A recent commentary in JAMA, “Patient-Physician Communication: It’s About Time,” (Levinson W & Pizzo PA, May 14, 2011, 305:1802-3) highlights the apparent benefit of clear physician communication on patient outcomes.Communication and interpersonal skills are one of the Miller-Coulson Academy’s domains of clinical excellence.The JAMA commentary points out how these skills, which take time to teach and to practice, tend to be undervalued in medical schools, residency programs, and academic medical centers in general; especially in comparison to scientific knowledge and medical technology.

“Although time to listen to patients and teach communication skills may be scarce, technology is plentiful.Academic medical centers almost worship technology.”

In their commentary, Levinson and Pizzo urge academic medical centers to take the lead in assigning value to patient-doctor communication.Although these skills may be more challenging to measure, they remind us that metrics are available and suggest these skills be assessed in clinicians and even tied to financial incentives.In this way, physicians would be recognized for spending more time with patients instead of less, as opposed to the current system that rewards physicians based on the number of patients seen in a given amount of time.The authors close with a statement evocative of David Hellmann’s reminder to us that medicine is a public trust and a call to renew our commitment to that trust:

“If the medical profession wishes to maintain or perhaps regain trust and respect from the public, it must meet patients’ needs with a renewed commitment to excellence in the communication skills of physicians.It is time to make this commitment.”

The Miller-Coulson Academy of Clinical recognizes communication and interpersonal skills as a pillar of clinical excellence. In his recent Miller Lecture on this campus, Peter Pronovost called us all to act to improve the quality of patient care.By operationalizing, teaching, measuring, and incentivizing of these skills, as well as demonstrating their impact on patient outcomes, the Academy could reinvigorate the practice of compassionate patient care.

A link to an extract of the JAMA article can be found here

Margaret S. Chisolm, MD

Assistant Professor

Department of Psychiatry and Behavioral Sciences

Johns Hopkins University School of Medicine

 

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A Patient’s Story

by Academy of Clinical Excellence on May 12, 2011

Every once in a while we receive a note from a grateful patient who wishes to share their experience. The following letter is from a patient of Dr. Kraus:

About a year ago, I received a transplant of a four-month-old kidney into my 74 year old body.While the transplant itself was an enormous success, there was one particular hiccup in the recovery process that deserves some attention.

A few days after being discharged, I was back in the hospital due to a urinary leak.While standing in front of the sink, I felt light-headed.The wheelchair was right behind me so I sat down, then blacked out for a few seconds.

Dr. Ed Kraus came to evaluate the situation.He and an intern showed up.Dr. Kraus introduced the Intern as a Harvard Med graduate.He explained that Hopkins is a teaching hospital and asked if it would be all right if the Intern examined me.I replied that would be OK.Both looked at my chart and examined me.Dr. Kraus asked her to evaluate my condition then recommend a course of treatment.

Looking at the chart, the Intern postulated that the high sugar level in my urine might be a factor.Dr. Kraus nodded and asked her to examine my leg.“What do you see?” he asked.

She felt my leg and pinched my skin.“His skin is shriveled like a prune’s,” she said.

“And what does that tell you?” Dr. Kraus asked.

She looked at my chart again.“He’s getting a high sodium I.V.That’s wrong,” she said.

“What should it be?”

“Low sodium iv.He’s dehydrated.That’s why he passed out,” she said.

What was so memorable about this whole process was Dr. Kraus’ use of the Socratic method of teaching.A time-tested and proven teaching method.I was happy to be the recipient of such wisdom.

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Eye Contact

by Academy of Clinical Excellence on May 5, 2011

“Look at me when I speak to you young man” was a primary parental injunction of my childhood and passed “en loco parentis” to my teachers. I learned that eye contact, at least in Western culture, was important to the development of a respectful attentive relationship. My mentor, Dr. Rammelkamp, as I said in a previous post, taught that relationship is the most important tool in the physician’s bag. Even if my childhood fantasy, that my mother, Beatrice Kraus (z’l) could look into my eyes and see my mind with all of its thoughts, was untrue, she was savvy to the cues that would betray my brother and me. I believe that we may be losing eye-contact and thus a critical element in the development of relationship to the escalating demands for efficiency.

