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Wholly Hopkins
Matters of note from around Johns Hopkins


University: Hopkins Scientist Wins Nobel Prize

Policy: Plans Laid for Hopkins High

Medicine: Internal Medicine Readjusts Residents' Hours

Sports: Changes Could Alter Athletics

Research: Diamonds Are a Researcher's Best Friend

Humanities: Facing the Music of Antiquity

Libraries: Water-Damaged Books Drying Out

Public Policy: Bioterrorism Staff Departs

Medicine: Change in Rounds Means Major Results

Community: It Takes a Village to House a Campus

Wholly Hopkins Departments: Bottom Line | Here & Abroad | Vignette | Datebook | Syllabus | Findings | Academese | Forever Altered | Vital Signs | Up & Comer | JHUniverse

Peter Agre hits one out of the park.
Photo by Will Kirk
Hopkins Scientist Wins Nobel Prize in Chemistry

Serendipity turned into international acclaim last month when the Swedish Academy announced that Hopkins' Peter Agre (MD '74) was co-recipient of the 2003 Nobel Prize in chemistry. Agre, professor of biological chemistry at the School of Medicine, shared the $1.3 million prize for the discovery in 1991 of aquaporins, proteins that form channels for the transport of water through cell membranes. The other winner of the chemistry prize was Roderick MacKinnon, a scientist at Rockefeller University who determined the structure of cell channels for the passage of salts.

At the October 8 press conference following the announcement of his award, Agre wryly noted that for a time in the 12th grade he carried a D in chemistry: "If my high school chemistry teacher is still with us, he probably aspirated his morning coffee" when he heard the news, Agre joked.

In the mid-1980s, Agre was studying the Rh factor in mothers' blood that can produce an immune reaction that destroys red blood cells in a fetus. He and lab technician Barbara Smith kept trying to purify a sub-unit of the Rh antigen, only to find sample after sample contaminated by a small, unexpected protein. When they examined the protein, they found that it had an amino-acid sequence they'd never seen before. The protein was abundant in red blood cells, and the more the scientists looked, the more they found it elsewhere in the body.

For decades biologists had supposed the existence of some kind of channel in cellular membranes to facilitate the transport of water. But no one had ever found it. When Agre's lab cloned the newly discovered protein's DNA and injected the corresponding RNA into frogs' eggs, the effect was stunning. The eggs, normally impervious to water, suddenly took in so much fluid that in three minutes they swelled and burst. The protein that Agre had chanced upon was the long-sought water channel. Scientists believe that a better understanding of aquaporins may answer questions about edema in the brain after a stroke, the incidence of cataracts, malfunctions in the kidneys, and other ailments.

At his press conference, the amiable, modest Agre, who joined the Hopkins faculty in 1981, said, "I didn't do the work. My colleagues at Hopkins and many young people in the laboratory did the work. I made the coffee and sharpened pencils, things like that. This is really our award. This could have happened to several of my colleagues. I feel like the guy who was lucky enough to be at the plate when a fastball got pitched down the middle." — Dale Keiger

Plans Laid for Hopkins High

Hopkins education researcher Robert Balfanz looks ahead to next September in anticipation of a rare opportunity. When school starts next fall in Baltimore, he and some colleagues and a select group of teachers will open a new, experimental high school to its first class of freshmen.

"We're trying to find an alternative to the traditional neighborhood high schools that simply, in many cases, become dropout factories," says Balfanz, of the Hopkins Center for Social Organization of Schools (CSOS). He co-directs the project with Maxine Wood, CSOS's director of new school development.

For nine years, CSOS has helped large, urban public high schools that face severe problems with attendance, low test scores, and high dropout rates. The center has developed a model that segments the schools into smaller academies. Each emphasizes closer relationships among students, teachers, and administrators; an environment that is conducive to learning; and curricular innovations intended to bring all students up to an advanced high-school level of work in math and English. CSOS has helped more than 30 schools around the country to incorporate its model. The new school, to be located in Baltimore City, provides the first opportunity for CSOS to start from scratch to implement its ideas.

