PURPOSE:The aim of this study was to present a patient with systemic lupus erythematosus on longstanding hydroxychloroquine (HCQ) use for whom HCQ was stopped because of signs of toxicity and then resumed four years later because of dire systemic need. METHODS:This is a long-term retrospective study. Humphrey visual fields (10-2 and 24-2), fundus autofluorescence imaging, and spectral domain optical coherence tomography (OCT) were used to follow progression over time. RESULTS:The patient was on HCQ for 26 years, with a cumulative dose over 3,000 g. HCQ was stopped in 2011 because of macular toxicity. She remained off HCQ for four years, during which time she developed type 1 diabetes due to an immunologic attack on the pancreas and then JC (John Cunningham) viremia after a period of treatment with mycophenolate, which put her at risk for progressive multifocal leukoencephalopathy. Mycophenolate was discontinued, and HCQ was resumed with careful follow-up over the next 7 years. The toxic maculopathy showed only mild slow progression since HCQ was resumed. CONCLUSION:Careful annual monitoring using Humphrey visual field 10-2 and spectral domain OCT imaging remains the standard of care for the patients on HCQ. However, it may be possible with close monitoring when there is compelling systemic need to resume HCQ after it has been stopped, with only slow progression of the retinopathy. This allowed the patient to have an improved quality of life and reduced the risk of severe morbidity and mortality.

Artificial intelligence in radiology critically depends on vast amounts of quality data, and there are controversies surrounding the topic of data ownership. In the current clinical framework, the secondary use of clinical data should be treated as a form of public good to benefit future patients. In this article, we propose that the physicians' input in data curation and interpretation adds value to the data and is crucial for building clinically relevant artificial intelligence models.

In 2017 The American Journal of Medicine launched a new series entitled “Personomics” (a neologism coined by one of us [RCZ]) to allow contributors to describe how knowing the patient as a person had helped solve a diagnostic mystery, improved treatment, spurred scientific discovery, fortified a patient's dignity, illustrated the hazards of making assumptions about a patient, or prompted a physician to experience a frisson of the joy of medicine.1Hellmann DB Ziegelstein RC Personomics: a new series in the Green Journal.Am J Med. 2017 Jun; 130: 622Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In contrast to other laudable series published in other medical journals, “Personomics” is uniquely centered on the patient as a person. Although rooted in antiquity, knowing the patient as a person has grown in value with modernity. The remarkable advances in biomedical science—in genomics, proteomics, metabolomics, and in many other “omics”—provide access to many aspects of individuality heretofore inaccessible. However, it is personomics alone that provides an understanding of patients’ unique life experiences and allows clinicians to deliver the promise of medicine if they know their patients as people. The neologism, “personomics,” was created to indicate that physicians need to be as committed, scientific, and thorough in knowing their patient's unique personal background as they are in knowing their genes and proteins.2Ziegelstein RC Personomics.JAMA Intern Med. 2015; 175: 888-889Crossref PubMed Scopus (63) Google Scholar The National Institute for Health and Clinical Excellence guidelines for getting to know patients as people include the following domains: 1) the patient as an individual, 2) the patient's life circumstances, 3) the patient's concerns, 4) the patient's needs and perspective, and 5) don't make assumptions.3Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. National Institute for Health and Care Excellence (NICE), London2021 Jun 17Google Scholar Gaining access to information on an individual's biological uniqueness through the tools of precision medicine is exhilarating, and learning about a patient as a person is equally so, and adds meaning and joy to the practice of medicine. Given this background and the passage of 6 years, it seems timely to ask for a progress report on personomics. The response of contributors to “Personomics” has been gratifying on many levels. Since its launch in 2017, “Personomics” has attracted many submissions, and nearly 50 essays have been published. The authors have been strikingly diverse, hailing from many different institutions and from several different countries. The contributors represent the full continuum of professional experience, from those at the dawn of their careers to those basking in the sun's late afternoon glow, and at every level of experience in between. Every domain of knowing the patient as a person articulated above by The National Institute for Health and Clinical Excellence2Ziegelstein RC Personomics.JAMA Intern Med. 2015; 175: 888-889Crossref PubMed Scopus (63) Google Scholar and by the “call” in our introductory description of this section1Hellmann DB Ziegelstein RC Personomics: a new series in the Green Journal.Am J Med. 2017 Jun; 130: 622Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar has been described in the “Personomics” essays. There have been stories that have highlighted how personomics helps solve a diagnostic mystery, as in the appreciation of a patient's grief in “Off the Charts” by Suzanne Koven.4Koven S Off the charts.Am J Med. 2017; 130: 872-873Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Other essays have highlighted how personomics improves treatment, captured beautifully by Jyotsna Ghosh:5Ghosh J Do you know who this is?.Am J Med. 2021; 134: 292-293Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar “Records, histories, and lab results add up to information, but not to insight; and certainly not to wisdom.” Still other pieces have spoken to how personomics spurs scientific discovery, as in Antony Rosen's description of how a “patient's story stopped [him] cold” and helped lead to an appreciation of the scientific basis for the relationship of cancer and autoimmunity in “Moments of Wonder.”6Rosen A Moments of wonder.Am J Med. 2018; 131: 852-853Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar A number of essays have described how personomics fortifies a patient's dignity, as the description of a patient by Richard Scott Morehead: “And so, he lies before me, much like his forebears did long ago. With great patience he listens to me explain how things are: his chest wound and failing lungs defy our skill. His wife later visits, and I hear of his children. I recognize his desire to live; however, the engagement this time will be limited. His dignity, borne of a long struggle, will be respected.”7Morehead RS. "If I should die, think only this of me…" [e-pub ahead of print]. Am J Med. doi:10.1016/j.amjmed.2023.01.045, accessedGoogle Scholar The ability of personomics to illustrate the hazards of making assumptions about a patient was clearly described in “A Tale of Two Gabriellas” by Matsuko Takeshige and colleagues8Takeshige M Takeshige T Takeshige U A tale of two Gabriellas.Am J Med. 2020; 133: 1227-1228Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar: “I felt foolish and gullible in thinking that she did not have financial difficulty with medication and other supplies; I assumed that she could afford them. How wrong I was.” Finally, essays have also demonstrated how personomics contributes to the joy of medicine, as in Hursuong Vongsachang's description of her calls to a patient after hospital discharge: “The calls filled me with a sense of common humanity despite our different dispositions. And that is why we embark on this career after all.”9Vongsachang H Lessons from three pairs of socks for a third-year medical student.Am J Med. 2020; 133: 644-645Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Like the practice of medicine itself, the essays have sounded notes of awe, joy, and wonder mixed with somber sounds or regret, worry, and sadness. In total, all of them add to our sense that the profession of medicine is a jewel, and every attempt to know a patient as a person helps to burnish that gem. These essays and the passage of time have convinced us of the critical importance of personomics in the practice of medicine today. As was true 6 years ago, it is not possible to care best for patients today without knowing them as people. The tragedy of over 1 million Americans dying of COVID-19 infection over the past 4 years teaches many lessons, including that the trust of patients in physicians and the health system depends on patients being understood and respected. Does good medical care always require knowing the patient as a person? Recently, a colleague raised that question, arguing, for example, that a physician suturing a patient with a skull laceration does not need to know the patient personally to provide good medical care. One of us [DBH] had an experience that spoke to that question: Nearly 4 decades ago, I received a call from the babysitter that my then 3-year-old son had sustained a head laceration. He had been playing with his beloved and now iconic red Fisher-Price car. Being adventuresome, he did not enjoy sitting in the car nearly as much as he did standing on its bright yellow roof. On that day that shiny red object adhered to the laws of physics that says that a car with excellent wheels will move when a 3-year-old boy is jumping on its roof! The laws of physics also made a convincing argument that my son's head would strike the floor and produce a 2-inch laceration. I rushed home only to find my son calmly playing with another toy, largely oblivious to the scalp wound. Realizing that the wound needed suturing, I told my son that I would take him to the hospital where I worked. Upon hearing this, my son began to cry and sob that he did not want to go. For the first 15 minutes or so I thought he was crying because he was experiencing increasing wound pain or the fear of painful treatment. However, on the trip over, between sobs, he revealed that he was crying out of fear of encountering the Big Bad Wolf. Turns out that I had totally forgotten that months before his injury, in a misguided attempt to reduce his fear of the Big Bad Wolf who had surfaced in one our storybooks, I had reassured him that the wolf had been captured and caged in my hospital—far from our house. My previous attempt to assuage a fear had become the chief cause of his misery! After my wife immediately and convincingly corrected the story, our son stopped crying, and calmly allowed the pediatrician to dress his wound. If personomics can bear on the outcome of suturing skull lacerations in a 3-year-old, then perhaps knowing the patient as a person has an important impact on the outcome for every patient. The “Personomics” series has flourished over the past 6 years. We thank Dr. Alpert, the editor of the Journal, for agreeing to launch this series. We salute the contributors who have submitted essays that have limned the challenges and joys of knowing the patient as a person. Reading the essays has helped us become better physicians. We believe that knowing patients as people brings out the best in our profession and will deliver to our patients the promise of medicine.

