Spring/Summer 2002

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A Fresh Look in Surgery
The new chief was a choice outside the box.

There were those who told Freischlag she'd never get the job.
There were those who told Freischlag she'd never get the job.

When Julie Freischlag stepped into the top position in the Department of Surgery on March 1, she became a historic first. No other woman had ever headed a major clinical department here (Barbara De Lateur, until now the only woman clinical director, leads Physical Medicine and Rehabilitation). But from Freischlag's point of view, the appointment just made sense. "Women have been in the profession long enough to have learned all the ropes," she says. "They're qualified, and they're available."

As chief, Freischlag, 48, will continue to see vascular surgery patients and operate once or twice a week. She will also need to be an innovator. Her chief focus, Freischlag says, will be on reshaping the surgical training program. Enormously popular among the house staff at UCLA, where she has just left the job of chief of vascular surgery, she plans to meet weekly with groups of residents here.

Some 60 residents and fellows train at any one time in the Hopkins department, and the vigorous program continues to attract the best and brightest applicants. Elsewhere surgical internships are losing their luster. From 1978 to 1989, 10 percent of medical school seniors listed general surgery as their first specialty choice; by 2002 that figure had dropped to about 6 percent. And, although women now comprise nearly 50 percent of medical school classes, only about 3 percent go into surgery.

Why so? "The number one, two and three reasons are lifestyle, lifestyle, lifestyle," Freischlag says. The grueling hours of the surgical residency represent a long-standing tradition, if not a badge of honor. "We were in-house every other night on-call," Freischlag recalls of her own residency. "We just figured that was what you had to do in order to be a great surgeon."

Things are about to change. An 80-hour limit on duty hours mandated by the Accreditation Council for Graduate Medical Education takes effect on July 1. Furthermore, Freischlag intends to participate in a pilot program, developed by the American Board of Surgery, that would shorten surgical training in general. Residents, after doing their core training, would enter specialty training a year earlier. One of the things that intrigued Freischlag about the Hopkins chairmanship was the opportunity to refashion surgical training in its birthplace. The residency concept was more or less invented here at the end of the 19th century by William Halsted, the first chairman of surgery.

About one thing Freischlag remains adamant. Most of the activities she initiates will be carried out during the work-week. "I have a 7-year-old son," she says, "and the dimension that I bring is that you can do it all, but you can't do it all in one day." She is married to Philip Roethle, a businessman who specializes in manufacturing accounting.

In ruminating on her selection to head the venerated Department of Surgery, Freischlag admits she never dreamed she'd get the job. A man she's not. Nor is she East Coast establishment, having grown up in downstate Illinois, attended Rush Medical School in Chicago and trained at UCLA Medical Center. When the search committee pinpointed her as a candidate, a few colleagues were quick to tell her she'd never be named to the position. When she was,"everyone began to realize that if you're qualified, you can get it … people now are looking for the best person." She pauses, then says slowly, "But the impact of my getting this job goes way outside of Hopkins."

Perhaps nothing better epitomizes just how far Freischlag's come than a recent remark by her young son, Taylor. Riding together in the car, on the way to his school on a recent morning, he turned to her and asked: "Hey Mom, can boys be surgeons too?"

Anne Bennett Swingle

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Face Time/David Hellmann
The director of medicine at Johns Hopkins Bayview Medical Center talks about life with a bit more elbow room.

David Hellmann

Some two years ago, David Hellmann, then-executive vice chairman of the Department of Medicine, agreed to move his office a mile and a half east to Hopkins' other academic medical center. Hellmann, who's been at Hopkins since he began medical school 30 years ago (except for six years at the University of California at San Francisco), had been asked to lead the Department of Medicine at Johns Hopkins Bayview. In doing so, the Mary Betty Stevens Professor of Rheumatology knew he would be heading to a place many of his colleagues on the East Baltimore campus thought of as more clinical than scholarly. Today, after the merger a little over a year ago of the faculty practices on the two campuses, there's a new realization that Bayview brings a unique menu to the institutional table. And Hellmann has introduced his own style of openness to the department he heads. One of his most interesting innovations has been to include nurses when he visits patients' bedsides with students and residents twice a week.

