Grace in the Secular World of Medicine

grace_in_the_secular_world_of_medicineThe sweetness of Tom Duffy’s return to Johns Hopkins, to deliver the 12th Annual Miller Lecture, is something to be savored on many levels. Our Miller Lecture, established at Johns Hopkins Bayview through the generosity of the Miller family, celebrates the qualities that make for an excellent clinician – the humanism and compassion, the diagnostic delicacy and craftsmanship – that haven’t traditionally been celebrated at academic medical centers.

Thomas P. Duffy, M.D., is a magnificent clinician. In fact, a longtime Hopkins administrator ranked him as one of the three greatest Hopkins clinicians ever. (The administrator’s other two picks for greatest Hopkins clinicians, in case you’re wondering, are the late pioneering hematologist, C. Lockhard Conley, and the late consummate diagnostician, Philip Tumulty.)

But wait: Duffy is a Yale man; in fact, he’s Professor Emeritus of Internal Medicine and Hematology at Yale University School of Medicine. That’s because Yale was lucky enough to snatch him up 40 years ago – after Hopkins let him go “because he was ‘only a clinician,’” says David B. Hellmann, M.D., Aliki Perroti Professor of Medicine, Vice Dean of Johns Hopkins Bayview Medical Center and Director of the CIM. “One of the greatest clinicians in the world. We are absolutely delighted that he agreed to come back for the Miller Lecture and the induction of the 2015 members of the Miller-Coulson Academy of Clinical Excellence, which celebrates master clinicians.”

“No one had a hint of real service. They were learning from their patients and generating new knowledge and publishing new textbooks. I’m not condemning; I understand them. But it was a culture that was remarkably late in understanding that physicians lead a life beyond the ordinary.”

Duffy’s return highlights the sea change in the recognition and valuing of clinical excellence at Johns Hopkins. Now, our Miller-Coulson Academy, an initiative of the Center for Innovative Medicine, is leading the way in academic medicine, inspiring similar initiatives and rigorous portfolio systems by which clinical performance can be evaluated at other institutions.

The topic of Duffy’s lecture? Grace.

Duffy has many fond memories of his training at Hopkins and of the outstanding clinicians he knew – legends such as A. McGehee Harvey, Philip Tumulty, Ben Baker, and Mason Lord, who taught him physical diagnosis at Baltimore City Hospital (now Johns Hopkins Bayview) and whose name adorns the building that houses our Department of Medicine. These doctors epitomize the Hopkins tradition of clinical excellence “that is part of its very fiber.”

But Duffy, who is also a medical historian, notes the divergent legacies of two of the original “Big Four” founding faculty of Johns Hopkins Hospital when it opened back in 1889. One of them is no stranger to readers of Breakthrough and friends of the CIM: Sir William Osler, the first Professor of Medicine at Hopkins, whose clinical teachings and observations remain true and profound today. The other was William Welch, a pathologist and brilliant scientist who studied in some of the greatest universities in Europe; he started the first postgraduate program for physicians in America, and his own notable trainees included Simon Flexner, Walter Reed, and two who would become Nobel Laureates, Peyton Rous and George Whipple.

Welch was the “ringleader,” Duffy notes, of a circle of early Hopkins faculty who were “enchanted by the German biomedical model of education.” What they were so enamoured of is contained in a book by a Prussian-born surgeon, Theodor Billroth. When the book, The Medical Sciences in the German Universities, was translated into English in 1924, Welch wrote an introduction. “The book is astonishing,” comments Duffy; among its other qualities, it is highly anti-Semitic. “When it was published in Vienna, there were riots. There are statements to the effect that patients should relate to their doctors the way a servant does to his master. The book is heavy on ideas and knowledge. There is no hint of ideals.” In embracing Billroth and German-style medical education, the medical profession in America “set forth on a journey of garnering knowledge, but never the recognition that a life in medicine is one of service.” More on this in a minute.

Duffy credits the tradition of clinical excellence at Hopkins to the other philosophical branch – the work of Osler, “his extended influence on many people, his words, his writings. I believe that he inhabits the air of Hopkins; he always did for me.” The clinicians who taught Duffy carried on the “sacred responsibility” of Osler’s clinical excellence. “The tradition doesn’t just happen on a Tuesday or Wednesday; it takes a heritage that is capitalized upon and that people continue to be excited by and about. Medicine is an oral tradition. It’s passed on, as emblazoned in the Hippocratic oath.”

