Johns Hopkins Reflections on Clinical Excellence

Helping to Allay Patient Fears

2011-09-13T11:57:00.000-07:00

Medical grand rounds resumed this week, signifying the startof another academic year that will be filled with learning and professionalgrowth.

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

Before coming to Dr. Hellmann, she had been seen by multiplephysicians who were unsure what was going on. Dr. Hellmann established that shehad Granulomatosis with Polyangiitis (formerly called Wegener’s) and initiatedtherapy. The patient recounted that one of the unique things that Dr. Hellmanndid 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, andattention that she has received through her care, the patient explained thather fears have been allayed and that she feels as if she and her physician havetaken back control over the illness.

Another Reason to Counsel Patients to Exercise

2011-08-09T08:11:00.000-07:00

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

2011-08-04T06:50:00.000-07:00

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

2011-07-29T08:02:00.000-07:00

“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.

[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

2011-07-26T10:51:00.000-07:00

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

The Sad State of Psychiatry

2011-07-05T10:11:00.000-07:00

Marcia Angell’s recently published two-part series on psychiatry in the New York Review of Books (“The Epidemic of Mental Illness: Why” http://www.nyrb.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/ and “The Truth about the Drug Companies” http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry ) is a serious indictment of contemporary psychiatry. Although, not every statement Angell makes nor every conclusion she draws about the field is entirely accurate, the essays contain more wheat than chaff, which doesn’t speak well for the sad state of psychiatry.

In reviewing three books (Emperor’s New Drugs: Exploding the Antidepressant Myth by Irving Kirsch; Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America by Robert Whitaker; and Unhinged: The Trouble with Psychiatry – A Doctor’s Revelations about a Profession in Crisis by Daniel Carlat), Angell’s first essay highlights the dramatic changes in the apparent prevalence of psychiatric disorders as evidenced by increasing psychiatric disability claims, number of individuals in psychiatric treatment (sharply up for children), and psychiatric medication sales. All of this data, although – in part - alarming, is relatively straightforward and undeniable. I vehemently share her concern about the rise in individuals receiving disability for treatable mood disorders. I would add that disability payments can then make certain co-occurring illnesses (such as substance use disorders) more difficult to treat, creating even more disability. Angell’s discussion of the relationship between the pharmaceutical industry and the FDA vis a vis the outcomes of randomized controlled efficacy trials (RCTs) contains some truths, but I do not conclude, as she does, that these trials demonstrate that antidepressants are no better than placebo for the treatment of depression. The complexities of psychiatric RCT design, especially regarding inherent problems with diagnostic criteria (which she addresses, in a different context in the second essay), make me doubt that these medications have no efficacy for certain patients carefully diagnosed by a clinician as moderately or severely depressed. Angell does a great job, however, discussing the role of the placebo effect in trials and – in general – I agree with and applaud the essay’s questioning, skeptical tone regarding the “epidemic” of psychiatric disability and medication sales/treatment.

In her second essay, Angell adds another book to her review, the disturbingly influential Diagnostic and Statistical Manual (DSM). She takes on this “bible” of psychiatry, which she clearly sees is cozily cradled by the arms of Big Pharma. Her understanding of the origin of the DSM (designed to ensure reliability in psychiatric research) and its major weaknesses (its lack of empirical validity and intentionally atheoretical approach met to sidestep the internecine war within psychiatry) is sharp and insightful. And Angell recognizes the impact on individuals and society of such a scientifically and intellectually flabby checklist-approach to psychiatric diagnosis.

To those of us who trained in psychiatry at Johns Hopkins, Angell’s critique of the field is all too familiar. Since the launch of DSM-III in the 1980s, the psychiatry department at Hopkins has consistently and publicly challenged the DSM’s categorical approach to patient formulation. We have witnessed the harmful effects of the ascendancy of the DSM on our field, including the creation of a generation of psychiatrists who no longer routinely conduct a thorough psychiatric evaluation for each patient. It’s now a rare psychiatrist who takes stock of an individual’s life story, intelligence, temperament, and behaviors before reducing the origin of the patient’s complaint to brain disease.

