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 Di s c ove ry w ith H um anis m in Me dicine
Vol. 5, Issue 3: July. 2016
Changing Education to Align with the Needs of Millennials While generational differences are nothing new, the rapid pace of development and the unprecedented number of different generations working together have made generational competency—awareness of the different perspectives, expectations, and values of co-occurring generations—an essential knowledge set. Today’s medical learners are, by and large, Millennials, born between 1981 and 2004. They are being taught by GenXers (born 1961-1980), Baby Boomers (born 1943-1960), Traditionalists (born 1900-1942)— and older Millennials. Millennials grew up in a different world than their predecessors. Their early lives were marked by burgeoning technology and a certain amount of social and political instability. Many were raised by “helicopter parents” and taught to value challenges and achievement. They expect learning to be fun and meaningful, with clear expectations and plenty of feedback. They are comfortable with diversity (they are the most diverse generation so far), but also respect hierarchy and structure. These features contribute to their comfort working in teams in which different members have different things to contribute. They are less motivated by power and money than previous generations and seek a balance of meaningful activities in their lives rather than being defined solely by their work. All of these features affect medical education. Dr. Nathan Smith, Millennial and 2016 graduate of the Department of Medicine, says that Millennials expect guidelines in medical practice
to evolve rapidly. Thus, they expect to develop a core of knowledge and strategies for solving problems and finding additional information rather than mastering all that can be known about a subject. “There is so much information out there, and more accumulates every day,” he observed. “Even subspecialties have become ‘unmasterable,’ so you get used to reaching out for additional input.” Ironically, the amount of information available to use for the patient’s well-being can interfere with connecting with the patient as a person if one does not develop good interpersonal skills. Dr. Smith says the potential to pay too much attention to a phone or computer and not enough to the patient is a real danger, but does not believe the devices have created new problems. “The doctors who are glued to their phones today were the ones glued to a paper chart or clipboard in times gone by,” he said. He is optimistic that changes in medical education will lead to more patient-centered care, noting that testing used to be exclusively on “hard facts,” but now includes topics in communication, bioethics, and medical humanities. Monday Morning Quarterback rounds, Team-Based Learning, Quiz Bowls, and use of the Sim Center are examples of teaching methods employed in the department that resonate for Millennials. They like challenges, continued on page 2
Points of View
rounds in the morning. In the afternoon, I did procedures and carried out the orders for the day, made sure patients went for their scheduled tests, and admitted new patients. In the evening, we had rounds by the Registrar (PGY4-PGY6) that typically lasted 2 to 3 hours. After a short break for dinner, I would go back to complete the notes on the patients and write orders for the next day. It was well into the night by the time my work was done, and I began my 3to 4-block walk to my hostel room. Of course, call nights were spent in the hospital covering anywhere from 45 to 70 sick patients. As I stood there and took in the scene, I resolved to go out for dinner that night with my friends, and I did. This period was one of the most exhilarating in my life. I was learning at a dizzying pace and gaining so much knowledge and clinical experience, it was as if a whole new world had opened up for me. This month laid the foundation of my career in medicine, and I am forever grateful to the dedicated physicians who worked so hard to impart their knowledge and the patients who provided me with such a valuable and diverse clinical experience.