About 8 weeks after Clare died, now 10 years ago, her husband, Keith, e-mailed to ask if he could come see me. I agreed to his request immediately and looked forward to seeing him. For 24 years, I had had the privilege of caring for Clare and helping her and her family navigate the myriad health challenges caused by her Takayasu arteritis, including 5 cardiac valve replacement surgeries and 25-plus medical hospitalizations. In the more than 100 times that I had seen Clare in the office or in the hospital, I had almost never seen her without Keith.

Antineutrophil cytoplasmic autoantibody–associated vasculitides (AAV) are necrotizing small-vessel vasculitides characterized by a relapsing course. Rituximab is recommended for both remission induction and maintenance in AAV. 1 Kidney Disease: Improving Global Outcomes (KDIGO) Glomerular Diseases Work GroupKDIGO 2021 clinical practice guideline for the management of glomerular diseases. Kidney Int. 2021; 100: S1-S276 Abstract Full Text Full Text PDF PubMed Scopus (758) Google Scholar Hypogammaglobulinemia is being increasingly recognized with over 50% of patients developing moderate-to-severe hypogammaglobulinemia, and infection risk remains a key concern in these patients. 2 Tieu J. Smith R.M. Gopaluni S. et al. Rituximab associated hypogammaglobulinemia in autoimmune disease. Front Immunol. 2021; 12: 671503 Crossref Scopus (44) Google Scholar Infection is not only a serious complication in immunosuppressed patients but has also been theorized to play a role in triggering AAV such as through pathways of molecular mimicry or lymphocyte activation. 3 Flint J. Morgan M.D. Savage C.O. Pathogenesis of ANCA-associated vasculitis. Rheum Dis Clin North Am. 2010; 36: 463-477 Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar In patients with serum IgG less than 300 mg/dl, it is recommended to use alternatives for rituximab. S.c. Ig therapy (SCIG) has been used to treat antibody deficiency in AAV. 4 Kant S. Azar A. Gapud E.J. et al. Subcutaneous immunoglobulin for antibody deficiency in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Cureus. 2019; 11: e6367 Google Scholar I.v. Ig dosed at 2 g/kg given over 5 days has been shown to improve disease activity in active AAV, 5 Jayne D.R. Chapel H. Adu D. et al. Intravenous immunoglobulin for ANCA-associated systemic vasculitis with persistent disease activity. QJM. 2000; 93: 433-439 Crossref PubMed Scopus (424) Google Scholar but their role in modulating maintenance immunosuppression is unknown. We report a potential benefit of SCIG in modulating maintenance immunosuppression in a single-center series of 5 patients with AAV.

The definition of medicine as a public trust was summarized by Schroeder et al in 1989: “[M]edicine is entrusted by society to improve the health of the public through education, patient care and research. In return, medicine receives significant public funding, respect, and autonomy” [1]. Medicine’s role as a public trust has a past, present, and a speculative future. Key institutions in the 19th century functioned as a “Silicon Valley” of medicine, bringing forth important contributions and defining the role of medicine as a public trust.

A 68-year-old man with a history of bladder cancer presented with delirium, renal insufficiency, unintentional weight loss, and leukopenia. Examination was notable for a subtle facial droop on the left side, bibasilar crackles in the lungs, and hepatosplenomegaly. A diagnosis was made.

Three sisters of Northern European descent provided an opportunity to examine the longterm course and possible familial aspects of a rare disease, polyarteritis nodosa (PAN). Approval and consent was obtained from each patient. The sisters have been cared for in the Johns Hopkins Vasculitis Center for the past 3 decades. At age 7, the first sister developed rash, fever, lethargy, and a deviated right eye and was treated empirically for tuberculosis. At age 8, these symptoms recurred along with abdominal pain, hypertension, and stroke. Renal angiography demonstrated microaneurysms and a skin biopsy confirmed the diagnosis of PAN. She was initiated on prednisone and azathioprine (AZA). Within the following year, she developed 2 bowel perforations with pathology demonstrating PAN and was treated with cyclophosphamide (CYC). By age 17, methotrexate was added for abdominal pain in the context of worsening mesenteric angiography. At age 19, she developed mononeuritis multiplex, and acute abdominal pain led to discovery of a ruptured renal aneurysm and upper gastrointestinal (GI) bleed, necessitating gastrectomy. She was treated with prednisone, CYC, and total parenteral nutrition. From ages 19 to 25 years, she had 8 hospitalizations for abdominal angina and GI bleeding and 1 for stroke. Angiography during this period showed 95–99% stenosis of the celiac artery and diffuse changes of PAN in the superior and inferior mesenteric arteries as well as active skin lesions. … Address correspondence to Dr. J. Liebowitz, Johns Hopkins University, Division of Rheumatology, 5200 Eastern Ave., MFL Bldg., Center Tower, Suite 4100, Baltimore, Maryland 21224, USA. E-mail: jliebow3{at}jhmi.edu

I took care of Sammy 41 years ago when I was an intern. After knowing him for almost 4 weeks, I faced the dilemma of whether to tell him goodbye; Sammy, you see, was dying.