By contrast, at Hopkins we have remained committed to a measured, systematic approach to the psychiatric evaluation of each and every patient. Although we recognize the time-consuming nature of such an evaluation, we also know that it’s essential to the practice of psychiatry. Only by taking a thorough history and performing a complete mental status examination on every patient is a psychiatrist able to understand each patient as an individual. And only by understanding the whole patient, can a clinician develop a comprehensive and personalized treatment plan. This systematic and robust approach, based on The Perspectives of Psychiatry by McHugh and Slavney, allows the clinician to transcend the criteria-based nature of the DSM. The Perspectives approach ensures the consideration of many possible biological and psychological origins of a patient’s distress.

Although DSM-V is on the horizon, critics like Angell are giving voice to concerns shared by many, including those of us at Hopkins, about the state of psychiatry. We encourage such public conversation to continue as there is a clear need for questioning the state of contemporary psychiatry. I hope that other psychiatrists will join us as we continue to advocate for a more personalized and systematic diagnosis and treatment approach for all patients.

Margaret S. Chisolm, MD

Assistant Professor

Department of Psychiatry and Behavioral Sciences

Johns Hopkins University School of Medicine

Emotional Lability After Stroke

2011-06-08T09:20:00.000-07:00

I was seeing L back in the office for the first time since he had suffered a stroke. Now age 55, he had suffered with complications of diabetes mellitus since the age of seven. Despite the development of retinopathy, neuropathy and renal failure leading to a kidney transplant, he had remained upbeat, motivated to take care of his health and most importantly he always found joy in life. Today he was clearly different.

The stroke had caused a large bleed in the right side of his brain. His wife had called 911 after he had fallen from sudden left sided weakness. Initially she thought he was hypoglycemic, but his glucose was fine. Soon after arriving in the emergency room, he became obtunded and required intubation and placement on a ventilator. Miraculously, he started to steadily improve over the next 72 hours and was extubated. He quickly regained strength and was able to walk. He improved so quickly that he decided (with my support) not to go to a rehabilitation hospital, but rather to go home and receive home physical therapy.

So here he was before me with tears in his eyes and I did not know how to understand them. We had walked from the waiting room to my office together and his gait was amazingly normal. We had chatted while walking and he had appeared his old self. Once he sat down, his eyes had swelled with tears. I let him regain his composure and he finally explained.

Since returning home from having the stroke, he had started having vivid recollections of childhood events. Several were triggering crying spells. One event, however, was dominating his thoughts as if it had happened the day before:

“I am four years old and helping my mom and dad decorate the Christmas tree. I dropped a light bulb and somehow it sparked. Within a few seconds, there was a fire and the tree and all the presents underneath it were in flames. My dad put out the fire, but all the presents were destroyed. I had ruined everybody’s Christmas. I was heartbroken. My mom and dad tried to reassure me that it was not my fault and that they were not angry with me. I couldn’t stop crying for days. But now here I am over 50 years later and I can’t stop crying over this event that all of sudden seems like it occurred yesterday.”

It was clear that somehow the stroke had activated this painful memory and made him have uncontrolled crying. He denied feeling depressed. We talked more that day and later that afternoon I scoured the literature looking to find out if there were descriptions of this happening after a stroke. Sure enough, there were several reports of post-stroke pathological crying attributed to “stroke-induced partial destruction of the serotonergic raphe nuclei in the brainstem or their ascending projections to the hemispheres.” However, I could not find an explanation as to why he was having such a vivid recollection of a distant memory, as most stroke patients indeed have memory difficulties.

I called him about a week later and discussed with him what I had found. He related that he was getting better gradually and was no longer crying quite as much. He felt even better as we discussed emotionality being common after a stroke. Now we are working on getting him back to work. I am sure he will succeed.

On Humility

2011-06-03T08:38:00.000-07:00

Humility. The art of detachment, the virtue of method, and the quality of thoroughness may make you students, in the true sense of the word, successful practitioners, or even great investigators, but your characters may still lack that which can alone give permanence to powers—the grace of humility.
As the divine Italian, at the very entrance to Purgatory, was led by his gentle master to the banks of the island and girt with a rush, indicating thereby that he had cast off all pride and self-conceit, and was prepared for his perilous ascent to the realms above, so should you, now at the outset of your journey, take the reed of humility in your hands, in token that you appreciate the length of the way, the difficulties to be overcome, and the fallibility of the faculties upon which you depend.

