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Joy in Medicine

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Clinicians often enter the field of medicine because they love to take care of patients, yet today’s providers are facing a higher burnout rate than ever before because of overwhelming demands from all directions. 

Through the monthly podcast Joy in Medicine, Paul B. Rothman, M.D.’s comprehensive look at clinical burnout and how to address it will explore the various methods clinicians use to identify and implement strategies that benefit patient care and help seize joy in their practice.

Elizabeth Tracey, M.S., and Charlie Cummings, M.D., host Joy in Medicine in partnership with WYPR-FM.

Joy in Leadership

Joy in Medicine

Hosts: Elizabeth Tracey and Dr. Charlie Cummings

Program notes:

0:17 Things becoming more complicated in medicine
1:17 Established the Innovation Hub
2:19 Quiet place to compose themselves
3:18 Talking, doors getting slammed
4:18 Used the room on the day it opened
5:20 Thank the people that created it
6:22 Provides staff respite
7:21 Gentle, dim light
8:25 Underlying ethos
9:37 End

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Full Transcript

00:00 Charlie Cummings: Welcome to this month's Joy in Medicine podcast. I'm Charlie Cummings.

00:04 Elizabeth Tracey: And I'm Elizabeth Tracey.

00:06 CC: This month, Elizabeth and I talk with Chip Davis, President of Johns Hopkins Sibley Memorial Hospital. An episode we're calling Creating Joy Through Leadership. As things become more complicated in medicine, I think the release and relief from the day to day stresses on healthcare providers is becoming more and more magnified. And your focus has been to sort of, take the hard edges out of medical care.

00:36 Chip Davis: Well thank you Charlie. I think that many of us would think while we have wonderful things about the American healthcare system, in some ways it's just an unsustainable model. Moving forward, what could we learn from outside of healthcare, apply that. And I have a fundamental belief that the best people to do that are the people who provide the care on a daily basis to patients and from patients themselves. So one of the things that we've been doing at Sibley, for a number of years, is trying to engage our workforce in new creative and innovative delivery models. As well as what do they need to be able to support those delivery models. So we did a couple of things. One, we established, what we call our Innovation Hub.

01:22 ET: The Innovation Hub marries Chip's experience with observing profound organizational shifts from outside healthcare with concepts from design thinking and Lean Sigma. Along with the dedicated physical space, embedded coaches facilitate participation and engagement for all concerned.

01:42 CD: Healthcare has been a pretty hierarchical industry. That old model of leadership from purely top-down is one that really has stifled, if you will, front line creativity and opportunity to be engaged. I just think remarkable things happen when you unleash that.

02:02 ET: One recent success story from the Innovation Hub at Sibley is called the Tranquility Room.

02:08 CD: One of the things in talking to a number of the nurses that they said was sometimes they just needed a quiet space to go to, to compose themselves. In particular if there was a death on the unit or something else happened, they just needed a short break. So, when we designed our new hospital, we actually designed something that came out of this work in our Innovation Hub called the Tranquility room. It's very easy to get to for anybody in the hospital. The staff feel as if they need a private space where they're separate.

02:43 ET: We had the opportunity to talk with one of the Tranquility Room's designers in the Innovation Hub in Sibley.

02:49 Yoko Sen:My name is Yoko Sen. I am a sound designer. Little background of the Tranquility room is I, myself was a patient for a while and I was very affected by noise because I'm a musician. So we started out by doing research on noise in hospitals. As much as people complain about alarms and machine noise, people also complained about behavior. Talking, doors getting slammed. Noise affects stress, but we also solved that stress is causing noisy behaviors. Instead of putting more posters that tell people to shut up, could we do something to help reduce the stress level of staff members with the intention of helping to reduce the behavior that makes noise. So that was actually the intention behind the Tranquility Room for staff members.

03:48 Suzanne Dutton:strong> So this beautiful space was created where it has Yoko's music in the background and it has very low lighting and four different pods where people can kind of be by themselves. And we have hot tea, water, and things like that.

04:05 ET: That second speaker is Suzanne Dutton, a geriatric advanced practice nurse at Sibley who is currently writing a dissertation on nurse burnout. Suzanne had the opportunity to use the Tranquility Room on the day it opened with a newly fledged nurse at Sibley, Anthony McCue.

04:23 SD: The day that the Tranquility Room opened, on our medical surgical unit, there was a unexpected death of somebody that had been on the unit for a while. The nurse that was taking care of the patient is a new graduate nurse and so it was his very first death. And to understand everything that you have to do when a patient dies, the protocols, the calling of the family, and preparing the body, of course is very traumatic the first time that you actually go through that. My office is right there and I could see that he was overwhelmed. So I just said to him, we are gonna to meet in the Tranquility Room at 1:30 and I got a nurse that I work with to cover his patients for almost a half an hour. We went and had some tea and sat in the Tranquility Room and just debriefed everything that just had happened to him. And he was really grateful and was asking me to please thank the people that created it.

05:22 ET: Here's what happened in Anthony's own words.

05:26 Anthony McCue: It was a heartbreaking incident and then Suzanne Dutton, she came up to me and she asked me if I had time to come down to the Tranquility Room. I hadn't heard about it, like what is this place? And then I went with her and the place was magical. It was a rewarding experience.

05:46 ET: So this was a tough circumstance, the first time that you saw a patient die.

05:50 AM: Yes, yeah I don't think, not all hospitals have this Tranquility Room but I'm pretty sure it was a brilliant idea. And so it's awesome.

05:58 ET: Did that help you in your sorta coming and getting your arms around...

06:02 AM: Yes, I felt really rejuvenated coming back to work. It was a big help, 'cause I worked 12 hour shifts. Longer days but that 10 minutes, it counts.

06:11 ET: Harpreet Gujral, co-director of integrative medicine at Sibley, explains how meaningful such a space, singularly devoted to providing staff respite and rejuvenation can be.

06:25 Harpreet Gujral: As you know, we're on the go all the time. By taking this one minute mindfulness break, by taking this five minute mindfulness break, they're able to pause and then become more efficient. So instead of saying, I'm waiting for my vacation day. I'm able to say, well you know what, lunch time, 10 o'clock 11 o'clock, I'm gonna go in and I'm gonna just pause. Five minutes. Hang out in a space that's dimly lit. No other sounds, my phone is off. For five minutes my buddy's gonna take over. And I'm just gonna go in there.

6:55 ET: Harpreet says the physical attributes of the Tranquility Room facilitate these goals.

07:00 HG: It's right in between two units. An oncology unit and a telemetry unit. It is accessible by any employee with a badge. It is really focused on several things. Lighting, very gentle nature of music. Lighting is such that it's not the bright lights that we normally have in the hospital. Just very gentle, dim light. There are three recliners in three pods and the fourth pod is the yoga mat with a meditation cushion. And so someone can just walk in and experience the very calm, quiet away from hospital environment so we can find our calm and respite.