Teaching sessions at pa-tients' bedsides usually include a bunch of doctors and no nurses. What made you change that?
I learned when I was an intern that it was often the nurse who knew more about a patient than I did. I always tell young doctors, If you want to be a really good physician, talk to a nurse.

Hospitals all over have been having a hard time recruiting and keeping nurses. Nurses often say they feel frustrated with overwork and little consideration. How do you think a change like the one you've made might alter that outlook?
What I want to do is create an environment here that does for nurses what Johns Hopkins does for physicians. The reason nurses want enough staffing, clean floors and for medications to arrive on time is so they can spend their time on nursing. I don't control staffing or pharmacy or cleanliness, but I can influence how physicians incorporate nurses. Nurses are not simply employees. They are an intrinsic part of our medical care.

With your switch to the Bayview campus, did you find it strange no longer being at the perceived center of the Hopkins Medicine universe?
When I got to Bayview, I'd hear about the disadvantages of the place: We're not Hopkins Hospital. But I said, What are the first two words of our name? Johns Hopkins is known around the world, it's one of the most famous names in medicine. Bayview
is Johns Hopkins with more convenient parking. This is Johns Hopkins with grass.

Is the culture different?
Malcolm Gladwell wrote a book called The Tipping Point: How Little Things Can Make a Big Difference. He talked about scientists who were trying to figure out why the neocortex of the brain became so big in people. They looked at a lot of correlations, and it turns out that what correlated best was the size of the social group-we are good for about 100 to 150 interactions. Beyond that, we become dysfunctional. What I truly appreciate here is that people's goal seems to be to help me get something done.

For example?
Toshiba has developed a new CT scanner that lets you see coronary arteries so well you don't need an angiogram. They were sending the first one to the United States, and Hopkins Hospital was supposed to get it. But there were some turf battles, so Dr. [Myron] Weisfeldt [Department of Medicine chairman] said, OK, what about Bayview? The leadership here eliminated all the obstacles, in two days. That kind of thing can happen at Bayview because of its human neocortex size.

So the next task is what?
The Transcontinental Railroad linked the East and the West. You can grow wheat in Kansas, which you can't do in Boston. Now, we need to build the intellectual railroad that ties the two campuses together.

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Name? Address? Rap Sheet?

A stellar curriculum vitae or first-rate resume has always been the sine qua non for garnering a School of Medicine job offer. Today, however, there's a new requirement for getting on the payroll. Starting May 1, everyone asked to sign on-as a member of either the faculty or the staff-undergoes a criminal background check. The decision, says Dean/CEO Edward Miller, reflects the need to practice due diligence in a world where heightened security has become the norm. "Not everyone is always truthful on their job applications," Miller says. "We need to be sure that our employees can work with patients, finances, chemicals and hazardous materials."

Long a part of the hiring process in the business world, background checks are becoming commonplace for teachers, church and scouting volunteers, nannies, even shopping-mall Santas.

The School of Medicine background checks aren't being conducted on all candidates for a job opening, but once the finalist is picked, an outside vendor will get the process under way (turnaround time is about 48 hours). Facts to be verified include name, Social Security number, U.S. addresses, and the existence of any felony or misdemeanor convictions in the past seven years. Arrest information is not included. Anyone who will have significant financial duties, work with children or be required to drive will also get a check of his credit history, sex offender status or motor vehicle history. If anything turns up, the hiring department, along with the security, legal and human resources departments consult to reach a decision on whether to bring the person on board.

"Knowing more about employees is an important element in minimizing risks," says Miller. "Now more than ever, there's a need to protect our patients and visitors, our community, our equipment and resources, and our employees. This is the right thing to do and the right time to do it."


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In Stradivari's Footsteps

Steve Piantadosi carving his violin.
Steve Piantadosi carving his violin.