In these days of aggressive self-assertion, when the stress of competition is so keen and the desire to make the most of oneself so universal, it may seem a little old-fashioned to preach the necessity of this virtue, but I insist for its own sake, and for the sake of what it brings, that a due humility should take the place of honour on the list.

- Sir William Osler

A perspective piece, titled "On Humility", appeared in the Annals of Internal Medicine in August. It provides some food for thought on what it means to be clinically excellent. It can be found here.

Communications and Interpersonal Skills

2011-05-26T08:08:00.000-07:00

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

A Patient's Story

2011-05-12T10:53:00.000-07:00

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.

Eye Contact

2011-05-05T10:39:00.000-07:00

“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

Turning back the clock to pre-Oslerian era

2011-04-14T10:26:00.000-07:00

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

Fostering Healing and Hope Through the Doctor-Patient Relationship

2011-04-06T05:55:00.000-07:00

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

Grand Rounds Report from the Department of Psychiatry – Prescribing Psychotherapy

2011-03-27T09:59:00.000-07:00

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

Medical Student Reflection III: Small ways to show respect for patients

2011-03-24T10:30:00.000-07:00

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

Medical Student Reflection II: History as conversation, or: creative medicine

2011-03-16T12:30:00.000-07:00

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

Medical Student Reflection I: Easing into a new patient, avoiding a pitfall

2011-03-03T23:15:00.000-08:00

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

Rituals in Medicine

2011-03-01T05:48:00.000-08:00

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

A New Model for Primary Care

2011-02-21T09:56:00.001-08:00

There is currently a shortage in the number of primary care physicians and many are speculating that the demand will continue to exceed the supply in the coming years.

New models for primary care delivery are being considered and tested.

The attached article on primary care was in the the New York Times and it describes One Medical Group, a model for primary care that hopes to set a nationwide example and create a particularly appealing experience for both physicians and patients. The group is now serving communities in both San Francisco and New York. One Medical Group’s founder is Dr. Tom X. Lee, the physician who also co-founded Epocrates.

One Medical Group is attempting to offer most of the services provided by concierge-type medical practices with only a minimal additional cost to patients, $150 to $200 / year. While it is unfortunate that any out-of-pocket costs to patients are required to make this model work, One Medical Group is expecting that many patients who are dissatisfied with access to their physician will switch to seek care at one of their growing number of sites.

Please see the article that was in The New York Times for additional details:

http://www.nytimes.com/2011/02/01/health/01medical.html?src=twrhp

Grand Rounds Report: Miller-Coulson Academy

2011-02-02T11:24:00.000-08:00

Earlier this month, I had the immense privilege of being the psychiatrist on a panel, along with fellow Miller-Coulson Academy members Roy Ziegelstein (Cardiology) and Steven Schwartz (Surgical ICU), at the recent Medical Grand Rounds. With the expert input of another member of the Academy, Raf Llinas (neurologist), the panel was able to demonstrate several components of effective clinical reasoning.

Disclosure: Scott Wright, Director of the Miller-Coulson Academy, had contacted us three discussants the night before to give us a clue. He said, “I will present a case of a middle age male who was recently admitted to our hospital.”

The format of the round the next day was as follows: Dr. Wright gradually revealed elements of the patient’s story, stopping periodically for commentary from the discussants as the clinical story unfolded. He started by saying that clinical problem-solving exercises are “somewhat artificial” and can be “nerve wracking,” but a “very nice learning opportunity.” He was right on all three counts. It was like a high-pressure game show, except in front of a brilliant audience and a Hopkins dean.

True to his word, Dr. Wright began by asking each of us how we approach a complex patient case. I replied that I listened with an ear to understand whether the patient’s problems are emerging from something they have (biological origin), do (behavioral origin), are (personality origin) or have encountered (psychological origin). Dr. Ziegelstein remarked he always wanted to hear the patient’s story and do an examination, rather than relying on anyone else’s history and exam. Dr. Schwartz said his patients usually are not able to tell their own story, so he tries to look at the big picture, and as a first step, makes sure that airway breathing and circulation are intact.