On a Friday in late January during my medical studies, I vividly recall walking along the glass windows of the long hallway that fronted the operating rooms on the fourth floor of the hospital. It was the end of my first month as a house officer, and I was mesmerized by the scene I was witnessing on the road below me. It was a sunny day, and I stood transfixed, absorbing the movement of Rajiv Dhand, MD, Chair people, including, pedestrians, people on bicycles, rickshaws, and in cars and buses going about their “everyday lives”. It dawned on me that I had not seen the light of day for a whole month and had not left the institute’s campus during that time. My life had been overrun by a hectic daily routine of early morning blood draws, followed by pre-rounds and then attending 1
New Fellowships: The Department of Medicine is growing and changing yearly. We are very excited to be adding a critical care fellowship program and an interventional cardiology fellowship program in July 2016. These programs will help us to attract excellent resident applicants and will bring prestige to our institution. Dr. Tina Dudney, Pulmonary and Critical Care Medicine Fellowship Program Director, explained that the critical care fellowship will enhance and expand existing postgraduate training by increasing resident and fellow opportunities for more direct clinical supervision, didactic sessions, and research experience. Dr. Dale C. Wortham, Cardiology Fellowship Program Director, recently obtained approval for the new interventional cardiology fellowship, which will give an option for further training after the general cardiology fellowship. Given the high rate of heart disease in this area, interventions are required, and these can be quite complex. The fellows will be trained to offer the many procedures needed by patients. Both programs will help our residents by promoting the mission and vision of the institution through increasing subspecialty expertise available to patients and practitioners.
International Scholarship: Putting the Department of Medicine “On the Map” Faculty in the Department of Medicine are developing more international affiliations and are receiving more international recognition for their expertise. Dr. Rajiv Dhand is currently serving as president-elect of the International Society of Aerosols in Medicine (ISAM) and will become president next year. He is the editor-in-chief of the ISAM Textbook of Aerosol Medicine, a comprehensive textbook of aerosol medicine, which has contributions by over 50 authors from all over the world. Dr. Dhand gave an invited presentation as a plenary speaker at Inhalation Asia 2015 in Shenyang, China. The department hosted international scholar Dr. Hua Wang, an intensivist from Southern Medical University in Guangzhou, China. While here at UT Medical Center, Dr. Wang studied aerosol delivery in noninvasive ventilation in collaboration with Dr. Dhand, Dr. J. Turner, Dr. Mike McCormack, Scott Elder and Daniel Church. Dr. Dhand presented the results of this collaboration and also gave another poster presentation at the May 2016 American Thoracic Society International Conference in San Francisco, CA. Dr. J. Turner presented at the 16th World Conference on Lung Cancer; International Association for the Study of Lung Cancer (IASLC), in Denver, CO, in September 2015. Pulmonary fellow Dr. Dipaben Modi, whose work was mentored by Dr. Turner and Dr. Tina Dudney, also presented at the same conference. Dr. Turner also moderated a session at the Chest World Conference in Shanghai, China, April 2016. He gave three presentations at the World Congress for Bronchology and Interventional Pulmonology and World Congress for Bronchoesophagology in Florence, Italy, in May 2016, and served as Chair of TBNA, EBUS-TBNA and EUS(B)TBNA (transbronchial needle aspiration, endobronchial ultrasound and endoscopic ultrasound bronchoscopy). Dr. Turner was the keynote speaker at the 10th Forum of Bronchology and Interventional Pulmonology in Suzhou, China, in May this year. Dr. Jonathan Wall’s team of investigators, including Dr. Emily Martin and Dr. Stephen Kennel, are actively engaged in amyloid research. They presented at the Conference of the German Network on Systemic AL Amyloidosis (GERAMY) in Heidelberg, Germany, in November 2015, and will be presenting at the 15th International Symposium on Amyloidosis in Uppsala, Sweden, in July 2016. Dr. Wahid Hanna has been involved with twinning programs in Egypt and will begin a new twinning program between our medical center and the University of Mansoura in Egypt to improve hemophilia care and treatment in Egypt. Residents and fellows also shared their expertise with international audiences. Dr. Rafael Alba Yunen gave a presentation, coauthored by Dr. Clay Callison and Dr. Paul Branca, in Bangkok, Thailand, in November 2015. In May 2016, Dr. Alba Yunen presented at the 19th World Congress for Bronchology and Interventional Pulmonology. Dr. Charlie Allderdice gave a poster presentation, coauthored by Dr. Mark Rasnake, at the SGIM 38th Annual Meeting in Toronto, ON, in April 2015. The Department of Medicine is proud of the international participation by our faculty members, which demonstrates the expertise of our physicians and brings prestige to our institution. Our academic footprint is enriched and expanded through participation in these international events, and the mission of building scholarship in our department is enhanced.
