Chief Rounds: An Oral History of the Assistant Chief of Service at Johns Hopkins

[MUSIC] We all like to think that we are good
doctors. And if if I’m thought to be a good doctor,
it’s because of the Osler service.>>In the matter of resident physicians
and interns, these men should as now be
salaried. They should be selected with the greatest
care. We should select men, indifferently from
the entire country. Wherever we can hear of a superior man who
wishes to do scientific hospital work. I hold, that it should be distinctly
understood from the outset, that this is not a ordinary
hospital. William Osler.>>Before Johns Hopkins was
established, hospitals in America were places where poor people came
to die. And when Johns Hopkins established a
university, a medical school and a hospital was the
first time that you had smart people of good will committed to healing and using science to
combat suffering. [MUSIC]>>The early residents, like their
successors, were men of high competence, sound training and outstanding
personal qualities, long tenure was the rule. Thayer, who graduated from Harvard Medical
School in 1889, was assistant resident physician for one year and then
resident physician for seven years. The pearl of the residency system has been
the public wards. Known since 1931 as the Osler Medical
Service. This was the only resident staff in the
department of medicine until 1915, when a separate resident staff for
the private service was initiated. The latter was known for many years as the
Marburg Service. Victor McKusick.>>My intern year, I lived in one of
the large rooms on the third floor of the
Administration Building. I shall never forget my first patient. Patient admissions were light and with
almost two weeks before a new patient was admitted with intestinal bleeding due
to a syphilitic ulceration of the bowel. To illustrate the primitive state of
therapy in those days, we did the daring thing of giving them a
subcutaneous infusion of saline. Every year of my assistant residency, there was an epidemic of meningococcal
meningitis. During the Depression, nutrition was poor
amongst the East Baltimore residents, and cases of
pellagra were common. We had very little in the way of therapy. All we could do for patients with bacterial endocarditis was to give
supportive therapy and see them through the various embolic events that took place before
death. Mac Harvey. [MUSIC]>>The growth of the sub-specialty
divisions had in some other institutions resulted in a complete loss of the
tradition of the general internist. Hopkins however, was extraordinarily
fortunate to have outstanding generalists as
leaders. This started with Dr. Harvey, whose skill
and judgement, and differential diagnosis covered the
entire range of internal medicine. Richard Rodeheffer.>>A character of the chief residency
changed significantly in the 1950s and 60s, and
the job of the recent residents has become at
least twice as big as 25 years ago. The house staff and the number of
impatients have more then doubled in size. And with the shortened average length of
stay, the chief resident has been unable to spend as much time at the
beside as previously. His job has become a particularly hectic
one, less satisfying to him, and a less satisfactory preparation for a
major role in academic medicine. Victor McKusick.>>We had two services in those days. We had the Osler Service, which was very
popular. Students and house staff loved it. Then we had the Marburg Private Service
which wasn’t doing well at all. It was hard to get anyone to work there,
so Dr. Harvey asked me, could I take it over and see what we
could do with it. We passed a rule that no visiting
physician could leave an order on a patient without going through
the house staff first. Then we picked out some of the best
teachers, like Ben Baker and Ward Allen. And set up ward rounds that were exactly
like those on the Osler Ward Service. Philip Tumulty. [MUSIC]>>Three short-comings of the program
became evident as the 1960s progressed. First, the Osler program suffered from
lack of exposure to the part time faculty who admitted many
patients to Marburg. Second, house officers had relatively
little contact with the research specialty
divisions. Third, socioeconomic changes after World
War two narrowed the spectrum of clinical problems seen
among osler patients. Victor McKusick.>>In response to these shortcomings
there were three modifications that the training
program made in 1970-71. One was to add a third year of residency. It had typically been just two. The second was to have the senior
residents rotate on the new specialty services and learn the
best organ oriented science. And the third was to combine two
historically separate services, the Osler service with
the Marburg service.>>Dr. Tumulty and Dr. McKusick had
been talking a lot about how to reorganize the Osler
Medical Service to meet some of the challenges that were being
posed by some external forces, not the least of which
was health care reimbursement.>>So there were senior people, but
they were house staff. And they were technically the attending
physicians, but because they were house staff there, there was no way they could
charge a professional fee. So, the economics were one of the drivers
of the new system, actually.>>It is intended that on July 1, 1975, four services will be created and
designated as firms. Each firm will be headed by a junior
faculty member whose experience and competence are comparable
to those of our present chief residents. The title will be Assistant Chief of
Service.>>And Dr. McKusick, greeted me and
escorted me into his office. He said, please sit down. We shook hands. He said, please sit down. I said, thank you. He said, I’d like you to be an ACS next
year. I said, I’d be honored to be an ACS next
year. He said, thank you for coming in.>>Each ACS will serve for two years,
so that on the first of July each year two new ACS’s will begin
a term of responsibility. The general medical character of the firms
will be jealously guarded. If one defines primary care as continuous
and comprehensively integrated care, then such is the appropriate label for much of
that provided by the firms. Victor McKusick.>>Well, actually, I received an e-mail
from a division director of general internal medicine at
University Hospital of Norway. And he wrote to me to ask how it was that
I was able to convince the institution to adopt general internal medicine wards
as the basis of the residency program. And I wrote back, I told him I had to
laugh, because Osler had devised things that way 100 years ago, and it had been confirmed several times over the
succeeding generations. So I had the good luck of becoming a GIM
division director in a place that has general
internal medicine at its heart.>>Well, the house staff was divided
into quarters instead of halves, so that was much more
manageable. I mentioned the economics of it. The Assistant Chief of Service with Dr.
