D epartment
of
M edicine
Con ne c ti ng T e c h n o lo g y , Ed uca t i o n a n d D i s cove ry w ith H um anis m in Me dicine
Vol. 3 Issue 4 October 2014
Healing the Medical Record
Through his writing, Charles Dickens is credited with creating a tidal wave of social change in England regarding child labor, the care of orphans, public sanitation, and more. While few can aspire to being as influential as Dickens, our words are powerful. What we say and how we say it may influence others’ attitudes about a person, group, or particular situation. Careless use of words may send a message that is not intended. In his article, “The Language of Medical Case Histories,” published in the Annals of Internal Medicine several years ago, Dr. William J. Donnelly listed several maladies in medical documentation that either reduce the patient’s problem to a biological puzzle or cast the patient in a light that makes them appear to be of inferior intellect or not trustworthy. For example, supplanting the chief complaint with a clinical term such as “gallstones,” hijacks the only place in the history where the patient is allowed to speak for themselves. “I hurt in my stomach, under my right ribs after every meal” is cause for concern regarding the gallbladder, but preserving the patient’s own words leaves an opportunity to explore other possibilities, including their concerns regarding the origin and implications of these symptoms. Introducing the patient as “This is a 45-year-old white male” reduces the person to a biological specimen and his symptoms to little more than a biological malfunction. “Mr. Jones is a 48-year-old professional golfer” is an introduction of the man and the person, and we automatically worry that his illness might jeopardize his career. The history of the present illness is riddled with phrases such as “the patient claims” or “the patient denies,” which create a threatening image of the physician conducting an interrogation on a person he believes might not be telling the truth. “The patient refused her sleeping pill” sounds as if there were a heated argument, when it is far more likely that a good-hearted night shift nurse offered an elective sleeping
aid and a grateful patient said, “No thanks.” This destructive dialect has winnowed its way into every form of medical communication. It permeates our medical histories, progress notes, and discharge summaries. It appears at morning report and grand rounds. It creeps into hallway conversations when we curbside our colleagues about a perplexing patient. Competent, compassionate physicians and nurses talk and write this way without realizing that a lay person hearing or reading our words might think that the patient was an adversary. The damaging effect of words can be countered by writing in a way that does not cast doubt on the patient’s credibility or insight. Preserving the patient’s presence and documenting their perspective in our communications would project a more accurate reflection of the mutual trust and respect that exists in a healthy physician-patient relationship. Healing the medical record might go a long way toward changing the perception that the medical profession has become cold, impersonal, and uncaring. Let the healing begin.
Points of View
Rajiv Dhand, M.D., Chair
Academic medical centers, “teaching hospitals,” serve a vital role in our complex health care system. The primary purpose of such centers is to provide training for medical students and resident physicians to become competent, independent practitioners who are comfortable using the most current technology and treatments. Physicians are groomed under the guidance and direct observation of skilled physicians and teachers,
while they also have the opportunity to manage patients and learn the best practice for a wide variety of diseases. This system of rigorous training is meant to achieve a high standard of excellence and to uphold the skills expected in the physician workforce. Over time, academic medical centers have emerged as “safety net” hospitals that provide care to the indigent, the homeless, and the uninsured and underserved segments of our population. Academic medical centers bear the responsibility of caring for patients with the most complex illnesses and serving as the primary centers for research and scholarly activity. At these centers, new ideas are generated, new science is created, and new technologies and the latest continued on page 3