When Steven Piantadosi ended up specializing in the obscure field of oncology biostatistics after he finished medical school 26 years ago, it wasn't what anyone would have called a run-of-the-mill professionial choice. That, however, is nothing compared to Piantadosi's choice of hobby-making violins. Now in his 15th year on the School of Medicine faculty and director of biostatistics for the Sidney Kimmel Cancer Center, Piantadosi spends his days culling and synthesizing piles of clinical trials data. Evenings and weekends he heads for his basement workbench to put in a few hours with his latest creation-a spruce and tiger-maple violin that he's been carving for the last year. And this summer, for the second year in a row, Piantadosi will spend three-weeks at the University of New Hampshire's Violin Craftmanship Institute.

Like most amateur violin makers, Piantadosi started by playing violins. He began taking lessons at 12 and actually became quite proficient (his last performance was at a grad school party, where he performed a Beethoven sonata). Then, about 20 years ago, he got a sudden urge to carve his own instrument. He'd always been good at woodworking, so he bought a kit, a how-to book and a set of Japanese violin-making tools and-voila-his hobby was launched.

Then, last summer in New Hampshire, Piantadosi met Karl Roy and realized he'd been doing everything wrong. Roy, the former director of a renowned German violin-making school, runs the famous institute, and one of the first things he did in class was hold up a standard how-to book and show the students the marks he'd peppered all over those instructions that a true violin craftsman would never follow. Furthermore, Piantadosi's Japanese tools weren't at all up to the master's standards. Not that it much mattered. Roy expected the exacting work of joining, measuring and gluing the violin plate to be done by hand. That frustrated Piantadosi. What usually took 15 minutes using his power tools now required one long sweaty day.

Still, Piantadosi thrived as Roy pointed out the minute roughness in the curve of a classmate's scroll and the tiny subtleties of the delicate stringed instrument. Roy's insistence on precision even spurred Piantadosi (new German instruments in hand) to demand more of himself.

Now, Piantadosi is even more obsessed with his hobby. His violin, he points out, will have a greater longevity than his scientific conclusions. "In medicine," he says, "you produce results that you expect to hold true for only a given amount of time. A violin can outlive you."

- Seana Coffin

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It's All About What You Need to Know
Strict new patient privacy rules change the way hospitals across the nation do business

Anyone who comes in contact with patient information needs to be taught about HIPAA.
Anyone who comes in contact with patient information needs to be taught about HIPAA.

On April 14, millions of Americans no doubt visited their doctors seeking relief for any number of ailments. These patients signed the usual consent and insurance forms. And then, for the first time, they were asked to review a detailed document about their privacy rights that federal law had made mandatory as of that day.

Until recently, patient privacy was largely a matter of trust. Historically, patient information belonged to health care providers and insurers. In fact, patients didn't even gain the right to view their own medical records until some states began passing laws in the late 1970s and early 1980s.

Now there's been a 180-degree turn with a federal law called the Health Insurance Portability and Accountability Act (HIPAA) which puts control of medical information squarely into patients' hands. The sweeping new regulations govern everything from how to store medical charts (facing the wall, please) to the proper way to dispose of patient information (shredding). When the policies took effect in mid-April, they represented a sea change in how institutions like Hopkins would operate.

"There's no question that a patient's right to privacy is important," says Joanne Pollak, vice president and general counsel and vice president for compliance for Johns Hopkins Medicine and for The Johns Hopkins University and Health System. "There's also no question we'll have to follow the HIPAA rules on privacy. These rules will cause an administrative burden, but HIPAA is not something we can choose to ignore."

Leading off the changes is the notice that informs patients of their rights and that they now will be required to review. At Hopkins, where some half-million patients are seen each year, the document is a booklet that's 12 pages long, and takes a fairly well educated person at least 10 minutes to read.

In addition, HIPAA will result in many changes for health care workers. In addition to doctors, nurses and billing personnel, anyone who comes in contact with patient information, even incidentally, needs to be taught about HIPAA. "We're talking maybe 12,000 people," says Carol Richardson, Hopkins' privacy officer.