I’m not going to present the case and the discussion in detail here, but will summarize the experience and encourage you to attend one of these in the future to witness the excitement first-hand. It’s not only an intellectually engaging time, but also one which showcases how to use the wisdom of colleagues. We first heard the chief complaint (dizziness followed by a fall), which raised questions for Dr. Ziegelstein of cardiac problems and for Dr. Schwartz of head injury. Then came the personal history (a never-married, socially isolated middle-aged paint salesman who lives with his sister), which raised questions for me of psychiatric issues. As the case continued to unfold, we learned that the patient began having tonic clonic seizures. The patient said he drank 2-3 shots of vodka daily (which Dr. Ziegelsten advised might be an underestimate). He had abnormal vital signs (elevated blood pressure and pulse) and diagnostic tests (elevated white blood cell count, 1^st degree A-V block with left atrial enlargement and right subinsular hematoma on head CT). Although panel members noted these abnormalities, we were not distracted by them and remained open to a range of etiologies for the patient’s presentation, including cardiac, traumatic, neurologic, and psychiatric.

A turning point in the presentation came when Dr. Wright described the patient’s subsequent hospital course which was marked by a fluctuating altered mental status, agitation, and confusion. This is when I got really excited, as these signs, symptoms, and course are the hallmark of delirium: a psychiatric diagnosis. Now we just needed an etiology. Given the report of some alcohol use, the tonic clonic seizures, and the delirium, alcohol dependence and withdrawal seemed to be the most likely diagnoses for this patient. Dr. Wright, then, reported that the patient’s sister estimated his (the patient’s) alcohol use at upwards of 10 shots of vodka daily, these diagnoses became even more clear. With benzodiazepine treatment, the patient became less confused, stronger and could more safely ambulate over the last 5 days of his 10-day hospitalization and was transferred to sub-acute care for additional rehabilitation.

In addition to the Miller-Coulson Academy’s case presentation and discussion demonstrating how to approach a complex patient, how to use the wisdom of our colleagues, and how to avoid being distracted by abnormal test results, it underscored the basic logic of clinical reasoning. Clinicians are trained to recognize the clustering of symptoms, signs and course that define a clinical syndrome. Clinicians and biomedical investigators then proceed to identify the bodily pathology generating the clinical syndrome’s features, with the ultimate goal of finding the etiology (cause) of the pathology. Withdrawal from alcohol usually results in the hyper-alert, agitated, form of delirium, as seen in this patient. This form is more commonly known as delirium tremens (also known as DTs).

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

DOCTOR’S DILEMMA

2011-01-19T11:07:00.000-08:00

When caring for the patient collides with complying with the system.

He was hemiplegic with a tracheostomy needing a ventilator 12-16 hours a day. He was highly intelligent and a genius at fixing computer hardware and software problems - solving many problems for our staff, patients and visitors. He was also cantankerous and demanding, forcing us to agree to his schedule and needs. When we failed to do so, he would curse, throw things, and be verbally abusive to our nurses and staff. However, he finally settled down and we were able to adjust our routines to his preferences, which included not taking vital signs except when he permitted and allowing for an occasional “schnapps”. Under new rules from the State, he was transferred to a less acute skilled ventilator facility. Unable to adjust at the lower cost facilities, he died.

I am responsible for the care of patients, usually older and invariably frail, who have survived surgery and intensive care but remain ill and on life support (ventilators, dialysis, tube feedings and now left ventricular assistive devices LVADS). Some have end stage conditions requiring comfort and compassionate care at the end of life. Others can be liberated from artificial life support and return home. Yet there are some who, in limbo, require attentive care on ventilators for many years. They and their loved ones have elected to preserve life despite costs and adversity. The financial costs fall to insurance companies and when this support runs out, Medicare then Medicaid become the payers - which ultimately means the taxpayer.

The Department of Health and Mental Hygiene issued nursing home transmittal 202 April 11, 2006 which revised the criteria in the state of MD for chronic level of care that required patients not meeting the criteria should be transferred to lower cost centers, called ‘skilled ventilator facilities’. This sort of facility was where my patient was transferred. I resisted his transfer knowing how difficult it was for him to adjust but ultimately gave in. At our facility, he was engaged and content. One year after leaving our care - he died depressed and bitter. When I learned of his death and the misfortunes that fell upon him during his final year, I resolved to follow up personally all transfers similarly mandated by the State’s contractor under the new guidelines.