07:43 ET: Yoko celebrates the Tranquility Room's meeting Anthony's need on the day it opened.

07:48 YS: During the process we really talked to staff members. And this need for emotional recovery kept coming up. We tended to focus on physical, like I'm on my feet all day long, but really when emotional charged event happens, which is every day, there is really no space, physical space inside the hospital that most people could go to have the moment of emotional recovery. So I'm glad that it's served the purpose on the first day.

08:20 ET: Chip identifies the underlying ethos that powers projects like the Tranquility Room.

08:27 CD: I think these reflect our philosophy of going directly to the people, at Sibley it's 2,200 people, that go to work everyday, I believe, wanting to do the best for their fellow man. Giving them the tools and resources they need to really do that the best way possible. And for leadership, instead of for me, instead of telling people what to do, knocking the barriers down that they identify in order for us to provide the best possible care to our patients and their families. And allowing our staff to have a voice in the redesigning of the care delivery model and empowering them to really do that.

09:11 ET: You've been listening to the music of Yoko Sen as it's heard in the Tranquility Room. Thanks so much Yoko, for your permission to use that on this month's podcast.

09:21 CC: Thanks for listening. Join us next month when we talk about the joy in surgery. This podcast series is brought to you in part through the generosity of the John Connelly Foundation, which focuses on medicine and humanism.



Joy in Medicine

Hosts: Elizabeth Tracey and Dr. Charlie Cummings

Program notes:

0:35 Jeremy Greene and state and federal advocacy
1:35 Focus on the patient in front of me
2:32 Became brand name only
3:22 Sherita Golden
4:22 Didn't real know how to treat
5:22 As front line clinicians we can share challenges
5:56 Lee Biddison
6:50 Feels unjust
7:50 Industrialized medicine
8:50 Start to move the needle on drug prices
9:50 Continue to speak about things that are problematic
11:08 End

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Full Transcript

00:00 Charlie Cummings: It was the best of times, it was the worst of times. Elizabeth, I don't know if you're a Charles Dickens fan, but that phrase might be used today to describe politics both nationally and around the world, yet many clinicians are taking up a political role now in advocating for their patients, especially as it relates to drug prices. We talk with a few of them in this month's Joy In Medicine podcast. I'm Charlie Cummings.

00:25 Elizabeth Tracey: And I'm Elizabeth Tracey. Charlie and I had the pleasure of talking with Jeremy Greene, a physician at Johns Hopkins, a medical historian and author, and a political activist on drug pricing both on the state and national level.

00:41 CC: How do you muster the moxie required to take on big pharma, or big government, or big health care? How do you shine a light that everybody sees and ultimately transforms thought? That's an almost non-ending, enormous adversary that doesn't go away and seems to have resources that are inexhaustible.

01:07 Jeremy Green: I have to admit, I rarely think of what I'm doing as just taking on big pharma, or just combating the entirety of a broken health care system. I understand the way you're framing the question that either of those things sound impossible, like sort of a Don Quixote, tilting at windmills kind of task. Why take that on to begin with? I really tend to focus on the patient in front of me in clinic. If you focus on the patient in front of you any given day, you recognize that there are so many different ways in which an individual physician can really advocate for the person in front of them. When I'm acting as an advocate, it's not really about me. It's about me as someone who is in a position to be able to speak for a number of people who don't necessarily get spoken for, such as why it is unconscionable for people who don't have insurance in the United States today to not be able to afford insulin when that drug was discovered in 1921, first patented in 1923.

02:07 ET: Jeremy recalls a recent experience with a patient.

02:05 JG: I saw a patient who came in suffering from the complications of an asthma attack. Actually, her asthma attack was so severe it looked like she was on the verge of needing to be hospitalized. We managed to bring her down in clinic and get her safely managed on oral steroids, and she did okay. She had been seen before, and she had been given the right medicine. She had been given albuterol as a metered dose inhaler. This is a drug that many people think of as generic. It had been generic. It became only available by brand name fairly recently due to a side effect of the way that we chose to respond to the ozone hole. So when physicians write a prescription for albuterol, this old drug, they don't necessarily realize that the puff can cost $80. Depending on your patient and how close she is to the poverty line, and this particular patient was uninsured, was working two jobs, didn't speak English, at first couldn't afford the albuterol inhaler, then finally managed to find a way to afford it, and wasn't instructed how to use it, basically was spraying it like a Binaca sprayer into the back of her mouth, and so the whole process by which she became an urgent or perhaps emergent case in my clinic was entirely preventable and related to deeper social structures. Why is an old drug so expensive?

03:21 ET: Sherita Golden, vice chair of the Department of Medicine at Johns Hopkins and a diabetes expert, credits a patient with bringing her to advocacy.

03:31 Sherita Golden: At University of Virginia where I went to medical school, you had to do your first history and physical with a preceptor, so you went and saw the patient, and then you had to write everything up and present it. This gentleman was only 35 and he had type 1 diabetes, and he had every complication. He was blind in one eye, he had had a partial toe amputation, and then he also had undergone a kidney transplant for end-stage renal disease. He had such severe low blood sugars that he'd had two motor vehicle accidents and had his license revoked. He was completely disabled. And I just remember being really struck by his story, because he actually knew all of his medicines. He was very organized about his care. This wasn't someone who hadn't taken care of himself. But I think at the time we didn't really know how to adequately treat diabetes. When I was a fourth-year medical student two years later, the results of a diabetes control and complications trial was published, and it showed that with tight glucose control you could prevent all those devastating complications. I realized that I'd be able to really prevent those kind of complications in the future by aggressively treating diabetes, which goes back to the insulin issue. We want to have the flexibility as clinicians to be able to choose the regimen that's going to be most effective.

04:47 ET: Sherita says the meteoric rise in price of various insulins leads her to become an even more vociferous advocate with the American Diabetes Association.

04:59 SG: This is a huge challenge, and it's one of the reasons that the cost of care for diabetes has skyrocketed recently. I think it's really critical for us to be advocates for our patients, and so to identify a professional organization that allows them to advocate in a more impactful way, those are ways that we can really advocate, because as front-line clinicians, we can actually share with those who make some of these decisions what the real challenges are. In a way, it's like taking that frustration that you have about your prescription for your patient who really needs it being denied, and really taking it to the people who can make policies to change those decisions. It makes you feel like you're actually a part of the solution for your patient.

05:50 ET: Lee Biddison, vice chair for clinical affairs at Johns Hopkins, says battling for patients because of issues related to drug prices is one source of clinician burnout.

