A few weeks ago, at medical grand rounds, Dr. Jeffrey C. Trost, presented our equivalent of “the morbidity and mortality conference” entitled the "Patient Safety and Quality Conference".Dr. Trost presented the case of an older gentleman who was sent to our emergency department from a nursing home with a thigh hematoma and a supratherapeutic INR (he was taking Warfarin for atrial fibrillation). He was admitted to the medicine ward, and was subsequently taken to the operating room. After the operation, the patient was transferred to the medical intensive care unit (ICU) for postoperative care and monitoring.

Over the course of a limited number of hours, the patient’s care and supervision was transferred from providers at the nursing home, to emergency medical technicians, to the emergency room, to the medical ward team, to the surgical team, and then finally to the ICU.

Dr. Trost highlighted the importance of effective ‘information handoffs’ required in order to deliver high-quality care to our patients. He presented a model for us to consider when the stakes are high and time is short – the example from Dr. Ken Catchpole’s article “Patient handovers within the hospital: translating knowledge from motor racing to healthcare” were presented.

The audience was also reminded of how horrible errors with unfortunate outcomes can occur when inadequate attention is directed toward the hand-off. In one of Dr. Pauline Chen’s NYT articles, she tells the story of one surgeon scrubbing out after painstakingly resecting a tumor from a young boy’s face while carefully protecting a nerve only to have the next surgeon (scrubbing in to finish the case) snip the nerve.

Now more than ever, medicine is a collaborative team effort. We must all learn from best practices and remember to handoff patient care in the way that we would want it done if the patient was our child or parent.

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In the spring, the Miller-Coulson Academy of Clinical Excellence hosted its second annual Excellence in Patient Care Symposium. New members were inducted into the Academy and shared their philosophy on patient care and clinical excellence. Two patients shared thier perspective on what it means to them to recieve clinically excellent care, and a medical student read the "profession of values" that the first year Johns Hopkins University School of Medicine students created this year and spoke about the importance of clinically excellent role models and master clinicians for medical students. Dr. Gurpreet Dhaliwal, of the University of California at San Francisco School of Medicine presented Medical Grand Rounds with a talk entitled, "Clinical Judgement -- Good to Great".

Here is a quick recap of the 2010 symposium:

[youtube=http://www.youtube.com/watch?v=hZ73gYewM7I?fs=1]

Mark your calendars-- the third annual Excellence in Patient Care Symposium will be held on April 26, 2011 at the Johns Hopkins Bayview Medical Center.

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Grand Rounds Report: Clinical Excellence Pearls

by Academy of Clinical Excellence on October 13, 2010

The Miller-Coulson Academy of Clinical Excellence Grand Rounds was a real showcase of clinical excellence. Dr. Wright discussed an elderly woman with a 2-month illness marked by erythema nodosum, fatigue, and weakness who came to the United States from Greece in the 1960s. The differential diagnosis and overall approach to the patient was expertly discussed by Dr. Zenilman (Infectious Diseases), Dr. Browner (Oncology), and Dr. Kraus (Nephrology). Dr. Duncan (Surgery) discussed his approach to the patient and his discussions with the patient and family, and Dr. Gross (the patient’s primary care provider) discussed the long-term management of the patient.

Many “pearls” emerged from the discussion, but I have chosen to list three:

1. Let the patient tell his/her story.

The answer to a seemingly complex problem often comes from the history, and that can only be understood by letting the patient tell his/her story.

2. Recognize that the patient’s preferences often must dictate the evaluation.

There may be an “ideal” diagnostic approach to a patient’s illness, but sometimes the patient may only “allow” one test, as was the case here. This made it even more important to choose a test (in this case, surgical excision of a lymph node) that was likely to be highest yield and that was acceptable to the patient.

3. Complex problems often require input and coordination from multiple providers, each contributing a different expertise.

The conference today showed the tremendous benefit of having specialists from different disciplines discuss a case together. Clearly, this provides the best care for the patient. Creating opportunities for this to occur “in real life“ is important.

