Medical Student Reflection XIV

by Academy of Clinical Excellence on May 3, 2016

Reflection imageOver the past two weeks, which also happened to be my final two weeks of clinical time before graduation, I have had the privilege to observe some of the physician members of the Miller-Coulson Academy. I elected to enroll in this rotation because I figured that there was likely no better way to end my time at Hopkins than by working alongside and learning from the institution’s best clinicians. What really set the tone for my experience was the fact that my first day coincided with the Miller-Coulson Academy’s 8th Annual Excellence in Patient Care Symposium. It was wonderful to be in the company of a standing-room only audience to witness ten physicians be inducted as new members of the academy. As each new member was introduced, a quote from a grateful patient was displayed on the screen behind him/her. I paid close attention to these quotes and recorded the terms that were most frequently used. As I now consider my full two-week experience, I think it is only fitting for me to use the words of the patients to guide my reflection of this elective experience.

The physicians of the Miller-Coulson Academy embodied compassion and empathy. I recognized this when Dr. Fetting asked each and every patient “How is your spirit?” with the same sincere demeanor as he asked about a patient’s pain, appetite, and the like. In one particular case, I was struck when Dr. Fetting, who has spent decades caring for women with breast cancer, admitted to me before a new patient encounter during which he would have to discuss a difficult diagnosis that “conversations like this never get easier.”

The physicians of the Miller-Coulson Academy are genuine. I witnessed this in the way that Dr. Sellmeyer described metabolic bone disease and its therapies to her patients in clear and understandable terms and in the way that she responded to the often-asked question, “Would you recommend this treatment to your mother?” I witnessed this too in the way that Dr. Kraus transitioned so skillfully from speaking gently with a young patient who is facing a second kidney transplant to speaking candidly with a patient who is not adhering to the prescribed immunosuppressive regimen.

The physicians of the Miller-Coulson Academy impart hope to patients and their families. On the days that I spent in clinic with Dr. Clarke, I could sense the comfort and support that Dr. Clarke provided to his patients, many of whom have spent years coping with complex gastrointestinal symptoms.

The physicians of the Miller-Coulson Academy are advocates for their patients. I witnessed this as Dr. Laheru devoted a substantial amount of time and effort to communicating with other providers not only within the Johns Hopkins network but at institutions across the country to ensure that his patients received outstanding, well-coordinated care. Moreover, I valued that Dr. Greenough advocated not only for the care of his individual patients but also for the improvement of health care delivery on a community and national level.

The physicians of the Miller-Coulson Academy are tireless. During one of my first days, Dr. Wolfe asked me, a fourth-year medical student, to provide her, a highly-respected internist, with feedback about her interactions with patients, how she conducted clinic visits, and the like. To me, this request represented just how much she, as well as every single one of the Miller-Coulson Academy physicians, strives to continually improve their practice of medicine.  This sentiment emerged again as Dr. Ziegelstein remarked during last week’s Grand Rounds that “clinical excellence is not a coincidence.” Rather, it is a remarkable skill set that must be continually fostered and nurtured.

Finally, the physicians of the Miller-Coulson Academy are a gift. I heard the words “gratitude,” “thanks,” and “love” countless times over the past two weeks. The physicians of the Miller-Coulson Academy are a gift not only to their patients but also to our entire health care system. They are a gift to students and trainees like me who seek role models who exhibit clinical excellence on a daily basis.

Overall, my elective experience during the past two weeks served as an excellent conclusion to my medical school career. As I embark on the next stage of my education and training, I hope to be able to emulate the qualities and skills of the Miller-Coulson Academy physicians in the care that I provide to my patients, their families, and their communities.

- Bryn Carroll, MS IV

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Reflection imageDuring my two weeks with clinicians from the Miller-Coulson Academy, I found myself reflecting quite a bit on where I was 10 years ago: living on an 88-foot schooner in the Caribbean Sea during my senior year of college, learning from amazing people from all over the world. How’d I get myself thinking about that? Well, It wasn’t just the cold weather and rain in Baltimore; I started thinking about story telling.

During my time living and teaching on sailboats, I always looked to effective captains who were able to captivate, inspire, and understand their crew. Back then I realized that one key ingredient was being an incredible storyteller because when living full-time on a boat with students and professional staff, it takes grace and incredible communication to run a boat smoothly and safely. With the Miller-Coulson Academy, I realized that the clinicians used many of foundations of good storytelling that I learned many years ago to provide extraordinary care to their patients.