Classes next September will start with 150 freshmen in what CSOS calls a Success Academy. "In the ninth grade, the overwhelming majority of kids come in two to three years behind grade level in math and reading," says Balfanz. "These kids actually have high aspirations. If you ask them if they plan to go to college, almost every one of them will say yes. ... [But] by the end of the first semester, these kids are dropouts in all but name." By dedicating eight teachers to work with 150 freshmen, Balfanz says, the new school hopes to get the pupils on a fresh track for steady attendance and solid work in core courses.

During the ensuing three years, the high school will add a grade each year, as students advance to upper-grade career academies. Schools within a school, these academies, which have not been designated yet, will help prepare students for more specific career areas such as business, the arts, health sciences, and the hospitality industry. "You've got to give kids a reason to come to school," Balfanz says. "We try to show how what they do in school is linked in a broad sense to a career they might be interested in."

The school will be funded by the city, with additional start-up money from the Gates Foundation and local foundations. Admissions will be open and non-selective, possibly done by lottery if there are more applicants than openings. — DK

Illustration by Robert Neubecker Medicine:
Internal Medicine Readjusts Residents' Hours

Last July, leaders of Johns Hopkins Medicine's Internal Medicine residency program received a complaint that the program had violated newly enforced labor rules limiting resident work hours. Program leaders "acted vigorously and immediately" to adjust resident work schedules so as to comply with the standards, according to Mike Weisfeldt, chair of the Department of Medicine. Nevertheless, in August the Accreditation Council for Graduate Medical Education (ACGME) issued a summary withdrawal of accreditation for the Internal Medicine residency program.

The action put Internal Medicine at risk of losing its accreditation effective June 30, 2004. But Hopkins has officially applied to the ACGME for a reconsideration of certification withdrawal. At press time, on October 5, the ACGME's Residency Review Committee for Internal Medicine ruled after further investigation that Hopkins be granted probationary accreditation. ACGME said the case would be further considered by mid-December. Currently, the department trains some 110 residents.

On July 1, new work hour standards adopted by the ACGME went into effect, limiting residents to working no more than 80 hours per week, averaged over four weeks. The regulations also mandated that residents be on call in the hospital no more than every third night; have at least 10 hours off between work periods; and have at least one day off out of every seven.

Nine days into the new enforcement period, a new Hopkins intern sent an e-mail to ACGME officials stating that some Internal Medicine residents were working more than 100 hours per week. That complaint was forwarded to Medicine in edited form. "The only work hour violation was in the [Medical Intensive Care Unit], affecting four residents who had worked every second night rather than every third night," according to Estelle Fishbein, Johns Hopkins vice president and general counsel.

Following a site visit, the ACGME announced its plans to subsequently withdraw accreditation. That move came "after a highly irregular telephone conference call that did not comply with ACGME's own procedural rules," Fishbein points out.

The ACGME's action surprised many Hopkins officials, who countered that program leaders had rectified work hours issues as soon as they were informed of the violations and that they had so informed ACGME. An intensive independent audit conducted September 8-10 concluded that Hopkins' Internal Medicine program was in full compliance with the duty hour rules.

The charges also pertained entirely to scheduling issues, not to the quality of Internal Medicine's educational program, which has always received stellar ratings, says Levi Watkins, associate dean for postdoctoral programs and chair of the committee that reviews Hopkins' residency programs. Hopkins officials further note that there had been no finding that the quality of resident education had been seriously compromised; in fact, close to 100 percent of Internal Medicine residents at Hopkins pass their Board exams on their first attempt. The ACGME has received allegations of work hour rules at several other residency training programs across the country and is investigating at least six of those, according to ACGME officials.

As Hopkins awaits further consideration of its accreditation standing, residents and experienced doctors across Johns Hopkins are still coming to terms with the ACGME's new work hour rules, which were established to prevent overtired residents from harming their patients or themselves. Many people in the 9-to-5 workday world would wonder why any resident would object to rules that limit doctors in training to a maximum average work week of 80 hours. But many residents say the work restrictions run counter to the culture of doctoring, where physicians are accustomed to going home when their patients are stabilized, not when the shift is up. "The hours have generally been demanding," says John Dooley, a third-year resident in Internal Medicine at Johns Hopkins. "But at the same time they allow us to experience what we can and to maximize our time. The long hours are what make us good doctors."

