CIM Good Doctors and Nurses

For the better part of a decade, the CIM’s Aliki Initiative has been teaching young doctors to care for their patients as people. First, we focused on giving residents and medical students the luxury of having more time to spend with patients on a ward in the hospital. Then, we watched proudly as those young doctors and teaching faculty took the Aliki approach with them when they moved on to other rotations. And over the last few years, we have seen that when these doctors finish their training, they tend to remain “Aliki-ized.”

And they’re not the only ones. Two years ago, chaplain interns from Johns Hopkins Bayview began rounding with the Aliki team, adding a new dimension to knowing the patient as a person. The Aliki Initiative has spread to an unexpected place, as well – the intensive care unit, where doctors hardly ever get to know their patients as people, because they’re hooked up to tubes and machines and are hardly ever awake. And yet, knowing who these people are, and who their families would like them to be again, has made for better medicine.

But wait, as the old TV pitch says – there’s more! Meet the CIM Good Doctor Initiative. “It’s hard to keep a good idea from spreading, and this has been the case, and our goal from the start,” says Vice Dean David Hellmann, M.D, the CIM’s co-founder and director. Now, nursing students and a nurse Attending are joining the team, too. If you’ve spent time in a hospital, or even watched medical shows on TV, maybe you’re used to seeing doctors and nurses rounding together. They do. But they sure don’t learn how to be doctors and nurses together as students.

It’s hard to capture how novel this is, but in the world of medical education, it’s a groundbreaker – because this just isn’t done. It should be, but it isn’t. “To my knowledge, no one has ever thought of having a nurse Attending teaching medical students,” says Hellmann. “No one has put nursing students on a floor specifically to achieve collaboration with physicians for the sake of the patient. It’s like describing the Wright Brothers without understanding that for thousands of years, everyone who had tried to fly crashed.” The evolution of the program is an interesting story, too, he adds: “We developed the Aliki Initiative to train better doctors. But by keeping our eye on the real goal – helping our patients, rather than just focusing on doctors – we realized we could do better. We also got some good advice from two of our International Advisory Board members, both nurses, Dana Case and Mary Ousley, to include nursing. This shows how powerful it is to focus on medicine as a public trust. It’s a great compass that keeps us on the right path.”

Key to this new initiative are Patricia Davidson, Ph.D., Dean of the School of Nursing, and Maria Koszalka, R.N., Ed.D., Vice President for Patient Care Services at Johns Hopkins Bayview, who have “jumped right in,” says Hellmann, “with time and enthusiasm,” and with the support to fund a nurse Attending. “Interprofessional health care is the way of the future,” says Davidson. “The third leading cause of death in the U.S. is from adverse events in hospitals, and many of these can be prevented. Communication is essential in helping to change this.”

Interprofessional education, bringing people with distinct knowledge and skills together, will add new dimensions to teaching both doctors and nurses how best to help patients and their families, says Laura Hanyok, Director of Faculty Development for the Aliki Initiative. (Among her many jobs, she also is Director of Interprofessional Education for the School of Medicine, and she directs the residency continuity practice for the Internal Medicine Residency Program.) Hanyok, who also has a joint appointment in the Johns Hopkins School of Nursing, has been named a Josiah Macy, Jr., Foundation Faculty Scholar; this program is designed to nurture the careers of educational innovators in medicine and nursing. “Taking a team approach reduces errors and improves quality of care,” she says. But “traditionally, the nursing students work with the nurses, and medical students work with the doctors. They never really talk with each other.”

The goal is to provide a better product and a better experience for patients, says Davidson. “One of the things that inspires me about the CIM is that it’s really about keeping patients and their families at the center of care and experience,” she explains. “There’s a lot of rhetoric out there – probably every hospital in the world talks about patient- or person-centered care. But it’s different when you genuinely feel that the interests of the patients, families and community are brought together. This addresses the culture of academic medicine, and culture trumps strategy every time. You can talk about patient-centered care and interprofessional collaboration, but unless you change the culture, it doesn’t mean very much.” Davidson also appreciates the CIM’s view of medicine as the center for social good, and health as a human right. “I think that’s a wonderful philosophy to espouse, particularly in Baltimore.”

True interprofessional collaboration is especially important in a time when nurses are in more demand than ever, and a shortage is either looming or already here, depending on whom you talk to. “If nurses aren’t in supportive and enabling environments, they will go somewhere else.”

The program is still very new. The attending nurse has been recruited, is undergoing her orientation, and doing a lot of planning, Davidson says. “Of course, what I’m really excited about as the Dean is to provide the opportunity for our amazing nursing students to learn with the medical students. This is going to provide an extraordinary opportunity for nurses and doctors to learn together in a real world environment. It is very odd that they work together, but they don’t train together. Nurses learn in nursing schools, doctors learn in medical schools, pharmacists learn in pharmacy schools; maybe they get together in the cafeteria.” But teaching doctors and nurses to work together will make their practice more efficient and effective, she adds. “If we understand better what each of us does, we will be minimizing waste. For example, how many physical assessments does a patient need? Nurses do one, the physician does one, the occupational therapist does one.” This can be confusing to the patient, particularly if it results in conflicting information. “People often put up barriers to interprofessional education. But I believe if you can get hundreds of airplanes to come into Atlanta without crashing, then we can work out how to get medical and nursing students learning together.”

Hanyok hopes that nursing students will soon be able to make home visits with the team and take part of the transition of care from the hospital (to home, a rehab facility, or long-term care facility. She also hopes that broadening the program will teach students another skill that not everyone naturally possesses: teamwork. “We realize that learning the skills of communication and collaboration and teamwork are really important and not something that everyone can naturally do. We used to assume that physicians knew how to communicate effectively with patients, and it wasn’t taught.” It is now: one of the Aliki program’s first innovations was actually breaking down how to talk to a patient into nuts-and-bolts teaching points and specific, learnable skills.

“It’s essential for people on a medical team to know what their counterparts in other disciplines do, and how that expertise can help the patients, she notes. Hanyok has found that students want more opportunities like this. “They understand why it makes sense for them to learn and train together. They say, ‘we’re going to be working together side by side, why not work together now?’ They really get this.”