At the same time, not sufficiently valuing clinical excellence in and of itself is a problem endemic in academic medicine everywhere. “It’s a very constant refrain.” At a medical meeting several years ago, Ken Ludmerer – Pulitzer Prize-nominated medical historian, professor of history and of biostatics at Washington University in St. Louis, and longtime friend of the CIM – made a comment that stuck with Duffy. “He said that there were a remarkably large number, a laudatory number of (faculty) chairs at his institution, and not a single one was occupied by a clinician. And then he said, ‘Not only is that unfair, that is unethical.’”

Duffy points out that the real currency at academic medical centers is the generation of new knowledge, “which in our world is usually lab-based. I think the mistake that institutions make is that clinical excellence does not compete with scientific excellence. My prejudice is that they are synergistic with one another.”

“People think I’m naïve, that my conception of medicine as the richest life that any human being can live – if they choose it for the right reasons – is naïve.”

But clinical excellence, Duffy believes, by itself is not enough. And this leads us back to service, and grace, and the focus of Duffy’s talk. “One has to understand where fulfillment is,” he says. “What constitutes grace in the everyday life of a physician? I believe that it is in encountering patients, and caring for them. I’m never going to win a Nobel Prize, but I have repeated moments of grace as a result of my life in caring for other human beings,” in responding to the call of others. “People think I’m naïve, that my conception of medicine as the richest life that any human being can live – if they choose it for the right reasons – is naïve. These days, many of the wrong reasons are leading people to be very unhappy in the profession,” and society is unhappy with medicine, too. “Isn’t it strange that at a time when medicine can do so much, when medicine is at the zenith of its scientific and intellectual knowledge, that things fall apart? That old center is not holding.”

Duffy recently re-read The Immortal Life of Henrietta Lacks. Lacks was an impoverished tobacco farmer and patient on the “colored” ward of Johns Hopkins Hospital in the 1950s. Her cells were taken without her knowledge, cloned and used in developing the polio vaccine, gene mapping, in vitro fertilization (IVF), and many other projects, for which she received not a dime. “I knew all of the players – Richard TeLinde, Georgeanna Seegar Jones and Howard Jones,” pioneers of IVF. “These were the Southern gentlemen and gentleladies that I respected and wanted to grow up as. But no one had a hint of real service. They were learning from their patients and generating new knowledge and publishing new textbooks. I’m not condemning; I understand them. But it was a culture that was remarkably late in understanding that physicians lead a life beyond the ordinary.”

Grace is usually talked of in a theological context. So, “where is the secular equivalent?” It is in the act of reaching outside oneself. In his lecture, Duffy moves into the profound thoughts of philosophers, including the French mystic, Simone Weil, who described grace as occurring when one human being looks with loving tenderness upon another. He talks about another French philosopher, the Jewish scholar, Emmanuel Levinas, who said that nowhere is this grace more evident than when a human being looks upon the other who is suffering and dying. “In every patient encounter, there is a reciprocity that results in the gracing of the physician in fulfilling the call of the other.”

Clinical excellence – and scientific achievement, for that matter – are the means to a greater end, Duffy says. Not the end in themselves. “I think we don’t educate our young people properly. We educate them to believe that their fulfillment in medicine is purely intellectual. They do not capitalize on the richness, the joy that comes with acknowledging this solar battery that is available to them. They are looking for fulfillment in the wrong place.”

But fulfillment can be found in the gift of grace, and this comes in “responding to the call of others and giving ourselves and our knowledge.” It happens, or it ought to happen, when the physician reaches outside the self toward another. The simple act of raising the stethoscope is just the beginning.

August 2nd, 2015

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Aliki in the Real World

aliki_in_the_real_worldMaybe it’s happened to you, or to someone you know: You go to see the doctor. You sit there, in a gown on the examining table, doing your best to describe your symptoms and confide your worries to…the top of someone’s head! Or a profile! Because the doctor is typing away at your electronic medical record on a computer, not looking up before firing the next question at you. There is no eye contact. You leave the office with a prescription, or maybe an order for a lab test, and also kind of a sad suspicion that the doctor doesn’t really care much at all.

It shouldn’t be that way, but it is – for a lot of people, all over the country. Which is why Sujay Pathak, M.D., who just finished his medical residency at Johns Hopkins Bayview, has made it his goal to “Aliki-fy” his practice with Johns Hopkins Community Physicians at Wyman Park Medical Center in Baltimore.

