Medical Student Reflection VI

by Academy of Clinical Excellence on September 18, 2014

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On my very first day of the Miller-Coulson elective, I eagerly entered the first patient room excited to observe the many dynamics of doctor-patient communication. A young man had traveled from another country with his parents to discuss the need for brain surgery to remove a tumor causing frequent seizures. I was curious to see how the neurosurgeon would discuss such a serious procedure while building trust with a family and addressing their concerns.

To my chagrin, I entered the room and could not understand anything. Fortunately for the family, Dr. Quinones spoke Spanish and they greeted him with hugs and kisses. Unfortunately for me, my Spanish skills were minimal at best. I had signed up for the Miller-Coulson elective to have the unique opportunity to learn communication skills by observing the “best of the best” at the bedside, and I wrongly assumed, in that moment, that I would have to wait for the next English-speaking patient encounter for this experience to really begin.

I soon realized my mistake as I recognized that in this setting, I had the unique ability to focus solely on the non-verbal cues within the discussion. For example, I noticed that Dr. Quinones walked in the room and greeted the family very warmly, with strong handshakes for the son and father, a hug for the mother, and smiles for all. When he sat down he turned his chair away from the computer and faced the family. More specifically, he angled himself towards the son. Later in the interview he would look at the parents to address their concerns, but through his body language, he made a point of identifying the patient as his primary concern while still validating the parent’s importance.

Throughout the interview, I noticed an augmentation and lowering in the tone of Dr. Quinones’ voice. Initially, his voice was enthusiastic and uplifting as they talked about life outside of medicine. Then as he began interviewing about symptoms and listening to the patient’s story, his tone quieted and softened. Most importantly, I heard his voice hardly at all as the son did most of the speaking. During this time, Dr. Quinones looked at him intently. After the son finished speaking, there would often be a pause before Dr. Quinones said something, as if he was still critically thinking about what was just shared. This reminded me of a quote I had heard previously: “Most people do not listen with the intent to understand; they listen with the intent to reply.” It was clear, however, that Dr. Quinones was not just waiting until the patient finished talking to reply; instead, he was digesting every word of the patient’s story.

When it was Dr. Quinones’ turn to speak, I noticed he spoke slowly. I could recognize that he said some of the same words twice, as if he repeated himself to ensure comprehension. He would pause his speech until the family members nodded. When the mother’s eyes began to tear, he reached and touched her on the arm while speaking in a calming voice. He paused and asked: “Preguntas?” After some serious moments, Dr. Quinones would say something and grin, and then the family would erupt with laughter. The serious tone would again return, but the environment seemed a bit more optimistic. Throughout the interview, Dr. Quinones would often use his hands to dramatize his speech, and he continued to sit at eye-level with the family throughout the interview.

During the next two weeks, I made it a point to observe the non-verbal communication skills of other Miller-Coulson Academy Members. There were other instances when a physician’s body positioning helped to focus on the patient and take the focus away from an over-bearing family member. In other instances, I noticed how touch, hand gestures, or even humor were used to emphasize a point or comfort a patient. I am grateful that my first patient encounter during the Miller-Coulson elective brought my attention to non-verbal cues so that this would be a focus for the rest of my experience.

Shannon Walker, MSIV

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I was invited to write a guest post for the Arnold P. Gold foundation blog on any subject I liked. I shared my ideas about changing how we approach addiction medicine education:

- Meg Chisolm, MD

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Social Media and Clinical Excellence

by Academy of Clinical Excellence on June 20, 2014

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Interesting paper from Academy member discussing how social media relates to clinical excellence:

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Advocating for your patients

by Academy of Clinical Excellence on June 4, 2014

STEWART rosalyn






Understanding a patient and family’s values and goals for care is of utmost importance to being a great advocate for your patients. Sometimes this involves thinking out of the box and incorporating integrative medicine practices to achieve overarching goals to help always, relieve often and cure sometimes.

- Rosalyn Stewart, MD

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Academy in Hopkins Publication

by Academy of Clinical Excellence on June 3, 2014

Please read the following article in the June 2014 issue of 'Change - Moving Hopkins Forward.'

Academy Awards
The Miller-Coulson Academy of Clinical Excellence embodies the best in patient care at Johns Hopkins

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Patient Satisfaction

by Academy of Clinical Excellence on June 3, 2014

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Patient satisfaction is most definitely an important healthcare outcome. Please see the link to an article and blog post about an innovative way to collect this information.


