InTouch Newsletter Vol. 12 Issue 4

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. 12 Issue 4 Oct. 2023

The Integrative Medicine Approach to Patient Care There are many paths in medicine. Physicians in the United States are trained in Western medicine, typically called “evidenced-based” medicine due to emphasis on the development of guidelines for the treatment of disease. Eastern medicine has quite a different approach and uses natural laws as a basis for their fundamentals. The body’s anatomy and physiology work together and correspond to the large universe so that when everything is in harmony one achieves health. Because everything is connected, practitioners in Eastern medicine have a more holistic approach.

Integrative medicine is an intersection of Western and Eastern medicine and brings together complementary approaches in a coordinated way. Integrative medicine uses multimodal approaches to health in various combinations to treat the entire person. It’s a unique intersection of Western, evidenced-based medicine complemented with approaches used in Eastern medicine.

Dr. Rocio Huet, MD is the founder and director of UT Medical Center’s Integrative Medicine Clinic. She’s board certified in internal medicine and integrative medicine. She graduated medical school from the University of Michigan and completed an internal medicine residency at University of TN Knoxville. She worked as an internist for a few years and was exposed to integrative medicine at a conference meeting and decided to complete a fellowship in integrative medicine thereafter. Dr. Huet says she was drawn to integrative medicine because she really got to know her patients on every level. At the core of integrative medicine is looking at the entire person, not just diagnoses.

She is not limited to short 15-minute office visits but can take more time with each patient and learn about their physical, mental, and spiritual health. At new office visits, she uses an intake form that is very comprehensive and asks about life stressors, religion/spirituality preferences, community connections, and their purpose in life. This

information is used to complete a wellness plan, which her patients play a large role in making. A group of providers who participate in the patient’s care meet weekly and discuss the wellness plan and how to best approach the patient’s goals and health.

The team of providers includes a physician, dietician, psychologist, and acupuncturist. Dieticians review dietary plans to best help the patient, such as choosing lower inflammatory foods for those with irritable bowel disease or chronic arthritis. Plant-based diets are emphasized but not mandatory and dietary plans are personalized for each patient. Food is viewed as medicine because what we put into our bodies directly affects our health. The mind is thought to be connected to the body and a psychologist works directly with patients to identify how people react to stress. The enneagram is used frequently in identifying areas for personal development and growth. Acupuncture can be used for a variety of treatments but specifically, Dr. Huet has seen it help tremendously with migraines and chronic pain. Although treating every aspect of a patient improves the quality of care, the most important component in decreasing mortality is social support and feeling connected to those around you.

Points of View

times higher than in South Korea. Furthermore, the U.S. is the only high-income country that does not guarantee health coverage for its citizens, and we lag behind other developed countries in metrics of life expectancy at birth, infant and maternal mortality rates, rates of obesity, and overall longevity. During the recent pandemic, the death rate due to COVID-19 in the U.S. ranked among the highest in the world! There have been strident calls for transforming the U.S. healthcare system but a consensus on what changes are needed remains elusive and it is unclear if any proposed system will have the desired outcomes in terms of improving the health of the population.

Healthcare in America has become too hospital-centric. From birth to death Americans rely heavily on hospitals to provide care for routine procedures, such as childbirth, that for many centuries continued on page 2 were conducted safely at home. Likewise,

THE TRUE PURPOSE OF HEALTHCARE Few people could argue that the current healthcare system is meeting its objectives of promoting the health of all Americans.

The current healthcare system is among the best, if not the best, in the world, but it is geared more towards treating the sick than towards maintenance of Rajiv Dhand, MD, Chair health. The expense of U.S. healthcare is unsustainable in the long run. For example, in the U.S., healthrelated spending per person is nearly twice that in Germany, and four 1

Advanced GI Procedures – Better Treatments & Training There have been impressive advancements in the field of Interventional Gastroenterology in recent years.

University Gastroenterology and The UT Medical Center are proud to utilize these new technologies to bring the most innovative care to our community. Dr. Shaker Barham recently joined University Gastroenterology in the summer of 2022 and has a special interest in advanced endoscopy. He completed Medical School at the University of Jordan and an Internal Medicine Residency at the New York Medical College – a part of Saint Michael’s Medical Center in NJ. He then completed his fellowship in Gastroenterology as well as an additional year of Advanced and Therapeutic Endoscopy at Saint Joseph’s University Medical Center in NJ. University Gastroenterology has successfully performed endoscopic, minimally invasive, organ sparing procedures to treat esophageal, gastric, and duodenal cancers, as well as large colonic polyps. In addition to treating complicated biliary problems, utilizing SpyGlass allows direct visualization of the bile duct to obtain biopsy or lithotripsy under visualization. Endoscopic ultrasound has been a very important diagnostic and therapeutic tool for the management of pancreatic and biliary disorders as well as staging of GI malignancies. Endoscopic treatment of pancreatic necrosis and fluid collections can be done negating the need for surgery. Motility disorders including achalasia and gastroparesis can now be treated with endoscopic myotomy (POEM). These advanced procedures confer less cost, rapid recovery, lower morbidity and mortality when compared to traditional surgical alternatives. The UT Medical Center and University Gastroenterology continue to strive to provide the most innovative and minimally invasive procedures for our patients.

