of networking opportunities, he hopes to form a much needed family medicine community at BIDMC-APG.

MBuss

Mary K. Buss, MD, MPH

Dr. Buss will focus her efforts on rebuilding and expanding the inpatient palliative care program at BIDMC, including an evaluation of the impact of palliative care consultation on outcomes, such as hospital length of stay and readmission rates. Dr. Buss was recently appointed the chief of the section of palliative care in the Division of General Medicine. She founded and now directs the Outpatient Palliative Care program. She has led efforts to open a hospice and palliative medicine fellowship in partnership with the Boston Veterans Administration. She will function as the fellowship program director for the first class arriving in July 2017. Dr. Buss completed fellowship training in both medical oncology and hospice and palliative medicine. She continues to see patients as both a medical oncologist and palliative care specialist.

RGlassman

Rebecca Glassman, MD

Dr. Glassman aims to enhance the integration of primary care residents in Healthcare Associates. Primary care residents currently spend six continuous months in outpatient clinics participating in quality improvement and innovation projects. Glassman hopes to utilize their enthusiasm for practice improvement to influence positive change in the practice. She plans to involve the primary care residents in population health management, where they will serve as teachers, leaders and change agents for the faculty and categorical residents. Glassman graduated from the University of Pennsylvania and Tufts School of Medicine. She trained in primary care internal medicine at BIDMC and served as primary care chief medical resident. She has been a primary care physician in the central clinic since 2014.

Dr. Glassman piloted the primary care track as a senior resident, and has been coleading the program since its inception in 2015. She has worked to develop and refine the six-month continuous ambulatory block, actively participating in innovation and quality projects including the implemented of the Lung Cancer Screening Program. She is assistant director of primary care track, Healthcare Associates.

MLibby

Matthew Libby, DO

Dr. Libby is working to develop Outer Cape Health Services – a network of rural Federally Qualified Health Centers on Cape Cod – into a highly-functioning Patient-Centered Medical Home, using his home site in Wellfleet as a pilot model. He strives to accomplish change guided by the principles of the Quadruple Aim: to improve patient experience of care, population health, cost efficiency, and clinician and staff job satisfaction. Libby received a BS in physics from University of Massachusetts and worked for several years afterward in math and physics education. He later earned a Doctor of Osteopathic Medicine degree from the University of New England, and completed his family medicine residency at the Greater Lawrence Family Health Center.

Since 2015 he has been practicing primary care, urgent care and outpatient addiction treatment at Outer Cape Health Services in Wellfleet, MA. During that time has taken on roles as clinical director of information technology, director of medical education and site medical director in Wellfleet.

RSlocum

Robert Slocum, DO, MPH

Dr. Slocum plans to develop an integrated primary care/substance use treatment program at Anna Jaques Hospital in Newburyport. The program will seek to provide substance use treatment, including buprenorphine for opioid use disorder, which utilizes a chronic disease management model commonly applied to illnesses such as diabetes and COPD. This will include case management and proactive support delivered by a multidisciplinary team, focused on best practices and patient centered care. Dr. Slocum is a 1993 graduate of UMass Amherst with a bachelor's degree in exercise science and a minor in psychology. He worked for several years doing research in San Francisco prior to enrolling at Touro University College of Osteopathic Medicine in Northern California. He then completed a family medicine residency at Jamaica Hospital in Queens, NY.

In 2014, after working for several years in community health, Dr. Slocum joined the medical staff at Anna Jaques Hospital. He received a master's degree in public health from UMass Amherst in 2016 and is very interested in improving primary care delivery at the population level. Recently, Dr. Slocum was named director of ambulatory clinical informatics at AJH with the goal of improving the quality, efficiency and safety of primary care services.

Dr. Chandrasekhar

Aditya Chandrasekhar, MD, MPH

Lead Physician, Fenway Health

Dr. Chandrasekhar plans to work on strategies to improve patient access at Fenway Health. As the practice continues to rapidly expand, patients face increased wait times for available appointments. He hopes to address this issue by developing sustainable alternative models for high demand services like screening for sexually transmitted diseases and pre-exposure prophylaxis against HIV. He will help pilot nurse-driven clinic visits and explore better triage and scheduling practices to help improve patient access.

