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. 11 Issue 4 Oct. 2022
Robotic Bronchoscopy and guides them to the nodule of concern. Dr. Bevill, along with Drs. Branca, Callison, and Soto are trained in this procedure. Dr. Josan, one of the new pulmonary and critical care attendings, is also trained in robotic bronchoscopy and is looking forward to practicing here at UTMCK. There is a large population of individuals in East Tennessee with lung nodules and therfore, a high prevalence of lung cancer. Dr. Bevill, (pictured), hopes that by being able to diagnose and treat earlystage cancers this procedure will improve our survival of lung cancer overall. He believes this new technology will allow our pulmonologists more confidence in diagnosing smaller lesions with less risk for the patients. Historically, interventional radiologists biopsied most of these nodules located in the periphery of the lung. Dr. Bevill and other trained medical specialists are now able to confidently assess these smaller nodules in the periphery and can also provide mediastinal staging at the same time, allowing one procedure for both lung cancer diagnosis and staging. This technology also decreases procedural side effects such as pneumothorax, during biopsies of high-risk patients. Since implementing this procedure at UTMCK in the spring of 2022, over 60 robotic bronchoscopies have been performed.
Robotic bronchoscopy is an exciting new technology that we have here at UT Medical Center. It is similar to navigation bronchoscopy but allows the proceduralist more confidence in reaching smaller and more challenging nodules. The physician uses a controller to more precisely maneuver the flexible bronchoscopy tube which is usually smaller than one used in traditional bronchoscopy. Additionally, a 3-D map of the patient’s own lung is displayed on the computer screen, having been previously mapped out on a CT scan. Robotic bronchoscopy enables the proceduralist to accurately visualize the tube in relation to the lung
Points of View
The process of hiring new attending physicians at the University of Tennessee Medical Center (UTMC) is complex. Other than a residents outpatient clinic and three resident in-patient teams, the department does not provide any other clinical services. This means that any recruitment involves negotiation between the GSM and individual clinical practices, many of which are now hospital owned via University Health Service or UHS. The need for additional physicians is driven by clinical demand and often originates in the private practices or on the hospital side of the enterprise. Less commonly, the DOM recruits for additional faculty members to enhance our teaching or research mission. Thus, most recruited physicians have a contract with the clinical enterprise for their role as clinician educators. Some physicians have faculty appointments to support their role as educators and only a smaller number have paid faculty appointments if they engage in the teaching program as chairs, program directors, or clerkship directors. Faculty appointments need the approval of the University of Tennessee Health Science Center in Memphis, TN. Thus, most recruitments involve multiple stakeholders. Over the past continued on page 2
RECRUITING QUALITY FACULTY PHYSICIANS Most of the 17 Divisions that comprise the Department of Medicine (DOM), the largest department in the Graduate School of Medicine (GSM), have seen steady growth over the past few years. We have added more categorical residents over the years, as well as increased the Rajiv Dhand, MD, Chair number of fellowships offered with the addition of the hematology/medical oncology fellowship in July this year. The number of fellows in the cardiovascular and pulmonary/critical care medicine fellowships also grew to a complement of 9 fellows each. Recent recruitment of new attending physicians has expanded the number of physicians working throughout the Department of Medicine to over 189 physicians. 1
Resident Wellness Numerous demands from the COVID-19 pandemic have weighed on healthcare professionals of all types. Internal medicine residents here at the UT Medical Center in Knoxville, TN (UTMCK) were certainly no exception as they were heavily involved in caring for COVID-19 patients both in the critical care and acute care settings. Plans for the development of a new internal medicine (IM) lounge were set forth as part of the UT Graduate School of Medicine’s (UTGSM) efforts in maintaining focus and commitment to the betterment of resident wellness. Renovations to the 4 East Crossover Conference room began in the early months of 2021 with the assistance of leadership from the Graduate School of Medicine (GSM), University Health Services, and medicine residents themselves. Residents expressed interest in computer workstations with dictation capability, a full-size refrigerator, television, seating arrangements, snacks, and storage space with the goal of creating an environment to facilitate both work and fellowship with peers. At the efforts of the aforementioned individuals and several others, these requests were accommodated in full, and the Department of Medicine recently held an inauguration for the space. Residents have particularly enjoyed using this space on inpatient specialty rotations in preparing new consults and for general documentation. Furthermore, the ground floor of the GSM building is undergoing changes as well to relocate and improve the former GSM resident lounge. Many residents have stated the new space will be helpful for administrative tasks in addition to clinical work given its proximity to the Medicine Conference Room. Overall, the IM residents would like to extend special thanks to Dr. Shali, Dr. Dhand, Dr. Shamiyeh, Dr. Gray, Mrs. Cassandra Mosley and Mrs. Robin Underwood for their efforts and dedication to promoting a positive and streamlined learning environment.