"I think it's very reasonable to put some limit on work hours," says Sigrid Berg, a second-year resident in Internal Medicine. "The problem is that you [have to] set an arbitrary limit. But if a patient gets sick with chest pains [when I'm done with my work hours], do I transfer the patient to another doctor who doesn't know them, or stay and work 84 hours instead of the 80-hour limit?" Since the task of a resident is to learn, as well as to practice, medicine, some residents are concerned that the new work hour limits will not give them enough time to experience the variety and depth of cases and procedures they will need to pass their certification exams.

Even before the ACGME work rules went into effect in July, Johns Hopkins over the past decade has made many adjustments to lighten residents' workload and hours. Internal Medicine for example, introduced a hospitalist service, in which teams of attending physicians and nurses ("hospitalists") take responsibility for the care of some patients without requiring the help of residents. Medicine also added 10 new resident positions. Cardiac surgery, Watkins' department, is now sharing a fellow with George Washington University, enabling an every-fourth-night on-call schedule.

These measures have not been without added cost, notes Watkins. The annual bill for the hospitalist service is about $1 million.

Residency programs have also introduced a variety of scheduling innovations to comply with the strictly enforced ACGME work hour rules. Pediatrics has changed from a schedule in which residents were on call in the hospital every fourth night to one in which resident teams work consecutive weeks of days only or nights only and do not work both days and nights within the same week.

Program leaders are also introducing new technologies to help residents provide continuous patient care and stay in compliance with ACGME rules. Each resident will now be provided a two-way pager to relay patient information as they sign on and off from a work shift. In the next two years, Hopkins is also planning to introduce a simulation center to be used for a portion of residents' training. Residents will learn aspects of medicine through videos, computer programs, and simulations performed by patient actors. The center is being developed, in part, to compensate for restrictions on residents' duty hours.

Such technologies for learning medicine might appear strange to William Osler, the first physician-in-chief at Johns Hopkins, who developed the medical residency system in which young doctors learn at the patient's bedside and at the side of physician mentors.

Then again, so too might the notion of restricting residents to 80 hours. — Melissa Hendricks

Proposed Changes Could Alter Athletics

A new proposal before the National Collegiate Athletic Association (NCAA) could dramatically change the future of Hopkins athletics. For decades, Hopkins has fielded teams at the NCAA's Division III level, with one obvious exception: lacrosse. The Blue Jays play men's and women's lacrosse in Division I, which permits the athletic scholarships that have attracted the athletes who make Hopkins a perennial contender for the national championship.

Last August, the Division III Presidents Council, composed of the presidents of 15 D-III schools, approved a reform package that, if adopted in its entirety at the NCAA national convention next January, would end in 2008 a 20-year-old exception that has allowed a few schools like Hopkins to compete primarily as D-III institutions, yet give scholarships for D-I programs in one or two sports.

The chairman of the council, John M. McCardell Jr., president of Middlebury College in Vermont, explained the recommendation: "If there is a single distinguishing characteristic of Division III, it is that we do not give athletic scholarships. What we are saying is that if you wish to remain a member of Division III, then within four years you need to bring your practices into full compliance with Division III philosophy."

Hopkins has responded by noting that the eight D-III schools in question have awarded scholarships in D-I sports since 1983 with no discernible impact on D-III overall: They remain committed to D-III ideals, Hopkins says, and there's little evidence to support arguments that they gain a competitive advantage in D-III recruiting by competing at the D-I level in one or two sports. (Every other school in the D-III Centennial Conference must compete with Hopkins in most sports save lacrosse, and they have unanimously voiced their support for Hopkins in the debate over the D-I exception.) Programs such as D- I lacrosse at Hopkins and D-I ice hockey at Colorado College have long traditions of national prominence and thus are of great importance to their schools and communities.

