If you care deeply about the practice of medicine – if you value doctors who are not only astute clinicians, but decent people who show compassion and empathy for their patients, and good teachers and mentors who encourage young doctors and doctors-to-be how to care deeply, too – you’re not alone.
This is what the Center for Innovative Medicine’s Miller-Coulson Academy of Clinical Excellence is all about, and the idea has spread from Johns Hopkins Bayview to Johns Hopkins Hospital and beyond, as other institutions adopt the Academy’s ideas and establish similar programs. The Academy has a blog, and from time to time, we here at Breakthrough like to share that blog on these pages. The following story comes from a post by John Marshall, a fourth-year medical student at Johns Hopkins, who wrote about a patient encounter he witnessed during his rotation with an Academy member – “Dr. R” in this story. You can read this and more blog posts at: http://clinicalexcellence.blogs.hopkinsmedicine.org
“Ms. M greeted us cheerfully as we walked into the room,” Marshall begins. “She was a middle-aged Caucasian woman, but the lines on her face and the long white hair made her appear perhaps a decade older.” Ms. M had suffered from major depression on and off for many years and was now in the midst of a relapse. She had lost her job – been laid off when the company she worked for downsized. “She had collected unemployment for six months, but now was without income. While this triggered a major depressive episode, it also made her angry as she lost her independence and moved in with her son and daughter-in-law.”
She had lost her job – been laid off when the company she worked for downsized. This triggered a major depressive episode. It also made her angry.
Ms. M was going through hell, and her depression was accompanied by overwhelming feelings of guilt, shame, sadness, and “episodes of rage where she locked herself in her room for fear of verbally assaulting those she loved,” Marshall writes.
But there’s more – the doctor side of this doctor-patient encounter. Dr. R brought “her own empathetic frame of reference,” and this, “I believe, is what allowed this provider to gather the appropriate details of the story,” says Marshall. Before the visit, Dr. R already knew of Ms. M’s history of depression, her predisposition for relapse, her recent eviction, her medical comorbidities,” and how important her mental health would be in managing these other health problems. Dr. R “actually entered the room with mental health as the most important subject to address, and thus she was able to respond appropriately as the patient divulged the issues most important to her. And as a rheumatologist would ask questions to assess for involvement of lupus in new organ systems and use knowledge of lupus to alert the patient to possible complications, Dr. R asked questions to assess for complications of Ms. M’s social situation.”
Dr. R’s questions included,“How are you getting along with your son?” and “How are you paying for prescriptions?” As it turned out, the answer to this question “provoked frustration on all parties as we realized the pharmacy had rejected her newly acquired Medicaid prescription account, because she had not yet received the prescription card which Dr. R had helped her apply for at her last visit.” Ms. M really needed her prescription; in addition to the depression, she had shortness of breath from chronic obstructive pulmonary disease. She desperately needed an inhaler as well as the antidepressant Dr. R was prescribing today.
“Therefore, in the middle of the visit, Dr. R called the pharmacy, sent her prescriptions over electronically, and double-checked that they would be covered by the prescription plan number in the absence of the card. Dr. R shouldered the patient’s burdens as her own, and not just for twenty minutes in the clinic.”
What did Marshall learn here about clinical excellence? “First, diagnostic acumen cannot be underestimated… But just as importantly, this acumen absolutely must be applied in the context of a therapeutic relationship. An incredibly large amount of progress was made in this patient’s care in twenty minutes because the agenda was motivated by knowing the intricate details of the patient’s medical history, personality, predispositions, and social situation. Every move Dr. R made was motivated by her memory of who the patient was and why certain actions should be prioritized and others should not. And finally, expert care moves beyond empathetic listening and towards the shouldering of burdens carried by our patients. A process happened in the mind and spirit of the provider, whereby she internalized the patient’s concerns, fears, and hopes, processed the most important action items, and actually did them. I feel very fortunate not just to have witnessed true and genuine service today, but to consider how that internalization and move to action will happen in my own mind and spirit for the duration of my career in primary care.”
John Marshall, MSIV
Don Willett November 13th, 2015
Maybe you saw them in high school: the stark pictures of a desiccated multi-pack-a-day smoker, holding a cigarette to the tracheotomy hole in his or her throat. They were shocking on purpose, and this kind of fear campaign worked pretty well for decades. The number of smokers in America dropped sharply from about 45 percent in the 1960s to close to 20 percent today. But there it sits, right around 20 percent. We’ve plateaued. And yet, like a stuck needle on a record player, health advocates have kept on using the same scare tactics to get people to quit – and smokers, who have heard it countless times, are tuning it out.
Culture of health vs. culture of death: Michael Smith, Ph.D., Director of the Center for Behavior and Health (CBH) and the CIM’s Alafouzos Scholar, believes it’s time for a new, positive strategy that celebrates all the good things that come from being a quitter – and he’s got a doozy of a new approach. Because this is CIM where, as Director David Hellmann, M.D., puts it, “we go where the experts are, and tap into others’ skills to be more effective,” Smith went right outside the box for ideas – to the Center for Social Design at the Maryland Institute College of Art (MICA).