Changing Education to Align with the Needs of Millennials
continued from page 1
and they like opportunities to think through problems, work collaboratively, and to learn by doing. Dr. Bill Metheny, DIO of the Graduate School of Medicine, is not sure medical education has changed enough. “Today’s attendings are being asked to teach things they were never taught themselves, like how to work in teams and how to maintain personal wellness,” he notes. Work-life balance, which was not a concept in times past, drives many decisions now. Millennials work hard but also want to take care of their health and their family life. More information can be found at http://www.xyoaa.org/sites/all/modules/ckeditor/ckfinder/ckfinder/userfiles/files/education_ materials/Millennials’%20Learning%20Tips.pdf
2
Personal Reflection By Niva Misra-Sammons, MD When I reflect back on my time in the Department of Medicine, I think not only of the last three years of residency but also of the last 13 years that I have been fortunate enough to be a part of both UT Medical Center and the Graduate School of Medicine. At age 15, my father passed away. He was a physician and helped me nightly with my homework. When I was asked to say a few words at his funeral, the only words I could get out were that I would “be a doctor” because I knew that was a dream we shared. In the following summer, with the help of my mom, older sister (who at the time was an internal medicine resident herself), and friends, I was introduced to Dr. Mitch Goldman’s Medical Explorations program. Through this program, I had the opportunity to work with many wonderful physician mentors in different specialties and became even more excited about a career in medicine. These wonderful physicians stood by my side through the rest of high school and college. I also made friends through the program that I still have today. The department was welcoming to me even in high school. I met many of my sister’s attendings, who are now my attendings. I felt like a part of their community then and have watched the department grow and change. I have seen many favorable changes to the residency, including schedule changes to promote a balanced lifestyle for residents. I met my husband, Brandon (now a second year medicine resident), during my last year of college. He was a great source of encouragement when I went through the medical school application process. I was fortunate enough to be accepted to my first choice, the East Tennessee State University (ETSU), James H. Quillen College of Medicine. During my medical training, I came to UT for a week-long rotation in my second year and worked with Dr. Rasnake. I then knew that UT Internal Medicine was the right program for me. I was fortunate enough to match here and even more fortunate my husband matched in the year later. The last three years of residency have not been easy. There were difficult call shifts in the ICU and long call shifts on house staff. Given that I knew the hospital so well, I could even picture my sister walking through the same halls I was now walking at night. Many nights, I could almost feel the spirit of residents past, and felt that I was part of a new cycle. However, I have learned so much in the past three years. I have met so many wonderful staff members and have new physician mentors. The experience now feels rewarding and gratifying. When I look back on the last 13 years, I am thankful to so many people that have helped me along on my journey to become a physician. I want to make all those people proud who were kind enough to mentor me. To this day, I am still learning to be calm. I have learned how to communicate more effectively. I still want to improve my knowledge but have promised myself to do that every day for the rest of my career. Most of all, I feel that through my own journey, I did keep that promise to my dad and have made him proud. When I look back, the “black and white” is gone and I only “see in color.”
