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. 8 Issue 4 Oct. 2019
Audio / Visual Recording with Clinical Encounters
as long as he is aware of the recording. Specifically, in the ICU he is in favor of families recording bedside conversations, citing that having a recording may help families who may second-guess decisions they made months or years later. “For patients who survive critical illness, a record of what they went through may help mitigate the feeling of ‘lost time’ they experience as part of post-intensive care syndrome”. Dr. Daniel Ely, Associate Professor and Internal Medicine Physician, also sees the advantages of recording encounters in the primary care setting. He personally has had patients ask to record his discussions regarding diagnostic results and end-of-life planning. “Patients legitimately don’t assimilate all that we tell them in an office visit,” states Dr. Ely. He also mentions that several patients record discussions for the benefit of family members who are unable to make it to the office visit. He feels that physicians should not prevent patients from understanding their healthcare, especially when it makes us uncomfortable. In summary, it is important for physicians to understand that they may be recorded without their knowledge during patient encounters. Because this could potentially have legal ramifications, medical practices may want to establish guidelines regarding patient recordings. Dr. Ely states: “It should be a goal of physicians to be comfortable with what we say in whatever setting. If you present objective, factual data, you should never be able to have things used against you. This will build trusting relationships between physicians and patients which can last for years.”
In 2015, a jury awarded a Virginia man $500,000 after he recorded an anesthesiologist and gastroenterologist making derogatory remarks about his health during a routine colonoscopy. Most states, including Virginia and Tennessee, are one-party consent states. This means that only one participant in a conversation must consent for a recording to be legal. Patients or their visitors can record interactions with their physician without disclosure, as long as they participate in the conversation. However, privacy laws make it impractical for most physicians to record patient encounters, as HIPAA requires that recordings be protected in the same way as other personal health information. At first glance, the one-party consent law seems to put the physician on the defensive. We asked a couple of physicians at UTMC to comment on their thoughts and clinical experiences. Dr. Paul Branca, Clinical Associate Professor and Director of the Medical Intensive Care Unit, has no problem with people recording him
Points of View
I would like to highlight his extraordinary qualities as an outstanding human being. On first meeting Dr. Obenour, one was immediately struck by his humility and kindness. He was soft spoken and gentle with a quiet sense of humor. His colleagues fondly remember his compassion for his patients, students and especially for his staff. He was totally dedicated to his patients and a strong advocate for the medical profession. He trained many generations of physicians Dr. Richard Obenour and mentored several current faculty members in the department. Early on in his career, he recognized the significant impact that a well-organized team-based approach could have within the health care system. He actively participated in teaching and training the current and future respiratory therapists, nurses, and other staff to achieve their full potential continued on page 2
TRIBUTE TO DR. RICHARD OBENOUR I am devoting this column to pay homage to one of the department’s most distinguished and illustrious physicians, Professor Emeritus Richard A. Obenour, MD. We deeply mourn Dr. Obenour who passed away on August 12, 2019. He devoted almost his entire working career, spanning more than 50 years, to the department and University of Tennessee Rajiv Dhand, MD, Chair Medical Center (UTMC). Dr. Obenour’s achievements as a clinician and leading pulmonologist are well known. He established the Knoxville Pulmonary Group (that later evolved into University Pulmonary and Critical Care). In the course of his distinguished career, Dr. Obenour held many leadership positions in the department, at UTMC, and in the Knoxville medical community. 1
The Congenital Heart Disease Clinic at UTMCK We are excited to share the news of the recent addition of the Adult Congenital Heart Disease Clinic here at UT Medical Center. The rapid progression over the past several years regarding procedures and treatments has led to Adult Congenital Heart Disease becoming an exciting and growing field as more patients born with congenital heart disease are living into adulthood. Thanks to Dr. Jeff Jennings, an Assistant Professor and board-certified pediatric cardiologist who specializes in congenital heart disease, we provide this unique service at UTMC. Tuesday, February 5th, 2019, marked the first day on which patients were seen in the clinic. Dr. Jennings runs the clinic alongside our cardiology fellows here at UT. He has had multiple fellows rotate through his clinic where they have had the privilege of seeing a variety of common, as well as rare congenital heart diseases. As these patients progress into adulthood many challenges and questions may arise. Our clinic provides them stability. One particular example includes those seeking guidance and counseling regarding pregnancy. The clinic allows the opportunity for these patients to obtain continuity of care into adulthood while also providing unique and valuable experiences to our cardiology fellows. Dr. William Black, a second-year cardiology fellow, reiterates how valuable an experience it is as it is such a rapidly growing field. Adult congenital heart disease is an ever-evolving field and our cardiology fellows get a unique glimpse of it through our program.