The proposed reform package, most of which Hopkins supports, is meant to maintain D-III's tradition of keeping college athletics in proper perspective and to avoid many of the problems, scandals, and distorted values of big-time athletic programs. Recommended measures would mandate shorter team schedules and new limits on off-season practice. They would end redshirting, which allows an athlete to sit out from a sport for one season without sacrificing a year of eligibility. And they would establish an audit procedure to compare the need-based financial aid provided to athletes and non-athletes. (Research has shown that some D-III schools, while adhering to the prohibition against athletic scholarships per se, grant other forms of financial aid, as well as admission, disproportionately to athletes.)

At press time, the council was scheduled to meet again at the end of October and further discuss the reform proposals. Hopkins and the seven other schools with D-I sports have sent a letter to the council expressing their opposition to ending the D-I exception, and the presidents of those schools have been speaking with council members. The council could decide not to send the proposal to the national convention, or could amend it.

Athletic director Tom Calder says that making Hopkins lacrosse a Division III team is not an option. Division I lacrosse, he says, "is a major part of the history and culture of this institution."
Photo by Tamara Hoffer
Hopkins has no intention of downgrading its lacrosse program to D-III, says Tom Calder, athletic director. "That's not acceptable. [Division I lacrosse] is a major part of the history and culture of this institution. It would change our lacrosse world so much it wouldn't be acceptable to our university."

If the reform package is approved next January, Hopkins could campaign for the 2005 NCAA convention to repeal the rule change. "It isn't uncommon for legislation to be passed and in a year it changes, or changes back," Calder says. "We would love for things to stay the way they are now." Hopkins also could step up to D-I across the board, and continue to provide scholarships in lacrosse but not in other sports. (Not all D-I programs provide athletic scholarships; the Ivy League, for example, does not.) Says Calder, "We're not going to wait until the convention to start looking at these things. We've already started." — DK

Diamonds Are a Researcher's Best Friend

The three-dimensional bar graph has become ubiquitous for representing medical, scientific, and financial data. But it's flawed, says Alvaro Muñoz, professor of epidemiology at Hopkins' Bloomberg School of Public Health . Due to the visual perspective employed, bars of equal value may not appear equal, and bars in the foreground may obscure lesser bars in the background, rendering part of the graph useless. More importantly, 3-D bar graphs are used when two variables determine an outcome. Each variable contributes equally to that outcome, but the graph may create the visual impression that one variable has more importance.

"Bar graphs are limited in that they don't treat the two predictors in an equal manner," Muñoz says. "That, for providing information to the world, is very important."

Alvaro Muñoz believes that his diamond graph (top) represents data more accurately than the traditional bar graph (bottom).

Muñoz's answer: diamonds. He began with the standard 3-D bar graph, which portrays bars on a diamond grid, viewed from one corner. But then Muñoz tilted the diamond to create a two-dimensional overhead perspective; greater values, which on the bar graph were represented by taller bars, now appear as larger polygons on a diamond grid. This eliminates mistaken perception arising from the visual perspective, not to mention the problem of taller bars obscuring shorter ones. Says Muñoz, "You can rotate this graph any way you want and it will never mislead you."

Muñoz and co-authors Xiuhong Li of the Bloomberg school, Patrick M. Tarwater of the University of Texas Health Science Center at Houston, and Jennifer M. Buechner of the University of Wisconsin-Madison, presented their new graphing method in August in The American Statistician.DK

Facing the Music of Antiquity

The foundation of Dimitrios Yatromanolakis' current research includes several dozen pieces of papyrus. These papyri bear orderly lines of ancient Greek text written, in some cases, more than 2,000 years ago. Between the lines appear other markings — letters and dots — that make these papyri, as well as some parchment and inscriptions, the equivalent of the world's oldest Western sheet music.

Yatromanolakis, an assistant professor in Hopkins' classics department, studies and reconstructs this music. "I am interested in the possible reconstruction of ancient sound," he says. "There's some reluctance, if not resistance, on the part of classicists to face the musical reality of antiquity."