Awards and Honors Drs. TJ Mitchell and Nathan Smith, PGY-3s, and Dr. Marc Collins, PGY-2, won the Rawson Award presented at the 2016 Department of Medicine Residents’ and Fellows’ Awards Dinner, which was held on Sunday, June 12, at the Ft. Loudon Yacht Club. This award is presented annually to 2nd and 3rd year residents who embody the spirit of teaching and possess excellent clinical skills. 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. The UT Internal Medicine Center presented Clinic Star Awards throughout this academic year. The recipients were Drs. Sachin Amin, Marc Collins, John Dewald, Katoura Williams, Charles Allderdice, and Azaria Ehlers. The Clinic Star of the Year Award was presented to Dr. Nathan Smith at the Department of Medicine’s Residents’ and Fellows’ Graduation Dinner on June 12th. We wish to congratulate Dr. Smith on receiving this well-deserved award. Dr. Rolland Regester was honored on June 29, 2016 at the GSM New Resident and Faculty Awards Reception with the receipt of the “Excellence in Teaching Volunteer Faculty Award”, which recognizes superior dedication, excellence, and enthusiasm in medical education. Dr. Purkey was invited to give the keynote speech to future M-3s at the Student Clinician’s Ceremony at the UT Health Science Center, Memphis, TN. She was presented with an award by the class of 2017 “In recognition of [her] professionalism, empathy, and superior care to patients.” Dr. Purkey gave the students valuable advice culled from her years of practice, encouraging the students to show respect to continued on page 5
3
GSM Retirement – Dr. Carol Ellis The Department of Medicine wishes to congratulate Dr. Carol Ellis on her retirement from the Graduate School of Medicine. She provided many years of exceptional service to the Department of Medicine and will be missed by the faculty, residents, fellows, and staff. Dr. Ellis was past program director of the Internal Medicine Residency. More recently, she provided regular housestaff medicine coverage and served as an attending in the didactic residents’ clinic as well as the new REACT clinic.
Comings and Goings:
• Sachin Amin, MD, will move to Chattanooga to be a hospitalist at Erlanger. • Kendra Black, MD, is staying here in Knoxville, working as a hospitalist for StatCare. • Joshua Hayes, MD, will be a hospitalist with Carolinas Healthcare Systems at Carolinas Medical Center Northeast Hospital in Concord, NC • William (Drew) Kittrell, MD, will become a hospitalist at UTMCK. • Niva Misra, MD, will become a hospitalist for StatCare at Fort Sanders/ Tennova. • Brock (TJ) Mitchell, MD, is joining UT Internists at UTMCK. • Nathan Smith, MD, will become a hospitalist at UTMCK. • Andrew Streicher, MD, will move to Baton Rouge, LA, to become a hospitalist at Ochsner Medical Center. • Rafaela Wesley, DO, will move to Cartersville, GA, to become a hospitalist at Cartersville Medical Center. • Jennifer Winbigler, MD, will become a hospitalist at Blount Memorial Hospital.
Comings
New Internal Medicine Residents 2016-2017 • Matthew Allison, MD, East Tennessee State University • Christopher Hill, MD, East Tennessee State University • Clayton Humphrey, DO, Lincoln Memorial University • Christina Kitsos, MD, American University of the Caribbean • Sister Teresa Mary Kozlovski, MD, Georgetown University School of Medicine • William Lorson, DO, Lincoln Memorial University • Joseph Pendley, DO, Lincoln Memorial University • Blair Reynolds, MD, University of Tennessee Health Science Center College of Medicine • Leigh Schlactus, MD, East Tennessee State University • Henry Shiflett, DO, Lincoln Memorial University • Benjamin Verzi, MD, University of Tennessee Health Science Center College of Medicine • Christopher Waggoner, DO, Edward Via College of Osteopathic Medicine New Transitional Year Residents 2016-2017 • Jonathan Allred, MD, East Tennessee State University • Brandon Birckhead, MD, Mayo Clinic • Matthew McKeever, MD, University of Texas Southwestern Medical School • Cole Smith, MD, University of Tennessee Health Science Center College of Medicine • Eric Sollenberger, MD, University of Tennessee Health Science Center College of Medicine • Adam Zalis, MD , Charles E. Schmidt College of Medicine, Florida Atlantic University
Pictured in front row from left to right: Drs. Daphne Norwood, Niva Misra, Neena Agrawal, Rafaela Wesley, and Jennifer Winbigler Standing: Drs. Kendra Black, Mark Rasnake, Rajiv Dhand, Joshua Hayes, William (Drew) Kittrell, Brock (TJ) Mitchell, Nathan Smith, and Juli Williams Not pictured: Drs. Sachin Amin, Charles Allderdice, and Andrew Streicher
New Cardiology Fellows 2016-2017 • Rajiv Sharma, MD, The Jewish Hospital, Mercy Health, Cincinnati, OH • Robert Tonks, MD, Advanced Heart Failure and Transplant Cardiology Fellowship at Duke University
Internal Medicine Class of 2016
Transitional Year Graduates • CJ Gaston, MD, will begin a radiology residency at UTMCK. • Nicholas Sutton, MD, will begin a radiology residency at UTMCK. • Laura Pruitt, MD, will begin a dermatology residency at East Carolina University. • Nathaniel Slater, MD, will begin a dermatology residency at the University of North Carolina. • Trevor Rosenlof, MD, will be going to University of Missouri-Columbia to do ophthalmology. • Jarred Tanksley, MD, will begin a radiation oncology residency at Duke University.
