In Touch Newsletter - July 2017

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. 6, Issue 3: Jul. 2017

Technology’s Influence On Graduate Medical Education

Advances in technology have evolved at a rapid pace and created a dynamic field in medicine. New information, drugs, diagnostic tests, medical devices, and diseases are increasing at astonishing rates. These changes have drastically impacted the environment of graduate medical education. At times, these changes are quite visible.

Dr. Aimee Wehber saw a prominent shift in the role of cell phones. When she started medical school, students and residents stealthily checked their cellphones. Now, everyone is consulting an app on their phone, Googling rare diseases, or returning pages on PerfectServe. Not only is the mode of paging changing but medical records as well. The implementation of the electronic medical record (EMR) came with mixed reviews.

It provides a centralized location for years of medical records that multiple different providers can access simultaneously.

However, the opportunity to clone notes in an attempt to boost productivity is enticing. Dr. Marc Collins noticed a trend for time-crunched residents to rely on prior information in lieu of interviewing patients. With EMR came the challenge of documentation that Dr. Kristen McFarland witnessed, “As a medical student, we spent more time at bedside teaching. It has shifted to teaching behind a computer as residents need to

learn how to document and properly code to ensure adequate reimbursement.”

While EMR is a double-edged sword, technology has created a plethora of educational tools. There are innumerable smart phone applications, online board review courses, and even YouTube to brush up on physical exam skills or to review basic physiology concepts. Last year, the Hopkins Ambulatory online modules were introduced into the curriculum and met with warm praises from the residents. It can be overwhelming with the amount of information, however, Dr. Norwood emphasizes, “online education tools provide a wealth of knowledge, but it is a balancing act between knowing key information and knowing where to find it.”

Dr. Rasnake incorporated technology into the residency’s curriculum to harness an untapped resource. He utilizes the Simulation Lab to teach incoming interns how to properly place central lines. As the year progresses, Dr. Rasnake has future senior residents run mock codes which are taped for feedback. This year he expanded the curriculum by introducing basic ultrasound skills. Interns are now required to learn basic echocardiography skills. The goal is for interns to familiarize themselves with basic views, windows, continued on page 3

Points of View

physician-patient relationship. In the past, physicians provided information about the causation and treatment of their disease(s) to patients, but with almost unlimited information now available over the web, patients have access to information in chat rooms and blogs which may not be readily available in medical journals or textbooks. “Informed” patients then use the knowledge gained to evaluate the recommendations of their physicians. However, as physicians know only too well, there are many grey areas in medicine and patients may be misinformed or misinterpret the information they receive from the web. Moreover, on occasion, patients may find contradictory information and not know what to believe. At times, patients may be lured into trying risky and unproven “cures” for various maladies, putting them at odds with advice from their physicians. With patients becoming active consumers of health information, in several situations and on many occasions, the Internet has become a third party in the patient-physician relationship.

The Internet has made profound changes in people’s lives, and use of the Internet now permeates almost every aspect of human activity.

Increasingly, the public is turning to the Internet for information and guidance. The widespread use of the Internet has also had a major impact on the delivery of health care. In fact, health information Rajiv Dhand, MD, Chair is one of the most frequent topics searched online. We are all familiar with patients consulting “Doctor Google” before and after they have received a diagnosis from their physicians. Internet searches allow patients to empower themselves with current knowledge about their illness, and this is redefining the 1

Resident Spotlight – Meet Drs. Angotti, Dewald, and Lakkakula The Chief Residents for 2017-2018 are Drs. Jonathan Angotti, Jonathan Dewald, and Vamsee Lakkakula. They are honored and ecstatic to enhance educational opportunities ensuring both residents and students receive an exceptional training experience.

Dr. Angotti hails from Cordova, Tennessee. He is the ICU chief. He is working alongside a committee dedicated to restructuring the ICU lecture series. The goal is for all students, interns, and residents to receive core critical care presentations year round. When he is not wrangling the ICU schedule, he plays with his 100-pound Wolf-German Shepherd mix and snow white Siberian Husky. He is a keen photographer, and his SnapChats are not to be missed. Post-residency, he plans to pursue a Pulmonary Critical Care Fellowship.