It's not that classicists deny that ancient Greeks made music. Images of men and women playing the kithara, a stringed instrument, or the aulos, a reed pipe, are ubiquitous on Greek pottery. There are innumerable references to music and music-making in Greek texts. But conventional wisdom has always held that not enough material exists to allow the actual reconstruction of that music.

By combining his knowledge of music and the classics, Dimitrios Yatromanolakis brings the music of the ancient past to life.
Photo by Chris Hartlove
Not true, says Yatromanolakis. He believes that about 20 pieces are complete enough to be performed, once he understands enough about the ancient notation system, the musical performance practice of the time, and the equivalencies in rhythm and sound with modern music.

As a boy, Yatromanolakis, who is Athenian by birth, received classical training in guitar, piano, and voice. "I always wanted to pursue a musical career," he says, "but at a certain point, I thought it would be very interesting to combine classics and archaeology with music." He earned a PhD at Oxford, studying the poets Sappho and Alc‘us and the cultural poetics of archaic Lesbos. Then he began serious work on the music that was an important part of the performance of ancient Greek poetry and the performance of plays by Euripides and other tragedians. His current project is researching mousikoi agonies, a form of poetic and musical competition that was an integral part of ancient Greek religious festivals.

If a contemporary musician is to play ancient Greek music with all possible accuracy someday, Yatromanolakis must figure out, among other things, equivalencies: This inverted letter gamma on the papyrus must be the approximate equivalent of a certain tone on the Western classical musical scale; this mark indicates a quarter note, or a rest. But he has to be careful not to take comparisons with European classical music too far, lest he distort the ancient music, modernizing and Europeanizing it. The Greek authors of these texts were not writing 19th-century classical music, with its octaves and time signatures and chord progressions. The Greeks used microtones, for example, the notes between the notes of the scale, so to speak, as when a guitarist bends a string. This is more characteristic of, say, an Indian composition for sitar than an 18th-century sonata.

A similar cultural determinism can unduly influence comparative study. Yatromanolakis says, "Many people think that if you want comparative material for the study of ancient Greece, you should look at the traditional music of the Balkans, or Italy. I want to avoid these culturally determined notions. That's one reason I've moved to cultures which are far from Greece." Ancient Greek employed a pitch accent, like Chinese. Thus Yatromanolakis is finding it useful to study Chinese music like keutchu. He's examining Japanese instrumental court music called gagaku, as well as Chinese traditional music and Beijing opera. An ancient Greek genre called nomoi bears some resemblance to Indian ragas.

His scholarship requires a wide range of disciplines. He needs expertise in the classical texts, of course, plus ancient religious practice and cultural history, epigraphy (the study of inscriptions), paleography (the study of writing systems), papyrology, ethnomusicology, and musical archaeology. He can play the kithara, and sing. Part of his work involves reconstructing ancient instruments, based on, among other things, vase paintings, historical discussions in ancient literature, and the remains of actual instruments.

Says Yatromanolakis, "If you decipher the system properly, and then think in terms of how these things should sound vocally, and then think what instruments you should use, and construct the instruments eventually we will be able to perform these things. We will never be able to say, 'I'm sure that this was performed this way.' We cannot be sure how medieval music was performed. But we still perform it." — DK

Sonya Jordan Libraries:
Water-Damaged Peabody Books Beginning to Dry Out

If there's anything a librarian does not want to hear upon entering the stacks, it's dripping water. So you can imagine Sonja Jordan's consternation on August 4 when the Sheridan Libraries' director of preservation received a Monday morning call from a maintenance manager at the George Peabody Library. The library holds 138,000 volumes from the 18th, 19th, and early 20th centuries. Daniel Morgan had telephoned to report that he had just entered the library and found water dripping and collecting on part of all of the floors of the Peabody bookshelves.