Dr. Chandrasekhar earned his medical degree at Grant Medical College in Mumbai, India. Following medical school, he obtained a master's degree in public health at the Johns Hopkins Bloomberg School of Public Health, before completing his residency in internal medicine at the University of Massachusetts Medical School. Since graduating residency in 2014, he has practiced as a primary care physician at Fenway Health. Since 2016, he has served as a lead physician at Fenway Health and splits his time between providing direct patient care and managing floor operations.

Dr. Fernandez

Leonor Fernandez, MD

Director of Patient Engagement, Healthcare Associates

Dr. Fernandez will be developing a model for enhancing the quality and experience of care for patients with limited English proficiency (LEP) at Healthcare Associates (HCA). She will outline and develop strategies that promote effective and humane care and communication across language barriers for all patients. Her project will explore current care for linguistic minorities and identify key indicators of quality that need attention. She will first gather data and feedback and identify specific needs of HCA LEP patients. She will then define and advance practice norms and help build organizational knowledge, culture and resources that promote respectful, high-quality care for patients with LEP at HCA.

Dr. Fernandez is an educator, former associate firm chief for Tullis Medicine Firm and Rabkin Medical Education Fellow. She has led local and national CME conferences on health disparities, on the care of immigrants and patients with limited English, and on the role of implicit bias and cultural competence in health care. She directs patient engagement at Healthcare Associates and is a researcher with OpenNotes, where she studies the effect of shared notes, trust and transparency in health care. She is a primary care doctor for diverse group of patients at HCA.

Dr. Olveczky

Daniele Ölveczky, MD, MS

Officer of Inclusion, Department of Internal Medicine

Dr. Ölveczky will work with Healthcare Associates (HCA) to integrate inclusion and diversity principles into HCA’s strategic plan, which focuses on four key areas; fiscal responsibility, quality of care, staff/provider wellness and patient engagement. As a Linde fellow, Dr. Ölveczky will examine the projects underway in these areas, ensuring that they incorporate principles of multiculturalism and inclusion.

Dr. Ölveczky attended Johns Hopkins University School of Medicine where she obtained an MD and a master's degree in neuroscience. She completed her residency at BIDMC followed by a geriatrics fellowship at BIDMC and BWH. She is currently a hospitalist at BIDMC, where she works primarily as a nocturnist. As co-chair of the HMS Academy Cross Cultural Interest Group, she has led faculty development workshops at the HMS Academy about the importance of diversity and the Hidden Curriculum in medical education, as well as negotiating racism at the bedside, which was the highest attended workshop in the history of the academy. She will complete her HMS Miles Shore and HMS Academy Fellowships this year during which she studied how to standardize the incorporation of race, religion, gender, sexual preference and ethnicity into undergraduate medical education curricula. She has been named the inaugural Officer of Inclusion for the Department of Internal Medicine.

Yamini Saravanan, MD, MHS

Medicine Clerkship Director, Cambridge Integrated Clerkship, Cambridge Health Alliance

Dr. Saravanan plans to improve care for patients with opiate addiction at Cambridge Health Alliance (CHA). Her project will seek to understand and address the current barriers to prescribing buprenorphine by primary care providers at CHA. She will pilot a team-based approach to buprenorphine prescribing in primary care, with behavioral health teams nested in primary care to better address the complex care needs of these patients. There is much variation among primary care sites in the number of buprenorphine prescribers, and services offered to patients with opiate addiction. This proposal seeks to identify the perceived challenges of providers in prescribing buprenorphine, and pilot a process of identifying and managing patients appropriate for buprenorphine treatment in primary care by engaging our behavioral health team.