New Interventional Cardiology Fellow 2016-2017 • Neelima Katukuri, MD, Staff cardiologist at John D. Dingell VA Medical Center, Detroit, MI, and Assistant Professor at Wayne State University, Detroit, MI New Pulmonary/Critical Care Fellows 2016-2017 • Sameh Attia, MBBCh, Critical Care Hospitalist at Rhode Island Hospital, Providence, RI • Raakesh Hassan, MB, BS, Critical Care fellow at Henry Ford Hospital/ Wayne State University • Bimaje Akpa, MB, BS, Chief medicine resident at Meharry Medical College, Nashville, TN • Ashish Thakkar, MD, Academic Hospitalist at Rochester General Hospital, Rochester, NY
Cardiovascular Fellowship Graduates • Steven Dolacky, MD, starts an interventional cardiology fellowship at Albany Medical Center, Albany, NY. • Madhur Roberts, MD, starts an advanced cardiac imaging fellowship at Piedmont Heart Institute, Atlanta, GA.
Goings
Internal Medicine Graduates • Neena Agrawal, MD, is staying here in Knoxville, working as hospitalist in Oak Ridge. • Charles Allderdice, MD, is starting a cardiology fellowship at East Carolina University, Greenville, NC.
Pulmonary Fellowship Graduates • Rafael Alba Yunen, MD, will become a pulmonary disease/critical care physician at Georgia Health System, Brunswick, GA. • Victor Gordon, MD, will become a pulmonary disease/sleep medicine physician at Covenant Healthcare, Saginaw, MI. 4
Awards and Honors
continued from page 33
their colleagues and to all members of the hospital team. In case the students experienced stress or despair during their training, Dr. Purkey thoughtfully provided them with her personal cell phone number. We wish to congratulate her on this well-deserved award for her hard work and excellent clinical and interpersonal skills.
2nd Annual Medicine Research Award Contest The Department of Medicine held its second Annual Residents’ and Fellows’ Research Contest at the Medicine Grand Rounds on June 14, 2016. The event was lively and informative with excellent presentations, and the audience enjoyed participating by voting for the winners. Dr. Lindsay RumbergerRivera won first place for her presentation, “Improving the Accuracy of CT Scanning in the Diagnosis of Small Bowel Obstruction: To Scan or Not to Scan…Again?” Dr. Jaime Morris won second place for “An Unusual and Delayed Presentation of CNS Post-Transplantation Lymphoproliferative Disorder Following Kidney Transplant,” and Dr. Reem Hussein won third place for her presentation, “An Uncommon Case of Acute Central and Peripheral Demyelination.”
Guest Speakers, Department of Medicine Grand Rounds May 24, 2016 Timothy P. M. Whelan, MD “New Therapeutic Options in Idiopathic Pulmonary Fibrosis: The Path to Improved Diagnosis and Patient Outcomes” CME HIGHLIGHTS AND FUTURE OPPORTUNITIES The Fourth Annual Medicine CME Conference “Practice Updates for the Primary Care Physician” was held April 29-30, 2016, at the Holiday Inn World’s Fair Park. This year’s successful conference had more than 70 attendees from nine different states. There were multiple presentations on a variety of interesting
topics, including new treatments and medications for conditions related to pulmonary, cardiology, and diabetes, and also interesting topics on the care of the elderly as well as dementia. The internal medicine residents, Drs. Reem Hussein and Katoura Williams, did an excellent job presenting interesting cases. We are very pleased that the conference continues to gain recognition. • 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, for 1.00 hour CME credit.
