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School of Medicine
In an age of technological distractions and financial pressures, the Aliki Initiative is breaking new ground in patient care by training young doctors in an old practice: getting to know patients as people.
Illustration by Traci DeBarko
History in the Making
The Patient as Text
In the fall of 1886, William Osler, a renowned Canadian physician who had recently been hired by the University of Pennsylvania, traveled to Baltimore to visit the nascent Johns Hopkins University. “It is the university of the future,” he wrote to a Canadian friend. “When the Medical School is organized all others will be distanced in the country.”
The Johns Hopkins trustees were equally impressed by their visitor. In 1888, Osler was hired by The Johns Hopkins Hospital as its physician-in-chief (salary: $5,000). When the Johns Hopkins University School of Medicine opened its doors in 1893, Osler played a pivotal role in reshaping American medical education.
“Osler is arguably the greatest physician that North America has ever produced,” says pathology professor Ralph Hruban ’85. “He was willing to take a chance on a brand-new university because he could see that it was a place where science would be applied to medicine, unburdened by the deadwood of the past.”
One of Osler’s most enduring innovations was his insistence that third- and fourth-year medical students spend most of their time on the hospital wards, rather than in libraries or laboratories. “Teach him how to observe, give him plenty of facts to observe, and the lessons will come out of the facts themselves,” Osler declared in a 1903 lecture. “For the junior student in medicine or surgery, it is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself.”
Osler’s clerkship model quickly spread to other elite medical schools. “Before Hopkins, you could go to medical school in the United States and never see a patient,” Hruban says. “After Hopkins opened, that was forever changed.”
Osler’s second innovation was the development of a hierarchical residency system, in which the hospital was staffed primarily by young trainee physicians. This was not a purely new idea: Osler borrowed it from hospitals he had admired on visits to Europe. But Johns Hopkins is generally regarded as the first North American hospital to adopt the residency model.
“Altogether, it was a fundamental change in medical education,” Hruban says. “Suddenly, there were much higher standards for admission. Medical students had to have gone to college, and they had to have command of several languages. And then, after graduation, they had the added responsibility of residency training.”
Osler’s achievements were not only pedagogical, of course. He is also regarded as one of the greatest clinicians of his era, and as an innovator in both the physical assessment of patients and in the laboratory analysis of diseased tissue. His masterwork, The Principles and Practice of Medicine, published in 1892 on the eve of the school of medicine’s opening, was the archetype of the modern medical textbook.“In his early years in Montreal, he performed more than 1,000 autopsies,” Hruban says. “And these were often of his own patients. He knew their histories, and he knew their clinical findings. At autopsy, he would see the valvular disease that had caused the heart sounds he’d heard. That integration, bridging across disciplines, is part of what made him such an extraordinary physician.”
This morning, nine patients are in the care of the green team on the Med B unit at Johns Hopkins Bayview Medical Center.
They’re here for the usual range of problems that you’ll see on a medical-surgical unit: One patient has chronic kidney disease and had to be emergently treated for a potassium level of 7.5 the other day. One may have pneumonia and has a sputum sample pending. One has severe diarrhea from a C. diff. infection that’s been resistant to treatment.
But the green team’s attending physician, Alicia Arbaje, wants her trainees to think about—and talk to—their patients in much more human terms, because these nine are more than the sum of their symptoms and lab results. One patient can no longer go to church because she’s been falling so often. One would like to be able to keep living on a houseboat. One lives in a rural area and has a work schedule that makes it tough for him to pick up prescription medications.
Physicians on the green team gained those details by sitting down with each patient and learning about their unique life circumstances.
Just before the early-morning huddle ends, Arbaje asks her team (a senior resident, two interns, two third-year medical students and a clinical nurse specialist) to close their eyes and concentrate on their breathing. “Think about the privilege of being able to care for these people,” she says. “Try to reconnect with your sources of joy in practicing medicine.”
Since 2007, the green team at Johns Hopkins Bayview has been the centerpiece of the Aliki Initiative, a project designed to train interns, residents and medical students to provide humanistic, patient-centered care. Every intern at Johns Hopkins Bayview spends four weeks on the Aliki service, and internal medicine residents spend an additional two to six weeks during the later years of residency. During these Aliki rotations, residents are trained to write notes that begin with social histories, not symptoms, and to make structured follow-up calls to patients and their primary care providers after discharge. They also visit patients’ homes and other sites of care where patients might be treated after they’re discharged from Johns Hopkins Bayview.
“It’s so important to learn how to work with information that isn’t strictly medical,” says Kathleen Chin ’19, a third-year medical student on her medicine clerkship with the green team this morning. “The Aliki service has helped me think about discharges and other transitions of care.”
