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The Best, Bar None
Measuring excellence among clinicians has long been an elusive quest. That’s changing, thanks to a rigorous new program that uses external peer review — and other metrics — to identify and celebrate Johns Hopkins’ most gifted providers of patient care.
Illustration by Miguel Montaner | Photos by David Colwell
Kimberly Peairs (right)
“We’ve been a very traditional institution when it comes to promotion, and I do understand how and why that came to be. But now is the time to broaden our thinking.”
Margaret Chisolm (left)
“Publications, grants, citations — that’s all pretty straightforward stuff that you can count up and use to measure success and impact, but the metrics are more elusive when you’re looking for a set of criteria to measure clinical skills.”
During a Psychiatry Clerkship in medical school at the University of Maryland, Margaret Chisolm landed a challenging case. While taking a patient’s history, Chisolm learned that the woman suffered from schizophrenia and had severe burns on much of her body. To date, the patient had spent most of her life in a state psychiatric hospital.
Some days later, Chisolm saw the woman sitting by herself on a sofa in a lounge area of the psych unit. Chisolm broke off from the group of students she was with to say hello.
“I felt like I should talk with her, but not formally,” Chisolm recalls. “I just wanted to chat, one person to another.”
The woman was quite delusional. Her thought patterns were a jumble. Chisolm tried her best to follow along as a series of memories and images came tumbling out in disconnected threads.
“And I found that by sitting quietly and listening closely, I was able to begin to understand her experiences in a more personal, immediate way,” Chisolm says.
She kept listening. She lost track of time. She looked up to find an attending psychiatrist staring at her from across the room. He began to walk toward her.
“I was terrified,” Chisolm says.
She feared she’d done something wrong by breaking away to spend time alone with her patient. But then the attending leaned over and slowly whispered three words in her ear: “Don’t. Ever. Change.”
Not surprisingly, the words gave quite a boost to Chisolm’s confidence in her patient care instincts. She came to Johns Hopkins as a resident in the 1980s, then stayed on with the faculty at Johns Hopkins Bayview Medical Center, where she now serves as an associate professor and director of education in psychiatry.
Early in her faculty years, Chisolm maintained her focus on patient care. But as time went on, she found herself thinking seriously about cutting back on clinic time to make room for research.
“I began thinking that in order to really succeed on the faculty, the best thing I could do was focus on scientific discovery,” she recalls. “I had one National Institutes of Health grant at the time. I reached a point where I was starting to focus almost exclusively in my planning on how to get more NIH grants.”
Chisolm’s doubts about the long-term career value of her commitment to clinical work is not at all unusual, says Scott Wright, who spends a lot of time working with young physicians as deputy director for medical education research at Hopkins Bayview and director of the medical education track for Johns Hopkins’ general internal medicine fellowship.
Wright even has a name for the phenomenon: “those subversive whispers.”
“Sometimes, it is more of a subtle message, and other times, it is specific guidance from a mentor,” Wright says. “What the whispers say to young physicians is that if you want to have a successful academic career, you need to limit patient care and spend most of your time on research.”
The whispers are not necessarily inaccurate. Recognition and concern have been growing in academic medicine in recent years about the way the faculty promotions process is heavily weighted in favor of research.
The reason for this favoritism is not a mystery. It’s a result of the fact that excellence in research tends to be relatively easy to measure, while excellence in clinical care — and teaching, too — can be difficult to quantify.
“Publications, grants, citations—that’s all pretty straightforward stuff that you can count up and use to measure success and impact,” Chisolm says. “But the metrics are more elusive when you’re looking for a set of criteria to measure clinical skills.”
Young physicians trying to gauge their career options can see this imbalance quite clearly, says David Hellmann, director of the Department of Medicine, vice dean for Hopkins Bayview and director of the Johns Hopkins Center for Innovative Medicine.
“If you ask around — and we have — most people here at Hopkins will tell you that the quickest way to be promoted is to do basic research,” he says. “It goes beyond that: There is a strong sense out there among the faculty that clinical excellence is not really counted at all.”