Fast forward 50 years…I had to stop my teaching on rounds several weeks ago and command some attention. Except for the presenter, each of the residents had his or her face buried in a “cow” or some other electronic device. Giving them the benefit of the doubt, I surmised that they were each diligently writing notes or orders on their patients, albeit even on ones that we had not even seen! After all, reduced work hours without corresponding increases in resources demand efficiency. My wife, Joanne, visited her internist in the new 301 Building’s clinical space. She noted the configuration of the spacious exam room. There was a small desk with a keyboard and a large computer screen, a chair for the provider in front of it and one for the patient at the side. Even with robust visual fields you couldn’t see the screen and the face simultaneously! Joanne and her physician sat across the room from the computer and commiserated that there was an implied expectation that data should be input at the time of the interview. The pernicious assumption that it increases efficiency to be able to question, listen and input data simultaneously is likely an error. The problem is that if you don’t look, you’ll miss the twinge on her face or the tear in her eye. “Multitasking” divides our attention. State legislatures around the country have outlawed texting while driving for just that reason. It doesn’t make much sense, then, to allow, it if not to encourage it when meeting with our patients and discussing their presentations in Rounds.

Joanne and I watched a table of 6 young people, likely natives in the digital world, each with a device, texting one another across the table. It’s hard for me to believe that emoticons and abbreviations will ever efficiently convey my mother’s “look” of disapproval or her “look” of love. Even if there is an evolution of mores regarding eye contact amongst the generational sub-cultures triggered by the online and electronic opportunities, the majority of us are digitally naïve. Our adult patients expect us to look at them and we should not lose sight of our sight as a source of clinical information. We’ve not “evolved” to the point that eye contact is the sole province of the security credential, of an iris scan!

Edward Kraus, MD
Division of Nephrology
Johns Hopkins University School of Medicine

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Turning back the clock to pre-Oslerian era

by Academy of Clinical Excellence on April 14, 2011

An article recently appeared on the front page of the New York Times: “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy,” which was the most widely e-mailed article of the day (March 6, 2011). The article profiles Dr. Donald Levine, who personifies psychiatrists’ movement towards pharmacotherapy and away from psychotherapy. The author writes “The switch from talk therapy to medications has swept psychiatric practices and hospitals, leaving many older psychiatrists feeling unhappy and inadequate. A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.” Although the article highlights an important and timely issue, it misses many key forces driving the change in U.S. psychiatric practice, including the wide availability and marketing of psychiatric medications.
A larger issue for psychiatry, not addressed in this article, is how the decision to practice either pharmacotherapy or psychotherapy turns back the clock for psychiatry and psychiatric patients. In this sense, the article unfortunately propagates an antiquated view of the practice of modern psychiatry. Modern psychiatry is best appreciated as a medical discipline which follows traditional medical approaches to evaluation, diagnosis, and treatment. This focus on practicing either pharmacotherapy or psychotherapy relegates our profession to the pre-Oslerian era, when evaluation and diagnosis of the patient were less relevant than the types of treatments that individual physicians had been trained to provide. If a psychiatrist’s practice (or any physician’s) is limited to one intervention, and is not derived by thorough evaluation and formulation of the individual patient, it negates what we’ve learned from Osler:
  • The conditions with which patients present to psychiatrists differ in their origin: not all psychiatric conditions are the same
  • A thorough evaluation is critical to differentiating these conditions along their distinct natures

 

  • Evidence should drive decision-making about which treatment(s) to prescribe for which condition

 

  • A systematic approach should be used to decide whether a patient is being helped by the treatment(s) prescribed

 

  • If a patient is not improving, diagnostic and treatment decisions should be revisited

 

William Osler had it right in so many ways when he said: "Listen to your patient.” We psychiatrists, as all physicians, do best for our patients when we listen to Osler…

 
With acknowledgment to Constantine G. Lyketsos for his thoughtful input on this post.
 