Approximately 8,500 of the books were damaged, but quick action by library staff may have minimized losses. Upon receiving Morgan's call, Jordan — just starting her second month at Hopkins — immediately initiated the library's disaster plan. Within 10 minutes she was on the scene, surveying the extent of the damage. "When [Morgan] told me the water was on six floors, I was aghast," she says. "What kind of flood could we have that it was on all six floors?"

The answer was a flood that wasn't as bad as Jordan initially feared, but bad enough. Water backed up from a condensate drain in the library air-conditioning system had spilled over collection pans, gone into the ceiling, and leaked on the books. "None of them were actually sitting in standing water or were submerged," Jordan says. Nevertheless, water had dripped on their spines and, in some cases, collected on shelves where it had been wicked up into the pages.

One of Peabody's 8.500 or so water-logged books
Photo by Elizabeth Malby, The Baltimore Sun
Jordan phoned Document Reprocessors, a firm in New York state that specializes in just this sort of emergency. The company dispatched special freezer trucks to Baltimore, and library workers formed a human chain to carefully remove books from the shelves and prepare them for loading. By quickly freezing the books, the restorers could halt the formation of mold, one of the primary complications of wet books.

Document Reprocessors transported the books overnight to New York, and in special chambers began a vacuum freeze-drying process that crystallizes the moisture in the books then takes the water crystals straight to a vapor state and out of the chamber. The crystals never liquefy; in a sense, the moisture is sucked right out of the paper, minimizing swelling and other damage. Books bound in leather and vellum were to be specially handled, to dry the bindings in a way that reduces damage to them.

According to the company's initial assessment, most of the books should be restored to good condition. By the end of September, says Jordan, the volumes had been sorted according to what kind of treatment they would need, and the restoration process had begun. She was scheduled to visit the company in mid-October. "I'm sure I will be pleasantly surprised," she says. She anticipates return of all materials by the end of the year.

"We were very lucky," she says. "It was a large disaster in terms of the number of books affected. But in terms of the degree of damage to any single volume, it was really limited." — DK

Public Policy:
Hopkins Bioterrorism Staff Departs to Form New Pittsburgh Center

In the five years since its founding, the Johns Hopkins Center for Civilian Biodefense Strategies, part of the Bloomberg School of Public Health, has become known as an authoritative source of analysis of biodefense practices and policy. The center was responsible for convening the first two national conferences on bioterrorism for medical and public health professionals, and, since September 11, has gained international recognition for its work.

Now the center's staff of 20 is leaving Hopkins to create a new $12 million center at the University of Pittsburgh Medical Center (UPMC).

Donald A. Henderson This month, Tara O' Toole, director of the Hopkins center, will become the new chief executive officer of the University of Pittsburgh's Center for Biosecurity, and Thomas V. Inglesby, currently the deputy director of Hopkins' center, will become its chief operations officer. The founder of the Hopkins center, Donald A. Henderson (MPH '60), a Johns Hopkins University Distinguished Service Professor and former dean of the School of Public Health at Hopkins, will be a special adviser to the UPMC center and professor of public health and medicine at the University of Pittsburgh.

"It was a very difficult decision," says Henderson, who is credited for leading the worldwide effort to eradicate smallpox. He was one of the first public health experts to draw attention to the dangers of bioterrorism and served as President George W. Bush's chief bioterrorism adviser from 2001 to 2003. "[Hopkins] is the only center of its type that deals not just with bioterrorism policy but with the broader issues of public health and medicine."

But Henderson says that exploring policies and strategies is no longer enough; researchers need to be able to test their concepts in practice, with biodefense-related medical training, health care delivery, and public health.

"We really needed to tie in closely those who are actively involved in the practice of public health preparedness," says Henderson. Hopkins, he says, has "very limited" relationships with emergency preparedness personnel in the area. In contrast, the relationships between UPMC, a 20-hospital system, and emergency preparedness staffs are "cutting edge," he says. "[The city of] Pittsburgh has been extremely active in developing an extensive program extending over western Pennsylvania. It's one of the real leaders in the country."

In addition, Henderson notes, the new center, which will be based in Baltimore, will be able to apply its expertise to care for people affected by natural disasters, outbreaks of diseases, and other emergencies.

