Lisa Brown was on mission to find fresh basil. The only problem was that she didn’t really know what it looked, smelled, or tasted like. And Harrisburg’s Broad Street Market had so many leafy green vegetables that she didn’t know where to start.
As a participant in Penn State Hershey’s Prevention Produce program serving women in transitional housing, she was excited to try a new recipe, even though it called for an herb she wasn’t familiar with.
“I never bought that before,” she said.
When she finally found a bunch, Brown wrinkled up her nose, but conceded the basil might taste better than it smelled – especially in a recipe.
Prevention Produce is part of a larger Food as Medicine program led by medical students and was launched by students at Penn State College of Medicine last year. Food as Medicine – or FAM as it is known – also oversees a plot in the community garden on the Penn State Hershey campus that is used for donations to charitable initiatives, and is developing efforts to change the hospital inpatient food menu, among other projects.
While national attention is being drawn to the issue of inaccurate or delayed medical diagnoses, Penn State Hershey has been actively addressing issues that can lead to diagnostic errors with programs from medical education through to the clinic.
The Institute of Medicine of the National Academies of Sciences, Engineering and Medicine brought attention to the issue last week when it presented eight recommendations in its report, “Improving Diagnosis in Health Care.
The recommendations are a follow-up to the Institute of Medicine’s 2000 landmark report “To Err is Human: Building a Safer Health System,” and 2001’s “The Quality Chasm: A New Health System for the 21st Century,” both of which influenced patient safety measures at healthcare systems nationwide.
Dr. Timothy Mosher, chair, Penn State Hershey Department of Radiology, said that collecting accurate data to measure the scope of diagnostic errors is difficult. The issue is often underestimated. According to the institute’s report, most people will be victims of diagnostic error to one degree or another at some point in their lives.
“That fact itself should be enough of an attention-getter,” Mosher said. “We have to develop better systems.”
To help reduce errors, Penn State Hershey introduced the FailSafe program to its emergency department in 2012. FailSafe communicates all findings during a visit to not only the patient’s family doctor, but to the patient as well.
“There are things that show up on scans when someone is in the ER for other reasons,” said Dr. Michael Bruno, professor of radiology and medicine and vice chair for quality and patient safety. “We would ask the patient to follow up with their family doctor, but invariably, many wouldn’t do that. We wanted to do something to help those patients and communicate with them better.”
Findings are sent to the patient’s family doctor. If the patient does not have a family doctor a referral is made to a doctor in the Department of Family and Community Medicine. Patients are also sent a letter that details what should be followed up on, as well as an explanation of how a family doctor can get the report and images from the emergency department visit.
Bruno said the program has worked so well that the organization is considering expanding it to include all outpatient departments in the near future.
Follow-up calls referring to the letter are one thing he would like to add to the program to increase patient engagement.
The Institute of Medicine’s report recommends putting patients at the center of the healthcare team, involving them more in the diagnostic process, and developing a system and culture that improves the diagnostic process by identifying, learning from and reducing diagnostic errors and near misses.
At Penn State Hershey, an interdisciplinary muskoskeletal/osteosarcoma diagnosis team sits down to review and confirm or rethink new patient diagnoses. It has done so three times each month since 2007.
Dr. Ed Fox, orthopaedic oncologist, Dr. Donald Flemming, professor of radiology and orthopaedics, and Dr. Elizabeth Frauenhoffer, professor of pathology and orthopaedics, pool their respective areas of expertise with a common knowledge of orthopaedic oncology to make sure diagnoses do not occur in a vacuum.
Frauenhoffer said the practice is pretty standard in most academic pathology departments, although some review the cases afterwards for educational purposes rather than for diagnostic certainty and treatment planning.
“Medicine is not a black-and-white science,” Fox said. “It is an interpretation of things, and you don’t always get the whole picture from one report.”
Frauenhoffer said having a comfort level with each other makes it easier for the three of them to express doubt about a diagnosis or question another’s interpretation.
“We don’t have to keep up a façade that we know everything,” she said.
Flemming agreed that the dynamic of the group is important.
“The strength is that we are able to communicate openly,” he said. “We can embrace each other’s errors and be humble and not ridiculously critical, because we have all made mistakes.”
Sitting down in person and questioning possible errors in the process once helped the team keep a patient from receiving unnecessary chemotherapy.
“If we had been working in a silo, that wouldn’t have happened,” Fox said.
The Institute of Medicine report also highlighted medical education and training in the diagnostic process as a way to improve diagnostic accuracy.
About a year ago, Penn State College of Medicine hired a director of critical thinking and problem solving who works with college leadership to modify learning materials and course objectives so future physicians learn how to identify and address cognitive flaws and their role in diagnostic error.
This spring, a new critical thinking course will train students to “apply higher cognitive skills to deliberate thinking that leads to appropriate action.” Medical students will be evaluated on their ability to demonstrate skepticism, curiosity and uncertainty when confronted with new information. They will need to show they can hold competing information and ideas together, and that they can make a mindful evaluation of their own thinking processes and biases.
