Archives for posts with tag: Johns Hopkins

modern-decor-lucite-giraffe-jonathan-adlerEvery week I precept (teach and supervise) in the residents’ internal medicine clinic at the Outpatient Center of Johns Hopkins Hospital, on Caroline Street in Baltimore. The patients are mostly Baltimoreans, mostly African Americans, though an increasing number are Spanish-speaking immigrants.

I tried something new these past couple of weeks. Whenever a resident presented a patient to me (as is required), I listened to the introduction, smiled, and then let myself interrupt with the following request:

“Please tell me one non-medical thing about the patient.”

You see, most often, the patient is presented this way: “Mr. S. is a 69 year old man with CKD [chronic kidney disease], bipolar [disorder], CAD [coronary artery disease], hypertension and hyperlipidemia, here for followup.” But I was interested in knowing something about the patient as a person, when he’s not in clinic.

The residents’ responses to this request of mine seemed to fall into one of several categories.

There were those who had clearly never thought of such an approach; one said, “The patient is very pleasant. Does that count?” No, I said. A number of residents seemed to recognize that they might indeed ask about, for example, where the patient lives or what they do, but they hadn’t had time.

Still others had asked about such things, but needed to be given permission, so to speak, to talk about such things right up front – to give the patient’s love of crossword puzzles, devoted membership in her church choir, and collection of giraffe figurines the same pride of place as her creatinine and medication adherence.

(There was even one resident who gave a laugh and went right on with her presentation — I’m not sure if she didn’t understand, or was just ignoring me.)

None of the residents gave such personal information about the patient in the lead-in to their presentation before I asked for it. Only certain kinds of knowledge of patients are allowable – their biomedical data, their physiological malfunctions, and (some of) their symptoms. But not their personal lives, not what makes their lives — to them — worth living. Not them as people.

Of course, the criteria of allowable knowledge are transmitted only implicitly in medical school and residency. But they are powerful. They are an atmosphere all around a doctor in clinic – so much so that even I, several rungs above residents in the hierarchy, feel self-conscious asking them to give me one (just one!), apologetically named “non-medical thing,” about a patient. And even then, I must justify it — “It’s about seeing the patient as a whole person.”

What non-medical thing have you asked your patient about, or shared with your doctor?

bioethicsinstitute.org/partnering

It’s time to register (free) for our Partnering with Patients conference, June 1, 2016, at Johns Hopkins. It’s open to all.

Please submit an abstract in any field related to shared decision making. Deadline May 1.

Questions? Seebioethicsinstitute.org/partnering.

Partnering with Patients in Decision-Making: Continuing the Conversation at Johns Hopkins will take place on June 1st, 2016, from 8am to 5pm, in the Owens Auditorium in the Cancer Research Building. Open to all, this meeting will feature discussions of clinical, educational, and research approaches to decision making in the Johns Hopkins Medicine context, emphasizing diversity, interdisciplinarity, and the particular needs of Baltimore. Two keynote speakers with national reputations, as well as a poster session, will help make this a day to assess where we stand and move forward to enable change. The meeting is free of charge.

Our generous sponsors are the School of Nursing, the Patient Experience Office at Johns Hopkins Hospital, and the journal The Patient — Patient-Centered Outcomes Research, as well as the Primary Care Consortium. Institutional sponsors include the School of Medicine, the School of Public Health, and the Berman Institute of Bioethics.

Please respond to this poll to let us know whether you might attend and how you might like to be involved further.
https://www.surveymonkey.com/r/VV25NMS

Best wishes,
Zackary Berger, MD, PhD
For the organizing committee

I am doing some research for a book I am writing – more details anon, at least if it gets written, finds favor in the eyes of my agent, and turns into a bound-and-published butterfly. Some of the resources I needed were only available in the stacks of the Johns Hopkins medical library. To their credit, rather than turning the huge, high-ceilinged bibliotemple into yet another office complex, or tearing it down for laboratory space, the librarians – sorry, informationists – asked the users what they wanted. “Let’s keep the library,” said the users, “but renovate it.”

I use the library an awful lot, mostly as a route to borrow resources from other libraries (often on medical themes but just as often on Jewish topics, which probably confuses somebody). Usually, the library brings books directly to my office, which for me is the equivalent of lying on a couch in my toga being fed peeled grapes. The delivery guy is as reliable as the mythical appointed couriers of the Post Office, making it to my office with snow-covered boots and a plastic bag full of library holdings.

Last week, I got an email that a book I had requested was already available, so I would not get it delivered. “See Notes,” said the email, and then, on the line below: “See stacks.”

Stacks! I had never ventured into the Welch Library stacks. In previous stages of my career and years of school, I had always spent time among the books when I least needed to. I found it a refuge. When everything is supposedly available at your fingertips, sometimes you need to be lured into a space where you find by serendipity, not by search. But here, I have not made the time, or, more likely, not allowed myself the luxury of wasted time.

