Click here: Do You Need Back Surgery -- Really?
-Daniel Sciubba, MD
HIV care requires significant sensitivity and compassion from healthcare providers. Here is link to manuscript defining clinical excellence in HIV care, using the domains of clinical excellence as defined by the Miller-Coulson Academy.
-Mike Fingerhood, MD
There’s a lot of discussion these days among healthcare professionals about “patient-centered care”. But how do patients and their families actually define this? Here’s a perspective published a little while ago that made me reflect on my own assumptions and reconsider my interactions with patients and caregivers.
- Linda Lee, MD
A choreographed dance twirls on, here then there, seemingly unpredictable. A cycling team moves about the large field of racers, the team’s order in flux for two hundred and ninety-nine laps, the lead-out happening fluidly but not until lap three hundred. A dynamic interplay of complex molecules lining the cell membrane seems chaotic until the oxygen molecule combines with hydrogen, and we realize the gradients around the membrane have changed ever so slightly to allow creation of energy.
And so it is with the mind of the expert clinician moving through time as patients come and go. Each patient encounter is different, the agenda quickly set, the humor wittingly played, the diagnosis not missed, the facts presented clearly, admonishment not withheld, and encouragement given generously. I recognize snippets of scripts with which I am by now well acquainted - the chest pain differential, the depression screening, and the bad news delivery. And yet these disappear into a more fluid background as quickly as they come, by no means determining the course of the interview but rather playing their appropriate part. The result is somehow a patient who clearly receives exactly what was needed in the moment of the visit. The difference between the expert clinician and me is that the expert’s interview, clinic day, and even mind, dances. The result is strikingly beautiful.
John Marshall, MS
Ms. M greeted us cheerfully as we walked into the room. She was a middle-aged Caucasian woman, but the lines on her face and the long white hair made her appear perhaps a decade older. She had suffered from major depression on and off for many years and was now in the midst of a relapse. Unfortunately, as the interview progressed, the story unfolded of her recent eviction from her home as well having to give away her pets. A former desk worker, she had been laid off as part of her company’s large downsizing process over eight months ago. She had collected unemployment for six months but now was without income. While this triggered a major depressive episode, it also made her angry as she lost her independence and moved in with her son and daughter-in-law. Her depressive phenomenology included not just guilt, shame, and sadness, but episodes of rage where she locked herself in her room for fear of verbally assaulting those she loved. The victim of a slow economy and systemic injustice, her ability to thrive as a person was in jeopardy.
While this is a moving story, I believe it is a story which could have been missed without this unique provider bringing to this unique patient encounter her own empathetic frame of reference. This frame of reference I believe is what allowed this provider to gather the appropriate details of the story, and for the story’s retelling I have arranged those details in a patient-centered, nonjudgmental way which aligns with the spirit of the provider. To illustrate how this frame of reference motivated the provider, I will finish the story.
Before Ms. M came to clinic, the provider Dr. R was already aware of her history of depression, her predisposition for relapse, her recent eviction, her medical comorbidities, and the importance that her mental health would be in managing those comorbidities. She actually entered the room with mental health as the most important subject to address, and thus she was able to respond appropriately as the patient divulged the issues most important to her. And as a rheumatologist would ask questions to assess for involvement of Lupus in new organ systems and use knowledge of Lupus to alert the patient to possible complications, Dr. R asked questions to assess for complications of Ms. M’s social situation. “How are you getting along with your son?” “How are you paying for prescriptions?” The latter provoked frustration on all parties as we realized the pharmacy had rejected her newly acquired Medicaid prescription account because she had not yet received the prescription card which Dr. R had helped her apply for at her last visit. In the context of a recent acute visit for shortness of breath ruled out for cardiac ischemia equivalent and instead attributed to COPD, Dr. R knew that she should not go long without her inhaler, and that she should not delay starting the antidepressant which was being prescribed today. Therefore, in the middle of the visit, Dr. R called the pharmacy, sent her prescriptions over electronically, and double checked that they would be covered by the prescription plan number in the absence of the card. Joining in the patient’s anger at injustice, Dr. R shouldered the patient’s burdens as her own, and not just for twenty minutes in the clinic.
