In Touch April 2014

Department of Medicine

Con necting Tec h n olog y, Educ a tion a n d D iscov e r y w i t h H u m a n i s m i n M e d i ci ne

Vol. 3 Issue 2 April 2014

The Quiet Servant

The theme for this issue of In Touch is “Service.” Last April we highlighted the work of a few individuals and in the process did not acknowledge the work of dozens more. Service beyond the day-today practice of our specialties is the rule, not the exception, in the Department of Medicine.

There are many who work within the system to make life better for their patients. They create fundraisers to help cancer patients who cannot afford chemotherapy. They solicit donations to provide gas cards for patients whose finances are so limited they can hardly afford to drive to their appointments. They establish programs to give Christmas baskets to families devastated by the financial, physical, emotional and spiritual ravages of catastrophic disease.

Some serve as board members of organizations whose vision is to establish a clinic that will never show a profit. Their mission is to make a place that welcomes the disenfranchised, the helpless, the hopeless, those people who work as hard as they can but find that health care is still a luxury they cannot afford. They negotiate free lab services, solicit free medicine, and search for free space in which to answer a call not fulfilled in their private practices, which is to be a physician to someone who otherwise would not have one.

A few work on a grander scale, organizing medical mission trips to third world countries where they work in villages lacking plumbing or clean water, places where the most common form of malnutrition is not obesity. They become experts in creating, organizing. They transform into specialists treating AIDS, malaria, and tuberculosis, diseases they may never see at home.

It is impossible to know the full measure of service the ambassadors from this department have given. Their cumulative years of service would probably be measured in decades. The lives they have touched might fill Neyland stadium. Yet, even with the aggregate of good that has been and will be done, these folks will not see their name on a brass plaque in a beautiful new clinic on the good side of town, nor will

Points of View

Rajiv Dhand, M.D., Chair

they be given a bonus for exceeding expectations of those who see the practice of medicine as a commodity and not a calling.

We are surrounded by these people whose joy does not come from being noticed, folks who allow their heart to guide their mind, visionaries who follow a calling that is gratifying rather than lucrative, quiet servants who seek to change lives and find that in the process, their own is enriched.

During my training there was an inordinate emphasis on the clinical examination. Missing a physical “finding” often meant the difference between success and failure in the final examination. Medical students and residents spent countless hours palpating abdomens, listening to heart murmurs and lung sounds, and eliciting neurological signs to localize lesions in the brain and spinal cord. Several years ago, I was consulting on a veteran in his mid-40s whose chest CT scan showed 2 sub-centimeter lung nodules in his right lung. He had been diagnosed with a malignant melanoma 16 years previously

while stationed in Okinawa, Japan, and still bore the disfiguring scars of a radical neck dissection to remove metastatic lymph nodes. The remainder of his physical examination was normal except for the absence of his left ankle jerk. An MRI of the spine found multiple epidural lesions, which were confirmed to be epidural metastases from melanoma on surgical biopsy. Thus, the etiology of the lung lesions was determined by a good neurological examination!

The clinical examination often reveals subtle signs that provide telltale clues to the underlying diagnosis. Unfortunately, a thorough clinical examination is rapidly becoming a relic of the past. There is an over-reliance on modern technology to arrive at a diagnosis that could be more readily provided by careful use of our “special” senses. We must encourage our medical students and residents to be skilled at eliciting and interpreting abnormal physical signs in a variety of disorders. In my view, acquiring these skills is necessary to becoming the consummate physician.

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Read Me A Story Pediatric Genetics Consult • Family history of a genetic condition • Intellectual disability/ Developmental delay • Multiple congenital anomalies • Failure to thrive • Abnormal newborn screen • Dysmorphic features/ Ambiguous genitalia • Idiopathic short or tall stature • Unexplained seizures

Adult Genetics Consult • Family history of a genetic condition • Personalized Medicine

People oversimplify the complexity of human organs by comparing them to man-made machines. The eye is like a camera. The brain is like a computer. The lungs are just a bellows sucking in air and blowing it out again. Matt Ridley, the author of Genome, compares the human genetic code to a book. There are 23 chapters called chromosomes, thousands of stories called genes, paragraphs called exons interrupted by commercials called introns, all written in letters called bases grouped into words called codons. There are billions of letters forming the words that tell more than 20 million stories, forming a manuscript equivalent in size to 800 copies of the King James Version of the Bible.

