Dr. Hellmann: Reporting from the ABIM Meeting

by Academy of Clinical Excellence on February 17, 2010

February 6, 2010
Palm Spring, California

Dear All:

I hear snow is falling in Baltimore so it may be cruel to report from the ABIM meeting in Palm Springs where it is about 70. Perhaps the joke will be on me when I try to fly back to Baltimore this weekend.

This ABIM meeting is the winter retreat, which brings together both the directors (about 24 people) and the foundation (about 15 people including yours truly). Some guests were also invited including Drs. Boulware (head of the RRC), David Irby (vice dean for education at UCSF), Molly Cooke (heads the teaching academy at UCSF), and Anders Erickson (a professor of psychology at Florida who has devoted his career to studying how people become expert at things--he has introduced the concept of "deliberate practice" as the means to mastery of playing chess, the cello, or doctor).

The Chair of the Board of Directors is Wendy Levinson, who is Chair of Medicine at Toronto (she gave grand rounds here a few years ago). She has focused the retreat on competency based learning.

Dr. Larry Smith of Mt. Sinai (and the Dean for one of the new medical schools opening in a year) riveted the group by detailing examples of bad outcomes that can be attributed to our failure to ensure competency in diagnosis and treatment.

One of the other guests is Dr. Diane Wayne, the program director at Northwestern. She has performed a number of important studies that demonstrate her program's ability to define rigorous training modules that teach residents to become competent in performing various procedures. One of her projects uses the simulation lab for training residents how to insert central venous catheters, which resulted in a decrease in line infections and saved the hospital 700k (to say nothing of the benefits to patients). Her work has shown that residents who go through her training program also need fewer tries to insert a central venous catheter and puncture the artery significantly less often. With the dean's support (Larry Jamison, the dean at Northwestern, is an ABIM director), the efforts to formally teach and test for competencies have extended to several of their fellowship programs.

If we really put the patient, family and community first, how would we design our educational programs at Bayview to ensure the competency of our trainees?

This ABIM conference dovetails with a book I am reading. One of the chapters of The Innovators Prescription, by Clayton Christensen (Harvard business school professor), describes the difference in training that one of his colleagues experienced when he worked one summer at an American car manufacture and one summer at Toyota (the pre-this year Toyota!). His job at both places was to install the front passenger seat. At the American plant he was told the steps, given an overview and then put on the line. He had 58 seconds to do it. Although he was technically gifted (a graduate of MIT), he repeatedly failed and had to stop the assembly line.

At Toyota, he was told at orientation that he had the privilege of installing the passenger seat, and that the process required him to master 7 specific steps. Each step was described in detail. Moreover, he was not allowed to go to step 2 until he had demonstrated mastery of step 1. He was told the training duration could vary from 2 hrs or 2 wks--what was not allowed to vary was the (perfect) result.

Time for us to do more? Do more with simulation? Do more to verify that our trainees are competent listening to the heart, listening to the patient, ordering tests, doing ultrasound, doing bronchoscopy (Landon)?? Etc

Excited by what more we can contribute.

Stay warm,

David Hellmann, MD

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by Academy of Clinical Excellence on January 25, 2010

Somehow, I always find my non-medical reading connecting to my daily life as a physician. I recently finished the latest book by one of my favorite authors, John Irving, entitled, “Last Night in Twisted River.” In the book, one of the characters is a writer who must endure after the death of his son and father- “We don’t always have a choice how we get to know one another. Sometimes people fall into our lives cleanly- as if out of the sky, or as if there was a direct flight from heaven to earth- the same sudden way we lose people, who once seemed they would always be part of our lives.”

On the morning of the day I read the chapter with this quote, I had spent thirty minutes with an older gentleman, Mr. B, whose wife (she was also a patient of mine) had died a few weeks previous. On the day of her death, he had come upstairs to bring her coffee when he realized she had died in her sleep during the night. Now weeks later, that image of her in bed was haunting him. He was having trouble sleeping, had lost weight from not eating and was frighteningly lonely. He used almost the identical words from the book, expressing the thought of how he thought she would always be part of his life.

Mr. B had never been one to express any emotion in the years I had known him. I had seen him and his wife together on several occasions and they had definitely not been warm with each other. Yet here today in front of me, he bared his soul in expressing words of love for his wife that I realized he had probably not expressed to her in many years. He was tearful and extremely appreciative of me just sitting and listening. I was glad to be his doctor, glad to have known his wife and glad they had been part of my life. This is the part of medicine you don’t generally read about and don’t get tested on when working on board recertification, but is the prime reason I am still thankful I chose a career as a general internist.
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Simple Joys: Moments with Baxter

by Academy of Clinical Excellence on December 1, 2009

This video is proof that clinical excellence can find its way into patient care in the most creative ways...Who would have thought a 19 year old dog could have such a powerful affect on patients at the end of their lives?

