Department of Medicine — Summer 2023

Richard Rothstein, MD, in a telehealth visit.

A Message from Our Chair

I am again delighted to share our latest newsletter highlighting areas of research, teaching, patient care, and culture in the Department of Medicine (DoM). In this issue, we share the innovative programs for “onboarding” advanced practice providers (APPs) that have been passionately designed, championed, and implemented by Cheryl A. Elinsky, MS, PA-C. This work, which began in the section of General Internal Medicine and spread throughout the Department of Medicine, has since been adopted by other departments and divisions at Dartmouth Hitchcock Medical Center (DHMC).

The development of additional training and mentoring opportunities for new APPs has resulted in enhanced preparation and more rapid assimilation into clinical practice, as well as better engagement and confidence. Recognizing the importance of her work, Dartmouth Hitchcock appointed Cheryl as the inaugural director of Continuing Professional Development and Education for APPs in the Office of Advanced Practice Providers, and she was presented with the Department of Medicine’s Chair’s Award for Excellence in Teaching.

Our department supports access to healthcare for everyone, and many clinicians volunteer at two community health centers that provide free care for people in challenging life circumstances. Kelly

Kieffer, MD, RES ’00, MS ’11, and Tim Gardner, MD, RES ’04, FEL ’07, MS ’13, describe engagement at the Good Neighbor Health Clinic and Mascoma Community Health Care, including the opportunity for volunteer clinicians to mentor Geisel medical students and model the altruistic calling at the core of medical practice.

Karen Huyck, MD, PhD, MPH, and Jon Lurie, MD, MS ’97, RES ’99, describe their work with Vermont RETAIN (Retaining Employment and Talent After Injury/Illness Network), a project with the Vermont Department of Labor. These DHMC investigators are developing and studying pathways to provide needed resources for early stay-at-work and return-to-work programs with a goal of increasing employment retention and decreasing work disability.

The Department of Medicine’s telehealth practice, implemented broadly across departmental sections, is highlighted in an article about its use in the areas of Rheumatology, Gastroenterology and Hepatology, Infectious Disease, Obesity Medicine, and Critical Care. The department was an early leader in telehealth, practicing telemedicine before the pandemic accelerated its rapid and exponential adoption. For our rural healthcare system, telemedicine practice helps our clinicians meet patient needs in a patientcentric way. Our TeleICU service provides critical care expertise to support hospitalists caring for patients at smaller facilities, and guidance that contributes to safe and effective local care.

In the previous newsletter, I announced my decision to step down this summer from the position of chair of our Medicine department as part of my transition to a part-time schedule. I will be refocusing my clinical and academic energies on the exciting new Center for Digestive Health. A national search is underway for my replacement. We are also working to fill several sectional leadership positions, which can be found at dhproviders.org . Meanwhile, we have much to finish before the end of my tenure, and I am so proud of the robust scholarship and dedicated clinical care provided by our faculty and staff. Thank you for all you are doing!

Richard Rothstein, MD, FEL ’85 Chair, Department of Medicine

If you are interested in learning more about opportunities to engage with and support our departmental activities, please contact Megan Dodge in the Medical & Healthcare Advancement Office at Megan.Dodge@hitchcock.org

Volunteers provide wider access to healthcare

Physicians offer free medical services to the community

The Department of Medicine supports access to healthcare for everyone, regardless of their life situation. To help make this a reality, physicians in the department volunteer their time at two community health clinics, offering free services to people who might not otherwise get the medical care they need.

“Healthcare is really expensive, and people have a right to quality healthcare no matter their economic circumstances,” says Kelly Kieffer, MD, RES ’00, MS ’11, the department’s vice chair for education and one of many volunteer physicians at the Good Neighbor Health Clinic (GNHC) in White River Junction, Vermont. “I feel like this is a way I can contribute to the community.”

The GNHC opened in 1992 to serve patients who don’t have health insurance or are underinsured. In her six years of volunteering at the clinic, Kieffer says she has created trusting, longitudinal physician-patient

relationships with her core group of patients whom she sees regularly. She says this trust helps her patients stay engaged with their own healthcare.

She also values what she has learned as a healthcare provider through her volunteer work, including how to help uninsured patients afford their medications.

