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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Medical Student Reflection V

by Academy of Clinical Excellence on August 27, 2013

Perhaps I learned just as much from providers as from their patients, for the artwork of clinical excellence is displayed through the medium of patients' stories. In fact, I felt that patients of these physicians differed from others I have seen; they differed in the fact of wanting to open up and share the good and bad, willingly wanting to reflect on their experiences. Maybe this is a result of the culture the physician helps create: one of openness, healing, and participation rather than one that is closed, directive, or hierarchical.

I saw examples of meeting a patient in his own construct/worldview/ paradigm of understanding (whether 'immature' or 'correct') instead of attacking issues from one's own view of 'what you think is going on.' In this way, the provider became an assistant to the patient, helping him progress in his own life story. And sometimes, as seen in addiction counseling, the role of the physician advocate becomes a very dramatic role in this story: helping him realize he wants to be the 'protagonist' and author of his own life story instead of playing merely a minor character and observer of all these things that are controlling and directing him. But on the other extreme, the physician guarded herself from becoming the omnipotent director of the story, for this creates a dependence that again removes the patient from autonomy of his own life. A great example of keeping this in check was the acknowledgment of having a limited expertise, of letting the patient know when the answer is not clear or known by you. And even once in referral, still walking alongside the patient and keeping his best interest at heart by referring with a specific question to be answered and by following-up with these points upon seeing him again.

At the end of this rotation, I have begun to realize how the art of a clinician shines in display on the canvas of the patient. And so what is the role of the 'problem patient', the difficult and non-compliant? Maybe in this more intricate interaction - this testing by fire - can only true compassion and excellence be demonstrated. So I ask myself and all providers this question often: do you practice medicine for the patient who is grateful or for the one who pushes you away? From where do you get your satisfaction and reward?

Phillip Mote
M.D. Class of 2015
Johns Hopkins School of Medicine

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Teachers / Educators – We need to do more!

by Academy of Clinical Excellence on April 23, 2013

April 16th will go down in my history book as a life changing day - the day I was inducted into the Miller Coulson Academy of Clinical Excellence.

This was undoubtedly one of the most joyous days in my life. In fact one of my good friends teased me that my presentation was an ‘Oscar like’ speech. I agree – it was truly an Oscar moment for me. I wanted to make the most of it and thank everyone who has influenced my growth and development.

But as I was reveling in this joy, tragedy struck us – the Boston Marathon tragedy happened.

As news unfolded, I was shocked to realize that these were two young students who killed and injured people and terrorized the world.

My first question was - ‘how can young students do this?’

It is easy to point fingers and blame it on their personality, bad upbringing, bad influence etc.

But what about teachers? They were still in school. If they could have only connected positively with a teacher or teachers – maybe they would have appreciated the goodness and beauty of life; may be this would not have happened.  

One can say that this is very simplistic, naïve thinking. But for me, my teachers have played an important role in my growth and development not only academically but also as a person.

The Boston marathon tragedy has been a wakeup call for me. As I keep thinking about this, I am reminded about a prayer that I learned in my middle school.

Guru Govind dou khade, kaake laagoon paye
Balihari guru aapki, Govind diyo milaye."

I face both God and my guru. Who should I bow to first?
I first bow to my guru because he's the one who showed me the path to God.

As teachers & educators we have a very important role. Our job is not only to train students so that they can be knowledgeable and successful academically but to educate them to be caring and responsible citizens.

- Vani Rao

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HIV Care

by Academy of Clinical Excellence on March 26, 2013

Last week, I attended the 23rd 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

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Passion for Primary Care

by Academy of Clinical Excellence on March 20, 2013

Dr. Scott WrightRecent 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.

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by Academy of Clinical Excellence on March 13, 2013

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!

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A resident reflects on a career in primary care

by swright on February 28, 2013

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.

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