06:01 Lee Biddison: I think drug pricing has become a real problem in a number of different arenas. There is strictly the cost issue, and then there's the regulatory burden that's associated with it, or the paperwork burdens associated with it, for providers. Prior authorizations, those types of activities that end up being nothing more than essentially meaningless paperwork, and taking people away from doing what they really love to do, which is engaging with patients to help them have better outcomes. I think it's significant because it is a piece of a larger context. The regulatory burden, the checking of the boxes, the being sure that every form is filled out and filled out correctly, in triplicate, so to speak, is a big piece of what's frustrating clinicians. Is it solely the issue of prior authorization? No, but that's a piece of that activity, a piece of one that probably grates in a particular way because it feels unjust.

07:00 ET: Are you galvanized to advocate? Shannon Brownlee, senior vice president of the Lown Institute, which seeks to reform health care via a grassroots approach, invites clinicians to join in.

07:13 Shannon Brownlee: What the Lown Institute wants to do is help us reimagine our health care system, our medical services delivery system, in a way that makes it better for clinicians as well as for patients. When you get right down to it, so much of health care and caring about people is about this interaction between individuals, between nurse and patient, between doctor and patient, between nurse and doctor, and the quality of those relationships and those interactions has been degraded by the way we've built this system. We have industrialized medicine to the point where burnout doesn't even convey the depth of despair that many clinicians feel and the sadness that they feel at the loss of that sacred space between clinician and patient.

02:00 Jade Flynn: I'm Jade Flynn, I'm the nurse educator for the bio-containment unit as well as the nurse clinician in the neuro-science critical care unit. MEPRA came at a time where I was contemplating leaving nursing, just because of the emotional toll. One big thing that I came away with was gratitude. I come away from a shift that was ugly. There's always something that I can identify that I was grateful for. And most of the time, it's my coworkers. The people that were in the trenches with me that day. That were able to pull me out when I needed help. It gave me the license to take time for myself. Meditation was big. I always thought it was more like a hippie dippie kind of thing. But it was more about having a conversation with yourself. And the self reflection about, "Okay, this is how you're feeling, and that's okay." Take deep breaths and noticing what you're feeling throughout your whole body. And not really finding the answer right away of like, okay, I'm feeling this. But just noticing it and being like, "okay. I'll come back to that later."

08:06 ET: Tell me how physicians can get involved, how nurses can get involved.

08:10 SB: Our other initiative that really can get clinicians involved is the Right Care Alliance, which is a grassroots movement to improve health care and health. Our first campaign this year is on drug prices, which we all know are skyrocketing, and they're out of control, and there aren't really good mechanism for getting them in control. This social movement, which is now 35,000 people strong ... it includes clinicians, but it also includes patients, lawyers, community activists. We hope that this on-the-ground action in statehouses, maybe at the national level, but mostly at the local level, will start to move the needle on drug prices. We also have a set of councils for the Right Care Alliance, and the clinicians who are involved in the councils are effectively our brain trust.

08:58 ET: Would it be your assertion that these kinds of things are going to provide sufficient payback that it will help ameliorate some of the many problems we hear from clinicians about their practice?

09:10 SB: Clinicians feel powerless right now. The institution, the manager, the CEO, the payer, somebody else is running their lives. And I think they kind of have two choices. They can either feel terribly powerless and try to soldier on, or they can somehow get involved in some way of making change.

09:35 ET: Lee says both time for self and others is necessary.

09:35 LB: Keep doing the right thing. I think that it's critical for us as providers to continue to speak about things that we see as incredibly problematic and to continue to press for the change that's necessary. I also think that it's possible to get a little burned out in that advocacy, so trying to take time to take a break and recognize that there are multiple people working on the issue I think is important, too.

10:10 ET: Jeremy invokes the power of the election cycle.

05:15 JG: I think there's a process of staving off fatalism. One can say oh, this problem has existed for so long, it keeps on getting worse every year, and yet nothing is done about it, therefore nothing is doable. And I think we really push back on that last process, and we think actually there's so many things that we can do, and let's try and list as many of them as we can, and then bend our tasks to the ones that we think are the most likely, and then we'll reassess come November, and we'll put our tools to the ones we think are most likely then.

10:48 ET: That's this month's Joy In Medicine. Thanks again to Brian Garibaldi, physician and musician, for our marvelous music. I'm Elizabeth Tracey.

11:01 CC: This podcast series is brought to you in part through the generosity of the John Conley Foundation, which focuses on medicine and humanism.


Mindful Ethical Practice and Resilience Academy (MEPRA)

Joy in Medicine

Hosts: Elizabeth Tracey and Dr. Charlie Cummings

Program notes:

0:13 Medicine abounds with acronyms
1:11 Will be 13 years
2:10 Was contemplating leaving nursing
3:07 Ethical competence
4:07 Know thyself sentiment
5:09 This is hitting me on different areas of my body
6:09 The role of courage
7:05 I'm a believer now
8:05 Made a huge impact
9:04 There was a procedure
10:04 Bringing the patient home
11:15 End

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Full Transcript

00:02 Elizabeth Tracy: Welcome to the Joy in Medicine Podcast series. I'm Elizabeth Tracy.

00:06 Charlie Cummings: And I'm Charlie Cummings.

00:08 ET: COPD.

00:09 CC: MRI.

00:15 ET: CT.

00:15 CC: PRN. You know all this medicine abounds with acronyms. And this months Joy in Medicine podcast features one of them. MEPRA. We talk with Cynda Rushton, MEPRA's founder about this program that she developed.

00:27 Cynda Rushton: You're referring to the Mindful Ethical Practice and Resilience Academy, affectionately called MEPRA.

00:34 ET: So tell me more about this program then. With are the specific skills that are part of it?

00:39 CR: MEPRA focuses on three things. The cultivation of mindfulness, which involves learning basic mindfulness skills. We have a daily guided meditation, 10 minutes, that includes also reflective practice, where people reflect on what they're noticing in their selves. But also, invites them to engage positive emotions of what they're grateful for.

01:05 ET: Here's one MEPRA graduate.

01:07 Jen Simmons: I'm Jen Simmons. I am a nurse in the surgical ICU at Hopkins and I've been here, it will be 13 years in September. There's so many people I love and respect that really swear by meditation and its benefits. My feeling was always like, "That's great. If you like this, I love it. But nah, it's not really my thing." I'm more of a grit your teeth and get through the tough stuff. Of course things are gonna be hard and you just have bad days and get through it. But it was the intentional stillness that really changed me. It brought this calm and this sense of personal control, that I was sort of missing from a lot of aspects of my life. I know I have that tool when I need it. That if I'm feeling erratic or if I'm feeling hyped up, I have this tool set that I can rely on to help improve me in any situation.

01:55 ET: How has it helped here?

01:57 JS: I'm a lot more patient.

01:58 ET: And another MEPRA advocate.

