D epartment
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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 4 Oct 2018
New Faculty Bringing Special Skills to the Care of Their Patients The Department of Medicine is fortunate to have two new faculty members bringing specialized skills to patient care: Dr. Muddassir Mehmood, specializing in advanced heart failure, and Dr. Francisco Soto, specializing in pulmonary hypertension (PH). During his cardiology fellowship, Dr. Mehmood became intrigued by the right side of the heart, the “forgotten ventricle,” believing there was much about heart failure and pulmonary hypertension that needed to be explored. “Once the right side of the heart fails, management becomes very challenging,” explains Dr. Mehmood. Since coming to UT, Dr. Mehmood has worked on developing a specialized interdisciplinary heart failure clinic. “Heart failure patients are unique,” he notes. “They require special attention, and successful treatment requires a partnership between the patient, family, and providers.” He envisions developing a team of health professionals to educate and empower patients to better manage their disease. “Heart failure is a chronic progressive disease,” he says. “Once traditional management options are maximized, we keep an eye out for early recognition of advanced stages of heart failure and discuss cardiac replacement therapies such a mechanical heart pump or transplant when appropriate.” Dr. Mehmood is energized by challenges and recognizes the importance of clinical discovery and teaching. He is actively involved in research and education and hopes to bring technologic innovations in heart failure to UT. Pulmonary, critical care, and sleep specialist Dr. Francisco Soto has been researching and treating PH for over 15 years. At one time, PH was an “orphan” disease; there were no treatment options for it. Now, patients who would have been doomed are able to live satisfying lives. New medications and modes of delivery can change a severely debilitated quality of life into a flourishing one. Dr. Soto became fascinated by the relationship between the heart and the lungs during his training, and learned to do cardiac procedures such
as right-heart catheterizations, cardiothoracic ultrasound evaluation, and echocardiography interpretation. He believes that “learning to speak cardiology” stimulates the academic conversation between pulmonologists and cardiologists, something that benefits the patients directly. “Advanced knowledge of the heart can also help pulmonologists treat pulmonary manifestations of heart disease and PH more successfully,” says Dr. Soto. For example, patients who are affected by both CHF and COPD can have symptoms that cannot be explained when considering the heart or lungs in isolation. The full scope of the patient’s problem only becomes evident when one understands the interaction between the compromised organs. One of Dr. Soto’s goals is to help develop a multidisciplinary PH clinic that becomes a referral center for the region and the neighboring states. Both Dr. Soto and Dr. Mehmood describe themselves as “big-picture thinkers” who thrive on interdisciplinary collaboration. They are committed to using a diverse array of resources to care for patients, including integrating palliative care early for optimum symptom management and care planning. Patients in East Tennessee who have cardiopulmonary disease will benefit from the care of these two talented and compassionate physicians.
Points of View
Rajiv Dhand, MD, Chair
clinical loads, which reduce time for participation in activities outside the clinical realm. In addition, interest has diminished in attending face-to-face meetings, and mandating such attendance would be contrary to the stated purpose of increasing engagement. Moreover, our department faculty are often off-site, so face-to-face meetings are not popular or practical. In the past, lack of interest in faculty development may have been due to the heavy emphasis on development of teaching skills – a legacy, perhaps, from institutions of higher learning that initiated such efforts. A practical and innovative solution could be using the Internet for communication and diversification of topics to make them more useful for faculty members in their continued on page 2
Faculty development is an essential component of an academic organization’s success. Because of this, there is an increasing interest in faculty development programs for health care institutions. Such programs provide a way for the faculty to further develop and nurture their skills. For several years, I have had to wrestle with finding a practical method of providing faculty development resources for our department. Our faculty face high 1
Opening of ID Clinic Since March 2017, the Department of Medicine’s infectious disease (ID) faculty—Dr. Mahmoud Shorman, Dr. Simi Vincent, and Dr. Mark Rasnake—have seen 916 patients at the ID clinic. The ID clinic is a great resource for both outpatient physicians and for patients seen by the ID service in the hospital. Before the clinic’s inception, hospital patients were sent home with IV antibiotic infusions for 6-8 weeks of treatment. Even though labs were followed up by physicians, according to Dr. Shorman, “There was no telling what happened after [a patient went home]”; infections might have resolved or complications might have developed. Dr. Rasnake commented, “People’s illness doesn’t stop the day they get discharged.” Through the ID clinic, patients can be followed safely after discharge from the hospital, and many hospital admissions can be prevented through outpatient management. For instance, patients from the orthopedic or urologic clinics with multidrug-resistant infections can be referred to the ID clinic and receive IV antibiotic therapy at the outpatient infusion center rather than in the hospital. The clinic allows ID physicians the opportunity to monitor therapy to resolution and see the fruition of their labors when patients return in a healthy state. Dr. Rasnake describes his work at the clinic as “cognitively rewarding and emotionally uplifting.” Residents and medical students also benefit from the educational opportunity to rotate through the clinic. Future endeavors of the clinic may include research, pre-exposure prophylaxis (PrEP), and travel medicine.
