Hopkins Humanity and Medicine Conference

Humanity and Medicine Conference
Johns Hopkins School of Medicine
December 10, 2016

submitted by DJ Elpern

Hopkins SymposiumThe Turner Auditorium. I haven’t been in this room for 37 years… Not much appears to have changed. It is an imposing amphitheater that suits the Oslerian tradition of Hopkins.

What follows are some random notes I took.  There was much more that I missed.  It was a day of rich pickings and I wish I could have gorged on more that was offered.  The following photo could be a key theme of this day at the Turner Auditorium.  The physician (observing) not doing something to the patient.

Osler contemplating

William Osler Contemplating (circa 1903)

The meeting began with a stressing of the importance of the social history as the place we should start with patients. Later in the day, Lloyd Minor, the Dean of Stanford showed a pie chart which illustrated this. Sixty percent or so of how we are sick or well is determined by social and environmental factors. How sad it is that we usually ignore this. Someone quoted, Osler  “to learn medicine by studying the individual patient,” advocating what he called the natural method of teaching, in which the student “begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end.”

(At the conference, they were using a conference hashtag #conf hashtag – for questions and comments – I am not sure how that works; but any millennial can teach me)

Yuri Agrawal, one of the key organizers of the conference, and introduced a number of the speakers. She is an ENT surgeon and researcher. She shared some of her thoughts re: millennials. She feels that medicine is no longer a dyad (patient and doctor), but now it’s a team activity – the patient, a team of physicians and the patient’s caregivers and family. I am not convinced that this is the epitome, but agree that there are roles for both approaches and that the dyad is fast disappearing as a common model.

Kenneth Ludmerer : see his books. Review of Let Me Heal
He compared the practice of medicine when JHH was founded ~ 1893 and contrasted that with 2016

Now, in spite of all the amazing advances, there is more patient dissatisfaction with medical care than 100 years ago. Presently, doctors seem primarily focused on their income! (American medicine: home of the brave and the land of the fee.}

We have problems with the soul of medicine, not the technology.
Where we are failing as physicians?

  1. Inadequate listening
  2. Inadequate understanding of the distinction between disease and illness
  3. Inadequate physical examination
  4. Flabby thinking
  5. Hand on the door phenomenon
  6. Cutting corners
  7. Failure to view the patient as a friend

(Indeed, many physicians today regard the patient as an adversary)

There is a prevalent failure to view the patient as friend – instead we regard them as cash cows. “I need my doctor to be my friend.”

Many patients today are asking whether the physicians in the health care system are on their side?

Indeed, there are many times when patients need protection from medical care!

Origins of some of the Dilemmas regarding Medical Care

  1. Decline of clinical skills
  2. Loss of time doctors spend with patients. Turnstile effect (hand on doorknob)
  3. Absence of academic and professional leadership. They are too busy in the lab and applying for grants

We need to teach trainees how to be physicians. Who will do that?

RESTORING THE SOCIAL CONTRACT
The values of medicine are timeless – they go back to the Greeks

Daniele Ofri
A show woman!
This TED talk is very similar to her presentation at JHH.
She stressed the importance of fear to us as physicians.
Fear is a perfectly normal state for a physician to be in.
It’s true that we, as physicians, learn to live with fear
She also talked about the shame we feel after we make errors.
Shame can put us in a fog!
We need to address how we face our mistakes because making errors is part of the human condition.
There is a difference between curing the patient and healing the patient

We all make errors with patients. If you disclose your error to the patient, the patient may actually come to trust you more.  There are two victims of medical error – the second victim is the doctor who made the error. Some physicians become dysfunctional, some even commit suicide.