Dr. Dewald is from Mansfield, Ohio. As clinic chief, he is smoothing out the new resident clinic PRN system that went live on May 8th. It was implemented to improve workflow and create a team environment to accommodate the growing volume of clinic patients. Currently, his spare time is split between fellowship applications for Pulmonary Critical Care, cheering on the Cleveland Cavaliers, and helping his beautiful fiancée, Meredith, plan their impending nuptials on August 5th.

Dr. Lakkakula calls Chattanooga home—despite being commonly confused as a native Hawaiian. He has never been, but he plans to remedy this in December. When he is not using his extensive knowledge at trivia, he spends time with his tabby cat, Simba, who has the mindset of a dog. After residency, he is planning on a cardiology fellowship. During his stint as housestaff chief, he will implement weekly student, intern, and resident presentations to include high yield board facts and augment clinical practice.

New Faculty

Please join us in welcoming two new faculty members to the Department of Medicine.

We are delighted to welcome Dr. Christopher Tolleson as a Clinical Associate Professor in the Division of Neurology. Dr. Tolleson attended medical school and completed an internship in internal medicine at the Medical College of Georgia in Augusta, Georgia. He completed his residency in neurology at the University of North Carolina Chapel Hill Hospital and completed a fellowship Christopher M. Tolleson, in movement disorders at Vanderbilt MD University. Dr. Tolleson began working in the Knoxville Neurology Clinic on Sutherland Avenue in May.

Rocio A. Huet, MD

We are pleased to welcome Dr. Rocio Huet as a Clinical Assistant Professor in the Division of Internal Medicine. Dr. Huet attended medical school at the University of Michigan Medical School.

She completed her internship in internal medicine at the University of Missouri, Kansas City Consortium for Health Education and did a residency at the University of Tennessee Research Center and Hospital. Dr. Huet has practiced with University Internal Medicine and Integrative Health since 2010.

Retirements Dr. Dale Wortham We wish to extend best wishes to Dr. Dale Wortham who retired on June 30. Dr. Wortham was hired as professor in 1994. He has served as Program Director of the Cardiology Program, as Chairman of the Department of Medicine Promotion and Tenure Committee and as Interim Program Director of the Interventional Cardiology Fellowship Program. He was recipient of the R.A. Obenour, Jr. Award in 2011-2012 and was recipient of the Beasley Pylon Award in 2015.

Dr. Wortham’s talents and contributions will be sorely missed.

Susan Hill The Department of Medicine wishes to congratulate Susan Hill on her retirement on April 27th. Susan joined the department in 2005 and provided loyal and dedicated service. She will be missed by her coworkers, the faculty, and residents.

Penny Reagan On April 1st Penny Reagan, Administrative Director of the Internal Medicine and Obstetrics/Gynecology Clinic, retired from full-time service. After a twoweek hiatus, Penny returned to help out in the Clinic.

She works in the Clinic an average of two days per week, and occupies her other days gardening, canning, making pottery, and spending time with her grandchildren.

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Comings and Goings

Tara Shields, MD – Private Practice in Oak Ridge, TN Cody Stroupe, MD – Cardiology Fellowship @ Oschner New Orleans Aimee Wehber, MD – Cardiology Fellowship here at UT

Goings

Transitional Year Graduates Jonathan Allred, MD, will begin a radiology residency at UTMCK. Brandon Birckhead, MD, will be going to the University of Wisconsin for a radiation oncology residency.

Matthew McKeever, MD, will begin a radiation oncology residency at the University of Chicago.

Cole Smith, MD, will be going to Oklahoma City (Integris Baptist Medical Center) to do a radiology residency.

Eric Sollenberger, MD, is going to U. Memphis @ Hamilton Eye Institute to do ophthalmology.

Adam Zalis, MD, will begin a radiology residency at UTMCK.