McKusick being the Chief of Service was a faculty
position. It was envisioned as a two year job. So the first four ACS’s, two of them did
two years. And then the idea was they were going to
leap frog over time. Turned out the job was about as hard as
ours was. It was just unrealistic. Ken Boffman and Craig Smith were the first
two that did two years. I think there were only two others, one
other pair, that did two years.>>When the firm system was, was
founded, one of the pressures was of course that the service had just merged and by definition doubled in one short
year. What were called DRGs, that is disease
coding systems were being developed to facilitate
reimbursement. The whole issue of patient insurance was
becoming a big national issue, and we felt that.>>It was in the mint of my internship
that the firm system was announced. This upset me to the degree that I seriously contemplated leaving the Johns
Hopkins hospital. My concern being that a new system, with
an increase presence of the ACS, would minimize my responsibility, and ultimately, my
education. James C Wade.>>In the early years there was some
resistance from the interns and residents to having that kind
of person above them. So, it took special kinds of people to
make that work.>>But there were many such challenges
that were that were faced. The, yet, inspite of that, we remained
focused. We were able to remain focused with the
support of the faculty, and the patients, and maintaining the relationship, our
relationship with the patients. And as an ACS, our relationship with the
house staff which was clearly the biggest challenge and the greatest
source of gratification. [MUSIC].>>Okay. I’ll talk to them, because I’m curious if
that’s the reason why she misses the block appointments that
we make for her.>>Yeah, I think that she usually goes
there.>>So I think it was no HTTZ that, I think, either you could do twice a day
beta blocker. The nice thing about [INAUDIBLE] a more
gentle onset. So it doesn’t give you sort of a rapid
onset.>>Mm-hm.>>So that’s nice. But you could do twice a day instead, and
split it out to have more even coverage. Or you could add Hydrel. I worry about doing a TID medicine in her
or even doing Hydrel BID, but why don’t we do her
Toprol XLs, 200?>>Yeah.>>Why don’t we do’ em Tropol 100 BID? Let’s see what happens.>>Okay.>>And then she can go home today.>>Sounds good.>>Okay. Alright, great. Let’s rock and roll.>>Mr. Merricks, how are you?>>I’m doing good. I’m doing good.>>It’s good to see you. Good. Okay, you remem, you recognize everybody?>>Mm-hm, yeah.>>Okay. Alright.>>Yeah.>>Dr. Cline’s gonna tell us your story
and as you see, you’re famous now.>>So, I think the, the heart of our
method of teaching is trying to take inexperienced people with a lot of knowledge and give them a lot of
experience. And couple that with even more knowledge to make them seasoned, capable, and
unafraid. Or unperturbable, which is the meaning of
equanimity toss that we talk about a lot.>>The four characteristics that we
that are really important to look for in an ACS include clinical excellence, leadership, the ability to inspire, and
Aequanimitas.>>Imperturbability, means coolness and
presence of mind, under all circumstances, calmness amid storm, clearness of
judgment, and moments of grave peril. The physician who has the misfortune to be without it, who betrays indecision and
worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the
confidence of his patients. William Osler.>>That’s what’s on the tie, that’s
what’s on the pins. Men will wear the tie every Friday. Women with the scarves every Friday. Pins we now give to graduating seniors,
and they wear it on their white coats or their
lapels. And it’s also all over, and so many of the
the items that we give to people will have
emblazed upon them Aequanimitas.>>Being Canadian he was eligible for
and became knighted sir, and I guess when you get that you have to come up with
a coat of arms. So he had his son Revere design that. Well, when Dr McKusick was trying to come
up with a pattern for the tie, they looked at that
coat of arms. There’s a lot of detail in there, so they
decided to go with just a simple shield with, with
Aequanimitas.>>And it captures the essence of what we value in physicians coming through this
program. It’s just really that, that leadership and
that imperturbability in situations of, of chaos, and bringing calmness to, to
the current situation.>>I think the ACS is is is oh, tries to model what we think are core
values at Johns Hopkins. But also do them in a way that is respectful of their colleagues, of