Panel Discussion students and residents (This was possibly the best part of the program)
Daren Simkin related a memorable anecdote… (He kindly sent it to me)

“My first week on medicine clerkship at Bayview we were taking care of a patient in late middle age. a gentleman who had pancreatic cancer and diffuse peritoneal carcinomatosis. He hadn’t had a bowel movement in a week or so. His abdomen was grossly distended, hard as a rock, and his eyes were starting to bug out of his sockets.
We had just finished a rather tense meeting with his wife and two adult daughters to talk about hospice. We retreated back up to his room when suddenly he, who had been leaning against the table, breathing desperately, suddenly froze and started to vomit. We helped him onto the bed, onto his side. He continued to vomit out his last breaths as his wife ran into the room, jumped in bed alongside him, spooned him, and said “I love you pumpkin… I love you pumpkin”. She said that over and over again.
Their two adult daughters jumped on the bed as well. One of them tried to lead the others in a rendition of the Beatles’ “In My Life”. The first verse worked pretty well and then it sort of dissolved.
I think of this scene because it was uncomposed, it was clumsy, and it was vulnerable. It was humanity. And I remain struck now by the difference in how the patient and his family were reacting to the scene and how I, as a trainee, was reacting to the scene – observing and absorbing the details.
How this is going to impact my patient care in the future, I don’t know. I guess I’ll find out in the years to come.”

A black student told us a powerful story about s young black father and his baby in the Pediatric ER.  They called security to escort him away from the doctors.  She felt shee could have defused the situation with a simple act of kindness.
This was a successful session.  It could be repeated.

The students were asked, “Has your own humanity increased or decreased in medical school and residency?
“We meet people from all walks of life – this is a plus.”
“Sometimes we are too rushed to honor the patient’s humanity.”
“Take the time to listen to our patients”
One student addressed the humanity piece – she has to take TIME (a 4 letter word)
So much of this gets back to the importance of the social history

Seeing humanistic medicine in practice may be a way to learn (modeling) to be humanistic.
We Need to communicate our PRESENCE to the patient

Humanity can look very different but still be present

A speaker asked us to google “nurse” and google physician and see what kind of images are retrieved. The nurse images are generally warmer and more welcoming, more humane.

It’s important to patients when you, as a physician, find out who they are. Treat the patient who has the disease, do not just treat the disease the patient has. (Attributed to Osler, but he never said this.)

How to privilege the information on the web…

The students of today are much more comfortable with the EMR than older docs, therefore, the EMR may not be such an I’m impediment to them.

Jacek Mostwin. jmostwinATjhmi.edu
This was an excellent, thought provoking talk. Is it written up?
See also: Engaging the Spiritual Dimension: A Doctor’s Tale. This is a moving video written and produced by Dr. Mostwin

This talk focused on Pathographies (sometimes called Autopathographies)
“What matters is that all this did happen.” Book memoir about the holocaust by the Polish-Jewish pediatrician, Janusz Konczak

What do biographies and memoirs tell us?
Pathographies…   Dorothea Lynch Breast cancer memoir. Exploding Into Life

Auto-pathography is the patient’s story. J Aronson get article.
“It’s what I’ve done”
BMJ. 2000 Dec 23; 321(7276): 1599–1602.

Autopathography: the patient’s tale Jeffrey K Aronson, clinical reader (About JKA)

Pathographies are often written by writers! But each patient’s story can be one. We need to record the pathographies of “ordinary” people. Maybe something like Story Corps for illness narratives.

The writing needs to come from a deep place of need. Not important that it be literary.

“A Hole in My Life”: Battling Chronic Dizziness” is a book Philippa Thompson.

Lloyd Minor: Dean, Stanford University School of Medicine
The implications of precision health
He’s a politician… In my opinion, he was selling Stanford Medicine
Hi tech has to enable hi touch. – that’s the challenge
Minor feels the 21st Century is that of biomedicine
A book used for Stanford medical students by Sheri Fink “Memorial Hospital” is about the aftermath of Katrina and the ethical dilemmas faced by the physicians and other staff. (It was a powerful and harrowing book)

Stanford Letter Project. This can be applied to more than just end of life issues. I think all of us would benefit from filling it out. The letter is a useful tool.

Role of social determinants of health. See Minor’s photo social and environmental causes of health and disease.

Determinants of Health

Determinants of Health

Physician Panel… How physicians can benefit from the humanities

2nd panel speaker (David Hellman) described an asthma patient’s ER visit on Sept 13th, 2014 – The patient has lived in NYC on Sept. 11, 2001 and her asthma was a manifestation of PTSD. You had to know the patient to draw this conclusion. – ( See FT Fitzgerald – on Curiosity)

What happens when we do not know our patients? – We then treat them at our and their peril!