Cardiac MRI & Hypertrophic Cardiomyopathy Cardiac Magnetic Resonance Imaging (Cardiac MRI) offers a detailed, non-invasive assessment of the cardiovascular system, and since Dr. Kassira joined University Cardiology two years ago, over 500 referrals for cardiac MRIs have been performed at UT Medical Center. The test takes on average 45 to 60 minutes to complete. The patient needs to lie flat and lay still to prevent motion artifact. Patients also need to perform 10-15 second breath holds for better images and left ventricular assessment. There are various indications for obtaining a cardiac MRI such as better imaging in a patient with a technically difficult echocardiogram, infiltrative cardiac diseases, pericardial evaluation, valvular heart disease, congenital heart disease, cardiac mass evaluation, evaluation for scar burden in patients with ventricular tachycardia and premature ventricular contractions, among others. However, one indication of particular interest is using cardiac MRI in the assessment of hypertrophic obstructive cardiomyopathy (HOCM). HOCM is characterized by left ventricular hypertrophy which most commonly affects the ventricular septum (although any area of the ventricle may be affected) leading to obstruction to the outflow from the left ventricle. Cardiac MRI is useful in assessing septal wall thickening, variant types of hypertrophy, as well as systolic anterior motion (SAM) of the anterior leaflet of the mitral valve which can further lead to outflow tract obstruction. Additionally, cardiac MRI is a useful tool in risk stratification for an implantable cardioverter-defibrillator (ICD) placement. If quantification by late gadolinium enhancement (LGE), a marker of cardiac fibrosis, reveals scar burden >15%, then ICD placement is indicated to prevent sudden cardiac death.
Points of View
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few years, efforts to streamline this process and bring all recruitment under one umbrella have been unsuccessful. A new initiative by the Chief Medical Officer, Dr Gray, is slated for implementation in January 2023 and will, hopefully, bring more structure to this process. Despite many challenges, several new attending physicians have been hired in the department over the past year. We have seen recruitment in several areas including, cardiology, pulmonary critical care, general internal medicine, infectious disease, hematology/ oncology, gastroenterology, rheumatology, nephrology, neurology, psychiatry, sleep medicine, and endocrinology. We need more physicians to keep pace with our ever-increasing clinical demands. We plan to sustain our growth by continuing to recruit physicians, even as we strive to provide highly specialized services and the best possible quality of care for our patients and the community. 2
Diversity, Equity, & Inclusion – Dr. Ghassan Wadi Our next featured DEI colleague is Dr. Ghassan Wadi, a third year Internal Medicine resident. Dr. Wadi was born in New Jersey in 1993, moved to Jordan in 1995, and lived there for a large part of his life before moving to Tennessee for residency. Jordan is a country in Western Asia located between the desert and “more greener parts” as Dr. Wadi describes it, he goes on to say, “Jordan is a beautiful place with amazing weather.” He states, “people are extremely welcoming and are very generous towards everyone.” He describes Jordan’s culture as “very diverse both ethnically and religiously” placing a strong emphasis on the family unit and respecting your elders. He states that anyone visiting Jordan should see Amman, the capital, which he describes as a “modern city with multiple ancient ruins.” When asked about traditional foods he states, “the food scene is extremely diverse, you can find any food you can think of.” His favorite dish, called Dolma, contains cooked grape leaves stuffed with a rice and lamb mixture. When speaking about traditions Dr. Wadi states “the two biggest holidays are a small and big Eid.” Eid-al-Fitr is known as a “smaller Eid” that follows the end of Ramadan, while Eid-al-Adha is known as “greater Eid” and is celebrated after a five-day pilgrimage to Mecca. During both occasions “people are expected to wear their best clothes, feed those in need, and bring joy to those around you.” Jordan holds a lot of importance for Dr. Wadi and he hopes to visit soon.