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Photo credit: Perna, Algerina, Baltimore SunMiller-Coulson Academy of Clinical Excellence member, Mark Duncan, M.D., spoke to the Baltimore Sun about the difficulty of delivering bad news within the context of the Johns Hopkins Hospital shooting last week:

Delivering bad news one of medicine's great difficulties Hopkins shooting highlights the complexities doctors face in talking with patients, family members

September 20, 2010

By Childs Walker and Scott Calvert, The Baltimore Sun

...However, the incident touched on an issue of great interest and concern to the medical community — the complexity of relaying emotionally rending news to patients and loved ones who might already be under stress.

"An incident like this does make one reflect on how we do it," says Dr. Mark Duncan, a veteran cancer surgeon at Johns Hopkins Bayview Medical Center. "It's probably one of the more important things we do in the job."

Duncan says he typically sits down with a patient's loved ones, offers empathetic touches on the hand or shoulder and answers every question that arises. Most of the time, recipients are accepting, even gracious."

At the end of the encounter, the family will thank you profusely," he says. "Often far beyond what you think you merit. It's just the fact that you're there with them, that you care."

...

Such exchanges are far more common than misunderstandings or emotional outbursts, says Duncan, the Bayview surgeon. Trouble is more likely in trauma situations, when a surgeon hasn't had time to build rapport with the patient or family. Sometimes he tries to have a nurse or another doctor at his side to avoid the chance of a one-on-one dispute.

The good news, Duncan says, is that the medical community has come a long way in recognizing the importance of communication with patients.

"It's easy to get excited about a six-hour surgery with all kinds of technical wizardry," Duncan says he tells young medical residents. "But lending comfort and understanding to someone who is not going to be cured is a tremendous opportunity to deliver care."

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Yesterday, I had the opportunity to present Medical Grand Rounds at Johns Hopkins Bayview. After discussing a patient who was admitted with to the medical intensive care unit with very low systolic blood pressure (who was later discovered to have low blood pressures when he is well), I presented data and perspective related to the following question: When should doctors follow standard treatment protocols and when is it better to override protocols and deliver individualized care?

The structure of an intensive care unit may play an important role in providing excellent care. A number of studies have shown that the physician and nursing staffing of an intensive care unit, as well as the presence of clinical protocols, designed to ensure that patients receive proven therapies, can affect both the care of patients as well as clinical outcomes. The real challenge for clinicians is in determining when a patient should or should not receive care according to a protocol or care pathway. There are clearly patients who benefit from care driven by protocols or guidelines; in fact many or most patients would fit in this category. However, some patients may not "fit" the category of patients who might benefit from the standardized care present in a protocol. For example, some patients may have additional diseases, specialized circumstances, or perhaps even a different genetic marker that might make them less likely to respond to the therapy encoded in the protocol.

The clinically excellent physician relies on knowledge, evidence, experience, judgment to determine which patients might not benefit from receiving the protocol, and is then willing to override the protocol.

Jonathan Sevransky, MD, MPH
Division of Pulmonary & Critical Care Medicine
Johns Hopkins Bayview Medical Center

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Earlier this week, I came across an article about a recent California study that found that doctors who communicate with their patients via email may actually achieve better health outcomes with their patients.
Patients with diabetes and hypertension, who communicated with their doctors through email, achieved their goals more efficiently. Perhaps this was achieved by not having to exclusively wait for appointments to have their treatment adjusted.

This study reaffirms what I have noticed in my own practice. Email communication with patients can be very effective – with benefits to both the patient and physician. I ask many of my hypertension patients to monitor their blood pressure and report back to me weekly via email. At that point we can make adjustments, schedule an appointment if need be, or I can offer congratulations for their compliance and efforts to realize the improvements. While diabetes and hypertension are examples of how objective data can be delivered by email back to the physicians, some of my patients send pictures of rashes and how these are responding to prescribed therapies.

