InTouch Newsletter April 2024

Improved Patient Care: Post PCMH Designation

Recently, the Internal Medicine Resident Clinic was recognized and earned the (PCMH) Patient-Centered Medical Home Certification. According to the Centers for Disease Control and Prevention (CDC), the PCMH model aims to deliver high quality primary care while also remaining cost-effective. This model maintains effective chronic disease management, improves patient and physician satisfaction, and increases the level of preventative care in addition to many other benefits.

According to Dr. Williams, the Resident Clinic Medical Director, gaining this designation allows the clinic to expand in important ways such as hiring a Patient Engagement Coordinator, Rachel Wilson, as well as a data analyst, Shelby Moses. With these new additions, enhanced data-gathering improves engagement with our patients about their day-to-day needs. The designation also provided enough funding to hire these staff members, with little to no negatives in terms of clinic performance and expanded the clinic’s hours of operation. Overall, more patients are seen day-to-day, despite some new time slots being hard to fill. We are confident that this new model of care will be a great pathway to success for years to come!

Since earning the PCMH designation, the model of care does not appear to have any negative long-lasting effects on resident’s well-being or the staff’s workload. There is a slight increase in responsibilities for the residents because they have to stay on top of double-checking quality care codes for each patient encounter. Fortunately, a new system that is currently being implemented, will significantly reduce these timely coding requirements. The increased workload for the clinic staff has been manageable and as a positive side effect, required administrative staff to be more engaged with the frontline clinic staff. Therefore, with the PCMH model in place, our clinic is more cohesive than ever before! With stream-lined data collection, the PCMH model allows for more efficient monitoring of clinic patient data and the easier formation of

Rajiv Dhand, MD, Chair

Points of View

JOY IN MEDICINE

What makes someone want to become a doctor? This question may not have a simple answer. When I harken back to my childhood, I distinctly remember “treating” my friends with injections and pills. I see that exact reflection in my granddaughter’s “Doctor Kit.” There’s a stethoscope, tongue depressor, syringe, reflex hammer, and even an otoscope and ophthalmoscope in that box. She was so thrilled to listen to her heart with the stethoscope! Later, as a medical student, I wanted to learn as much about medicine as possible to be the “best” doctor for my patients.

new and necessary Quality Improvement (QI) projects. Currently, our internal medicine interns and residents are split into three groups; all of whom are assigned to a specific QI project post-PCMH designation. These projects focus on three main areas: Osteoporosis, Colon Cancer Screening and Breast Cancer Screening. A fourth medical topic of interest is focused on closely monitoring and controlling hypertension as part of the Tennessee Heart Health Projects. Our clinic has already been participating in this health tracking goal but it’s been even better captured post-PCMH designation.

Clearly, the Patient-Centered Medical Home model of care has improved our resident clinic. This is true not only from a patient-care perspective but also from both an administrative and resident point of view. With this model, we are able to attain more funding and achieve a gradual improvement in the day-to-day operations of our Internal Medicine Resident Clinic!

There was excitement in accurately diagnosing a patient’s condition and seeing them get better with treatment brought a great deal of satisfaction and even joy. An under-appreciated aspect of practicing medicine is how intricately a doctor’s well-being is associated with the wellness of their patients!

Today, we face a harsh reality. Many physicians are battling with frustration and burnout. What has changed in the medical profession to rob physicians of their happiness, and how can we restore the joy in medical practice? From my vantage point, most physicians are unwavering in their dedication to their patients. They often put their own physical and emotional well-being on the line to prioritize the needs of those they serve. If a physician lacks the desire to aid their patients, then perhaps they have chosen the wrong profession.

So, what has changed to make physicians feel disillusioned and cynical about their careers? There could be

continued on page 2

Medical Poetry

Dr. Ronald Lands is a Clinical Professor at the UT Graduate School of Medicine and a retired medical oncologist and hematologist. Dr. Lands received his doctorate in medicine at UT Memphis and stayed there to complete his residency and fellowship training. After earning his MD and finishing his post-graduate training, Dr. Lands decided to return home; as a native of East Tennessee. Returning to his hometown brought the privilege of treating friends and family but also the challenge of processing their suffering and illness. As a way to better process these difficult emotions and journeys, Dr. Lands began writing about his patients and their stories. He says, “I developed a deeper understanding of their hopes, dreams and suffering by understanding their story”. After practicing medicine for many years, Dr. Lands obtained a Master of Fine Arts at Queen’s University in Charlotte, North Carolina and was fully emerged in literature. He returned to UT Medical Center and led a resident elective (also open to 4th year medical students) on narrative medicine from 2012 to 2015 with the goal of developing an appreciation for the “blend of biology and biography that is the essence of medicine.” Dr. Lands has continued writing about his patients and their experiences in poems and books. He reminds us that narrative medicine is a way physicians can join their patients in illness and each patient has a story that is waiting to be listened to.

