Last week, I attended the 23^rd Annual Clinical Care of the Patient with HIV Infection course sponsored by Johns Hopkins and held in Baltimore. The course triggered a lot of reflection on my experiences caring for HIV patients over the past 29 years.

I took care of my first patient with HIV in April 1984 as a medical student on my pediatric rotation in the Bronx, New York.  She was a one year old with perinatal HIV infection who was admitted with pneumonia.  She died after a two week hospitalization, much of it spent on a ventilator in the intensive care unit.

During my subsequent medical residency in Baltimore, I continued to care for large numbers of adults with horrendous complications of HIV infection, including CMV retinitis causing blindness, central nervous system lymphomas and disfiguring Kaposi sarcoma. 

After residency, I continue to care for patients with HIV and in the early 1990s helped direct a sub-acute/hospice unit for AIDS patients.  At the meeting last week, I chatted with three of the physician assistants who worked on that unit with me.  One of the physician assistants reminded me how depressing it was working there, as over 75% of our patients died.

Thankfully, HIV care changed in 1996 with the advent of effective three drugs regimens to treat HIV. Horrible complications are now rare, but still occasionally seen, mostly in individuals who are unaware of their HIV infection or not engaged in care.  Amazingly, the conference had talks on organ transplantation in individuals with HIV and the notion of “functional cures” by attacking latent HIV reservoirs. 

All seemed upbeat until the lunchtime talk on the second day of the conference.  Dr. Chris Beyrer of the Johns Hopkins University School of Public Health presented data on HIV in men who have sex with men.  He shocked the audience with data showing that in the City of Baltimore, 48% of gay black men are HIV infected.  I cannot think of any other disease affecting a demographic group to this extent.  Indeed, despite all the good news and optimism, there is still plenty of work to be done.

- Mike Fingerhood, MD

Recent School of Nursing Graduate, Katy Olive, and medical student Max Romano discussed their interest in primary care. Hearing their passion about pursuing careers in primary care were among the most inspiring comments at the 'Primary Care Consortium' conference on February 21, 2013. 

http://webcast.jhu.edu/Mediasite/Play/e5344f74bfeb4bd3bff8c077c24777201d?playFrom=4079000&duration=4923000

One of the benefits I've found using Twitter is that it allows me to engage with other medical educators who are as passionate as I am about relationship-centered care. We share links on Twitter to articles and other resources that inform and inspire us in our teaching and patient care, such as this wonderful short video on empathy.  Enjoy!http://t.co/UiI4yGjScv

Last week Hopkins held a kick-off event for its Primary Care Consortium.  A breadth of stakeholders at the institution ranging from the President and Deans to trainees from three schools (School of Public Health, School of Nursing, and School of Medicine) attended.

Below please find a link to inspiring comments made by Dr. Lauren Graham - a 3rd year resident in the primary care track of the internal medicine residency at Johns Hopkins Bayview Medical Center.

http://webcast.jhu.edu/Mediasite/Play/e5344f74bfeb4bd3bff8c077c24777201d?playFrom=4940000&duration=5293000

This recent Valentine’s Day-themed blog post from the NY Times is surprisingly relevant to our work as clinicians. Its author Gordon Marino offers a powerful reflection on tenderness and how the warmth and intimacy of this feeling compares to respect.  Enjoy!

Some highlights:

“If a primary aim in life is to develop into a caring and connected human being (admittedly, a big “if”), rather than, say, thinking of oneself as a tourist collecting as many pleasant and fulfilling experiences as possible, then surely a capacity for tenderness must play a role.”

“In general, tenderness involves increased sensitivity.”

“…and we are perhaps moved by the impulse to reach out with a comforting hand.”

“While I have all the respect in the world for respect, it is a chilly sort of feeling — if it is a feeling at all. Respect is a fence that prevents us from harming one another. But strengthening the ties that bind and make us human requires something more pliant, more intimate.”

http://opinionator.blogs.nytimes.com/2013/02/13/try-a-little-tenderness/?emc=eta1

Margaret S. Chisolm, MD
Associate Professor
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University

THE GIFT OF RECEIVING
a poem by Dr. Randy Barker

When you were my patient
Or my patient's family,
We noticed each other.
This I hold to be true.
"They're a can-do couple full of heart
and that's how they'll put off leaving home."
"He has those four grandchildren!"
"She's going to check my necktie today
just like she checks out her Blue every day."
"His wife got hurt so bad
Thank goodness he says she's OK now."

We held those stories to be true,
But look what we discovered
When we decided one more time
To offer each other
The gift of receiving.
To offer each other
The gift of receiving.
I thank you!

"I’ve been thinking a lot about compassion and respect lately.  A very caring medical student shared with me how challenging it was for her to remain compassionate and respectful when caring for a particular patient who, in a delirious state, through no fault of his own, was uncharacteristically combative and rude.  Being compassionate and respectful in certain circumstances, which can emerge from environmental, provider, and/or patient factors, can be challenging even to the most seasoned clinicians.  But compassionate and respectful we must be, even in the face of violent and help-rejecting behavior, even when displayed intentionally and characteristically by the patient.  We must remind ourselves to focus on the therapeutic relationship, not the behavior.  Compassion and respect are essential to this relationship and to healing.

I recently attended the Association for Academic Psychiatry meeting in Nashville, Tennessee where I participated in a Master Educator class, went to a great talk on Woody Guthrie’s work’s relationship to his illness, and led a workshop on Twitter for psychiatric educators.  I learned a lot there.  But I learned even more when I wandered away from the meeting to hear some of the city’s great live music.  One song I heard that night, in particular, has stuck with me.  Its title has become a mantra of sorts that I turn to when I find my compassion and respect being challenged.  I encourage you to have a listen.  It might help you always treat every patient with compassion and respect regardless of the circumstances if you remember, in the words of Mary Gauthier, that “Every single one of us could use some mercy now.” - Margaret Chisolm, MD

Listen to Mary Gauthier sing "Mercy Now"

I often discuss sports with my patients.  For me it is an easy and genuine way to build rapport.  Over the last few years, the Baltimore Ravens have been a frequent topic of conversation.  When it came to Brian, the Ravens were a true passion.

I met him in July 2009.  He was retired from a career in the military and now was leading a business venture.  He was a master story teller and loved to chat.  We always made sure he had the last appointment of the morning, because return visits lasted up to an hour- fifteen minutes for medical concerns and forty five minutes for chatting. 

Then disaster struck in October 2011.  A new complaint of dysphagia turned out to be esophageal cancer with liver metastases.  He elected to have chemotherapy in Florida, where he had a condominium, so he could gaze out his window at the tranquility of the ocean each morning. We talked on the phone weekly for an update on his health and to talk about the Ravens.

In January 2012, the Ravens won their division and received a first round bye with a home playoff game for the first time in years.  Brian called me with a request to join him at the game in Baltimore.  He was weak from chemotherapy, but was flying up to Baltimore on a private jet to go to the game. 

At the stadium, he greeted me with a hug.  He appeared frail, but of course was his usual jovial self.  The entrance of Ray Lewis brought a huge smile. We watched the game together, rooting for the Ravens as they won to advance to the AFC championship game (what happened the following week was a different sad story).  We parted after the game with another hug as he was flying back to Florida later that night.

Brian passed away about two months later.  A few days ago, I received a message that his wife had called.  When I called, she was not home, so I chatted with his daughter for about fifteen minutes.  She could definitely chat like her dad.  Of course, much of the conversation was about the Ravens.  For sure, as I watch the Super Bowl this coming weekend, I will be thinking of Brian. Go Ravens.