02:00 Jade Flynn: I'm Jade Flynn, I'm the nurse educator for the bio-containment unit as well as the nurse clinician in the neuro-science critical care unit. MEPRA came at a time where I was contemplating leaving nursing, just because of the emotional toll. One big thing that I came away with was gratitude. I come away from a shift that was ugly. There's always something that I can identify that I was grateful for. And most of the time, it's my coworkers. The people that were in the trenches with me that day. That were able to pull me out when I needed help. It gave me the license to take time for myself. Meditation was big. I always thought it was more like a hippie dippie kind of thing. But it was more about having a conversation with yourself. And the self reflection about, "Okay, this is how you're feeling, and that's okay." Take deep breaths and noticing what you're feeling throughout your whole body. And not really finding the answer right away of like, okay, I'm feeling this. But just noticing it and being like, "okay. I'll come back to that later."

03:01 ET: Cynda describes another MEPRA building block.

03:04 CR: The second one was [inaudible 00:03:06] being ethical competence, which includes the ability to recognize ethical issues. To be able to deliberate about them. To be able to think about what, why's and compassionate ethical action looks like. How we actually implement the decisions. Embedded in both of those are some important skills around communication. Because nurses often know what the issue is, but they have trouble translating it into speaking about it in a way that they can be heard and their concern can be taken seriously and acted upon. I think we take value for granted until they're challenged. And then we have to explain what matters to us. So what we're trying to do in this idea of ethical competence is to clarify those values so that we know, when I'm in a tough situation, I'm gonna go back to my anchor. I'm gonna ask myself, what does respect require of me in this situation?

04:03 CC: To me, the seminal thought of this is the know thyself sentiment. I think medicine is both gifted by having people who have an enhanced awareness and at the same time, challenged by having the need to become complete person once you get over that hurdle and realize that it's part of the maturation process. Where you want to be as a physician, that becomes better.

04:29 CR: [inaudible 00:04:29] resiliency comprises the third MEPRA skill. The third part is the development of resilience. It's not only resilience in general, it's moral resilience, which is about being able to restore and preserve integrity in response to moral adversity. All kinds of moral adversity.

04:48 ET: Jen explains how resiliency serves her.

04:51 JS: If there's a situation with a family that resonates with something that's going on at home, it's gonna pop up in ways you weren't expecting. But when you go through a program and it gives you training to recognize that change, that when your emotions are unregulated or when something biologically is different. And you say like, "Wait a minute, this cognitive process is hitting me on different levels in my body," and you take time to address those, it is a lot less weight.

05:14 ET: Charlie comments.

05:15 CC: I think the moral resilience ... resilience is a good word. I thought about I said, "That's really a good word." Because it does allow one to digest the whole situation and then allows one to modify their beliefs. The fact that you can actually change from a previously endorsed assessment of a situation, that's good stuff.

05:38 ET: Cynda says personal history plays a role.

05:41 CR: Part of what we do in MEPRA is try to help people remember why they got into this work in the first place. What was that, that brought you here? And how do you get reconnected to that? What is it that you intend to do in your work so that there's that sense of purpose? There's a resource, you remembering that. It's that when things are tough, it can kind of help us have something to hold on to.

06:05 ET: Another question is important. What is the role of courage?

06:09 CR: Oh yeah.

06:10 CC: It takes courage to go into uncertain territory. It takes great courage to challenge the status quo.

06:18 CR: I would say courage is the engine of integrity. You have to have courage to be who you really are. You have to have courage to do the right thing. You have to have courage to be accountable for your decision. To take a risk. The easy thing is to just put your head down and keep doing what everybody else is doing. It's not easy to be our values.

06:47 ET: A final part of MEPRA training involves a high fidelity interaction with both a family member and a clinician in the simulation center, which impressed Charlie.

06:58 CC: The skeptic in me said, "There's no way they could really do this unless it's battlefield conditions." I'm a believer now where I was a skeptic before. That is a real positive.

07:09 ET: Jen too appreciated the interaction.

07:12 JS: Having the space to practice, digging into your core values and being able to speak from this place of integrity, to say this personally matters to me, is a way to flip things on that hierarchical scale that really gets anyone to listen to the message you're delivering, regardless of their position of power. It's a very humanizing way to talk to somebody.

07:35 ET: Jade is using her MEPRA experience to create culture change.

07:40 Jade Flynn: Well it's more of a grass roots approach. I started the win board. It's called the what I notice board. I noticed that we start the shift or we go to one another and say, "Well, we have two beds open and we have 18 cases on the board. How are we gonna make this happen?" And I wanted to change that record and say, "Okay, what else have you noticed? What I noticed was that Alisha made a huge impact on this patient's well being today because she got our patient out the bed and walked her to the window for the first time in a month. To really look at the positives rather then the negatives. The pick ups rather then the put downs. It is something to celebrate.

08:17 ET: Davis Darsh, a MEPRA graduate and advocate and SIC U nurse, gives a recent example of MEPRA's benefits.

08:26 Davis Darsh:I've always been a patient advocate, but MEPRA has made me become even more of a strong patient advocate for patients who are in situations, especially end of life. And just the other day, we had a patient who, I felt like there was a disconnect between the surgical team, the ICU team, the patient and the family. The family really wanted to end life sustaining measures. The patient also really wanted to go home and be able to die peacefully at home in his cabin in the woods. We all wanted that. But it was, how are we going to get there? There was a procedure that needed to be done on this patient that the surgical team really thought needed to happen. Our team was kind of on the fence about. The patient was kind of on the fence about. But the wife didn't really think it was necessary.

09:16 DD [cont]: So just knowing that I'm empowered to go speak directly to the attending provider of the ICU and I said, "Look," I said, "I think we're not on the same page here. I'm struggling with this internally. I know the wife is struggling with this internally. I think the patient knows what he wants, but I don't think he knows why he knows what he wants. And I think we need to make sure that we truly explain why this procedure is something that we think is going to get him home. We're not sure. It's possible he could die on the table if he gets this procedure. But we think it's the right thing." Even after explaining the possibility of death on the table, he was willing to take those risks and he ultimately was able to be excavated here in the surgical ICU and is able to go home and die at home. I think we all felt as a team, including the patient's family, felt better about the decision.

10:09 DD [cont]: MEPRA gave me the tools to help better present the situation to the team.

10:13 ET: Cynda sums MEPRA's impact for nurses so far, this way.

10:18 CR: Every single one of them wants to be able to practice in the way that they feel honors their values and has integrity for them. And when they can't do that, it's when they really feel the most distress. They're seeing themselves as being empowered to make changes to create the kind of culture that they want to practice in.

10:44 ET: That's the latest Joy In Medicine podcast. Our music by Brian Girabaldy is something we deeply appreciate.

10:49 [music]

10:52 CC: This Podcast series is brought to you, in part, through the generosity of the John Connelly Foundation, which focuses on medicine and humanizing.