What a great reminder to strive to be creative in providing patients with comforting moments and opportunities for joy in the midst of pain and suffering.

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Caught Between Scylla and Charybdis

by Academy of Clinical Excellence on November 12, 2009

Recently Dr. Scott Wright took a first “cut” at how to display clinical excellence by enlisting two physicians who were members of The Miller-Coulson Academy of Clinical Excellence, and a resident in a medical grand rounds format at The Johns Hopkins Bayview Medical Center. He chose a patient unknown to the three clinicians and asked them to discuss the case step by step as the story unfolded. Important clinical points were made by each of the physicians. In the end, heart failure due to Thiamine deficiency turned out to be the cause of the illness. The patient was not alcoholic and had no signs of central or peripheral nervous systems deficits. The rounds emphasized the diagnostic acumen and clinical thinking of three exceptional clinicians. However, there is a further challenge. How can other less tangible traits of expert physicians be displayed to students and colleagues in a traditional academic arena?

The consummate physician has many attributes beyond diagnostic acumen, among these are a reasoned judgment of when and when not to do diagnostic tests, how to engage, listen to and communicate with a patient, and above all how to treat each patient as an exceptional individual person with a unique history and genetic makeup, a person who often wants to be and needs to be a partner in any decisions to be made. The adventure Dr. Wright and his colleagues have embarked upon raises formidable challenges. How in a public albeit professional arena can one display publicly what is intrinsically very private? (e.g. the content of what goes on between a doctor and his or her patient.) One approach may be choosing instances which require an expert physician to depart from the guidelines established by large epidemiologic studies when individual patient circumstances may make such an approach neither necessary or rational.

How physicians and patients must make such judgments will probe the treacherous water every physician must deal with on a regular basis. Dr. Wright has taken an important first step. Now we must move into more treacherous waters that may distinguish an exceptional captain of the fragile ship of physicians and patient dialogue and display how treatment can be individualized in a way that can successfully navigate between the Scylla of slavishly following guidelines and the Charybdis of ignoring evidence.

William B. Greenough III, M.D.
Professor of Medicine
Division of Geriatric Medicine
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Mixing Religion and Medicine?

by Academy of Clinical Excellence on November 3, 2009

I recently read the new Mitch Albom book, “Have a Little Faith.” As with his other books, “Tuesdays with Morrie” and “The Five People You Meet in Heaven”, I found myself tearful and introspective at the conclusion. “Have a Little Faith” weaves a story of the author, who is by no means religious, being asked by his childhood rabbi to deliver his eulogy when the rabbi dies. However, the request is made by the rabbi when he is well and in fact, Mitch Albom has a full eight years to truly get to know and understand the rabbi. During this time, he also starts to better understand himself and evaluate his own faith.
After reading the book, I started to think how my long term relationships with patients, some of whom I have known over twenty years, have helped me give hope to patients. I have seen patients use faith to help persevere against amazing obstacles- medical and social. However, I then started to think along the lines of the author, about how faith impacts patients and my own care for patients.
Historically, I think physicians have very carefully avoided the topic of faith. At one extreme, I remember being very shocked (to put it mildly) as an intern, when I saw a second year resident who used to ask his patients if he could pray for them, and he would kneel at the foot of their bed and pray for them. However, I then started to think about how I encourage my patients with substance abuse to attend Alcoholics Anonymous or Narcotics Anonymous.
These are the steps:
1. We admitted we were powerless over alcohol - that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure
them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.
My patients in recovery will always point out that Alcoholics Anonymous is a spiritual program, and not religious. But after reviewing the steps, am I mixing religion with medicine, by encouraging attendance?
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At medical grand rounds, there was a homecoming of sorts in that Dr. Eric DeJonge returned to give the ‘Annual Mason F. Lord Lecture’. He began by telling the audience about the butterflies in his stomach that were associated with returning to this campus where he had trained for his residency and fellowship. At the outset and throughout the talk, he acknowledged how his approaches and practices continue to be influenced by the exceptional role models that he learned from while here.
His talk centered on the comprehensive ‘home based care program’ that he coordinates in the community surrounding his hospital in Washington DC. We were reminded that because 10% of Medicare patients account for 60% of costs, it is imperative that we figure out how to more effectively care for this cohort. His program that focuses on the highest risk, largely home bound, frail elderly has focused on providing value in the comprehensive care that they deliver - carefully considering quality together with the associated costs.