“I’ve learned a lot about how to consider the cost of medications and how to choose which ones to prescribe,” Kieffer says. “Maybe the medication is not my first choice, but it’s a good option for this person and it’s financially feasible.”

Continued on page 12

Kelly Kieffer, MD, RES ’00, MS ’11, (from left), medical student Adriana Radosavljevic ’25, and community volunteer Taylor Turner volunteer at the Good Neighbor Health Clinic in White River Junction, Vermont, to provide free healthcare to uninsured people in the community.

RETAINING EMPLOYEES After

Injury

or Illness

Research project puts work-health coaches in primary care practices to support patients

Unemployment due to illness or injury is a strong predictor of a wide variety of negative health outcomes, but clinicians often aren’t equipped to assist patients in managing the impact of a health condition on their ability to work. Through a new project, Dartmouth Health physicians and researchers are taking action to address this problem.

“Primary care physicians provide early injury and illness care, but they don’t get a lot of training on the intersections of employment and health,” says Karen Huyck, MD, PhD, MPH, the medical director for Vermont RETAIN, a project with the Vermont Department of Labor through a federal grant from the U.S. Department of Labor. “Physicians focus on the treatment but don’t often ask patients, ‘Are you able to do your job with your injury? Are you going to be out of work because of this?’ We as providers often don’t ask those questions because they’re seemingly outside the scope of our typical care plans.”

To fill that gap, Vermont RETAIN (Retaining Employment and Talent After Injury/Illness Network) is an early stay-at-work, return-towork program that aims to increase employment retention and decrease work disability by putting work-health coaches in primary care settings. These coaches connect patients with existing employment resources and services to help them stay at work or return to work quickly as they recover their health.

“The longer someone is out of work, the risk of not returning goes up significantly,” says Jon Lurie, MD, MS ’97, RES ’99, a hospitalist at Dartmouth Hitchcock Medical Center and an investigator on the outcomes of Vermont RETAIN. “It’s very hard to return to work after three months of unemployment, and after one year there’s an extremely low rate of return. The sooner you can get people moving toward the goal of getting back to work, the better chance you have of maintaining that.”

The most effective way to do that, Huyck and Lurie hypothesize, is through work-health coaching to help patients access existing services in Vermont. These coaches are trained in a variety of fields— nursing, social work, physical therapy, and other backgrounds—and they work as a team to address a patient’s specific need. The coaches also have access to other professionals who can advise on legal aid, mental health, employee assistance programs (EAPs), and many other specialties. To reduce the burden on the primary care practice, Huyck says, the patient can self-screen for risk of work disability and get support from a work-health coach to learn self-advocacy skills and how to navigate the available state resources.

“It can be an extraordinarily frustrating process to access government assistance, even though there are many services to help people stay in the workforce,” says Lurie, who is currently working

Jon Lurie, MD, MS ’97, RES ’99 Hospitalist at Dartmouth Hitchcock Medical Center

on phase 2 of the project. “People who are sick or injured and unable to work are not always in the best position to advocate for themselves.”

Vermont RETAIN has already enrolled more than 70 primary care practices to participate in the project, randomized into intervention or control groups. Both groups receive best-practice tips, resources, and provider access to phone consultations about patient work-health issues; intervention groups also are assigned a work-health coach to support patients. About 70 eligible patients are currently enrolled, and the goal is to enroll at least 2,000 as the study ramps up. As phase 2 continues, Lurie and the Dartmouth Health team are measuring participant outcomes to identify the most effective aspects of the intervention in order to refine and tailor it for the future.

So far, provider and patient feedback on the program has been promising.

“I received the resources you provided and have already reached out to the transportation resources directly to see if they can help with supporting my daily commute,” says Karen V., a patient participating in the study. “It is wonderful to know, all in one place, the many resources available to those who are disabled. You encourage me to keep being strong and to continue to participate meaningfully in this world in spite of my limitations!”

Huyck emphasizes that providers need to understand that patients who are unable to work may feel vulnerable and find it a difficult topic to discuss. Lurie agrees.

“New Englanders, and people in Vermont in particular, don’t like to ask for help,” Lurie says. “This program gives them permission and validates that it’s OK to ask for help.”

