What is the Fine Art of Health Care?

picture of me in FAOH wkshpI have developed an innovative and interdisciplinary program at the University of Miami that uses art to hone observation and communication skills in the service of clinical diagnosis. Working in partnership the Lowe Art Museum, Miller School of Medicine, School of Nursing and Department of Psychology have filled a gap in medical education to strengthen healthcare.

Over the last eight years I have read over 100s of publications and books, watched a number of videos, and listened to webinars that explore ideas, challenges and look for solutions for healthcare in the 21st century. Through weekly blog posts I look forward to dialogue on these issues.

 

Reflection in Academic Medicine

Letters to the Editor in Academic Medicine can be thoughtful.  The LTE on reThe Thinkerflection is!  It’s written by a medical student and the subject is ‘reflection’ on best practice skills. My take:  it’s important for students in medical education to reflect on not just medical procedures and ‘hard skills’.  Practicing reflection on bedside manner is also important and it’s not just about self-reflection; it helps to do the reflection in a group situation.  Thinking about thinking or metacognition, important in ANY type of practice and medicine and how one handles stressful situations can help with physician burn-out (according the the piece in AM file:///X:/Medicine%20and%20Art/FAOH%20Blog/Reflecting_on_Reflection___A_Medical_Student_s.5.pdf

I Felt Alone But I Wasn’t: Depression Is Rampant Among Doctors In Training, by Dr. Elisabeth Poorman

 

ElissaPoorman1-1000x617

Thank you Dr. Poorman (kind of an ironic name for such a rich article written by a woman).  This article is so raw.  So needed.  Why why in 2016 are residents being made to work incredibly long hours.  They are overtired, stressed and many, unfortunately, commit suicide (see article).  Dr. Poorman spells out possible solutions for this pervasive problem; beginning with what I believe is a more transparent system, in which faculty/practicing physicians fess up to what’s needed to protect these residents from burn-out.  Taking care of oneself seems to be one solution in the obvious necessity of attending to their patients.

 

 

 

The Art of Observation: A Pedagogical Framework Caroline Wellbery, MD, PhD, and Rebecca A. McAteer, MD

Before_the_Mirror-ManetThe article, The Art of Observation, appeared in Academic Medicine in December 2015.  The power of the arts/humanities in medical education seems to be ubiquitous, not just in the US but worldwide.  We folks who have been working in the field of the arts for awhile understand that visual literacy, just like reading literacy, is not just an acquired trait; one must look, look harder and then look again.  And looking at art, with a group of peers, can be a discovery in one’s self.  The lens with which we see things may not always be in accordance with those around us.  What does that mean for medicine?  To me it means that coming up with a differential diagnosis may be a laborious process.  Guess that’s why most misdiagnosis and errors occur in the ER.  People in the process of dying require quick answers.  Maybe some of those errors could be prevented with closer looking?  I like the fact that in the article, The Art of Observation the pedagogical approaches to medicine are varied and include:  writing, listening, close observation and VTS.  In my opinion more medical schools need to carefully revisit their curriculums; figure out what really works, and what may need revision.  Is there time for reflective practice within their practice?  Is there time on Grand Rounds for inter-professional input?

The Checklist, Atul Gawande

An old article, titled:  The Checklist, written by one of my favorite surgeons/writers/soothsayer, Atul Gawande, is an oldie but goodie.  A simple tool, the checklist, has proven to save thousands of lives.  Dr. Provonost, of Johns Hopkins Hospital saw the error of doctor’s ways by skipping simple steps, making sure surgical lines are safe from infection because they skipped one step in putting in the lines.  If lives can be saved from following medical checklists why can’t hearts be saved by following compassionate and empathetic checklists.  For example:  when entering a patient’s room, calling that patient by his/her name, looking the patient in the eye, talking to the patient and in doing so creating a sense of trust.  Trust between a physician and their doctor has been underrated.  However, there has been research on patients who like their doctors are less likely to sue.  Nurses who trust those physicians with whom they work are more likely to follow directions and work more closely with them to help their patients.  The article was written in 2007.  The ‘discovery’ of the benefits of a checklist by Dr. Provonost was in 2001.  Not so many years and the lives saved have been numerous.  Not to mention the cost to hospitals.  We all know that the faster a patient recovers the more money a hospital saves.  So the fact that more and more medical schools are incorporating the teaching of ‘soft skills’ into their curriculum speaks to the importance of a checklist for compassion.