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My Story by Sissy Ensor I was hired by Dr. Alfred Beasley and started my first day at UT Memorial Research Center and Hospital before there was ever a UT Graduate School of Medicine or University Health Systems. February 11, 1980. Back then (no, I’m not going to start into the “we didn’t wear shoes, it was uphill both ways and snowing”) our office, which had two of us, carried the weight of the Department of Medicine as well as the Graduate Medical Education office, since Dr. Beasley was both the Chairman of Medicine and the Director of Grad Ed. Drs. Beasley, Whitaker and Eastham were the attendings--the only attendings! It wasn’t out of the ordinary to see residents who had been here 38+ consecutive hours. Not exactly the good ol’ days for them. The original call schedule consisted of a bunch of magnets located behind me on a board – every department had their own color code. Green was Internal Medicine, blue was Family Practice, Surgery was red, Pathology was black (surprise!), ER was yellow, and Ob-Gyn was white. We also had dots for Orthopedics (yes, back then we actually had an Orthopedics residency) and Radiology – one was purple, the other orange, but I don’t remember which. We had dots all over the place… and two huge fireproof cabinets, which I thought were the Cadillacs of file cabinets. Two years after I started, we bought the second computer sold in Knoxville – it was called a “Displaywriter.” The ‘floppy disc’ was about 1 ft x 1 ft, black and flimsy. I was amazed and wondered how on earth I could keep up with such technology! I hugged my IBM Selectric typewriter (complete with interchangeable ball elements for larger type) good-bye and began learning the tech-talk – create document/revise document/delete document and never, ever type c/format. The monitor alone Dr. Sissy Ensor weighed 25 pounds and was about the size of a piece of paper. I couldn’t believe I could type something, then rest my finger on the backspace button and watch it all disappear… no more bottles of pink/yellow/blue/white Liquid Paper™! The Department of Medicine/Graduate Education lasted three years in the Clinical Education Center (CEC) building, then we were moved to the 4th floor of the Research Center. A tad bit more space but far away from everything! Pretty soon, we started adding faculty. My coworker quit, and for a while, I was solo. It wasn’t pretty, but we all survived! We “lived” there about four to five years when I was told that I would have to decide between the Department of Medicine and Graduate Education, as the two had gotten too big for one person to handle. We also relocated to the 2nd floor of the Physicians Office Building. It’s Building B now, but way back then, it was the only “physicians building.” Suite 222 was the old cardiology office. Grad Ed moved back to the CEC Building, and I went with Internal Med. What a busy office – more and more faculty were added, which meant more office personnel were needed. During those days, we had 11-12 staff to share the workload. The administrative offices were at the very back of Suite 222, and I felt very special because I had a clear view of Alcoa Highway. Those were the days of “skorts” (shorts made to look like a skirt), jackets with shoulder pads that made you look like a linebacker, and flat shoes (yea!). That was also the time I started traveling for the program, attending either the APDIM meetings or residency fairs. I’ll never forget my first APDIM meeting – it was in New Orleans, LA, and coordinators were just beginning to attend these. I walked into the conference room and there were about 400+ Program Directors and Chairs and about 5 coordinators. Needless to say, I stood out a bit in my bright coral-colored “skort” in this sea of dark suits and old-doctor looking clothes. I sat down and began taking notes, not knowing what on earth these people were talking about. By day 2, I was starting to follow along when one old PD stood up to the microphone and proceeded to tell (yell) the ACGME folks, “We will not do what you are asking us to do!” and slammed a large bound document to the floor. There was cheering and clapping in response to this. I gulped… uh…huh? Doctors don’t act like this! This was starting to sound like one of those tent revivals. He was talking about the PIF (Program Information Form) document, which resembled a large-print edition of War and Peace. The more the ACGME folks tried to calm him down, the louder he got. Just when it got to the point where I thought everybody would break out in “Give Me That Old-Time Religion” song, he sat down. Phooey…so much for excitement. I believe that PD must have retired soon after because I don’t remember ever seeing him again. However, after filling out that first version of the PIF, I, too, wanted to jump up to a microphone and shout, “This Should Not Be Allowed!!” It ‘flagged’ everything from the fact we had no male patients in the GYN office to other similar no-brainers. It was so tedious and long. After multiple years in Suite 222, we