Dr. Saravanan earned her medical degree at the George Washington University School of Medicine. Preceding medical school, she received a master's degree in health sciences from the Johns Hopkins School of Public Health, and worked for the World Health Organization in Washington, D.C. She completed her residency in internal medicine in 2007 from the Cambridge Health Alliance, and has worked at the Primary Care Center at CHA. Dr. Saravanan completed the Academy Fellowship at HMS and developed a curriculum for third year resident in leading shared medical appointments for patients with diabetes mellitus. Dr. Saravanan also completed the Innovation Fellowship through the Center of Primary Care and explored the patient factors, through patient narratives, contributing to emergency department over-utilization. Dr. Saravanan is interested in bridging health systems improvement with medical education. She currently is the medicine clerkship director for the Cambridge Integrated Clerkship.

Dr. Mintzer

Erica Mintzer, MD

Medical Director, Malden Family Medicine Center

Dr. Erica Mintzer is the incoming Medical Director for Malden Family Medicine Center, which is Cambridge Health Alliance’s largest primary care site. Dr. Mintzer aims to achieve the ACO quality measure for early entry into prenatal care by enhancing preconception planning in primary care. She will establish One Key Question (“Would you like to become pregnant in the next year?”) as a previsit screening tool at Malden and then share this practice with other CHA primary care sites. Dr. Mintzer received a Bachelor of Arts in Latin American literature from Dartmouth College and then worked for three years at Tellus Institute, an environmental think tank. She graduated from Yale School of Medicine and Boston University Family Medicine Residency. Since 2012, she has practiced primary care at Codman Square Health Center and labor and delivery at Boston Medical Center. At Codman, she assumed the roles of perinatal provider champion and Family Medicine Department director.

Dr. Nilson

Elizabeth Nilson, MD, MPH, FACP

Director for Complex Care Communication in General Medicine, Lahey Hospital & Medical Center

Dr. Elizabeth Nilson is the director for complex care communication in general medicine at Lahey Hospital & Medical Center. Dr. Nilson’s project will integrate Ariadne’s “Serious Illness Conversation Guide” into the general medicine group at Lahey Hospital & Medical Center as part of a larger institution-wide initiative. This will include training providers in advanced communication skills training and use of the guide, identification of a work-flow to schedule high risk patients with their primary care provider for the conversation and the construction of a method for primary care providers to work collaboratively with subspecialty colleagues around aspects of advancing illness like prognosis, side effects, burdens of potential treatments and integrating patient goals and wishes into the care plan.

Dr. Nilson attended University of Massachusetts Medical School, trained in internal medicine at NY Presbyterian - Weill Cornell Medical Center, served as chief resident at NY Downtown Hospital and completed the certificate program in Clinical Ethics Consultation through the Albert Einstein College of Medicine, the Preventive Medicine Residency at NY Presbyterian-Cornell and Columbia’s Mailman School of Public Health and the Partners/Harvard Palliative Care Education and Practice course. She worked at an ethics consultant and general internist at NY Presbyterian-Cornell prior to coming to Lahey in 2009. She is vice-chair for ethics at Lahey, and has been the residency director of the Internal Medicine Program at Lahey since 2010.

Dr. Norian

Elizabeth Norian, MD

Medical Director of the Resident Clinic and Assistant Medical Director, Healthcare Associates

Dr. Elizabeth Norian is a 2008 graduate of George Washington School of Medicine and Health Sciences. She completed her training in internal medicine in 2011 at BIDMC where she was a participant in the Primary Care Track and the Clinician Educator Track. Following residency, Dr. Norian served as primary care chief medical resident at BIDMC where she developed a curriculum on chronic disease management, still in use today. After her chief year, Dr. Norian moved to the Veteran’s Affairs Hospital (VA) in West Roxbury, Boston, MA, in the primary care service line. There, she cared for Boston’s veterans and served as the director of medical student ambulatory education. At the VA, Dr. Norian partnered with educators at Boston University School of Medicine and ultimately served as assistant clerkship director of the advanced ambulatory care clerkship there. While in this position, she developed a VA-specific didactic curriculum to expand students’ understanding of issues that veterans face including PTSD and military sexual trauma. Dr. Norian returned to BIDMC in 2017 when she took the dual position of medical director of the Resident Clinic at Healthcare Associates (HCA) and as an assistant medical director of HCA at large. In this current position, Dr. Norian has worked with residency and practice leadership to integrate fully the resident practice into that of HCA. In her first year, she developed a monthly Preceptor Team Meeting, and this past year, Dr. Norian developed and implemented the Preceptor 360 Evaluation. Her work as a voice for both the residents and the practice has codified her understanding of the importance of communication and continuity for patients.