-Scott Wright, MD

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Clinical Excellence Pearl from Pediatrics Noon Conference

by Academy of Clinical Excellence on April 9, 2014






I  attended a superb pediatrics noon conference last week. The presenter, Dr. Maggie Moon, emphasized the following stategies that can be helpful to use during a difficult patient encounter:

  1. Avoid labeling the patient.
  2. Treat the patient with respect.
  3. Work to establish a trusting relationship with the patient.
  4. Have self-awareness and self-control about negative emotions toward the patient.
  5. Keep a healthy emotional distance from the patient without becoming distant.
  6. Draw upon the virtues of empathy and compassion to understand the patient.
  7. Exhibit patience when working with the patient.
  8. Use non-judgmental listening to elicit the patient’s perspective.
  9. Establish a dialogue to determine if there are cultural, psychosocial, or personal experiential factors contributing to the patient’s behavior.
  10. Create the “third story” as a means of mediating the encounter.
  11. Share control with the patient and make concessions when possible.
  12. Set limits in a straightforward manner.
  13. Be tolerant but do not tolerate verbal or physical abuse.
  14. Involve the patient in the decision-making process.
  15. Negotiate a behavioral contract specifying what the patient is to do and what the staff is to do.
  16. Draw upon the expertise of other members of the healthcare team.
  17. Develop the practical wisdom of knowing how to deal with the inherent uncertainty of the difficult encounter.

- Rosalyn Stewart, MD, MS, MBA

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Of Efficiency and Effectiveness

by Academy of Clinical Excellence on November 5, 2013

I have been to several meetings recently where the topic of discussion is ‘how we can be more like the Mayo Clinic’. Mayo Clinic is held as a paragon of efficiency. Patients are seen quickly, consultations are performed rapidly, and diagnoses are made universally. It is not surprising that Johns Hopkins would be interested in emulating their model of success.

However, the Mayo Clinic differs from Johns Hopkins in many key cultural aspects. If you talk to the clinicians from the Mayo Clinic; the culture and the way that they attack diagnoses is entirely different from what we do at Johns Hopkins. Most significantly, there is only a small Inpatient Service. While St. Mary's Hospital is nearby, it is technically separate from the Clinic itself and does not enjoy the same infrastructure. Second of all, the conceptual model of clinicians at the Mayo Clinic is, “we all practice the same,” and, “don’t do anything crazy.” Any clinician at Johns Hopkins knows that this is not the culture at this institution. Finally, patients apply to be seen at the Mayo Clinic. It is rare that a patient without insurance is seen, and patients can be turned away when there “is no other intervention to be offered,” based only on the review of the record. Johns Hopkins prides itself on providing the highest quality of care to any individual in need.

Not only are many of the cultural aspects different than those at Johns Hopkins; the Mayo Clinic has the unique infrastructure to excel as a highly efficient, clinical service. Their medical record system is excellent, outpatient consults can be obtained within a 24-hour period, tests are done and read in a very short period of time, and every patient leaves with a diagnosis, even if the diagnosis is simply the presenting complaint. In reviewing patients of mine who had been previously seen at the Mayo Clinic, I have found that an enormous battery of tests was performed and the diagnoses were often determined through “sheer brute force of testing.

The John Hopkins and Johns Hopkins Bayview are not an ultra efficient hospital. You cannot obtain complete outpatient consultations within 24 hours, or testing at a rapid rate with rapid interpretation of the results. This inefficiency seems at odds with our stance that we are the number one hospital in the country. But I think it is actually the explanation for ranking. Clinicians at Johns Hopkins Hospital are the best in the country at the “work around” and deal with multiple levels of inefficiency: scheduling inefficiency, testing inefficiency, consultation inefficiency, billing inefficiency, and grant administration inefficiency. But, by struggling to overcome these challenges, the faculty are more able and willing to “think outside the box”, troubleshoot, problem solve, and consider “crazy solutions” to clinical and administrative problems. It is this pressure that helps us innovate in a way the Mayo Clinic never has. This makes us an effective organization.

Schwinn can produce hundreds of bicycles at a low cost, and with decent quality. The old Italian man who labored in his basement painstakingly crafting the custom bikes for Lance Armstrong, worked at high cost with outstanding quality, innovation, and “out-of-the-box” thinking. Companies should be careful about switching from one type of service line to the other. The most recent example is Mercedes-Benz, who produced extremely high-quality luxury cars here in the United State. Presently, most people who buy luxury cars by Lexis or BMW, because there was a falloff in quality Mercedes-Benz as they attempted to increase the efficiency of their production at the expense of effectiveness. There are dozens of examples of this in the business world.

As a general rule, if you want to increase the number of a certain type of product, you make that creation of that product as efficient as possible. To that end, the application of grants and administration of research funding is one thing at Hopkins that should be of the highest level of efficiency. With the goal of obtaining as many funding opportunities as possible to allow us to carry out the cutting edge research that has made us great, the institutional application process should be as easy as possible rather than an added obstacle. Unfortunately, this is not the case for many departments. Our lack of efficiency in grants management is a cause for concern.