By retelling this story now, I hope to show how clinical expertise must involve at least three components. First, diagnostic acumen cannot be underestimated. Her prior visit was for acute shortness of breath, and in the context of a cardiac history and risk factors, Dr. R appropriately acted quickly in an outpatient setting to rule out cardiac ischemia. This is a great service to the patient which as students we spend the majority of our time learning. But just as importantly, this acumen absolutely must be applied in the context of a therapeutic relationship. An incredibly large amount of progress was made in this patient’s care in twenty minutes because the agenda was motivated by knowing the intricate details of the patient’s medical history, personality, predispositions, and social situation. Every move Dr. R made was motivated by her memory of who the patient was and why certain actions should be prioritized and others should not. And finally, expert care moves beyond empathetic listening and towards the shouldering of burdens carried by our patients. A process happened in the mind and spirit of the provider whereby she internalized the patient’s concerns, fears, and hopes, processed the most important action items, and actually did them. I feel very fortunate not just to have witnessed true and genuine service today, but to consider how that internalization process and move to action will happen in my own mind and spirit for the duration of my career in primary care.
John Marshall, MSIV
I cannot think of a much better way to spend my last two weeks of elective time at Johns Hopkins School of Medicine than by being able to work with and observe the outstanding clinicians who are recognized by the Miller Coulson Academy. It is remarkable to be exposed to such a concentration of physicians who provide such positive role-modeling of the types of patient-centered care that I hope to emulate as I move on to residency. In particular, it was reassuring that even at a research-focused academic center like Hopkins, there are movements to recognize clinicians for clinical excellence in addition to academic success.
And so I'd like to share with anyone reading this entry a few of the "clinical excellence pearls" that I have picked up through my observations over the last few weeks. Some of these reinforce previous observations throughout medical school, and others are general rules that I've noticed are followed by those that I consider the best clinicians at Hopkins.
Overall, these are just a few of the take-away points I was able to observe while working with some of the best clinicians at Johns Hopkins. The practice of medicine is an art, and there are many different ways to approach patient interactions. I can only hope that as I continue my training, I can build upon what I was able to learn during this elective in an attempt to provide my patients with the highest quality clinical experience.
Heather Walls, MSIV
One of the focal events of my Miller Coulson Academy elective happened early on in the course of my two weeks, when I was scheduled to attend the clinic of transplant nephrologist, Dr. K. Unlike many of the other clinics I have attended throughout medical school--where patients are squeezed into fifteen minute time slots--Dr. K had the 'luxury' of hour-long visits with his patients. Naturally, looking at the schedule the night before, I went to clinic expecting a much more relaxed, and less hectic clinic than those I had previously observed.
What I hadn't been counting on, however, was the fact that as a transplant nephrologist at Johns Hopkins, Dr. K's patient panel included some of the most complicated post-kidney transplant patients in the country--some who had even flown hours just to make their appointment. Every minute allotted to each visit, and very often a few more, was spent addressing a wide variety of patient concerns ranging from immunosuppression to mental health concerns to fears of eventual transplant rejection. I was blown away by how focused Dr. K was on his patients, and how much trust they placed in him to manage often very complicated clinical situations.
In one of the rare moments between patients, Dr. K introduced me to one of his colleagues, who was working in an adjacent exam room. After understanding that I was a medical student observing clinical excellence through working with Miller Coulson Academy members, the doctor suggested that Dr. K was a "dying breed" and that his type of patient centered care was "not sustainable in modern medicine." While I understood the validity and motivations behind this comment, I became concerned that the focused, patient-centered care that I had so appreciated in Dr. K's approach was something that may be unattainable in my future career. Surely, I would not have so much time to spend with each patient, so how could I apply what I was learning to my future life?