Dr. Norian’s Linde project seeks to improve the care team’s communication and continuity with their patients. Current literature shows the importance of continuity of care for patients with their care team. Patients with better continuity have better health outcomes, incur lower costs and report greater satisfaction with their care. Dr. Norian will first evaluate HCA’s current state of continuity for specific patient groups, including those that benefit the most from continuity including the elderly and the medically complex. Additional work will be done to determine rates of continuity for specific physician groups, such as low or high session providers. Following this evaluation, a system to improve communication between care team members will be designed with the aim to improve continuity of care within the care team.

Dr. Etherton

Sarah Shelby Etherton, MD

Lead Physician, Fenway Health

Dr. Shelby Etherton plans to create a “Wellness and Provider Satisfaction Program” at Fenway Health as her project for the Linde Fellowship. By improving provider wellness and job satisfaction through this new program, Fenway would hopefully improve quality of life for providers, improve the sense of community and support, and prevent staff turnover. Furthermore, with improved provider happiness and satisfaction, Fenway Health might also expect better patient outcomes and improved patient satisfaction.

Dr. Shelby Etherton earned her medical degree at the University of Texas Southwestern Medical School in Dallas, TX. Following medical school, she completed her residency in internal medicine at the Santa Clara Valley Medical Center in San Jose, CA. After finishing residency in 2011, she practiced as a primary care physician for two years at the University of Texas’s HIV Clinic in Dallas, then in 2013 moved to Boston and began work at Fenway Health. At Fenway Health she is a primary care doctor with additional training in HIV medicine, transgender care and the treatment of opioid use disorder with buprenorphine. Since 2017, she has served as a lead physician at Fenway Health and splits her time between providing direct patient care and managing floor operations for the internal medicine side of the South End Fenway Health location.

Jessamyn Blau, MD

Jessamyn Blau, MD

Regional Director, CHA Broadway Care Center

Dr. Blau is an internal medicine physician at Cambridge Health Alliance and the medical director of the Broadway Care Center in Somerville. She additionally currently serves as the medical director for COVID-19 outpatient care at CHA. As care needs have dramatically shifted during the course of the COVID-19 pandemic, by necessity so has the way in which care is provided. As part of a primary care transformation strategy developed for the post-COVID-19 era, Dr. Blau is working with CHA primary care leadership to develop and implement a regionalization model of the twelve primary care clinics at CHA, focusing principally on iterating best practices within one of the three regions, which includes the Broadway Care Center.

The goal of this strategy is to better use and share resources across the CHA system while acknowledging the unique constraints on in-person visits in the context of the COVID-19 pandemic. For her Linde project, Dr. Blau will specifically focus on developing and evaluating scheduling and triage strategies that best address patient needs and preferences in this new model, helping patients to choose the type of care — telemedicine or in person, continuity or not — that is most appropriate for each particular care episode and to integrate this model into the operational and clinical structures of the region.

Dr. Blau graduated from Yale University with a bachelor's in political science and subsequently completed master's degrees at Sciences Po Paris and Columbia University. She attended the University of Rochester School of Medicine and Dentistry and completed her internal medicine residency at the University of Washington. She worked as a hospitalist at Northwest Hospital in Seattle before joining CHA in 2018.

Gretchen Dietrich, MD

Gretchen Dietrich, MD

Medical Director, Beth Israel Lahey Health Primary Care in Arlington, North Billerica, and Wilmington

Dr. Gretchen Dietrich is the medical director of the Beth Israel Lahey Health Primary Care practices in Arlington, North Billerica and Wilmington. She received a Bachelor of Arts in mathematics and computer science from Tufts University and then worked for eight years at Teradyne, Inc. writing software and managing software engineers in the Wireless Group.