The issue goes beyond personal questions about ego and fairness — straight to questions of institutional priorities. Why bring in great clinicians if they are just going to get steered away from doing what they do best? If the best-of-the-best clinicians feel underappreciated and unrewarded, why would they stay at Johns Hopkins — or in academic medicine at all? If they leave, what happens to the quality of clinical care training programs for medical students and residents?
“We must not lose sight of the fact that we need great clinicians in academic medicine,” says Kimberly Peairs, clinical director of general internal medicine at the Johns Hopkins Health Care and Surgery Center located at Green Spring Station. “We need to hold onto the ones we have, and we need to attract new ones. It’s so very important to the development of our trainees. They have to have great role models who they can really see up close and interact with.
“We’ve been a very traditional institution when it comes to promotion, and I do understand how and why that came to be,” Peairs continues. “But now is the time to broaden our thinking.”
That call to action from Peairs pretty well sums up the mission of the Miller-Coulson Academy of Clinical Excellence at Johns Hopkins. Hellmann and Wright are the architects of the program, while Chisolm and Peairs have both earned membership in the academy through a competitive application process.
“We all know that here in our midst, there are some truly exceptional clinicians, some very good ones and some others who are not as strong,” Wright says. “The problem that we are tackling is that when a physician is behind a closed door alone with a patient, it is very hard for anyone to know whether that doctor is masterful—or just competent.”
The story of this endeavor dates back more than a decade, to a day when Hellmann found himself fielding a provocative question: “Why aren’t we creating more Dr. Tumultys?” The question came from a patient, Ann Miller, and the reference was to the late Phillip Tumulty, who spent 40 years on the Johns Hopkins faculty championing a brand of patient care that his New York Times obituary sums up as a “back-to-basics, humanistic approach.”
“In the 1960s, ’70s and ’80s, Dr. Tumulty was like William Osler incarnate around here,” Hellmann says, referring to one of the first physicians of the Johns Hopkins University School of Medicine. “He was beloved by patients and revered by students and residents.”
A few years after fielding that question, Hellmann found himself engaged in a conversation with Miller’s daughter, Sarah Miller Coulson. She and her husband, Frank Coulson, wanted to give a gift to the Center for Innovative Medicine. Sarah was asking Hellmann what kind of program he might launch with $1 million.
Ann Miller’s question about Dr. Tumulty came into Hellmann’s mind.
“I found myself thinking more and more about what a great question that was, and how we could be working harder in this institution to nurture and develop great clinicians,” he says.
Step one in that direction involved naming a quartet of Miller-Coulson Scholars tasked with defining precisely what the term “clinical excellence” means. The team included Wright, internist Steven Kravet, and geriatricians Colleen Christmas and Samuel “Chris” Durso.
The four got to work in 2006. As they scoured the medical literature, they realized that they would be breaking new ground. There were plenty of navel-gazing, anecdote-based essays over the years on the topic of clinical excellence, but nothing in the literature had a sense of scientific seriousness.
“It’s a very multidimensional application. My feeling while putting it together, was that this really is a rigorous attempt to objectify things, that are difficult to measure.” —Kimberly Peairs
“The four of us agreed right away that if we didn’t do this in a rigorous way, we were going to fail,” says Wright. “We wouldn’t dispel the doubts of skeptical colleagues. And the work would never be embraced by the Hopkins leadership.”
The four scholars conducted a quantitative survey of the Johns Hopkins faculty. They also collected qualitative data through interviews with clinical care experts at the 10 top hospitals in the U.S. News rankings. More than two years of work went into the definition that was published in the September 2008 issue of Mayo Clinic Proceedings.
Hellmann then set out to develop a way to recognize and honor the top clinical talent at Hopkins Bayview by launching the Miller-Coulson Academy. He asked Wright to take the lead.
“Scott has a long track record of taking difficult concepts in an area like education and finding ways to frame questions so that you can get useful information and write strong papers,” says Hellmann. “That’s the kind of person who could give something new like this the credibility that it needed.”
In fact, the academy’s founding was greeted in those early days with strong skepticism from several members of the promotions powers that be at Johns Hopkins. “They told me we were trying to come up with a solution for a problem that didn’t exist,” Hellmann says. “They felt nothing needed doing.”