Margaret S. Chisolm, MD
Assistant Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine
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The doctor-patient relationship is the foundation from which a physician works to help a patient restore hope and foster healing. Given the immense amount of medical knowledge medical students and residents must absorb and remember during their clinical training, it is easy for our learners to lose sight of the person in need of their care.
In the New York Times article, “18 Stethoscopes, 1 Heart Murmur and Many Missed Connections,” science journalist Madeline Drexler beautifully captures the experience of being a volunteer patient in Harvard’s second-year clinical skills course. She reports how one-by-one, students examined her heart, listening for the distinct click of mitral valve prolapse. She writes, “I didn’t become a full-fledged person until the 10th exam.” What distinguished this student from the others? “He looked me in the eye and shook my hand.” Drexler says it was not until the 18th student that “someone bothered to ask my first name.” She reflects, “How wonderful it felt to finally say my name, to be heard and seen.”
Drexler’s article includes physicians’ clinical pearls, my favorite among them: “At the end of every interview, say to the patient, ‘How has it been for you, being in the hospital?’ How would the simple act of asking this one question impact patient satisfaction and outcomes? I think plenty. As Drexler writes, “As any patient knows, the touchstone of a good doctor is the ability to feel one’s heart.”
 
Here’s a link to Drexler’s article in the New York Times
 
Margaret S. Chisolm, MD
Assistant Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine
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Psychotherapy is a method common in some form to all cultures that address human suffering. The late Jerome Frank, a Hopkins psychiatrist, empirically studied psychotherapies that succeeded and failed to define several characteristics common to all successful therapies. In addition, he found that patients seek psychotherapy for reassurance, hope and support, much as they did in the past from the clergy. Frank concluded that psychotherapy – at its core - is Persuasion and Healing, the title he chose for his classic work on the subject. The practice and teaching of this powerful and timeless treatment has long been a central part of the mission of academic psychiatrists. However, recent evidence suggests that the use of psychotherapy as a treatment for patients with psychiatric conditions is diminishing, a phenomenon which would surely have interested and concerned Frank. Given that a central part of my mission as a psychiatrist is the practice and teaching of psychiatry and psychotherapy, it certainly concerns me.
 

For much of the 20th century, psychiatrist meant psychotherapist, and most psychiatrists practicing in the community provided psychotherapy only. In the early 1960s, psychiatrists often saw patients five days a week for individual psychotherapy. However, multiple forces have been at work to create a new generation of psychiatrists. Between 1996 and 2005 the percentage of psychiatry office visits involving psychotherapy decreased from about 44 percent (already a significant decline from the 1980s) to 29 percent, a 35 percent reduction in less than 10 years (Mojtabai and Olfson 2008). While this waning practice of psychotherapy among psychiatrists is attributed to several forces, the primary genesis is the increasing availability of medications that have become available to treat a number of psychiatric diseases.

 
 
As defined by Frank, psychotherapy involves a ritualized, emotionally-arousing encounter between an empathic healer and a suffering individual in which the healer persuades the individual to change attitudes and behaviors to relieve suffering. So many chronic medical conditions can be prevented and even cured when a patient is able to change his attitude and behavior. Although many psychiatrists have willingly abdicated the role of psychotherapist, all clinically excellent physicians embrace this role, as psychotherapy’s mission of hope has wide applicability to all patients seeking relief from suffering. These days, managed care bureaucracy and technologic innovation have the potential to overshadow the personal dimension of medicine. It is essential to convey to patients, caregivers and the larger society, the crucial role psychiatry and psychotherapy has to play in health care. As a member of the Miller-Coulson Academy, I hope to extend my passion for teaching the art of psychotherapy to a greater and more diverse group of health care professionals.
 
For a fuller discussion of the topic, see Dr. Chisolm's essay in the Spring 2011 issue of Perspectives in Biology and Medicine. This topic was also examined in a recent NYT article:http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?_r=1&hp;
 
Margaret S. Chisolm, MD Assistant Professor Department of Psychiatry and Behavioral Sciences Johns Hopkins University School of Medicine
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After watching one of the Academy members deliver bad news to his patient, I asked if he had a systematic way of approaching such situations. “It’s like asking a girl out,” he replied. “There’s no instruction book. You have to feel it out - it’ll be different for every patient.”

I have to admit, I was disappointed. Part of my reason for taking this elective -- shadowing most of the members of the Academy for Clinical Excellence -- was to learn the elusive secrets of medicine, the tricks to ensure that my future patients will hold me in high regard.While I haven’t discovered any secrets, I have noticed that all of the Academy members provide small, often subtle gestures of respect for their patients. None is earth-shattering, and no gesture on its own would change a patient’s opinion of a doctor. But when two or three are combined during the course of a patient visit, a sense of compassion and respect is clearly conveyed to the patient.

