In Pediatrics, Practice Makes Perfect Sense
hat physicians who complete pediatrics residencies become pediatricians may not sound like news, but it is. Ten years ago, three of four of those who came through this residency program at Johns Hopkins opted for fellowships that at least delayed their entry into practice and more often led them into fields like academic pediatrics or genetics-based research. Today, those numbers are reversed, as 17 of the 23 grads last year jumped straight into general practice in an office or community-hospital setting, according to program director Julia A. McMillan, M.D.
This turnabout coincides with concerted efforts to broaden the pediatrics residency’s focus beyond the halls of Hopkins. “In the past, there probably was a tendency for residents to get the message that if you couldn’t do anything else, you’d do general pediatrics,” McMillan explains. “They’d leave here knowing a great deal about how pediatricians work in teaching hospitals but not very much about how they work in community-settings.”
Changes in the residency program in recent years include adding a second monthlong rotation in general pediatrics at the Hospital’s Harriet Lane clinic; shifting “continuity clinic,” in which house staff follow regular patients, over a period of up to three years, out of the Hospital and into community-settings for half of the residents; and adding new programs specializing in behavior and development issues to prepare doctors to deal with maturational issues that are so much a part of pediatrics practice. Finally, two programs now send trainees outside the Hospital for experience in generalist-settings: Every resident completes a rotation at St. Agnes, one of Baltimore’s community hospitals, and about a dozen a year travel to Arizona to work with the Indian Health Service.
For former resident Susan Chaitovitz, M.D., the Tuba City, Ariz., experience sparked a rethinking of her priorities. Treating young Native American patients provided “my first real glimpse of what you can do in primary care,” she says. “I learned that it’s not all running noses.” Chaitovitz had originally planned on doing a fellowship, but at the conclusion of her residency in 1997 she instead signed on with the Pediatric Center of Frederick, Md. “I love this job,” she says. “It’s been a lot more challenging than even I thought it would be,” especially dealing with the likes of sports-medicine issues, behavioral and social problems, and issues of continuity of care.
Another factor contributing to the trend toward general practice, McMillan notes, is simple economics. With many residents carrying debt loads of up to $100,000, they’re more likely to see lower-paying fellowships as less attractive. Finally, today’s residents are arriving at Hopkins with a different outlook from their predecessors. “There’s a feeling in the air that this country doesn’t need more subspecialists, that we need more generalists,” McMillan says. “These residents are coming here with more of a psychological bent toward doing this kind of thing.”
-- Jim Duffy
Now at a Bookstore Near You
t’s meant to be like a call to your friend the doctor,” says Michael J. Klag, of the recently published home reference the Johns Hopkins Family Health Book (New York: HarperCollins, $49.95). The hefty tome—it weighs nine pounds and numbers more than 1,650 pages—for which Klag served as editor in chief, is full of just about anything anyone might want to know about the symptoms and treatments for hundreds of common and uncommon medical conditions. Divided into chapters on all the body’s systems (brain and nervous; ear, nose and throat; etc.), the reference walks readers through problems that occur within each system and discusses treatments and outlooks for the conditions. Handy sidebars, charts and illustrations make for easy understanding.
Under “Brain and Nervous System,” for example, you’ll
find a section on concussion. It describes what to look for, when to call the doctor and the expected outcome (full recovery). The volume also includes chapters on first aid (with red-edged pages for quick access) and a complete guide to navigating today’s complicated health-care system. The Family Health Book is now
selling briskly at a bookstore near you.
Klag, M.D., M.P.H., director of the Division of General Internal Medicine, spent three years editing the book, working at first mainly on nights and weekends and then—when anxiety set in a year before the publication date of Jan. 1, 1999—during every available waking moment. A practicing physician himself, he reviewed every draft as chapters bounced back and forth between faculty reviewers (there were more than 100 altogether), writers and editors. The best thing he had going for him, Klag says, was a strong marriage and tolerant kids. They learned to deal with Dad when, for example, he was sitting in the third seat of a Chevy Suburban while en route to Yellowstone last summer with a stack of book chapters on his lap, searching every town along the way for a FedEx office.