A total of 18 patients on my service have been declared “stable” ready for transfer to skilled ventilator facilities. Fifteen have died – often soon after their transfer. Currently, at the patients’ and their families’ urging, I have refused to move other patients declared “stable” and ready for skilled vent facilities. My decision was based on data - comparing survival of those declared “stable” and not transferred from our ventilator unit with those who were transferred. The resulting analysis shows a statistically significant increased mortality rate that is associated with the transfers. This follow up information suggested that the criteria and processes for deciding who to transfer was flawed.

Armed with this follow up data, I have not agreed to transfer patients against their will, or the wishes of their of loved ones. I have worked with legal aid of Maryland to defend my patients against these seemingly arbitrary criteria, and have since gone to the Administrative court, subpoenaed by my patients, to appeal the decisions for transfer. Only one patient won her case, but later lost in an appeal in the Circuit Court. In the course of this contest, the state has made some minor modifications in the paper guidelines which define “stability” but have not agreed to see the patients or their families. As might be predicted, these changes do not adequately address the problem.

Our facility is losing financial support for those patients who have refused to be transferred and suffers substantial financial hardship with the threat of not being able to continue to support ventilator patients should losses escalate. The administration, though under great pressure fiscally, has supported my decision not to comply with transferring out patients termed “stable” by the State’s contractor when they and their families have refused to be moved. However, the pressures on our “not for profit” facility continue to escalate.

In long term care, staff (including physicians, nurses, and others) come to know patients and their families’ very well - with a sense of caring and protection that often goes well beyond what can be established in acute care settings. To practice best care, one must know what happens to our patients in the current health care system when they are transferred through the many series of “silos” which they must pass. Decisions for transfer not based on follow up data may result in injuries, rehospitalization, or death. Truly caring for ones patients’ demands knowing what happens to them; sometimes this requires collecting the critical data that others will not. This is what has become necessary if we are truly committed to clinical excellence in our system in which subcontractors and insurance operatives who have never seen the patient are making the decisions.

William B. Greenough III, M.D.

Professor of Medicine

Division of Geriatric Medicine

Johns Hopkins Bayview Medical Center

Doctors Who Put The Patient First

2011-01-05T10:20:00.000-08:00

My colleague, Dr. Colleen Christmas, sent me this letter that she sent to another physician. She wanted to share what happened and her gratitude to the doctors who had made it possible. Too often these stories go untold, enjoy:

Dear Dr. Kang,

I am a geriatrician here at Hopkins for the past 14 years, and never have I been more proud of the collaborative and innovative spirit here as I was yesterday, thanks to Drs. Hinds and Wang.

I care for a patient who is bed-bound with a very painful squamous cell carcinoma (SCC) on his ear. We tried using narcotics to keep him comfortable but he had a lot of toxicity with that, so I tried getting him in to see a dermatologist in hopes he could have some palliative treatment. Unfortunately, in trying to get him in for a derm appointment his daughter dropped him trying to get him out of bed and he broke his fibula. This resulted in an overnight stay in the hospital and a quick biopsy of the lesion demonstrating the SCC pathology. The derm team then advised he would need to come in for a plastic surgery appointment despite my insistence that it was too dangerous to try to take him out of the home again and we were really looking for palliation. Thank heavens I was then introduced to Ginette Hinds who was willing to think way outside of the box with me. She and Tim Wang made a house-call with me last night and resected the lesion at the bedside, which he tolerated very well, and the family (and I) was incredibly grateful.

Once, about a decade ago, I cajoled an orthopedics resident to come make a home visit with me, but I am quite certain what happened last night has never happened here before, and probably nowhere else either.

Tim and Ginette, I will be waiting to return the favor somehow.

Happy holidays,

Colleen Christmas, MD

Program Director, Johns Hopkins Bayview Medical Center

Division of Geriatric Medicine

Division of General Internal Medicine

Grand Rounds Report: Clinical Pathologic Conference

2010-12-22T08:20:00.001-08:00

Of all the formats of Grand Rounds, Clinical Pathologic Conferences (CPCs) are my favorite as they move through a nice progression of a resident presentation of clinical data, followed by a discussion led by a scholarly physician, and finally ending with a pathologist who provides the punch line (that is hopefully the answer provided by the scholarly physician). This past week’s Grand Rounds followed this pattern, but provided more clinical acumen than usual.