patients, of nurses. And give the highest level of medical care
in addition to learning facts and doing a
daily job.>>I think the moments that I’ve been
proudest of is when I know that my interns and
residents feel safe. That they are smart, and that they’re able
to do what they know is right for a patient without needing
even my approval or my input. And seeing them become independent is
really the goal of your ACS year.>>Skills that we would want to develop
to det, what you really need to know as clinician when you’re, or physician, when
you’re encountered with a really sick patient is, is just
that. Who’s sick and who is not acutely sick? And that is invaluable because whether
you’re inpatient or out patient physician, that is a skill set you
need to know. You need to walk into a room and say this
patient is really ill and unstable. and, and learning that is invaluable. And you do that as you grow through your
internship year. At the end of the year if my interns could
walk in and say I’m worried about this person, even if
just by look alone they weren’t that ill. Then that’s invaluable. I think the learning aspect, you know, there’s a teaching portion and a learning
portion. I think part of the learning aspect is
knowing what you don’t know from a book knowledge stand point, but what you
can teach and, and you do know. And I think part of what we were always
taught early on was that the most important thing
to know when you go to the bedside of a patient is to know whether that patient is sick or
not sick immediately. There are a lot of things you can look up, there are a lot of people out there,
probably some of my interns have more encyclopedic
knowledge than I do about medicine and can name triads
and pentads. But more importantly, you know, I feel
like one of the greatest parts of teaching and of
learning, is that, which has evolved for me over time, is that if you
sit down with a patient long enough, they will tell
you what’s wrong. They may not know the name of it. They may not know what to do for it, but
they will tell you in some way, shape, or form what
is wrong with them. And I think that’s what’s most important. It’s important to confer to a young mind. Listen, and you’ll know.>>The hardest part of the ACS year is learning to multitask and wear a lot of
different hats. And by that, I mean being a good clinician, a good educator, a parent an
administrator. And doing that while you’re trying to be a
good roll model for everyone. And that, that is a challenge. But at the end of the year the growth that
you have as an individual is unbelievable. What’s not challenging, and I think we’re
very lucky, because what’s not challenging is
finding the four people who have these skills, is
deciding amongst the many people who have these
characteristics. Which four we think would be best to have
this position.>>And again, that’s we feel very
fortunate that every year, year upon year, the most difficult task at
deciding amongst the group of people that have all of these
characteristics and more who do we think would be best to serve in the
position of ACS. [MUSIC]>>I think one of the most rewarding
aspects again is kind of like that family feel, and just having one of the
best jobs I imagine, in the country.>>You know, when you start in July
everyone is uncomfortable, nobody knows exactly what their doing, and there’s a
lot to teach in the mornings. And then you reach the point where you’re
not teaching much in the mornings, because people are, are,
are doing so much more.>>I remember this one one intern that
we had, Elizabeth Holt who’s an, an amazing physician and it was
October, and we were, we were having so many admissions,
we were getting slammed. And and she was swamped and she had this
one patient that was transferred from surgery, that was so complicated and
required just so much TLC.>>For me this was Jenny Price, and
I’ll, I’ll still remember the morning but it’s, it’s
who’s a phenomenal physician. And she had a night, which is the night
that all interns dread having, where you admit six or seven very,
very, sick and complicated patients. And when we come in, in the morning you
get a sense of what the acuity was overnight
and, and, you’re nervous.>>And she kept that patient alive, and it was just an amazing feat of clinical
care. And, and, she took it, it was her, it was,
she was gonna do it. And she it, despite the fact that she was
getting six admissions every night. It was amazing, the surgeons were just
were just flabbergasted.>>And as Jenny started to present, and
as you sat and you, and you listened, you
realize by the end of the, the morning that every single thing that should have been done