Dogs in the ICU

Joy in Medicine

Hosts: Elizabeth Tracey and Dr. Charlie Cummings

Program notes:

0:30 ICU sounds
1:31 Infection and sepsis
2:31 This dog is the center of my life
3:31 Dogs come to visit the staff appreciates it
4:31 Spark excitement in patients
5:32 Everyone works so hard
6:32 In rehabilitation
7:32 Reduces burnout and improves joy
8:35 Training a dog to do this
9:35 Rapidly did better
10:44 End

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Full Transcript

>> Welcome to the Joy in Medicine podcast series, I'm Elizabeth Tracey.

>> And I'm Charlie Cummings.

>> And this month we're talking about how dogs can bring joy to everyone in the intensive care unit. Perhaps you've had the unfortunate experience of being familiar with these sounds. Sounds typically heard in an intensive care unit. But here's another sound that's sometimes heard in the Medical Intensive Care Unit at John's Hopkins. Yes, that's right, it's a dog, and here's a young patient talking about her recent experience in the Medical Intensive Care Unit at Johns Hopkins.

>> My name is Brea Griffith, I'm from Brooklyn, New York, but I live in Belair, Maryland, and I'm a student right now.

>> You had an experience where you were at Johns Hopkins, tell me some more about that.

>> Oh, well, I have Crohn's disease, and eventually I became malnourished, so they prescribed me TPN through a PICC line in my arm, which is like an IV. Eventually the PICC line got infected. The infection was spreading, and I ended up having sepsis, pneumonia, and blood clots, and then my lung collapsed and I had to go through surgery. I wake up in the ICU with three chest tubes, I'm like, "What's going on?" I was in the ICU for about 42 days, just trying to recover from that each day. They helped me learn how to walk again, because I was in a coma, well a drug induced coma, for about three weeks. At one time, they had called my parents and told them to come in, because they weren't sure if I was going to make it through the night. It was very painful, and was a very long time I was in bed.

>> Brea, how old are you?

>> I'm 23 years old. And then, eventually, this golden retriever came to my room, and as soon as I saw the golden retriever, I was like, "Oh my goodness." She came in, and she jumped up on my bed, and she was real gentle, and she rested her head on my leg, and my mind just went somewhere else, I wasn't even in the ICU anymore. I just felt like this dog is the center of my life right now

>> Dale Needham is a critical care medicine expert and a pioneer in transforming care for patients in the ICU. He's also one author of a recent paper taking a look at how dogs can be employed in the MICU.

>> The role of animal-assisted therapy, or animal-assisted interventions in the ICU is just one part of a larger part of our Johns Hopkins Critical Care Physical Medicine Rehabilitation program where we aim for patients to be awake, alert, moving, and trying to do some of their regular activities. If the patients are awake and alert, could an animal, for example a dog, help in their recovery, and in lifting their spirits, and having them do functional tasks that they may be more willing to do if there's an animal to help incentivize them, for patients that really have that love of animals. I don't think we should discount the benefit to hospital staff. Whenever one of the dogs comes to visit a patient, there are many smiles on the hospital staff as well. It's something that helps lighten the mood, and it makes the ICU a more fun and enjoyable place as we help patients get better.

>> Megan Hosey, a rehabilitation expert at Johns Hopkins, and versed author of the recent paper on AAI: Animal-Assisted Intervention in the ICU, says dogs are amazing.

>> Sedating patients in the ICU, and giving them lots of bed rest, might lead to poorer outcomes, and what we're really doing is coming up with ideas about how to prevent that. Except for if you're ventilated, and pretty sick, for a lot of people that's a scary and intimidating process to think about getting up and walking around in those conditions. What we do is bring in dogs to give a sense of purpose, and maybe alleviate some of the anxiety to some of the early mobilization. If I'm getting up while I'm mechanically ventilated, that's really scary, but if I can get up to pet the dog, or give it a treat, that might sort of spark some excitement in patients, and give them a little bit of an extra sense of purpose with their mobilization.

>> Stephanie Cooper-Greenberg is a long-time visitor, along with her canines, to Johns Hopkins. She also manages Pet Partners at Johns Hopkins, which trains and certifies dogs for visitation.

>> There's a team that's been going to the ICU for many, many years. I thought to myself, the first chuckle was: You didn't really need a study to tell you that this works, and how valuable it is, and how important it is to the patient, how really important it is to the family, and how amazingly important which was discreet, and I uncovered the fact that the staff needed it more than maybe even the patients. There's a tremendous amount of moral distress and anxiety, and wanting your patient to do better, and sometimes when a dog walks in, its a game changer. All the physicians, all the nurses, everyone who's involved in someone's care, just work so unbelievably hard. And then we come in with a dog, I'm just the dog walker, a dog comes in and gets all the credit.

>> Charlie offers his take.

>> Now, I'm a dog lover, that's true, and I impart to them great potential for making people feel good. And the reason is, dogs are absolutely, totally impartial. They have no preconceived notions about illness, about people and how they're suffering through illness, they have none of it, they are just pure emotional. I am really happy to be with you. I think dogs are God's gift to mankind to take him through some really tough time, or her through tough times. I've got to make sure I'm politically correct.

>> Dex Mantheiy is a Senior Clinical Program Coordinator in the Department of Physical medicine and Rehabilitation, and works often with Megan and Dale in rehabilitating patients, and he also has the pleasure of working with the dogs.

>> It became, just something I looked forward to, something that was always kind of in the back of my mind during the work day. It was like, I hope we get to do animal-assisted therapy today with somebody.

>> Talk to me about, you're in a specialty that is associated with a great deal of burnout, and with a lot of times where people say, "Wow, just get me out of that place, I don't want to be there," Does the dog thing help you with that?

>> It does, and actually, probably one of the more unique things here, is that AAT isn't just for the patient. They will bring it in for staff, to just kind of help decompress. Like today the nurses were so bright to see the dog, during rounds doctors kind of stopped and took notice, and it brought a smile to them. So, it seems to help just everybody.

>> In reflecting on his fairly lengthy career in the ICU, Dale also is a fan.

>> This is tremendously helpful for me when we can actually see that we're making meaningful differences in patients lives. I think this is really important and reduces burnout, and gives us joy and meaning to what we're doing. It's also, from my perspective, very interesting to be in an innovative environment where we're doing new things, and we're pushing boundaries. Animals in the ICU, music in the ICU, what else can we bring into the ICU to normalize that experience. It's very interdisciplinary, and that, I think, makes work so much more fun, not just being in my own silo. When I'm surrounded by an interdisciplinary team, I learn from them every day. I'm going to get insights into things that I otherwise would not even know about, which are critical, though, to improving the care that we provide. So I think that also increases my job satisfaction, my joy in medicine.

>> Megan is clearly a convert. Witnessing this has been so powerful for you, that you're considering doing it yourself, is that right?