She graduated from Tufts University School of Medicine and the Boston University Family Medicine Residency. Initially practicing in a small family medicine practice in Somerville, she has been seeing patients at the BILH practice in Arlington since 2017. She has been the medical director of the Arlington, North Billerica and Wilmington practices since 2019.

Dr. Dietrich's goal is to improve the rate at which PCPs achieve their individual ACO quality goals by working with the Epic team to provide data that is both more timely and accurate and also with legacy Lahey providers on best practices for using the improved data. She will pilot this at her three practices before rolling it out to other primary care practices.

Andrew Nichols, MD

Andrew Nichols, MD

Medical Director, Mount Auburn Healthcare Lexington

Dr. Nichols is a primary care physician and medical director of Beth Israel Lahey Primary Care at 57 Bedford Street in Lexington. Dr. Nichols' training in internal medicine was at Boston Medical Center, where he was hired out of residency and became founding physician and medical director of Commonwealth Medical Group on the Boston University main campus. He subsequently moved to Mount Auburn Hospital, where he also assumed the role of medical director of his present practice. He has been actively involved in MACIPA (Mount Auburn IPA) and has been a physician champion for EMR implementations, most recently an Epic implementation at Mount Auburn Hospital.

Dr. Nichols' Linde project will evaluate present office practice workflows and EMR use with an eye toward optimizing physician productivity, while cutting down physician burnout, and increasing the overall quality of care delivered. This will involve a baseline assessment of present practices, and then data analysis to seek out correlations between office workflows, the use of the medical record, and resulting physician productivity and satisfaction. The ultimate goal will be to identify best practices in office workflow/EMR utilization to disseminate amongst the larger provider community.

Tina R. Waugh, MD

Tina R. Waugh, MD

Department Chair, Family Medicine, Beverly Hospital Practice Medical Director, Lahey Health Primary Care

Dr. Tina Waugh is a 1997 graduate of Boston University School of Medicine. Dr. Waugh completed her residency at the Beverly Hospital Family Medicine Residency Program, and has been on staff at Beverly Hospital ever since. She began her career in private practice where she worked for 13 years, serving as president of the corporation for most of this time. In 2013, she transitioned her practice to the Beverly Hospital owned Northeast Medical Practices, now Lahey Health Primary Care. Dr. Waugh currently serves as department chair of family medicine at Beverly Hospital, and medical director of her primary care practice.

She serves on several committees in the Northeast PHO, as Medical director of her Tufts Medicare Preferred group, and has served on many hospital committees through the years. Dr. Waugh has been an active advocate for advanced care planning, leading a multi-disciplinary task force at Beverly Hospital to improve end-of-life care, and subsequently serving on the Lahey Advanced Care Planning steering committee. She was the 2010 recipient of the Phillip Herrick Award at Northeast Health System, which is awarded to a staff physician who exemplifies leadership, outstanding medical care and community service.

Recognizing that data shows that including more women at the upper levels of leadership improves a company's performance, and employees at women-led companies demonstrate stronger belief in the strategy set by senior leadership, Dr. Waugh's Linde project seeks to improve the experience of female providers at BILH. She hopes to improve the organization's ability to recruit and retain talented female physicians, and encourage women to seek leadership roles within the organization.

Anita Erler, MD

Anita Erler, MD

Medical Director, Beth Israel Lahey Health Primary Care, Peabody

Dr. Erler is the medical director of the BILH primary care practice in Peabody. She has been seeing patients at this practice since 1997 and has been the medical director since 2021. She is a graduate of Tufts University School of Medicine, and completed her residency in internal medicine at Lahey Hospital & Medical Center.

Dr. Erler's Linde project will address improving metrics of the diabetes bundle of the patients at the Peabody practice involving improving A1C, BP control and timely annual eye exams. She will focus on a team approach to achieve this goal, with POC A1C testing, EMR smart sets and education for patients with pharmacotherapy referrals as well as to providers with evidence-based recommendations.