People who are sick or injured and unable to work are not always in the best position to advocate for themselves.”

The Department of Medicine was an early leader in telehealth. They were doing telemedicine even before the pandemic.”

Katelyn Darling Director of Telespecialty Services and Outpatient Virtual Visits

Long-Distance Expertise

Virtual appointments and consultations help remove barriers to delivering specialty care

on-demand consultations with patients and physicians at smaller community or critical care hospitals in the region. Scheduled outpatient virtual visits peaked at more than 2,500 per day at the height of the pandemic and are currently leveling off at about 700 per day.

“The Department of Medicine was an early leader in telehealth,” says Katelyn Darling, director of Telespecialty Services and Outpatient Virtual Visits. “They were doing telemedicine even before the pandemic. They got their providers trained and patients set up before the shutdowns, so they had fewer technology failures.”

SSince the onset of the pandemic, virtual appointments have become widely used and greatly appreciated by patients and physicians alike. Dartmouth Health has long been ahead of the curve in the move toward telemedicine.

“This is a rural area and access to specialty care is challenging,” says Kevin Curtis, MD, MS, the medical director of Dartmouth Health (DH) Connected Care, which partners with healthcare providers and medical facilities throughout northern New England. “A patient might be hours away and have to take a day off of work. Travel might be difficult, or they might not have childcare. So how do we bring specialty care to this area with a strong focus on rural care?”

The answer was the Center for TeleHealth, established at DH more than a decade ago, and its services have broadened in that time to include

The department continues to lend its expertise to people who need specialty care and medical advice— even if they’re 100 miles away.

Rheumatology

Long before the pandemic, Daniel Albert, MD, and other DH rheumatologists had an arrangement with outlying hospitals to treat patients virtually from those facilities. Rather than driving several hours

Corey Siegel, MD, RES ’02, FEL ’05, MS ’09, (left) section chief of Gastroenterology and Hepatology, says telemedicine has helped physicians at Dartmouth Hitchcock Medical Center provide specialty care to patients all over the region.

round-trip to Dartmouth Hitchcock Medical Center (DHMC), patients went to their regional hospital and had a virtual consultation with a DH rheumatologist. A nurse at the local hospital assisted the patient in-person. While the volume was low at the time, patients found the virtual visits much more convenient.

When COVID-19 struck the country, however, patients did not want to go to their local hospitals for fear of contracting the virus, so DH switched to virtual visits in patients’ homes. Albert estimates that 80% of his appointments were virtual during the worst surges, and he now serves about 30% of his patients through telemedicine. He sees patients in-person if that’s their preference or when they need a physical exam or have other medical conditions that make telemedicine difficult.

“I like to do telemedicine because patients like it,” Albert says. “I also like that patients often feel more open about their medical situation when they’re at home. I can see their home environment, and that gives me perspective of people’s living situation—a significant other who might not attend an in-person appointment, or kids and pets. I get a more rounded view of the whole person.”

Gastroenterology and Hepatology

Patients who need subspecialty care for complex conditions might have to drive two or more hours one way to see physicians at DH, says Corey Siegel, MD, RES ’02, FEL ’05, MS ’09, section chief of Gastroenterology and Hepatology. He says telemedicine has been

a valuable way to deliver care for subspecialty chronic disease management for patients with no alternatives closer to home.

The Inflammatory Bowel Disease (IBD) Center in the GI section started a new program funded by the Helmsley Charitable Trust called RADIUS—rural APPs (advanced practice providers) delivering IBD care in the United States. Through this program, DH providers partner with small regional practices to deliver specialty care for people living with Crohn’s disease and ulcerative colitis in northern New England. In a two-hour virtual visit, these patients see a team of DH providers—an IBD specialist, a psychologist, a dietician, a pharmacist, and a nurse coordinator.

“We’ve had wonderful feedback from patients about how comprehensive the visit is,” Siegel says. “Having IBD is not only about the bowels but also about how the disease affects their entire life. It takes a team to give the best care to this group of patients, and now patients can see the entire subspecialty team from home.

The DH specialists mentor rural APPs who continue the patient’s care at a regional practice. “It’s a way to provide high-level care without patients having to drive here,” Siegel says. “The APPs in these rural practices are able to care for their patients in their own communities with the virtual support of our team of providers.