Treating Movement Disorders with Deep Brain Stimulation Dr. Chris Tolleson, Clinical Associate Professor, is a neurologist specializing in movement disorders and has a special interest in Parkinson’s Disease. “Parkinson’s is the second most common neurodegenerative disorder behind Alzheimer’s Disease,” said Dr. Tolleson, who has been at UTMC since 2017. While there is no cure, the primary motor symptoms (tremor, stiffness, slowness of movement) can be relieved with medical management. Unfortunately, however, medications can become less effective over time. At that point, deep-brain stimulation (DBS) may be considered. This approach involves the implantation of electrodes into specific areas in the brain. These electrodes are connected by a wire to an implantable pulse generator (IPG) that sits under the skin typically in the upper chest. The IPG can then be programmed by a neurologist to deliver electrical stimulation to the brain through the electrodes to help control hypokinesia, rigidity and tremor. DBS substantially improves motor scores and quality of life, having been shown in numerous studies to be superior to medications alone. At this time, Cole Neuroscience Center patients who opt for DBS must have their surgery at other institutions like Vanderbuilt University but can return here for their long-term care. Dr. Tolleson’s goal is for the Cole Neuroscience Center to be designated as a Center of Excellence by the Parkinson’s Foundation. He is proud of the level of care already offered here for Parkinson’s patients, but he notes that meeting the needs of this population will require additional space, equipment, and personnel, as well as more research to better understand this disease. “We serve a large number of Parkinson’s patients – 900 and growing,” he said. “We are committed to providing them with the very best care possible.”
Resident Spotlight – Dr. Kristin O’Connor This edition’s feature resident is Dr. Kristin O’Connor. Dr. O’Connor was raised in Knoxville, attended the University of Tennessee at Knoxville for her undergraduate degree, and then went to medical school at St. George’s University. When she decided on a residency in internal medicine, her heart pulled her back home to Knoxville. She is currently thriving in the second-year class here at UTMC. She and her husband Trey are avid Volunteer fans and also enjoy the lakes and mountains surrounding our city. After residency, she plans to pursue a fellowship in nephrology.
Points of View
continued from page 1
as valued team members. One of Dr. Obenour’s innovative contributions was the development of a system that evaluates each individual’s contributions and productivity in the workplace. I fondly refer to it as the “Obenour Scale” and it is still being used today. Perhaps his most outstanding and endearing quality to me was his dedication to scholarship. In the later phases of his career he limited himself to giving lectures for the residents and pulmonary fellows. Yet he loved to read widely and each time I went to his office I found him reading the latest issue of the New England Journal of Medicine so that he could remain abreast of new developments in medicine. He also contributed philanthropically to several initiatives in the department and UTMC. Each year, we award the distinguished alumnus award in his honor. Following the tragic death of his young son, the R.A. Obenour Jr. endowment was instituted in his memory. Each year this is awarded to one of our faculty members for excellence in teaching. In Dr. Obenour, we have lost a dear friend and colleague. We owe him a debt of gratitude for his unfailing commitment and loyalty to the department. We will greatly miss him. 2
Staff Awards and Honors Sallie Macy Recognized for 45 Years of Service
Sallie Macy, a research technologist in the Amyloidosis and Cancer Theranostics Program, is celebrating her 45th year at UT Medical Center. A native of Wilmington, Delaware, Sallie came to East Tennessee to attend Maryville College in 1970. After graduating, she began performing all the histochemical stains that were required in a local laboratory and hematology/oncology clinic. After receiving training at the Centers for Disease Control, Sallie assumed responsibility for performing leukemia stains for all hospitals in Knox County as well as Blount Memorial Hospital. In 1986 Sallie joined Dr. Alan Solomon in his Human Immunology and Cancer Program where she continued to perform clinical histochemistry and began work on the immunohistochemical evaluation of plasma cell disorders and amyloidosis. Since that time, Sallie has garnered respect from amyloid researchers throughout the world for her work on tissue amyloid staining. She has co-authored more than 20 publications and her work has appeared in countless more. Her studies of novel amyloid-reactive reagents remains a pillar of the current amyloidosis research program and her passion for making a difference in the lives of patients with these diseases remains an inspiration to all who work with her. In 2018 she was presented with an Excellence award by the Graduate School of Medicine. Dr. Emily Martin, Assistant Professor, states, “Sallie’s love of her work and its potential to make a difference in the lives of amyloidosis patients is a constant source of encouragement and determination for our research program. She has a heart of gold, and she motivates me daily to continue searching for ways to help these patients.” Dr. Jonathan Wall, Director of Research, comments, “I have worked with Sal for more than 25 years and continue to learn from, and rely on, her unique expertise. She is a remarkable person who contributes to the success of our amyloid research in so many ways - always focusing on how the patients can benefit from everything we do.”
New Faculty We are pleased to welcome Dr. Sameh Attia as a Clinical Assistant Professor in the Division of Pulmonary Medicine. Dr. Attia earned his Bachelors of Medicine and Surgery from Ain Shams University Faculty of Medicine in Cairo, Egypt. He completed an internal medicine residency at Kingsbrook Jewish Medical Center in Brooklyn, New York. He completed a pulmonary disease and critical care medicine fellowship at the University of Tennessee Graduate School of Medicine in Knoxville, Tennessee. Dr. Attia joined University Pulmonary and Critical Care in August 2019. We are excited to welcome Dr. Michael Liske as an Assistant Professor in the Pediatric Clerkship. Dr. Liske graduated with his Bachelor of Science degree in chemistry from Oral Roberts University in Tulsa, Oklahoma. He earned his Doctor of Medicine from the University of Michigan Medical School in Ann Arbor, Michigan. He
Mississippi Medical Center in Jackson, MS. He completed his internal medicine residency at the Medical University of South Carolina in Charleston, SC. He also decided to stay an extra year as a chief resident for the program before continuing his fellowship in pulmonary and critical care medicine at the same university. Dr. Bevill joined UPCC in August 2019.