The Bloomberg School has since announced that it is merging its biodefense center with related programs to create the Institute for Global Health and Security. The new institute will bring together Hopkins' Center for Public Health Preparedness, the Mid-Atlantic Public Health Training Center, the Risk Sciences and Public Policy Institute, and Scientists Working Against Terrorism, as well as a number of other programs.

Bloomberg School Dean Alfred Sommer says that though Henderson and his staff had done "absolutely terrific" work at Hopkins, their departure will not hurt the school nor cause the two institutions to become competitors in the field.

"We're not interested in duplicating what they're doing," says Sommer. "We do research and education, not advocacy. The fact they are moving one or two blocks away and are changing their flag from Johns Hopkins to Pittsburgh I think it's a terrific opportunity for them and for the nation." — Maria Blackburn

Peter Pronovost introduced the corporate idea of setting goals to the longstanding tradition of grand rounds. Medicine:
Small Change in Rounds Means Major Results

Peter Pronovost (MD '91, PhD '99) is known to be a stickler for safety. An associate professor and physician in the field of anesthesiology and critical care medicine, he has devoted his research to finding ways to minimize medical mistakes. His mission has a history that's all too personal: When he was a student at Hopkins, his own father died following a missed diagnosis at a hospital in New England.

But it was a small change he brought to the ritual of daily rounds that has turned out to make a world of difference in patient care. In a yearlong study, Pronovost found that by establishing a list of specific patient-oriented goals for the staff during rounds, the medical team was able to cut the length of those patients' hospital stays by nearly half.

Two years ago, while conducting a safety review of the Surgical Intensive Care Unit (SICU), Pronovost asked staff to speculate how the next patient might accidentally be harmed. "Everyone said lack of communication between caregivers was the greatest threat to safety," recalls Pronovost, an energetic attending physician whose face lights with animation when he talks with his medical team. The answer surprised him because the practice of morning rounds on the unit is designed to get the entire staff up to speed on each case.

So he decided to put the system to the test. He conducted an informal survey of nurses and residents and was amazed to find that even at the end of rounds, fewer than 10 percent knew what was happening for each patient that day.

Of all the traditions of a teaching hospital, "rounding" may be among the oldest and most entrenched. In fact, one of Hopkins Medical School's founding trademarks was the morning bedside review of patient cases by a peripatetic team of doctors-in-training and an attending physician who used the opportunity to teach. Pronovost, whose background also includes a business degree, realized that the long- held custom could borrow a strategy from the corporate world: drawing up a list of projected goals. Standing before a patient who'd recently undergone gastrointestinal surgery and now suffered from a body-wide infection, he whipped up a list of goals for the SICU team. "It simply addressed what needed to happen that day to get the patient to the next level of care," he explains.

Peter Pronovost introduced the corporate idea of setting goals to the longstanding tradition of grand rounds. Rounds at Hopkins circa 1905.
Photo of Peter Pronovost by Keith Weller
Archival photo courtesy The Alan Mason Chesney Medical Archives of the Johns Hopkins Medical Institutions
Pronovost went through 10 rounds of revisions with that initial list — formulated as a questionnaire ranging from cardiovascular issues to whether the patient's family has been updated — to make it appropriate for the entire SICU routine.

The following morning, Pronovost says, "we were using it on all the patients." By the end of the week, he adds with a laugh, "people were telling me they couldn't practice without it anymore." His goal sheet, in the mode of The Seven Habits of Highly Effective People, quickly became a tool in the various ICUs around Hopkins — and made news around the country. More than 1,500 e-mails poured in from hospitals requesting a copy of the checklist. What's different from the typical handwritten notes on a patient's chart is the use of specific language and the focus on getting tasks done by a particular time. "It puts the whole team on the same page from the beginning of the day," attests SICU charge nurse Maureen Kuyper.

