Madam Speaker, as Congress works to extend health insurance coverage and improve the quality of care for all Americans, I would like to commend the Johns Hopkins Center for Innovative Medicine and their Aliki Initiative, an effort to…
Madam Speaker, as Congress works to extend health insurance coverage and improve the quality of care for all Americans, I would like to commend the Johns Hopkins Center for Innovative Medicine and their Aliki Initiative, an effort to restructure medical education with an emphasis on patient-centered care, for creating an innovative program that puts patients first. The Center for Innovative Medicine, launched five years ago by Dr. David Hellmann and Mr. Richard Paisner, has three goals: getting doctors to know their patients as people, members of families and communities; encouraging collaboration among all members of the Johns Hopkins Bayview campus; and creating a culture where everyone on the Bayview campus feels like a part of something special.
The Center's Aliki Initiative focuses on the first goal and has been called the most important innovation in graduate medical education in a generation by the renowned historian Dr. Kenneth Ludmerer. As described in Pharos, the journal of Alpha Omega Alpha, the honor society of medical schools, the Aliki Initiative seeks to train young doctors to get to know their patients as people. Through the generosity of Mrs. Aliki Perroti, internal medicine residents care for patients hospitalized at Johns Hopkins Bayview Medical Center under the direction of Dr. Roy Ziegelstein and Dr. Cynthia Rand. This initiative emphasizes that optimal medical care can only be delivered if medical treatments are tailored to the individual patient, and this can only be done if doctors get to know patients better as people, which sometimes involves visiting them at home after hospital discharge. Dr. Charles B. Green, Surgeon General of the Air Force, circulated the Pharos article to all Air Force Medical Service personnel and said, ``It [the article] emphasizes the necessity for all of us to understand that health care must be patient-centric. We must know our patients and ensure schedules provide time for care teams to spend with patients. We must focus on the patients to help them achieve new levels of health.''
Madam Speaker, I commend the hardworking people at Johns Hopkins Bayview Medical Center, the Center for Innovative Medicine and the Center's Aliki Initiative. Their work should be seen as a model for improving the quality of care for all Americans. I'd like to enter the full text of the Pharos article into the Record.
Teaching Residents to Know Their Patients as Individuals
the aliki initiative at johns hopkins bayview medical center
Neda Ratanawongsa, MD, MPH; Cynthia S. Rand, PhD; Cathleen
F. Magill, MD, MHS; Jennifer Hayashi, MD; Lynsey Brandt, MD;
Colleen Christmas, MD; Janet D. Record, MD; Eric E. Howell,
MD; Molly A. Federowicz, MA; David B. Hellmann, MD; Roy C.
Ziegelstein, MD
Ms. P: Case summary
Ms. P is a fifty-year-old woman with a history of
hypertension who presented to the hospital with a severe
allergic reaction to over-the-counter pain medications.
During her hospitalization, Ms. P admitted to the intern that
she had experienced the same allergic reaction before and
felt ashamed that it had occurred again. In discussing how
Ms. P organizes her medications, she also admitted that she
only intermittently takes her blood pressure medications. She
revealed that she is a busy caregiver for her mother and son,
both of whom live with Ms. P and have complex medical
problems of their own. The intern, consulting with her
resident and attending, wondered how she can best help
Ms. P return home safely and avoid future problems with her
medications.
Sir William Osler, if reincarnated and the attending for
Ms. P, would have taken this opportunity to teach his
residents the importance of knowing her as a person, for it
was he who famously observed, ``It is much more important to
know what sort of a patient has a disease than what sort of
a disease a patient has.'' Despite increasing evidence
that knowing the patient as an individual improves patient
outcomes, graduate medical education (GME) pays little
attention to affording residents the opportunity to know
their patients well.
If you ask the members of an inpatient ward team what keeps
them from knowing their patients, most--from students to
residents to attendings--say, ``We don't have enough time.''
Medical historian Kenneth Ludmerer laments the recent focus
of residency training on service over education, with
residents caring for greater numbers of patients for shorter
periods of time. He argues that a fundamental educational
principle of traditional medical education requires that
residents learn deeply from and about fewer patients, citing
the landmark report by Abraham Flexner: ``Men become educated
by steeping themselves thoroughly in a few subjects, not by
nibbling at many.''
Hippocrates wrote, ``Healing is a matter of time, but it is
sometimes also a matter of opportunity.'' At Johns Hopkins
Bayview Medical Center, we are seizing the opportunity to
give residents the gift of time to allow them to become
healers and know their patients in the way Osler recommended.