Resident Spotlight – Dr. Ashley Gutiérrez -Santana Dr. Ashley Gutiérrez was born and raised in San Juan, Puerto Rico where she resided until the age of 26 when she became a wonderful addition to the UT Graduate School of Medicine’s Internal Medicine Residency Program. Growing up amongst two sisters, she enjoyed spending time at the beach and hiking in the nearby jungles of El Yunque National Park. She studied at the University of Puerto Rico for her undergraduate education before attending San Juan Bautista Medical School on her path towards becoming a physician. As her training progressed, she scheduled rotations within the continental United States including the medicine department here at the UT Medical Center in Knoxville, TN (UTMCK). Dr. Gutiérrez states, “I really enjoyed my time in Tennessee and was delighted to see how kind the people are in just normal day to day situations. It was a place where I could really see myself being happy while getting great foundational training in medicine.” She began residency in July of 2021 and has expressed interest in managing acutely ill and complex patients either through pursuing pulmonary and critical care fellowship or as a hospitalist in the years to come. In regards to scholarly activity, she currently has several case reports highlighting topics such as hyperglycemia as an immunocompromising factor contributing to a case of nocardia farcinica pneumonia to be presented at the CHEST Annual Meeting, October 16-19th, 2022, a case of local and protracted diagnosis of leprosy to be presented at Tennessee ACP Annual Scientific Meeting, October 21st - 22nd, 2022, and a case of tension pneumomediastinum related to COVID-19 infection that she presented virtually at the Society of Critical Care Medicine Conference - April 2022. In her spare time, she enjoys taking care of indoor plants and spending time with her coresidents exploring the Knoxville community. The Department of Medicine would also like to extend a belated welcome to her as a writer on the InTouch Newsletter Committee and express gratitude for her time and contributions to prior editions of the InTouch Newsletter.
Faculty Announcements - New Faculty We are excited to welcome Dr. Robert Geier to the rank of Clinical Assistant Professor. He is licensed by the American Board of Internal Medicine and is also a member of the American Association of Clinical Endocrinology. Dr. Geier is a graduate of the Lincoln Memorial University – DeBusk College of Medicine and he completed his fellowship in Endocrinology, Diabetes, and Metabolism at the University of Kentucky.
We are delighted to welcome Dr. Kashif Shaikh to the rank of Clinical Assistant Professor. He is licensed by the American Board of Internal Medicine and certified in Level III Cardiac CT, Level II Cardiac MRI, Echocardiography, and Nuclear Cardiology. Dr. Shaikh is a graduate of Ziauddin Medical University in Karachi, Pakistan. He completed his internal medicine residency at the University of South Dakota Sanford School of Medicine in Vermillion, South Dakota, followed by a fellowship in Advanced Cardiac Imaging at Harbor-UCLA Medical Center in Torrance, California.
CME OPPORTUNITIES—MARK YOUR CALENDARS! Hybrid Attendance is offered via Zoom or Microsoft Teams but In-Person Attendance is highly encouraged.
• Cardiology Conferences, held weekly on Wednesdays in the Medicine Conference Room for .75 hour CME credit. • Medicine Grand Rounds, held on the 2nd and 4th Tuesdays of each month in the Medicine Conference Room for 1.00 hour CME credit. • Ethics Case Rounds, held on the 4th Thursday of the month at noon in Wood Auditorium and are available for 1.00 hour CME credit. • Pulm/HTN Conferences, held on the 2nd Monday of the month at noon in different locations and are available for 1.00 hour CME credit.
