Humanism for Patients

On April 23^rd, Dr. Don Berwick gave a lecture at Yale School of Medicine for the Humanities in Medicine series. Each lecture in the series is named after someone special. This particular lecture was named after Dr. Morris Dillard, who was actually my interviewer when I was applying to Yale medical school. Dr. Dillard, who I guess is about 80 years old, is still very sharp and active in the Yale clinical community. In fact, he was the one who stood at the door to the lecture room, and personally greeted everyone. When he saw me, I worried that he would not remember or recognize me. Immediately, however, he smiled at me, and made bowing motions with his arms as if he was playing a violin. He had remembered me after all, recalling our interview when we had talked about me playing the violin during medical school and afterwards. He still remembered this aspect of me, over a year later.

Don Berwick’s lecture was about many things. As a first-year medical student, what I took away from the talk was the importance of humanism, a concept that is repeatedly thrown at us in our pre-clinical clerkship course, but which rarely sinks in unless delivered with inspiration and precision. At this early stage, when we are beginning to develop our habits, routines, and attitudes regarding helping the patient, learning about humanism is critically important.

We were told about being a humanistic doctor. Dr. Berwick’s personal experience of learning about humanism came, in part, from one of his patients at Children’s Hospital in Boston, where he was an attending. He described a young 14-year old boy, with a chronic illness, who had been admitted to the hospital over 80 times. This boy told him three ways to be a better doctor. First, he said, please, please, tell me what you are going to do to me, before you do it. Second, talk to each other more (and this point was directly related to a larger topic of the talk, the fragmentation of the health care system). Third, ask me (the patient) for help. Patients often know more about their condition than their doctors can ever hope to know. So, it is our responsibility to ask. In a very moving manner, Dr. Berwick shared with us something very personal about his own health and what his health means to him, something that none of his own doctors know about, which allowed us—future, current, and retired physicians—to experience first-hand how incomplete our ability to care for our patients is if we never ask, what do you want? What does your health mean to you?

Finally, always thank your patient. Thank them for coming in, thank them for sharing their secrets with you, thank them for placing their trust in you. Dr. Berwick made these points in reference to Dr. Dillard, who continues to exemplify the best humanism a doctor can have. If Dr. Dillard is able to remember that I play the violin, over a year later, I have no doubt how grateful his patients must be for his strong sense of genuine care and appreciation for others.


-Adam Sang
1^st year med student

Tell me...

As a first year medical student, I spend most of my time in lecture halls dimly lit by computer projectors learning the basic sciences of medicine. Once every week I get the chance to escape from the lecture halls and spend time in the clinic with patients through a yearlong course where we learn and practice different elements of the patient interview. This course is a welcome reminder of a core reason we are drawn to this profession. However, these experiences are not without challenges.

One of the first concepts we are introduced to is building rapport with a patient and getting to know them as people. Upon this foundation, we add layers of information regarding the patient’s current illness and medical history, social support and family history. Our preceptors also incorporate in these lessons introductions to how to discuss tough issues such as alcohol and drug use, sexual history, and domestic violence. For myself and many of my classmates, it has been difficult to become comfortable with assessing when these questions are appropriate and how to discuss them in a nonjudgmental manner. Even when the patient is actually one of our preceptors role-playing, these patients are strangers and establishing mutual trust is difficult.

Whether asking about possible domestic violence or gathering all the details of the present illness, an overarching challenge that I have encountered as an interviewer is to avoid jumping to conclusions based on a patient’s initial responses. Sometimes, the excitement of remembering a detail in class that might apply to the patient (“It’s the positive pleural pressure!”) inadvertently directs me to jump to specific, closed questions that may miss an important component of the patient’s health. I have to constantly remind myself to go back to the broad, open questions, and I imagine that this balance will be easier with more clinical knowledge and experience.

A challenge from a different perspective is a patient’s reluctance to reveal all the facts or not knowing what information is pertinent to his or her health. The issue is not as simple as the stereotype of patients who lie because they think it will please their physicians, and I did not begin to appreciate this complexity until the first time I was a patient since starting medical school.

My recent visit to the university clinic was for a routine annual physical. As my physician began to ask the same questions that I had been learning throughout the year, I had a feeling of being a detached observer of the interview. I thought to myself, “Well, this is how I would expect a patient to answer,” and then I realized that it was I who was the patient.

