Medical Student Reflection I: Reflections from the Hallway

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

As medical students, we witness incredibly personal moments in the name of developing into excellent doctors—from births to hospice visits to code status discussions. So it was surprising to me that after four years, Ms. C was the very first patient to request me to leave the exam room. Her doctor’s “one-liner” outlined Ms. C’s full recovery from a serious illness and her residual anxiety, not always medical-related, that responded to much more frequent visits to the office than any protocol prescribes. Although she welcomed me into the room with her doctor and gave only some hints at underlying worries, it was not until the physical exam portion that Ms. C drew the line. She was apologetic but firm: this conversation was for her and her doctor, alone.

I respect patients’ wish for privacy, and even more, respect the doctors who earn and keep that special trust. There is something in the sitting and listening quietly while someone shares their deepest fears. But how can we hope to reach that point? Her doctor gave me her perspective on establishing the doctor-patient relationship. She said, “I learn about the social stuff, I learn them inside and out as a person. The medical part comes afterwards.” I have heard this sentiment repeatedly from members of the Academy for Clinical Excellence who are adored and trusted by their patients. Sometimes, it is more important to write the names of all the grandchildren in the chart, to know golf handicaps, to remember favorite sports stars than to recall blood pressures, lab numbers, or medication lists. While I did not personally get to know Ms. C, she has taught me more by what I did not directly observe and had to infer from my place in the hall, outside the room containing her and her doctor. From the initial visit to the ones fifteen years later, the foundation for a doctor-patient relationship is ultimately a human connection based on listening, sharing, humor, the desire to know our patients as people, and above all, earned trust.

--Helen Prevas, MS IV

Helping to Allay Patient Fears

Medical grand rounds resumed this week, signifying the start of another academic year that will be filled with learning and professional growth.

As has become tradition, our Chairman Dr. Hellmann was the first speaker and the talk was entitled "A Nurse with an Enigmatic and Chronic Illness". Along with the help of the patient and her sister, Dr. Hellmann recounted the experiences of a 62 year old woman who suffered for months with fatigue, weakness, and myalgias. We learned that she is a nurse, a talented painter, a world traveler, and a devoted wife, sister, mother, and grandmother. 

Before coming to Dr. Hellmann, she had been seen by multiple physicians who were unsure what was going on. Dr. Hellmann established that she had Granulomatosis with Polyangiitis (formerly called Wegener’s) and initiated therapy. The patient recounted that one of the unique things that Dr. Hellmann did that other providers had not was to ask her to think about her ‘goals for care’. At one of her visits, the patient brought with her the following written goal: “To lose fear of the disease and the treatment”.  

As a result of the humanism, education, access, and attention that she has received through her care, the patient explained that her fears have been allayed and that she feels as if she and her physician have taken back control over the illness.

Another Reason to Counsel Patients to Exercise

A friend sent me this article from the Montreal Gazette about a 93-year-old man who has exercised vigorously throughout his whole life. When counseling our patients to exercise (http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html ), we often emphasize the benefits on weight and cardiovascular health, however this article describes how important exercise has been in reducing stress and maintaining the mental health of this particular individual.

Disclosure: Sol Levine is my grandfather.

Deliberate Practice

A colleague sent me this interesting article, Composition 1.01: How Email Can Change the Way Professors Teach. It describes how Whittier-Ferguson, a Professor of English at the University of Michigan, is using email to help his students become more proficient writers.

Through the use of emails, Professor Whittier-Ferguson is giving his students feedback in real time as they are composing their writing assignments. This feedback from the expert in real-time while the student is "practicing" their writing creates the teachable moment at just the right time for growth.

This careful observation coupled with specific feedback is at the cornerstone of deliberate practice.

In clinical medicine, engaging in deliberate practice (with observation and feedback to trainees and colleagues) may be easier than doing so in writing. Nonetheless, this piece has prompted me to reflect about innovative and better ways of doing this.