There was a unique aspect from the start, as the widow of the unfortunate deceased patient was in the audience. She was introduced at the start and spoke most eloquently at the end. The case was that of a 52 year old man who presented with a few day history of a seemingly innocuous upper respiratory infection that progressed to more significant right ear and neck pain. Once admitted to the hospital, neck swelling became quite prominent and imaging showed a massively enlarged thyroid. Despite broad spectrum antibiotics, the patient developed sepsis and died.

The discussant was Dr. D. William Schlott, Philip A. Tumulty Associate Professor of Medicine. His discussion was led off by his reminiscing about how it had been 50 years since he first had been at Johns Hopkins Bayview Medical Center (then Baltimore City Hospital) as a medical student. He discussed how from early in his career, he was always encouraged to go see patients (even if he was not caring for them) who had an unusual physical finding or an unusual illness. He related that he had never seen a patient presenting like the current case, with massive thyroid enlargement and a picture of sepsis.

When charged with figuring out the case, he first turned to the internet, to peruse the literature. He was fairly certain the diagnosis was suppurative thyroiditis, but to make sure, he took a crucial second step, “turning to a partner in medicine.” He sought out who he believed was the best clinical radiologist and had him look at the patient’s neck CT with him. The radiologist agreed with the diagnosis and was able to point out findings specific to the diagnosis. However, at the same time, Dr. Schlott did caution that too often physicians rely on imaging, rather than clinical sense.

This was one of those Medical Grand Rounds that made me reflect on the beauty of medicine. Even after 50 years of practicing medicine, a master clinician had just discussed and made a diagnosis of something he had never before seen.

Please share comments.

How Do You Put “Relationship” on a “Sign-Out”?

2010-12-08T09:10:00.000-08:00

Dr. Charles Rammelkamp, my mentor at Cleveland Metropolitan General Hospital, taught my class of residents the importance of the continuity of relationships in the care of patients. Our firm cared for patients both in and out of the hospital. If “your patient” wasn’t followed by you personally, he or she was followed by a member of your team, essentially a small group practice.

Rammel, as we called him, taught us that relationship is the most powerful tool in our black bag. The institution of resident duty hour rules along with the imminent tightening of these rules, the increasingly shortened patient lengths of stay in hospital, and the burgeoning documentation and regulatory requirements have seemingly changed the delivery of care in academic settings and have eroded the time available to spend at the bedside and in the clinic-- time that is all important for building a therapeutic relationship. “Continuity” has been replaced by “episodes of care” linked, but quite tenuously, by discharge summaries and “sign-out” lists. The Joint Commission’s National Patient Safety Goals Standard on hand-off communications notwithstanding, I haven’t figured out a way to put “relationship” on my sign-out without either burdening my colleagues or sewing discontent with the patient and their family.

I lost a patient recently. He was particularly special to me. Our relationship had transcended cultural and religious differences. We had shared celebrations and then several weeks ago his family and I had to endure his sudden death at the end of a complicated hospitalization that spanned multiple hospital services and teams. He and his family sought my counsel at every juncture even when I was “off-service”. I would not have done anything differently therapeutically from what my colleagues did during his hospitalization but the “hand-offs” and my input did not and could not include the relationship that had been forged over time, through adversity and celebration. In the end only I could guard him, not leaving him alone. It was left to me to tell his family of their loss and to try to console them. For me, it was an inconsolable surreal scene. The “covering” team could not manage that transition of care.

Please share your thoughts.

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

Grand Rounds Report: A Great Two Strike Hitter

2010-12-03T09:16:00.001-08:00

Roy C. Ziegelstein, MD, along with Reda E. Girgis, MB, BCh and Kathleen T. Grieve, RN, BSN, MHA, CC presented at Grand Rounds this week “A Great Two Strike Hitter”. Mrs. MB, an 83 year old patient who was kind enough to share her experiences in person, and the presenters discussed Mrs. B’s experience living a long and productive life despite complications of rheumatic heart disease requiring surgery twice for mechanical mitral valves in adulthood (strike 1) and GI bleeding in the setting of life-long anticoagulation for that mechanical valve (strike 2).