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! 5
In Touch Vol. 5, Issue 3: July 2016
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 Niva Misra, 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 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.
Ethics Case Rounds Ethics has become an increasingly important part of medical practice, and we are fortunate to have Dr. Annette Mendola as our clinical ethicist. She has been conducting a monthly Ethics Case Rounds, and we are taking this opportunity to present some of the cases presented during these sessions. We hope that you will find this new quarterly feature to be of interest and educational value. “I Do Not Consent” Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality. Dr. Sachin Amin, PGY-3, sounded worried. “We have a lady here in the ED requesting treatment for pain,” he said. “Her blood glucose is over 1000; however, she says she will not consent to receiving insulin or any other treatment except pain medication.” The patient, “Kayla,” was a young, well-groomed woman who was seated at the edge of the bed. She was calm, with normal affect and animation, and no signs of delusions or thought disorder. She said her diabetes had been “devastating” because of debilitating fatigue and pain, although she acknowledged that she had not been following her diabetes regimen. She said diabetes is a terminal condition because there is no cure; therefore, insulin is a form of life support that she does not consent to receive. She is not suicidal, she says, “just ready to die.” Her chart indicated that she was prescribed with substantial narcotics for chronic pain from a car accident that resulted in a miscarriage three years ago, but she said the meds “don’t touch” her pain. Her sister, looking tense and exhausted, was at bedside. She said Kayla and her three children have been living with her since the car accident. She did not agree with Kayla’s refusing insulin but said, “one of these days she’s going to push it too far and it will be too late.” People have the right to refuse medical treatment, including life saving treatment; however, care providers have an obligation to ensure that patients understand what they are choosing. The goals of informed consent are: 1. to respect patient choices (even if we do not agree with those choices); and 2. to ensure that patients do not make choices under duress, without enough information, or while their ability to process information or the consequences of the decision is limited. Chow, et al. (2010) encourage use of the mnemonic CURVES to assess decision making capacity in emergency situations. In brief, consider: • Choose and Communicate – Can the patient communicate a choice? • Understand – Does the patient understand the risks, benefits, alternatives, and consequences of the decision? • Reason – Is the patient able to provide a logical explanation for the decision? • Value – Is the decision in accordance with the patient’s value system? • Emergency – Is there a serious and imminent risk to the patient’s well-being? • Surrogate – Is there a surrogate decision maker available? Kayla was communicating a choice, but it was not clear whether the choice was truly in accordance with her values or simply a maladaptive way of asking for help. She provided an explanation—and a very clever one—but it was not logical: Kayla came to the ED for treatment of pain despite having pain medication at her disposal. She also did not evince pain or fatigue and had not been following the treatment regimen that would have addressed the source of her symptoms. Additionally, the consequences of her choice would be dire: refusing insulin would be very likely to result in her death. Kayla did not demonstrate sufficient decision making capacity to refuse treatment for a life-threatening condition in that context. Dr. Amin spoke with Kayla. “We need to get your pain under control, because we don’t want you to be hurting,” he told her. “But we can’t give pain medication safely unless your blood sugar is controlled. We will give you some insulin, and as soon as it is safe, we will treat your pain. And we will transfer you to a bed upstairs to make sure you are all right.” Kayla accepted this. A few days later she was admitted to a facility for treatment of depression. Comments on this case may be sent to amendola@utmck.edu • Chow, DV, et al. “CURVES: A Mnemonic for Determining Medical Decision-Making Capacity and Providing Emergency Treatment in the Acute Setting”; Chest 137(2); 2010; 421-427 6