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an online version of the magazine Winter 2005
Features
Medical School Reformer  
 
  The public and science both demand that physicians be trained differently. The person grappling with this at the School of Medicine is the quiet, precise vice dean for education.
BY MARY Ellen Miller
 
 
 
 

Ed Miller was mentally running through a list of names, putting aside the usual suspects, when it hit him. It was the middle of the night, and his first instinct was to phone a colleague to try out his idea. But he restrained himself.

“What do you think about Nichols?” the dean/CEO of Johns Hopkins Medicine asked Dick Traystman, then vice chair for research in anesthesiology and critical care medicine, at 7 o'clock the next morning.

Traystman, mentor and close friend of the man in question, thought Miller's choice was inspired.

A while later, David Nichols was conducting rounds on the pediatric intensive care unit, for which he served as director, when one of his fellows leaned forward and informed him that the dean was standing behind him. “I turn around, and there's this big guy, and he says, ‘When you finish here, could you come see me?'”

When Nichols arrived, the dean got right to the point: “I'd like you to be vice dean for education.” Taken aback, Nichols asked for a day to think about it. The next day, he accepted.

Since joining the dean's office in January 2000, Nichols has established the Office of Academic Computing, created an associate dean position to oversee what medical students are being taught, and he is tackling the sticky issue of compensating faculty for teaching time. But his biggest project—one that began in 2001 and will probably not be completed until 2007—is reforming the medical school curriculum.

David Nichols came to his new role with significant credentials. He was a full professor of anesthesiology and critical care medicine, with a secondary appointment in pediatrics. On the hospital side, he was director of pediatric anesthesia as well as the PICU. Since arriving at Hopkins in 1984, he had built a reputation as an outstanding mentor in his specialty. Still, when his promotion was announced, many people, including members of the Educational Policy Committee, wondered, Who is this guy?

Nichols, who just turned 53, is the consummate teacher. It is both in his blood (both his parents taught) and in his temperament. There is a centeredness and joy about his laughter. He speaks in a quiet, precise manner that paradoxically both projects warmth and commands attention.

“He is tough, but he doesn't give the impression of being tough,” says Traystman, who left Hopkins 18 months ago to become associate vice president for research planning and development at Oregon Health & Science University . “He holds his standards very high, and the people who work with him figure that out right away. But Dave does it in such a nice way that nobody could be mad at him.”

The success of Nichols' fellows—who constitute the leaders in pediatric critical care around the world, stretching from Seattle to Cambridge , England to Australia —attests to how solid a mentor he is. It's that strength that closed the deal for the dean, who first met Nichols in 1994 when Miller joined Hopkins as chairman of anesthesiology. “He's very unassuming, very knowledgeable, very articulate, and people always turn to him,” says Miller. “It was obvious to me that he was the best mentor, and that he was really interested in education and young people.”

By all accounts, Nichols has an exceptionally organized mind that he uses to make crisp analyses. “He's a critical thinker, a tertiary thinker,” says Eric Jackson, a former fellow and one of three African Americans in Nichols' small division of pediatric anesthesiology and critical care medicine. “Also, he's not intimidating. A mentor's only as good as they can be used, and if they're inaccessible or aloof, they're of no value. In his case, he always makes time for people, not just for minorities but for everyone.”

A member of the Diversity Council, Nichols cares more about the issue for the sake of Johns Hopkins than as an individual. “I think Hopkins will have difficulty recruiting top talent if we don't have a diverse environment.” But while he believes the number of African Americans here is low—11 percent of medical students, 3 percent of faculty and 6 percent of house staff—he seems personally blind to color. “I start by looking for excellence wherever I can find [it],” he says, “then I want to make sure it's not wasted, that it doesn't get lost in a very big institution.”

 

*****

 

Making the leap from a small division to the dean's office is not something everyone can do without losing balance. Dave Nichols went from supervising about 15 professionals in the closed circle of pediatric intensive care to holding responsibility for thousands of people, including medical students, residents, graduate students, postdoctoral fellows, as well as the staffs of continuing medical education and the Welch Medical Library.

At his first Educational Policy Committee meeting, he admitted to the group that he had no prior involvement at the policy level with medical students. Then he tapped into the “many smart minds” around the table to educate himself, and gave decision-making authority to the committee. “I still view the EPC as an entity that should rule on all important issues affecting undergraduate medical education before I even come to a conclusion on them,” he says.

Nichols at the student life committee listens to faculty member Kelly Gebo.  
> Nichols at the student life committee listens to faculty member Kelly Gebo.

“He ran that first meeting well,” recalls pulmonologist Charles Wiener, director of education for the Department of Medicine. “I didn't know him at all, but what was apparent was that he's a great listener. Dave's always looking to build consensus, to get everybody on the same page and to establish links between people.”