Peter Pronovost “What’s the most important thing in the world? “It’s the people, it’s the people, it’s the people” (Maori saying: He aha te mea nui o te ao? He tangata! He tangata! He tangata!). We need a human-centered medical culture. This is important! KEY
WHAT’S YOUR JOB? (The Parable of the Three Stone Cutters relates to the way we practice medicine). Pronovost is worth listening to. Love (agape?) underlies what we should be doing. Micro-moments of love in our workplace. (My secretary models this.) It happens. Pronovst told a story about stopping at Dunkin Doughnuts on Valentines Day on the way to do rounds with the residents. The shop was frequented by homeless people getting out of the cold. He bought breakfast for a homeless couple, and then many of the other middle class customers followed his example by treated other homeless who were there to coffee and doughnuts. Love is contagious. (see the last lines of The Bridge of San Luis Rey)

Robert Higgins spoke –he is a transplant surgeon who believes that surgery is the science of hope.

see Emily Dickenson:

Surgeons must be very careful
When they take the knife!
Underneath their fine incisions
Stirs the Culprit – Life!

When treating patients we need to think, with every one, that they are “just like me”

AN ONCOLOGY NURSE’S COMMENT- she reflected on her interactions with patients – She was with a dying woman, and the pathos caused her to cry and she could not hide her tears from the patient. She was mortified that she had acted so unprofessionally, but the patient said, “Thank you for crying” – Her crying showed that the patient’s suffering was recognized, was honored. The nurse’s story was moving and genuine.. We have to show that we care. (Osler wrote about “aequanimitas” – but this has been misinterpreted. In his life, Osler showed that he, too, could cry. Cushing describes examples in his biography of Osler)

Abraham Verghese –
CP Snow introduced the concept of The Two Cultures (the Humanities and Science) in the Rede Lecture 1959. Verghese proposes there are three cultures. The Humanities, Science, Technology.

When, as physicians, we treat patients “evidence based medicine” is often held up to be the gold standard. Yet, averages hide the fact that each patient is unique, each is an individual.  – There is a technique of photo-merging that blends up to 2000 photos of faces! The result is a composite – not an individual. This translates into a bland approximation of a human. Can one treat the average? This is the problem with EBM – it creates composites.

Verghese showed a picture of Osler contemplating a patient at the bedside..

Verghese spent some time on Sir Luke Filde’s painting, “The Doctor.” The back story is that the scene depicts the artist’s son who died at age 8 on Christmas eve. The focus of the painting is on the patient, not the doctor. It might have been called “The Vigil”

Sir Luke Fildes, 'The Doctor' exhibited 1891

The Doctor by Sir Luke Fildes (1901) Housed in the Tate Gallery

Patient dissatisfaction – A Broyard. quote.
I wouldn’t demand a lot of my doctor’s time; I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once. I would like to think of him as going through my character, as he goes through my flesh, to get at my illness, for each man is ill in his own way. Proust complained that his physician did not allow for his having read Shakespeare. A. Broyard, Doctor Talk to Me. NY Times, August 1990

Verghese alluded to the fact that doctors treat patients they don’t really know. We don’t know the depth of their lives. We see them at a moment in time. He alluded to something called the Social Biome and illustrated it with a story about his mother who just died a few weeks ago. Who, at the fancy and prestigious Boston Hospital she was in, had, or took, the time to get to know her? He asks, “Who really knows the patient?” She received the best care, but no one knew her

Sinski AIM 2016 (can’t find this)

Also see:
Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes.
Verghese A, Charlton B, Kassirer JP, Ramsey M, Ioannidis JP.

He feels there are really Three Cultures: Medicine, the Humanities, Science and Technology, and we need to integrate all disciplines. (And I have felt, for years, that our three cultures are Medicine, the Humanities, Science and Business – and the last one dominates in our practice of medicine today.

Verghese has recently founded a new “institute” at Stanford called Presence: The Art and Science of Human Connection. – He has written, “In a world where we are hyper-linked by technology, we are increasingly separated by a lack of human connection. Even as technology is critical to quality and safety in the delivery of care, it inadvertently creates barriers between the patient and the health-care team.”

To quote Verghese, “At its heart, medicine is a human to human business.”

 

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