Mrs. B related how she was “extremely sick” when she was 6 years old. The doctor heard a heart murmur and told the mother that he did not expect Mrs. B to reach her 18^th birthday. Mrs. B did, obviously, make it to her 18^th birthday, and lead a successful and productive adult life. She had a daughter, and did well until she reached her forties, when atrial fibrillation developed. She was found to have severe mitral valve disease and severe pulmonary hypertension in 1977, and underwent surgery for her first mechanical mitral valve.

The next 20 years were “good ones” for Mrs. B, but by 2003 her she was experiencing shortness of breath with minimal exertion, and episodes of syncope. Her first mechanical mitral valve showed severe stenosis by catheter, and her pulmonary artery pressures were 100 mmHg. Despite the high risk, she underwent a re-do of her mechanical mitral valve, with the hope that her high PA pressures would resolve, at least in part with improvement in her mitral valve function. She did well surgically. Unfortunately, her episodes of syncope continued, as did her very high PA pressures. This leads us to the first clinical pearl: left heart disease accounts for 80% of pulmonary hypertension. Left atrial pressures drive pulmonary hypertension. Fortunately, experimental treatment with an edothelin receptor antagonist (bosentan), improves her symptoms.

Six months later however, she developed GI bleeding. Mrs. B required multiple, multiple transfusions, but EGD and colonoscopy could not find the source. Enteroscopy to the jejunum and capsule endoscopy are negative. She was initially assumed (and later confirmed by enteroscopy) to have bleeding AVMs. This leads us to the second clinical pearl: 5% of patients with GI bleeding have no source identified, and this is called GI bleeding of obscure origin. Most of these patients are bleeding from the small bowel, and commonly from AVMs. Mrs. B also had moderate to severe aortic stenosis, leading to the third clinical pearl: Heyde’s syndrome, or AVM bleeding associated with aortic stenosis. Heyde’s syndrome is thought to represent an increased tendency to bleed, rather than an increase in AVMs.

The fourth clinical pearl is AVM growth may be related to increases of vascular endothelial growth factor, or VEGF and Thalidomide and its analogue lenalidomide (Revlimid) may be an effective treatment. Mrs. B did well for two years on Thalidomide treatment, but eventually it had to be withdrawn due to peripheral neuropathy.

Lastly, the presenters showcased how patient centered care (in this case using the Guided Care model), with tight coordination of outpatient resources, including physicians, nurses and even infusion centers can avoid hospitalizations and improve patient outcomes. Mrs. B was able to avoid hospitalizations, by getting close oversight and even blood transfusions as an outpatient. This leads us to the fifth and final clinical pearl: Patient-centered, coordinated care may have significant benefits to patients with chronic illness.

Please share your comments.

Eric E. Howell, M.D.
Division Director, Collaborative Inpatient Medicine Service
Division of Hospital Medicine
Johns Hopkins Bayview Medical Center

Counseling and Consultation Time

2010-11-17T08:22:00.000-08:00

Is there anything that we give our patient that is more valuable than our time? We are encouraged to see patients for shorter and shorter periods of time, but time is the one thing that our patients really appreciate. I see a lot of patients referred by other physicians who've seen outside neurologists. I've yet to see a patient who didn't receive: a reasonable work up, a reasonable differential and nice concise note. But most patients say the same thing, "he didn't spend time with me”, “he didn't explain what was going on”, "he didn't tell me why this is happening to me”.

At the request of one of my favorite internal medicine faculty I called a patient I've never seen before in Arkansas who had just been given the diagnosis of ALS. I saw the records, the thought processes, and evaluation, were all correct. Every ‘I’ dotted every ‘T’ was crossed correctly. That's what he has, ALS. I called him while I was driving into work one morning during some particularly bad traffic. He and I spoke for about 45 minutes. He told me all about himself. How worried he was that his illness would decimate what he's able to leave his wife and family financially and about how we plan to work until the very end. He also told me a story about something he said to his neurologist. He told his neurologist that since he had such a rare and unusual type of ALS that maybe the neurologist should be paying him. I burst out laughing. The man told me that his neurologist didn’t even crack a smile.