Hearing this, Wright put the hypothesis to the test, launching a survey of faculty in the school of medicine who spend a majority of their time caring for patients. “Basically, Scott asked everybody, ‘Do we have a problem?’” Hellmann says. “The resounding answer was, ‘Houston, we have a big problem.’”
Next, Wright set out to develop an application for academy membership. He was looking for an instrument that could separate the best-of-the-best clinicians from those who are not — or not yet — in that rank.
There were no road maps available. A handful of other medical schools had formal programs of recognition for clinicians, but these lacked rigor. Some were popularity contests judged by top administrators; others were preretirement kudos extended to just about every veteran on the faculty.
The breakthrough for the Miller-Coulson Scholars came when they considered modeling the application process on what happens in the easier-to-evaluate research fields. They looked especially at the study section — a team of experts from outside the institution who review and score a grant application. The academy’s application is the clinical equivalent. Wright set up a network of experts representing different specialties and based at top institutions around the country who are each given a small honorarium to review and score academy applications.
“It’s a fairly blind assessment,” Wright says. “Getting input from beyond this institution, from people who don’t know the candidate, is extremely valuable.” Internal evaluation teams score the applications as well.
Chisolm and Peairs have both been through the process of putting an academy portfolio together. To become eligible to apply for membership, they first needed to receive at least five nominations from a general call that asks the entire faculty to name their clinically excellent colleagues.
“It’s a very multidimensional application, in the sense that it’s trying to get at many different facets of clinical activities,” Peairs says. “My feeling while putting it together was that this really is a rigorous attempt to objectify things that are difficult to measure.”
In addition to a wealth of data about their patient populations, applicants must provide lists with 10 names each in the categories of patient, physician, learner and nonphysician provider who agree to give confidential evaluations. The criteria in those evaluations match the domains outlined in the academy’s definition of clinical excellence, including communication, diagnostic acumen, all-around knowledge and several others.
The scale used is quite imposing. To rank 5 on a scale of 5, the evaluator must agree that the applicant is “the very best doctor I’ve ever come across.” To rank at 3 of 5, the physician must be in the “top 25 percent of all doctors I’ve come across.”
“People often say to me, ‘Oh, Scott, it’s easy to find 10 patients or 10 students or 10 nonphysician providers who love you,’” Wright says. “There’s some truth in that, and that’s why we chose to set the scale as we did. Are they all really going to say that the applicant is the very best doctor they’ve ever seen, bar none?”
Other portfolio items relate to institutional draw, including collecting information about the proportion of patients who travel significant distances — more than 25 miles — to see the physician. Reviewers of the portfolios understand that this particular metric is most relevant for specialist physicians and not so much for internists focused on AIDS care or emergency room physicians.
The first round of academy applications came in 2009. All told, just 34 physicians have been accepted in six years. Only 30 to 40 percent of applicants are successful each year. While the process is quite selective, every year, there is tremendous consensus about the decisions, which makes Wright feel as if the application process is truly identifying only the best of the best. (The academy shares extensive feedback from reviewers with unsuccessful applicants, several of whom have reapplied and then secured admission to the academy.)
In the end, Chisolm resisted the call of those subversive whispers. Her career remains centered today on the work she sees as her dual calling, clinician and teacher.
She had never heard of the academy until she received an email in 2010 inviting her to apply. She was inducted into the academy that year. It was in her acceptance speech that she shared the story of the challenging patient in her clerkship and the attending physician who suggested she never change.
“The academy changed the course of my career,” Chisolm says. “It made me a part of this wonderful new community. So much of what we do at Hopkins is structured inside our departments that I didn’t really meet clinicians in other specialties before. But in meeting and then working with Scott Wright and so many others in the academy, it reinforced for me the sense that I wasn’t alone, that there really was the possibility of building a rewarding and successful career as a clinician-educator.”
As the 10th anniversary of the founding gift by the Miller and Coulson families approaches, the academy that bears their names is moving to the next level.