“I don’t get more than 15 or 20 minutes with each person,” he says, “and I don’t try to handle everything in each visit. I just try to work from the standpoint that we’re going to start by knowing each other as people.” He spends the first few minutes of each visit just talking with his patients, finding out who they are, asking about their families, what they like to do for fun, where they grew up, how long they’ve been married. “If they’ve been married more than 20 years, I ask them what’s the secret. I tell them I just got married a couple of months ago, and I want to learn from them.” He also asks his patients what they prefer to be called; nicknames are important in his inner-city urban population. “A lot of people don’t go by the first name that is in their chart.” For example, one man named James goes by Jelly; a man named Byron is Buddy to his friends; another man’s nickname is Cougar.

“I find myself incredibly happy in my medical practice.”

Then, Pathak writes it all down in the chart. “I think I end up painting a pretty vivid picture. I learn about their kids, their grandkids, where they work. I have a really bad memory, but before I walk into the room with a patient, I look at the chart and remind myself who they are. I remember who this person is, and what their face looks like. And then, when I ask them how their wife is, their faces light up, because they realize, ‘This person knows who I am, and cares about me.’ Just because I took the time to jot it down. That makes a really big difference.”

“I learn all sorts of things that directly influence their health care. Most guys just won’t tell you that their wives are dying of cancer unless you ask.”

Pathak believes that by developing a relationship with his patients, he can have a greater influence on their health. “I work a lot on behavior change,” he says. “I tell people what the guidelines say, how much you should be exercising, what you’re supposed to be eating and not eating”– but none of it comes as news to most of his patients; they already know it. So, Pathak gets his patients to set small goals that are reasonable – nothing earthshaking, just little changes that can add up over time.

“I will say, ‘In three months, Cougar, I’m going to ask you, are you still doing X, and I want you to say yes. What X is, is completely up to you. You know yourself, you know your life, how much time you have available to you. Tell me what you can do for exercise, or eating, or whatever goal we’re working on. Tell me what’s realistic.’ And I put it in their chart. Then I shake their hand, and I put a little note in the chart that says, ‘His goal today is X, and we have shaken on this.’ And then I show them the note and that we shook on it.”

Pathak has been doing this for about nine months now, and while some of his patients don’t keep to the goal they set, many of them do – because it was their goal, not the doctor’s.

“This is a fantastic setting in which to practice Aliki medicine,” he says. Knowing his patients as people has been essential: “I learn all sorts of things that directly influence their health care. Most guys just won’t tell you that their wives are dying of cancer unless you ask, and it’s going to be a hollow, empty experience for them unless I ask, ‘How’s your wife, what stage of treatment is she going through?’ But people don’t volunteer this information.” You have to ask.

“I find myself incredibly happy in my medical practice,” says Pathak. “It’s gratifying to call patients about their lab test, and have them tell me that I’m the first doctor that’s ever called them. And they’re 70. Considering that many of my patients are veterans, or widows of veterans, and given the sacrifices they have made for all of us, I find this both heartwarming and sad. But at least they can tell I’m doing something different.”

For the vast majority of his patients, Pathak says, taking this little bit of extra time each visit just to talk “creates an almost immediate bond between me and them that helps us get somewhere,” and helps him find the best way to help his patients improve their health. For example, “if I know they are active in church, we discuss exercise plans that involve walking around the sanctuary a few times a week. If they tell me they are afraid of crowds, we discuss home workouts.” If a patient doesn’t adhere to a plan, “I know to start asking about their mood, or their family stresses, or what other roles they play that force them to put their own health last.”

“Their faces light up, because they realize, ‘This person knows who I am and cares about me.’ Just because I took the time to jot it down. That makes a really big difference.”

Best of all: “I’m bonding with this lovely group of patients. I can see myself staying here for the rest of my career, aging alongside my patients, maybe caring for their children. It’s a thought that brings me a lot of joy.”

August 2nd, 2015

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The Art of Personomics

the_art_of_personomicsRoy Ziegelstein, M.D., a Miller-Coulson Master Clinician, cardiologist, and now Vice Dean for Education at the Johns Hopkins School of Medicine, was part of the Aliki Initiative from the ground up. He was there, talking for countless hours in those very early meetings a decade ago with David Hellmann, Colleen Christmas, and Cindy Rand, and later with Janet Record and Laura Hanyok, about what medical students and residents really need to know so that they can care for their patients.