Email also allows us to quickly share lab results with patients - without wasting paper or stamps, or having the patient wait anxiously.Issues related to the protection of patient healthcare information must be considered and discussed with patients. In general, I prefer to respond to emails sent by patients rather than initiate communications to be sure the email address I am sending my message to is the correct one. As such, I ask patients to email me 3 days after labs were drawn to request the results.
It goes without saying that improved accessibility to one’s healthcare provider helps the patient feel more secure and, as the article states, empowered in their healthcare. The benefit, as a physician, of email communication is that it is immediate and I can rest assured knowing that my patients can reach me.

You can find the study here: Improved Quality At Kaiser Permanente Through E-Mail Between Physicians And Patients

 

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Don’t Ever Change

by Academy of Clinical Excellence on July 2, 2010

As part of the great privilege of being inducted into the Miller-Coulson Academy of Clinical Excellence, I was asked to reflect on the topic of professionalism and humanism. The following is an excerpt from my remarks:
When I was a medical student, in one of my clerkships I was assigned to follow a patient with schizophrenia, severely disfigured from burns, who had spent most of her life in a state psychiatric hospital. One day, I glimpsed her sitting alone on the day room sofa and sat down next to her to chat – not formally, as had been done the day before at her admission – just as two people talking. I could see she was thought disordered and delusional, but - sitting quietly with her and listening closely - I began to understand her experiences in a more personal and moving way. After a half an hour, the attending psychiatrist stopped over to have a word. Worried that I’d violated some professional code, I was surprised and delighted when he whispered in my ear: “Don’t ever change.”
When I think of professionalism and humanism, I think of those three words: “Don’t ever change.” As Abraham Verghese suggested at the recent Miller Lecture on this campus, students enter medical school as caring individuals who want to help patients by connecting with them on a personal level. However, this desire gets worn down, if not away, by their medical training. Students need all of us to remind them – by words and example - to not ever lose their ability to connect with patients as individuals, and to appreciate that each patient has something important to contribute to their care and to the world we share.
........
The human relationship between clinician and patient will always remain of paramount importance to achieve the changes in patients’ attitudes and behavior essential to healing. I am proud to work in an institution that at this moment is vigorously calling for more scholarship to assess health outcomes associated with the teaching and practice of humanistic medicine. I am convinced that clinical excellence can be taught and does improve patient outcomes. The Miller-Coulson Academy of Clinical Excellence provides a forum to address the importance of the art, as well as the science, of medicine in the care of our fellow human beings.
Margaret S. Chisolm, MD
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University
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Merging Addiction Treatment & Primary Care Medicine?

by Academy of Clinical Excellence on June 17, 2010

I had the recent privilege of being invited to a meeting with Dr. Thom McLellan, Deputy Director of the Office of National Drug Control Policy for the White House. No, the President was not present, but with two other physicians, I was part of an almost 90 minute discussion with Dr McLellan and one of his associates.

The discussion focused largely on the merging of addiction treatment with primary medical care. He already knew of our practice in which we incorporate buprenorphine treatment for opiate dependence in the primary care setting. We discussed ways of advocating substance abuse screening and brief intervention training for medical students, residents and practicing physicians. We also touched on board exams including questions related to addiction and ways to make addressing addiction in patients less of a barrier.

Probably, the most provocative discussion focused on changing the concept of addiction treatment. There is no area of medicine where a treatment for a medical condition can be viewed in the context of “punishment”. Yet, that is often the case as even drug courts, which in my view serve a terrific role, offer the alternatives of jail or treatment (pick your punishment?).