In the past decade, point-of-care ultrasound (POCUS) has shown tremendous potential to supplement bedside patient assessment.1Narula J. Chandrashekhar Y. Braunwald E. Time to add a fifth pillar to bedside physical examination: inspection, palpation, percussion, auscultation, and insonation.JAMA Cardiol. 2018; 3: 346-350Crossref PubMed Scopus (120) Google Scholar POCUS provides real-time data in a timely manner without incurring high monetary costs, engages patients in understanding the complexities of their condition, and empowers physicians to educate, strengthening the patient-physician relationship. However, multisystem diagnostic POCUS education is not generally included in nephrology fellowship curricula. We developed a nephrology-specific POCUS curriculum designed to address common clinical scenarios encountered by nephrologists and implemented it in the Johns Hopkins University Nephrology Fellowship.2Mullangi S. Sozio S.M. Segal P. Menez S. Martire C. Shafi T. Point-of-care ultrasound education to improve care of dialysis patients.Semin Dial. 2018; 31: 154-162Crossref PubMed Scopus (14) Google Scholar In this report, we describe our initial experience with the program. The curriculum consists of modules on ultrasound basics, heart, lung, inferior vena cava, kidney, bladder, and dialysis fistula (Item S1). A board-certified ultrasonographer (C.M.) with more than 10 years' experience teaching POCUS to internal medicine residents teaches the curriculum. Each module starts with a didactic session followed by an online image interpretation test. We teach hands-on ultrasound image acquisition skills by guided and then independent ultrasound acquisitions. We objectively assess each nephrology fellow's POCUS skills using a POCUS-Objective Structured Clinical Examination (POCUS-OSCE), developed by internal consensus and administered by C.M. at the end of each module. During the elective, 8 hours are spent on didactic lectures; 10 hours, on guided scanning; 30 hours, on independent scanning; and 8 hours, on image reviews. We assess nephrology fellows' subjective confidence with POCUS by pre- and posttests, administered at the start and end of fellowship, respectively. The test is scored on a 5-point Likert scale (extremely unconfident, somewhat unconfident, neutral, confident, and extremely confident) and converted to a score ranging from 0 to 100 (0 indicates extremely unconfident; 100, extremely confident). To summarize our findings, we compared pre- and posttest scores using paired t test and summarized POCUS-OSCE scores as proportions. During the past 2 academic years (2016-2018), 12 fellows participated in the course. At the start of their nephrology fellowship, 8 (67%) reported using POCUS for diagnostic purposes, but only 1 had formal training in its use. Table 1 summarizes the fellows' subjective and objective assessment of POCUS skills. Subjectively, the fellows reported significant skill improvement in each of the system-specific POCUS areas, except evaluation of pleural effusions. The objective assessment of fellows' skills using POCUS-OSCE were always Good or Outstanding; the highest scores for image acquisition were for lungs and bladder, and for image interpretation, for kidney, bladder, and fistula. Fellows' global assessment of skills at the end of the fellowship demonstrated a high level of confidence in assessing volume status using POCUS. Fellows also valued POCUS skills highly because 100% recommended POCUS training for other nephrologists and 92% recommended training for faculty. Freeform comments by the fellows also reflected this high level of enthusiasm. Overall results were unchanged after excluding data from the fellow with prior POCUS training.Table 1Johns Hopkins Nephrology Fellowship POCUS Curriculum Experience1. Assessment of Nephrology Fellows' Multisystem Diagnostic POCUS EducationOrgan SystemFellows' PerceptionsObjective Structured Clinical Evaluation (OSCE)bAll fellows received scored either Good or Outstanding on OSCE. There were no Unsatisfactory evaluations.SkillsaPre- and posttest questions "How comfortable do you feel with the following skills."ScoresPRatingUltrasound ImageSkills for Interaction With PatientsPretestPosttestAcquisitionQualityInterpretationHumanisticCounselingHeartLV function37.575.00.003Outstanding27%27%27%91%91%Pericardial effusion41.783.3<0.001Good72%72%72%9%9%Inferior vena cavaDiameter47.977.10.006Outstanding42%42%42%100%100%Good58%58%58%——LungsPulmonary edema29.260.40.009Outstanding100%100%30%100%100%Pleural effusion43.762.50.2Good——70%——KidneySize29.279.2<0.001Outstanding36%36%100%100%100%Echogenicity20.879.2<0.001Good64%64%———Hydronephrosis31.277.1<0.001BladderVolume29.279.2<0.001Outstanding100%100%100%100%100%Good—————FistulaDepth & diameter16.758.30.004Outstanding56%56%89%100%89%Good44%44%11%—11%2. Nephrology Fellows' Global Assessment of POCUS Skills•Confidence in principles and use of ultrasound:Confident/Extremely Confident: 92%•Confidence in using POCUS for assessing volume status:Confident/Extremely Confident: 100%•Confidence in using POCUS for managing hypotensive pt:Confident/Extremely Confident: 92%3. Nephrology Fellows' Judgment of the Value of POCUS•Formal ultrasound training will improve care provided to patients:Likely/Absolutely Likely: 100%•Formal ultrasound training will make a Nephrology Fellowship program more attractive:Likely/Absolutely Likely: 75%•Formal ultrasound training will increase the interest in nephrology:Likely/Absolutely Likely: 67%•POCUS education should be part of nephrology fellowship:Agree/Strongly Agree: 100%•I would recommend POCUS education for other nephrology colleagues who have not been trained:Agree/Strongly Agree: 100%•I would recommend nephrology faculty be trained in POCUS:Agree/Strongly Agree: 92%4. Nephrology Fellows' Selected Freeform Comments"Excellent tool to enhance patient care" | "I believe this is a great tool for bedside assessment and will give more objective information for the interpretation of volume status" | "It should be required. It is a simple technique which gives adequate objective information for patient care" | "Must be a part of nephrology fellowship training" | "Should be integrated into the curriculum; helpful to have bedside skills with ultrasound in aiding in diagnosis of hydro, volume status, etc"Note: Number of fellows with completed modules and OSCE: Heart, n = 11; IVC, n = 12; Lungs, n = 10; Kidney, n = 11; Bladder, n = 10; Fistula, n = 9.Abbreviations: LV, left ventricular.a Pre- and posttest questions "How comfortable do you feel with the following skills."b All fellows received scored either Good or Outstanding on OSCE. There were no Unsatisfactory evaluations. Open table in a new tab Note: Number of fellows with completed modules and OSCE: Heart, n = 11; IVC, n = 12; Lungs, n = 10; Kidney, n = 11; Bladder, n = 10; Fistula, n = 9. Abbreviations: LV, left ventricular. Multisystem diagnostic POCUS is currently an area of high interest in nephrology,3Niyyar V.D. O'Neill W.C. Point-of-care ultrasound in the practice of nephrology.Kidney Int. 2018; 93: 1052-1059Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar and this topic was recently discussed by the authors (T.S. and S.M.S.) in detail at the 2018 American Society of Nephrology Training Program Retreat. POCUS curricula have been implemented widely in emergency medicine training and are beginning to be integrated in medical school, critical care, and hospital medicine training. Although varying in content, all curricula draw upon similar teaching modalities, including lectures, quizzes, and image acquisition and review. Our experience highlights that a POCUS curriculum can be incorporated in nephrology fellowships and is highly valued by the fellows. Development of standardized curricula that can be implemented across institutions is likely to have widespread appeal. We recently described potential applications for POCUS in nephrology.2Mullangi S. Sozio S.M. Segal P. Menez S. Martire C. Shafi T. Point-of-care ultrasound education to improve care of dialysis patients.Semin Dial. 2018; 31: 154-162Crossref PubMed Scopus (14) Google Scholar Key among these are volume assessment in the setting of suspected volume overload, one of the most important skills for routine nephrology practice, applicable to almost every patient on dialysis therapy or being managed for acute kidney injury.4Kaptein M.J. Kaptein J.S. Oo Z. Kaptein E.M. Relationship of inferior vena cava collapsibility to ultrafiltration volume achieved in critically ill hemodialysis patients.Int J Nephrol Renovasc Dis. 2018; 11: 195-209Crossref PubMed Scopus (15) Google Scholar, 5Ross D.W. Abbasi M.M. Jhaveri K.D. et al.Lung ultrasonography in end-stage renal disease: moving from evidence to practice-a narrative review.Clin Kidney J. 2018; 11: 172-178Crossref PubMed Scopus (17) Google Scholar Enhancing volume assessment physical examination with POCUS can provide additional information that can be easily incorporated in patient care. Our experience demonstrates that these skills can be integrated in nephrology training and are highly valued by nephrology fellows. Some limitations of our curriculum include lack of an independent POCUS-OSCE examiner and lack of information for skills retention. Future studies need to address these areas by testing and retesting by an independent examiner. Use of web-based modules and remotely monitored OSCE are potential solutions.6Gargani L. Sicari R. Raciti M. et al.Efficacy of a remote web-based lung ultrasound training for nephrologists and cardiologists: a LUST trial sub-project.Nephrol Dial Transplant. 2016; 31: 1982-1988Crossref PubMed Scopus (46) Google Scholar In conclusion, we report that a multisystem diagnostic POCUS elective can be implemented in nephrology fellowships and can impart clinically relevant diagnostic skills that are valued highly by nephrology fellows. We call for the development of standardized curricula specific to nephrology and to define competencies in ultrasound knowledge, image acquisition, and interpretation. Research idea and study design: SS, TS, DBH, PS, CM, data acquisition: TS, CM, data analysis/interpretation: SM, SS, TS, SL, CM, statistical analysis: SS, TS, supervision or mentorship: TS. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. This work was supported by the Johns Hopkins Center for Innovative Medicine (CIM). Dr Shafi is a CIM Scholar and Dr Shafi and Ms Martire were supported by CIM. Dr Shafi was also supported by grants R03DK104012 from the National Institute of Diabetes and Digestive and Kidney Diseases, R01HL132372 from the National Heart, Lung, and Blood Institute, and R01NR017399 from National Institute of Nursing Research. Ms Mullangi was supported by the American Society of Nephrology, STARS, and TREKS awards. The authors declare that they have no relevant financial interests. We thank the Department of Medicine at Johns Hopkins Bayview Medical Center for institutional commitment to the project. Parts of this work were presented at the American Society of Nephrology 2017 Annual Meeting, New Orleans, LA, October 31-November 5, 2017. Received October 9, 2018. Evaluated by 3 external peer reviewers, with direct editorial input from an Associate Editor, who served as Acting Editor-in-Chief. Accepted in revised form January 11, 2019. The involvement of an Acting Editor-in-Chief was to comply with AJKD's procedures for potential conflicts of interest for editors, described in the Information for Authors & Journal Policies. Download .pdf (.13 MB) Help with pdf files Supplementary File (PDF)Item S1: Elective template, pre-/post-test, and OSCE. Integrating Point-of-Care Ultrasonography Into Nephrology Fellowship Training: A Model CurriculumAmerican Journal of Kidney DiseasesVol. 74Issue 1PreviewPoint-of-care ultrasonography (POCUS) is a relatively easy-to-learn skill that can be incorporated into day-to-day clinical practice and the trainee curriculum to enhance patient care. POCUS is primarily intended to address focused clinical questions at the bedside and serve as an adjunct to physical examination. More recently, POCUS is being increasingly adopted by health care professionals from various medical specialties. However, most general nephrology training programs have not yet fully embraced the rapidly evolving field of POCUS. Full-Text PDF

Perspectives Viewpoints•A key to sustaining impact in academic Departments of Medicine is to develop a diverse, mission-focused leadership structure that capitalizes on faculty strengths to execute the tripartite mission—clinical care, research, and education.•An effective leadership structure should engage the entire department workforce (faculty, nursing, and administration) in a unified mission and vision.•Developing faculty and supporting their highest scholarship achievements is key to success of the academic mission. •A key to sustaining impact in academic Departments of Medicine is to develop a diverse, mission-focused leadership structure that capitalizes on faculty strengths to execute the tripartite mission—clinical care, research, and education.•An effective leadership structure should engage the entire department workforce (faculty, nursing, and administration) in a unified mission and vision.•Developing faculty and supporting their highest scholarship achievements is key to success of the academic mission. Development of an effective, functional leadership structure is critical to the success of any large-scale organization. The department of medicine (DOM) includes over 1800 full- and part-time faculty, 900 nurses, 881 trainees, and more than 1000 employees in nonclinical roles. Like many academic departments, faculty carry out our missions on 2 campuses—Johns Hopkins Hospital (JHH) and Johns Hopkins Bayview Medical Center (JHBMC). These campuses provide complementary strengths, different patient demographics, and serve as program development laboratories for our entire health system. Our overall departmental budget is composed of 3 revenue streams: approximately one-half is from sponsored research, one-quarter from hospital joint agreements, and one-quarter from professional fees. In this unique organizationally and financially integrated model, called a “functional unit,”1Heyssel RM Gaintner JR Kues IW Jones AA Lipstein SH Decentralized management in a teaching hospital.N Engl J Med. 1984; 310: 1477-1480Crossref PubMed Scopus (70) Google Scholar physicians, nurses, and administrators are part of a single financial unit with a shared mission. We have developed a comprehensive vice chair faculty leadership structure that allows efficient execution of our tripartite mission, while at the same time engaging the entire workforce in a unified vision. The vice chair (VC) structure is organized around 4 areas: education, clinical care, research, and people. All VC positions were solicited through an open request for applications process. A detailed job description was disseminated to all department faculty, and applicants underwent comprehensive interviews with the department director and other stakeholders, including division directors, nursing leaders, school of medicine leaders, and health system leadership. The request for applications process enabled us to identify faculty with talent and leadership aspirations, select the strongest candidates with a passion for the academic mission, and create a culture of transparency. Because of the “functional unit” structure of the department, the director has a broader scope of reports and responsibilities than might be present in traditional academic departments. Given the breadth and complexity of these roles, the director created a new executive vice chair (EVC) position. The EVC meets weekly with the department director, advises the director on departmental direction, policy, and operations, and attends various meetings representing the director, serving as departmental leader in the director's absence. The EVC is also responsible for overseeing a monthly VC meeting. To ensure that each VC is meeting his or her goals, the EVC conducts annual reviews with each VC. The EVC aids the director in faculty recruitment and retention, including recruitment and orientation of new division directors and VCs. The EVC provides oversight to division directors and administrators in preparing annual division reviews in collaboration with the VC for faculty development and promotions. Finally, a critical role for the EVC that evolved was to help shape departmental culture and enhance engagement for all employees by 1) leading the development of a unifying mission and vision statement (Table1) and 2) initiating and overseeing the department's new civic engagement initiative.2Golden SH Cudjoe TKM Galiatsatos P et al.A perspective on the Baltimore Freddie Gray riots: turning tragedy into civic engagement and culture change in an academic department of medicine.Acad Med. 2018; 93: 1808-1813Google ScholarTable1Mission, Vision, and Core Values: Department of Medicine, Johns Hopkins University School of MedicineMissionVision and Core ValuesWe are people serving people, to promote health and alleviate suffering locally and globally by:• Delivering exceptional care• Developing and educating future leaders• Driving innovation and discoveryWe want to:• Inspire a culture of respect, integrity, service, equity, and excellence (our core values)• Engage all Department of Medicine employees in serving our patients• Lead the world in personalized patient care, medical education, and biomedical discovery and innovation Open table in a new tab The vision for the DOM Faculty Development and Promotions Office is to support the highest academic achievements for all faculty across biomedical research, medical education, clinical care, program building, innovation, commercialization, quality, safety, and improving systems of care. At Johns Hopkins School of Medicine, there is a single promotion pathway (ie, only tenure track without a clinician/educator nontenure track) with criteria for national recognition (promotion to Associate Professor) and national leadership or international recognition (promotion to Professor). The DOM Faculty Development Office works with the School of Medicine's Office of Faculty Development to develop guidance on preparation of promotion packages, especially for those outside the traditional physician-scientist pathway. The department supports efforts to maximize recognition by taking an active role in nominating faculty for appropriate awards and maintaining a master directory of awards offered by internal medicine-related professional organizations. Further, a process for recognizing and rewarding clinical excellence was established in the department. The Miller-Coulson Academy for Clinical Excellence3Christmas C Kravet SJ Durso SC Wright SM Clinical excellence in academia: Perspectives from masterful academic clinicians.Mayo Clin Proc. 2008; 83: 989-994Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar began at JHBMC and is now available to all faculty on a competitive basis, and more recently has extended to recognize outstanding advanced practice clinicians and trainees. The VC for Faculty Development and Promotions is supported by 2 associate VCs (AVCs)—the AVC for Women's Academic Careers and the AVC for Diversity and Inclusion (Table2). These AVCs work closely with the VC to ensure that women and faculty underrepresented in medicine (URIM) are successful. Activities include supporting the career development of women and URIM faculty through enhanced mentorship, access to career development opportunities specific to women and minorities, leadership training, and nominating qualified individuals for awards, speaking opportunities, and leadership positions. Regular meetings and exit interviews with women and URIM faculty are used to identify potential barriers that may differentially impact their careers. The office has developed an “equity benchmarking tool” to collect and maintain data on key metrics that reflect the expressed core value of equity and the commitment to departmental transparency.Table2Vice Chair Job Descriptions and ResponsibilitiesExecutive Vice Chair• Directly advise the Director on departmental direction, policy, and operations, attend various meetings representing the Director and serve as the surrogate department leader in the absence of the Director.• Meet weekly with the Department of Medicine executive leadership team.• Work with the Director, Vice Chair for Clinical Operations, and JHM to lay the foundation for interdisciplinary clinical service line agreements for complex disease management and wellness.• Aid the Director in faculty recruitment and retention, including recruitment of new Division Directors, Vice Chairs, and other departmental leaders.