He was there when they figured out how to implement a curriculum of caring – teaching young doctors, down to a handy list of questions they could keep in their pockets, exactly how to glean the nuggets of who was lying in that hospital bed. How to learn just who that person was: What was her life like; how many medications was he supposed to take (and how many could he actually afford); did he have a way to get to the drugstore or buy groceries; was she taking care of an ailing spouse as well as herself?

Always, they told each other and taught their students, it was the person who mattered most. They quoted the great Sir William Osler, the first professor of medicine at Johns Hopkins, who said more than a century ago, “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”

“People have different personalities, resilience, and resources that influence how they will adapt to illness. So basically, a disease that can turn one person’s personal and family life upside down may not affect another person the same way at all.”

The Aliki Initiative’s philosophy and methods are disseminating throughout Johns Hopkins and, in our graduates, beyond our walls into the community and beyond. Recently, in an editorial in the Journal of the American Medical Association (JAMA), Ziegelstein talked about these principles using a new word: Personomics. “The suffix, ‘-ome,’ or ‘omics’ is often added to an area of human biology, conveying the impression that the field is supported by hard science,” Ziegelstein says. “Given the importance of the psychological, social, cultural, behavioral, and economic factors of each person, it seems only fitting that ‘personomics’ be added to the precision medicine toolkit, and that it be used to refer to an individual’s unique life circumstances.”

He wrote the article in response to another editorial that appeared in the New England Journal of Medicine. In the NEJM piece, Francis Collins, M.D., Ph.D., director of the National Institutes of Health, and Harold Varmus, M.D., Director of the National Cancer Institute, had commented on President Barack Obama’s new Precision Medicine Initiative. They discussed the remarkable possibilities for improving health by determining each person’s individual genotypes, gut microbes, and other uniquely tailored sets of data.

Indeed, “the possibilities are almost unimaginable,” agrees Ziegelstein, who is also the Miller Scholar. “However, an important element has been left out of the discussion. Individuals are not only distinguished by their biological variability; they also differ greatly in terms of how disease affects their lives.” And this is where the Aliki approach has proven so valuable. “People have different personalities, resilience, and resources that influence how they will adapt to illness,” Ziegelstein continues, “so that the same disease can alter one individual’s personal and family life completely and not affect that of another person much at all.”

Also – a point the CIM has been making for years with its Pyramid model of academic medicine, which puts the patient and the community at the apex – “diseases do not just affect individuals; they affect their families and friends, and their communities.” All of these factors can help or hinder someone’s resistance to disease and response to treatment. “The influence of the unique circumstances of the person – the “personome” – is just as powerful as the impact of that individual’s genome, proteome, pharmacogenome, metabolome, and epigenome,” Ziegelstein argues.

Because residents as well as community physicians now must log so much time at the computer, working on government-mandated electronic medical records, they often get to know the virtual patient – the one whose lab values and CT scans they’re reading on the screen – better than the actual, flesh-and-blood man or woman sitting just a few feet away in the clinic or hospital room. “The paucity of time spent with the patient, coupled with an overreliance on imaging and laboratory tests, has eroded history-taking and physical examination skills,” Ziegelstein writes.

Also, most medical schools don’t really teach students about real-life variables such as behavioral, cultural, or financial issues. These might include a patient’s ability to pay for prescription drugs or physical therapy; the availability of fresh groceries for a better diet, and cultural impetus to choose healthy foods over soda and chips; a safe place to exercise and the opportunity, and desire, to do it.

“The importance of understanding each patient as a person is as critical…as anything else in medical school or residency training,” notes Ziegelstein. “It is not simply that it improves patient satisfaction or contributes to the joy of medical practice, it actually contributes importantly to identifying the correct diagnosis and optimal treatment for the individual patient.”

Knowing the person is just as essential as understanding the patient’s molecular biology and genetics. “The potential of pharmacogenomics to allow health care providers to prescribe the right drug at the right dose to the right patient matters only if this treatment is available at the right pharmacy at the right price so that it will actually be taken in the right amount on the right day at the right time.”

The take-home message, in an age where medical technology grows more sophisticated than anything we could have imagined a few decades ago, is that it won’t ever be truly personalized medicine if the doctor doesn’t have any idea who the person really is.

August 2nd, 2015

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