The passionate multidisciplinary team that cares for these vulnerable patients includes nurses, social workers, and physicians. Select tenets that have guided the program have included:
- Exceptional individualized care
- Efficient service
- Careful selection of specialist involvement
- Preventing crises
- Reliance on dependable health information technology
- Building trusting relationships with patients and caregivers based on accessibility, openness, and education.

Embedded video from CNN Video

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Dr. Rick Hodes, a former house officer at our hospital (then Baltimore City Hospitals), shared his experiences as a physician caring for literally thousands of people in Ethiopia.

Many in the audience on this day might have felt that they were at a parade, but instead of the gaiety and pageantry of colorful floats with Disney characters, patients afflicted by the most horrific maladies passed by, each evoking our curiosity as well as overwhelming sadness. We were shown examples of noma (cancrum oris) which resulted in the destruction of the faces of young people. We also saw children, permanently disfigured by the bites of hyenas. There was lamellar ichthyosis, osteosarcoma, Burkitt lymphoma, corneal opacities from measles, polio, VATER syndrome, rheumatic heart disease, and trachoma. And perhaps most spectacular were examples of more than 100 patients Dr. Hodes cares for with almost unbelievably distorted spines from TB spondylitis.

But those who watched this parade could not help but be moved by the tremendous professionalism and humanism demonstrated by a caring physician, one who has chosen to dedicate his life to those less fortunate than he, and less fortunate than most people in his native country. Dr. Hodes demonstrated his passion for, and overwhelming dedication to, those who might otherwise not get medical care. He showed how collaboration, a concept we teach our physicians in this country, is so crucial to providing outstanding care to his patients. Collaboration with Dutch plastic surgeons who offer to help these disfigured children when no one else will. Collaboration with a particularly gifted surgeon who devised an innovative approach to repairing spines distorted by tuberculosis. Collaboration with various charity organizations who donate medical supplies to Mother Teresa’s mission where Dr. Hodes’ patients find safe haven. Collaboration with the manufacturer of imatinib mesylate, who donates this drug so that Dr. Hodes can treat individuals with various cancers. Collaboration with heart surgeons in India who repair cardiac valves destroyed by rheumatic fever. Collaboration with some of the world’s leading oncologists, allowing Dr. Hodes to develop drug regimens tailored specifically to fit the needs of patients and the surrounding culture and environment as he delivers chemotherapy on his front porch. It is this collaboration and understanding of patient preferences and culture that defines the competency of “systems-based practice,” i.e., the ability to skillfully negotiate the health care system to meet the needs of our patients.

Dr. Hodes ended his talk with a quote from Theodore Roosevelt that sums things up:

“Do what you can with what you have, where you are.”

And while that certainly applies to the care Dr. Hodes provides in Mother Teresa’s mission in Ethiopia, it seems good advice to us all.

Here is a short video that provides a bit of insight into Dr. Hodes' work in Ethiopia:

*image and video from Readers Digest.

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Sometimes, trying to distill a ‘clinical excellence pearl’ from grand rounds is difficult.Today, the challenge is what to include in this post because the session entirely focused on the outstanding patient care delivery. The title for today’s session was ‘On being a physician’ and it was presented by Dr. John Burton who had long been Chief of Geriatrics at Johns Hopkins and is acknowledged as one of the founders of Geriatric Medicine.