"Need to know" is one of two guiding principles of HIPAA. Nurses, for instance, need to know the health information about patients on their own unit, but not about patients on another. Security guards can know the name and location-but not the diagnosis and treatment plan-of people they are paid to protect.

The second guiding principle is the "minimum necessary" concept. "In the simplest sense," says Richardson, "people should only use the patient data they need for a particular purpose." To be able to submit a claim for reimbursement, for example, a billing coordinator needs access to information about the patient's current visit, not the entire patient history. A physician planning a teaching lesson doesn't need to identify a patient by name, date of admission or any other data to conduct the lesson. The concept does not apply to treatment situations, however, meaning that physicians and other providers should have full access to patient information for treatment purposes.

"The intent [of HIPAA] is to raise patients' awareness," says Richardson. "We are letting them know: this is how we can or cannot use your data."

- Mary Ellen Miller

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Rank and Smile


Spring marks the kickoff for the latest round of rankings, and the season opener is always U.S. News & World Report's annual lineup of America's best graduate schools. In the magazine's medical schools category, this year's front-runners-for the 13th consecutive time-are Harvard and Johns Hopkins. Harvard's overall score was 100, with Hopkins closing in at 97, four points higher than last year.

Hot on our heels, however, is Washington University in St. Louis: This year, the Mid-Westerner joins us in the #2 spotlight. Rounding out the top 10 research-intensive medical schools overall are the University of Pennsylvania, Duke, University of California San Francisco, Columbia, University of Michigan, Stanford and Yale.
In clinical specialties, the School of Medicine moved into the top position this year in Geriatrics and in Drug/Alcohol Abuse (both up from #4 last year) and again ranked #1 in Biomedical Engineering (trailed by the Massachusetts Institute of Technology). We hold the #2 rank in Internal Medicine (just behind Harvard) and in AIDS (behind UCSF). Like last year, we're #3 in Pediatrics and #4 in Women's Health.

Hopkins' other health division schools also were among the best in their disciplines: the Bloomberg School of Public Health ranked #1, and the School of Nursing, #6.

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The View from Stryer's Shoulders
Jeremy Berg takes a classic textbook into the 21st century.

Berg spent five years on his redo of Biochemistry.
Berg spent five years on his redo of Biochemistry.

For nearly three decades, the bible for teachers of biochemistry has been titled simply Biochemistry. It's one of the top 10 best-selling textbooks of all time, it enjoys the largest market share in the field, and the first four editions, written by Stanford University Professor of Neurobiology Lubert Stryer, sold 1.2 million copies. Its organization is so clear, its writing so accessible, that devotees affectionately call it simply Uncle Stryer.
Would you tackle the fifth edition?

Seven years ago, Stryer put that very question to one of his own former students.
"I was honored, shocked, intimidated," says Jeremy Berg, director of biophysics and biophysical chemistry at the School of Medicine. "I spent six months thinking, There's no way I can do this, followed by, How can I pass this up? It was a double-edged sword. Having a pedestal as a launching pad was huge. On the other hand, I could become known as the guy who ruined Stryer."

What finally nudged Berg into taking the plunge was asking himself what he could bring to the project. The answer turned out to be evolution. "The way we think of biochemistry has changed so much since Stryer's first edition in 1975," Berg says. "Through the 60s and 70s, there were only about four proteins for which 3-D structures had been determined. Stryer saw that was the future-he brought 3-D structure to biochemistry for the first time. Being able to manipulate genes was the next big change. Now, we think in terms of evolutionary relationships-how molecules with a common origin play diverse biological roles."

Initially, Berg was excited because he thought he'd be collaborating with Stryer. Stryer quickly put that notion put to rest. "He has two modes," says Berg, "total control and non-involvement. I sent him the first chapter and got several pages of feedback. With the second chapter, I got one paragraph; with the third, nothing. That's when I realized the torch had been passed. He was saying, I trust you."

