In Touch Newsletter - July 2018

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. 7 Issue 3 Jul 2018

Electronic Resources and Medical Education

on a section of material.” Other resources broadcast technical expertise in doing procedures to a widespread audience of learners. Clinical librarian Rebecca Harrington says YouTube videos are widely used as a resource, particularly for medical students and residents, and can be a useful peer-to-peer tool as well.

Of course, human expertise from our medical librarians and others enhance electronic resources. Harrington observes that, as search engines change to organize the volume of research generated, knowing what search terms to use can be a challenge. Terms evolve and change over time, and the same phenomenon can have different names in different disciplines or specialties. The staff at Preston Medical Library Health Information Center are on hand to help ensure you are getting the most out of the resources available.

Technological resources for education and information have limits, too. “It’s definitely possible to get ‘app overload,’” says Dr. Norwood.

Not every app is for every person. “You have to find your own workflow and decide what works best for you. And, of course, you still have to evaluate the information the app provides and decide if it is relevant.”

She notes that over-reliance on apps can blunt critical thinking. Part of learning how to use electronic resources is understanding when and for what to use them. Finally, clinical judgment, common sense, and professionalism must be learned from excellent teachers. No electronic resource can replace the guidance of a trusted mentor.

Approaches to medical education have co-evolved with information resources. While lectures and books are still part of medical education, physicians and medical students alike also use newer methods like medical simulation and mobile apps.

Where once one might have expected to master a body of medical knowledge, the rapid pace of discovery today has made this mastery impractical. Instead, learning how to access new and nuanced information has become a fundamental skill. Electronic resources have become essential for both learning and as a reference for all stages of medical education, from pre-med and medical school through residency and continuing education. Systems like Blackboard and Canvas, search engines like PubMed, and point-of-care resources like UpToDate have become ubiquitous. More recently, there has been a proliferation of apps and tools that can find and synthesize information, help juggle complex schedules, and even award CME credit. “Electronic resources tend to be underutilized, especially by faculty,” notes Dr. Daphne Norwood. “People may not be aware of everything that is out there.”

Some e-resources are improvements on their traditional predecessors.

“Resources like AccessMedicine and AccessSurgery are, essentially, the evolution of the medical textbook,” says Michael Lindsey, electronic resources librarian at the Preston Medical Library Health Information Center. “They combine screens of traditional text with multimedia cases. Users can even ask it to make up a bank of study questions based

Points of View

Rajiv Dhand, MD, Chair

to do research, we need a culture that promotes academics and scholarly activity. At present, the clinical workload tension as well as limited resources and research infrastructure are major deterrents to promoting research in our department. Over the past few years, several faculty members with strong academic interests have joined the department and are complementing the already flourishing basic science program that includes Dr. Wall and his team of talented investigators. Our research committee led by Drs. Emily Martin and Mark Rasnake is functioning well and plans to step up its efforts to streamline research in our department. A coalition is building to enhance research in the cardiology, pulmonary, infectious diseases, continued on page 3 rheumatology, and hematology/oncology

Looking back over the past several years, we have made significant strides as a department toward our missions of providing clinical care, education and public service. As we look to the future, the development of a research program needs greater emphasis. A strong research program requires a grassroots effort and commitment from members of the department across all disciplines.

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Comings and Goings

2018 Graduating Class pictured with Drs. Rasnake, Williams, and Sissy Ensor

NEW TRANSITIONAL YEAR RESIDENTS Matthew Curry, MD – University of Oklahoma College of Medicine Jacob DePolo, MD – Marshall University College of Medicine Kerry Hennessy, MD – University of Tennessee Health Science Center College of Medicine Andrew Johnston, MD – University of Tennessee Health Science Center College of Medicine Nicholas Link, MD – University of Louisville School of Medicine Kenan Wilhoit, MD – East Tennessee State University, Quillen College of Medicine

INTERNAL MEDICINE GRADUATES Jonathan Angotti, MD – Pulmonary and Critical Care Medicine Fellowship, Medical University of South Carolina, Charleston Matthew Boulos, DO – Pulmonary Nocturnist, Duke University Avi Das, MD – Hospitalist at Centennial Medical Center, Nashville, TN Jonathan Dewald, MD – Pulmonary and Critical Care Medicine Fellowship, St. Elizabeth’s Medical Center, Boston, MA Azaria Ehlers, MD – Locum Tenens Lesley Jackson, MD – Global Health Fellowship, Beth Israel Deaconess Medical Center, Boston, MA Vamsee Lakkakula, MD – Cardiovascular Fellowship, East Carolina University, Greenville, NC Dennis Lester, MD – Hospitalist here at UT Vimal Patel, DO – Hospitalist at Sacred Heart Hospital on the Emerald Coast, Miramar Beach, FL Adam Price MD – Nephrology Fellowship, Medical University of South Carolina, Charleston Spencer Pugh, MD – Pulmonary and Critical Care Medicine Fellowship here at UT Amber Sholl, DO – Hospitalist at Bon Secours St. Mary’s Hospital in Richmond, VA