Given the sheer number of codons (words) involved, the potential for error is immense. If the book is exposed to a challenging environment, a few pages may be rendered unreadable. The random omission of a paragraph, the duplication of a sentence, or a misplaced punctuation mark, may change the meaning of an entire chapter. A single word change introduced generations ago provided a selective advantage against malaria but caused a devastating hereditary disease known as sickle cell anemia.

Medical geneticists are the curators of this 5000 volume book. Clinical geneticists see patients whose families have a pattern of symptoms or diseases that are suspected to be a heritable disorder.

They are sometimes asked to see patients with intellectual disabilities and dysmorphic physical features that until recently have been identified only in descriptive terms. Just like clinicians in other specialties, they take a medical history and examine the patient. The family medical history is particularly important because people who have a family member with a particular disease may be at risk of developing that same disease.

Clinical geneticists collaborate with other medical genetics specialists who are experts in the molecular, cytogenetic and biochemical analysis of the genome. They use ever evolving state-ofthe-art technology to examine a patient’s DNA and attempt to identify mutations that might answer some of these pertinent clinical questions.

Geneticists work with an interdisciplinary team of nutritionists, social workers and genetic counselors, professionals with advanced studies in genetic diseases. Together they advise couples before or during pregnancy who are at an increased risk of passing genetic abnormalities to their children. They make recommendations to people who may have an increased risk of hereditary cancer or thrombophilia. They provide guidance to parents whose child may have been found to have a disease discovered during newborn screening.

So…the genome is like a book. Life is a narrative. Read the book. Get a translator if you need it. Tell the story.

Adult Cystic Fibrosis Center Cystic Fibrosis (CF) is a genetic disease that causes the glands of the respiratory and gastrointestinal tract to produce thick, sticky mucus.

Accumulation in the airways causes cough, difficulty breathing and frequent pulmonary infections. Damage to the gastrointestinal tract may cause malabsorption and wasting. In the 1950s, CF patients usually died in childhood. Now, the average life expectancy is in the mid-30s.

This change in the natural history of the disease has created a need for CF experts who are physicians to adults. The University of Tennessee Medical Center in conjunction with East Tennessee Children’s Hospital developed the only Adult Cystic Fibrosis Center in East Tennessee to meet this need. Its presence has allowed many patients to relocate their care to Knoxville rather than drive several hours to other medical centers.

Bruce Ludwig, MD, has been the medical director of the CF center since it opened in January 2011. He leads a multidisciplinary team of physicians, nurses, nurse practitioners, physical therapists, respiratory therapists, social workers and registered dietitians who see patients three days per month. They support the patient in all aspects of the disease, from hospital admissions for acute crises, to outpatient chronic disease management, as well as dealing with the unique stresses experienced by those who live with a disease they have had since birth. Dr. Ludwig plans to expand the research efforts of the CF Center to include a full menu of clinical, pharmaceutical and investigator driven studies. He is From left to right you have Kenny Hayes, Pharmacist; Scott Elder, Respiratory Therapist; Rhonda Mathes, RN Study Coordinator, Bruce Ludwig, MD; Medical hopeful that newer medicines will modify the behavior of the disease, further prolonging survival and improving quality of life.

Director; Kelly McClung, RN Study Nurse; Natalie Varner,PhD; Research Coordinator HLVI 2

Resident Feature: Serenity through Service

As a Religious Sister of Mercy, I made four promises to God. The first three of these vows are common to all those in a religious community, namely poverty, chastity, and obedience. The fourth vow, unique to my Community, is that of service to the poor, sick, and ignorant. In 1831, in Dublin, Ireland, Catherine McAuley founded a community of religious women known as the Religious Sisters of Mercy, to perpetuate her service to the poor. She began by taking up poor young girls from the street and teaching them a trade so that they would not succumb to a life of prostitution. Today, the Community carries on this legacy of mercy by educating themselves to a high degree so that they may in turn help others to lift themselves out of their situation of need. As a Religious Sister of Mercy and a resident physician at UT, I find myself challenged daily to form my mind intellectually and my soul spiritually. The key to living them both peacefully has been to realize that they must be fully integrated, and I must never tire of living not for myself but for others. Through a rigorous schedule of daily prayer and study, I hope to improve the service I offer those in need.