Infectious Disease

Infectious disease is a small specialty with few physicians in the New England area, but their expertise is invaluable

I like to do telemedicine because patients like it. I also like that patients often feel more open about their medical situation when they’re at home.”

Daniel Albert, MD Rheumatologist

to patients living with HIV/AIDS, hepatitis C, and other diseases. Distance, however, can be a barrier to delivering this expert care.

The outpatient parenteral (IV) antimicrobial therapy (OPAT) program helps mitigate that problem, serving patients who are discharged from DHMC but still need close monitoring for their long-term antibiotics, says Bryan Marsh, MD, D ’80, RES ’93, FEL ’96, section chief of Infectious Disease and International Health. OPAT allows high-risk patients in rural areas to see a dedicated nurse practitioner at their local hospital for interim follow-up care. The patient returns to DHMC only for an end-of-treatment visit.

“OPAT improves post-discharge care for patients who need institutional medical care,” Marsh says. “Without OPAT, some of these patients wouldn’t come back and be seen by a provider, and they wouldn’t get the standard of care they need.”

Weight and Wellness

At the DH Weight and Wellness Center, both outpatient appointments and group classes are offered virtually for patients who need coaching and lifestyle medicine, such as counseling from psychologists, dieticians, or fitness trainers.

Auden McClure, MD ’99, RES ’02, FEL ’04, RES ’08, MPH ’08, the interim section chief of Obesity Medicine and co-director of the Pediatric Lipid and Weight Management Center, says the weekly and monthly virtual group classes are beneficial

because they allow DH providers to reach more people at one time. They also facilitate group interaction and peer support no matter how far apart people may live from one another.

Providers are aware that patients have different needs, particularly if they do not have access to the internet or are not comfortable with the technology.

“We partner with the patient to see what’s best for them, either in-person or virtual,” McClure says. “We don’t want telemedicine to be a barrier; it’s an additional tool.”

Critical Care Support

Small, rural community or critical care hospitals often don’t have a specialist on call in the emergency department. Thankfully, the Department of Medicine’s TeleICU and TeleEmergency experts are only a video conference away.

“Most ICUs in the country are staffed by hospitalists who don’t have critical care training,” says Jeffrey Munson, MD, MSCE, medical director of the medical intensive care unit. “We provide critical care expertise to support hospitalists who are caring for their patients at different facilities.”

A critical care specialist on the TeleICU team rounds on patients virtually at four regional hospitals, and someone is on call 24/7 to monitor patients’ vitals and to answer bedside questions from physicians and nurses. High-definition video-audio calls, Munson says, allow the TeleICU provider to see the patient, almost as if they’re in the same room. “It’s better than a phone call because we get a better sense of the situation and the best advice to give.”

TeleICU has two objectives: ensuring patients get the best possible care and helping patients stay at their regional hospital rather than being transferred to a tertiary care center. “This helps alleviate bed capacity problems,” Munson says, “and makes sure patients are getting safe and effective care.”

The TeleICU service at Dartmouth Hitchcock Medical Center helps provide critical care expertise at smaller hospitals, so patients can stay close to home.

PHOTO BY: KATA SASVARI

Department of Medicine

Scholarship Enhancement in Academic Medicine (SEAM) Awards Program

“We partner with the patient to see what’s best for them, either in-person or virtual. We don’t want telemedicine to be a barrier; it’s an additional tool.”

Looking to the Future

Now that telemedicine has become part of the everyday medical experience for patients and providers, DH intends to determine how well it’s working through research. For example, Albert recently published a paper called “Addressing Competency in Rheumatology Telehealth Care Delivery ” and authored two chapters in a new book titled Telerheumatology He also has published research on his earlier years of providing rheumatology telemedicine, including “Disruptions in Rheumatology Care and the Rise of Telehealth in Response to the COVID-19 Pandemic.”

Additionally, Albert secured a grant to develop several short, animated videos to educate providers and patients on preparing for a telerheumatology visit.

“COVID removed many barriers and made telemedicine possible in this country,” Albert says. “Now we must figure out what it’s good for and what it’s not good for so people are appropriately triaged. It’s an ongoing enterprise that’s important to Dartmouth Health.”