CARDIOVASCULAR FELLOWSHIP GRADUATES Scott Cook, MD – Interventional Cardiology Fellowship at Virginia Tech Carilion Clinic, Roanoke, VA Kayleigh Litton, DO – Interventional Cardiology Fellowship here at UT NEW CARDIOLOGY FELLOWS William Black, MD – Brookwood Baptist Health, Birmingham, AL Jenna-Lyn Johnson, MD – Virginia Commonwealth University, Richmond, VA INTERVENTIONAL CARDIOLOGY FELLOWSHIP GRADUATE Kevin Oguayo, MD – Completing program on August 31, 2018

NEW INTERNAL MEDICINE RESIDENTS Omar Alsharif, MD – University of Tennessee Health Science Center College of Medicine Nikhil Jain, MD – St. George’s University College of Medicine Kathryn Majdick, MD – American University of the Caribbean Morgan Morelli, MD – University of Toledo College of Medicine William Nunemaker, DO – Lincoln Memorial University Kristin O’Connor, MD – St. George’s University College of Medicine Clinton Phillips, MD - University of Tennessee Health Science Center College of Medicine Scott Shubeck, DO - Lincoln Memorial University Karim Sleiman, MD, PGY-2 - East Carolina University, Greenville, NC Bryan Walker, MD – George Washington University School of Medicine Samuel Walker, DO – Edward Via College of Osteopathic Medicine Virginia James Wang, MD - University of Tennessee Health Science Center College of Medicine Heidi Worth, MD – American University of the Caribbean

Points of View

TRANSITIONAL YEAR GRADUATES Ernest Fonocho, MD – Radiology residency here at UT Daniel Fulks, MD – Radiology residency here at UT Alexander Hicks, MD – Dermatology residency at Vanderbilt Wesley Ingram, MD – Radiology residency here at UT Alan Itkin, MD – Radiology residency here at UT Evelina Pierce, MD – Dermatology residency at the University of Alabama at Birmingham Anne Rajkumar, MD – Radiation Oncology residency at Vanderbilt

NEW INTERVENTIONAL CARDIOLOGY FELLOW Kayleigh Litton, DO – University of Tennessee Graduate School of Medicine – Knoxville PULMONARY/CRITICAL CARE FELLOWSHIP GRADUATES Raakesh Sathya, MBBS Naveed Sheikh, MBBS NEW PULMONARY DISEASE/CRITICAL CARE MEDICINE FELLOWS Spencer Pugh, MD – University of Tennessee Graduate School of Medicine – Knoxville Fatima Wong, DO – Virginia Tech Carilion, Roanoke, VA

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divisions among others in the department. We also plan to be part of strategic alliances with statewide partners such as the Clinical Trials Network of Tennessee (CTN2), developed by UTHSC to promote clinical trials. Several members of the department have submitted grants to the National Institutes of Health (NIH) and other private foundations for funding. Securing grant funding will further enhance the reputation and prestige of our department. We sincerely wish our investigators success in their efforts because a vibrant and robust research program is crucial in becoming a true leader in academic medicine. We all need to come together to support this endeavor.

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Resident Spotlight - Meet Drs. Blair Reynolds, Christopher Hill, and Henry Shiflett The chief residents for 2018-2019 are Drs. Blair Reynolds, Chris Hill, and Henry Shiflett. They are all excited about their new leadership roles within the Internal Medicine Program and look forward to enhancing the educational experience of our residents and rotating medical students.

Dr. Hill will serve as the inpatient chief and will focus on patient census and overall hospital flow while working alongside the three house staff medicine teams consisting of the department’s academic hospitalists, Faculty Internal Medicine, and UTH faculty. His aim will be to continue to increase the inpatient census for our house staff teams, which will, in turn, lead to more exposure to a variety of disease processes for our residents. In the future, he will remain at UT Medical Center as part of the UT Hospitalist staff. Outside of residency, he likes to spend time kayaking around Knoxville with his wife and their fur-baby, a black lab. His favorite hobby, though, is food: cooking and especially eating.