Compassion When Treating Substance Users

“You encourage people by seeing good in them” – Nelson Mandela[1]

I know that science doesn’t always inform public policy. If so, high schoolers would begin their day later than elementary school children; cursive writing would be taught before print; syringe exchange programs would be the rule instead of the exception; preventive health care would be a right instead of a privilege, etc. So why was I so surprised when I saw billboards popping up along Baltimore’s highways proclaiming “DUI Is for Losers”? (Don’t believe me, see images of the entire campaign for yourself here http://integrateddesignscorp.com/duiloser.html)

Now, don’t get me wrong I’m against drunk driving as much as the next person. No, that’s a lie. I’m against it more than the next person since I’ve seen firsthand the destruction of life and property it’s wrought. Firsthand. And I treat substance-dependent men and women, many of whom have been charged with DUIs at some time in their life. I’ve heard their compelling and, often, tragic stories of loss. I know that driving drunk can cause unimaginable heartache and irreversible consequences.

But ad campaigns that focus their efforts on stigmatizing individuals with substance use disorders rather than the behaviors themselves aren’t productive. I’ve seen several patients who have accidentally killed their loved ones while intoxicated, and been incarcerated for their crimes, but who nevertheless continue to drive drunk. If that degree of loss and consequence doesn’t motivate someone to change, no loss or consequence will.

All parents have heard the adage: “Criticize the behavior, not the child.” The same holds true for clinicians treating individuals with substance use disorders. Behavioral science teaches us to stigmatize the behavior we want to change, but to build up and motivate the individual to change.[2] I assure you that people with substance use disorders have more than enough self-loathing; they don’t need any more from us. In fact, an individual’s negative self attitude and hopelessness only sustains substance use. So name-calling, which is the basis of the “Loser” campaign above, and focusing on “loss and consequences” (http://www.mica.edu/News/Students_Develop_Campaign_to_Curb_Drunk_Driving_Statewide.html) is a misguided strategy to promote change and will be unproductive at best and counterproductive at worst.

What works to motivate change? Helping individuals find positive, rewarding, self-esteem boosting behaviors that can compete with the substance use. Positive “reinforcements” like education, employment, exercise, substance-free recreational activities, and the realization that theirs is a life worth living. We can play a role in this realization and, guess what, it’s not by name-calling and shaming. It’s by recognizing that NOT having a substance use disorder is an unearned privilege and showing compassion towards those who do.

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[1] http://www.nytimes.com/books/first/s/sampson-mandela.html

[2] Smedslund G, Berg RC, Hammerstrøm KT, Steiro A, Leiknes KA, Dahl HM, Karlsen K. Cochrane Database Syst Rev. 2011 May 11

Margaret S. Chisolm, MD

Assistant Professor

Department of Psychiatry and Behavioral Sciences

Johns Hopkins University School of Medicine

The Hopkins Psychiatry Approach to Patients

This year, for the first time ever, the Department of Psychiatry and Behavioral Sciences has been ranked #1 in the country by U.S. News & World Report. To appreciate why this is such an important achievement for our department, a little historical context is needed.


Since 1980, the Diagnostic and Statistical Manual (DSM), which categorizes mental conditions based on their outward appearances – the signs and symptoms they produce – has reigned as the dominant classificatory system for psychiatric conditions in the U.S. Since 1980, Hopkins Psychiatry has steadfastly viewed the DSM system as fundamentally flawed and has consistently expressed concern about its negative impact on the field. Hopkins Psychiatry has strongly advocated for the clinical utility of an alternative approach built on concepts developed by Adolf Meyer and Karl Jaspers in the early 20^th century (and later articulated by Paul McHugh and Phillip Slavney in The Perspectives of Psychiatry (1).

The Hopkins Psychiatry, or Perspectives, approach presumes that different psychiatric disorders have different natures (e.g., schizophrenia and anorexia nervosa are fundamentally different in their origins) and stresses that understanding the brain will not lead to a causal understanding of all mental illness since many psychiatric disorders are not the result of a broken brain. This approach emphasizes the importance of taking a thorough and detailed history in order to appreciate the full context of an individual’s psychiatric distress. For over three decades, the Perspectives approach has been used to teach Hopkins medical students and residents how to formulate and treat patients with psychiatric disorders. Over 100 peer-reviewed journal articles and book chapters have used this approach in a substantive way, however it has not yet been widely adopted by other institutions for use in patient care or teaching. This recognition by U.S. News & World Report helps us move U.S. psychiatry towards a more personalized and systematic approach for the diagnosis and treatment of our patients.

[1] McHugh PR, Slavney PR. The perspectives of psychiatry: Johns Hopkins University Press Baltimore, MD; 1998.

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