  1. Know the story background before you start
    1. You can’t tell a good story unless you have it laid out in some logical way and without understanding the context. Every physician that I worked with provided an illustrious briefing about EVERY patient before we went into the room (Somehow Dr. Duncan ran his whole 20+ patient list with unique details about each patient). They knew why the patient was coming in and could provide a background that made me feel like I already knew the patient before entering their room. They gave me context and background.
  2. Be present
    1. On a boat, that means eye contact with all the crew and being aware of how they are responding to a story – often this can give insight into interpersonal struggles within the crew. All of the MC physicians walked into a patient room with enthusiasm and awareness, sat down next to their patients in an inpatient room, shook hands or gave hugs, garnished cards, but mostly, they were focused on their patients and the trainees throughout the visit – without wavering when the opportunity presented itself.  Most, in fact, left their cell phones in their office as to not be distracted.
  3. Engage your audience
    1. On boats, this sometimes means, calling out crewmembers by name or having them add tidbits to the story as you go. In the clinical setting, this meant turning the computer screen to review records and type with the patient watching or dictating your whole note with the patient, family, and care team in the room (way to go, Dr. Kraus!).
  4. Remember details
    1. A good story is made through context and details, whether it’s explaining the specific sea conditions or knowing about a patient’s favorite restaurant. Dr. Peairs, Dr. Fingerhood and Dr. Christmas were truly outstanding at this – frequently able to speak endearingly about complicated social issues as well as exciting details of a patient’s life. By focusing on details about a person, these physicians are also able to pick-up on nuanced details about the health of their patients -- such as loss of interest in activities or unsafe relationships. It’s the details that make a story worth listening to and it’s the details that make a patient-physician relationship.
  5. Do not place direct value judgment, but editorialize when necessary
    1. As the captain, it’s important not to ostracize young crew (especially the college age student aboard), but frequently it’s important to speak from experience when highlighting points in stories, particularly when used as anecdotes for teaching. Good physicians do this frequently whether telling patients about prior patient experiences or helping trainees understand processes (as Dr. Greenough did effortlessly with each patient we encountered – from discussing how wounds heal to how patients experience the modern technologies of wound care to how to improve modern technologies based on his years of practical experience).
  6. Know how to sum it up and deliver the punch line
    1. At the end of the day, a great story builds to a crescendo and good storytellers do this masterfully after years of practice. For good clinicians, this comes in the diagnostics and assessment/plan – through years of experience, the mastery and grace of diagnosing and treating an illness to improve the life of the detailed and nuanced patient that you have gotten to know is what makes the Miller-Coulson Academy clinicians truly excellent at care.

Over the last two weeks, it has been a pleasure to reflect on a character-molding experience from a decade ago in my final year of college and to realize that the last two weeks, in my final year of medical school, will likely be something that I reflect on a decade from now as I start to mold my own practice. Here’s what I know so far: It’s hard to tell great stories, especially day after day, but excellent physicians have mastered the tenets of great storytelling in clinical practice, day after day, patient after patient.

Julia Riddle, MS 4

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Medical Student Reflection XII

by Academy of Clinical Excellence on December 4, 2015

Reflection imageThis past week, I’ve had the fortune of working with several members of the Miller-Coulson Academy – Johns Hopkins faculty physicians who have been recognized, through a very stringent and selective review process, to be masterful clinicians in their respective fields.

As I end a year of rotations – the bulk of my clinical time in medical school – this has been a valuable time for me to pause and reflect on what exactly it means to be “clinically excellent.” I’ve always been diplomatic in assuming that different people might define this phrase differently. That, for example, what an excellent primary care provider finds gratifying or empowering about his or her work, an excellent surgeon or sub-specialist might find tedious or unfulfilling. And that may be true to an extent.

But what has struck me above all else, this week, is the remarkable degree of similarity between these diverse practitioners. I laughed when I heard, for the third time in a week, a faculty member tell me apologetically, “I bet the other Academy folks are more efficient than me!” “Well, not exactly,” I didn’t have the heart to reply. But they were all incredibly dedicated to their patients – listening intently (electronic medical record off to the side, or not at all), responding earnestly to concerns, and counseling carefully. Even for a single morning or afternoon, they were wonderful educators and mentors, introducing me warmly to their patients, and taking time out of busy patient encounters (this was true of a surgeon I shadowed in the OR as well) to teach me about their work.

Uniting all of this was an unabashed sense of joy in practicing clinical medicine. A profound sense of fulfillment and reciprocal gratitude for being able to bring one’s knowledge and training to bear in a meaningful, human way. “Come with me,” was the unspoken message I got when I stepped into the room with excellent clinicians. “I have some wonderful people for you to meet. They might have medical issues. Thankfully, I’ve been trained for these sorts of situations. We’re going to take care of them, and we’re going to have a great time.” If “efficiency” was on these clinicians’ minds, it certainly did not let it impact the care that was provided. It was heartening to watch.

