Try a Little Tenderness

by Academy of Clinical Excellence on February 15, 2013

This recent Valentine’s Day-themed blog post from the NY Times is surprisingly relevant to our work as clinicians. Its author Gordon Marino offers a powerful reflection on tenderness and how the warmth and intimacy of this feeling compares to respect.  Enjoy!

Some highlights:

“If a primary aim in life is to develop into a caring and connected human being (admittedly, a big “if”), rather than, say, thinking of oneself as a tourist collecting as many pleasant and fulfilling experiences as possible, then surely a capacity for tenderness must play a role.”

“In general, tenderness involves increased sensitivity.”

“…and we are perhaps moved by the impulse to reach out with a comforting hand.”

“While I have all the respect in the world for respect, it is a chilly sort of feeling — if it is a feeling at all. Respect is a fence that prevents us from harming one another. But strengthening the ties that bind and make us human requires something more pliant, more intimate.”

http://opinionator.blogs.nytimes.com/2013/02/13/try-a-little-tenderness/?emc=eta1

Margaret S. Chisolm, MD
Associate Professor
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University

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THE GIFT OF RECEIVING

by Academy of Clinical Excellence on February 7, 2013

THE GIFT OF RECEIVING
a poem by Dr. Randy Barker

When you were my patient
Or my patient's family,
We noticed each other.
This I hold to be true.
"They're a can-do couple full of heart
and that's how they'll put off leaving home."
"He has those four grandchildren!"
"She's going to check my necktie today
just like she checks out her Blue every day."
"His wife got hurt so bad
Thank goodness he says she's OK now."

We held those stories to be true,
But look what we discovered
When we decided one more time
To offer each other
The gift of receiving.
To offer each other
The gift of receiving.
I thank you!

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Today at Medical Grand Rounds, Dr. Randy Barker described a process that he undertook recently after retiring from years in primary care practice.  Dr. Barker sent letters to many of his longtime patients asking if he could come by for a social visit.  The Grand Rounds was filled with beautiful stories and pictures.  While Dr. Barker had always been exemplary for getting to know his patients as people, he explained that the visits gave him deeper insight and provided detail that he had sometimes wondered about.

Seeing the patients in their homes gave him the opportunity to discover even more explicitly what was most important to each of his patients. One realization that Dr. Barker described was the discovery that religion and spirituality appeared to be an even greater part of many of his patients' lives than he had surmised.  He also described realizing more vividly than before the many things that he had in common with so many of his patients. 

At the end of the talk Dr. Barker shared a poem that he wrote which spoke about the transformation of many of the doctor-patient relationships into friendship.

Many of the patients who were visited attended the grand rounds and were in the audience. They stood up in turn and expressed their gratitude to Dr. Barker for his unwavering compassion and they reminded us all to follow in the footsteps of this tremendous role model.

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Mercy Now

by mchisol1 on January 28, 2013

"I’ve been thinking a lot about compassion and respect lately.  A very caring medical student shared with me how challenging it was for her to remain compassionate and respectful when caring for a particular patient who, in a delirious state, through no fault of his own, was uncharacteristically combative and rude.  Being compassionate and respectful in certain circumstances, which can emerge from environmental, provider, and/or patient factors, can be challenging even to the most seasoned clinicians.  But compassionate and respectful we must be, even in the face of violent and help-rejecting behavior, even when displayed intentionally and characteristically by the patient.  We must remind ourselves to focus on the therapeutic relationship, not the behavior.  Compassion and respect are essential to this relationship and to healing.

I recently attended the Association for Academic Psychiatry meeting in Nashville, Tennessee where I participated in a Master Educator class, went to a great talk on Woody Guthrie’s work’s relationship to his illness, and led a workshop on Twitter for psychiatric educators.  I learned a lot there.  But I learned even more when I wandered away from the meeting to hear some of the city’s great live music.  One song I heard that night, in particular, has stuck with me.  Its title has become a mantra of sorts that I turn to when I find my compassion and respect being challenged.  I encourage you to have a listen.  It might help you always treat every patient with compassion and respect regardless of the circumstances if you remember, in the words of Mary Gauthier, that “Every single one of us could use some mercy now.” - Margaret Chisolm, MD

Listen to Mary Gauthier sing "Mercy Now"

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Go Ravens

by michael fingerhood on January 28, 2013

I often discuss sports with my patients.  For me it is an easy and genuine way to build rapport.  Over the last few years, the Baltimore Ravens have been a frequent topic of conversation.  When it came to Brian, the Ravens were a true passion.

I met him in July 2009.  He was retired from a career in the military and now was leading a business venture.  He was a master story teller and loved to chat.  We always made sure he had the last appointment of the morning, because return visits lasted up to an hour- fifteen minutes for medical concerns and forty five minutes for chatting. 