See article here checklisthttp://www.newyorker.com/magazine/2007/12/10/the-checklist

The Dangers of Digital Diagnosis by Robert Watchter

We know that medicine is now democratized; people have apps, access to WebMed, read medical journals (I do).  This makes everyone a doctor.  Or at least that’s what we’d like to believe.  And Dr. Robert Watchter makes a good case for why this can be dangerous.  Digitized has its benefits:  electronic medical records that everyone has a right to access, patients no longer view doctors as gods, physicians can have information in a timely matter, and sometimes surgeries can be performed 1,000s of miles away.  I personally know a radiologist who lived in Switzerland and was able to access images, electronically, helping the surgeon in an operating room.  However, according to Dr. Wachter no computer can take the place of a physician and patients who become their own doctors can be misguided, at best, and die (worst case scenario) because they either misdiagnose, come up with illnesses that may not be relevant or see nothing when there actually is a disease present.

In the TEDmed video, The Dangers of Digital Diagnosis I Dr. Watchter makes the case for why physicians will always be necessary.  https://urldefense.proofpoint.com/v2/url?u=http-3A__tedmed.com_talks_show-3Fid-3D530888-23.V6ITFHhKZVk.email&d=CwIDaQ&c=y2w-uYmhgFWijp_IQN0DhA&r=tK0xAJ3G91cX09z6N0ntmvdqW9jIkuTbnthdqBiC2lo&m=_6B16h6kGyi6SBlV4VyJTtjBCKyJfz8yVvTMNeCCXKE&s=RmfZkBGT3QyZo09DMo29BqLPLU23qfERsN2SLpBXpT0&e=

Doctor Yearns For Return To Time When Physicians Were ‘Artisans’

SomI'm mad as hell...ehow the title of this article just makes me sad.  Are physicians at the point of no return; and the pressures of being a physician are so tough that doctors are desperate for the good ol’ days when they could actually practice empathy and take the time to get to know their patients, as people, in order to be the most effective care giver?  Makes me wonder if what those of us who are trying to educate the new generation to take the time, to step back, slow down, and really understand the patient and their history in order to make the best, and most educated, diagnosis?  Are we swimming upstream?  Who, and when, will doctors put their proverbial feet down and say to policy makers, “we’re mad as hell and won’t take it anymore”.  We want to be compensated for our work and we MUST be able to spend more time with patients and do less paper work!

How Fine Art Can Make Better Doctors (on the radio)

How fine art can make better doctors is topic of inaugural episode of Yale netcast series

Dr. Jacqueline Dolev and Dr. Irwin M. Braverman discuss “The Art of Noticing” in the first episode of a new series of Yale netcasts. (Photo by John Curtis / Yale University)

An innovative workshop at the Yale Center for British Art designed to improve the observational skills of medical students is the focus of the first episode of a new series of Yale netcasts.

Titled “Doctor, Doctor: Conversations About Medicine,” the occasional series will explore topics of interest to physicians and their patients. The series is produced by the Office of Development and Alumni Affairs at the Yale School of Medicine.

“Doctor, Doctor” seeks “to bring together physicians from different backgrounds across disciplines, generations, and geography to encourage conversations that shed new light on critical areas of medicine,” said Tiffany Penn from the Office of Alumni Communications. The intended audience, she says, is “Yale School of Medicine alumni and anyone interested in current topics in science and medicine.”

In the first episode, “The Art of Noticing,” School of Medicine alumni Dr. Jacqueline Dolev ’01 M.D. and Dr. Irwin M. Braverman ’55 M.D. explain how trips to a museum improved students’ powers of observation. Braverman, professor emeritus of dermatology, is the co-creator of the Workshop on Observational Skills, which has been offered at the School of Medicine since the late 1990s. Dolev, a practicing dermatologist in San Francisco and one of the first students in the course, was impressed enough by the experience to make the program the subject of her medical school thesis.

In the netcast, Dolev relates how the initial batch of students believed the workshop, in which participants study paintings and then discuss what may be taking place based on their observations, would be fun but were dubious about its effectiveness. As an artist herself, Dolev felt “intuitively that it was going to work” and that “it could be proven quantitatively.” She completed a two-year study, published in the Journal of the American Medical Association, that demonstrated the workshop resulted in a 20% improvement in observational skills in participants.