Happily, my experience with Dr. K did not exist solely in isolation, and instead for the next week and a half, I had the opportunity to work with many other members of the Miller Coulson Academy. Although these physicians had more traditional time constraints, they somehow managed to distill the same focus and dedication to their patients as Dr. K. I realized that patient-centered care can happen in many ways, and with a variety of styles, and can exist even in the changing landscape of medicine. While it may not always be practical to take an hour or more for each patient seen, it is still possible to focus on the patient experience even in a fifteen minute visit. Furthermore, I was gratified to be able to observe patient-centered skills in a wide range of clinicians, from surgeons to primary care physicians to those practicing end of life care.
So in a way, instead of a "dying breed" those who practice patient centered care are an "evolving breed". There are so many ways to be present with patients, and I was able to observe this over the last two weeks. I hope to be able to take the pearls of wisdom that I observed through this elective to continue that tradition of clinical excellence in my career.
Heather Walls, MSIV
We often talk about “patient or family centered care” but rarely see it practiced in our culture. Clinical excellence is contingent on the physician being aware of what Halima has described as the “village”.
In a time when discharge summaries do not even tell us who a person is, even in a short sentence, we are a very long way from understanding and supporting the “village”. This is a huge challenge for “clinical excellence”.
Miller-Coulson Academy of Clinical Excellence in the news:
The use of computers and electronic patient medical records has changed the practice of medicine. There have been improvements in efficiency, storage and sharing of information, and analysis of data. However, the insertion of a computer screen between a physician and patient, in my opinion, has somewhat negatively changed doctor-patient communication. During my Miller-Coulson rotation, one of my goals was to observe how different faculty members have navigated this new tool and used it to their advantage in improving communication. Overall, I found that there is much diversity in how physicians use the computer system, but they can be divided into 3 main categories: (1) those who use EPIC throughout the patient encounter, (2) those who never touch the computer, and (3) those who only use EPIC as a reference.
Those in the first group write their notes on the computer while interviewing the patient. They go from looking directly at the patient to looking at the computer screen while they type. When I previously saw this as a medical student, it was somewhat jarring. I noticed there were times when a patient would share something serious or become emotional, but the physician’s focus on the computer would take them away from connecting with the patient. I noticed, however, that Miller-Coulson faculty make a point to position themselves so that their body faced both the patient and the computer screen, providing for better eye contact. The physicians would stop typing as appropriate when a patient’s story necessitated their full attention. Overall, I saw ways to mitigate the use of the computer through body positioning, eye contact, and a sensitivity to the patient’s emotions.
Those in the second group do not use the computer at all in the room. They sit with their body directly facing the patient, and with their eyes focused on them throughout the interview. Usually, this physician will have looked through the records the night before and jotted down some notes on a piece of paper. He or she may write other notes with pen and paper during the interview, to be typed into a note after leaving the patient’s room or later in the day. This approach is more time-consuming, as a search through old records and a writing of the new note must take place before and after the encounter. However, the physician is able to fully focus on the patient and is more focused on social cues, non-verbal behavior, and building trust.
Those in the third group enter the room, greet the patient, and make small talk before starting the interview. They do not type through their questioning, but they may look up records or imaging on EPIC, research a drug’s side effects, or just type patient instructions before the encounter is over. Typing or dictating the note is left until after the encounter is over. I believe this approach provides a nice balance of using the computer appropriately without it intruding on the patient’s story.
This topic of patient-physician communication in the era of the computer has reached the medical literature. I recommend a short opinion letter entitled: “Computer-patient-physician relationship” published in the International Journal of Clinical Practice. It references data showing that “gaze and eye contact are strongly associated with patients’ perceptions of clinician empathy and interest in the patient and with patients’ satisfaction and trust, which beget adherence and better ‘hard’ health outcomes.” The author suggests ‘five commandments’ to navigate the computer era:
Overall, I think there are multiple styles that can work to smoothly integrate computers into our doctor-patient relationship. From the Miller-Coulson faculty, I learned various tactics to overcome obstacles of the computer, such as: body positioning towards the patient and away from the computer, ‘blind’ typing, chart review before clinic, and sharing the computer screen with patients. I’m grateful for the opportunity to learn from such great clinicians as I develop my own style of doctor—(computer)—patient communication.
- Shannon Walker, MSIV