“I thought we should talk to some artists and do a collaboration,” Smith says, “and come up with messages that are different, that we could package around a broader area of health behaviors.” To develop the ideas for the campaign, members of the CBH actually went back to school – to sessions of a special class, whose students and professor were focused on building the CBH’s behavior-changing principles into the messages they created. There was a lot of brainstorming, a lot of kicking around different ideas, and a lot of listening. “They ran with it.”
Everyone recognizes that smoking is a huge problem; it’s the number one cause of preventable death. But even though doctors always ask if their patients smoke, and they talk about how smoking is bad, “they have such a short time with a patient to try to effect any change, doctors often feel pessimistic, they don’t know how to counsel.” (Another CIM effort is addressing this, too; see side story.) In turn, he adds, patients are embarrassed. They don’t want to talk about it.” They know smoking is harmful for their health; of course they do – it says so right on each pack of cigarettes. Smoking is prohibited on the Johns Hopkins Bayview campus, but some of our streets are Baltimore City streets, “and people have a right to smoke in those areas. It’s hard to have a coherent policy when you can’t necessarily say no smoking anywhere on campus.” And it’s not just patients, either; many Bayview employees smoke, as well. “We want to create a culture of health at Johns Hopkins Bayview,” says Smith, “and if we’re going to do that, smoking needs to be one of the things we talk about.”
“We want to create a culture of health, and if we’re going to do that, smoking needs to be one of the things we talk about.”
Smith wants to convey another message, as well: what it’s like for someone who is trying to quit. It is really, really hard. Doctors and loved ones may get discouraged if they talk to someone about quitting and the person either keeps right on smoking, or quits but starts back up again. They shouldn’t, says Smith. Very few people manage to quit smoking in one hard-core attempt. Instead, it takes several tries – on average, 11. “Each attempt to quit is not a failure. Instead, smokers are increasing their own readiness to change over time. There may be setbacks, but in the broader perspective, every effort builds on the previous one. If you talk to a smoker about quitting, it may not kick in this time, but it’s important that the seed has been planted.”
The new campaign, says Smith, “meets the audience where they are.” It encourages “health-seeking” behavior, identifies systems of support, including counseling and appropriate medications to help fight the addiction. It is “non-shaming” – this is particularly important, because if people feel ashamed, they tend to withdraw and turn away, seeing judgment instead of a desire to help – hopeful, empowering, and honest. “We want people to know that smoking cessation is not a one-day event, and that quitting smoking at any time has measurable, wide-reaching benefits,” not just to health but to the wallet; and the money saved from an expensive habit can be used to buy fun stuff. The campaign celebrates quitters.
It takes about seven minutes to smoke a single cigarette. So, one arm of the campaign is “7 for 11” – encouraging smokers to swap seven minutes of nicotine for 11 minutes of extra life. The CBH will establish an attractive, engaging “Quit Center,” a place for smokers to go for resources about quitting. “We hope this will take the burden off doctors to be experts on smoking cessation,” says Smith. “Instead, they can refer their patients to the Quit Center.” This “7 for 11” idea will appear many places – at campus bus shelters, on park benches, T shirts, tote bags, buttons, a “Quit Kit” box packed with information, and even an app, on which “quitters can track their attempts, communicate with other quitters at Bayview, and calculate their financial and health savings.” The app also gives progress updates to the quitter’s doctor or counselor.
Very few people manage to quit smoking in one hard-core attempt. It usually takes several tries – on average, 11.
Another arm of the campaign is signage – posters and banners with the message that “Quitters make their dreams happen.” Some of these message may include, “This puff of smoke didn’t buy this trip to Ocean City,” showing a couple relaxing on the beach; or “This puff of smoke didn’t buy this pair of heels,” showing a pair of Jimmy Choo-height pumps. Other posters show a cute puppy, or a Ravens ticket, and even an engagement ring, all purchased with money that didn’t buy cigarettes. A recognition wall, with photos of people who are giving up smoking, will say, “Quitters break free at Bayview.”
“Each attempt to quit is not a failure. Instead, smokers are increasing their own readiness to change over time. There may be setbacks, but in the broader perspective, every effort builds on the previous one.”
There’s a twist on the familiar “do not smoke” symbol – the red circle around a smoking cigarette with a slash through it. A new MICA-created logo is an airy blue circle with a broken cigarette instead of the slash – making the shape of the letter “Q.” This “shows a cigarette being ripped in half, and the quitter is breaking free from being controlled by addiction.” There’s even a board game that shows how hard it is to quit. For example, you may draw a card that says: “Your boss invites you for a smoke break and to keep up a good relationship, you decide to take a smoke with him.” Lose four points. On the other hand, if your card says you decided to meditate instead of smoke a cigarette, you gain four points.
The next step, says Smith, is to pilot these ideas, “test them out, see which messages seem to work best, and which don’t.”