The workshop is now a required part of the first-year curriculum at the Yale School of Medicine. In the past 15 years, similar programs have been offered at more than two dozen U.S. medical schools and colleges in London, Dublin, and Taiwan, as well as at the New York Police Department and Scotland Yard. The program has become so successful, Braverman jokes in the netcast, that “if we could monetize this franchise, we could all retire.”

Several more episodes of the series are planned for 2016, says Penn. Although the netcasts will primarily feature alumni of the School of Medicine, some “will also include others with a connection to Yale or a strong connection to the topic at hand,” she added.

“With more than 6,000 living alumni — a great many of them leaders in medicine — Yale School of Medicine has an exceptional roster of potential alumni guests,” she said.

The Doctor’s New Dilemma (Suzanne Koven, M.D. N Engl J Med 2016; 374:608-609February 18, 2016DOI: 10.1056/NEJMp1513708)

 

The surgeon

Why is it that psychiatrists are afforded 50 minutes to determine a patient’s mental health issues when we all know that the connection between mind/body is significant and physicians are limited to 15 minutes?  The article, The Doctor’s New Dilemma (I find it interesting that it’s written by a female physician), addresses this conundrum: does a physician risk delving into areas with his/her patient and going off the rails only to result in the physician ending up with no more information on a diagnosis yet with the possibility that this said physician will gain the trust of the patient?!  Seems to me that if trust might be essential to a positive outcome with a patient that that risk should be taken. AND that there are policy changes that effect more time can be spent with patients.

Wisdom in Medicine: What Helps Physicians after a Medical Error

I have never known a single person in my 60 year life who hasn’t made a mistake.  Admission of the mistake is another story.  So what happens when a physican morbidity and mortalitymakes a mistake?  According to the article in Academic Medicine (February, 2016: volume 91, issue 2) it’s essential for physicians to admit and to reflect upon those mistakes.  However, how to go about that is something that is lacking in a doctor’s training,   “Despite its implicit role in training programs, wisdom is not routinely discussed in medicine.31 Ardelt’s32 three-dimensional wisdom model describes wisdom as the integration of cognitive, compassionate, and reflective components. A wise physician is one who can comprehend the deeper meaning of the interpersonal and intrapersonal aspects of life, tolerate ambiguity and uncertainty, and understand the limits of his/her knowledge. Wisdom also encompasses the capacity for compassion and empathy, the ability to see situations and phenomena from many different perspectives, and the practice of self-reflection.33–35 Although the experience of medical error can be devastating for patients and physicians alike, such a trauma might provide a potent opportunity for the development of wisdom”.36,37

Read article:  Wisdom in Medicine: What helps Physicans after a Medical Error

Getting the Diagnosis Wrong, by Danielle Offri, NYTs October 8, 2015

Getting a diagnosis is a matter of life and death and according to the Institute of Medicine doctors misdiagnose one out of ten or twenty times.  The good news is the IOM recognizes that fault doesn’t lie solely on physician’s shoulders; error occurs most often because of faulty communication. In an effort to cut down on misdiagnosis more teams are being put into place with more frequency, “Teams can include a single discipline or involve the input from multiple practitioner types including doctors, nurses, pharmacists, physiotherapists, social workers, psychologists and potentially administrative staff. The role these practitioners play will vary between teams and within teams at different times. Roles of individuals on the team are often flexible and opportunistic such as the leadership changing depending on the required expertise or the nurse taking on the patient education role as they are the ones that have the most patient contact. In support of patient-centred care and patient safety, the patient and their carers are increasingly being considered as active members of the health-care team. As well as being important in terms of issues such as shared decision making and informed consent, engaging the patient as a team member can improve the safety and quality of their care as they are a value information source being the only member of the team who is present at all times during their care.” http://www.who.int/patientsafety/education/curriculum/who_mc_topic-4.pdf

Dr. Rosen wrote a book called Vital Conversations: Improving Communication Between Doctors and Patients.  The premise is, and I’m paraphrasing here, all roads to misdiagnosis have to do with lapses in communication: doctors weren’t listening to their patients, or peers, patients weren’t listening to their physicians and the list goes on.

Read Danielle Offri’s article Getting the Diagnosis Wrong