Although he completed fellowship training in Nephrology, he decided to pursue a career in the ‘primary care of older adults’ and he began by describing how much he has enjoyed and cherished his clinical role.
To assist him in the presentation today, Dr. Burton was accompanied by a patient with whom he has had a relationship for decades. Mrs. H had been nurse supervisor at our hospital (previously named City Hospital) back when he was an intern. Geriatric Nurse Jane Marks coordinates the home care program also shared her views about nurse-physician collaboration in caring. She has been instrumental in helping the division’s physicians to provide high quality primary care.
The following 5 ideas were emphasized as this master clinician described Mrs. H's personal and clinical evolution as she aged.
1. Effective medical care for patients who have multiple chronic illnesses requires collaboration among multiple physicians and is dependent on excellent communication between primary care physicians and specialists.
2. Older patients often have a constellation of many illnesses which may result in variable loss of physiological function. As such, he reminded us of two important lessons: (i) that one 83-year old person is one 83 year-old and so it is imperative that we consider each individual individually, and (ii) atypical presentations are the norm in older patients with multiple chronic illnesses.
3. When caring for patients like Mrs. H, you can’t possibly get it right all the time. When making medical decisions, doctors have to weigh the various options, explain them to the patient, and together decide upon the plan. Close follow-up is necessary to re-evaluate the shared decision so that alterations in the plans can be made if need be. Humility is required as is a priori acknowledgement that we won’t always get it right.
4. Delivery of optimal primary care involves a team of individuals including the patient, their caregivers, the nurses, and the primary care physicians, and consulting physician. Communication, trust, and openness between all team members is essential. Dr. Burton also explained the value of home visits for gaining insight into to the patient’s world, strengthening the relationship, and reassuring patients when they are not strong or well enough to come to the medical center.
5. Dr. Burton modeled and explained his commitment to lifelong learning he spoke about how he carries around a card in his pocket and makes notes during the week about clinical questions and uncertainties. At the end of each week, he tries to learn about these issues and reconcile them for his own learning and for the good of the patient.
While his presentation clearly exposed challenges associated with practicing primary care in contemporary medicine, the joys and rewards seemed to more than make up for these. Dr. Burton is an ideal role model and he alone could solve the primary care workforce issue by inspiring young physicians to follow in his giant footsteps.
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The Medical Grand Rounds on September 22 was different than many of the others I have attended. Not only was there not a patient present, but there was not even really a specific disease discussed. The presentation, by Dr. Bruce Bochner, Professor of Medicine and Chief of the Division of Allergy and Immunology, focused on the way in which his own relationship with the pharmaceutical industry has been a synergistic one, advantageous to his own professional growth and how it has resulted in research that might not have otherwise been possible. As disclosure, he acknowledged that he is a consultant to ‘Pharma’ and that he has several grants supporting his work from the pharmaceutical industry.
The domain of clinical excellence that was touched on in this Grand Rounds was the scholarly approach to clinical practice. Dr. Bochner presented the case of a 52-year old man who was incidentally was found to have a white blood cell count of 42,000 - with 95% of them being eosinophils. Eosinophils are blood cells that are part of our immune system that combat infection (particularly parasitic infection) and control mechanisms associated with allergy and asthma. While caring for this patient, and with the patient’s consent, he set out to try to learn something new about eosinophil pathophysiology. In particular, he hoped to use this patient's blood (which was chock-full of eosinophils) to identify a new ‘eosinophil-specific’ molecule. The pharmaceutical company had the equipment, personnel, and finances to support this venture. Traditional research funding mechanism would not have been as supportive given the lack of specificity of the research question and hypothesis. The happy end to the story was the identification of ‘Siglec-8’ which is found on the surface of eosinophils. Further work has led to the development of antibodies against Siglec-8 which have the potential to be useful in diseases that are characterized by a surplus of eosinophils.
Dr. Bochner’s presentation reminded me that clinically excellent physicians in academia understand that scientific discovery can start with a single patient. In caring for patients and through collaborations with our researcher colleagues, we have the opportunity to improve our understanding of human disease for the benefit of the patients that we serve today and those that will see us tomorrow.
There were some comments at the end of the presentation related to concerns and unfavorable consequences that might arise from interactions with ‘Pharma’. This controversial discussion was intentionally left out of this post in an effort to appreciate Grand Rounds through the lens of clinical excellence.
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My patient Mr. Zaczek, like most patients, has certain expectations of his doctors, and in my view, those expectations are justified. I think one of these expectations is that the doctor be available. In the article that we co-authored together in the Annals of Internal Medicine is an e-mail that Mr. Zaczek sent to me. His e-mail provides evidence of his expectation that he can communicate easily and comfortably with his doctors, feeling that he and they are in a partnership. I truly believe that whether they e-mail or not, and whether they express themselves in the way Mr. Zaczek did or not, this is truly what our patients expect and desire.

When I received Mr. Zaczek’s e-mail, I was honored that he should feel that we have the type of relationship in which he can freely and comfortably express his thoughts in this way, and I was also honored by the trust in me that his e-mail conveyed. Of course, I was also struck by his intelligence and humor, and I immediately thought the e-mail should be published. In particular, I thought that as doctor and patient co-authors, we could make some very powerful points about the importance of communication between a doctor and a patient. I thought we could comment about the patient-centered medical home model, which to me is a way of highlighting the importance of developing the systems required to facilitate the development and maintenance of relationships like the one I believe I have with Mr. Zaczek, and hopefully have with my other patients as well. And while I recognize that these systems are badly needed, it seems to me that everything starts with the patient and the doctor forming a partnership that I believe results in better patient care and greater satisfaction with that care, ideally both for the patient and the physician.

It is the sense of partnership, implied by Mr. Zaczek’s e-mail that is, to me, a key part of “clinical excellence” that will be discussed and highlighted on this blog.

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