Dr. Reynolds is originally from Milan, TN. She received her undergraduate degree from Middle Tennessee State University and received her medical degree from the University of Tennessee Pictured from left to right: Drs. Henry Shiflett, Blair Reynolds, Health Science Center in Memphis. She will be serving as the ICU chief this year and anticipates pulmonary and critical care fellowship interviews this fall. She is looking forward to continuing to and Chris Hill improve the daily ICU lectures for residents and medical students. When she is not working, she enjoys traveling and spending time with her husband, Jonathan, and their two dogs, Amelia and Willow.

Dr. Shiflett will serve as the clinic chief, focusing on improvement of quality measure data collection and clinic reimbursement. This work encompasses organizing coders, billers, office staff, attendings, and residents alike to integrate our EMR, improving patient care and efficiency. He plans to pursue fellowship training in infectious disease following completion of residency. A native Knoxvillian, he spends much of his time with local family and friends, but escapes to the Smoky Mountains to backpack and fish when possible.

New Interventional Cardiology Program Director Tjuan Overly, MD We are pleased to announce Dr. Tjuan Overly assumed the role of program director for the Interventional Cardiovascular Fellowship Program on July 1, 2018.

New Associate Program Director for the Internal Medicine Residency Program Janet Lubas, MD Dr. Janet Lubas joins Dr. Daphne Norwood as an associate program director for the Internal Medicine Residency Program on July 1, 2018.

Faculty and Resident Awards and Honors: Rawson Recipients Dr. Lesley Jackson PGY-3 and Dr. Sister Teresa Mary Kozlovski PGY-2 were presented with the Rawson Award at the 2018 Department of Medicine Residents’ and Fellows’ Awards Dinner, which was held on Saturday, June 2, at the Ft. Loudon 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.

CME Opportunities—Mark Your Calendars!

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

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

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

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Clinic Star of the Year

Dr. Dennis Lester pictured with Dr. Juli Williams, Clinic Director

Each year the UT Internal Medicine Center presents Clinic Star Awards throughout the academic year. The recipients this year were Drs. Lesley Jackson, Bill Lorson, David Wilson, Spencer Pugh, Ben Verzi, and Zach Marlette.

The Clinic Star of the Year Award was presented to Dr. Dennis Lester at the department’s graduation celebration on June 2nd.

Congratulations to Dr. Lester on receiving this welldeserved award.

4th Annual Department of Medicine Research Award Contest The Department of Medicine held its fourth Annual Residents’ and Fellows’ Research Contest on June 12, 2018. The audience enjoyed voting live for the winners following these informative presentations.

Pictured from left to right: Drs. Bimaje Dr. Jason Frisbee won first Akpa, Rajiv Dhand, Blair Reynolds, and place for his presentation, Jason Frisbee “Adverse outcomes associated with potentially inappropriate antibiotic use in heart failure admissions,” Dr. Blair Reynolds won second place for “Do plasma levels of biomarkers reflect muscle injury in patients admitted to the floors in acute care hospitals?”, and Dr. Bimaje Akpa won third place for his presentation, “Incidence & clinical features of muscle weakness in patients admitted to UTMCK.”

Faculty Awards: We are pleased to announce the Jim Neutens Award for Best Teaching Division of the Year We created a new award in honor of Dr. Jim Neutens’ service to our department while serving as Dean. The award will recognize the department’s best teaching division of the year, to be voted on by the graduating internal medicine residents. It will reflect which division made the greatest positive impact during the graduates training with our department. We are pleased to congratulate the Division of Pulmonary and Critical Care Medicine as the first recipient of this meaningful award.

Dr. Rajiv Dhand revealing to Dr. Jim Dr. J. Turner accepting the 1st Division Neutens the new Division of the Year of the Year Award for Pulmonary and Award named in his honor Critical Care Medicine

New Faculty

We are delighted to welcome Dr. Tracy Grabman as a clinical assistant professor working with our psychiatry clerkship. Dr. Grabman attained her Doctor of Medicine at the University of Tennessee Health Science Center College of Medicine in Memphis, Tennessee. She completed a psychiatry residency and a fellowship in child and adolescent psychiatry at the Medical University of South Carolina in Charleston, South Carolina. Dr. Grabman has attended at the Helen Ross McNabb Center since 2016.

We are pleased to welcome Dr. Roberto Fernandez as a clinical assistant professor in the Division of Neurology. Dr. Fernandez attained his Doctor of Medicine and Surgery at the Escuela Autónoma de Ciencias Medicas in San José, Costa Rica. He completed an internal medicine residency a neurology residency and a behavioral neurology fellowship at the University of Rochester in Rochester, New York. Dr. Fernandez became the medical director of the Pat Summit Clinic in February 2017.