The Aliki Initiative--a new educational program named for
philanthropist Mrs. Aliki Perroti, who supports our efforts--
reduces residents' workloads and creates new opportunities
for residents to know their patients more fully both inside
and outside the hospital. The program provides residents the
time both to get to know their patients and to learn from the
reflect with their teachers.
the importance of patients' narratives
The opportunity to know patients as individuals is one of
the greatest rewards in medicine. The narratives of our
patients' lives fuel our passion for this work and keep us
grounded in the art and humanity of medicine. By allowing us
into their lives--whether through a single, brief interaction
in the hospital or an enduring relationship over decades--
patients bestow on us a special privilege.
Beyond this, however, our capacity to know patients as
individuals allows us to translate the best evidence-based
medicine into the highest quality, personalized care. In
1977, George Engel exhorted physicians to break free from the
constraints of the biomedical model to understand ``the
patient as well as the illness'' by uncovering the
psychological and social aspects of patients' lives and life
views. This patient-centered framework of care is associated
with improved patient outcomes, including better quality of
life, improved adherence, pain reduction, and improved blood
pressure control.
Despite its demonstrated benefits, the widespread failure
of the health care system to provide individualized, patient-
centered care is directly linked to suboptimal patient
outcomes. A survey of 39,090 patients by Consumer Reports
published in 2007 shows that fifty-eight percent of them feel
their doctors do not know them as individuals. Another report
in zoos indicates that, on discharge from the hospital, fewer
than half of patients can list or explain the purposes and
side effects of their medications. A study by D. R. Calkins
and colleagues published in 1997 shows that physicians, on
the other hand, tend to overestimate the quality of their
discharge instructions. A 2007 paper by Derjung Tarn and
coworkers noted that physicians prescribing new medications
only stated the name of the medication seventy-four percent
of the time and addressed adverse effects and duration of
therapy about one-third of the time. This failure by
physicians to communicate critical elements of medication use
may contribute to failure by patients to take medications as
directed. Similarly, Sunil Kripalani and colleagues in an
article published in 2007 report that communication between
hospital physicians and primary care physicians is often
lacking or suboptimal in detail, affecting the quality of
care in twenty-five percent of follow-up visits.
Patient centeredness--one of six core aims for improving the quality of
health care in the United States
The Institute of Medicine (IOM) report Crossing the Quality
Chasm highlights patient-centeredness as one of the six core
aims for improving the U.S. health care system. The report
defines patient-centeredness as: ``Providing care that is
respectful of and responsive to individual patient
preferences, needs, and values, and ensuring that patient
values guide all clinical decisions.'' Toward that goal, the
IOM in the follow-up report Health Professions Education: A
Bridge to Quality proposes that skills in providing patient-
centered care should be a central competency for health
professionals.
Unfortunately, traditional GME is not prepared for this
imperative. The goal of GME is not only to provide trainees
with the knowledge and skills to care for patients like Ms.
P, but also to inculcate in them the core values of the
medical profession. GME today, however, is largely driven by
the service needs of medical centers instead of thoughtful
educational priorities. Residency graduates emerge from three
years of stressful, demanding training ill-equipped to
provide the type of patient-centered, quality care Ms. P
deserves. Rather than learning to care for patients
collaboratively across transitions and in the greater context
of their lives, health care is both practiced and taught in
``silos.'' At the same time, the structure and financing of
GME elevates the business of medicine over the vocation of
medicine, creating a hidden curriculum in which ``the values
of the profession are becoming increasingly difficult for
learners to discern.''
Medical school curricula at many schools show an increased
emphasis on patient-centered care and the value of effective
patient-provider communication. However, once these
physicians-in-training enter the typical residency program,
they find that their training experiences do not reinforce
this emphasis and are not structured to allow them to know
and understand their patients as individuals. Unlike
proficiency in traditional medical knowledge or clinical
judgment, the skill of knowing one's patient as an individual
may decline under the influence of a hidden curriculum that
may not promote humanistic care. Duty hour reforms limiting
the number of hours without adjusting the volume of work may
lead some residents to make conscious decisions about how to
spend their time, as voiced by one resident in a 2005 survey:
``It is harder to have as much time to speak with and really
get to know patients, which impacts the ability to have
shared decisions and understand patient perspectives.''
Finally, GME leaves little time for reflective learning.
Reflection allows physicians-in-training to think about the
meaning of their experiences with patients and how these
experiences are influencing their own overall professional
development. Although medical educators promote the potential
value of self-reflection through activities like
critical incident reports and portfolios, trainees'
capacity for reflection may decline with the workload and
fatigue of residency training.
Thus today's young physicians-in-training may master the
mechanics of delivering medical care, yet never have the
opportunity to learn the art of healing.
Creative philanthropy--key to success of the Rockefeller Foundation
At the turn of the twentieth century, Frederick T. Gates
advised John D. Rockefeller to establish an institute of
medical research focused on medical education reform.