Spencer Rittner, MD

Spencer Rittner, MD

Medical Director of Population Health Management, BILH Primary Care

Dr. Rittner is a fellowship-trained and board-certified family medicine physician. He practices primary care at Beth Israel Lahey Health Family Medicine of Brookline and currently serves as the medical director of Population Health Management at Beth Israel Lahey Health Primary Care.

Spencer earned a BS in biology at Brandeis University and continued his medical education at Tufts University School of Medicine. He completed his family medicine residency at Cambridge Health Alliance and a fellowship in quality improvement at the Institute for Healthcare Improvement (IHI). During his time at IHI, he worked on the 100 Million Healthier Lives Campaign SCALE initiative, helped create a toolkit to support organizations in improving specific population health metrics, completed the Improvement Advisor Professional Development Program and developed a quality infrastructure driver diagram for primary care.

Over the past four years at Beth Israel Lahey Health Primary Care, Spencer has helped to lead the organization’s population health strategy, co-managed the population health specialist team, and partnered the Beth Israel Lahey Health Performance Network on multiple initiatives. He also serves as Beth Israel Lahey Health Primary Care group visit lead, develops several CME initiatives across primary care, and co-leads the Primary Care Patient and Family Advisory Council. Spencer is also a medical director of the CRICO Ambulatory Safety Net grant.

Dr. Rittner’s Linde Fellowship Project will focus on broadening the data presented to the primary care teams from risk-only patient data to all patients, regardless of insurance. Expanding to all patient data will ensure equitable patient access to high-quality care. He aims to have the all-patient data displayed on a population health dashboard that is readily available to the primary care teams.

Elissa Stecker, MD

Elissa Stecker, MD

Medical Director, Mount Auburn Healthcare at Waltham

Dr. Stecker has been a primary care physician at Beth Israel Lahey Health Primary Care – Waverley Oaks Road for approximately nine years, and she has been serving as the Medical Director of the practice since October 2020.

Dr. Stecker graduated medical school at Drexel University College of Medicine in Philadelphia, PA, in 2010. She completed an internal medicine residency at Tufts Medical Center in Boston, MA, in 2013 and is board certified in internal medicine. In addition to her work in clinical medicine, Dr. Stecker served in a leadership role as the director of clinical operations for Mount Auburn Professional Services (MAPS) during the COVID-19 pandemic and continues to work closely with the BILH Mount Auburn Regional Operations team. She also serves as a representative on the BILH Primary Care Leadership Council and the Mount Auburn Hospital Community Benefits Advisory Committee.

Through her work as a Linde Fellow, Dr. Stecker strives to enhance patient access, patient satisfaction and care team experience by introducing RN/MD Co-visits to our primary care repertoire. These visits are initiated by our RNs, who are then joined by the physician to cooperatively form a plan of care for the patient. Team-based care allows greater patient access by providing highly efficient and effective quality care while reducing the physician face-to-face time required, thereby allowing additional scheduled co-visit slots. Co-visits create an opportunity for the primary care RN to diversify their role from predominantly triage based to include direct patient care while enhancing their job satisfaction.

Alexa Triot, MD

Alexa Triot, MD

Assistant Medical Director, Healthcare Associates

Dr. Triot is a primary care physician at Healthcare Associates, the primary care practice at BIDMC. She received her MD from the University of Cincinnati College of Medicine; she completed residency and served as chief resident in internal medicine at BIDMC. She currently serves as an assistant medical director at Healthcare Associates and is a patient safety core faculty member for the Stoneman Quality Improvement and Safety elective for internal medicine residents.

Early in Dr. Triot's career at Healthcare Associates, she recognized the importance of weight management in providing high-quality primary care. She subsequently became board certified in obesity medicine in 2020. She is eager to bring weight management services to the entire practice by designing and piloting an embedded weight management clinic with an accompanying clinical pathway within Healthcare Associates.