The SEAM Awards Program supports academic “dreams.” Successful proposals may include innovations in teaching, discovery/research, publication/ presentation, practice improvement, and/or digital scholarly communications, with the ultimate goal of enhanced quality of patient care. The SEAM Awards funding exceeds $1,255,127 since 2018.

Academic Year 2023 SEAM Awards

Reprogramming the Immune Microenvironment Using a Copper Depletion Strategy in Metastatic Non-Small Cell Lung Cancer

Project Leader:

Ivy L. Riano-Monsalve, MD, PGY4 Instructor in Medicine, Geisel School of Medicine; PGY4 Hematology and Oncology Fellow, Section of Hematology and Medical Oncology

DNA Methylation as a Marker of Corticosteroid Response in Polymyalgia Rheumatica (PMR)

Project Leader:

Vivekanand Tiwari, MD, FEL ’22 Assistant Professor of Medicine, Geisel School of Medicine; Section of Rheumatology

Pragmatic Randomized Trial for Arterial Catheters in the Critical Care Environment (GRACE Trial/ NCT:05411315)

Project Leader:

Terrence Wong, MD, PGY5 Instructor in Medicine, Geisel School of Medicine; PGY5 Pulmonary and Critical Care Medicine Fellow, Section of Pulmonary and Critical Care Medicine

Project Co-Leader:

David J. Feller-Kopman, MD

Professor of Medicine, Geisel School of Medicine; Section Chief, Pulmonary and Critical Care Medicine

Auden McClure, MD ’99, RES ’02, FEL ’04, RES ’08, MPH ’08 Interim section chief of Obesity Medicine

Intensive training for APPs

Onboarding and post-grad programs support advanced practice providers

increasing in number as members of healthcare teams across the nation, and while they are highly educated, many newly graduated APPs desire additional clinical and didactic experiences as they begin their role as a physician assistant (PA) or advanced practice registered nurse (APRN).

Because Dartmouth Health is committed to helping these new graduates become confident and competent in caring for patients and families, the Department of Medicine and other departments are providing infrastructure to support their transition to advanced practice.

“In most cases, there are gaps between what they learned in the classroom and what they may or may not have been exposed to as a student during their clinical year. These gaps make for a very challenging start to their clinical practice,” says Cheryl A. Elinsky, MS, PA-C, director of Continuing Professional Development and Education for Advanced Practice Providers in the Office of Advanced Practice, a position she started in January. “It’s one thing to learn something in the classroom, but it’s different to see it in a patient. I wanted to augment what they learned in school in a supportive, welcoming collegial environment.”

Elinsky began this work in 2016 when she requested to help onboard seven new APPs in General Internal Medicine. The reputation of these group sessions, which she titled Topics in Medicine, spread through the department, and APPs in different sections also wanted to join the case-based onboarding sessions. Elinsky brought the idea to Richard Rothstein, MD, FEL ’85, chair of the Department of Medicine, and he encouraged her to apply for a SEAM award, which she earned two years in a row. Susan Reeves, EdD, RN, CENP, executive vice president of Dartmouth Hitchcock Medical Center and chief nursing executive for Dartmouth Health, then garnered philanthropic support for this work.

“We honored Cheryl with the Chair’s Award for Excellence in Teaching in December 2021, the first time it was given to a non-MD,” Rothstein says. “Her efforts to support non-MD clinicians is extraordinary.”

In addition to the onboarding Topics in Medicine sessions, the Department of Medicine offers three postgraduate programs: Adult Critical Care, Hospice and Palliative Medicine, and Hospital Medicine. Three additional APP postgraduate programs are offered in other departments, and each of these six programs accept a maximum of two participants annually. The programs

Cheryl Elinsky, MS, PA-C (left), provides continuing education with Hospice and Palliative Medicine APP fellows Nadine Carter and Andrew Harte.

provide intensive didactic and clinical experiences in a specific clinical area to enhance the initial advanced practice education.

“What we hope for is that they will complete a postgraduate program and be adequately prepared to participate in clinical practice with confidence and competence,” Elinsky says. “We hope they can be hired immediately and start out really strong, versus a new graduate who is learning on the job.”