Rockefeller's $32 million endowment of the General Education
Board comprised the largest gift to higher education up to
that time. In 1905, Henry Pritchett of the Carnegie
Foundation commissioned Abraham Flexner to study the state of
medical education in North America and to make
recommendations to improve it. This effort resulted in the
publication of the Flexner Report, perhaps the most
influential document in the history of American medical
education. These achievements a century ago represent
striking examples of the ways creative philanthropy can both
reform and shape medical education to meet the needs of
society.
The need for educational reform is once again upon us, but
the funding constraints of a market-driven health care
environment hamper innovation by hospitals and educators.
Reform in the twenty-first century may require educators to
consider again the potential of partnering with the public.
The Aliki Initiative is a program designed to create
physicians who treat all patients with compassionate,
competent, and personalized care.
The Aliki Initiative aims to develop caring doctors who
have a genuine and deep appreciation of the importance of
knowing each patient's unique personal circumstances and who
make patient care recommendations that apply the best
evidence to the individual patient. The program reduces the
number of patients assigned to each resident, providing
residents more time to spend with patients during and after
their hospitalizations, and thus offering new opportunities
for residents to learn from and about their patients.
The Johns Hopkins Bayview Medical Center is an academic
medical center serving 8700 medicine inpatients per year;
twenty percent are poor. Patients hospitalized on the medical
service receive care either from a hospitalist service or
from one of four house staff teams. Teams contain one
resident, two interns, two students on basic medicine
clerkship rotation, a faculty attending, and a case manager.
A traditional team admits ten patients every fourth night on
``long-call'' and four patients during an intervening
``short-call.'' In October 2007, one team became an Aliki
Team, admitting five long-call patients and two short-call
patients. Hospitalists care for the patients who would
otherwise be admitted by this house staff team.
Lower patient load enables more teaching to the Aliki Team
With this reduced census, the Aliki Team has the time to
participate in teaching sessions and mentored experiences
designed to foster appreciation of knowing each patient as a
unique person and understanding each patient's psychosocial
circumstances. This begins from the admission encounter, when
house staff learn to elicit a more meaningful, detailed
history that includes patients' understanding of their
illness and their health. By engaging in this dialogue with
patients, their caregivers, and their outpatient
health care providers, house staff learn who and what
patients have left behind when they arrive at the hospital,
an often forgotten but equally important transition time.
Residents also learn how to provide counseling and
treatment to match patients' needs and concerns. One key
component of the Aliki Initiative is learning to assess and
overcome potential barriers to medication adherence,
particularly by tailoring evidence-based treatment to the
patients' particular preferences and resources.
During each day of the hospitalization, house staff
continue these conversations, honing their skills in patient
education and joining with patients in shared decision making
about diagnostic or therapeutic options. Leading up to and on
the day of discharge, house staff prepare patients and their
caregivers for the transition to home, rehabilitation
centers, or other settings in the patients' communities.
In contrast to usual practice following discharge,
residents call all patients within a few days of discharge to
answer questions, check their understanding of the
hospitalization and treatment recommendations, review their
understanding and ability to adhere to the discharge
treatment regimen, and offer assistance with any problems
that have arisen in the transition.
Finally, the Aliki Initiative provides the most powerful
learning opportunity of all: team members learn to know their
patients as individuals within their own homes and
communities. Five or more patients per month give residents
permission to visit them after discharge in their homes or
subacute care facilities. Often, patients allow residents to
photograph or film these visits, so the house staff can teach
their colleagues about these rich, rewarding experiences
during a monthly Aliki morning report conference.
Outcome--narrative medicine yields better patient care
Since October 2007, over half of our house staff have
participated in the Aliki rotation. During hospitalizations,
residents spend more time at the bedside with their patients
and patients' loved ones, discussing medications and other
treatments and coordinating care with outpatient providers.
Interns and residents say they gain their greatest insights
during their time with patients after discharge, when they
call all of their patients and visit five or six patients at
their homes or subacute care facilities.
In addition to enhanced time with patients, team members
have the time to reflect on their professional and personal
growth, both individually and as a team. Each month, faculty
and attendings working with the Aliki house staff meet to
debrief the team about their experiences. The most striking
and consistent observation is how often house staff report
``being surprised'' by what they have learned about their
patients. Prior assumptions about a patient's preferences,
barriers, abilities, or concerns are regularly challenged
when residents take the time to know patients individually.
This deeper insight, in turn, has repeatedly led to
opportunities to provide better patient care. Below we
present some examples of ``assumption-challenging'' Aliki
experiences and how they impacted patients and house staff.
Ms. P: The Home Visit
A few days after discharge from the hospital, the Aliki
Team intern and attending visited Ms. P at her home, learning
more about her home situation and meeting her mother and son.
They discovered that--in an attempt to remind herself to take
her medications--Ms. P keeps her medications on her dining
room table. Otherwise, she reported, the medications are
``out of sight, out of mind:' The intern realized that both
Ms. P's mother and her son also keep their prescription and
over-the-counter medications in the same location, increasing
the chances that any of them could take the wrong medication.