>> Yes, that is right. My husband and I actually have plans this spring to adopt a dog who will hopefully have a good temperament for this kind of thing. We'll go through Pet Partners, that trains you to be able to do that, then I would be able to do it myself.

>> Bringing dogs to the ICU has also helped one very long-time member of the Johns Hopkins faculty keep his joy.

>> Hi, I'm Fred Askin.

>> And, you have a role here at Johns Hopkins that's a physician role.

>> Right, I'm the Director of Surgical Pathology at the Bay View Campus.

>> But you also do something else that's pretty amazing: you bring your dog. Your dog is sitting right here with us, Pippy, and adorable West Highland Terrier, to come and visit with patients.

>> Working with Pippy as a therapy dog has just made me feel like I'm making a very valuable contribution to patient care.

>> Clearly it is very valuable to patients, here's Brea.

>> Her name was Winnie, and Winnie was just so cute and so gentle, and she could see I'm in pain. I had these chest tubes coming out of me, and she just was so careful, and she came back about three times. I rapidly started doing better, I went from the ICU to a step-down. It really changed my mood, like all that pain I was in. I said to the owner, I said, "You know what, my pain is gone." For me it was just an amazing experience, rather than sitting in a bed, staring at these walls, all the charts and machines going off. I just felt like that was a blessing. The dog helped a lot.

>> I think all you have to do is look at the results. I mean, how can you not be in favor of that?

>> This Podcast series is brought to you, in part, through the generosity of the John Connelly Foundation, which focuses on medicine and humanism.


The Society of Bedside Medicine: Part II

Joy in Medicine graphic

Hosts: Elizabeth Tracey and Dr. Charlie Cummings

Program notes:

0:35 Burnout is a very common phenomenon
1:36 For me one of the most important is joy of discovery
2:25 I think I know how to help
3:25 Simply pausing, looking and listening
4:35 Practicing at the highest level
5:35 Reduce health care costs
6:34 What lives on in memory
7:35 We just have to get her out of the hospital
8:35 Her organ systems began to fail
9:35 One of the most meaningful
10:55 End

Press the play button to listen now:

Full Transcript

>> Welcome to episode two of the Joy in Medicine podcast series, I'm Elizabeth Tracey.

>> And I'm Charlie Cummings.

>> We're continuing our look this month at the Society of Bedside Medicine, an international group of clinician educators who aim to train young physicians in the joys of the physical exam, and hopefully alleviate at least some of the burnout many in medicine report.

>> Burnout is a multi-pronged phenomenon, very common in arenas that extract a high degree of energy and input from the person. It's not exclusive to medicine, burnout's burnout, but I think being aware that it occurs and trying to alleviate when possible and eliminate where possible the cause is appropriate. But stress leading to burnout is something that has to be dealt with in any high-pressure arena.

>> Brian Garibaldi, co-president of the society and a lung expert at Johns Hopkins, explains how robust physical exam skills help. You're aware, and so am I, that physicians are leaving the profession in droves, and there's this shadow of burnout that's over the health care world, really, not only physicians, nurses and all kinds of care providers. How can the acquisition and the perfecting of skills such as you've described help people to avoid burnout?

>> I think it can work in a number of different ways. I think probably for me, one of the most important ways in which it helps me avoid burnout is that joy of discovery. That's what we all went into this profession for, was to help uncover and discover why someone's not well and to help them navigate how to get back to wellness if possible. I think intentionally honing your physical exam and your history skills and your communication skills, and using them with people at the bedside, is one of the most wonderful ways of getting that reinforcement and getting the satisfaction from your job that you trained for. There's a joy of discovery when you're with someone and you're listening to their problems, and you begin to have a sense of, "Oh, I think I have an idea of what this might be, "and I know what we need to do together to figure this out." Then you get the opportunity to examine them and things begin to come a little bit more clear, and you're like, "Aha, I think I know what it is "and I think I know how we can help you."

>> Stephen Russell is an attending physician at the University of Alabama at Birmingham, and a member of the Society of Bedside Medicine board. He says those physical exam skills come in handy when it comes to providing the patient with a timely diagnosis.

>> Headache is a very common complaint, and I can clearly remember a man in his 70s who came in with a headache that was different from the type of pain that he had had before. When the time was taken to actually do the physical exam first, rather than reflexively go to the CT scan, we had an opportunity to realize that this particular patient had shingles. It was actually in his scalp which was hard to see. But by doing the physical exam and by walking through that with a resident who was there with me, we had a chance to see that the pain that he was having was the same type of pain that he may have had if it was in another part of his body. So by simply pausing, looking, listening to him, and then using our exam to be directed based on what he was telling us, we were able to actually make a diagnosis before we even moved to the next test that we thought might be needed. And in reality, we didn't actually have to do that test, we could move straight to treatment.

>> Russell believes that the Society of Bedside Medicine brings joy by calling out physicians to be their best selves.

>> One thing I think that is often overlooked with the physical exam is that the physical exam is part of the craft of being an experienced clinician. What people need to understand is that part of being a well-rounded, well-taught, well-thought out physician is understanding all of the tools at your disposal. And by not fully understanding and appreciating and practicing the physical exam, you're not fully reaching to the highest level of your craft, of your chosen profession. So by using the physical exam, understanding the physical exam, and learning about the nuances of the physical exam, you're actually practicing at the highest level of your chosen profession.

>> Erica Orsini, a second-year medicine resident at Johns Hopkins, recalls an enduring lesson in physical diagnosis.

>> I've really gotten in the habit of always looking at patients' hands, because you can really glean a lot of information just from looking at their nail beds and if there's pallor, you can find evidence of rheumatologic disease. And I recall my intern year I had a patient with joint pain and it was not readily clear what it was from, and my chief resident walked in and could see right away that he had tophaceous gout all over his hands, and I remember feeling kind of silly that I hadn't noticed. So now I just make it a habit, whenever I'm examining someone, just to, "Hey, let me take a look at your hands."

>> Erica intends to work in global health and says physical exam skills are especially important in such settings and can also reduce health care costs.

>> I often imagine myself working in kind of like a low-resource environment, and I want to absorb as much of the information I can from these master clinicians because I always think in the back of my mind, "What if I didn't have "a CT scan readily available, or labs, "or those things were difficult to get, what would I do?" I think it should be rolled out really in every training program across the country. We're definitely trying to reduce the cost of health care. We spend more on health care here in the United States than anywhere else, and we don't have the best outcomes.

>> Willard Applefeld, another second-year medicine resident at Hopkins, says bedside medicine helps him practice presence.