For a few questions, I experienced a split second of hesitation to wonder if what I was about to say would be an important detail or if it was just medical school-induced hypochondria. Small things like past tobacco use or an unusual mole. Feeling compelled to be a “model” patient, I did report this information to my physician. She smiled and told me that the occasional cigars in college did not constitute being a past smoker. However, my physician also examined my skin and referred me to a dermatologist. Reflecting on these minimal internal debates, I can only begin to understand what it would be like to be wary of discussing much more serious and personal issues with a physician.

I do not think addressing these issues of communication between patient and physician are as easy as reaffirming confidentiality of the interview. In my observations, the physician does set the stage by expressing empathy and trying to build a connection. I have been surprised that silence can be as effective in interviews as follow up questions. A purposeful pause following a patient response can lead to the patient reframing a more complete response and revealing a significant detail. Yet, I worry if there will be the ability to conduct full interviews as time becomes compressed through medical school and during residency. I hope that my classmates (and future colleagues) and I do not forget the skill of maintaining a full dialogue with our patients.

-Michael Jaung
1st year med student
Harvard Medical School

What do you wish you were learning?

If you're like most students, you probably don't have much of a say over what you're learning in school. You may just be focused on making it through in one piece.

But are you learning the things you'll need to know after graduation?

During today's On Call teleconference, Dr. David B. Nash* listed five crucial skills that most health professions students aren't learning in school. These abilities included the following:

• Working effectively in teams
• Understanding work as a process
• Collecting, analyzing, and displaying data on the outcomes of care
• Working collaboratively with managers and patients
• Being able and willing to learn from mistakes

All these skills, Nash argued, are necessary if students are to improve care and patient safety.

Continue or join the conversation. What do you wish you were learning in school? Do you think the skills listed above are really crucial? What will it take to change what's routinely taught to students of medicine, nursing, pharmacy, and other health professions?

If you're a faculty member, what are the obstacles you face in changing the curriculum? What successes have you had?

You can post your thoughts by clicking the "Comment" button below this post. David Nash will be checking this site and will respond occasionally. Also, check back here in a week or so for a link to the audio recording of the call.

*Nash, MD, MBA, is a professor of health policy and dean of the Jefferson School of Population Health in Philadelphia, Pennsylvania.

26.22 miles

Today is Patriot's Day and over 26,000 people have come together to run the Boston Marathon.

It's 26.22 miles. That's about the distance from Fort Lauderdale, FL to Miami, FL. That 35-40 minute drive is one of the main reasons why I don't make the trip down to Miami more often.

On average, it takes about 4.5-5 hours to run the marathon. In my world, that's how long it takes me to get from Boston to New York on Bolt Bus. If it wasn't for the promise of good company in New York, I would never board the bus.

Training usually takes a minimum of five to six months of running at least 3-4 days a week. The only things I can think of that I have done consistently for that length of time include eating, sleeping, going to class, and going to work!

Running the Boston Marathon or any race is an achievement that extends beyond the triumphant moments of fist-pumping at the end of the race, beyond the length of the race, and far beyond race day. The finish and the race are just short episodes in a much longer narrative journey. Only when the race is taken in the context of the journey does it become truly meaningful.

Take Dick and Rick Hoyt for example. Of the thousands and thousands of runners who have run the Boston Marathon, Dick and Rick are just two in a sea of people. Their best time is an astonishing 2:40:47. This moves Dick and Rick into smaller and distinguished group of people. But more important than the numerical time accomplishment is their narrative story.

Dick and Rick Hoyt are probably the most recognized duo in the history of the Boston Marathon. Dick is Rick's father and Rick has cerebral palsy. After Rick's diagnosis, doctors had recommended that Rick be institutionalized, but his parents refused and promised to help Rick lead as normal of a life as possible. Upon realizing that Rick loved sports, Dick and Rick began participating in races with Dick pushing his son in a wheelchair. The two truly embraced their passions for racing and began to participate in marathons and triathlons. Dick would tug Rick in a little boat for swims and Rick would sit on the front portion of his father's bike for cycling. According to Wikipedia, Dick and Rick as of August 2008 have competed in 66 marathons and 229 triathlons!

Now consider their best marathon time of 2:40:47. This father son duo are in the top 90th percentile of all runners. 2:40:47 is no longer just good, it's a remarkable and inspiring time.

Dick and Rick are running the Boston Marathon right now. This is their 27th Boston Marathon. Dick is 68 years old and Rick is 47.