Second Annual Medicine Conference The Second Annual Medicine Conference: Today’s Technology and Treatment Trends was held February 28 – March 1, 2014 at UT Conference Center, Knoxville. The topics were selected for their relevance to primary care practice. These distinguished speakers, including several experts from the UT Graduate School of Medicine, gave presentations on a broad spectrum of topics that evinced a great deal of interest from the audience: David Patterson, PhD

Pictured from left to right are Annette Mendola, PhD, Russell J. Smith, MD, Tom Miller, MD, Rajiv Dhand, MD, and Daniel Ely, MD.

Norm Walton, MD

Annette Mendola, PhD

Laura Bullock, PharmD James Cox, MD

Mark Anderson, MD

William Law, Jr., MD

John Callison, MD

Richard Gibson, MD

Brian Wiseman, MD

Tom Miller, MD

This annual educational activity is directed by Dr. Dan Ely and Dr. Russell Smith.

Continuing Education Opportunities:

The University of Tennessee Graduate School of Medicine, Department of Medicine, offers the following educational courses.

Department of Medicine Grand Rounds

Cardiology

(Approved for 1 hour AMA credit)

(Approved for .75 hour AMA credit)

8:00 AM – 9:00 AM 2nd and 4th Tuesdays, Morrison’s Conference Room, except for April 22nd, which will be the department’s quarterly meeting.

University of Tennessee Medical Center, Knoxville

12:15 PM – 1:00 PM Weekly on Wednesdays in Morrison’s Conference Room

Tenth Annual Hematology Conference: An Update on Selected ASH Topics

From L to Right Thomas Habermann, MD, Wahid Hanna, MD, Craig Kitchens, MD, Michael Keating, MB, BS, MD

The Tenth Annual Hematology Conference was held January 11, 2014. This local conference is an excellent opportunity for physicians who do not attend a national conference to hear acclaimed speakers discuss recent advances in hematology. The annual update occurs as soon as possible after the American Society of Hematology (ASH) international conference, while allowing time for the featured speakers to develop unique presentations combining their areas of expertise with new information garnered from the ASH presentations. Nationally acclaimed experts in their fields led discussions, including Thomas Habermann, MD, Mayo Clinic; Michael Keating, MB, BS, MD Anderson Cancer Center; Craig Kitchens, MD, University of Florida; Rami Komrokji, MD, H. Lee Moffitt Cancer Center; and Sagar Lonial, MD, Winship Cancer Institute.

The update is directed by Wahid Hanna, MD, Professor, UT Graduate School of Medicine, Department of Medicine.

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Clinic Star Award

The UT Internal Medicine Center is now awarding stellar residents with the Clinic Star Award. A “Resident of the Month” is given to an internal medicine resident who excels in the areas of patient care, medical knowledge, practice improvement, interpersonal/communication skills, and professionalism. The award winners thus far this academic year are: Dr. Christen Fleming—September 2013 Dr. Nathan Smith—October 2013 Dr. Andy Dake—November 2013 Dr. Mehul Patel—December 2013 Dr. Brock (TJ) Mitchell—January 2014 Dr. Moses Osoro—February 2014 The winners receive a gift card, and at the end of the year, one of the recipients is chosen by ballot as the Clinic Star of the Year. We are proud of our residents’ excellent performance in their clinic and are glad to see their excellence rewarded.

Guest Speakers On Tuesday, February 25, 2014, we had the pleasure of Christopher Bunick, MD, Instructor, Yale Department of Dermatology, presenting the Department of Medicine Grand Rounds “Molecular Dermatology: Understanding the Structure and Function of Skin Barrier Proteins Using X-Ray Crystallography”

Christopher Bunick, MD

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.

In Touch

Volume 3, Issue 2: April 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 UT Graduate School of Medicine Department of Medicine 1924 Alcoa Highway, U-114 Knoxville, TN 37920 Telephone: 865-305-9340

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!

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