Ultimately, Pronovost's goal sheet tipped the scales in outcomes, helping to bounce patients out of the ICU sooner. (A typical stay in the SICU dropped from 3.2 days to 2.3; the length of stay in the Weinberg Cancer ICU went from 2.2 to 1.1 days.) The goal sheet also transformed how doctors approach treatment. "Physicians typically presume a patient's not ready to be weaned from a ventilator," Pronovost explains, "but now we have a systematic way of testing the patient's progress every day. Now we can let the patient say if they're ready."

A regular crafter of daily and weekly personal goals, Pronovost relies on the same type of tool for his own time management. (He's recently added two goals to his list: exercising and getting home for dinner.) "It's one of the most common-sense changes I've brought to the system," he notes. "It's not super-sophisticated, but it's certainly had an enormous impact." — Kate Ledger

On Campus:
Enemy at the Gates?

"Mass consternation." — Right-wing author and provocateur Ann Coulter, answering the question, posed by Jonathan Pitts of The Baltimore Sun, "What do you hope to achieve in your appearance at a liberal bastion like Johns Hopkins?" Coulter spoke in September as part of the 2003 Milton S. Eisenhower Symposium. The student-organized lecture series was titled "The Great American Experiment: A Juxtaposition of Capitalism and Democracy" and also featured talks by Patch Adams, John Stossel, Michael Moore, Patricia Ireland, and Nelson Mandela.

It Takes a Village to House a Campus

Brian Drolet worries about his classes, his work with the student council (he's junior class president), his GPA, his future. He also has to worry about off-campus housing.

Drolet, who is from Nashua, New Hampshire, returned to school one week before the start of his sophomore year to look for an apartment. He and his roommates found a three-bedroom on 39th Street and rented it in January — while still living in campus housing — just to make sure it would be available this fall when they needed it. Though he likes his apartment, he's not necessarily thrilled with the hassles that off-campus housing brings.

"The nice thing about living in the dorm is that there's a certain amount of ease in living there," he says. "I'm sure it eases parents' minds, too."

The Charles Village Project is actually two buildings — an 11-story building facing Charles Street (top) and a 10-story building on St. Paul Street (bottom) — that will be connected by a bridge.

Last year's study by the Hopkins Commission on Undergraduate Education found that Homewood undergraduates lacked a feeling of community in their residential environments. As a result, the commission recommended that the university develop new student residences at Homewood that would help foster a sense of community.

In order to offer students more housing options, Hopkins has planned a 350,000-square-foot dormitory/bookstore/retail complex slated to be built across from campus on Charles Street. The new Charles Village Project will feature housing for 615 Hopkins students, parking, and ground-floor retail space, all anchored by a two-story, 25,000-square- foot bookstore to replace the all-too-small one in Gilman Hall. Demolition is expected to start in January 2004, and the project will be completed by fall 2005.

Struever Bros. Eccles & Rouse, one of the two developers, is also working on a project along both sides of the 3200 block of St. Paul that will be a combination of retail space, market-rate apartments, and some high-end condominiums.

Together, the two projects are being seen as a means to revitalize the Charles Village area and give Hopkins undergraduates at Homewood a place with a "college town" feel.

Not all area residents and business owners are happy. Some have expressed concern about the scale of both projects, the type of retailers being considered, and the effect the new buildings will have on parking, traffic, and small businesses.

Stephen Gewirtz, a Charles Village resident and member of the Abell Improvement Association, likes the proposed projects and is looking forward to having a big bookstore he can walk to near his home. However, he's worried about how the dormitory will affect parking on Charles Village's already crowded streets. "Hopkins needs to make some kind of commitment on paper regarding parking," he says.

In response, Struever Bros. formed a task force of residents (including Gewirtz), businesspeople, and representatives from the university and Union Memorial Hospital that met over several months to discuss the plans. To accommodate community concerns, the developer has lowered building heights, expanded parking and traffic studies, and changed some of the streetscapes to better suit what neighbors wanted.

"We're not simply looking to meet the needs of people to have a place to sleep and eat," says David McDonough, senior director of development oversight for Hopkins real estate. "We're trying to create a sense of community for Hopkins' undergraduate student population and an enhanced sense of community between Charles Village residents and the Hopkins community." — MB

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