For its first five years, the academy was a Hopkins Bayview-only operation. In 2014, Paul Rothman, dean of the medical faculty and CEO of Johns Hopkins Medicine, asked Hellmann and Wright to expand the academy into an institutionwide endeavor. The class inducted this past May, which included Peairs, was based at The Johns Hopkins Hospital. In 2015, Wright anticipates taking nominations for Sibley Memorial, Suburban, Howard County General and All Children’s hospitals.
Outside institutions are taking notice of the academy’s progress as well. Wright has worked with other medical schools — including Ohio State, Columbia and McGill — who are setting up their own programs that measure and reward clinical excellence.
Additional evidence of the credibility of this work has come from journal editors. Working in concert with academy colleagues in various specialties, Wright has been adapting the definition of clinical excellence for the specifics of various disciplines. Papers have already been published for psychiatry, cardiology and pediatrics. Coming up are primary care, hospital medicine, geriatrics, and physical medicine and rehabilitation.
Hellmann and Wright are looking to build on this momentum going forward. They want to make the academy even more of a “working” academy than it already is. Members already lead regular sessions of Grand Rounds. They’re also involved in an elective course that has medical students shadowing them through patient care activities.
The academy is now looking to bolster a fledgling coaching program for faculty members. The program recently won approval for continuing medical education credits.
“One thing that’s very much needed is to get our doctors to look in the mirror more and see where they can improve — there isn’t enough feedback,” Hellmann says. “When you see your institution on the cover of U.S. News every year, you can end up thinking everything is perfect. We should be working harder to help them understand where their skills are at and how they can get better.”
To this point, Chisolm says, the coaching program has been considered by some in the faculty as something remedial, a sign that skills are lacking.
“The real vision is to make signing up a feather in your cap,” she says. “If we can deliver real help to all the people at Hopkins who are striving to be the best clinicians they can be — now that’s an exciting project.”
Then there are the concerns that started the ball rolling in the first place — promotions and career advancement. Chisolm received a promotion to associate in 2012. More recently, she has been serving on the institution’s Associate Professor Promotions Committee.
She says that academy membership already has some impact in promotions decisions and points to her own promotion as an example. Academy membership led to scholarship opportunities she would not have had otherwise. She has published a pair of papers on clinical excellence: one on defining clinical excellence in the psychiatry field, and another on using social media to enhance clinical excellence.
Those papers, of course, went through the type of outside peer review that promotions committees are looking for. In addition, the application process by itself provides another round of external peer review.
As gratifying as all this recent progress has been, Hellmann and Wright remain in the early stages of a long process. The full vision, one that stretches over decades, would find the Miller-Coulson Academy playing the role of key building block on the way to a rebalanced promotions process across academic medicine — one where clinical excellence has its own clearly defined promotions path leading, perhaps, to its own set of endowed chairs.
“Imagine if we could create 30 professorships here that become the highest level to which clinicians can aspire. Wouldn’t that make this a heckuva place?” Hellmann asks. “So yes, we still have a lot of work to do, but at this point I think it’s safe to say that the bird has flown the nest. The academy is operating at a new level now, and I think it’s clear to everyone watching that it’s here to stay.”
Defining Clinical Excellence
“The clinically excellent academic physician has achieved a level of mastery in communication and interpersonal skills, professionalism and humanism, and negotiation of the health care system. Such physicians are exemplary with respect to diagnostic acumen, knowledge and their scholarly approach to clinical practice. They exhibit a passion for patient care, and they explicitly model all of the above to medical trainees, earning them a reputation for being exceptional.”
—from “Clinical Excellence in Academia: Perspectives from Masterful Clinicians,” which was written by Miller-Coulson Scholars and published in the September 2008 issue of Mayo Clinic Proceedings.
‘Honesty and Candor’ in Cancer Treatment
Oncologist Ross Donehower, who joined the Miller-Coulson Academy in 2014, has a plaque in his office with a quote from Oliver Wendell Holmes: “A man of moderate abilities can be a good physician if he devotes himself faithfully to the work.”
To Donehower, this says that the most important work of oncology lies in basic human skills. “We have an obligation to get know patients at a level beyond what disease they have and what treatments they are receiving,” he says. “In a good relationship, they will come to expect us to have honesty and candor in our discussions and to serve as advocates for them as they interact with a very complex medical system.”