What

it’s like to Practice Rural Medicine

Many residents have had the pleasure to work with the department’s newest academic hospitalist Dr. Lowe, but when he is not rounding on the housestaff service, he is practicing rural medicine in his hometown of Scott County, TN. He completed his medical training at Geisinger in Danville, Pennsylvania and chose to pursue a dual medicine-pediatrics residency as he felt that this would best prepare him for a career in rural primary care. Since relocating to East TN, he is now working at Mountain People’s Health Council (MPHC), which is a Federally Qualified Health Center (FQHC) organization that is funded by the federal government to serve the citizens of Scott County. There are currently 5 medical clinics as well as a pediatric clinic, dental clinic, and a built-in behavioral health clinic. One of the biggest barriers (setting aside the financial aspect) that Dr. Lowe has noticed limiting healthcare in rural settings is the lack of primary care physicians. At MPHC, Dr. Lowe is only one of three physicians on staff and he is the only pediatrician serving the entire county. This ultimately leads to poorly delivered or fragmented care, increased healthcare resource utilization through excess referrals, and over utilization of the ED/urgent care. There are so many sick patients who truly need a physician’s expertise, and Dr. Lowe is hoping that in the near future residents who are interested in a career in primary care will have the opportunity to rotate at MHPC. Becoming a physician was always Dr. Lowe’s dream, and now he is fulfilling his lifetime goal of serving the people where he grew up.

Resident Spotlight: “Dr. Bita Imam”

This month we would like to shine a spotlight on Dr. Bita Imam, a wonderful addition to the UT Graduate School of Medicine’s Internal Medicine Residency Class of 2026. Dr. Imam was born in Iran and moved to Canada at a young age. She describes a “thirst for knowledge” throughout her life. Dr. Imam pursued a PhD in Rehabilitation Sciences from the University of British Colombia and graduated in 2017. During this time, she describes working with patients with lower limb amputations and spinal cord injuries and although she “enjoyed the intellectual aspect”, she wanted to delve further into “treatment and patient care”. In tune with her thirst for knowledge, she decided to apply to medical school in 2019. After graduating she began residency in July 2023 where she has thrived and, while juggling busy intern year, continues to publish with her PhD advisor. She has expressed an interest in both primary care and Rheumatology.

Points of View

continued from page 1

many reasons for this shift. In my view, two factors stand out. The first is the advent of technology. A computer and a mouse may not have found their way into my granddaughter’s ‘Doctor kit’ yet, but they are responsible for the majority of the time that physicians spend in their workday. This work often spills over into their homes, extending well beyond their ‘normal’ workday. The notes generated in electronic medical records are often impersonal and fail to reflect the physician’s thoughts about the diagnosis and treatment. The sheer volume of data in these records can be overwhelming and repetitive without providing much useful information. To restore some balance, we need to redistribute the workload, allowing physicians to spend more time with their patients and less time with their keyboards. The other factor for physician dissatisfaction is the loss of control. There are too many “chefs in the kitchen,” so to speak, and physicians are bewildered by the regulations and “system” requirements that hinder them from providing efficient and personalized care to their patients. We are told to practice “Evidence-based” medicine. However, the evidence is based on a population with only one disease. In contrast, today, most people have multiple diseases and the art of practicing medicine is to personalize care for patients with a variety of concurrent disorders. Health insurance adds another layer of frustration to the mix. To overcome the malaise among physicians, we must restore the “physiciancentric” system of yore that prioritized caring for patients and remove the layers of bureaucracy that steal the joy of practicing medicine.

Diversity, Equity, Inclusion Spotlight: “Dr. Tina Dudney”

Even on the best days, communication in clinical settings is pressured. The stakes can be high and distrust increases when we can’t communicate effectively. Language barriers exacerbate this problem exponentially. GSM DIO Dr. Tina Dudney, UFP’s Dr. Taylor Wright, and Dr. Harrison Meadows from UTK’s department of World Languages and Cultures have been working on a Spanish elective for residents to help close these gaps.

“During COVID, we realized how much the ability to communicate was a social determinant of health,” said Dr. Dudney. “If providers, patients, and families can’t communicate effectively; patient care suffers. We need to address language barriers as a matter of health equity.”

Some language resources are in place at UTMC already. We are extremely fortunate to have two certified medical Spanish interpreters who are available Monday through Friday, 8am-5pm, for in-person interpreting. Additionally, CyraCom is a digital service that is accessible hospital-wide via iPads for interpretation in many languages, including American Sign Language (ASL).

The aim of the Spanish elective is not to replace medical interpreters, Dr. Dudney said, but for residents to become proficient enough to conduct some of the medical interview in Spanish. Doing so conveys respect and increases mutual understanding and trust between patients and providers. The first cohort will begin in January 2025 and another the following May and will include both interactive and asynchronous elements.

