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A Memorable Month on the Wards
By cutting residents’ patient load in half, Bayview is allowing young doctors to dig more deeply into their patients’ lives.

Harry Koffenberger, vice president of Corporate Security, in the department's command center. At work in the background are protective services officers Darlene Fairley (left) and Tanaya Hitt.
House call: Aliki resident Ashleigh Hicks visits patient Elizabeth Kovarik at her home in Rosedale.

The case of Mr. B had baffled his doctors. The 34-year-old with diabetes had been hospitalized 18 times over two years because he wasn’t taking his insulin properly. Psychiatry was called in for a consult and he was diagnosed as depressed. His chart read “disengaged and noncompliant.”

Then a team of young physicians visited his home in East Baltimore. They found a man very different from the one lying horizontally in his hospital bed. He was undeniably happy. He welcomed the doctors and introduced them to his cats. Furthermore, he showed interest in improving his diabetes control. He just couldn’t afford transportation to the hospital clinic. The problem was addressed by social work, and soon Mr. B became so involved in his health care that he began calling the team most days to talk over his blood sugar counts.

A new program for residents at Johns Hopkins Bayview Medical Center has helped solve conundrums such as Mr. B’s. Called the Aliki Initiative (named for its benefactress, Aliki Perroti, who donated $2.375 million to fund the program), it provides residents in internal medicine with a month-long rotation dedicated to getting to know their patients. Young physicians in training admit half as many patients as usual (the others go to the hospitalist service). With the extra time, they call patients and primary care physicians after discharge, visit selected patients at home or in rehab facilities and get a better look at the inner workings of nursing, social work and case management.

Between duty hours and shorter lengths of stay, residents are getting less face-to-face time with patients than ever. Roy Ziegelstein, executive vice-chairman for medicine at Bayview, says the problem is so critical that it will require “as large a revolution in medical education as there was 100 years ago when the Flexner Report revolutionized medical education.”

Oftentimes, the lack of contact with patients can lead to misdiagnosis. “It’s easier if an older person comes in with weight loss to begin an exhaustive evaluation for an underlying malignancy than to recognize that the person’s false teeth don’t fit,” explains Ziegelstein, who is also one of the associate directors of the internal medicine residency program. “Or to think a person is demented when they actually need a new hearing aid. This isn’t rocket science. I’m not talking about a new $6 million machine from Japan or a new surgical procedure. This allows us to adapt the way we train doctors to the challenges we face in residency education. To not adapt, at this point, is going to be fatal to our profession.”

It is routine for each Aliki team, which includes two interns and a resident, to call every patient after discharge. “They’re taught how to make that call,” says Ziegelstein, “what kind of information to obtain to make sure the patient understands his condition and is making a smooth transition to the next level of care.” The residents ask a series of questions, assessing whether patients are adhering to their medication regimen. They also ask about diet, exercise and whether the patient has help at home.

Because the residents return to their regular workload after four weeks, it’s important that they hone their skills for conducting conversations with patients during their Aliki experience. “It’s not very different from doing a central line or a lumbar puncture where you get better at it the more times you practice,” says assistant program director Neda Ratanawongsa. “Some people think that talking comes naturally, and that can be true. But talking about medical conditions and medications in a way that’s understandable to patients, and being able to find out what they comprehend, is a fairly advanced communication skill.”

Resident Jennifer Cheng, who was a member of the first Aliki team that commenced last October, says the program has made her better at identifying the vulnerable patients—“the patients with dementia who can’t tell us a good history,” for example—who might fall through the cracks after discharge unless she takes the extra time to communicate with other providers and family.

Being part of the initiative also taught her about barrier issues she’d never thought of before. Is the patient not taking medication because it’s too expensive? Is the patient not following instructions because he can’t read? If the patient can’t see well, how do we expect him to draw insulin? “There’s always more than meets the eye,” says Cheng. “I have a greater appreciation of how this snapshot in time that we see is all it is. It may be one one-millionth of who this person is.”

As part of the Aliki Initiative, residents themselves are being studied as part of an IRB-approved protocol. But even before any of the data are in, Ziegelstein says it’s obvious that the young doctors have embraced the program. “The overwhelming thing they say is that they learned not to make assumptions about patients based on the brief contact they have with them when they’re not at their best in the hospital. Because we do make assumptions—how intelligent they are, how motivated they are, what their resources are—and that’s a big mistake.”

Ratanawongsa says another benefit is that Aliki affords residents time to think. “To love being a doctor is an important goal of this project. People have said, I’ve actually had time to read again, time to talk with patients in depth, instead of focusing my time on paperwork or computers. That’s the kind of thing we want, for people to have a chance to reflect on what it is that they do this for.”

Mary Ellen Miller

 

 

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