New Outpatient Psychiatry Experience for Residents and Students The Department of Medicine is excited to announce the opening of the new psychiatric clinic headed by Dr. Paul Miller, assistant professor of medicine. Dr. Miller trained in Chicago at Rush-Presbyterian-St. Luke’s Medical Center, where he completed a dual residency in internal medicine and psychiatry. He then moved back to East Tennessee, where he has had a private psychiatry clinic in Maryville for the past several years. Dr. Miller discovered his passion for training young physicians in 2013 when he became the psychiatry clerkship director for third- and fourth-year medical students. He is now excited to relocate his practice to UTMC, where he will have more opportunity to train students and residents. In addition to seeing patients daily in his private practice, Dr. Miller directs residents’ psychiatric training on Friday mornings. Under Dr. Miller’s guidance, residents will receive directed psychiatric training and will see how psychiatrists manage common outpatient problems. Dr. Miller is eager to expand his practice at UTMC and plans to offer new services to the community.
Resident Spotlight – Sister Teresa Mary Sister Teresa Mary Kozlovski is a PGY-3 who was raised in Duluth, Minnesota. After high school, she joined the Religious Sisters of Mercy (RSM) of Alma, Michigan. She completed two years of formation before earning her bachelor’s degree from Michigan State University and her M.D. from Georgetown University School of Medicine in Washington, D.C. Sister Teresa Mary followed the footsteps of her fellow sister, Sister Mary Gretchen, by coming to UTMC for her residency in internal medicine. Sister Teresa Mary was also the PGY-2 recipient of the Rawson Award, voted on by her attendings, at our Department of Medicine Residents’ and Fellows’ Awards Dinner held on June 2nd. Each sister takes four vows including a vow of service to help others, primarily through education and healthcare. In Knoxville, Sister Teresa Mary lives at the RSM convent with seven other sisters, where days are structured around morning, evening, and nightly prayer. Sister Teresa Mary is not sure where she will be sent at the completion of her residency, but she trusts that wherever she goes, she will continue to serve to her fullest ability.
Points of View
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day-to-day roles. We have a team led by Dr. Norwood and Dr. Dudney that selects articles covering topics including teaching, education, wellbeing, scholarship, management, and leadership under the heading of Faculty Matters. We plan to send out two or three articles each month via MedHub, with an emphasis on articles covering development of clinical skills. This allows faculty members to read the articles according to their own schedule and provides information on relevant topics. Faculty are encouraged to read at least four of these articles per year. We plan to monitor participation and hope everyone will actively engage in this effort. 2
Faculty and Resident Awards and Honors We wish to congratulate three members of our faculty who received promotions effective July 1, 2018.
Paul Branca, MD, was promoted to Clinical Associate Professor of Medicine.
Li Hua, PhD, was promoted to Clinical Assistant Professor of Medicine.
Muhammad Masud, MD, was promoted to Clinical Assistant Professor of Medicine.
Faculty Announcements We are pleased to announce that Dr. Jeffry Bieber assumed the role of Division Chief of Rheumatology effective July 1. Dr. Bieber completed medical school and internal medicine residency at East Tennessee State University Quillen College of Medicine. He completed a fellowship in rheumatology at the University of California San Diego. He is an enthusiastic and dedicated clinician who has been an outstanding addition to our faculty. Please join us in congratulating Dr. Bieber on his new role in the department.