Internal Medicine Graduates

Cardiovascular Fellowship Graduates David Perkel, MD – Joining University Cardiology University Health Systems, and Clinical Assistant Professor of Medicine, Knoxville, TN Moses Osoro, MD – private practice – East Tennessee Medical Group, Blount Memorial, Maryville, T Interventional Cardiology Fellowship Graduates Neelima Katukuri, MD – Pending private practice

Internal Medicine Graduates

Marc Collins, MD – Rheumatology Fellowship @ UAB Reem Hussein, MD – Hospitalist here at UT Emmanuel Isang, MD – Hospitalist in Neptune, New Jersey Kristen McFarland, MD – Private Practice here at UT (UT Internists) Jaime Morris, DO – Cardiology Fellowship here at UT Amar Parikh, MD – Hospitalist in Oak Ridge, TN Katoura Patterson, DO – Private Practice in Lenoir City, TN Lindsay Rumberger Rivera, MD – Hospitalist in Anchorage, Alaska Brandon Sammons, DO – Private Practice in Tellico Village

Comings New Internal Medicine Residents Ryan Alexander, DO – Lincoln Memorial University Alexander Nourse, DO – Alabama College of Osteopathic Medicine Tyler McLaurine, MD – Medical University of the Americas – Nevis Alina Novoa, DO – Edward Via College of Osteopathic Medicine Spencer Leong, MD – St. George’s University James Livesay, DO – University of Pikeville-KY College of Osteopathic Medicine Zachary Marlette, MD – University of Tennessee Health Science Center Wm David Robinson, DO - Lincoln Memorial University Sneha Thakur, MD – New York Medical College David Wilson, DO - Lincoln Memorial University Ryan Dorman, DO - Lincoln Memorial University Jason Frisbee, DO - West Virginia School of Osteopathic Medicine New Transitional Year Residents Alexander Hicks, MD – ETSU, going into Derm @ Vanderbilt in 2018 Evelina Pierce, MD – UAB, going into Derm @ Univ Alabama in 2018

Pulmonary/Critical Care Fellowship Graduates Anil Singh, MD – private practice – Pulmonary Critical Care Consultants Group, Methodist Dallas Medical Center, Dallas, TX Rishi Sehgal, MD – Sleep Medicine Fellowship at Vanderbilt Anne Rajkumar, MD – UT, going into Rad/Onc @ Vanderbilt in 2018 Daniel Fulks, MD – West VA Univ Sch of Med, going into Radiology here in 2018 Alan Itkin, MD – International Univ of Hlth Sci, going into Radiology here in 2018 Ernest Fonocho, MD – Texas Tech Univ, going into Radiology here in 2018 Wesley Ingram, MD – Univ South AL, going into Radiology here in 2018 New Cardiology Fellows Jamie Morris, MD – University of Tennessee Graduate School of Medicine – Knoxville Aimee Wehber, MD – University of Tennessee Graduate School of Medicine – Knoxville New Interventional Cardiology Fellow No new fellow at this time New Pulmonary Disease/Critical Care Medicine Fellows Swati Baveja, MD – St. Vincent Hospital, Worcester, MA Mark McCommons, MD – East Tennessee State University, Johnson City, TN Naveed Sheikh, MD - Completed Pulmonary Disease Fellowship June 2014 from University of Tennessee Graduate School of Medicine, Knoxville, TN and since fellowship has been working as a pulmonolgist at Oak Ridge Pulmonary Practice. Is returning to complete a Critical Care Fellowship.

New Program Director for the Interventional Cardiovascular Fellowship We are pleased to announce Dr. J. Christopher Scott assumed the role as the Program Director for the Interventional Cardiovascular Fellowship Program on July 1, 2017.

Technology’s Influence On Graduate Medical Education

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normal and abnormal physiology. Additionally, there are opportunities to learn more ultrasound skills such as the Focused Assessment with Sonography for Trauma (FAST) exam, abdominal ultrasound, pelvic and transvaginal ultrasound techniques.

Technology created a shift in the paradigm of graduate medical education. The structure, content, and delivery of medical education continue to adapt as medicine evolves. These changes reflect the dynamic nature of healthcare and reflect on how graduate medical education must be dynamic as well. While it is imperative to stay abreast of new technology, it should be used to augment our current knowledge base and promote lifelong learning strategies.

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Faculty and Resident Awards and Honors We wish to congratulate Dr. Lesley Jackson for being elected as the chair to the Tennessee Medical Association Governing Council for the Resident-Fellow Section for the State of Tennessee. This is a huge honor and is the highest position a resident/fellow can hold on the TMA council.