A friendly staff person showed me the way: “Go down that hallway. Take the elevator.” Then she flitted away as if she had divulged a secret to me and was worried she might be found out. The elevator was a rickety thing, a banged-up box set on a shaft: “Be kind to the next user and close the gate AND the door!” The inspection certificate, defying my expectations, was up to date.

I found the book I wanted, but the quiet was an added gift: a surround sound version of that stillness found in a conservatory, a botanic garden, a chapel. I browsed a set of an Italian biology journal: glossy pages, full-color illustrations, the work of generations of scientists I would never know and never read.

The variety was luxuriant, rich, and ignored, a buried garden inside the very walls of biomedicine’s fortress. When would the voice of the granting authority find me and cast me out? Where was the flaming sword to guard against intruders?

The security guard smiled on my way out. “Did you find what you needed?”

I nodded, showing her what I could from my brief voyage: a bound book.

I had a great interview with Gail Zahtz last week. She really gets it all: the importance of encouraging relationships between patients and their primary care providers; the inequality pervading our current system; and the tensions between academic and community medicine. The interview was two hours by the clock but it went very fast. Have a listen.

I was shocked to read about what some doctors at my institution have been doing. Read the whole article, which is thoroughly researched, painstaking, and – not to mince words – damning. A group of radiologists, with a distinguished senior scholar at the head, have been interpreting X-rays and CT scans against medical and scientific consensus, sacrificing not just intellectual consistency but the fortunes of coal miners and other workers, whose diagnoses of black lung were thrown into shadow, and whose legal suits found in favor of their employers.

We can point fingers at these doctors. If I didn’t work at Hopkins, perhaps I would go on at greater length here about what their systematic deviation from scientific practice means for patients’ lives.

The more you think about it, though, the more you realize that we are all implicated, in greater or lesser measure, in similar activities. Our motives are perhaps not as venal; the connection to coal company’s payment not as relevant. But inconsistency of diagnostic practice, dealing out judgments, interpretations, and prescriptions not based on the best scientific evidence, and depending on pseudoscientific “lore” under the influence of economic factors are all widespread in today’s medicine.

In fact, if you consider how widespread in today’s medicine is the use of non-evidence-based treatment, you understand that this pneumoconiosis story is only the tip of a very black iceberg indeed.

Cross-posted to the blog at Talking To Your Doctor.

Let’s share the glad tidings: Johns Hopkins is again ranked as the number-one hospital in all the land. I’ve written about this before, sharing my misgivings about ranking hospitals. What is the methodology? How sensitive is the ranking to random error, bias, and qualities of hospitals that have nothing whatsoever to do with their – quality, like reputation? What are we supposed to do with that information, who really uses it, and do they get better care as a result?

There are enough misgiving here to fill several chapters of a book, and in fact one chapter of mine is devoted to them. But the problem with measuring extends far past the ranking of hospitals. Doctors are being ranked this way, too, with the idea that public reporting of such information will help people make better choices about their health.

At the same time, many are trying to urge our health care system towards greater patient-centeredness. Various research teams are developing measures to quantify how well a given visit with a physician enables shared decision making on the part of the patient-doctor pair.

So, when presented with an array of various numbers – the rank of the hospital; the quality of the doctor; and the patient-centeredness of the practice – which one should the patient choose? Do we ask patients, as a whole, which ranking they find more important? Is each person to mix up a batch of numbers to find whatever aggregate satisfies their preference?

These are big questions. As I outline in my book, there is evidence that precious few patients or doctors actually use these rankings. Perhaps if we include patient-centeredness in the mix, and automatically generate a weighted average (or some other statistical combination of measures) that corresponds to patients’ preferences, people will feel like they are getting the best doctor they can find. That would be something to truly celebrate.

For the past few months, our Johns Hopkins Division of General Internal Medicine has hosted an internist from Peking Union Medical College Hospital, Dr. Yu Wang [also on Weibo]. She leaves at the end of May. The aim is to help foster a relationship between our two institutions; UCSF and PUMCH are already working together. While I am no expert about the Chinese health system, I wanted to share some of what I learned from her during her visit.图片协和

PUMCH is a tertiary care hospital, similar to Hopkins. But while Hopkins has recently taken the bit of primary care in its teeth, PUMCH, says Dr. Wang, is not about to make that its priority. Rather, the Chinese government has apparently launched an initiative to train tens of thousands of new primary care providers across the country. (Johns Hopkins is newly involved in training some of these at Sun Yat-Sen University.)

When Dr. Wang discharges a patient from PUMCH, she gives them a detailed discharge summary to take to the doctor they next see – not their primary care doctor, because they don’t have one. Nor can she expect that they take the medications recommended for them during their stay in the hospital, because most medications, she says, are paid for out of pocket in China.