“I’m so grateful for the support of UHS and GSM, and for our collaborative partnership with UTK, as we improve communication between physicians and our patients and their families,” said Dr. Dudney.

Faculty Spotlight: Dr. Janet Purkey

The UT Department of Medicine congratulates our very own, Dr. Janet Purkey, for being selected as the WATE Channel 6 winner of Nexstar’s 2024: Remarkable Women of the Year Award. This prestigious award honors women across the nation who have inspired and lead the way for other women in the fields of public policy, social progress, and improved quality of life.

Since 2013, Dr. Purkey has served as Medical Director alongside a team of dedicated volunteers at the East Knox Free Medical Clinic (EKFMC) within Magnolia Avenue Methodist Church in Knoxville, TN on Monday afternoons. EKFMC fills a gap in medical care since most patients have no insurance while others with insurance are unable to afford the cost of transportation or co-pays. When reflecting on her years of service, she states, “I am humbled to have received this award because I truly love what I do! I have a heart to help others. Having internal medicine residents and medical students join me most Monday afternoons is a special joy because I enjoy teaching the next generation of physicians. They see a different set of ‘barriers to care’ in real time while performing much appreciated community service.” In her role as the Medical Student Clerkship Director, she oversees many 3rd year medical students completing their core clerkship in medicine as well as the occasional 4th year medical students. Furthermore, the Internal Medicine residents now have an elective rotation titled, Social Disparities & Healthcare, where they spend four weeks across multiple clinics serving the underserved!

Finally, Dr. Purkey states that, “we are always looking for volunteers, whether it’s a regular commitment or just a ‘one and done’, all levels of help are very much appreciated”. If you are looking for a way to help serve the EKFMC, please reach out to Dr. Purkey directly or the Department of Medicine.

Faculty & Staff Announcements: New Faculty

We are pleased to welcome Dr. Megan Bill for her appointment to the rank Clinical Assistant Professor. She completed her medical school at the Lincoln Memorial University DeBusk College of Osteopathic Medicine in Harrogate, TN. She completed a residency in neurology at Indiana University in Indianapolis, IN. Dr. Bill was very active in advocacy work and was Chief Resident of her neurology residency program.

We are excited to welcome Dr. Sarah Jenkins to the Department of Medicine as Clinical Assistant Professor. Dr. Jenkins completed her medical school at the University of Alabama at Birmingham, AL. She completed a residency in internal medicine at Wake Forest Baptist Medical Center in WinstonSalem, NC, followed by a fellowship in medical oncology at the National Institute of Health in Bethesda, MD. Dr. Jenkins was chosen for a predoctoral grant from the Department of Defense Breast Cancer Research Program.

We are delighted to welcome Dr. Igal Mirman for his appointment to the rank of Clinical Assistant Professor in the Department of Medicine. He completed his medical school at St. George’s University School of Medicine in Grenada, West Indies. Dr. Mirman completed a residency in neurology at the University of Tennessee at Memphis, followed by a fellowship in neuromuscular disorders at the Mayo Clinic in Rochester, MN. He served as Chief Resident at the University of Tennessee Health Science Center.

We are thrilled to welcome Dr. Sarah Parker to the Department of Medicine as Clinical Assistant Professor. Dr. Parker completed her medical school at the University of Illinois at UrbanaChampaign in Urbana, IL. She completed a residency in adult neurology followed by a fellowship in vascular neurology at the University of Illinois at Peoria in Peoria, IL. Dr. Parker was very active in teaching and was chosen for Neurology Residency Faculty of the Year in 2016.

We are happy to welcome Dr. Morgan Randall for his appointment to the rank Clinical Assistant Professor. He completed his medical school at the University of Kentucky in Lexington, KY.

Dr. Randall completed a residency in internal medicine at the Medical University of South Carolina in Charleston, SC followed by a fellowship in cardiovascular medicine and interventional cardiology at the University of Florida in Gainesville, FL.

Faculty Recognition: Dr. Albert Quiery

Dr. Randall was very active in teaching and research, he was chosen for the Carl J. Pepine, MD Research Award.

We wish to congratulate Dr. Albert Quiery for his appointment as Associate Program Director of the Hematology and Oncology Fellowship. Dr. Quiery completed his medical school at Albert Einstein College of Medicine in Bronx, NY. He completed a residency in internal medicine at Stony Brook University Health Sciences in Stony Brook, NY followed by a fellowship in hematology/oncology at Duke University in Durham, NC. Dr. Quiery founded the Geisinger Bone Marrow Transplant Program while working with Geisinger Health Systems in Pennsylvania. He is still very active in teaching and research. We are lucky to have him here at the UT Graduate School of Medicine (UTGSM).