>> That's the really interesting part about all of this is that you feel sometimes when you're at the bedside that there are all these conflicting priorities which are driving you away, the things that need to be done, the pages that need to be returned, the notes that need to be written, the orders that need to be placed, but when you really go back and think about it in your memory what lives on is not that feeling of, "Oh my goodness, I have so much else to do." What lives on in memory is the conversations you had or the encounter you had, and you don't remember how hurried you were or how stressed you were. You remember the person sitting there. I think fundamentally that's why everyone gets into medicine, or at lease most people, is to form that sort of human connection. And when you think about it, we sort of put up with everything else so that we can have that moment with somebody else at the bedside.

>> Willard says this lens has also helped him in dealing with end of life.

>> I try to keep a tally of the people I don't want to forget. I was on a service which is dedicated to GI illnesses and I took care of an immensely sweet lady by the name of Miss Bea, and she had a rare form of liver disease. She had lived with it her whole life, she never drank, never smoked, had an otherwise pretty healthy teetotalling sort of life. Her only problem was that she had this form of liver disease which eventually would require her to get a liver transplant. She'd come into the hospital in June and I remember that the ethos at June was we just have to get her out of the hospital, we just have to not break her, she's gonna get a liver, she's gonna get a liver soon and she's going to continue to have this great life, and eventually she'll get a liver transplant and live another dozens of years on top of this. Then I was the senior resident in the MICU which is the medical intensive care unit about a month or so later, and I met her again in the ED, in the emergency department. She'd been coming back from her doctor's appointment and had banged her leg on the door of her car and had a developing, and quite frankly nasty looking, skin and soft tissue infection, a cellulitis. I was told that she didn't quite need the medical intensive care unit's level of care but they wanted me to take a look at her regardless. I was concerned enough that I felt that she did actually need the MICU, and so I brought her to my service. Again, not a serious condition, people get cellulitis all the time. Unfortunately hers proved to be much worse and over subsequent days her organ systems began to fail. First her lungs, then her blood vessels, and she required IV medications to maintain her blood pressure. Then her liver began to get worse, then her kidneys stopped working. Eventually she needed a breathing tube, and as her liver failed and her kidneys failed and her lungs failed, she became more and more delirious. I got to know the family quite well during this time and we were initially quite hopeful. After all, a period of critical illness makes you higher on the transplant list and makes you more eligible for a transplant. Then we became more and more dismal in our prognosis, recognizing that she most likely would not recover from her current illness. And as she got worse and worse, I struggled with feelings of helplessness, questioning could we have done anything different. And again objectively reviewing the data and saying, "No, there really was nothing else we could have done." At the end of the day what we could offer her was a comfortable death surrounded by those who loved her. When I think of the treatments that I rendered throughout my medical training, it was that one which I think was one of the most meaningful ones, being able to give somebody and their loved ones a somewhat peaceful death. In the end I remember her daughter and her husband hugging me and thinking to myself, "She died, why are you hugging me?" And I realized that, at that moment, what was more important than treating her infection, or making sure her blood pressure stayed up, or making sure her liver numbers were in range, was the fact that she was comfortable and surrounded by her family when she died.

>> In his abundance of clinical expertise, Charlie sums it all up this way.

>> I think medicine isn't all pills, and drugs, and injections, and procedures. Sometimes those don't work. Sometimes what's needed is an emotional support that is beyond a prescription. I think that you can't change the course of disease sometimes and you can't alleviate an end result sometimes, but you can certainly provide support and introduce to the patient a reinforcing sense of self, of value of their life.

>> That's this month's Joy in Medicine, I'm Elizabeth Tracey.


The Society of Bedside Medicine: Part I

Joy in Medicine graphic

Hosts: Elizabeth Tracey and Dr. Charlie Cummings

Program notes:

0:30 Abundant clinical experience
1:31 Society of Bedside Medicine
2:32 Loss of interpersonal relationship
3:32 Clinic of patients with scarred lung diseases
4:30 Fundamentally important to doctor-patient relationship
5:33 A patient with crackles
6:31 Listened with stethoscope through the gown
7:32 Only one who made eye contact
8:32 Got to connect to your patient
9:34 Also important for doctors
10:32 Only appreciate in the presence of the patient
11:32 Doing everything in your power
12:31 Music by Brian Garibaldi
13:15 End

Press the play button to listen now:

Full Transcript

>> Welcome to the Joy In Medicine podcast series. I'm Elizabeth Tracey.

>> And I'm Charlie Cummings. I'm a physician at Johns Hopkins. I'm one of the albatrosses of the group in that I've been practicing medicine since 1961 I got out of medical school, so that's a long period of time.

>> I don't know if I would describe you as an albatross. I'd rather say that you're a guy with abundant clinical experience.

>> Well, and you know what, true, and it's a blessing because for me I have a perspective on illness that I think some of the younger folks don't have. One of the blessings of getting old is you do gain perspective.

>> I'd ask you to share just a little more about that. What perspective, specifically, does that give you?

>> An appreciation of the good fortune that I have for still being upright. I'm able to continue to enjoy life, and I think I'm able to continue to learn from life.

>> On that wonderful message I'm gonna turn another question to you, and that's why are we doing this series that we're calling Joy In Medicine what's important about that?

>> Yeah, well, you have to sit and watch what happens over time in medicine. I've seen the intrusion of technology. Technology is wonderful and has contributed to many life saving contributions, but it also has driven a wedge between the physician and the patient. It dehumanizes, I think, the power of the physician and the patient relationship.

>> You brought us really nicely to our first podcast in this series, and our first podcast really focuses on something called the Society of Bedside Medicine. It's really an initiative to bring physicians back to the bedside and practice their skills. What do you think about that? Why do we need it?

>> Medicine is based on human illnesses, and the observation of the human illness and the diagnosis, and, hopefully, treatment of the human illness. That's the key thing. You learn about the patient when you do the physical examination. I was speaking with a dear friend of mine who recently had a cardiac problem had an evaluation. This person is a very good physician, and he had his evaluation, and the cardiologist talked with him, and looked at the EKG strips, but at no time touched the patient, no time listened to the heart, no time did anything, gave his diagnosis, gave him some medication, and away he went. He said that was striking that that could happen, and what a loss it was in terms of an interpersonal relationship, that I think goes on a lot.

>> So then would you say is it fair to say that you would applaud this movement back to the bedside, and the development of this skillset?

>> Well, it's a reentry into what medicine is all about in my opinion.

>> That's the sound of a heartbeat. Of course, you know that already, but that second sound listen to this sound, do you know what this is?

>> So what you just heard are crackles, and crackles can mean a number of different things, but usually what they mean is that there's either fluid in the lungs, or there's some process that's caused either inflammation or scar in the lungs, so they're a sign of potentially a serious lung problem.

>> How often do you hear them in people?

>> In my clinic I hear crackles in almost everybody because I work in a clinic of patients who have scarred lung diseases, but when you start listening for crackles in the hospital you begin to hear them in a number of different diseases and contexts, and you can use them to help you understand what changes you need to make in someone's medications, or how to understand what's happening in their bodies.