It is a private practice model to see as many patients, get as much testing, and bill at as high a level as possible for patient care. I see many patients for second opinions in my outpatient clinic. Increasingly, I encounter relatively straightforward diagnoses that can be determined through a comprehensive history and physical examination, that were missed by expensive and invasive testing. Private practice is, and must be, an extremely efficient process, seeing huge numbers of patients, making relatively simple diagnoses, and instituting treatments. Our role as a tertiary care center has always been the more careful evaluation of patients. The ability to think critically about our patients and narrow the differential prior to ordering a multitude of tests, has been a privilege that should not be taken for granted. Once the basic work-up is unrevealing, at that point we move forward with testing in a measured fashion, and with treatments that are outside everyone else's experience. This has always been our role. Increasing the number of patients seen, and approaching them with “brute force” efficiency, especially as second or third opinions, may decrease our overall effectiveness, and cause us to lose that we value most. This concept is in line wth Dr. Zeiglestein’s call to reduce expensive testing, I applaud this attempt not only at cost cutting but also to return us to our strengths.

 Before we consider changing our approach to patients and the fundamental concepts that have made this hospital the number one hospital in the nation for over 20 years, I would suggest a careful evaluation of which aspects within our institution we would like to be efficient, and those we must ensure are effective.

-Raf Llinas, MD

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New JAMA article: Crossing Boundaries—Violation or Obligation?

by Academy of Clinical Excellence on October 3, 2013

This is a great article by a physician who was reprimanded for giving a patient money to buy a prescription, which the patient otherwise couldn’t afford.  Raises interesting ethical issues of relevance to all of us who want the best for our patients.

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Nobody Missed Him More

by Academy of Clinical Excellence on September 10, 2013

Looking up into my eyes, she smiled and slobbered all over my outstretched hand.  “Easy, Lucy,” Sandy said, chuckling.  “She gets so excited when folks come over to visit.”  She was a beautiful dog—a Boxer by breed, six years young.  Her fur was milk chocolate brown and glossy, with a slick sheen from head to toe.  Her bright red tongue dangled out from the side of her mouth as she sat there panting, feeling the effects of the excruciating Baltimore summer heat.

“She’s our baby,” Sandy continued, “but there ain’t no one she follows around like she does Bob.”  Bob smiled as he leaned forward on his La-Z-Boy chair, his dreadlocks dangling down across his face like the branches of a weeping willow.  “Does she sleep in your bed at night?” I asked him. “She sure does,” he replied, “right at the foot of the bed, and we get up together each morning to take a walk.”

“As hard as it was for me while Bob spent that month in the hospital,” Sandy said, shaking her head back and forth slowly, “wasn’t nobody who missed Bob more than that dog right there.”  I nodded and looked toward Lauren, the senior medical resident who accompanied me on this home visit.  In the hour we had been speaking with Bob and his mother, we had learned that, in just a few years, he had gone from a healthy, independent young man in his late twenties, living on his own and working with kids in a group home, to a 30 year old patient with Multiple Sclerosis, Type II Diabetes, and the memories of a nearly fatal bout with Thrombotic Thrombocytopenic Purpura that landed him in the ICU for the entirety of January.

“She paced all around this house, whimpering and whining, missing her man,” Sandy recalled.  “Lucy just didn’t know what to do with herself.  But when Bob got back home—well, she was as happy as can be and hasn’t left his side since.”

Bob whistled to Lucy, who got up and trotted over to his chair, her tail wagging with expectation.  “Wanna go outside, girl?” Bob asked and went to the back of the house to unlatch the screen door.  We watched as Bob joyfully strolled with Lucy to every corner of the backyard, a huge grin on his face all the while.  We talked some more with Sandy and then I heard the screen door slide open and saw Lucy jauntily bouncing back towards the living room.  Lucy turned in my direction and lay down on the rug, lifting her front left leg so that I could rub her belly.  She gave me a pleading glance and I succumbed to her wishes for an under-arm massage.  Bob smiled broadly and remarked, “You like dogs, huh?”  “I do,” I said as Lucy groaned happily. 

We chatted for some time until the clock struck 3:30 and Lauren and I said it was time for us to head back to the clinic.  We shook hands with Bob and his mom and gathered our things to go.  I took a look at Lucy and thought how fortunate her presence was, not just for this home visit in providing a means to connect with Bob and his mom on a more intimate level, but also as a source of strength in Bob’ circle of support.  When I look at Lucy, I think of her story as a stroke of luck in maintaining a calming and therapeutic presence in Bob’ life, a life that has been and will continue to be filled with obstacles and illness.  It’s always hard to know which relationships in a patient’s life will make a difference in how they cope with difficult circumstances.  Yet whatever amount of solace Lucy provides to Bob, it was a relief to me as his physician to see that there is something that brings him a sense of purpose and some measure of contentment, if only for a few moments at a time. 

“I’m really looking forward to being your doctor these next few years,” I said to Bob, “and I can’t wait to hear more about Lucy the next time I see you.”  “Me too,” Bob said as we both looked at Lucy, her head resting against Bob’ leg as she sat quietly by his side.

By Anat Chemerinski and Jason Liebowitz

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