Samantha Baras, MD

Samantha Baras, MD

Clinical Director of Pediatrics, The Dimock Center, Roxbury

Dr. Samantha Baras is the clinical director of pediatrics at the Dimock Center in Roxbury and has been a pediatrician there since 2016. She graduated from Harvard Medical School and completed her pediatrics residency at Massachusetts General Hospital.

Post-pandemic, her primary managerial focus has been on staff retention, promoting individual professional development and optimizing the workplace environment given how crucial a healthy workforce is to providing respectful, high-quality and collaborative primary care. Her project will involve an intentional and organized effort to identify the elements that keep employees happy and dedicated to their roles, as well as the elements that do the opposite, and create interventions as a team to enhance the work experience.

Jonathan Li, MD

Jonathan Li, MD

Medical Director of Population Health, Healthcare Associates

Dr. Li is a primary care physician at Healthcare Associates, the primary care practice at BIDMC. He received his MD from Rosalind Franklin University of Medicine and Science; he completed his internal medicine residency and chief residency at BIDMC. He currently serves as medical director of population health for Healthcare Associates and is active in residency education and quality improvement initiatives in the practice. Prior to medical school, he worked for several years as a management consultant.

As a lead member of Healthcare Associates' Diabetes Working Group quality improvement team, Dr. Li is passionate about ensuring that advances in diabetes treatments and technologies benefit all of our patients who live with diabetes. His Linde Fellowship project focuses on expanding the use of continuous glucose monitoring in primary care for patients with Type 2 diabetes, and leveraging the skillsets of the broad primary care team including nurses, clinical pharmacists, and others, to help patients gain the maximal benefit from this evidence-based advancement in diabetes care.

Ritika Parris, MD

Ritika Parris, MD

Director of Wellness for Graduate Medical Education, BIDMC, Faculty Wellness Advocate, Healthcare Associates

Dr. Parris is a primary care physician at Healthcare Associates (HCA), the primary care practice at BIDMC. After completing medical school at University of Pittsburgh, Ritika completed her residency at BIDMC, where she also served as chief resident in internal medicine. In addition to her clinical practice in primary care, Dr. Parris is the director of wellness for graduate medical education at BIDMC and the HCA faculty wellness advocate. She also serves on the Harvard Medical Faculty Physicians Board of Directors.

Dr. Parris's passion in physician wellness lies at the intersection of wellbeing and professional development. Through her work as a Linde Fellow, she plans to strengthen faculty mentorship at HCA through a formal program aimed at supporting both faculty mentors and mentees. The program would equip mentors with helpful skills and support engagement in a mentorship community. It aims to contribute to faculty satisfaction, skill development, and career advancement to foster a thriving and engaged primary care work force.

Suzanne Saindon, DO

Suzanne Saindon, DO

Practice Physician Lead, Beth Israel Lahey Health–Andover Primary Care

Dr. Saindon is a board-certified internal medicine primary care physician. She practices at Beth Israel Lahey Health-Andover Primary Care, where she is the practice physician lead.

Dr. Saindon earned her BS in biology from the College of the Holy Cross and used this degree to work at Massachusetts General Hospital in AIDS research, supporting multiple publications. She went on to graduate from Midwestern College of Osteopathic Medicine in 2011. She completed her residency training at St. Elizabeth’s Medical Center and subsequently served as the primary care physician member of the Medical Executive Committee. She also obtained subspecialty training and certification in obesity medicine and served as medical director of obesity medicine at the Center for Weight Control. She currently enjoys using this additional training to enhance her care as a PCP.

Through her work as a Linde Fellow, Dr. Saindon strives to improve the support provided during the vulnerable time between patient discharge and outpatient PCP follow up. She plans to implement a program – “The Next 7 days” – to bridge the gap through proactive outreach and intervention to prevent readmission, decrease medication errors, and improve patient satisfaction. Her intervention will include education of staff regarding common pitfalls and gaps in care, personalized practice-level phone and telehealth scheduled touch-points with medical assistant and nurse; involving PCP at the first sign of clinical deterioration.