Dr. Cody Stroupe won second place for “Persistent Bacteremia Secondary to Delayed Speciation of Lactobacillus in the Setting of Mitral Valve Endocarditis”, and Dr. Aimee Wehber won third place for her presentation, “Sepsis Masked by an Initial Trauma Presentation: A Case Illustrating Physician Bias.”

GSM Awards Presented on Resident and Fellow Research Day 2017

Rawson Recipients

We are pleased to announce that Lesley Jackson, MD, received 2nd place for her case presentation, “Multiple myeloma with amyloidosis: A clinical conundrum.”

Dr. Vamsee Lakkakula received 3rd place for his case presentation, “Cervicofacial emphysema: A rare complication following nasotracheal intubation.”

Dr. Kristen McFarland, PGY-3, and Dr. Jon Angotti, PGY-2, won the Rawson Award presented at the 2017 Department of Medicine Residents’ and Fellows’ Awards Dinner, which was held on Sunday, June 18, at the Concord Yacht Club. This award is given in fond memory of Freeman Rawson, MD, who was a Clinical Professor Emeritus and founding member of the Knoxville Cardiovascular Group. He joined the Department of Medicine in 1956 as one of our first teaching faculty and was known for his compassion and expertise. Dr. Rawson passed away in 2003.

Introducing the New Administrative Director for the Residents’ Clinic

The Residents’ Clinic has a new Administrative Director! Kay Rangnekar has filled the position that was vacated when Penny Reagan retired earlier this year.

“Kay brings a unique and valuable set of skills to the table,” says Medical Director Dr. Juli Williams. In addition to having a Masters in Health Management and Informatics and her certification in Medical Coding, Kay was a practicing dentist before her children were born. As a former clinician, she understands providers want to spend most of their time providing care, which is why she is interested in health care quality, information systems, and EMR software. “If processes are well-designed, then information can get to everyone who needs it without a lot of extra work of hunting for it,” she says.

“Coding and billing have become an integral part of health care delivery, and Kay has been instrumental in teaching residents how to do this well,” observes Dr. Williams. With Kay’s guidance, residents have been working on informatics solutions for issues in the Clinic. For example, they developed a protocol for getting established patients who have developed an acute problem in to clinic promptly, helping them to avoid going to the ED instead. The protocol benefits the patient, the clinic, and the ED, and it makes wise use of healthcare resources.

Kay believes streamlining the documentation, coding, and billing processes will decrease some of the burnout in primary care that is due to the increase in regulations and requirements.

“That,” she says, “is my goal.”

Clinic Star of the Year

The UT Internal Medicine Center presented Clinic Star Awards throughout this academic year. The recipients were Drs. Tara Shields, John Angotti, Leigh Schlactus, Reem Hussein, Dennis Lester, and Henry Shiflett.

The Clinic Star of the Year Award was presented to Dr. Kristen McFarland at the Department of Medicine’s Residents’ and Fellows’ Graduation Dinner on June 18th. We wish to congratulate Dr. McFarland on receiving this well-deserved award.

3rd Annual Medicine Research Award Contest

The Department of Medicine held its third Annual Residents’ and Fellows’ Research Contest at the Medicine Grand Rounds on June 13, 2017. There were several excellent presentations, and the audience enjoyed Pictured from left to right Drs. Cody voting live for the winners.

Stroup, Rajiv Dhand, Avi Das, and Dr. Avi Das won first place Aimee Wehber for his presentation, “Using TIMI Score to Provide High Value Care in Low Risk Patients”,

Guest Speakers and Annual Medicine CME Conference We were honored to have R. Hal Scofield, MD, present the Department of Medicine Grand Rounds, “Cystic Fibrosis Related Diabetes: New Pathophysiology and New Treatment,” on Tuesday, June 27, 2017. Dr. Scofield is a Professor of Medicine at the University of Oklahoma. His research concentrates on the immunology, genetics and endocrinology of systemic lupus erythematosus and Sjögren’s syndrome. He has published over 275 scientific articles, and has had continuous funding by the National Institutes of Health since 1991.