was done. Not only the big things, but every, I was
dotted, every t was crossed. And in a way that not only kept patients
safe and advanced their health, but also in a
way that would bring evidence into the plan and
teach others why we, why she chose to do things that
particular way. And it’s, it’s an amazing experience to
know that you know, in July everybody started at the same spot, and now in the
winter Jenny’s able to do this. And you, you feel proud you feel inspired,
and you realize that this system works.>>Being an ACS has, for me been
essentially a series of incredibly proud moments where I
took a group of people that I already thought the world
of, and have watched them excel at what they do, and
become even better.>>And you see the interns go from you
know, the deer in the head lamps look on July 1st,
to you know, tossing off six admissions with no,
without breaking a sweat and getting everything right, you know, as
the year goes through. And watching that transformation is is
pure gold. And, and I love doing that. I loved my interns. They, it was a great, great group.>>It’s a very, very special
relationship, I think, between an ACS and their house
staff. And it’s one that continues lifelong. So Sanjay said at the beginning of this
year, for the rest of their lives their interns will say
Laurel Brown was my ACS. Make sure that’s a statement that you’re
proud of.>>I, I have an award at home, which I, which I have very proudly displayed in
my office. That the house staff gave me my second year, which was the Mother of the Year
Award.>>I feel like a proud mama at many
times. And in fact, my interns even call me mama
bear. Because I feel so proud of them and let
them know.>>You know, you’re going through it. You can’t explain it. And, and you’ll have those bonds forever.>>I, I loved my fellow ACS’s and, you
know, we get back to the office and it would be 11
or midnight. And we have to, we’d have to do these dictations and Ilan Wittstein, who’s
a cardiologist still here at Hopkins, you know, would
just say the right things to crack us up. And when you’re there, and you see these
amazing friends and colleagues going through the same thing,
it was, it was alright.>>I guess the evening rounds that I would make with the
house staff. I’d go home for dinner so I’d be with my
wife and very young child at the time, and then come back to the hospital and
begin rounds usually around eight or night o’clock and that would go
til midnight usually. So I’d spend 45 minutes to an hour,
sometimes more, with each of my group of house
staff. And we had fun talking about patients,
talking about life got to know them very well. I think that’s probably, in retrospect,
what I would, value most about the experience.>>It, was, the, the most rewarding, professional year of my life, and that’s
because, of, the ability to, participate and, the, development and mentorship ten to 12 unbelievable
passionate and ambitious people who want to change
literally want to change medicine is an amazing opportunity.>>The Osler service gives us an
opportunity to, learn about patients, about disease, the spectrum of disease, the
presence of a given disease, and, and the context of multiple
co-morbidities. It teaches you to use, to develop clinical judgment so that one is not dependent
solely on cookbook medicine and and algorithms. And I think that understanding that is
fostered among our house staff is one of the One of
the, attributes, that the service brings to,
doctors in training, that serves their patients
very well. [MUSIC]>>It turns out the only way to get an
Osler tie is to be an Osler intern and so I thought I would never have one
and, until four years ago I attended a reunion of
OSLER house staff. And as I was leaving I got a tie and a
gift bag as I was leaving. And I thought to myself, am I really part
of the team, did they mean to give this to
me? So I called the following week and I was told, oh no you, you weren’t supposed to
get that. Please bring it right back. [MUSIC] What’s the best firm? Well, I think there’s absolutely no
question about that.>>Oh, that’s a loaded question. Right now, I’m from faculty Longcope, so I
have to say that. So it depends on what time of life you ask
me that question.>>Having been Barker firm, it’s clear
that Barker is the best of the firms.>>Thayer. Second, Janeway. Third, oh, third Barker. Last Longcope. Sorry all you Longcopers. [LAUGH]>>I’d be split between the two that I
was part of. [LAUGH] And now I can’t commit allegiance. I’m dedicated to them all.>>It’s a firm of giants. Janeway. [MUSIC].

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