For the Office of Consumer Health Information, which brokered and managed the project, there’s no doubt the headaches were worth it. As the branch of the Medical Institutions that helps Hopkins’ bottom line by linking faculty expertise to projects bankrolled by outside publishers, the office is joyful about the Encyclopedia’s immediate success. The book has been featured in special floor displays at Barnes & Noble superstores across the country, in March was the Book-of-the-Month Club’s main selection and had a first printing of 140,000 copies beyond those ordered by the book club. A review in the Los Angeles Times even advised that the huge reference might be “engrossing enough to start at page 1 and just keep on reading.”
Coming in 2000 will be the Johns Hopkins Women’s Health Book, followed in 2001 by the Johns Hopkins Children’s Health Book.
-- Anne Bennett Swingle
Taking It from the Top
d Miller leans forward in his chair, arms resting on the conference table, assessing his answer to a question just posed him. “What makes a great leader?” adult trauma surgeon Edward Cornwell III has asked. To answer, Miller recalls the Sunday afternoon in his home three years ago when then-University President Dan Nathans asked him to become the interim dean replacing the departing Michael Johns. It was a scary time, Miller remembers, because he realized that being a dean requires far different qualifications from being a department chair.
“You have to know how to delegate authority; you have to assume responsibility for the failures and recognize others for the successes; and you must have the ability and the patience to listen to others,” Miller answers slowly.
Warming up to the question, the Dean/CEO of Johns Hopkins Medicine continues, “You have to be a consensus builder and not dictate from the top down; you need a vision and a plan to carry it out; you have to put together a talented team; and finally, you must have the willingness to make tough decisions regardless of whether you’re liked or not.”
Welcome to the first class of the Johns Hopkins Medicine Leadership Development Program.
Running an academic medical center these days is a highly complex business. Realizing that faculty with the ability to take on crucial leadership roles don’t materialize out of thin air, administrators here have developed a formal program to expose 32 hand-picked potential leaders to the kind of strategic thinking they’ll need to do the job.
Front and center in the program’s second session is George L. Bunting Jr., member and first chair of the Hopkins Medicine Board of Trustees. Both Miller and he recall the tension-filled era several years ago when the Hospital and Health System and the School of Medicine were merged into one entity—a time when dramatic changes were taking place in the health-care marketplace. “We had to bring the two badly polarized organizations together, allow for a healing period and then quickly move forward,” Miller says. “We couldn’t have done it without a good leadership team and support of the trustees.”
Bunting gives the students some perspective on the role of the trustees and the importance of a working relationship between the board and those heading Hopkins Medicine. He talks about the board’s fiduciary responsibility, developing long-term strategies and overseeing operations to make sure the necessary resources are there. “You serve on a board with the objective of adding value in the long term for those who will succeed you,” he offers. “That’s easy to say, much harder to do.” Being an effective trustee, Bunting notes, is knowing when to be involved and when to let things take their course. “You can’t be looking into the CEO’s eyes every day telling him when and how to turn out the lights.”
The class asks about the relationship between the board and the faculty and wants more details about how to balance business and academic interests. It’s not the most appropriate thing for trustees to be communicating directly with faculty, Bunting says, “although the faculty here are not shy about seeking us out. Board members need to rely on their organizational leadership to pass on accurate and unfiltered information.” As to how the business and academic sides interact, he tells the class, “The only way I can answer that is that both sides have to buy into the same mission. Although there are still some areas to be worked on, I think we’ve done that.” Queried as to how trustees measure success, Bunting allows that it’s not a science by any means. “You talk to the leadership, you see if decisions are being made efficiently and easily, you use anecdotal information and sometimes you go on instinct.”
After class, participants say the sessions have been eye-openers. Ruminating about what she’s learned, Modena Wilson, professor of pediatrics, says, “Bunting helped me understand the attention the trustees give to the Institution’s direction. That’s something I never had a window on before.”
A Class in Business Smarts
hey sharpened their pencils and plunged into accounting. They tackled medical informatics and medical economics, plowed through legal issues in health care, did battle with biostatistics. And four years after starting down a path no physician had walked before, they won—becoming the first 13 doctors to earn Hopkins’ master of science in business degree with a concentration in medical- services management. “You really have to want to do this,” says Catherine DeAngelis, School of Medicine vice dean for academic affairs. “It takes a lot of time and commitment.”