again relocated back to the CEC building on the same floor on which I first started working. We took over the old Oral Surgery/Dentistry wing. To say we were cramped was a bit of an understatement. The office Dr. Obenour currently uses used to hold five secretaries. I shared an office with one assistant and the chief residents. The plan was to be located here about two years or so while a primary care building was to be built on the current parking garage beside the Heart Lung Vascular Institute (HLVI) building. I guess those plans changed since we’ve now been located back in our original CEC location since the mid90’s. We’ve downsized quite a bit since then on office assistants. We tried to hire some temporary help, but we didn’t have a whole lot of success with that – the last one came in to work on the first day, asked where the restroom was, and we never saw her again. She even left an extra pair of shoes under her desk! I guess this is not for everybody. My claim-to-fame is the rows of pictures hanging in the hallway – the first color photo of the residents was taken about two months after I started. There were only 10 residents in the program at that time. We’re now approved for 36 so, yes, I would say we’ve grown a bit. I have seen five Program Directors come and go (currently on #6 and don’t want to see him go anytime soon!) and four Chairmen (we’re on #5 now). I think we’ve got former residents in just about every state and several countries. It always makes me smile when I hear from those I haven’t heard from in a long time – I got a phone call just a few weeks ago from a resident asking for her NPI number from 2011. It’s nice to still be needed! 2
A Passion for Medical Education It was 2008 when she began her interaction with the transitional year interns. Dr. Daphne Norwood’s involvement in the education of these residents has evolved into her serving as Transitional Year Program Director. In this position, she ensures correct scheduling for the transitional year resident rotations and holds biyearly meetings with them. Dr. Norwood also participates in quarterly reviews with the heads of programs into which these interns will transition. Because of her success in this role, she became a member of the Association for Hospital Medical Education’s Council of Transitional Year Program Directors. The function of this group, in large part, is to “serve as an advocate for the transitional year programs and the physicians who direct these programs.” For the past two years, Dr. Norwood served on their Executive Council, and this past year, Dr. Norwood was nominated to chair the organization. In this role, she organizes the annual conference for the group, which will be held in San Diego in May 2015. She will organize and serve as moderator of a teleconference in October 2014 regarding the functioning of the clinical competency committee. She will survey the transitional year program directors and respond to requests and questions on the list serve for the group. If this is not enough to fill her time, Dr. Norwood additionally attends on housestaff Dr. Daphne Norwood medicine rotation 17 to 18 weeks a year, intermittently precepts morning report, facilitates resident research projects and team-based learning, mentors a select group of internal medicine residents, serves as substitute staff for the medicine residents’ clinic, and is the associate program director for internal medicine. She has excelled in her roles and because of this was awarded the “Excellence in Teaching” awards from both the Department of Medicine (2009) and the Graduate School of Medicine (2008). Dr. Norwood is married and is the mother of two wonderful daughters. Dr. Norwood received her Masters in Public Health/Epidemiology as well as her medical school degree from University of Medicine and Dentistry of New Jersey. She completed her residency in Minneapolis at Hennepin County Medical Center, the “city hospital” and a level-1 trauma center. Following completion of residency, she moved to Knoxville to work for Faculty Internal Medicine because of the “strong female internists” in the group. She worked with the group for twelve years before transitioning into her role as program director. We are proud of Dr. Norwood’s leadership abilities and her impact on the nation’s transitional year residency programs.
Faculty Announcements Dr. Paul Serrell retired in June 2014, and we are pleased to announce that he is now one of the attendings at our residents’ clinic, the UT Internal Medicine Center. Dr. Urath Suresh was appointed as the Division Chief of Nephrology on July 1, 2014.
Dr. Paul Serrell
Dr. Suresh
We are pleased to announce that Edward J. Primka, MD, has been appointed to Clinical Assistant Professor of Dermatology.