The intern also learned about the ways Ms. P copes with
caring for her family, including the supports she receives
from her community. Together, the intern and Ms. P
brainstormed about how to organize her medications more
safely and help her remember how to take them.
From the home visit the intern learned more about the
challenges of integrating a complex medical regimen into a
person's daily life and ways to engage patients in finding
solutions to these challenges. Ms. P expressed appreciation
that the intern took the time to come to her home: ``They
treated me like I was someone special.''
This learning experience is just one of many. Other
examples of Aliki experiences include:
An intern spent significant time with a man facing a
difficult decision about treatment for pancreatic cancer. The
patient initially told him, ``I'll do whatever you say,
Doc.'' Nevertheless, the intern patiently spoke with him
every day to learn about his goals of care and preferences.
He wasn't sure he was making any difference until one day the
patient told him, ``Doc, I don't want any of those things. I
want to go home.'' The intern helped him transition to home
hospice, and felt certain that this was ``the right thing to
do for him.''
A former Aliki resident working as the urgent care doctor
for the clinic described ``an Aliki moment'' during which he
discovered that a patient with gastrointestinal bleeding was
unable to afford his proton pump inhibitor after
hospitalization. Experience on an Aliki Team gave him the
skill and confidence to ask the patient explicitly and
thoughtfully about all barriers to adherence. The resident
switched the patient to a generic medication covered by the
patient's insurance and spent time counseling the patient
about the rationale for this therapy.
An intern visited a patient with urinary retention in a
subacute care facility and learned that the patient's Foley
catheter had been removed despite notations not to do so in
the ``hospital course'' section of the discharge summary, and
despite the patient's own recall of their recommendations.
The team resolved that in the future they would document more
explicit instructions with the medications list at the end of
discharge summaries and call ahead to subacute care
facilities for similar important follow-up issues.
Although residents were initially concerned that fewer
patients would mean less opportunity for traditional medical
learning, in fact, they report having more time for evidence-
based and bedside teaching. One team decided to focus on
physical diagnosis skills. The teaching attending physician
on this team described the experience as ``the first time I
am sure that the interns really knew how to examine a patient
by the end of my weeks with them.'' The supervising residents
also relished the additional time to search the literature
for articles and prepare teaching for the team.
House staff participating in the Aliki team feel greater
pride and more fulfilled in their work. In the words of one
intern, ``It's given me time to be the kind of doctor I've
always wanted to be and do the things I should be doing for
all my patients.''
Ms. P: Epilogue
Asked about the home visit, Ms. P said, ``I thought those
days were over. You know, how the doctors used to come to
your house. They came down, sat down to talk, to see how I
was getting out of the hospitalization. And that made me feel
good because some doctors don't have that interest or do a
follow-up to find out how the patients are doing . . . That's
letting the patients know that someone else cares. That made
me feel that I was important, and they're learning from me! .
. . They treated me like I was the only patient they had to
see that day. They treated me like I was someone special.''
Where from here? More opportunities for innovative medicine
Our early experience suggests that the Aliki Initiative has
the potential to increase residents' skills and motivation to
deliver patient-centered care. Ongoing and planned
evaluations of the program's outcomes include:
An assessment of Aliki residents' self-assessed behaviors,
attitudes, and skills before and after participation in the
experience.
Trainees' perceptions and understanding of medication
adherence and cost.
An audit of the medical records of patients cared for by an
Aliki team, compared with patients cared for in other
settings, to evaluate prespecified aspects of inpatient care,
transitions of care, and the quality of discharge
documentation.
In addition, we will examine the impact of the Aliki
Initiative on such patient outcomes as hospital length of
stay, quality and safety of the transition from hospital to
home or to another care team at a skilled nursing facility,
rates of rehospitalization, patients' knowledge about their
medical conditions and medications, and patients'
perspectives about the quality of their care and health care
providers. These evaluations may help educators at other
institutions determine what parts of this curriculum to try
at their own institutions, and to secure grant funding to
support such efforts. In addition, such evaluations may prove
helpful to policy makers as they shape the future funding
structure of GME.
Like the Flexner Report a century ago, the Aliki Initiative
resulted from private philanthropy directed to improving
medical training for the public good. When doctors and
private citizens together view medicine and medical education
as a public trust, everyone benefits. It also reminds medical
educators that we cannot accept the status quo and need to
show the public what our vision for patient-centered care can
and must be. As Molly Cooke and her coauthors write, ``No one
would cheer more loudly for a change in medical education
than Abraham Flexner. . . . He would undoubtedly support the
fundamental restructuring of medical education needed today.
Indeed, we suspect he would find it long overdue.''
Acknowledgment: The Aliki Initiative is funded through the
Johns Hopkins Center for Innovative Medicine, thanks to the
generosity of Mrs. Aliki Perroti.