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In Touch
Ethics Case Rounds Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality.
Penelope is a 75 y/o lady who was admitted with a urinary tract infection (UTI) and acute encephalopathy. Her medical history is notable for cognitive decline and hypertension. She had been living with her brother and sister-inlaw for several months, having been evicted from her apartment for nonpayment of rent and disruptive behavior. The admission note indicates family will not allow her to return as she is belligerent and forgetful, and wanders through the neighborhood, frequently getting lost. She is divorced with three children, none of whom were willing to take her in or make decisions for her. Penelope’s Montreal Cognitive Assessment score (MoCA) at 12/30 suggested cognitive impairment concerning for the ability to live alone. She volunteered that some people think she has dementia but insisted she does not. She maintained, “I make my own decisions, and I am going home,” but she could not explain what she meant by “home.” Ethical Discharge Plans All patients need a safe disposition following hospitalization, and discharge delays produce risks for all involved. Risks for the immediately affected patient include depression, nosocomial infection, and deconditioning. Other patients may be harmed by delays in treatment due to strain on hospital resources. Risks for providers include job pressure, strained interpersonal relationships, compassion fatigue, and moral distress; risks for the institution include costs due to treatment delays, costs due to loss of morale, and potential lack of payment. When a patient is medically stable for discharge but has no clearly safe discharge options, providers must balance harms that could arise for the patient from continued hospitalization, harms that could arise for the patient from a suboptimal discharge, the possibility of benefit for the patient from continued hospitalization to try to improve discharge options, and the needs of the hospital and other patients. Strategies to mitigate discharge delays include early identification of any limitations of resources available to the patient, ensuring that an appropriate decision maker has been identified, noting the (rare) possible need for a conservator, and coordinating interventions needed for discharge. Ethics consultation may help with identifying a decision maker, navigating ethical conflict, and balancing competing vulnerabilities. Penelope was agreeable to a plan for discharge to a supportive shelter with a case manager for help with transition to a supportive apartment, along with an application for her to have a representative payee to manage her money. Unfortunately, there was no availability at the supportive shelter and there was a long waiting list for supportive housing. Discharge to a regular shelter would be unsafe given her age and cognitive decline. The team considered petitioning for a conservator, but this is a lengthy process that would keep her hospitalized until the hearing, would restrict her liberty, and might not be successful. Even with a conservator (or family member who was willing to sign her in to a facility), there are limited placement options for physically healthy patients with dementia, and facilities are often reluctant to accept patients who are unwilling to be placed there. Two weeks into the hospitalization, Penelope’s son agreed to allow her to move in with him. However, 6 weeks later, she returned with another UTI, and her son said he was no longer willing to be involved. After her encephalopathy cleared, her MoCA score was lower than before. Given her failed attempts at independence, the hospital petitioned for a conservator. Ultimately, she was assigned a conservator and discharged to a long-term care facility. Comments on this case may be sent to amendola@utmck.edu References • Banja J, Eig J, Williams MV. Discharge dilemmas as system failures. Am J Bioeth. 2007;7(3):29-31. doi:10.1080/15265160601171762 • Schlairet MC. Complex hospital discharges: justice considered. HEC Forum. 2014;26(1):69-78. doi:10.1007/s10730013-9220-6
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 topics 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
Vol. 11 Issue 4: October 2022
Publisher Rajiv Dhand, MD, Chair, Department of Medicine and Associate Dean of Clinical Affairs Editor Annette Mendola, PhD Administrative Director Jenny Roark Contributors Jenny Roark Robin Underwood Rajiv Dhand, MD Annette Mendola, PhD Cassandra Mosley James Drew, MD Marc Oropilla, DO Shawna Stephens, DO Ashley Gutierrez-Santana, MD 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. Disclaimer: quotes/ interviews are edited for length and clarity