New Staff

Elana Smith recently joined the department as an administrative assistant. She recently graduated from UT with her bachelor’s degree in English. Among other things, Elana will serve on the department’s In Touch newsletter committee, will oversee the department’s CME conferences, and assist the vice chair with credentialing. We look forward to working with her and are excited about what she brings to the department.

Retirements

Guest Speakers

We wish to extend our best wishes to Dr. Crystal Gue, who retired from her academic role with house staff medicine on June 30. Dr. Gue was hired in 1993 following the completion of an internal medicine residency with our department.

She continues to practice full time at Faculty Internal Medicine, and will maintain a volunteer teaching appointment with the graduate school.

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Jose A. Arruda, MD, FACP, FASN, FAHA, FNKE Chief, Division of Nephrology at the University of Illinois Medical Center of Chicago “Nephrotic Syndrome & Idiopathic Membranous Glomerulonephritis”

Ethics Case Rounds - Honoring the Unheard Voice: Decision Making for Unrepresented Patients

In Touch

Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases.

Cases are de-identified to protect patient confidentiality.

Publishers James Neutens, PhD, Dean Rajiv Dhand, MD, Chair, Department of Medicine and Associate Dean of Clinical Affairs

“Linda” was a 45-year-old woman who had been found unresponsive. She was brought to the ED in acute respiratory failure, severely hypoglycemic, and septic. After a few days in the ICU she stabilized, but remained profoundly encephalopathic and extremely agitated when not under sedation, frequently requiring restraints. She responded to pain, but was nonverbal and did not follow commands.

From Linda’s PCP, we learned she had been intermittently homeless and in poor health. The PCP had no information about her wishes for medical care, but had the phone number of a brother, Billy. Billy was reluctant to speak to staff and didn’t always answer phone calls, though he did give consent for placement of a PEG tube.

For many weeks, Linda remained unresponsive except to pain. She continued to have breakthrough agitation and need restraints. Extensive testing suggested the most promising explanation for her encephalopathy was that she had sustained a significant CNS injury secondary to prolonged hypoxia and hypoglycemia. Her chances of meaningful neurologic recovery were very poor.

Linda had no known social contacts besides Billy, who had become increasingly difficult to get in touch with.

Therefore, UTMC initiated the expensive and lengthy process of conservatorship proceedings. A temporary conservator was appointed. She reviewed Linda’s records, began attempts to contact Billy, and requested an ethics consult to help with decision making.

Billy agreed to meet with the conservator and the Director of Clinical Ethics. He said he cares about his sister, but “I don’t know that much about her. We didn’t really hang together.” He didn’t know her likes, dislikes, fears, hopes, or values. He said he would appreciate updates about her but wouldn’t participate in decision making.

When a person’s values and preferences are unknown, medical decision-making must be based on that person’s “objective best interests.” Decision-makers should consider whether treatment can reasonably be expected to preserve the patient’s life, maintain or restore the patient’s health, relieve the patient’s suffering, and sustain the patient’s dignity.

Linda’s conservator met with a team of her providers. The consensus of the team was that Linda’s quality of life was very likely at a “new normal”: she was either agitated or sedated; she could not eat, communicate, or respond to stimuli other than pain; she did not appear to take comfort in the presence or touch of others. While her life could be preserved, we could not restore her health, relieve her suffering, or sustain her dignity.

Linda’s conservator, with the support of her care providers, decided to transition the goals of Linda’s care to comfort measures only. She petitioned the court to consider stopping artificial nutrition and hydration, as Tennessee law prohibits anyone except a capacitated patient or a health care agent (i.e. a surrogate appointed by the patient when capacitated) from discontinuing such measures.

When told of the decision, Billy said, “I think that’s best, because I would never want to live like that. But I couldn’t ever make the decision to stop.”

Linda was discharged to a nursing home on comfort care. One month later, a court order authorizing the withdrawal of artificial nutrition and hydration was signed. She died 10 days later.

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

References Pope, T and Sellars, T. “Legal briefing: The unbefriended: Making health care decisions for patients without surrogates (Part 1) Journal of Clinical Ethics 23 (1) Spring 2012: 84-96 Pope, T and Sellars, T. “Legal briefing: The unbefriended: Making health care decisions for patients without surrogates (Part 2) Journal of Clinical Ethics 23 (2) Summer 2012: 177-192

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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Vol. 7, Issue 3: July 2018

Editor Annette Mendola, PhD Administrative Director Susan Burchfield, CAP-OM Contributors Susan Burchfield Rajiv Dhand, MD Kandi Hodges Annette Mendola, PhD Kimberly Givens David Wilson, DO Elana Smith 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.