• Work with the Director to assess, develop plans, and operationalize effective partnerships between various JHM constituencies.• Serve as Acting Director (meeting attendance, signature authority) in the Director's absence.• Provide leadership and oversight to Division Directors and administrators in preparing annual division reviews, and actively participate in those reviews.• Oversee mission, vision, and departmental culture.Clinical Affairs Vice Chair for Clinical Affairs• Oversee and coordinate efforts to ensure that both inpatient and outpatient care is delivered in an effective, safe, high-quality, and patient-centered manner.• Guide implementation and maintenance of a comprehensive model for continuous quality improvement across all aspects of DOM clinical operations, including process and patient outcomes, patient and provider engagement and satisfaction, and financial performance.• Lead and support strategic planning efforts around the development of interdisciplinary programs that address complex illnesses, enhance efficiency, and improve access to clinical care.• Supervise Associate Vice Chair of Inpatient Operations in Epic implementation and dissemination, length of stay management, readmissions management, and monitoring and improving inpatient throughput.• Supervise Associate Vice Chair of Ambulatory Operations in monitoring primary and specialty clinic performance, access to clinical services, patient satisfaction scores, ambulatory care protocols, and After-Care Clinics and readmission prevention efforts. Associate Vice Chair for Inpatient OperationsCommon responsibilities at JHH and JHBMC• Oversee bed management throughout the DOM (including after-hours calls).• Serve as Hopkins Access Line liaison.• Monitor quality for handoffs and transitions within DOM and between departments.• Oversee quality control for consult services provided by the DOM.• Oversee departmental length of stay management and re-admission reduction efforts including proactive, strategic planning for utilization of alternate care sites.• Lead projects designed to enhance physician professional experience, joy of practice, and top of license work relating to inpatient care.• Monitor and lead improvement in inpatient throughput—emergency department time of decision to admit to discharge; discharge and transfer barriers.• Co-lead efforts in inpatient clinical documentation excellence in collaboration with the Vice Chair for Quality, Safety, and Service• Develop new models of care delivery in collaboration with VC for Clinical Affairs and other partnersResponsibilities specific to JHH:• Oversee inpatient EMR implementation.• Support HCAHPS monitoring and improvement.• Refine and implements collaborative models for inpatient redistribution between academic campuses.Responsibilities specific to JHBMC:• Co-lead DOM efforts on Maryland Hospital Avoidable Condition Reduction. Associate Vice Chair for Ambulatory Operations• Monitor primary and specialty clinic performance such as template and space utilization and access metrics such as time to appointment bump rates using Ambulatory Dashboards and other tools.• Serve as a champion for patient satisfaction and actively monitor CGCAHPS scores and identify best practices and opportunities for improvement.• Monitor documentation standards and open encounters.• Develop new and integrate Ambulatory Care Protocols into DOM clinical practice in collaboration with stakeholders.• Champion JHM Transitions of Care efforts with a specific focus on provider communication;• Serve as the department liaison to After-Care Clinics and other readmission prevention efforts;• Participate in department meetings and committees such as the Clinical Affairs leadership team, safety and quality improvement committees; and,• Represent the DOM at relevant JHM committees such as the Clinical Practice Association (CPA) practice management committee and John Hopkins Outpatient Care Ambulatory Triad. Vice Chair for Patient Safety, Quality, and ServiceSafety/Risk:• Review unexpected deaths and major adverse events with the goal of participating in root cause analysis (RCA) and identifying opportunities for improvement.• Develop and lead risk-reduction teams involving additional DOM leaders, as appropriate, to address problems related to processes and systems.• Review and investigate event reports and participate in and contribute to interdisciplinary case evaluations.• Investigate and report relevant cases to hospital committees (eg, Clinical Quality Improvement, Risk Management Committee)• Work to improve safety culture in the DOM units and ambulatory clinics.Patient Family-Centered Care:• Monitor HCAHPS scores and achieve results consistent with the JHM strategic plan and monitor CGCAHPS scores as needed/as appropriate.• Implement best practice bundle with focus on nurse leader rounding.• Evaluate physician-related complaints and refer for peer review as appropriate.Quality/performance Improvement (in collaboration with Physician Advisor):• Monitor external measures to ensure performance is on track with National Leader strategy (core measures, MHACs, hospital-acquired infections, hand hygiene, Physician Quality Reporting System, Meaningful Use, value-based purchasing/HEDIS, etc.). Actively utilize Department dashboard to measure quality and safety priority metrics and active performance improvement teams to address any measure seriously below performance target.• Coordinate review of deaths and major adverse events with DOM Morbidity & Mortality conference.• Develop Departmental/Functional Unit QI priorities and plan in collaboration with the Vice Chair for Clinical Affairs.Value:• Standardize care where appropriate, create algorithms, and implement decision support tools and reduce variation where appropriate.• Utilize clinical analytics to identify areas of opportunity to eliminate harm, improve quality outcomes, and reduce waste.• Utilize value/financial analytics to identify areas to reduce cost: utilization in labs, drugs, imaging, blood, and supplies.• Work to reduce hospital length of stay and reduce readmission.HealthCare IT Safety (in collaboration with Vice Chair for Data Integrity and Analytics):• Identify risks of potential harm related to Health IT systems and develop/implement risk mitigation strategies to prevent potential harm.Trainee and faculty education (in collaboration with Program Directors):• Resident training in the basics of safety, service, and value and communication of safety goals.• Ensure safety leaders within the departments/divisions/units have the appropriate skills and resources to lead quality efforts in their area.• Collaborate with the Residency Director, Vice Chair for Education, and Armstrong Institute Director to promote educational and scholarly opportunities in safety, quality, and service for trainees and faculty.Education Vice Chair for EducationTraining Programs:• Support training program directors in oversight of residency and fellowship education and assist in recruitment efforts.• Meet and exceed accreditation standards for all DOM training programs.Faculty• Support recognition of educator faculty through awards nominations, publicity, and connection to open leadership positions.• Collaborate with VC for Faculty Development with promotions processes and review educational scholarship of educator faculty.Students• Review Departmental letters of recommendation for JHUSOM Internal Medicine (IM) applicants.• Advise JHUSOM IM applicants.Other• Lead educational strategic planning process every 5years minimum and review educational program performance annually.• Oversee educational budget and build innovative funding strategies to support educational programs.• Chair DOM Medical Grand Rounds Committee.• Attend local and national education meetings (eg, Graduate Medical Education Committee, Association of Program Directors in Internal Medicine, AAMC)• Oversee Associate Vice Chair for Education Associate Vice Chair for EducationResponsible for DOM undergraduate medical education• Promote culture to inspire JHUSOM students to pursue IM careers.• Oversee and review basic and sub-internship clerkships and rotation directors at all sites.• Meet and exceed all accreditation standard for student programs.• Review and catalog all DOM teaching in preclinical curriculum.• Coordinate non-JHUSOM medical student observerships.• Oversee IM interest group in JHUSOM.• For IM residency applicants, author all Departmental letters of recommendation and advise all JHUSOM IM and combined program applicants.Other• Co-lead educational strategic planning process every 5years minimum and review educational program performance annually.• Support educational effort for DOM faculty.• Serve as the Co-Chair of DOM Medical Grand Rounds Committee and manage CME accreditation for Medical Grand Rounds.• Attend local and national meetings. Deputy Director of Education at JHBMCShare in some of the vice chair for Education and AVC for Education responsibilities listed above on the Bayview campus for its training programs.Research Vice Chair for Research (duties in partnership)• Build comprehensive strategic efforts to better support our mission of discovery.• Recruit investigators to serve as members of the Department's research committee and oversee the annual Research Retreat Steering Committee.• Develop guidelines for a fiscally sound, transparent, department-wide bridge-funding policy.• Oversee, analyze, and develop recommendations for departmental infrastructure required for pre- and postgrant accounting and administration.• Serve as DOM representative to the School of Medicine Research Council.• Serve on the DOM Emergency Preparedness Committee for Research and maintain the research business continuity plan.• Supervise, in partnership with the Administrator, DOM-sponsored research staff Vice Chair for Basic and Translational Research• Serve as the primary departmental liaison to basic science departments in the Johns Hopkins University School of Medicine.• In collaboration with the VC for Data Integrity and Analytics, maintain data retention policies and provide education and resources to ensure DOM laboratory compliance.• Guide the recruitment and professional development of basic science-oriented faculty.• Provide oversight to DOM Facility Operations to ensure effective use of all research space assigned to the Department, including policy development to guide space assignment.