Over the last decade, the Aliki project has played a major role in leading Johns Hopkins toward a stronger culture of patient-centered care, says Roy Ziegelstein, vice dean for education and co-director of the Aliki Initiative. Among other things, this has meant making time for face-to-face conversations with patients, and resisting the tide of technological distraction and financial pressures to move patients through the system quickly.
“Part of the challenge is that we’ve inherited a training model that, for understandable reasons, focuses on acute episodes of care,” Ziegelstein says. “And if doctors are time-pressured, they’ll often assume that they just need to know the bare minimum of medical ‘facts’ to get the patient through that acute episode of care. But that’s not correct. If you slow down and take the time to get to know the patient as a person, you’ll make more accurate diagnoses, provide better treatment choices and achieve greater patient satisfaction. In the long run, I’m confident that approach actually saves time.”
In an essay that appeared in JAMA Internal Medicine several years ago, Ziegelstein proposed that “personomics”—the process of learning about a patient’s unique life circumstances and the social context of health and illness—is just as important in delivering “precision medicine” as genomics, proteomics and all of the other emerging tools that help characterize a patient’s unique biology.
Getting the Full Picture
The impetus for the Aliki Initiative came in 2006 with a generous donation from Aliki Perroti, a Greek philanthropist who wanted to change the model for the way young doctors are trained. Her vision was beautiful in its simplicity: to give medical trainees the time they need to get to know their patients as people.
Led by David Hellmann, chair of the Department of Medicine at Johns Hopkins Bayview Medical Center, school of medicine leaders then faced the challenge of taking that broad mandate and turning it into a concrete set of training practices. “It was actually a fun challenge,” recalls Colleen Christmas, who directed Johns Hopkins Bayview’s residency program at the time and has been a core Aliki faculty member throughout the project. “How could we teach the next generation of doctors to do things a bit differently? It seemed to all of us that certain practices of caring, of getting to know patients as people, were getting squashed out of medicine. And in particular, that they were being squashed during residency training, which is exactly when they should be emphasized.”
The group came up with a core set of skills and behaviors that residents should demonstrate: patient-centered notes and presentations, with thorough social histories. Slow, structured conversations with patients about how they take their medications at home. Effective post-discharge phone calls to patients and their primary care providers.
Having settled on those core skills, however, the Aliki project faced a new challenge: What is the best way to teach them? “The Aliki group realized that they had this wonderful curriculum, but that the attending physicians didn’t necessarily know how to convey these skills,” says Laura Hanyok, assistant dean for graduate medical education. “It might seem intuitive to teach these things, but it’s really not. You need a strategy.”
The solution was to assemble a core group of Johns Hopkins faculty members who meet regularly to talk about pedagogical challenges. These 18 attending physicians, known as the Aliki Scholars, gather for seminars four times each year. “It’s really been a wonderful, solid group, with very little turnover during the past 10 years,” Hanyok says. “Each attending brings his or her own particular passion or expertise.”
In Arbaje’s case, the passion lies in effective transitions of care, a topic she has studied throughout her career as a geriatrician. She presses that challenge with the green team. “So much can go wrong in those first 24 to 48 hours after patients go home, especially older patients,” she says. “How can we reduce our errors at discharge so that patients aren’t readmitted?”
Says Alphonsa Rahman, the green team’s clinical nurse specialist, “we visited a nursing home recently, and the residents got a sense of how important it is to get the discharge instructions exactly right. We’d missed just one detail, and the patient wasn’t getting the care she needed. It’s important for residents to see what these facilities are like. If there’s only one nurse for three floors, certain kinds of care just may not be possible.”
A decade into its existence, how effective has the Aliki project been? The best-known piece of hard evidence for its impact is a 2011 paper that found that Johns Hopkins Bayview patients with congestive heart failure were significantly less likely to be readmitted within 30 days if they had been treated by the Aliki team than if they had been treated by one of the other teaching teams on the same medical unit. Similar comparisons have been tricky to make in more recent years, Hanyok says, because Aliki-style practices have started to spread throughout the hospital.
A fuller measure of the Aliki Initiative’s power, Christmas says, can be found in the testimony of residents who have been touched by the program. Nestoras Mathioudakis ’06, an endocrinologist at The Johns Hopkins Hospital who was in one of the earliest cohorts of Aliki-era residents (2009), says that he still thinks about lessons from Aliki rotations almost every day.
“Today, I work with diabetes patients, and I’d say that 75 percent of diabetes care is not really medical,” says Mathioudakis. “It’s addressing the psychological, social and economic factors that influence how patients manage their diabetes at home. And those skills that I learned through Aliki are just invaluable when I’m having those conversations with my patients.”