Scholarly Activity - Pulmonary Critical Care Publications:

• Biney IN, Ari A, Barjaktarevic IZ, Carlin B, Christiani DC, Cochran L, Drummond MB, Johnson K, Kealing D, Kuehl PJ, Li J, Mahler DA, Martinez S, Ohar J, Radonovich LJ, Sood A, Suggett J, Tal-Singer R, Tashkin D, Yates J, Cambridge L, Dailey PA, Mannino DM, Dhand R. Guidance on mitigating the risk of transmitting respiratory infections during nebulization by the COPD Foundation Nebulizer Consortium. Chest. 03/01/2024; 165 (3) : 653-668. PMID 37977263

CME OPPORTUNITIES—MARK YOUR CALENDARS!

currently hybrid attendance: half joining via Zoom or Microsoft Teams

• Cardiology Conferences, held weekly on Wednesdays from 12:15 – 1:00pm in the Medicine Conference Room and are available for 0.75 hour CME credit.

• Medicine Grand Rounds, held on the 2nd & 4th Tuesdays each month from 8:00-9:00am in the Medicine Conference Room and are available for 1.00 hour CME credit.

• Ethics Case Rounds, held on the 4th Thursday of each month from 12:00-1:00pm in Wood Auditorium and are available for 1.00 hour CME credit.

• Pulmonary/HTN Conferences, held on the 2nd Monday each month from 12:00 – 1:00pm, in different locations and are available for 1.00 hour CME credit.

Ethics Case Rounds: When Family Disagrees with the Living Will

Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality.

“Fred” is an 83 y/o gentleman who presented to the Emergency Department (ED) from a rehab facility with altered mental status, aphasia, and unequal pupils. He had a POST form that specified DNR, comfort measures, and no artificial nutrition. He was accompanied by his daughter, “Carmella,” who asked that the team “make him a Full Code and do everything”.

Fred had presented to UTMC with multiple injuries from a fall, including a subdural hematoma (SDH), two weeks prior. Prior to that admission, he had been living independently and was relatively active. Fortunately, his condition had improved, and he was discharged to inpatient rehab. An ethics consult was requested to assist with goals clarification.

Advance Care Plans

Advance care plans and POST forms are documents designed to communicate patients’ preferences for care to providers when the patient is incapacitated. While useful, they are limited by several factors. To begin with, they cannot anticipate every situation a patient may encounter, and patients don’t always understand the possible sequelae of the choices they make. Documents can be vague and open to interpretation, or overly specific. And if surrogates don’t understand (or agree with) the instructions therein, conflict can ensue. Educating surrogates about their role, i.e., to make decisions according to the patient’s values, goals, and preferences may help reduce their stress and lessen projection bias.

The ethics consultant met with Fred and Carmella in the ED. Fred was too somnolent to answer even simple questions, but Carmella was open to discussing goals of care. She said Fred was “a social butterfly” and liked being independent, but recognized he was “starting to slow down”. He had said he would tolerate living with family or in long-term care as long as he could maintain some mobility and independence. Ultimately, she felt he would want to have interventions that were likely to improve his ability to be independent for ADLs but would not want a QOL in which he was completely dependent.

After lengthy discussion, the daughter and team were agreeable to admission to see if there were interventions that would not be burdensome and could put him back on track for rehab. Carmella said if there were not, she would want to re-examine goals of care. She was agreeable to code status of DNR/I.

The following day, Fred was still aphasic, pleasantly confused, and did not appear distressed. The neurosurgeon said his condition was common after the kind of injury he had sustained and is often reversible. He said burr holes would be minimally invasive and would have a good chance to greatly improve his condition – but that if they did not, there would be nothing further to offer. Without intervention, his neuro condition would likely worsen. Carmella wanted to proceed with burr holes. All agreed that if he improved as a result, he would go to rehab, and if not, he would go home with Carmella with home health or hospice for support.

Burr hole procedure was performed, and Fred improved steadily. He was able to talk, eat, and work with PT/OT when he was discharged back to inpatient rehab.

Comments on this case may be sent to amendola@utmck.edu

References

• Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: A Framework for Goals of Care Conversations. J Oncol Pract. 2017 Oct;13(10):e844-e850. doi: 10.1200/JOP.2016.018796. Epub 2017 Apr 26. PMID: 28445100.

• Cunningham TV, Scheunemann LP, Arnold RM, White D. How do clinicians prepare family members for the role of surrogate decision-maker? J Med Ethics. 2018;44(1):21-26. doi:10.1136/medethics-2016-103808

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!

In Touch

Vol. 13 Issue 2: April 2024

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

Shawna Stephens, DO

Ashley Gutierrez-Santana, MD

Erin Hamric, DO

Logan Shaver, DO

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