Hopkins Doctor Seeks Education Training to Improve Bedside Care

By Dave DeFusco

Larry Canner

Brian Garibaldi, a pulmonologist at Johns Hopkins Hospital, visited Johnell Smith during one of his recent rounds.

The cotton-top tamarin, a New World monkey, weighs less than a pound. One of the smallest primates, it is easily recognized at the tropical forest edges of northwestern Colombia by its long, white sagittal crest extending from its forehead to its shoulders. It communicates with bird-like whistles, soft chirping, high-pitched trilling and staccato calls. Researchers describe its repertoire of 38 distinct sounds as unusually sophisticated, conforming to grammatical rules.

Those vocalizations inspired Brian Garibaldi, a pulmonologist at Johns Hopkins Hospital and candidate for a graduate degree in the Master of Education in the Health Professions (MEHP) program at the School of Education, to study a colony of cotton-top tamarins as a Harvard College sophomore. The introductory course he took in evolutionary biology included a lab component where he and his partners tried to piece together the parts of those vocalizations that were meaningful.

The MEHP is an online program that requires its candidates to complete a core curriculum focused on evidence-based teaching and to specialize in either educational research or educational leadership. Faculty are drawn from five Hopkins schools—Education, Medicine, Nursing, Public Health and Business.

“The focus was on trying to understand the evolutionary precursors of language,” said Garibaldi, an assistant professor of medicine and physiology in the School of Medicine. “My job was to analyze the acoustics of their vocalizations, to understand which parts of the long call—the greeting call over long distances—were required for the monkeys to recognize each other. The idea was to map this ability of language development in human infants.”

The research merged Garibaldi’s interest in biology, medicine and music. He had started playing classical guitar in junior high school and would, by the time he was a senior at Harvard, secure a John Finley Fellowship to study flamenco guitar in Madrid. After he graduated, he eschewed a job at a biotech firm in Boston and lived the itinerant life, taking private lessons for six months in Spain and then moving on to other countries to absorb their musical traditions and showcase his skills in local venues.

“With flamenco guitar, I like the way you can combine the melody and the rhythm,” he said. “As you’re strumming, you use your fingers to tap a beat on the soundboard. It sounds like a drum.”

He quickly learned at 22, though, that guitarists half his age could play with more dexterity. Medicine, not music, would be his destiny. After sojourning through 18 countries in Europe and the Middle East for a year on the strength of the fellowship, he returned home to enter medical school at Johns Hopkins University.

“I wanted to be in a field where I was thinking about the way the brain works, the way the body works and also challenging myself to learn new things on a daily basis,” said Garibaldi, who also has an appointment at Bayview Medical Center. “That’s the beauty of medicine. Every day you encounter a new puzzle or a different way of looking at a problem.”

He spends a good deal of his time at the Interstitial Lung Disease Clinic at Johns Hopkins Hospital caring for patients who suffer from persistent lung inflammation and scarring. “There are so many interesting things about the basic physiology of the lungs,” he said. “The control mechanisms for breathing. The way the cardiopulmonary system is optimally designed to extract oxygen from the air and deliver it to the tissues. Of course, there are also many ways in which the system can break down.”

He said the ability to communicate openly and honestly with patients and families is crucial, given that examinations and testing don’t always result in definitive diagnoses. That fundamental aspect of the doctor-patient relationship led him to the MEHP program.

An online program, the MEHP requires its candidates to complete a core curriculum focused on evidence-based teaching and to specialize in either educational research or educational leadership. Faculty are drawn from five Hopkins schools—Education, Medicine, Nursing, Public Health and Business.

“The main reason to get formal training in education is there are certain ways of approaching how you formulate questions for research that are related to, but different than, how you develop curricula,” said Garibaldi. “That skill set is important but not something I’m going to get exposed to in the ordinary course of business.”

After his first year on the Hopkins faculty, he was asked to help run a Hopkins-affiliated medical school in Malaysia. While at Hospital Kuala Lumpur, he discovered a passion for teaching about physical diagnosis at the bedside. The hospital had advanced technology, but medical teams used it sparingly, opting instead to spend more time using their eyes, hands and ears to diagnose disease. Technology was used as a supplement.

After that planned two-year stint ended abruptly, he returned to Baltimore and became a late registrant in the MEHP program.

“When I came back to the United States, I saw that it’s not a skill that we practice here as often. We’ve moved further away from the bedside,” he said. “I knew that I wanted to change that. To do it, though, I had to devise a program in a systematic, formal way. It was essential to get training in education.”

He said that everything he has done in the MEHP program has been directly related to something he’s been able to put into practice at the clinic. “They’re entirely synergistic,” he said. “The formal nature of the training made applying for grants easier. It helped me figure out how to ask the right questions and then how to apply for funding.”

The Berkheimer Faculty Scholars Program from the Johns Hopkins Institute for Excellence in Education and the Jeremiah A. Barondess Fellowship in the Clinical Transaction, sponsored by the New York Academy of Medicine and the Accreditation Council for Graduate Medical Education, have funded some of the bedside educational interventions piloted through MEHP. He thinks the skills he’s imparting to residents and interns through the physical diagnosis curriculum are helping them provide better care for all of their patients.

“I’ve been in the MEHP program for over two years,” he said. “The first year was spent developing the curriculum and the second year rolling it out to interns as part of a new internal medicine service.”

Garibaldi has also partnered with educators throughout the world as part of a larger movement to reinvigorate the practice of bedside medicine. He is the co-president and a founding member of the Society of Bedside Medicine, a group that was formed at the recent Stanford 25 Clinical Skills symposium to foster innovation in education and research in physical diagnosis and teaching.

“I certainly know from my own practice that my focus on the bedside physical exam over the last two years has made me a better provider,” he said. “I’m seeing, feeling and hearing things that are shaping the way I practice medicine. The goal at the end the day is to be a better physician than you were the day before.”

Doctor and Patient in the hospital in conversation