“I suspect we’re not unique, but it is unusual for a medical school to have a deliberate focus on this,” said Dr. Terry Wolpaw, vice dean for educational affairs at the College of Medicine.
The report’s focus on the need for teamwork in the diagnostic process won’t be anything new for College of Medicine graduates.
“Our students are learning in inter-professional teams from the day they walk in the door,” Wolpaw said. “The medical students work with nursing and physician assistant students so they learn to trust that other people in the team bring value and checks and balances to the thinking process.”
While plenty of work lies ahead as hospitals and health systems begin implementing recommendations, Mosher believes the Medical Center has a solid foundation to build on thanks to its efforts to date.
“The fact that we are thinking about and working on this issue shows that we are a bit ahead of the game,” he said.
When Michael Hoover learned that his father, Greg, was unable to leave the intensive care unit at Penn State Hershey Medical Center to attend his wedding, he and his fiancée decided to bring the wedding to his father.
Medical Center staff rallied around the cause, with several departments contributing to the special day.
The hospital’s valet parking arranged for Michael to pull up to the main doors with fiancée Kelsey Kennedy, their best man, maid of honor, and Kennedy’s parents on Friday afternoon, Sept. 25.
Nurse care coordinator Helen Papeika decorated a conference room across the hall from Greg’s sixth-floor room with flowers, tulle, and a large heart balloon, donated by the hospital gift shop.
Claire de Boer, director of the hospital’s Center Stage arts in healthcare program, arranged the couple’s processional and recessional song choices. Second-year medical student Victoria Jones played the traditional songs on a keyboard in the corner.
Nurses helped Fran Hoover get her husband into his suit and slide his wedding band back on. He was transported to the conference room with a portable monitor with staff monitoring him from the hall during the short service.
Once vows had been exchanged, Greg looked up with a smile and clasped his son’s hand to congratulate him. Papeika wore a second hat as wedding photographer to help the family document the event and snap the standard family group shots.
She led the couple to a conference table–covered in a white tablecloth and a vase of flowers– where they cut a small wedding cake provided by the hospital’s Food Services department. She poured grape juice into champagne flutes labeled “Bride” and “Groom” for a toast and snapped photos when the couple fed each other cake.
“It was amazing – more than I ever expected,” Kelsey said of the way the staff pulled the event together in less than a day. “They really went above and beyond.”
Papeika first heard of the idea mid-week when she rounded with the doctors. Greg mentioned his goal was to be discharged before the weekend, so he could see his son get married. She and the doctors weren’t so sure that would happen, so they decided to consider his request for an alternate plan.
Papeika called chaplain resident Garrett Book to find out what the rules were for such an unorthodox request. They reserved the first-floor chapel, but had to come up with plans to do it in either his hospital room or the conference room next door, depending on his condition.
She chatted with the unit’s regular housekeeper about moving conference room furniture, giving the floor an extra cleaning and making sure the windows were sparkly clean – just in case.
Nurse manager Abby Rudy suggested Papeika talk with Liz Massar, family care coordinator in Patient Experience.
Abby and Liz had connected a few weeks before at a nurse manager meeting. When Massar offered to help the nurse managers in any way she could, she never imagined that would involve planning a wedding on less than a day’s notice.
“I spent two hours making a lot of phone calls, and I was sweating bullets,” Liz said. “We have a lot of generous people on campus. Once I explained what it was for, I think it touched everybody. You want to help people in a positive way when they are here.”
Fran said the effort meant a lot to her family. “The way things were going with his health, we weren’t sure what was happening,” she said. “I came here after work and saw everything set up – I can’t believe what they pulled off.”
- Jennifer Vogelsong
Communicating with and relating to people with dementia can be difficult.
Family members, caregivers, and practitioners may become frustrated when they concentrate on what the person cannot remember, or what capacities have been lost, rather than finding ways to interact that focus on remaining strengths.
That is why Dr. Daniel George, assistant professor of humanities, has implemented an improvisational storytelling activity called TimeSlips at a local dementia care facility to offer his fourth-year medical students an opportunity to spend time with a patient population through the creative arts.
TimeSlips utilizes pictures as creative conversational prompts to spark participants’ imaginations. Their observations of the pictures are then strung together to tell a story.
“Because of our cultural understanding of dementia, most people wouldn’t expect those with cognitive impairment to be capable of telling stories, but this activity challenges our biases and stereotypes,” George said.
The program was developed in the 1990s by theatre professor Anne Basting while she worked in an assisted care facility. Basting was frustrated by the ineffectual activities that were being used to engage residents. So, she pulled a picture out of a magazine and asked the residents tell stories about the person in the picture.
When Elaine Eyster traveled to Dallas in mid-August to receive the National Hemophilia Foundation’s 2015 Physician of the Year award, she was more impressed by those in attendance than the plaque she received.
Many there had survived the HIV epidemic. Others had been cured of their Hepatitis C infections.