Medical residents aren’t the only ones who have benefited. Medical students who choose to do clerkships or subinternships on the Aliki service during their third and fourth years also often walk away with powerful impressions of the program. Megan Orlando ’16, who is now a second-year Ob-Gyn resident at the University of California, San Francisco, did a four-week clerkship with the Aliki service in 2014. She also worked on a research project about Johns Hopkins students’ perceptions of patient-centered care.
“I think it would be wonderful if every student at the medical school could spend time with the Aliki team,” Orlando says. “I remember really strongly the way the attendings prioritized the patient presentation. When the team went to the bedside, they’d have us use the ‘you’ form, inviting the patient into the conversation instead of talking about them in the third person.”
Cynthia Rand, a professor of medicine, has been part of the core Aliki faculty from the beginning. “There are always some residents for whom these skills are second nature,” Rand says. “And then there are some who understand the value of these skills but don’t feel comfortable with them yet. So we give them a structure for learning. And then there’s a third group for whom there’s a bit of cynicism or skepticism. For that last group, we hope that the Aliki experience will help them start to connect the dots and understand that knowing about the patient’s life is as important as knowing their A1C level.
“If a patient can’t get to the pharmacy,” Rand continues, “or if their life is consumed with caring for another family member, then they’re going to have a bad outcome no matter what meds you prescribe, unless you address those factors.”
Exporting the Model
While the Johns Hopkins Bayview green team has always been the core of Aliki, the project has expanded in other directions in the last few years. The new residency program at Johns Hopkins All Children’s Hospital, in Florida, draws heavily on the Aliki model. The critical care units at Johns Hopkins Bayview have begun to incorporate Aliki-style elements. And the project has become more interprofessional, expanding the Aliki team to include nurses, social workers and chaplains.
One ongoing experiment involves the green team’s clinical nurse specialist, Rahman, who has taken on the role of “nurse attending.” In this role, she helps interface between the green team residents and the nurses on the Med B unit, making sure that nurses understand the clinical plans and have the resources they need.
Another recent effort has involved thinking about patient-centered care on critical care units. “It’s challenging enough to provide patient-centered care on a standard medical unit,” says Hanyok. “But in an ICU, you often have a patient who isn’t able to communicate. So it becomes that much more important to develop rapport with family members to get a sense of the patient’s needs.”
Janet Record, an assistant professor of medicine who serves on the Aliki curriculum leadership team, recently invited two patients who’d been treated in Johns Hopkins Bayview’s medical ICU, along with their family members, to speak to residents during their noon conference meeting. These sessions were part of a new Aliki effort known as “Caring for the Seriously Ill,” organized by Record and several of her colleagues.
“These were powerful conversations,” Record says. “The patients talked about what they appreciated about their care and about what was challenging for them.” One patient, who had a long ICU stay related to a severe neurological illness, talked about the fears, disorientation and delirium she experienced on the unit. The second patient said she’d waited too long to come to the hospital for an arm wound because she was afraid she’d be judged for her IV drug use.
The Aliki model has spread not only within Johns Hopkins Medicine, but also beyond. The curriculum’s materials are publicly available on MedEd Portal, an online peer-reviewed open educational resource for the health sciences sponsored by the Association of American Medical Colleges. Elements of the Aliki program have been adapted for use at the medical schools of the University of Virginia and Brown University. And physicians who were trained at Johns Hopkins Bayview are informally bringing the Aliki approach to clinics and hospitals throughout the world.
During the first four years of the program, from 2007 to 2011, the green team at Johns Hopkins Bayview was given a lower-than-usual patient census, so the residents literally had more time to spend with each patient. But since 2011, when residents’ working hours were reduced nationwide, the green team has had roughly the same doctor/patient ratio as every other general medicine service at Johns Hopkins Bayview. So there are no structural barriers that would prevent Johns Hopkins Bayview residents from performing the Aliki skills—obtaining a better understanding of the patient’s unique life circumstances, follow-up phone calls and so on—during all of their rotations, not just when they’re assigned to the green team, notes Ziegelstein.For his part, he says that it is always worthwhile to invest in getting to know patients, even if certain trends in clinical practice are pressing physicians to spend less and less time face to face with the people they’re caring for. “It’s actually impossible in most circumstances to effectively take care of a patient without knowing that patient as a person,” he says. “The time spent up front in doing that has so many long-term benefits, not just in the joy of medicine and patient satisfaction, but in improved diagnostics and care.”
‘‘If a patient can’t get to the pharmacy, or if their life is consumed with caring for another family member, then they’re going to have a bad outcome no matter what meds you prescribe, unless you address those factors.”
– Cynthia Rand
Learn more about the Aliki Initiative
‘‘It seemed to all of us that certain practices of caring, of getting to know patients as people, were getting squashed out of medicine. And in particular, that they were being squashed during residency training, which is exactly when they should be emphasized.”
– Colleen Christmas