Dr. Primka
We wish to congratulate Annette Mendola, PhD, on her promotion from Instructor to Assistant Professor. Annette Mendola, PhD,
Points of View continued from page 1 cutting-edge therapies are tested. Another evolving role for academic medical centers is to promote standardization of care and to enhance the efficiency and safety of patient care. Academic centers are leaders in developing and implementing new strategies and processes for improving the delivery of health care and enhancing patient experiences when they are admitted to the hospital. Academic medical centers remain at the forefront of American medicine. The continuing success of these centers is essential for the mission to train highly skilled, competent and compassionate physicians. 3
Research Awards for Residents The Department of Medicine has established three new research awards, which will be presented each year at the residents’ graduation ceremony. A committee will review all resident research and select three residents to present at Grand Rounds in early June. Those in attendance will vote on the award recipient. A cash prize will be given--$300 for first place, $200 for second place, and $100 for third place. Transitional year residents have also done great research in the past and are welcome to participate.
Study Comparing Structures of Huntingtin Protein Valerie Berthelier, PhD, Assistant Professor of Medicine and Director of Conformational Disease and Therapeutics Research, co-led a study utilizing neutron scattering to establish a baseline understanding of Huntingtin structure. The study revealed structural differences in the normal and pathological forms of this protein, which is involved in the development of Huntington’s disease. Identifying these protein structures will lead to designing therapeutics that would effectively target those structures that are toxic or potentially toxic.
Study of Inhaler Efficacy in COPD Congratulations to Rajiv Dhand, MD, for receiving approval for an investigatorinitiated study funded by Mylan Pharmaceuticals. The study compares the efficacy of nebulizers versus dry powder inhalers in the treatment of patients recovering from severe exacerbations of COPD. Dr. Dhand expects to be recruiting patients by October 2014. For more information please contact Lauren Davis, Clinical Trials Coordinator, at 305-7975
CME Opportunities - Mark Your Calendars! The 3rd Annual Medicine CME Conference, offering 11 hours of CME credit, will be held April 17-18 at the Holiday Inn World’s Fair Site. We hope you can join us for this informative event.
Please join us, as well, for our weekly Cardiology Conferences, which are now available for .75 hour CME credit, and our Medicine Grand Rounds, which are generally held on the 2nd and 4th Tuesdays of each month for 1.00 hour CME credit.
Presentations, Publications, Awards Department of Medicine faculty, residents, and fellows share their knowledge and experience by publishing and presenting across the world. For a list of our most recent accomplishments, visit http://gsm.utmck.edu/internalmed/scholars.cfm.
Thank You For Your Support For information about philanthropic giving to the UT Graduate School of Medicine, Department of Medicine, please contact the development office at 865-305-6611 or development@utmck.edu. If you would like more information about any of the information in this issue of In Touch, please contact the Department of Medicine at 865-305-9340 or visit http://gsm.utmck.edu/internalmed/main.cfm. We look forward to your input. Thank you.
Stay In Touch! Alumni, please update your contact information by completing the simple form at http://gsm.utmck.edu/internalmed/alumni.cfm or by calling the Department of Medicine at 865-305-9340. Thank you! 4
In Touch Volume 3, Issue 4: October 2014 Publishers James Neutens, PhD, Dean Rajiv Dhand, MD, Chair Editor Ronald Lands, MD Administrative Director Susan Burchfield, CAP-OM Contributors Susan Burchfield Rajiv Dhand, MD Christen Fleming, MD Kandi Hodges Ronald Lands, MD Jane Obenour Design J Squared Graphics In Touch is produced by the University of Tennessee Graduate School of Medicine Department of Medicine. The mission of the newsletter is to build pride in the Department of Medicine by communicating the accessible, collaborative and human aspects of the department while highlighting pertinent achievements and activities. Contact Us In Touch University of Tennessee Graduate School of Medicine Department of Medicine 1924 Alcoa Highway, U-114 Knoxville, TN 37920 Telephone: 865-305-9340 E-mail: InTouchNewsletter@utmck.edu Web: http://gsm.utmck. edu/internalmed/main.cfm The University of Tennessee is an EEO/AA/Title VI/ Title IX/Section 504/ADA/ ADEA institution in the provision of its education and employment programs and services.