Don Willett November 13th, 2015
Where do we go from here? How can we take what we’ve done to the next level? These are some pretty big questions, and they were the focus of our recent CIM retreat. The idea came from Stephanie Cooper Greenberg, Director of our International Advisory Board. The retreat happened in September, at Greenberg’s home in Baltimore County, and was led by Mike Klag, M.D., Dean of the Bloomberg School of Public Health. On hand were 45 people – CIM Advisory Board members and friends including Patricia Davidson, Ed.D., Dean of the School of Nursing, and Sharon Akers, Executive Director of the Edward St. John Foundation, a philanthropic organization. (For more on Davidson, see story on Page 12, and for more on Akers, see Page 5.)
Greenberg takes her role as a “Hopkins outsider” seriously: “It occurred to me that I need to figure out how to be a translator to the outside world,” she says. “Often in business, we say, ‘I’d like to expand this, or go in this direction.’ I was curious to see where the members of the CIM would like to take their programs, if we could partner with the outside world: What is fundable, what is doable? What if you had more philanthropy, resources that were not internal to Bayview – if money were no object – where would you want to take this? That’s how the retreat was born,” to bring together the very busy people who make the CIM’s initiatives happen, and ask them to think about the next decade. Greenberg offered the use of her home, which is out in the country, “far enough away to get away from the work environment, but not too far away, and not a ballroom in some hotel. It’s very pastoral, very soothing; I thought, maybe that will work.”
“If money were no object, where would you want to take this?”
It did. Vice Dean David Hellmann, M.D., the CIM’s director, built some small-group discussion time into the retreat. Each group was given the task of coming up with a vision for the future direction of one of the CIM’s key areas – the Good Doctor, Precision Medicine, and Medicine for the Greater Good. “Then everyone came together at the end and gave a synopsis of the new vision statement for their programs,” says Greenberg. The members gave themselves more work to do; in future meetings, these vision statements will be thought about and worked on as the group looks ahead to the CIM’s next decade. (Of course, Breakthrough will be covering these plans as they unfold – stay tuned!)
“How do we improve health through interventions that may not touch an individual, but may touch a whole population? How do we create an environment that’s healthy?”
“What is impressive about the CIM,” says Klag, “is that it reconnects people back to why we became doctors, why we’re in academic medicine. Most of us didn’t go into academic medicine to run a practice or think about dollars; we wanted to think about the big picture, we wanted to do research. In this Center, David Hellmann has brought these themes together, and it reminds us why we’re at Hopkins.” Part of it is that most fundamental point of contact between the doctor and patient, “the core of medicine,” the focus of the CIM’s Good Doctor initiatives. “But also, we all know that there are determinants of health so much broader than what happens in a physician’s office” – the CIM’s Medicine for the Greater Good initiatives. “The people at the CIM are motivated to address those determinants because they care about patients. In public health, we look at all those determinants, too: how do we improve health through interventions that may not touch an individual, but may touch a whole population? How do we create an environment that’s healthy?”
Klag continues: “What’s amazing to me is that David continues to lead in a very innovative way. He’s got people doing things that they probably wouldn’t have been doing if they hadn’t interacted with him. It’s a diverse group, and they’re all there because David has convinced them that it’s worthwhile to be there.”
“You have something great here; let’s share it with the world.”
The School of Public Health began two decades after the Johns Hopkins Hospital opened; it was started by one of the Hospital’s founding faculty, pathologist William Henry Welch. “In a way, the CIM is like that,” says Klag, “people who care deeply about the clinical encounter, branching out into how we influence health at large – through behavior change and promoting health, not just fighting disease.” He mentions the ceremony in 1889 at the opening of the Johns Hopkins Hospital. One of the speakers was an English biologist named Thomas Henry Huxley, who talked about another hospital – St. Thomas’ teaching hospital in London. In particular, Huxley talked about two statues at that hospital: one of Aesculapius, the Greek and Roman god of medicine and healing, and the other of Hygieia, daughter of Aesculapius, the goddess of health. “Both had equal prominence,” says Klag, “ and he hoped that someday at Johns Hopkins Hosptial, there would also be a statue of Hygieia. I had the same feeling at the retreat – not only Aesculapius, but Hygeia. It was not only about medicine and curing, but promoting health.”
One of the speakers at the retreat was Akers, who talked about garnering funding to take the CIM’s ideas to the next level. “Some of the synonyms for philanthropy are public-spiritedness, unselfishness, humanity, and benevolence,” she says. “If you core down and look at the CIM, their premise is based on all of that.” She told the attendees that “through your expertise, dedication and leadership, you are truly helping to transform medicine as we know it. You are turning great science, medicine, research, and imagination into innovation and discovery.” Akers also hopes that the people who make up the CIM will “hold in their hearts and minds that they really are doing something that is transforming medicine.”
Greenberg adds, “I think there’s a burning desire in all of us to make the CIM grow and succeed and flourish in ways that it never thought it could. It certainly can; there’s no question about it. You have something great here; let’s share it with the world. At every meeting, every milestone, I expect great things.” When people were “throwing out ideas,” Greenberg joked that the ceilings in the room were pretty high, so there was room for big ideas to be thrown high. The next time the CIM holds a retreat, “Who knows? I might need to take the roof off.”
Don Willett November 13th, 2015