For those 26,000 runners out there today, the Boston Marathon is just an episode of their narrative stories. When they cross the finish line this afternoon, we are not cheering for their marathon time or bib number. We have gathered to celebrate and honor this one achievement in the context of their personal and individual stories. Similarly, in an 8-hour work day, assuming the average 17 minutes a doctor spends with each patient, a doctor sees about 28 patients per day. Patient X at 2PM is not just the 2PM appointment or the girl with the common cold. The 2PM appointment and the common cold are short health care episodes in her individual story.

Anyone who has ever been sick or experienced any discomfort, and that's everyone, will understand that health care is personal. It's a scene that would take at least a second of film time in the average movie. And because it's personal, health care is important to everyone. It is imperative for those who work in health care to not only acknowledge this fact, but honor it. Health care providers have been given the gift of being guests in the lives of others and thus must see their work in the broad context of a patient's family, community, and life as a whole. It's the least we can do as a token of thanks for this invitation into a patient's life.

So, while a cold or any other ailment is not something to be celebrated, please make the effort to remember the name and story that the cold is nestled in. It may seem like a silly reminder since the business of health care is patients, but I'm sure you would all agree that this is often times forgotten. Though when it is remembered, it's magical.

CONGRATULATIONS to Melissa! Our very own IHI Boston Marathon runner!

"Coming Full Circle"

From Pulse Magazine:

Excerpts from Coming Full Circle

By: Stacy Nigliazzo

Only thirty minutes into my evening ER nursing shift, and I was already behind...

...The doctor and I both instantly knew there was no chance of survival. It just wasn't time yet. He removed the speculum, and we watched as the tiny fingers slowly disappeared back inside...

...She smiled and whispered, "Honey, this old body's been very good to me, but I'm tired. It's just time."

To read the entire story and for more gripping short stories, narratives, and poems, subscribe to Pulse Magazine here.

Greetings. I just wanted to relay some observations of how we have improved care in the Intensive Care Unit at the hospital I am at. There are simple interventions you can implement in your own space or institution that will improve quality of care, communication, team dynamics, and patient safety. The unit is a very dynamic place and requires closer monitoring and attention.

In the Unit we have instituted afternoon rounds and midnight rounds where the resident and on-call intern will review the plan for the day and figure out which items have been completed. We will then evaluate the patient via vitals/physical exam/nurse input and discuss the plan for the late afternoon/evening. We then will create an assessment/plan for the next eight hours. During this time we also review medications and discontinue those that are no longer needed or require dose adjustment.

Another intervention is the creation of ventilator bundle set and sepsis bundle sets that are a checklist protocol based system that can be applied to a patient in situations where they need to intubated or taken care of when in sepsis. This allows us to make sure we have incorporated evidence based strategies in taking care of patients that require activation of these bundles.

We also are in the midst of creating Tuesday School (A 4 hour long protected time where residents/medical students participate in interactive medical education with application of numerous topics such as quality improvement and patient safety.

It would be fantastic to create opportunities for medical students in their curriculum during 3rd year with each rotation to spend 1 hour during the month learning basics of quality improvement. The idea would be to engage them to start thinking an observing in a way that may lead to ideas for interventions resulting in quality improvement.

I would be interested in hearing about other interventions and ideas folks have.

For those folks in Boston please make sure you attend the event on 4/23 at Harvard Medical School from 6:30 pm - 9:00 pm where we will go through a case discussion and network with other like minded faculty and students.

Also, Dr. David Nash from Jefferson Medical College will be discussing how to get quality improvement into your curriculum on 4/27 from 4:30-5:30 EST. It will also be a time for you to ask questions and learn some concrete skills.

Have a great weekend!
Jay

IHI Open School Boston Regional Event NEXT Thursday!

If you are in the Boston area...Mark Your Calendars!

Several Boston Chapter Leaders have collaborated to host an IHI Open School Boston Regional Event on Thursday, April 23rd from 6:30-9:00p.m. at the Harvard Medical School.

6:30-7:00 – Introduction/Ice Breaker
7:00- 8:00 – Case Study Discussion facilitated by Dan Hunt, MD and Meridale Vaught, MD from MGH
8:00-9:00 – Social/Networking

Registration is free and food and beverages will be provided. We now have 8 Chapters in the Boston area and I know they’d love to meet with local QI leaders and students. All students, faculty, and health professionals are invited to attend. Please share this with others. If you would like to attend any part of the event, please register by following this link.

I hope to see you all there!