Miller decided to separate the former vice deanship of faculty and education into two jobs after analyzing a number of brewing issues. He was concerned that young physicians were still being trained in a hospital setting while medicine had shifted to outpatient care. Also, due to an increase in federal research grants, the number of graduate students on campus was ballooning. “Then, there's this huge genetic revolution going on out there,” says Miller, “and I'm trying to figure out, How does that information get put into a medical school curriculum? I don't think it's intuitively obvious.”

Add to these issues the fact that the education mission has been eroding at academic medical centers. “It's the least appreciated mission,” admits Wiener, “the least financially lucrative,” although ironically, he points out, it's what made Hopkins famous.

The problem has gotten the attention of foundations, think tanks, regulatory and certifying organizations, that have come together to ask if the century-old method of training physicians hasn't outlived its usefulness in a world where patients come to appointments empowered by information from the Internet. A 2002 report by the Commonwealth Fund, “Training Tomorrow's Doctors: The Medical Education Mission of Academic Health Centers,” points out that among faculty, teaching responsibilities are less valued than research and patient care. Making matters worse, the report continues, the demands of medical practice and patients' expectations have changed dramatically, and some teaching hospitals may not be keeping pace.

“This is a time in which education is front and center on the agenda of academic health centers,” Nichols says. One hundred years after the Flexner Report, the medical education model “is being modified again because of two forces,” he continues. “On the social side, the public has made its wishes very clear. They want doctors to be able to communicate more effectively. They want to be assured that ethical standards are taught and incorporated. They want to make sure that doctors are practicing based on the best evidence, not because they're influenced by pharmaceutical company advertising.

“On the scientific side, it's the sequencing of the human genome that will impact the lives of this doctor generation and the next. The complexity factor is much greater than before and doctors [will need] a framework in which to think about it, because we recognize that there are certain limits to coping with complexity.

“It's a worldwide issue,” he continues. “We get together at meetings and are all grappling with how to teach this stuff in a way that people can grasp in four years, and, more importantly, in a way they'll carry with them as a lifelong learning tool.”

 

*****

 

In the aftermath of Sept. 11, the Johns Hopkins School of Medicine Class of 2004 started to unravel. Some members of the class were grieving for friends or family lost in the twin towers. When a classmate circulated an article by the intellectual dissident Noam Chomsky that hardly reflected the patriotism of that time, people became polarized. The student who inadvertently started the ruckus was vilified; Muslim students began feeling threatened.

David Nichols, vice dean for education for 18 months at that point, called the class together. “I reminded them that the rest of the country was stunned, anxious, unsure how to react. And if people with their gifts and talents and privilege reacted strictly with anger and emotional dissolution directed at one another, what could we expect of everyone else?”

The incident recalled Nichols' youth in Berlin , where he grew up in the 1950s and '60s. It was a time of soul searching in Germany about the Nazi period, especially among the professional and intellectual classes. “They, of all people, were supposed to have known better,” Nichols told the class. In particular, feelings of responsibility ran high among physicians, “who took an oath to heal and defend and support society.”

Nichols is good in a crisis. On the pediatric intensive care unit, where he is on service 12 weeks a year, he remains calm during emergencies and is in the habit of evaluating them afterward during debriefings with his team. Even though he now spends 70 percent of his time in the dean's office, sometimes his training comes in handy. When Hopkins faced the loss of approval from the Accreditation Council for Graduate Medical Education for its internal medicine residency program, Nichols switched into intensive care mode. “The institution was a sick patient, critically ill, and we had to fix it fast,” recalls Nichols. “At stake we had an extremely important residency program, and, by extension, the entire institution.”

But more often since joining the dean's office, Nichols tames his habit of making quick life-and-death decisions. He's acquired the patience to let ideas germinate. “[Early on], when I'd feel tempted to move quickly,” he says, “I'd be checked, because I'd hear another opinion from another person or a different group, and I'd be astounded by how rational those arguments sounded. I quickly came to appreciate that it's very important to get various views and positions on an issue.”

What he realized was that there are many correct perspectives on a given issue, and “the challenge is to choose among the correct ones, or even better, to come up with a synthesis that is the best of all worlds. “The solution to problems is not instantaneous,” Nichols says. “It may work in the ‘now' world of intensive care. But in this broader environment, it takes time. And the time invested is not time wasted.”

Charlie Wiener at the curriculum reform committee he heads.  
> Charlie Wiener at the curriculum reform committee he heads.

“He's good. He's real good,” says Wiener, who is chairman of the curriculum reform committee. “I remember calling him on a Saturday in the midst of the [residency accreditation] crisis for reassurance or advice—I don't recall the details. He was out raking leaves, so clearly he had no prep time, but he talked to me for 30 or 40 minutes. And by the end, I was thankful that he was our vice dean and my colleague, and that he was there for counsel.”

“He is so articulate and exact in his mannerisms,” says Leah Harris, fellowship director for pediatric critical care. “There is a grace and dignity and style to David Nichols we all want to emulate. He is both Mohammed and the mountain.”