Two other thoughts:

- One clinician opened an interview by asking the patient, “Tell me what you’re looking for in a doctor.” I think the patient and I had identical expressions – of pleasant surprise. As an almost-doctor-in-training, this is a question that I’d like to adopt for my own work. After all, who better to shape and improve our clinical identity than the people we serve?

- To fellow JH med students: if the medical school curriculum were cable TV, and the core rotations a bit like channel-flipping, then these two weeks for me have been the equivalent of stumbling onto a great late-night documentary on National Geographic. By which I mean, throughout the week, I kept having a sensation of watching a threatened species doing what it does best in its natural habitat – except instead of being mercilessly subjected to the forces of nature, these clinicians have been recognized by a highly selective panel and celebrated for their work. I’ve been ending my days feeling mystified, intrigued – and glad for the experience.

Jonathan Yeh, MS4

 

Jonathan is a 4th-year medical student at Johns Hopkins who is interested in geriatrics, oncology, and end-of-life care. He and his high school prom date (now a doctoral candidate at the Bloomberg School of Public Health) live in Baltimore City with their two cats.

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Back surgery

by Academy of Clinical Excellence on July 21, 2015

Slide1Acute back pain affects nearly everyone. When it is really bad, is surgery the only option?

Click here: Do You Need Back Surgery -- Really?

-Daniel Sciubba, MD

 

 

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Clinical Excellence in HIV Medicine

by Academy of Clinical Excellence on July 14, 2015

FINGERHOOD michaelHIV 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.

http://sma.org/southern-medical-journal/article/clinical-excellence-in-hiv-care/

-Mike Fingerhood, MD

 

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Patient-centered care

by Academy of Clinical Excellence on June 24, 2015

LEE5 editedThere’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.

http://polisci2.ucsd.edu/bazimmer/Brigitte_Zimmerman/Non-Academic_files/Zimmerman%20JAMA.pdf

- Linda Lee, MD

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Medical Student Reflection XI

by Academy of Clinical Excellence on June 17, 2015

Reflection imageA 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

 

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Medical Student Reflection X

by Academy of Clinical Excellence on June 8, 2015

Reflection imageMs. 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
May 2015

 

 

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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.

  1. The Goldilocks Principle: In other words, "not too much, not too little, but just right."  I have found that the clinicians who are known for clinical excellence know how to give patients exactly what they need, which can change based on the clinical situation or patient's personality. I had the opportunity to observe some extremely skilled physicians, who knew how to tell when three or thirty minutes were needed, when more or less explanation was warranted, and when a patient needed direct guidance or lots of space; I only hope that I can learn how to sense what patients need throughout my professional development.
  2. Never Underestimate the Importance of Body Language: Without fail, every single one of the Miller Coulson Academy clinicians I was able to observe--from busy surgeons to outpatient medicine to inpatient palliative care--were masters of non-verbal communication. I observed small examples every day, such as turning a computer screen so that typing a note would not interfere with eye contact, leaning forward in a chair to communicate interest, and pausing from writing notes to focus solely on a patient's story. As an observer in these situations, I was further able to see patient reactions to these small gestures, which gave me a better understanding of how patient learn to trust their physician. One day soon, when I am an overwhelmed intern who has just started residency, I hope I can remember the impact of these simple adjustments so that I can learn to be more present with my patients.
  3. Preparation is Key...: I think as a medical student, it's sometimes hard to recognize the "behind the scenes" preparation that goes into patient care. I was often impressed by just how intimately the physicians that I worked with knew their patients stories. Often, even before seeing a patient, the physician would be anticipating the needs of the patient and planning the patient encounter.
  4. ...But Don’t Be Afraid to Go Off-Script: Despite what I said in the previous statement, there were definitely times where we would walk into a patient encounter expecting one scenario and be confronted by something completely different. I was able to observe, in these moments, how important it can be to sometimes change the plan to meet a patient's needs. The flexibility to respond to unexpected situations seems to be invaluable in patient-centered care.
  5. Medicine is a Team Sport: Physicians do not practice in isolation, and it was gratifying to see how well good clinicians interact with the other members of the clinical care team. There are many people involved in ensuring a good patient experience, and when the team is all on the same page, things tend to go much more smoothly. I was able to see interactions with PAs and NPs, with nursing or technical staff, and even with administration. Finally, I appreciated the many times that the patient, or the patients family, was given an active role in the care team, something I hope to emulate in my future practice.

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

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MS Reflection VIII: “A Dying Breed” or Maybe Not

by Academy of Clinical Excellence on April 20, 2015

Reflection image

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

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