The redo took five years. To help keep the frenetic pace, John Tymoczko, a biologist at Carleton College, joined the project as co-author. Berg was determined not to mess up Stryer's straightforward style. Furthermore, he ended up doing the bulk of the illustrations himself. "The last year was insane," he says. "I was getting up at 3 a.m., five days a week and writing for three to four hours."

Besides the 974-page book itself, which made its debut in 2002, Berg helped organize a companion text on the clinical applications of biochemistry. He also assisted in creating the online version of the book, geared toward helping students visualize what they're learning.

Today, framed on Berg's office wall is the letter Stryer sent him when the book came out, praising his work in "giving new life to Biochemistry."

"I still felt like I was writing for him," Berg says. "Even though he wasn't looking over my shoulder, he was looking over my shoulder.


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Making Everything Nice for the Animals
After two years of fixing up its act, the University gets a good report.

The tension was palpable in March as animal research administrators here waited for the speaker to begin. Michael Ballinger, chief site visitor for the organization that accredits laboratory animal programs, was ready to reveal where the University stood after a grueling three-day inspection of its animal housing facilities, research laboratories and documents.

For years, Hopkins had put limited resources into its research animal programs. "That was OK when we had 5,000 animals," notes Janice Clements, director of comparative medicine. But beginning in the mid-1990s, the number of animals exploded by a rate of about 20 percent each year as more investigators began using genetically engineered rodents. Today, the University has 507 principal investigators (most at the School of Medicine) engaged in 1,432 active research protocols, involving about 116,500 animals, of which 110,557 are rats and mice.

Two years ago, the Association for the Assessment and Accreditation of Laboratory Animal Care International (AAALAC) caught Hopkins off guard with a sobering review of its animal care. At risk was a loss of accreditation as well as the institution's cherished research reputation. Shaken, the School of Medicine has spent the past two years making wholesale changes it hoped would address its deficiencies.

"Going into that meeting in March," says molecular genetics researcher Roger Reeves, chair of the Rodent Advisory Committee, "I had the feeling of having just completed my orals."

Clearly, the inspection team came away impressed. "We came here with grave concerns," Ballinger said, "about your animal care program. You had so much to do and so far to go. You should be congratulated for making some tough decisions." He also praised the institution's oversight and training efforts, noting that it had "gone way beyond what you needed to do."

Still, the team did pick up a few problems related to heating and ventilation in some animal housing areas in the School of Medicine and the Hospital. It found unacceptable variations in temperature and humidity levels in many rooms, along with odors in several areas that it described as "pretty dramatic." Ballinger said the problem was particularly difficult, "because you have so many older buildings." He said that the team would recommend that these issues be corrected before full accreditation was granted.
Officially, however, AAALAC lists Hopkins on its Web site as fully accredited. Participation in its review process is purely voluntary. But receiving its accreditation is considered the gold standard for animal research.

- Patrick Gilbert

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Time Off for the Kids
The School of Medicine gives birth to parental leave.

Looking to improve the quality of life for junior faculty, more and more of whom are women, the School of Medicine has taken steps to bring some uniformity to leaves for childbirth and adoption. The Advisory Board of the Medical Faculty recently approved guidelines that will grant primary child caregivers up to eight weeks of paid leave, and secondary child caregivers up to four weeks.

Janice Clements, vice dean for the faculty, pushed the issue to the forefront following consistent queries from faculty about applying for parental leave. "Many didn't know how to get started, or who to make a request to," Clements says.

The Medical School Council noted that it took up the problem because adequate time off for childbirth or adoption is related to the faculty's quality of life and career. Previously, each department handled parental leave differently. Sometimes it came down to the attitude of the chair toward family issues or, in the case of clinical departments, on the workload and the difficulties of covering the duties of those on leave.
"Departments varied so in the amount of leave they granted, the council felt some uniformity was needed," Clements says.

Now, according to the new guidelines, parental leave may also include vacation and sick leave in line with departmental policies and an additional four weeks of paid leave for medical complications. And finally, faculty may take advantage of the Family Medical Leave Act, which allows 12 weeks of unpaid leave for anyone who has been employed by the School of Medicine for one year.

- Patrick Gilbert