The Fifth Annual Medicine CME Conference, “Current Practices for Primary Care and Updates for Clinicians – 2017” was held March 24-25, 2017 at the Holiday Inn World’s Fair Park. A variety of beneficial subjects were covered at this successful conference including thyroid function, headache, breast cancer, dermatology, pain management, an integrative approach for handling difficult patients, PPIs, and asthma.

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CME Opportunities—Mark Your Calendars!

• Weekly Cardiology Conferences, generally held on Wednesdays each week for .75 hour CME credit.

• Medicine Grand Rounds, which are generally held on the 2nd and 4th Tuesdays of each month for 1.00 hour CME credit.

• Ethics Case Rounds, which are held on the 4th Thursday of the month at noon in Wood Auditorium, are available for 1.00 hour CME credit.

Ethics Case Rounds - Seeking Balance in the ICU Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases.

Cases are de-identified to protect patient confidentiality.

Anthony was a 75-year old gentleman who was described by all who knew him as having a magnetic personality and a “can do” attitude. He continued to enjoy life after colon cancer left him with a colostomy; traveling with his wife and listening to jazz with friends. Even after he developed renal failure from recurrent peritonitis and required regular dialysis, he accepted pain, discomfort, and limitations on his lifestyle with forbearance and good cheer. However, his health worsened, with longer hospitalizations in worse condition.

Though he rallied several times when he was not expected to, he had been more often in the hospital than out in the last year, and had been encephalopathic and nonverbal for most of that time. At the time of the Ethics consult he was in the critical care unit, septic and intubated.

His wife, Loretta, was devoted to him and persistently requested the most aggressive treatment possible.

Her goal was for him to return home, even if it took a lengthy and difficult recovery, because “that’s what he’s always wanted, all these years.” While she was advocating for his wishes, at times her advocacy seemed colored by denial. Denial is a normal phase of grief, and “[w]ise clinicians often tolerate a fair amount of denial in patients and families … But denial can also become dysfunctional. It is not beneficial to inflict painful and futile treatments upon a patient who is in denial.” (Sulmasy, 2007) Interdisciplinary team meetings were held periodically. After many weeks of ICU treatment, the team came to the consensus that Anthony was now “chronically critically ill.” He was not expected to wean from the ventilator and had very poor chances for meaningful neurological recovery.

According to Kon, et al, ICU care should generally be considered inappropriate when (a) there is no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting, and/or (b) there is no reasonable expectation that the patient’s neurologic function will improve sufficiently to allow the patient to perceive the benefits of treatment. Using these guidelines, the team began to map out potential ICU treatments that might not be appropriate, keeping in mind that in the past Anthony had improved when not expected to, and was willing to go through a lot even if his quality of life was fairly limited.

Sure enough, Anthony’s condition began to stabilize, and he was able to tolerate some time off the ventilator. While his prognosis was essentially the same, discharge to a facility could be pursued.

However, shortly after that he developed a new infection. His condition deteriorated slowly, then precipitously. Loretta continued to request every possible intervention. In keeping with the plan, second opinions were sought about requested interventions that were “potentially inappropriate.” Despite aggressive management, he suffered a cardiac arrest and succumbed after several rounds of CPR. References 1. Bosslet, G., et al.” An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units” Am J Respir Crit Care Med 191:11 pp. 1318-1330 Jun 1, 2015 2. Kon, et al. “Defining Futile and Potentially Inappropriate Interventions: A Policy Statement from the Society of Critical Care Medicine Ethics Committee” Crit Care Med 2016; 44: 1769-1774 3. Quill, T et al. “Discussing Treatment Preferences with Patients Who Want ‘Everything’” Annals of Internal Medicine 2009; 151: 345-349 4. Sulmasy, DP “Distinguishing Denial from Authentic Faith in Miracles: A Clinical-Pastoral Approach” Southern Medical Association vol 100, no 12 (2007) 1268-1272.

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!

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In Touch Vol. 6, Issue 3: July 2017

Publishers James Neutens, PhD, Dean Rajiv Dhand, MD, Chair, Department of Medicine and Associate Dean of Clinical Affairs Editor Annette Mendola, PhD Administrative Director Susan Burchfield, CAP-OM Contributors Susan Burchfield Rajiv Dhand, MD Kandi Hodges Annette Mendola, PhD Azaria Ehlers, MD Kimberly Givens 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.