>> That's Brian Garibaldi. Brian is both a pulmonologist, a lung expert at Johns Hopkins, and is also co-president of the Society of Bedside Medicine. Brian, I need to hear more about this. What exactly is the Society of Bedside Medicine?

>> The society is a group of clinician educators from across the world who have recognized that it's really important for us to get back to the bedside, and to spend time with out patients, and share discovery, share decision-making, and we're also very interested in improving physical exam skills because we've recognized that over the last several years there's been a decline in our ability to diagnose disease with our patients at the bedside using our eyes, our ears, our hands, and this is fundamentally important to the doctor-physician relationship, and really, really imperative to improve our skills so that we can focus on reducing diagnostic error, order tests more efficiently, reduce cost of care, and improve the experience for physicians and patients alike.

>> So those are the things I'm really interested in exploring. When you say improving the experience for both the physician and the patient why does it help to actually have a hands-on experience?

>> Starting from the patient's perspective patients recognize when a physician is spending time with them. They recognize if a physician hasn't touched them, or hasn't established a physical connection with them. Obviously, the history is one of the most important things that we do, but the physical exam is still incredibly important in making a number of different diagnoses, or really understanding how someone's body or disease is changing, and patients recognize when a doctor doesn't examine them at all, or tries to listen to their chest across their sweater and their vest they recognize that they're not getting the full attention of their physician.

>> Let's go back to those crackles. It turns out that Sheila Garrity, one of Brian's patients has them as a result of a rare type of pneumonia abbreviated BOOP.

>> A classic sign of the BOOP is this rub, it's a crackle that you hear with a stethoscope, and Brian had a special device to measure it. It's awesome to see a physician when a light bulb goes off. It's like, oh my gosh, do you want to hear it, and has me listen he calls in his residents. He'll listen, you need to listen to this because you don't hear it very often.

>> Because of these special crackles Brian asked Sheila to act as a standardized patient where physicians in training examined Sheila, and try to diagnose her.

>> Of the maybe 10 to 15 physicians that came in only one actually took down my gown, so the rest listened with the stethoscope through the gown. I have a swollen ankle and that was kind of a red herring because that has nothing to do with it, but they're like maybe it's deep vein thrombosis that's affected her lungs and they couldn't figure it out, so the one that took down the gown, you know, do you mind if I take down the gown, so then you see all these scars and bruises, and she started to talk and I couldn't help myself, I'm like you're so close come on, so she's looking and she said, "Were you treated for breast cancer?" And, you know, I'm not supposed to answer any questions like, and she said, "I wonder if she had radiation."

>> Sheila had radiation as part of her ongoing treatment for breast cancer. Treatment that has rendered her rather an expert on a patient's perspective.

>> The one person that actually asked if she could pull down my gown was the only one that made eye contact with me as well, so that is something in a teaching hospital that I believe often happens it's like, okay, we're working with these group of physicians here, and here's the patient, but the patient is really the ... Not guinea pig, but the patient we're just, you know, don't talk, we're just looking at you and doing all this, so the physical exam is that means of connection between the physician, and the patient which is key, and you need that even if there are 10 other people in the room which often happens when you're in the hospital, and there's rounds we look to the physician to set the tone. Good morning, you know, I've got my team with me, and looking at you in the eye, and here's what we're gonna do today, so that didn't happen with the team of trainees. Sometimes they would introduce themselves, but they were very nervous and there was no eye contact. Did I give you a message there? Was it the physical exam is key? Yeah, you got to connect with your patient.

>> I'd like to just return back to you and how you feel if you can compare and contrast for me an encounter with a physician where someone does do a physical exam, and an encounter where someone doesn't do one, or it seems perfunctory to you how that feels for you?

>> I feel as if I am not being properly cared for if I don't have a hands-on physical exam. For me that may say, okay, well, this is probably not the physician for me if they're just gonna sit there and talk, talk, talk, okay, listen to your heart through the gown, and look in your nose and no hands-on then I think that I would not stay with that physician.

>> Okay, so it's clear that the physical exam is important to patients, but as Brian has already stated it's also a really important thing for doctors. Here's Timothy Niessen, a hospitalist. That's somebody who specializes in the care of people who are hospitalized at Johns Hopkins.

>> You know, over the last decade that I've been working in medicine I see a lot more of our residents and trainees move away from the bedside, and towards the team rooms, the offices. Sometimes when you walk into the office you see only the back of everyone's head because they're all facing the computer. In fact, I know most of our interns, you know, by their balding patterns more than I know about their face, so getting all of our interns to go back towards the parts that bring a lot of joy in medicine like appreciating the sign of Kussmaul where the neck veins rise when you inspire until they collapse, which we just saw in rounds this morning. These kinds of things you'll never appreciate at a computer screen, you'll only appreciate in the presence of the patient, and the Society of Bedside Medicine is a nationwide organization to help bring about interest in tools to help doctors, and the people who train young doctors to get back to the bedside. This whole drawer of notes and letters, and other mementos of patients that I've cared for over time all of that comes from spending time with them at the bedside. That's what I try to teach our residents to sit down and just be present. That's the most important piece.

>> Pascal says, of course, that one should always carry something beautiful inside, and this is really beautiful, so if you don't mind I'll read it. It says, Thank you. Dear Dr. Niessen: We would like to just express our utmost gratitude for your total commitment to my mom's care, your tireless pursuit of the most correct course of action, and your warm encouragement in the most difficult of times. You gave my mom the support she needed just at the perfect moment. We could tell that you were doing everything in your power to determine the most correct course of action not just medically, but a course which also had my mom's best interests at the forefront. If you should ever have a really tough day we imagine that most days are tough, but a day that makes you want to say enough we want to remind you that your dedication and heart really made a really big difference, one that we will never forget in our family's life. Yeah, that's pretty good that's some good stuff.

>> Exactly, so it's in building these kinds of relationships for our young doctors that I really want to get them to the bedside so that they can share in these kinds of experiences over time, too, because it's not gonna happen in the team room with your face in front of the computer the entire time managing what Abraham Verghese calls the iPatient, right? The electronic representation of that person.

>> So that's the Joy In Medicine podcast series for this month. We are so very fortunate because all of the music that we've been hearing throughout this series, and will be hearing throughout this series was not only written, but also performed by Brian Garibaldi, a physician, the co-president of the Society of Bedside Medicine, and also an incredible musician, we're so thankful. We thank you so very much for listening to the Joy In Medicine podcast series. We intend to do one a month, and we hope that you'll tune in every month. I'm Elizabeth Tracey.

>> And I'm Charlie Cummings.

>> This podcast series is brought to you in part through the generosity of the John Conley Foundation, which focuses on medicine and humanism.