Below are a few of the gestures I’ve noticed:

Tell patients that you haven’t forgotten about them.
One afternoon a fellow was unexpectedly absent, so the attending doctor was running late for most of the clinic. In between seeing patients, she would stop into an exam room where a patient was waiting, and let the patient know that she hadn’t forgotten about them, she was sorry to be running late, and she would be in to see the patient as soon as possible.

Thank patients.
Several times during this elective, I’ve heard doctors thank their patients. It might be during the greeting (“thank you for coming”), at the end of the history (“thank you for providing all of those details - it’s very helpful”), after an admission that the patient hasn’t quit smoking (“thank you for being honest with me”), or at the end of the visit (again, “thank you for coming”).

Give patients a reliable way to contact you.
Often the Academy doctors will not only provide their card, but will write an additional email or phone number on the card, or will tell the patient which of the several ways of contacting them will be most likely to get through.

Introduce me (i.e., the med student)
Often the medical student and the patient feel the same hesitance about interrupting the attending doctor. If the attending begins the encounter without first introducing everyone in the room, the introductions will likely never be made. This ends up making both the med student and, more importantly, the patient feel a vague sense of discomfort throughout the visit.

(Briefly) evaluate medical concerns that are entirely outside of your speciality.
In a clinic for patients with renal transplants, a patient mentioned in passing that he recently slipped on some ice and fell on his shoulder. He had a negative x-ray, but still had some residual soreness. The doctor took a minute to examine his shoulder. I believe that small action reinforced the patient’s sense that his doctor cared for his whole person, not just for his kidney.

There's unfortunately no instruction book for becoming a great clinician. The doctors I’ve shadowed provide far more than small, subtle gestures for their patients. Yet by following a few of their more easily-copied practices, I hope to slowly progress on the path towards clinical excellence.

-Aaron Bobb, MSIV, JHSOM

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As a dutiful med student, I ask patients with pain the same standardized set of questions:
  • Where is the pain? Does it move anywhere else?
  • What does it feel like? How bad is it on a 1-10 scale?
  • How often does it come? Does it come on gradually, or all of a sudden?
  • Does anything make it better or worse?

If the patient has chest pain, I’ll add the requisite clarifiers to help rule in or rule out a heart attack:

  • Is it worse with exertion? Is it better with rest?
  • It is associated with sweating or nausea?
  • Does the pain go down your arm or up your jaw?

This is all well and good, and is what we med students spend much of our third and fourth years of medical school learning. If I were on a plane and the stranger sitting next to me clutched his chest, these are the questions I would immediately ask him. One of the required national board exams, the United States Medical Licensing Exam Step 2 CS (for “clinical skills”), encourages this approach by grading students objectively (one point for asking how bad the pain is on a 1-10 scale, one point for asking if it’s associated with nausea, etc.).

But the process leaves much to be desired, for the doctor and the patient. If I were to approach the next 100 patients with chest pain in this same way, I might feel more like a walking checklist than a doctor. The patients might feel barraged with rapid-fire questions. Important subtleties might be missed.

Most important, an opportunity for connecting with the patient would be lost. In a busy outpatient clinic, a doctor might only have seven minutes to spend in the room with the patient. He or she needs to connect with the patient, for humanistic as well as practical reasons. Is there a way of taking a patient’s history while simultaneously building rapport? Could a different style of history-taking provide as much, or more, information for diagnosis than the typical approach?

In clinic today, we saw a 32 year old thin, lanky man who had been feeling chest pain off and on since Thanksgiving. First, the fellow took his history in the standard fashion and examined him thoroughly. We learned that the pain was in his mid-upper chest, constant, severe, sharp, not associated with exertion or nausea. In sum, it was very unlikely that the pain was coming from his heart.

Then the attending doctor came in. After introducing herself, she asked:

“What do you like to do for fun?”

“For fun? Dancing, I guess.” The patient had a wry smile and looked away.

“Really?! What kind of dancing? Hip-hop?”

“Yup. My wife and I dance every Friday night?”

“Wow, every Friday? How long do you dance for?”

“About an hour.”

“That’s a long time. I bet you are really good.”

The patient smiled again. “Nah, not really.”

“I just saw that show - what’s it called - Live to Dance, with Paula Abdul. Have you seen that? Will you be on that show soon?”

