Tip:
Highlight text to annotate it
X
[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].