DeAngelis launched Hopkins’ Business of Medicine curriculum in 1994 as a one-year certificate program geared toward bringing faculty and other health-care professionals up to speed on managed-care issues. Successful from the get-go (it was named best continuing-medical-education program in the country a year later, and last year debuted on the Internet), the four 10-week classes actually left many doctors hungering for more.
“They started asking for a degree program that would include credit for projects they could do in their own departments, or divisions,” says DeAngelis. The result: a homework-laden, 48-credit master’s program tailored for physicians. “These classes are not taught by theoreticians,” she says. “I wanted the doctors to be able to look at budgets without running away, to be able to spot ‘creative accounting’ when they see it.”
For Paul Sponseller, Hopkins’ chief of pediatric orthopedic surgery, devoting a serious chunk of his life to getting yet another academic degree was worth the work. “For the clinical-practice improvement course, I made it a project to track the incidence of spine infections after surgery,” he says. “As a result, we’ve been able to introduce proactive measures to decrease their occurrence. We’ve also begun surveying physicians who refer patients to our department, asking what they do and don’t like.”
But the eye-opening part, says Sponseller, was the leadership course. “I saw how effective leaders accomplish change by thinking outside the box.”
-- Mary Ann Ayd
First Again in Research Funding
or the eighth year in a row, the School of Medicine is this country’s top earner of federal biomedical-research funding. According to figures released in March by the National Institutes of Health (NIH) for fiscal year 1998, Hopkins scientists earned more than $223 million. Most of that (around $200 million) went directly to support basic or clinical research. The FY ’98 figure reflects a 6 percent increase in funding over last year.
For the ninth consecutive year, the School of Medicine also was ranked second (behind Harvard) among the nation’s 124 medical schools by U.S. News & World Report. Specialties cited among the top 10 of their kind included biomedical engineering, internal medicine, AIDS, pediatrics, geriatrics, drug/alcohol abuse and women’s health.
No Burden Too Heavy
hen doctors walk through the doors in the morning to the clinic, the operating room or the lab, they don’t automatically leave their personal problems behind,” says clinical psychologist Mark Ginsberg, who spent the better part of this decade directing the University’s Faculty and Staff Assistance Program. “They are human.” At the School of Medicine or Hospital, when such personal problems get too big to handle for a resident or senior physician, an unusual source of help is available.
Called the Professional Assistance Committee (PAC) and set up 10 years ago by the Medical Board, the benevolent group is made up of faculty physicians who support troubled colleagues beginning to confront their demons. They are ready to help with professional or domestic conflicts, substance abuse or other emotional upheavals that may be affecting the M.D.’s on-the-job performance. “We view no burden as too heavy,” says cardiologist Steve Achuff, the committee’s chairman. The PAC, he adds, is the only panel designed to assist troubled physicians among major academic medical centers in the nation, but few at Hopkins know of its work.
According to Achuff, physicians seeking the committee’s assistance generally are referred by a colleague or a more senior M.D., such as an attending, division chief or department head. Most of those having problems are at early stages in their career—junior faculty or house staff—and dealing with anxieties arising from job pressures and the resulting stress these place on relationships. But about 10 percent are discontent with their professional choice and eventually may end up making changes as radical as getting completely out of medicine, or as benign as shifting from surgery to pathology. “If we can convince someone that they have clearly chosen the wrong path, we consider that a successful outcome,” Achuff says.
The assistance any one physician receives, Achuff says, can range from simple encouragement to seek professional services, to assistance in obtaining paid leave, or just a comforting shoulder to lean on. “Talking to one of us can help relieve feelings of isolation, and be all that is needed to get someone back on the right path,” he says. For the physician in deep conflict, however, the committee usually is only the first official step before making an appointment to talk to a therapist.
The Professional Assistance Committee is the only program among the nation’s major academic medical centers that’s keyed to helping physicians with personal problems.
PAC’s current goal, Achuff says, is to make more members of the medical staff aware of this unique resource and to expand its parameters from intervention to prevention. In the last year, for example, it has co-sponsored a series of discussions dealing with the strains on families and marriages because of recent changes in health care.
The committee bases much of its success on its commitment to confidentiality. Department chairs and division chiefs grant it the freedom to make decisions about advising a troubled physician about how to move ahead without keeping them in the loop. “One of the roles of the PAC is to create that kind of protective sanctuary for a colleague in trouble,” says Achuff. “The Medical Board treats us like Caesar’s wife—beyond reproach—and that’s how it has to be for us to succeed.”