In the communications realm, Donehower stresses an oncologist’s role as an interpreter for patients who often have trouble seeing the big picture through a series of reports delivered by one specialist after another.
“We need to give our patients accurate, useful prognostic information,” he says. “Using a quote I stole from an editorial on this topic in the Annals of Internal Medicine, I try to teach trainees that one way to think of is in the form of ‘truth, in the most optimistic way.’”
Inspired by Osler
Surgeon Christopher Wolfgang, co-director of the Pancreatic Cancer Multidisciplinary Clinic, spoke frankly about the aggressiveness of pancreatic cancer and the fact that “things do not end well” for the vast majority of patients at his academy induction in 2014.
Wolfgang has high hopes that clinicians and researchers will soon succeed in improving the survival curve for these patients. But he also emphasized how excellent clinicians can demonstrate the highest standards of humanism while caring for patients whose prognosis is dire.
“I think this is best summed up by one of our founders, Sir William Osler,” Wolfgang says. “He once said, ‘Care more for the individual patient than for the special features of disease. Put yourself in his place. The kindly words, the cheerful greeting, the sympathetic look, these the patient understands. Some of our most grateful patients have the most difficult and terminal problems. They often appreciate but do not understand the complex plans and therapies. But what they cherish is simply to know that we provide care, and hope, and this we can always do for them.’”
When gastroenterologist Frank Herlong was inducted into the Miller-Coulson Academy in 2010, he recalled his experience as an intern in the mid-1970s. He worked in an outpatient clinic on Osler 2, and his first patient was a woman named Ms. Smith (not her real name).
Her chart “was delivered in a cart and contained five volumes, each about 6 inches thick,” Herlong says. “I saw notes in this chart by Dr. Ross, the dean of the medical school, and by Dr. McKusick, the chair of the Department of Medicine. I wondered what she thought about this. Here, she had been cared for by the best doctors at Hopkins, and now I was her doctor.”
That chart also contained information that Herlong found quite troubling. Smith had once been admitted to what was the black ward of the hospital. She had received blood through a rigidly segregated blood bank.
“She had always expressed incredible gratitude and trust for her care at Hopkins,” Herlong says. “I felt strangely betrayed by my profession, and sad. I realized patients are often trusting and grateful, and sometimes that trust is not always justified.”
Herlong describes the next steps in his relationship with Smith, as one day she showed up with a friend in tow. She introduced the friend by saying, “This is Dr. Herlong. We’ve been doctoring together now for about a year.”
“I returned to my office and I thought about that,” Herlong says. “That was the first time I’d heard the word ‘doctor’ as an intransitive verb. I thought that was good. We don’t doctor to patients. We doctor with them. And the second part of the statement, too — we doctored together.”
Herlong’s final appointment with Smith was in June 1978. His time in the clinic was over—a new intern would be taking his place. As that last visit wound down, he reached out to shake her hand, but Smith drew him in with a big hug.
“She was a big woman, and it was a big hug,” says Herlong, who is now at the MD Anderson Cancer Center at the University of Texas. “I returned to my office and thought about how incredibly lucky I am to be in the profession I’m in and what a privilege it was to share those three years with Ms. Smith. And I thought about how I got so much more from her than she did from me.”
View a video about the Miller-Coulson Academy
Just 34 physicians have been accepted as Miller-Coulson Scholars in six years. Only 30 to 40 percent of applicants are successful each year.
To rank 5 on a scale of 5, the evaluator must agree that the applicant is “the very best doctor I’ve ever come across.”
Outside institutions are taking notice of the Miller-Coulson Academy, says Wright, who has worked with other medical schools — including Ohio State, Columbia and McGill — who are setting up programs to measure and reward clinical excellence.
“Imagine if we could create 30 professorships here that become the highest level to which clinicians can aspire. Wouldn’t that make this a heckuva place?”
It's a very multidimensional application. My feeling while putting it together, was that this really is rigorous attempt to objectify things, that are difficult to measure."