We then discussed the general topic of getting patients into treatment. In caring for patients, we also often say the patient has to hit rock bottom to accept treatment. Why do we allow that to happen? Shouldn’t we be motivating patients as soon as we know that substance abuse has been detrimental to their health? We don’t wait for a hypertensive patient to have a myocardial infarction before we try to intervene.
At the end of the meeting, Dr. McLellan, openly discussed his decision to leave his position this August after only one year. The Office of National Drug Control Policy for the White House has no separate powers, but rather interacts with many other government agencies. For someone very motivated to make change (pun intended), he found the setting frustrating and exasperating. He has been a lifelong advocate for individuals with addiction and his leaving is a loss for the medical field.
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As a physician in a teaching hospital, I have the privilege not just of caring for patients, but helping young doctors learn how to best care for patients. We work as a team, but the intern – or first year physician – is the patient’s primary physician in the hospital. Much of my job is to listen, observe, and help guide the intern into doing an even better job than they are already doing. Sometimes we focus on how to treat a particular disease, or what test is best to order to diagnose a condition. Other times the learning happens around communication and counseling skills. Sometimes I get really lucky, and get to observe the unique and important relationship that develops between a seriously ill person and his physician.

The gentleman had been fighting cancer for several years, and had reached the point where treatment was ineffective. His oncologist was beginning to discuss halting treatment and opting for hospice care. He was admitted to the hospital with fatigue and a possible pneumonia, but he was most interested in being able to ski again. He was very weak, but felt that he would improve and be able to get back to what he loved.

I sat and watched as the intern on my team sat down by him on the bed, and talked with him about skiing. How much he loved it, where he liked to go, and how they shared a love of the sport. They talked about his goals, and what he was most worried about. We learned how hard it has been from him to live with cancer, and how his fatigue has made it difficult for him to do everyday things like taking a shower.

The physician-in-training did a superb job understanding our patient’s priorities and what was important to him. They connected on a personal level which, for a moment, allowed the gentleman to escape from the hospital and imagine himself on the ski slopes. As a clinical teacher, I was convinced at that moment that this young doctor was moving down the path towards clinical excellence.

Laura Hanyok, M.D.
General Internal Medicine
Johns Hopkins University School of Medicine

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Is there a doctor on the plane?

by Academy of Clinical Excellence on May 4, 2010

After changing planes in Chicago, I was heading to San Francisco for the Annual Meeting of the American Society of Addiction Medicine. When I travel to meetings (with no kids to entertain), I always have mixed feelings about whether I prefer the person sitting next to me to be chatty or quiet. On the flight from Baltimore to Chicago, the person sitting next to me turned out to be a Hopkins surgeon who liked to chat. So far on this flight, I had been left alone and was immersed in my book. That was about to change, with an overhead announcement- “If there is a doctor on the plane, we need you immediately in the rear of the plane.”
I looked around. Two of my colleagues were on the plane. Neither one moved. I think one made believe he was asleep. I was sitting on the aisle, so I peered back. Someone was lying on their back in front of the bathroom. A second flight attendant was running back. I looked around again. Still there was no movement on the part of the passengers, or the gentleman on the floor. “Oh well, I can read later”, I said to myself and I stood and went back to see what was wrong.
It was a young man in his 20s who had passed out while heading to the bathroom. He was clearly breathing, but too groggy to speak. I asked the flight attendant to see if he was travelling with someone and a friend came back to provide some history. The passed out young man had no medical problems, but he had never flown before and was afraid to fly. Therefore, at nine in the morning, he had already had three glasses of red wine and no food.
I was provided a stethoscope and a blood pressure cuff and his blood pressure and heart rate were initially low, but within a few minutes, the gentleman was able to sit up, drink some juice and eat some food. His vitals were now normal. I then did some brief intervention for his unhealthy use of alcohol.
But then the most exciting part happened. The flight attendant brought me a headset and I got to talk with the pilot and air traffic control. They wanted me to describe what happened and then asked me, “Do we need to divert the plane to the closest airport?” I felt incredibly empowered. I could ruin everybody’s day by saying yes!! But, I knew the answer was no. The passed out gentleman was awake and eating. I had performed brief intervention on my way to an addiction meeting and just wanted to get to San Francisco, the home of the Grateful Dead. I told them no, but thought it was prudent to have a paramedic team be at the gate in San Francisco, which is what happened.
I got off the plane and discussed what had happened with the paramedics who were on the gangway outside the plane. My two physician colleagues, who were on the plane, met me in baggage claim.
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