Then disaster struck in October 2011.  A new complaint of dysphagia turned out to be esophageal cancer with liver metastases.  He elected to have chemotherapy in Florida, where he had a condominium, so he could gaze out his window at the tranquility of the ocean each morning. We talked on the phone weekly for an update on his health and to talk about the Ravens.

In January 2012, the Ravens won their division and received a first round bye with a home playoff game for the first time in years.  Brian called me with a request to join him at the game in Baltimore.  He was weak from chemotherapy, but was flying up to Baltimore on a private jet to go to the game. 

At the stadium, he greeted me with a hug.  He appeared frail, but of course was his usual jovial self.  The entrance of Ray Lewis brought a huge smile. We watched the game together, rooting for the Ravens as they won to advance to the AFC championship game (what happened the following week was a different sad story).  We parted after the game with another hug as he was flying back to Florida later that night.

Brian passed away about two months later.  A few days ago, I received a message that his wife had called.  When I called, she was not home, so I chatted with his daughter for about fifteen minutes.  She could definitely chat like her dad.  Of course, much of the conversation was about the Ravens.  For sure, as I watch the Super Bowl this coming weekend, I will be thinking of Brian. Go Ravens.

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Medical Student Reflection IV

by Academy of Clinical Excellence on January 25, 2013

A number of times during medical school, I’ve been told that as time passes, it becomes easier and easier to see patients as cases instead of as people.  After starting life on the wards, I realized how quickly this mentality begins.  In just a few weeks, my fellow medical students and I started discussing patients before rounds in terms of their diseases instead of their names.  We even started using impersonal language when talking about our patient load.  “What do you have?”  “I’ve got the purpuric rash, the FUO, and the UTI.”  Thinking about that now, the conversation just sounds wrong somehow.  Patients aren’t “whats,” they’re “whos.”  Why is it that it’s so natural to depersonalize them?  Is it just a habit we’ve continued to pick up from our superiors? Is it because diseases are easier for us to remember than names? Or because we take more interest in the illnesses than the people? Whatever the reason, I think there’s a consensus that it’s generally best to try to resist this habit. 

During my time on the elective in Clinical Excellence with the Miller-Coulson Academy, I shadowed two physicians, in particular, who made an effort break away from this trend.  One doctor asked one of his patients, a man with a rare demyelinating disease, to share his story with me.  The man had been through a terrifying experience – having his body shut down while his mind was completely aware of what was happening.  At the peak of his disease, he required ventilator support just to stay alive, and he was able to tell me in detail how scary that was.  After he had recovered enough to no longer need life support, he began several months of grueling physical therapy to regain as much motor function as possible.  When I met with him, he was sitting up eating lunch – unassisted – and was able to tell me the entire story himself, albeit with a little difficulty.  I was amazed to find no evidence of frustration or self-pity as he told his tale.  There was no part of him that wanted to give up or to ask “why me?”  All he had was appreciation for being alive and determination to get back to his normal life.  When I thought back about the experience later that evening, I didn’t think of “the demyelinating polyneuropathy.”  I thought of Mr. S, a man with an incredible story and an even more incredible sense of determination.

A second physician, who taught me to look beyond the condition and really see the patient, introduced me to a woman with chronic pain from sickle cell disease and invited her to tell me about her experience.  A few minutes into her story, she began to weep.  This woman, who had a successful work life and a family that loved her, said there were times when she had felt like “throwing in the towel” because the never-ending pain was too much to bear.  Even though she otherwise had a great life, the lifelong struggle with pain was enough to take the enjoyment out of it.  While she was in the hospital for a sickle cell crisis, her team was working to develop an effective pain regimen for her.  She was tired and felt beaten-down from the flare in her disease, but she had hope that things would get better.  As the attending physician and I were walking away from the patient’s room, she turned to me and said: “When you’re on your medicine rotation and your team admits a patient with chronic pain, don’t just think ‘oh another patient with chronic pain.’  Think of her and her story.”

- Rachel Meserole, MS III

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Clinical Excellence Pearl from Medical Grand Rounds

by Academy of Clinical Excellence on January 16, 2013

The history and physical examination is a time-honored aspect of the medical encounter whose benefits have been highlighted in countless articles in the medical literature.  At today’s Grand Rounds, we heard from a healthy young woman who works in health care like almost everyone in the audience, and like most of those in attendance, drinks several cups of caffeinated coffee every day.  When she developed severe and increasingly bothersome palpitations, she went to an urgent care facility and was referred to a cardiologist.  The cardiologist told her to cut down on caffeine.  She found that recommendation challenging to follow, as many in the audience probably would have, and her palpitations became even more severe.  One day while at work in the hospital, she felt particularly poorly and a colleague suggested she see a cardiologist here.  The striking feature of the history was how bothersome the palpitations were, prompting the patient to see two cardiologists in just a few months despite being the type of person who did not have a tendency to go to doctors much at all.  The striking feature of the physical examination was fixed splitting of the second heart sound, which strongly suggested that the patient had an atrial septal defect.  The utility of the history and physical examination as a means of determining the likelihood that serious heart disease underlies a fairly common symptom (like palpitations) was discussed.  