 

*****

 

David Nichols had a happy and singular childhood. The eldest of three sons, he was born on the campus of the Hampton Institute, a historically black college in Virginia , and moved to Berlin at 7 when his father, an English professor and Fulbright scholar, was asked to direct the Freie University . Growing up, Nichols had virtually no contact with other American, no less African-American, children, and he briefly considered becoming a German citizen. But curiosity about the social movement taking place in his native land eventually drew him back.

He entered Yale in 1969 amid civil rights demonstrations and protests against the Vietnam War. Towards the end of his freshman year, the university actually shut down in the face of campus demonstrations. “It was a tumultuous time,” says Nichols, who remembers how the National Guard lobbed canisters of tear gas in the streets of New Haven , “and for me it was magnified because I was adjusting to a new country, to college, to being away from home. I have to say it was an abrupt introduction to the United States .”

Still, Nichols was a serious student focused on medicine, the career he picked when he was 6. As a student counselor for Yale, he advised underclassmen interested in becoming doctors and found it was a role he loved.

Nichols went to medical school at Mt. Sinai in New York and completed his residency and fellowship at the Children's Hospital of Philadelphia , never bothering to apply to Hopkins because he'd heard it was unfriendly to African-Americans. When he went to look for a faculty position in 1984, he made the trip to Baltimore only as a courtesy to a friend.

He was astonished at what he found. “It was the most vibrant, the most exciting, the most stimulating, and, I have to say, the most welcoming place I'd visited. I was immediately smitten.”

He arrived at a historic time for Hopkins anesthesiology. The department was making the transition from a nursing-based specialty, which it had remained since the days of surgeon Alfred Blalock, to a physician-based department under the leadership of chairman Mark Rogers. Young doctors like Nichols who came looking for an academic career were rewarded with significant clinical work in the bustling PICU, as well as a fertile research environment. Nichols pursued his hypothesis of diaphragm fatigue using animal models, experiments that proved invaluable to his career.

It was during those early Hopkins days that Nichols met Dick Traystman. Traystman helped the new assistant professor set up his research project, and soon, a curious friendship developed between them, one that neither man has ever been able to fully explain.

“We come from completely different backgrounds and have completely different philosophical views of the world,” Traystman says. Nichols grew up in an affluent, well-educated family. Traystman had to fight his way out of a tenement in Bedford-Stuyvesant , N.Y. , and was the first person in his family to go to college. But even though Traystman now lives 3,000 miles away in Portland , Ore. , he and Nichols still speak at least once a week. (“We're much too emotional to e-mail!” Traystman shouts.) No topic is off limits. They argue about politics, the stock market, ethics, books and movies, yet have never had a fight.

“Everything is fair game,” Traystman says in his gravelly, excitable voice. “Both [of us] can express our opinions and tell the other one that he's absolutely crazy without any sense of reprisal. I can tease him about being black; he can tease me about being Jewish. If anybody would hear us, they could bring us up on charges!” The two even talk about retiring together in Barbados .

*****

 

 

But retirement isn't something Nichols even thinks about. All his energy is focused on one task—revising Hopkins ' medical school curriculum. One approach being considered by the curriculum reform committee takes its cue from Barton Childs, a retired faculty member who is a leader of genetics in medical education. Childs departs from the view of the “body as machine,” a model in which “you're either healthy or you're sick, and when your machine breaks down, you need a mechanic, a doctor, to fix your problem,” Nichols says.  
David Nichols

Instead, Childs sees the world “through the genetic lens,” where every patient is an individual and there is infinite variation on the spectrum of health and disease. In other words, there is no longer such a thing as “the diabetic in room 232.”

“The interplay of genes and proteins and environment is entirely unique for every patient,” explains Nichols, “so the physician's challenge is to understand the variability of the genetic and environmental factors that lead to disease, try to craft a prevention plan, and, if necessary, a treatment plan based on the patient's unique variability. And then to be able to evolve that plan over time as new information is added.”

There is no consensus that genetics should be the basis of medical education, however. At one end of the spectrum, a small number of diseases, like sickle cell anemia, are clearly linked to a gene defect. But at the other extreme, “Say you get hit by a car and you've got a broken leg, a brain injury and a contusion to the lung,” says Nichols. “Proteins are playing a role there, too, but the relationship between the problems you're having and your genotype is much less clear at the moment.”

Nichols favors this second, gene-centered concept. “It ultimately will serve this generation of physicians who will be practicing into the middle of this century by giving them a way to assimilate new information as genes are linked to disease.”

Implementing the new curriculum may be an even bigger hurdle than designing it. To do it the way he envisions will require money to compensate faculty for teaching time, to teach faculty how to be better teachers, and to provide an infrastructure that makes teaching easier.

If he is able to pull this off, it would be a landmark,” says Wiener. “It would be of national significance.”

 
 
 
 
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