It is said that William Osler, MD could spend five minutes with a patient and make them feel like he had spent an hour. Perhaps this was the surest sign of his genius and his most important contribution to the patients who taught him everything he knew.

Please share your thoughts/comments.

Rafael H. Llinás, MD
Associate Professor of Neurology
Johns Hopkins University School of Medicine

A Smile

2010-11-11T07:25:00.000-08:00

I had known him for a few months, when, for the first time, J greeted me with a smile. The persistent sad veil over his eyes had lifted. This simple facial expression changed my whole day.

J is from Central America and was hospitalized with what turned out to be disseminated tuberculosis affecting his lungs, liver, lymph system and gastrointestinal tract. At the same time, he was discovered to have advanced HIV and with a very low CD4 count and a viral load off the top of the scale. At discharge, it was arranged for him to have follow-up at the Baltimore City Health Department for his tuberculosis treatment which would entail directly observed therapy. The Health Department had contacted me to provide ongoing health care, especially related to his HIV diagnosis.

When I met J, he had finished about four weeks of tuberculosis treatment. He spoke no English and my medical school Spanish knowledge has definitely diminished over the years. We used a phone interpreter to help. I often felt a bit perplexed using the interpreter as J’s three minute responses sometimes became one sentence in English from the interpreter. J and I built rapport, but with the language barrier, it was not quite the same.

J had a family in Central America and was here working. He could not apply for medical assistance as he had no “papers”. We could provide him health care using our Ryan White Grant. Even with the grant, we needed to establish his residence in Baltimore City. On his second visit, he brought in a paper certifying that he “lives in Baltimore City with 3 amigos”. It was good enough for me.

Being treated for disseminated tuberculosis, J never felt well. It took several weeks, but slowly his fatigue and night sweats went away. He still weighed less than one hundred pounds. Four weeks into tuberculosis treatment, I initiated anti-retroviral treatment for his HIV. He developed immune reconstitution syndrome and felt terrible all over again. With a lot of encouragement and some prednisone, he finally was feeling better.

J had gained eight pounds since I last saw him and this was easy to see. I did not need an interpreter when he said happily, “Me siento muy bien.” We talked more and before leaving to have his blood drawn, he thanked me repeatedly and gave me a hug.

When I think about this patient now, I can still feel that hug and it reminds me that continued effort and encouragement can make all the difference for a patient and can help them to smile again.

Please share your thoughts/comments.

Grand Rounds Report: Bringing Health Information to Life

2010-11-05T12:21:00.000-07:00

David Blumenthal, MD, MPP, who serves as the National Coordinator for Health Information Technology, under President Barack Obama, spoke at Medical Grand Rounds this week.

Dr. Blumenthal’s objective in his role within the U.S. Department of Health and Human Services is to “build an interoperable, private and secure nationwide health information system and support the widespread, meaningful use of health IT”.

In the talk, he shared information about his background as a primary care physician and how this has influenced his view of information technology within healthcare; Healthcare I.T. makes one a better physician.

He shared two examples from his days as a primary care physician to illustrate this:
In caring for a patient diagnosed with a urinary tract infection, he input the medication that he had prescribed into the system Sulfamethoxazole/Trimethoprim and received a notice that the patient was allergic to sulfa. As a result of access to this information in real time, he was able to quickly change the prescription, averting a potential serious allergic reaction, before the patient left the office .

For another patient, he was ordering a test and the system alerted him to the fact that a similar test had been done for this patient within the last three months. This notification made him rethink the indication for the test and he ultimately elected not to order it. The resultant monetary savings for the system, and avoidance of additional patient exposure to radiation was beneficial to all parties.

The talk also included published studies proving that healthcare I.T. provides the opportunity to upgrade our health care delivery system: Quality goes up and costs go down with limited compromise of clinical autonomy.

Another interesting assertion was the notion that using electronic medical records routinely may become a marker for professionalism in medicine. Dr. Blumenthal explained that physicians who choose to practice without a tool that can enhance quality and safety, the electronic health record, may be breaching their commitment to our professional standards.

For more information on EHR’s:
http://patients.about.com/od/electronicpatientrecords/Electronic_Patient_Health_and_Medical_Record_Keeping.htm

Grand Rounds Report: The Importance of Effective Patient Care Hand-offs

2010-10-26T11:46:00.000-07:00

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.