The patient laughed again. “Yeah, I’ve seen it. I don’t break-dance like them. I do have a couple good moves though”

“Let me ask you - do you ever get that chest pain when you’re dancing?”

The patient thought for a moment, and answered, “No, not when I’m dancing.”

One might argue that the conversation answered only one question (does the pain come on with exertion?), but it did much more. The patient relaxed and connected with his doctor. I would argue that he would be more likely to trust and accept her diagnosis that his condition is benign, than he would if the fellow told him the same thing. The doctor connected with her patient. She told me later: “Ask me who the 32 year old man with chest pain was, and I won’t be able to tell you. Ask me who the man who likes to hip-hop dance was, and I’ll be able to tell you his whole history.”

-Aaron Bobb, MSIV, JHSOM

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Fourth year Johns Hopkins medical student, Aaron Bobb, just completed a 2 week elective offered by the Miller-Coulson Academy of Clinical Excellence. During his time, he shadowed many of the member physicians in their clinical settings. Through a series of blog posts, Aaron documents some of what he learned and witnessed during his elective.

The doctor and I entered the room knowing nothing about Ms. P. except that she wanted to transfer her care to Bayview. We found a well-appearing talkative woman in her late fifties, armed with a stack of medical records and several concerns. She recently had a “heart scan” and wanted the doctor’s opinion about it. She had chronic neck pain and dry eyes, and a genetic test for HLA-B27 came back positive, “confirming” a diagnosis of Reiter’s syndrome. She had stomach upset which she thought might be related to taking Lipitor. She wanted to know what her cholesterol level was.

As we stepped out of the room while Ms. P. changed into a gown for the physical exam, the doctor told me about his way of approaching new patients. “I try to be mostly receptive, almost passive. When you think about it, we’ve just met each other. She might not appreciate me pronouncing all of her ailments and how to fix them.”

Later during the visit, Ms. P. mentioned an encounter with a previous physician she’d seen for her stomach upset. “After being in the room with me for two minutes, he diagnosed H. pylori [gastritis] and gave me all these pills to take. I don’t like taking pills, and I didn’t like him.”

The doctor ended the visit by ensuring Ms. P. that he would read over her heart scan and find out when her last cholesterol level was tested. He prescribed no new medicines and agreed to hold off on the Lipitor for the time being. He deferred any blood work until he had time to look through her records.

I believe Ms. P. left the office feeling that her new doctor was thoughtful, conscientious and respectful. The doctor could have been more “efficient” by attempting to do more during the visit, but Ms. P. may have been less satisfied and confident in her doctor, and would likely be less adherent to any future treatments prescribed (and perhaps would search out yet another doctor).

That previous doctor, who prescribed the antibiotics for H. pylori, was likely correct in his diagnosis and treatment choice, but moved too fast for his patient. As medicine continues to increase in technicality and sophistication, doctors may need to slow down and do less to make sure their patients remain in the loop.

-Aaron Bobb, MSIV, JHSOM
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Rituals in Medicine

by Academy of Clinical Excellence on March 1, 2011

 

The late Jerome Frank, a Hopkins psychiatrist and esteemed scientific investigator of psychotherapy used the study of therapies that succeeded and failed to define several characteristics common to all successful therapies (Frank and Frank 1991). One of the characteristics he identified as most important to psychotherapy outcomes was the use of ritual. I believe Frank’s findings on the common elements of successful therapies have application to all of medicine, not just psychiatry.

Abraham Verghese, a professor at the Stanford University School of Medicine, author of the novel “Cutting for Stone,” wrote about the importance of ritual to the healing of patients in a recent opinion piece for the New York Times. In that article, he reflected: “In my experience, being skilled at examining the body has a salutary effect beyond finding important clues that lead to an early diagnosis. It is a ritual that remains important to the patient.” Later he stated: “I find that patients from almost any culture have deep expectations of a ritual when a doctor sees them….Rituals are about transformation, the crossing of a threshold, and in the case of the bedside exam, the transformation is the cementing of the doctor-patient relationship, a way of saying: ‘I will see you through this illness. I will be with you through thick and thin.’ It is paramount that doctors not forget the importance of this ritual.”

What other characteristics did Frank find common to all successful therapies? Do they also have a role to play in the healing of all patients? If so, can all doctors be trained in these skills, as they are in the physical examination?

Here’s a link to Verghese’s article in the New York Times

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

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