• Facilitate equipment transfers of incoming and departing faculty. Vice Chair for Clinical and Translational Research• Guide the recruitment and professional development of our physician-scientist and clinical and health services research-oriented faculty.• In collaboration with the Vice Chair for Data Integrity and Analytics, maintain data retention policies and provide education and resources to ensure IRB compliance with human subjects research.• Serve as the DOM research lead for LCME accreditation. Vice Chair for Innovation and Commercialization(focus on biomedical technologies aligning JHU with Applied Physics Laboratory and external organizations) Vice Chair for Innovation in Healthcare Implementation(focus on development of business and operational frameworks for faculty to implement and disseminate innovations in healthcare delivery through technology or business solutions)• Partner with other relevant departments across the University to connect with industry in order to understand the needs and wants of our commercial partners and help to develop relationships with industry partners for the projects identified to have the most potential for commercial interest.• Develop and communicate to faculty and staff a succinct description of the process of protection, patent, and commercialization and serve as a resource and advocate for those engaged in these processes.• Increase faculty awareness of opportunities for commercialization through multiple public (eg, Grand Rounds, Division Director Meeting, divisional faculty meeting, special seminar, new faculty orientation) and private (division director, individual faculty) presentations.• Identify patentable ideas and processes.• Ensure an up-to-date database of department faculty patent and commercialization efforts, regularly comparing our efforts with national benchmarks for academic departments of medicine.• Maintain a joint appointment in the Johns Hopkins Carey School of Business to serve as mentor to faculty and students with an interest in the business of biomedical innovation and to participate in relevant lecture series.• Be an active liaison with Johns Hopkins Technology Ventures (JHTV) to help connect DOM faculty with promising research to the appropriate resources provided by JHTV.• Interact with the department's development officers to capitalize on any potential philanthropic partnerships with industry.• Develop an infrastructure for innovation that results in increased licensing revenue, disclosures, patents, and startups in the DOM with an impact on the patient and translational health care. Vice Chair for Data Integrity and Analytics• Serve as DOM representative in facilitating big data issues across the tripartite mission at all campuses.• Collaborate with end users and central resources to innovate and optimize data management and analysis, particularly with large data sets.• Develop and communicate DOM customized solutions for big data issues across the missions.• Serve as the primary departmental liaison to enterprise-wide IT committees, including those focused on enterprise data governance activities to ensure the comparability and consistency of clinical data managed by electronic systems throughout the enterprise.• Facilitate data integrity and accuracy for research and quality improvement purposes from the EMR, including integration of clinical decision support into the EMR that enhances physician workflow and adherence to meaningful use requirements (in collaboration with VC for Patient Safety, Quality, and Service).• Develop a strategic plan to standardize software and IT systems across our campuses.• In collaboration with the Vice Chairs for Research, create and maintain (1) data retention policies and provide education and resources to ensure DOM laboratory compliance and (2) policies guiding best practices for database hygiene and curation.• Lead efforts to ensure electronic security and privacy and develop remediation plans, when necessary.• Work with the Director and Communications Director to develop efficient and effective department electronic communication strategies utilizing various electronic modalities.• Supervise, in partnership with the Academic Administrator, DOM MNet, IT, and Analytics staff.People Vice Chair for Faculty Development and Promotion• In partnership with the Chair of the Departmental Promotions Committee, determine faculty readiness for promotion and review.• Assemble a mentoring committee to review faculty at rank for extended time (>6 years).• Update and oversee the division review process in collaboration with the Director and Executive Vice Chair.• Review faculty annual review materials.• Maintain a calendar of standing award deadlines to facilitate timely nomination of faculty for research, clinical, and education awards; assist nominated faculty with the application process, and connect faculty to former DOM or institutional award recipients.• Recommend and support DOM faculty applying for departmental and institutional awards and local and national leadership development programs in the domains of clinical care, research and education.• Serve as a resource for institutional faculty mentoring programs and as an advisor to faculty in need of objective career mentoring advice outside of his or her division.• Support and collaborate with mentoring programs established by the Diversity Council and the Task Force on Women's Careers in Academic Medicine.• Oversee, with the administrative support of the DOM credentialing manager, the Reappointment Review Committee. Associate Vice Chair for Women's Careers in Academic Medicine• Chair the DOM Task Force on Women's Careers in Academic Medicine (TF) and advisory board, which may include: leading recruitment efforts to ensure a diverse and robust membership; leading monthly meetings; preparing an annual budget; developing a schedule of annual events; planning the TF Annual Dinner; guiding TF members to develop activities and projects that address the mission and priorities of the membership and department.• Meet regularly with the Vice President for Diversity and Inclusion for Johns Hopkins Medicine.• Serve on the DOM compensation model steering committee.• Participate in recruitment visits for incoming faculty and leaders.• Participate in the divisional annual review process. Associate Vice Chair for Diversity and Inclusion• Chair the DOM Diversity Council (DC) and advisory board to the DC, which may include: leading recruitment efforts to ensure a diverse and robust membership; leading monthly meetings; preparing an annual budget; developing a schedule of events; overseeing the planning of the annual visiting professorship program; and guiding DC members in projects and activities that address the mission and priorities of the council and department.• Partner with the residency directors at the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center to conduct targeted recruitment activities for groups under-represented in medicine (URIM).• Oversee the DOM URIM visiting clerkship program.• Meet regularly with the Vice President for Diversity and Inclusion for Johns Hopkins Medicine;• Serve on the DOM compensation model steering committee.• Participate in faculty recruitment visits for incoming faculty and leaders.• Participate in the divisional annual review process.AAMC = Association of American Medical Colleges; AVC = Associate Vice Chair; CGCAHPS = Clinician and Group Consumer Assessment of Healthcare Providers and Systems; CME = continuing medical education; CPA = Clinical Practice Association; DOM = Department of Medicine; EMR = electronic medical record; HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems; HEDIS = Healthcare Effectiveness Data and Information Set; IRB = institutional review board; IT = information technology; JHBMC = Johns Hopkins Bayview Medical Center; JHH = Johns Hopkins Hospital; JHM = Johns Hopkins Medicine; JHUSOM = Johns Hopkins University School of Medicine; LCME = Liaison Committee for Medical Education; MHAC = Maryland Hospital Acquired Condition; QI = Quality Improvement. Open table in a new tab AAMC = Association of American Medical Colleges; AVC = Associate Vice Chair; CGCAHPS = Clinician and Group Consumer Assessment of Healthcare Providers and Systems; CME = continuing medical education; CPA = Clinical Practice Association; DOM = Department of Medicine; EMR = electronic medical record; HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems; HEDIS = Healthcare Effectiveness Data and Information Set; IRB = institutional review board; IT = information technology; JHBMC = Johns Hopkins Bayview Medical Center; JHH = Johns Hopkins Hospital; JHM = Johns Hopkins Medicine; JHUSOM = Johns Hopkins University School of Medicine; LCME = Liaison Committee for Medical Education; MHAC = Maryland Hospital Acquired Condition; QI = Quality Improvement. The vision of the Clinical Affairs Office is to deliver the highest-quality patient- and family-centered care and foster an environment that educates trainees in core principles of safe, patient-centered care; to develop innovations in clinical care delivery utilizing financial models that generate a margin for mission-based programs and address areas of immediate departmental clinical safety and financial risk; and to lead clinical integration efforts within the department and across the health system by interfacing with partners to share best practices and to use rigorous analytic methodology to assess their impact on clinical and economic outcomes. The department clinical leadership team consists of 2 VCs–one for overall clinical affairs and one for quality, safety, and service—and 3 AVCs—2 focused on inpatient operations at each of the academic sites and one focused on ambulatory operations (Table2). Each of the VCs collaborates closely with nursing and administrative leadership in a triad or dyad to lead the daily clinical mission activities of the department. The VC for Clinical Affairs is directly responsible for clinical issues that cross inpatient and outpatient settings, including professionalism, professional satisfaction, and credentialing, and interfaces with divisional clinical directors. The VC for Clinical Affairs also represents the department on various hospital and school committees with significant clinical influence. The inpatient operations group focuses on hospital throughput, interhospital transfer processes, length of