I am planning a trip to China to visit PUMCH and I hope to have some first-person impressions then. Meanwhile, I hope to find some general sources about the Chinese health care system to enlighten me. A colleague of Dr. Wang’s, in the emergency department at PUMCH, is also on Weibo, and once I sign up for the service, I look forward to learning more about health care in China.

Thank you, Dr. Wang, for your visit and for helping connect our two institutions!

The people in Baltimore’s poorest ZIP codes die twenty years before those in the richest. I went to a meeting on Friday to try and help the health of the poorest, at least in the ZIP codes nearest to Johns Hopkins Hospital. Federal funding is behind this, as well as considerable clinical and research expertise.

It was a great meeting with important goals and inspiring ideas. At the same time, I felt like we were all blinding ourselves to a problem. We were talking about engaging patients in their care – vital to be sure, and there are a lot of patients who don’t see their doctors, do real damage to themselves, and don’t participate in what others try and do for them. On the other hand, there is a mountain of mistrust between Baltimore and Hopkins. I felt like we were all trying to look over it, and there it was in the middle of the polished table. 

How do we get over that mountain? Are good intentions and practical deeds enough? Is working with the community enough? Is there a way to apologize and make amends without shooting ourselves in the foot?

This post appeared today at KevinMD.

It happened just this week. For the first time, a patient asked me point-blank, “Doctor, why is Johns Hopkins better than any other hospital?”

I took a deep breath. I had to think carefully. It’s not that this was unexpected – Johns Hopkins has been anointed the country’s best hospital for 21 years running by US News. But I wanted to tell the patient the truth without alienating them or failing to mention the many admirable aspects of my institution.

One truth, however, cannot be denied: to call one hospital the best is not simple. 

Let’s start with the US News recommendations. The magazine does not reveal its methodology, but a paper in the Annals of Internal Medicine, a refereed medical journal, showed that the ratings correlate quite closely to the institutions’ reputation, and have little to do with objective criteria

There are methods to rank hospitals besides reputation, but they are still limited. Most publicized has been the dispute over the money that hospitals spend on patients near the end of their life. Researchers at Dartmouth have done a lot of work to control these expenditures for other differences of population and comorbidity. Leaving aside the striking geographic variation in end-of-life costs, the question then is whether the hospitals that spend more are doing so for a good reason. Dartmouth, in general,believes not – but there are other researchers who make the case (usually in more limited geographical regions) that more spending sometimes leads to better care on the part of hospitals

Then, there are methods to compare hospitals according to various measures necessary to good medical practice (“process measures”). Using the Hospital Compare website, you can compare hospitals on the completeness of their medical therapy for heart failure, or the time it takes a patient – in that hospital – to receive antibiotics for pneumonia in their emergency room (not to mention their rates of infection).

Of course, such measures – like any comparisons – can lead to unintended consequences. Some argue that pneumonia is more likely to be misdiagnosed if it forms part of a core measure, since there is no incentive to avoid giving unneeded antibiotics. This is a larger problem – no comparisons are made for lack of waste – but we won”t go into that here. In general, it is unclear whether public reporting of such data improves effectiveness or safety of healthcare.

A bigger problem, perhaps, for the patient-centeredness that  medicine should aspire to, is the lack of reliable, valid hospital comparison measures that are patient-determined. There is a patient survey which attempts to address patient-centered measures. It’s called the HCAHPS, and includes questionsabout doctor-patient communication and whether the patient feels like he or she was listened to in the hospital. (Interestingly, comparing Hopkins to other area hospitals shows no great difference on these measures.) However, the response rate is around 20 to 30% for most questions (it’s a mail-in survey), and there are no questions about important aspects of the patient experience, including whether the patient’s emotions and opinions about the plan of care were taken into account by their providers.

These measures, albeit imperfect, are based on data, unlike the US News rankings. Nevertheless, many patients do look to reputation to help them choose a hospital. Hospitals (like my own) use such rankings for publicity, which in turn influences public opinion about what makes a good hospital.

What does that mean for my workplace? Johns Hopkins is considered by US News to be the best hospital based on its reputation – which is not undeserved. I have wonderful colleagues. But like many other medical centers, we have a lot of work to do to accomplish the much-vaunted triple aim of better health, better-quality healthcare, and lower cost. Like everyone else, the patients we see are not healthy; our healthcare is not patient-centered; and we waste a lot of money. Luckily enough, we are starting to fix these issues in a real way. I hope soon to be involved in making care at Hopkins patient-centered no matter what department or clinic the patient happens to be in. This is a great time to make sure that Hopkins’ ranking justifies its reputation, and show that patients feel that way too, whenever we start to disseminate rankings that patients help determine.