Fete First: The Dean’s Bash for New Professors
tolaryngologist John Niparko called it a powerfully moving experience. Catherine DeAngelis, vice dean for academic affairs, termed it auspicious, and John Cameron, chief of surgery, says it is the beginning of a cherished tradition. What has these people talking in such platitudes is a gala dinner last winter at the swanky, downtown Engineer’s Club to honor 35 faculty members who achieved the most prestigious rank in academia—full professorship.
Reaching that rank has become increasingly challenging for younger members of the clinical faculty as their protected time for scholarly pursuit shrinks in the wake of financial pressures on academic medical centers. Indeed, an ad hoc committee appointed by Dean/CEO Edward Miller is poised to make some far-reaching recommendations on how to ease some of the pressures on beleaguered faculty striving for promotion.
Miller came up with the idea of a celebration that would bring new professors together with other colleagues, spouses and friends to lend some official recognition to their achievement. “I think it sends an important message to young faculty that there is light at the end of the tunnel and that hard work and perseverance are recognized by the leaders of the Institution,” Miller says.
Promotion to full professor, notes Cameron, is the most significant event that occurs in an individual’s career at Hopkins. “Yet, I can remember that on the day I was promoted, the great sense of achievement was followed the next day by the realization that no one really knew about it. It was somewhat of a letdown.”
Marcus Welby Redux
n the somewhat insular world of large teaching hospitals, it’s easy for clinical faculty to think their book-thick CVs and medical-school pedigrees make a difference to patients seeking the best in health care. According to a survey by the Association of American Medical Colleges (AAMC), however, what patients want most in a doctor is a smiling face and a caring attitude.
Patients already assume that an “M.D.” after a name means the person taking care of them is well-trained, the survey found. And whether a doctor was trained at Hopkins or some lesser-known medical center seems to matter little. Eighty-five percent of those surveyed, ranked concern, good bedside manners and willingness to listen as the attributes they look for in a physician. Only 27 percent said where a doctor trained mattered to them.
An Institutionwide program to improve the quality of service and the recent development of new practice standards by the Clinical Practice Association are helping to address some of the more salient points raised in the survey.
Practice standards, however, deal primarily with issues such as waiting times, access to physicians and following up on diagnostic test results, not bedside demeanor. Ken Wilczek, CPA executive director, points out that much of a physician’s interaction with patients can’t be defined by a standard because it is so personal. “Yet, the issues raised by the survey go right to the core of the physician-patient relationship,” he says.
“Obviously, patients are telling us they want the Marcus Welby approach to health care within the confines of a large teaching medical center,” says Wilczek, referring to the gentle, caring TV doctor played by Robert Young.
Doctors at Sea
nyone who’s ever worried about what would happen if they were stricken with a strange disease while hundreds of miles at sea can rest easier if they happen to be heading out on a Renaissance cruise. Renaissance voyagers who take ill or have an accident are helped to return in shipshape condition—or at least get the latest in consultative medical care while they’re on the high seas—by physicians at Johns Hopkins. In a new deal with the luxury-cruise company, physicians in the Emergency Department here are available to ship’s doctors to discuss treatment or triage decisions through telemedicine hookups that enable quick, on-line exchange of patients’ medical histories, test results and other vital information. In turn, Renaissance will carry Hopkins marketing materials on board and include information about Hopkins Medicine in its media materials and direct-mail marketing.
A Matter of Degree
new breed of graduate student will arrive in East Baltimore next fall to tackle the School of Medicine’s doctoral program in pathobiology. Recently approved by both the Advisory Board of the Medical Faculty and the Graduate Board of the University, the four- to six-year program of study will start with six to eight students in the first year and eventually carry as many as 40 students at a time. Of the country’s 20 top medical schools, 15 have programs in pathobiology, a discipline that seeks to elucidate aspects of disease by studying underlying molecular and cellular processes. Gary Pasternack, M.D., Ph.D., director of the Division of Molecular Pathology and director of graduate studies in the department, feels the new program will enhance the overall “intellectual ferment” in the department and help it attract top faculty. It “fills a notable void in the department and helps guarantee our ability to carry the tradition of excellence in our teaching and research missions into the next century,” he says.