The Topics in Medicine sessions and postgrad programs have provided an additional benefit to APPs as they transition to practice—getting to know their colleagues in other sections. Elinsky notes that these working relationships help reduce stress for new providers and improves retention.

“This place is big and can be overwhelming to new APPs. They may not have established collegial relationships with other providers,” Elinsky says. “It’s uncomfortable and awkward to not know someone and ask important questions regarding patient care. But when you know APPs in other sections from the onboarding sessions, you feel more comfortable asking for help with a difficult patient.”

Dorothy Mullaney, DNP, APRN, FAANP, chief APP officer for Dartmouth Health in the Office of Advanced Practice, notes that this collaboration among APPs also helps to make each section in the Department of Medicine more robust as APPs tap into one another’s professional experience.

“What’s especially excellent about Cheryl’s work is how willing she is to look at each individual provider, and while wanting to standardize onboarding and the postgraduate programs, she also individualizes the experience to each APP,” Mullaney says. “She’s so incredibly dedicated to the role of the APP and the need to support and grow that role.”

To learn more about the hospice and palliative medicine interdisciplinary training program for APPs, please see page 6 of the winter 2021 newsletter at d-h.org/medicine

Research in the Department of Medicine

The Department of Medicine continues to have a strong commitment to academic success through research scholarship under the leadership of Chair Richard Rothstein, MD, FEL ’85; Vice Chair of Research Richard Enelow, MD; and Director of Research Operations Jessica Chevalier, BS, CCRP.

In future newsletter editions, we will continue to highlight areas of active research by our faculty and learners. Below we present our current research portfolio, which includes all academic Department of Medicine faculty activities.

RESEARCH STUDIES

302

151 NEW PARTICIPANT ACCRUALS

101 ACTIVE GRANTS

332 58% 20%

studies

$8.09M SEMI-ANNUALIZED REVENUE

Tim Gardner, MD, RES ’04, FEL ’07, MS ’13 Gastroenterologist at Dartmouth Hitchcock Medical Center

Another free clinic, Mascoma Community Health Care, is a subspecialty satellite of the Good Neighbor clinic and serves patients who need gastrointestinal healthcare. Tim Gardner, MD, RES ’04, FEL ’07, MS ’13; Steve Bensen, MD ’90, RES ’94, FEL ’96; and Campbell Levy, MD, RES ’05, FEL ’08, are volunteer gastroenterology providers at the Mascoma clinic.

“At its heart, medicine—and not just physicians but also nurses and physical therapists and others—is altruistic. In the course of our lives, physicians can lose sight of that,” says Gardner, who is one of the clinic’s founders. “Volunteering is important because it brings medicine back to the essence of why we do it, to help people’s suffering. There are very few forums in our healthcare system in which that’s possible, completely altruistic, which is the point.”

All services—including screenings, labs, vaccines, and more—at the Mascoma and Good Neighbor clinics are completely free for their patients. Clinic sessions at both sites are primarily managed by first- and second-year Geisel School of Medicine students. Kieffer and Gardner enjoy the more relaxed opportunity they and the other attendings are able to spend working with the students, without worrying about time constraints or billing.

“The students see the patients and come up with management plans, and we just supervise them,” Gardner says. “Students are learning how to interact with patients and have more autonomy than they would in normal clinical rotations. And patients get subspecialty care for complicated diseases. It’s a win-win for everybody.”

Faculty Promotions & Appointments

Our faculty members are the foundation of the Department of Medicine. Their dedication and commitment to our mission and their work is exemplary. Being recognized for academic achievement is an honor bestowed upon our clinician-scholars by their faculty peers.

We are excited to announce the following faculty promotions and appointments granted Oct. 1, 2022, to May 1, 2023. Congratulations to them all!

Photographer: Mark Washburn Writer: Ashley Festa Designer: Linnea Spelman

* Indicates faculty appointment

Sonia Chimienti, MD* Professor Infectious Disease and International Health

Ellen Flaherty, MSN, PhD Associate Professor General Internal Medicine, Geriatrics

Cynthia Taub, MD* Professor Cardiovascular Medicine

Charles Thomas, MD* Professor Radiation Oncology

“ Volunteering is important because it brings medicine back to the essence of why we do it, to help people’s suffering.”