completed a pediatric residency and a chief residency at Wright-Patterson Air Force Base and Children’s Medical Center in Dayton, Ohio. He completed fellowships in pediatric cardiology at Northwestern University in Chicago, Illinois and at the University of Michigan in Ann Arbor, Michigan. Dr. Liske joined East Tennessee Pediatric Cardiology in August 2009. We are delighted to welcome Dr. Marcum Collins as a Clinical Assistant Professor in the Division of Rheumatology. Dr. Collins received his Doctor of Medicine from Ross University School of Medicine in St. Michael Barbados. He completed his internal medicine residency at UTMCK then pursued a fellowship in rheumatology at the University of Alabama at Birmingham. Dr. Collins joined University Rheumatology in August 2019. We are pleased to welcome Dr. Benjamin Bevill as a Clinical Assistant Professor in the Division of Pulmonary Medicine. Dr. Bevill received his Doctor of Medicine from University of
Guest Speakers, Department of Medicine Grand Rounds We were honored to have Alexander G. Duarte, MD, professor in the Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Texas Medical Branch present grand rounds entitled, “Non-Cystic Fibrosis Bronchiectasis” and the fellows boot camp entitled, “Nontuberculosis Mycobacterial (NTM) Lung Disease” on September 10, 2019.
CME Opportunities—Mark Your Calendars!
• Cardiology Conferences, held weekly on Wednesdays for .75 hour 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
Ethics Case Rounds – Respect for Persons, Mental Illness, and Gangrene
In Touch
Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are deidentified to protect patient confidentiality.
Publisher Rajiv Dhand, MD, Chair, Department of Medicine and Associate Dean of Clinical Affairs
Geraldine was a 67-year-old lady who was admitted from a long-term care facility with an eschar on her left heel and a necrotic left great toe. Her other problems included schizophrenia, hypertension, peripheral vascular disease, obesity, and diabetes. She has no known family contacts. Geraldine had been here a year earlier, with wet gangrene and osteomyelitis on her right foot. A below-theknee amputation (BKA) had been urgently needed to prevent further loss of limb, and possibly loss of life. She had initially refused surgery, stating “my foot is fine, it’s just dirty,” but ultimately she agreed to BKA as long as she could get a prosthesis. The BKA was performed, and she was discharged to a long-term care facility. Unfortunately, she never received a prosthesis. Geraldine was distrustful and often appeared hostile. She did not work with Physical Therapy or engage much with anyone. Amputation was recommended on her left leg, the extent of which could be as little as removing the toe and debriding the heel all the way to an above-the-knee amputation (AKA) if extensive damage is revealed. Geraldine had been refusing surgery, though she sometimes agreed to “think about it”. She did not acknowledge that she could be at risk of death. Her team of health care providers did not believe she had the decision-making capacity regarding amputation, as a high level of decision-making capacity is needed to refuse interventions that are low-risk and have serious consequences if not provided. However, if an incapacitated patient persists in refusing treatment, the risks of harm of providing that treatment over her objection must be balanced against its potential benefit. It appeared that amputation would be in her best interests, but we felt it important to learn more about her daily routine, likes, and dislikes from staff at her facility, and to obtain her assent prior to making a final decision. Staff from the nursing home said that Geraldine “pretty much stays in her room” and does not interact much. She was extremely independent and did not allow anyone to help with ADLs. They reported she was angry about the first amputation because she expected to get a prosthetic leg but had not gotten one. Staff’s descriptions of Geraldine’s life over the past year cast some doubt about whether amputation would be in her best interests. If amputation could be confined to the toe and if she would assent, it would likely be in her best interests. However, if she required an AKA, or would not assent, she would be better served by not interfering with the progression of the gangrene and providing for a peaceful death when that time comes. Several interdisciplinary meetings were held to generate options for a care plan that respected Geraldine’s health and well-being. The team decided to try performing an arteriogram and placing a stent for the time being. Geraldine assented to this intervention, and was discharged back to her facility with the option of pursuing amputation later. Comments on this case may be sent to amendola@utmck.edu References • Boazak, M. et al. “’You Aren’t Going to Cut on Me!’ Urgent Medical Decisions for Patients with Schizophrenia” Psychosomatics Volume 59, Issue 5, September–October 2018, Pages 506-511 • Taylor, M. et al. “What Are the Ethical Issues in Treating a Patient with Bilateral Leg Gangrene Incapable of Consenting to Amputation Secondary to Psychiatric Illness?” Clinical Orthopedics and Related Research (2015) 473:3998–4003.
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. 8, Issue 4: October 2019
Editor Annette Mendola, PhD Administrative Director Jenny Roark Contributors Jenny Roark Robin Underwood Kristin O’Connor, MD 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.