 

- Roy Ziegelstein, MD, MACP

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Grand Rounds Report from Allergy and Clinical Immunology

by swright on January 14, 2013

Dr. Scott WrightAt medical grand rounds this week, Dr. Bruce Bochner (Chief, Division of Allergy and CLINICAL Immunology) reviewed therapies that are directed at white blood cells, in particular eosinophils. 

In describing studies that have been published, some of which have shown that experimental anti-eosinophil therapies being successful and others less so, Dr. Bochner explained that a group of asthma doctors in Hamilton (Ontario) were trying to direct the “right” therapy to the “right” patients.  He explained that part of routine care in this asthma practice was to microscopically inspect the sputum of asthmatics to look for the presence of eosinophils.  Patients discovered to have increased eosinophils in their sputum were given therapies directed specifically at eosinophils and others patients were not given these therapies.

From my understanding of the presented results, it appeared as if patients receiving care from this particular practice were benefiting from improved clinical outcomes. 

I was left thinking that this group of pulmonologists are committed to clinical excellence because of their efforts to match the patient with the most appropriate therapy.

We have already begun to head well into the direction of 'individualized care' in medicine, but I thought that Dr. Bochner's highlighting these exemplars at McMaster was truly thought provoking.

 

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Medical Student Reflection III

by Academy of Clinical Excellence on January 4, 2013

I embarked on this short journey – a two week elective during which I shadowed one or two members of the Miller-Coulson Academy of Clinical Excellence each day – to observe the practice of medicine by physicians who have been deemed “clinically excellent.” As a third year medical student just beginning my rotations on the wards, I feel that now is the perfect time to reflect on the type of physician I want to become and the clinical habits I’d like to develop.  With one core rotation under my belt, I’ve discovered that this isn’t easy to do when most of my attention is directed toward learning the details of clinical signs, diagnoses, and treatment plans.  I saw this elective as an opportunity to follow excellent clinicians and really focus on the art of medicine rather than the content of it.

So why are these physicians considered clinically excellent?  They have been inducted into the academy for both the technical quality of the care they provide as well as the more personal side of their approach to patients.  I’ve spent only a few short hours with each of the members I’ve shadowed, which isn’t enough time for me to make informed judgments about their diagnostic acumen, medical knowledge, or other technical aspects of their care.  The interpersonal aspect of their interactions with patients, however, has been immediately evident.  

Each physician has his or her own style and personality when working with patients.  From joking with them to chatting about sports or hobbies to being upfront and to-the-point, all of the doctors I have shadowed have had their own way of connecting with patients.  There are three qualities or habits that I observed in nearly every one, though. 

  • The first habit that I noticed was the simple act of making physical contact with patients.  Some physicians chose to shake hands with the patients and the family or friends accompanying them.  Many chose to touch patients on the arm, whether it was during moments of humor or after a sad story.  A few even hugged some of their longstanding patients during the visit.  That little bit of physical contact immediately put patients at ease. 
  • All of the members I observed also truly listened to patients.  They rarely interrupted and I remember one appointment where the patient spoke for 7 minutes without a peep from the physician beyond an occasional “mhmm.”  A number of patients even commented on what amazing listeners the physicians were, and cited that as the reason they thought they were good doctors. 
  • The third quality that I noted was expressed in different ways by each member, but was evident in every patient interaction.  All of the physicians I shadowed had respect for their patients and cared for them as a whole person.  Some of them showed it by asking specifically what the patients’ goals of care were for making treatment recommendations.  Others did it by listening to questions and concerns about health problems that were not pertinent to the current visit or in the realm of the physician’s expertise.  Still others asked about patients’ personal lives both to get to know patients as people and to ensure that they had safe home environments.  A few checked to make sure that they could afford all of their medications, and one even showed that he cared just by spending five minutes looking for a remote control so a patient could turn up the volume on his television. 

- Rachel Meserole, MS III

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Dr. Scott Wright Almost 600,000 Americans die of cancer each year. 

Cancer screening rates for colorectal, breast, cervical, and prostate cancers have fallen in the last decade according to a recent study.

Please see Press Release from the study recently published in Frontiers in Cancer Epidemiology; http://www.eurekalert.org/pub_releases/2012-12/f-ucs122112.php

If this is going to improve, it will be critically important for patients to know information about risks and benefits of screening. Although there are many ways to achieve this end, meaningful discussions between patients and the physicians that they know and trust may be at the heart of the solution.

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