At a recent Medical Grand Rounds, I had the privilege of hearing Dr. Guy McKhann share some of his exciting research. For many years, he had been the Chairman of Neurology at Johns Hopkins Hospital and he was introduced as a ‘giant’ whose influence in patient care, education, and research has been tremendous.
His more recent research has focused on neurological outcomes following heart bypass (CABG) surgery. He explained fewer CABGs are performed than in the prior years (largely due to coronary stents) and that patients undergoing the procedures are older, more complex, and more chronically ill. His team has been tracking outcomes for approximately 9,500 patients who have had CABGs at Johns Hopkins Hospital since 1992; with an emphasis on post-operative neurological sequelae.
According to Dr. McKhann, some of the most clinically relevant findings of the research have been the identification of risk factors that portend poor neurological outcomes following any procedural intervention, both surgical and stents.Listening to the presentation and reflecting upon how the information relates to clinical excellence, 3 thoughts came to mind:

1. The scholarly approach, taken by Dr. McKhann and his team, to caring for patients has led to significant advances in our understanding of how best to take care of older, sick patients with blockages in their coronary arteries.2. If practicing physicians are to ‘translate’ clinical research for the benefit their patients, it is imperative that they remain committed to lifelong learning and keep up with this emerging knowledge.

3. Although Dr. McKhann’s discussion did not go into the subject of communicating with our patients, I spent part of the hour imagining what would be the best approach to help a patient to understand that we need to consider both the blocked arteries in their heart and the potential neurological consequences that might arise as efforts are made to ‘unblock’ them.
A patient-centered approach emphasizing shared decision-making and understanding patient preferences seem like a reasonable starting point.

During the allotted time for discussion and questions, several people in the audience who have trained under and learned much from Dr. McKhann alluded to the great influence that he has had on their professional development.

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I am writing this post from the 'First Stanford Symposium on Bedside Medicine' where I am one of about 50 people who were invited to attend. Other attendees include Dr. Steven McGee (author of Evidence Based Physical Diagnosis), Dr. Lynn Bickley (author of Bates’ Guide to Physical Examination), multiple folks from JAMA who have written or edited the ‘Rational Clinical Exam series’, and various folks representing different national boards.The conference is the brain child of Dr. Abraham Verghese who is a Professor of Medicine, an Infectious Disease specialist, and a noted author. His book, My Own Country, was a finalist for the National Book Critics Circle and his latest book (a novel, Cutting for Stone) has received critical acclaim and is selling well.

I know Abraham from our years working together at the ABIM. He has the best qualities of a priest, rabbi, or other holy man; but his religion is medicine - in general and the bedside exam in particular.

Yesterday, I spoke about our work looking at the role and usefulness of bedside ultrasound as part of the contemporary physicians black bag. Speaking about technology in front of the high priest of traditional bedside exam seemed like the height of effrontery but it actually seemed to go over ‘okay’.

At dinner, Abraham asked that we each come up with 3 ideas to promote teaching of bedside skills. Here are my initial ideas:

#1 - Write a post for the ‘Reflections on Clinical Excellence Blog’ about the conference. It is my hope that the post will stimulate discussion about the bedside exam (history and physical) whether it is truly at the core of clinical excellence. I hope that the Miller-Coulson Academy of Clinical Excellence will develop initiatives to promote it and teaching it. (I can check this one off as ‘done’).

#2 - Establish a fund (perhaps a full FTE) to pay 1-4 senior excellent faculty to spend time observing and teaching every student, resident, fellow and new faculty member performing a history and physical exam. The public would be shocked to learn that most doctors are never observed by a physician instructor and might gladly support such an effort.

#3 – Work with the residency program directors and chief residents to figure out how I can do a better job spending more time during “Chief Rounds” at the bedside--currently it occupies a minority of the time.

Additional thoughts and ideas are welcome.

David B. Hellmann, M.D., M.A.C.P.
Aliki Perroti Professor of Medicine
Vice Dean, Johns Hopkins BayviewMedical Center
Chairman, Department of Medicine
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I recently attended the Department of Medicine’s Grand Rounds at Johns Hopkins Bayview Medical Center. Drs. Hellmann, Trost, and Ziegelstein presented a talk entitled “Building Pyramids at JH Bayview: A young man with chest pain”.
The presentation focused on Mr. N, 49 yr old man, who was driven to the Emergency Department by his wife with chest pressure, sweating, nausea. Within minutes, he was diagnosed as having an acute myocardial infarction (heart attack) and he was whisked away to the ‘cath lab’ to have his coronary artery opened up with a stent.
The presenters allowed the patient and his wife, both of whom work at our institution, to tell their stories so that all in attendance could feel as if they truly know them as people – their children, their jobs, their vacation plans, how they work out together at the gym… They modeled the importance of knowing the patient with the disease rather than simply focusing on the disease that the patient has.
It has been shown that shorter elapsed time, from presentation until the opening of the blocked artery, can be the difference between life and death. Mr. N and his wife were amazed with how efficiently things proceeded. Dr. Trost explained the processes that have been put into place to allow the ‘Percutaneous Coronary Intervention (PCI) Program’ to realize the clinically excellent care that they offer – meeting or exceeding benchmarks in guidelines. The collaboration of the entire PCI team, both within the Division of Cardiology and beyond (with the EMTs, the ED, hospitalists…), was emphasized. The success of the program, which may be most accurately assessed by seeing full recovery in patients like Mr. N, is a source of pride for all members of the PCI team.

When asked if anything could have been done better during the brief hospitalization following the procedure, Mr. N told the audience that while walking the hallways as a patient in a gown with an IV pole in the step down unit, doctors passing him would avert their eyes and not say a word. He wished that they would have acknowledged his presence, and said “Good morning” or “How are you today?”.

In closing the session, Dr. Hellmann asked us all to thank Mr. & Mrs. N for coming and sharing their story by acknowledging the patients that we pass in our travels through the institution.
Getting to know our patients as people and connecting with those walking through the hospital are practices related to humanism in medicine, one of the domains of clinical excellence.
Walking back to my office from Grand Rounds, smiling at and saying hello to everyone I passed, did not taking any longer than usual.
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Clinical excellence, not competence, has been the beacon that I have always strived for in medicine.

Because achieving clinical excellence was a primary goal, although initially it was only vaguely defined in my mind, as a medical student and house officer, I was constantly on the lookout for the physicians that I thought were role models for clinical excellence. I would watch them carefully and make notes about how they carried themselves, what they would say, how they would say it, what they did, and I would often ask what they were thinking, and how they had arrived at specific conclusions. Role models for clinical excellence have had a significant impact on my professional growth and development in medicine.

I sometimes wonder if my enthusiasm for patient care would be different had I not trained under these role models of clinical excellence. In this blog, you can expect to hear perspectives about clinical excellence from an exceptional group of master clinicians and healers at Johns Hopkins. This blog will deliver role models for clinical excellence to you and you will be privy to their thoughts and evolving perspectives on this content area. They will write about patient encounters, lessons and pearls discovered in caring for patients across various clinical settings, and new insights related to clinical excellence that are unearthed at educational forums such as grand round and biomedical conferences. Bios will be provided for each contributor.

As is the case with many blogs, you are encouraged to respond to the posted ideas and to facilitate ongoing dialogue within this new learning community dedicated to clinical excellence.

Thank you for visiting this blog and we hope that the content will be stimulating and relevant to your specific interests related to clinical excellence. Please let us know if there are particular subject matters or ideas that you think should be covered and addressed by our bloggers.

Scott Wright, M.D.,
Professor of Medicine
Johns Hopkins University School of Medicine

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