stay, readmissions, and inpatient care policies and procedures. The ambulatory operations group oversees clinical practices on both academic campuses as well as more than 30 satellite locations. This team focuses on practice improvement, compliance with access goals and metrics, and integration and standardization of best practices across the department's multiple practice sites. The ambulatory group also represents the department to the Clinical Practice Association for key strategic initiatives. The triad team that focuses on quality, safety, and service (“quality”) efforts within the department is composed of the VC for Quality, Safety, and Service; representatives from nursing and administrative operations; and a senior faculty member department physician advisor. The quality team organizes its work around 4 domains4Mathews SC Pronovost PJ Daugherty Biddison EL et al.A Department of Medicine infrastructure for patient safety and clinical quality improvement.Am J Med Qual. 2018; 33: 989-994Google Scholar—patient safety, defined as internally recognized risk, detected by monitoring events reported through an electronic safety event reporting system; externally reported quality metrics such as risk-adjusted inpatient mortality, hospital-acquired condition rates, and core measure performance; patient experience, measured by the Hospital Consumer Assessment of Healthcare Providers and Systems survey; and value, identified as activities that focus on reducing the cost of care while maintaining quality. The key roles of the VC of Research are to connect individuals with specialized expertise, strengthen shared resources, improve faculty research funding success, and remove barriers to conducting research. The department has divided this responsibility between 2 individuals with complementary expertise in basic and clinical research, with translation as a common emphasis (Table2). They work synergistically on problems common to all types of research (eg, grants administration, infrastructure, core research services, communication, and collaboration), while also addressing issues unique to basic or clinical research. The primary objectives focus on supporting faculty to excel in scientific discovery by enhancing faculty competitiveness; fostering communication and collaboration; bolstering the research infrastructure; fostering the pipeline of physician-scientists; and expanding opportunities to develop and commercialize discoveries (in collaboration with the VCs for Innovation and Commercialization). To accommodate variation in the size and research portfolios of the divisions, a mixed model of grants administration has evolved, with some large divisions operating semi-autonomously while smaller divisions rely on central departmental personnel for pre- and post-award services. Coordination of all grants administrators at the departmental and divisional levels occur through an enhanced research administration and support team. New hires now participate in a common onboarding/training process to become familiar with the grants administration systems and procedures. A “float” research analyst is maintained to rapidly provide competent, trained staff to fill vacancies. Finally, standardized reporting formats are being used for post-award management with real-time information on budget balances, burn rates, and personnel. An intranet-based peer review portal was implemented to facilitate secure document sharing for researchers to engage grant pre-reviewers to read specific aims or complete grant proposals prior to submission. The committees are typically composed of seasoned faculty with experience on National Institutes of Health study sections. The research VCs, with support from the director, engaged and provide funding to the biostatistics epidemiology and data management core to offer up to 20hours of free research consultative services to all department faculty. This core provides customer-oriented, one-stop research support services that can help faculty navigate other existing institutional resources as well as provide hands-on assistance with research studies, grants, or manuscripts. The annual DOM Research Retreat is an excellent venue to update faculty and trainees on department research, stimulate interdisciplinary communication among clinical and basic scientists, recognize outstanding achievements, and introduce VC initiatives to the faculty. The department has led the way at the institution in bringing the process of innovation to market into the academic mainstream by creating a first-of-its-kind program called Innovation and Commercialization in Medicine (InCMed), led by 2 VCs in collaboration with Johns Hopkins Carey School of Business. The vision of InCMed is to make the department a nation-leading engine for innovation in health care that can translate discoveries in biomedical science and clinical care delivery into marketable products that add value to the lives of patients. Major goals include helping plan department-wide projects that can lead to clear commercialization pathways; providing networking across the medical campus and with other Johns Hopkins Medicine organizations, such as the Applied Physics Laboratory; providing support for faculty-led projects through teams of entrepreneurial students and postdoctoral trainees to encourage future generations to embrace innovation for health care improvement; and providing guidance for entrepreneurial faculty, including plans to formalize an additional track for academic advancement. The VC for Innovation and Commercialization (Table2) is responsible for the overall conduct and success of InCMed and works closely with the VC for Innovation in Healthcare Implementation. In addition, the VC focuses on developing educational programs and the infrastructure required to support biotech and medtech solutions for patient care. The VC for Innovation in Healthcare Implementation focuses on department innovations that improve the implementation and delivery of medicine, including commercializable process improvements, educational products and programs, and other faculty-driven initiatives that aim to improve health care delivery. Some of these critical improvements involve nonpatented intellectual property or new business models for which commercialization pathways can be complex. The vision for the VC for Data Integrity and Analytics is to innovate, harmonize, and maintain best practices spanning the life cycle of data from acquisition, storage, and analysis to reporting and retention in a manner that fosters excellence in patient care, research, and education. This VC develops tools to protect the privacy of patients and the integrity of science, fosters innovative uses of information technology (IT) infrastructure by all faculty and staff, and infuses data integrity into training at all levels. The VC for Data Integrity and Analytics engages in IT-related governance by disseminating policy messages, facilitating faculty access to analytics resources while also guiding their responsible use, and serving as a member of multiple policy-setting committees at the departmental and enterprise levels. This mission area is overseen by a VC for Education, an AVC for Education, a Deputy Director of Education at the JHBMC, and many other education program leads (Table2). The VC has oversight over all educational programs in the department. The AVC oversees all student and continuing medical education-related activities in the department. The department houses 2 residency programs: Osler Medical Housestaff Training Program at Johns Hopkins Hospital and Johns Hopkins Bayview Internal Medicine Residency Program. While these programs have different structures and separate leadership, their relationship is highly collaborative. There are several education priorities. First, we ensure that learners (eg, medical students, housestaff, and faculty) in the department have outstanding clinical skills, which includes optimizing ambulatory and inpatient clinical learning experiences with an emphasis on bedside rounding to best promote patient-centered care. Second, we created educational pathways to access the diverse spectrum of careers in health care, ensuring that residents with interest in specific career paths receive accelerated training by experts and thought leaders. Our first 3 implemented pathways in the Osler Program include:•The Global Health Pathway includes a portfolio of structured opportunities for motivated residents to conduct clinical and research-based global health rotations in low- and middle-income countries.•The Patient Safety and Quality Pathway provides residents with unique, guided opportunities to improve patient safety, quality of medical care, and high value care.•The Scientific Discovery Pathway is composed of a funded physician-scientist pathway (Molina Scholars) in which selected postgraduate year one housestaff receive a commitment from the department for fellowship training, research development, discretionary research funds, and mentored career development. Our third educational priority is to support faculty to participate in the teaching mission. Effective faculty teaching rewards include compensation model incentive, promotional credit, and enhanced faculty development. Our fourth goal is to develop leaders in ambulatory medicine by enhancing the curriculum, precepting models, IT systems, and engagement of ambulatory subspecialists. Finally, we train residents and students to know the patient as a person, facilitated by the Aliki curriculum.5Hanyok LA Record JD Christmas C Hellmann DB Rand CS Ziegelstein RC Update on the Aliki Initiative at year 10: changing the culture of medicine to know our patients as individuals.The Pharos. 2018; : 29-34Google Scholar Departments of Medicine are often the largest departments in schools of medicine, resulting in impactful contributions to the tripartite mission. A key to sustaining our impact is to develop a diverse, mission-focused leadership structure that capitalizes on the strengths of faculty and enables us to accomplish all aspects of the academic mission simultaneously. Over the 4years that this structure has been in place, we have seen tremendous growth in transparency, accountability, and progress. It is our hope that lessons learned from our journey will serve other academic departments of medicine as they seek to optimize efforts across the tripartite mission.