New Faculty We are pleased to welcome Dr. Muddassir Mehmood as a clinical associate professor in the Division of Cardiology. Dr. Mehmood attained his bachelor’s degree in medicine and surgery at Rawalpindi Medical College in Rawalpindi, Pakistan. He completed an internal medicine residency and a cardiovascular diseases fellowship at Wright State University in Dayton, Ohio, and an advanced heart failure and transplant cardiology fellowship at Allegheny General Hospital in Pittsburgh, Pennsylvania. Dr. Mehmood began working in UHS Cardiology in April 2018.
We are excited to welcome Dr. Nichole Miller as adjunct instructor in the Division of Neurology. Dr. Miller completed her Psy.D. in clinical psychology at the Chicago School of Professional Psychology. She completed a predoctoral clinical internship with a clinical neuropsychology track at the Central Arkansas Veteran Healthcare System in North Little Rock, Arkansas and completed a post-doctoral fellowship in clinical neuropsychology at the Geisel School of Medicine at Dartmouth/Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire. Dr. Miller began working in the Pat Summit Clinic in November 2017.
CME Opportunities—Mark Your Calendars! • Cardiology Conferences, held weekly on Wednesdays for .75 hours CME credit. • Medicine Grand Rounds, 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, are available for 1.00 hour CME credit. 3
In Touch
Ethics Case Rounds - Moral Luck Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality. “Henry” is a 48-year-old nurse who was admitted for a routine cholecystectomy. He was in otherwise good health and had been looking forward to an annual fishing trip post-recovery. He is divorced and has a good relationship with his mother and two adult sons. Henry completed an Advance Directive a few weeks before his surgery, identifying his older son as health care agent with his mother as backup. He had checked boxes for CPR and artificial nutrition, and had hand-written that he would only be willing to be on a ventilator short-term, and only if he was expected to recover. He specifically wrote that he did not want a tracheostomy, adding “No trach!” Unfortunately, Henry suffered complications after surgery, went into Acute Respiratory Distress Syndrome (ARDS), and required intubation. His prognosis was uncertain; ARDS carries roughly equal chances of death, full recovery, and recovery with deficits. After two weeks, he was still unstable and remained in a medically-induced coma. Without a tracheostomy, his most likely outcomes were recovering to a state of dependence and debility, or slow death in the ICU. His family struggled with the decision. His sons felt that as a nurse, Henry had his reasons for deliberately writing “No trach!” on his Advance Directive. However, his mother doubted he had imagined this scenario before the surgery, as he was expecting to recover quickly and get on with his life. They all agreed that he is an independent person who would not want to “just lay there” long-term. After talking about the situation among themselves, and with his friends and coworkers, his family believed Henry would have authorized the tracheostomy if he could hear the current medical information. However, his oldest son was unable to agree to the tracheostomy. “Dad tried to talk to me” about his wishes before surgery, he said, but “I just told him he was going to be fine. Now if this goes bad, I will never forgive myself.” When information about a patient’s wishes is ambiguous or conflicting, decision-making involves moral luck. Moral luck describes situations in which a person feels responsible for an action or its consequences, even though he or she doesn’t have full control over the situation. Moral luck can threaten good surrogate decision-making, as in this case. The son’s guilt over having not listened to his father interfered with his ability to use substituted judgment. However, whether surrogates have done the right thing depends on whether they did the best they could with the information they had at the time, not on the outcome of the decision. To address the son’s anguish, we acknowledged that the decision was difficult, but that he was considering the right things and that we are “in this together.” We acknowledged that despite our best efforts we still could make the wrong decision; if so we would explain, ask for forgiveness, and find ways to make amends. Finally, we encouraged self-forgiveness. Reluctance to talk about care planning prior to his father’s routine surgery was a small mistake, even if it had unexpectedly big consequences. Henry’s family made the decision to authorize a tracheostomy, with plans to transition to comfort measures if his condition did not improve. While Henry’s family made an ethically sound decision regardless of the outcome, we are happy to report that he did indeed recover and went on his fishing trip—just a little later than expected. Comments on this case may be sent to amendola@utmck.edu References Campbell, S.M., C.M. Ulrich, and C. Grady. 2016. A broader understanding of moral distress. American Journal of Bioethics 16(12): 2-9. McAninch A. 2016. Moral distress, moral injury, and moral luck. American Journal of Bioethics 16(12): 29-31.
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! 4
Vol. 7, Issue 4: October 2018
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 Kimberly Givens David Wilson, DO Elana Smith Sister Teresa Mary Kozlovski, MD 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.