“Earlier in my career most would have been in wheelchairs or walking around on crutches,” she said. “Because of the availability of good treatment, they are leading active, productive lives.”
When Eyster was in medical school, half of the boys born with a severe form of hemophilia died before their 19th birthday. Those who survived were destined to spend most of their lives on crutches or in wheelchairs as a result of joint and muscle damage from repeated bleeding episodes.
Eyster has spent more than four decades conducting research, caring for patients, working on teams, mentoring others and providing leadership to bring such changes about. That is why the executive committee of the Mid Atlantic Region III Federally funded Hemophilia Treatment Centers and the Hemophilia Center of Central PA in Hershey nominated her for the award.
James Ballard, professor of humanities, medicine and pathology at Penn State Hershey, was hired by Eyster 40 years ago as the institution’s second hematology fellow.
“She was my mentor, and we have had a long period of collaboration,” he said. “She is an incredibly talented person who has great scientific skills and is a great problem solver.”
He has seen Eyster care for hundreds of patients with hemophilia and advocate for their well-being on a regional and national level.
“She has been a friend and doctor to many, and I think she has reached a point in her career where it is obvious to everyone that she has made significant contributions scientifically and in terms of patient care and advocacy.”
Eyster’s early research focused on the HIV epidemic in the hemophilia population. In 1982, when three people with hemophilia who had been heavily transfused with blood clotting factors developed an immune disorder similar to those described in gay men, her team was in a unique position to investigate this mysterious illness.
She had saved samples of plasma because she was interested in the transmission of hepatitis by clotting factors.
“At that time, we didn’t know anything about what caused AIDS or how it was transmitted,” she said. Those samples played a key role in helping to explain how HIV infections were transmitted and how the immune deficiency progressed after an individual became infected.
Similar research conducted later with her collaborators at the NIH addressed the transmission and the outcomes of the hepatitis C virus infections that were acquired by almost all people with hemophilia who had received clotting factor concentrates during the 1970s and 80s, before effective donor screening and viral inactivation methods were developed.
“Hepatitis B was a big problem for people with hemophilia, so I was saving the samples because I thought there would be more to learn and I wanted to be prepared by having materials to study it,” she said. “Or – as my late husband would say – because I never threw anything away.”
Eyster was also instrumental in getting state funding to establish The Hemophilia Center of Central PA, which has grown over the years to serve about 450 active patients who now receive comprehensive hemophilia care at Penn State Hershey.
She hopes the future will bring development of replacement blood clotting factors that remain active for weeks rather than days for people with hemophilia– and that can be given subcutaneously rather than intravenously to prevent and treat bleeding.
Eyster also would like to see researchers find a way to prevent the body from attacking and destroying the transfused clotting factors – or develop an effective gene therapy that will allow people with hemophilia to produce their own clotting factors.
Although she no longer works full time, Eyster gets excited when she talks about the staff at the hemophilia center.
“It’s so gratifying to have such a great team of people to work with and to see what we can accomplish,” she said. “It has been a most rewarding experience to get to know so many families and to help care for so many wonderful people.”
A new printing technology at Penn State Hershey gives doctors and researchers new possibilities.
Instead of ink on paper, a 3D printer can “print” strands of material in layers to create solid items. Doctors can imagine, design and create prototypes of everything from surgical tools to medical devices like abdominal drains and orthopedic screws.
“There is a big splash about 3D printing — and with good reason,” said Dr. Randy Haluck, vice chairman for technology and innovation for the Department of Surgery.
In the past, a doctor who wanted only a few of something for testing or custom use would have to go through a manufacturing process set up to make thousands of the same thing. Now, a single item or a small batch can be printed.
“This is faster, more efficient and cheaper,” said Dr. Peter Dillon, chair, Department of Surgery.
Just as a draft of text can be printed on a two-dimensional surface and then tweaked and revised before printing again, the same can be done with the 3D machine.
With a career in retrovirology research, a passion for education, and a 24-year history at Penn State Hershey, Dr. Leslie Parent brings a strong skillset to her new position as vice dean for research and graduate education.
Parent transitioned to the role in early June from her former position as chief of the Division of Infectious Disease.
“I thought it was a great opportunity to help other people do better research,” Parent said. “That was what really motivated me: the opportunity to enhance the research going on here at the College of Medicine. We already have excellent, successful investigators. We can take something that already has such a strong foundation and look for ways to promote our research, engage more people in our research, and build a better and more complete infrastructure for research.”
Parent started in the Division of Infectious Disease as a fellow, completed a post-doctoral fellowship in retrovirology, and started her own NIH-funded laboratory in 1998. She was named chief of the division in 2007 and was later asked to co-lead the college’s M.D./Ph.D. program, helping train future physician scientists.
Parent believes she brings an optimistic attitude and persistence to the role.
“I like to explore all the possibilities and do our best to achieve the things we set out to do,” she said. “I like to set goals and then gather people around to work as a team to achieve those objectives. I think team work is really important and I hope that I can be someone who can build teams and use a lot of different people’s talents to achieve the things we want to do here.”