: Personalized tools relevant to an individual patient's unique characteristics may be an important component of personalized health care. We randomized 97 patients hospitalized with acute decompensated heart failure to receive a printout of an ultrasound image of their inferior vena cava (IVC) with an explanation of how the image is related to their fluid status (n = 50) or to receive no image and only generic heart failure information (n = 47). Adherence to medications, low-sodium diet, and daily weight measurement at baseline and 30 days after discharge were assessed using the Medical Outcomes Study Specific Adherence Scale, modified to a three-item version for heart failure (HF), (MOSSAS-3HF, maximum score = 15, indicating adherence all of the time). The baseline MOSSAS-3HF scores (mean ± standard deviation (SD)) were similar for intervention and control groups (7.4 ± 3.4 vs. 6.4 ± 3.7, p = 0.91). The MOSSAS-3HF scores improved for both groups but were not different at 30 days (11.8 ± 2.8 vs. 11.7 ± 3.0, p = 0.90). Survival without readmission or emergency department (ED) visit at 30 days was similar (82.6% vs. 84.1%, p = 0.85). A personalized HF tool did not affect rates of self-reported HF treatment adherence or survival without readmission or ED visit.

PROBLEMThe Johns Hopkins University School of Medicine Department of Medicine (DOM) sought ways of enhancing community engagement after the death of Freddie Gray and consequent unrest in Baltimore City.APPROACHThe DOM launched a five-part noon lecture series in May 2015-"Journeys in Medicine"-to facilitate discussion among DOM faculty, staff, trainees, and community residents regarding the city's unrest. This evolved into a department-wide civic engagement initiative in July 2016 to enhance employee and community engagement. The civic engagement committee is composed of two collaborative steering committees: Staff Engagement and Community Engagement.OUTCOMESThe DOM has sponsored and/or participated in programs to address major concerns raised during the Journeys in Medicine series-improving the strained relationship between police and the community, mentoring young people, involving more DOM employees in community activities, sharing research results with the community, and addressing cultural differences to enhance relationships and communication. To enhance staff engagement, a Nursing Diversity Council, complementing the Faculty Diversity Council, has been established. DOM faculty and staff have participated in and championed several disease-focused physical activity endeavors (e.g., walks) that, collectively, have raised over $40,000. Community service projects include supporting registration and screenings at a local health fair, a professional clothing drive, and DOM Days of Service.NEXT STEPSThe Johns Hopkins University School of Medicine DOM is developing an administrator leadership program and continuing to participate in meaningful activities, leading to tangible outcomes designed to strengthen connections to the surrounding neighborhood and enhance engagement among all DOM employees.

SEE RELATED ARTICLE, p. 657On an almost-daily basis, we are witnessing marvelous advances in biomedical science. Thanks to discoveries in genomics, proteomics, metabolomics, and in other fields, patients are increasingly receiving treatments designed to work precisely and personally for them. Yet it is also true that all the “omics” in the world cannot deliver the promise of medicine unless physicians also know their patients as people. A person's goals, hopes, fears, barriers to care, psychological state, and financial and family resources always must be considered in designing effective treatments. In short, for patients to receive the best care, detailed knowledge of the patient as a person, or “personomics,” must be viewed as a part of precision medicine. SEE RELATED ARTICLE, p. 657 The American Journal of Medicine is therefore pleased to announce it is launching a new series entitled Personomics (a neologism recently coined by one of us [RCZ]1Ziegelstein R.C. Personomics.JAMA Intern Med. 2015; 175: 888-889Crossref PubMed Scopus (59) Google Scholar) that would allow contributors to describe, in 1500 words, examples of how knowing the patient as a person helped solve a diagnostic enigma, designed a treatment plan for a given individual, fortified the patient's dignity, illustrated the hazards of making assumptions about people, or added awe and wonder to the daily work of a doctor. The National Institute for Health and Clinical Excellence (NICE) guidelines for getting to know patients as people2National Clinical Guideline Centre (UK)Patient Experience in Adult NHS Services: Improving the Experience of Care for People Using Adult NHS Services: Patient Experience in Generic Terms. Royal College of Physicians, London2012Google Scholar include the following domains:•The patient as an individual•The patient's life circumstances•The patient's concerns•The patient's needs and perspective•Don't make assumptions Many busy doctors reading this Journal have had experiences that illustrate the importance of each of these. We certainly remember the 60-year-old “office worker” the residents presented on Chiefs Rounds at Johns Hopkins in September 2005 who had been having “unexplained” exacerbations of asthma the same time each year. The mystery was solved when it was discovered that the patient lived in New York City and not Baltimore, and that she had been in her “office” in the Twin Towers of the World Trade Center on September 11, 2001 when the planes hit! We also recall the middle-aged truck driver who presented to our Baltimore Emergency Department with a multisystem disease that evaded diagnosis until he was asked, “What do you think is wrong?” Jaws dropped when he said “coccidioidomycosis,” an infection that pops up often in Tucson but rarely in a mid-Atlantic city. Turns out he was right! He had driven through Southern California shortly after one of the earthquakes, and had learned about “valley fever” from reading about other cases reported in his truckers' newspaper. And we will never forget the patient with liver failure and frequent admissions for longstanding and assumed refractory noncompliance who was prodded to change once a physician learned that what really mattered to the patient was not his own health but the care of his cocker spaniel, Lady. The patient became compliant once he realized that taking his medications would mean fewer kennel stays for Lady! Osler articulated an enduring truth when he observed that “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”3Brainy Quotes. William Osler quotes. Available at: https://www.brainyquote.com/quotes/quotes/w/williamosl391388.html. Accessed January 13, 2017.Google Scholar We hope that the Journal's new series on Personomics will illustrate that precision medicine and personal medicine are required to deliver the full promise of medicine. Black Pump IndependenceThe American Journal of MedicineVol. 130Issue 6Preview“And just why do you need this blood test?” the elderly woman demanded in her fierce quiet voice. She glared up at me past elegant, hand-drawn eyebrows. Full-Text PDF