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Dome - Sharing a Vision of Health

Dome September 2014

Sharing a Vision of Health

Date: September 4, 2014

Johns Hopkins is training physicians to motivate their patients to change unhealthy behaviors.


Diet Health illustration Garth Glazier
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Illustration by Garth Glazier

It’s something physicians see too often: A patient is hospitalized for acute symptoms of alcoholic pancreatitis—her third admission for the same reason. Although it’s possible to alleviate her pain and nausea, the underlying reason for her illness—her alcohol abuse—remains.

“Physicians’ way of treating the behavioral part has been to say, ‘You really should stop drinking,’” says Colleen Christmas, director of the Internal Medicine Residency Program at Johns Hopkins Bayview Medical Center. “As you can imagine, our success rate with that intervention hasn’t been very high.”

Unhealthy behaviors exacerbate many of the most common chronic diseases affecting adults today, including obesity, diabetes, arthritis and addictions. For that reason, says Robert Shochet, an assistant professor of medicine, one of the most important things a physician can do is partner with patients to create a shared vision of what their health could be, then help them take the necessary steps to get there. “Doctors don’t change patients; patients change themselves. But they need allies, and health professionals can offer vital guidance and ongoing support.”

Stepping into patients' shoes

Johns Hopkins begins training medical students to be such allies as soon as they enter medical school. In the course Obesity, Nutrition and Behavior Change, for instance, first-year students learn about motivational interviewing, a technique based on the premise that everyone has a reason to adopt healthier habits, even if it is deeply buried. Through such interviews, clinicians help patients identify how their behavior conflicts with a core value, such as the desire to be a good parent or to maintain a stable relationship.

The process can also uncover undiagnosed depression and anxiety. “Evidence shows that if those underlying conditions are not treated, there is less chance of successfully addressing an addiction,” says Christmas, who also directs the primary care track at the school of medicine. She says Behavioral Medicine on the Ward, a yearlong program launched last year at Hopkins Bayview, is helping residents learn techniques to assist patients in adopting healthier lifestyles.

Although behavior interventions have always been a doctor’s job, doing them effectively is more important than ever, says Roy Ziegelstein, the school of medicine’s vice dean for education.

“Many of the illnesses affecting people in the U.S. relate to health behaviors such as overeating or the use of drugs, cigarettes and alcohol,” he says. Meanwhile, the benefits of healthy routines, such as regular exercise, are also becoming more apparent. Health care reform’s emphasis on disease prevention and patient-centeredness is subtly changing the relationship between doctors and patients.

“Clinicians traditionally have taken the role of fixing the patient’s health problems. Now, we are expanding that to be consultants to patients as they take a more active role in their care,” says Stephen Wegener, an associate professor in the Department of Physical Medicine and Rehabilitation. “Serving as consultants to patients requires us to use additional skills to engage them and help them develop positive health behaviors.”

Behavioral Medicine on the Ward begins with a two-week rotation in which residents hone their abilities in motivational interviewing. Rachel Kruzan, a Hopkins Bayview internal medicine resident, says she is inspired by how quickly clinicians trained in this approach can help patients. Her colleague Jason Liebowitz, for example, was able to assist a man hospitalized for a heart attack who was also diagnosed with diabetes. Hailing from a large Italian family, the patient resisted giving up the pasta and bread he loved until Liebowitz helped him realize that he wanted to stay healthy enough to keep his physically demanding shipyard job. Between his discharge and first follow-up appointment, the patient followed a low-carb diet and shed several pounds. Most important, he kept his blood sugar under control.

An Apgar test for behavioral improvement?

Residents taking the course also use Vital Score, a tool to help change unhealthy behaviors. Invented by Hilary Hatch, an instructor at the Johns Hopkins Center for Behavior and Health, Vital Score is modeled after the Apgar score used to assess newborns at one and five minutes after birth. Using a numerical scale of one to 10, Vital Score measures the health of patients based on their answers to questions about exercise, smoking, sleep, diet and drinking.

Kruzan says that merely receiving a health rating will drive patients to try to improve it. “No matter what they score, whether it’s a four or seven, they ask me about gyms and diet and tell me they want to score higher when they come back,” she says.

To illustrate how difficult it is to change behavior, the program requires residents to initiate their own self-improvement regimens. For two weeks, they wear a Fitbit biometric bracelet to establish baseline readings of their activity levels, sleep patterns and more. Then they set a goal, like losing 5 pounds or increasing their sleep to at least seven hours per night, for the following month.

When Liebowitz chose to walk at least 10,000 steps per day, he also learned how much he has in common with his patients.

“Sometimes we physicians and residents hold ourselves to a different standard—we say we’re busy, we’re doing important work,” Liebowitz says. “But janitors and bus drivers, they work hard and do important work, too, and also have family responsibilities. Everyone faces the same challenges. With the right motivation, we can all change our health behaviors in a positive way.”

—Christina DuVernay

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Johns Hopkins trains physicians to be compassionate and culturally sensitive, in line with these Genes to Society curriculum goals:

  • To understand and respond to factors that influence the social, behavioral and economic factors in health, disease and medical care.
  • To demonstrate effective and compassionate interpersonal communication skill toward patients and families necessary to form and sustain effective medical care.
  • To present information and ideas in an organized and clear manner to educate or inform patients, families, colleagues and community.

Some school of medicine courses that support these goals include:

Health Care Disparities and Service Learning

This three-day course, which students take immediately after orientation, emphasizes cultural competency and its connection to communicating with patients.

Clinical Foundations of Medicine

Throughout this first-year course, students are trained to interact effectively with patients.

Obesity, Nutrition and Behavior Change

In this intensive four-day course, students are introduced to motivational interviewing.

Substance Abuse Care

Motivational interviewing is a focus of this second-year course.

Primary Care Elective
Students learn about culturally appropriate management of chronic diseases and the behavioral underpinnings of health in this four-week elective.

TRIPLE: Transition to Residency and Internship and Preparation for Life

In this fourth-year capstone course, students hone their skills at effective and compassionate communication.

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