Growing Expertise in the Field of Benign Hematology The Department of Medicine would like to welcome and introduce the newest volunteer faculty member in the Hematology/Oncology Division. Dr. Albert Quiery, M.D. is originally from New York City (NYC) and grew up in the Long Island area. He spent the majority of his young adult life through medical education and initial training in NYC as well. He then ventured further down the east coast to complete a Hematology/Oncology Fellowship at Duke University. After this milestone, he pursued further specialized training in New York for his primary interest within benign hematology. He learned the finer details of blood banking, transplant, and hemostasis, and thrombosis. Dr. Quiery’s first job as a certified hematologist was with Geisinger Health Systems in Pennsylvania, where he spent a total of 22 years. From there, he served as the Medical Director of the Rogel Cancer Center at the University of Michigan in Ann Arbor, focusing on the management of benign hematologic conditions as well as lymphoma.

Although, he did not have much free time throughout residency and specialty training, he did enjoy the love and responsibility of raising three children. Now that he is more established in his career, he has a growing interest in the humanities, becoming more familiar with various types of art and music. He also enjoys outdoor activities such as landscaping, gardening and hiking – making Knoxville/East Tennessee one of his favorite places to live. What he enjoys most about Knoxville is being close to his daughter, who lives in the Johnson City area, giving him the opportunity to spend precious time with his two grandchildren.

Dr. Quiery also has a background in medical ethics, having obtained his Master of Science in Bioethics. He conducted work and education in bioethics, social determinants of health, and medical humanities while at the University of Michigan. Dr. Quiery joined University Cancer Specialists at UT Medical Center as a benign hematologist in May 2023. He is currently working with a campus wide group called Faculty Collective on The Study of Mortality which involves investigating the varied experience of death from an interdisciplinary approach. Since May, he has found UT Medical Center to be a wonderful place to work and feels that all of the healthcare providers here truly care about their patients!

Points of View continued from page 1 providing end-of-life care, although important, involves an enormous expense at a hospital. A better, more integrated, and functional system that facilitates “death with dignity” would be more economical, and for many patients, more humane.

U.S. health insurance also needs reform. Millions of U.S. residents do not have access to health insurance, and they do not receive an adequate level of preventive/timely healthcare. The uninsured have limited ability to acquire health and preventative services and rely excessively on emergency departments for care. Because of the high cost of these services, uninsured patients delay seeking care until their condition becomes advanced and life-threatening. Even for those with health insurance, the process lacks transparency, and navigating the complexities of eligibility and claims can be intimidating. Therefore, changes in the paradigms of healthcare and insurance coverage are needed to reduce the emphasis on hospitals and the treatment of diseases and instead prioritize healthy physical, social, and economic environments where people have access to good quality care and health promotion is emphasized over disease treatment. In this model, the future success of hospitals may not be reflected in how many of their beds are occupied but instead in how many hospital beds could be eliminated because they are no longer needed.

The ever-increasing costs of healthcare require transformative solutions. A simpler, more functional, and streamlined system would reduce societal costs and negative patient health outcomes. Governmental and private industry efforts are needed for such a monumental transformation to be successful. We, as physicians, could play a major role by educating the public about health promotion and disease prevention and by stimulating research and innovation into alternative less expensive models of healthcare.

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Guest Speaker: Dr. Mark Hamblin We were delighted to have Mark Hamblin, MD, FCCP present a talk on “Pulmonary Fibrosis: Trials & Tribulations” for a Medicine Grand Rounds Conference on September 12th, 2023. Dr. Hamblin is an Associate Professor at the University of Kansas Medical Center. He is also the Director of the KU ILD & Rare Lung Disease Program. Dr. Hamblen cares for patients dealing with pulmonary fibrosis, inflammatory interstitial lung diseases and rare parenchymal lung diseases. He is also the principal investigator on multiple research studies focused on the study of pulmonary fibrosis, and rare parenchymal lung diseases such as sarcoidosis, lymphangioleiomyomatosis (LAM), diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH), and others. Dr. Hamblin also prepared a separate lecture for our pulmonary critical care medicine fellows discussing, “Hypersensitivity Pneumonitis: Updates on Guidelines for Diagnosis and Management.” Both lectures were greatly appreciated by the faculty, fellows, residents and medical students.

Resident Highlight – Dr. Kirk Reeves The Department of Medicine would like to introduce the newest addition to the PGY-2 class Dr. Kirk Reeves, DO. Dr. Reeves graduated from University of North Texas Health Science Center College of Osteopathic Medicine in 2022. He stayed in Texas to complete his intern year before moving to Knoxville to join the PGY-2 class here at University of Tennessee Knoxville. Dr. Reeves current long-term goal is to work as a hospitalist, but he is keeping an open mind as he completes his training. He has been a great addition to our program, and it is with great pleasure that we welcome him to Vol nation!

Scholarly Activity 2023 • Shali L, Taylor J, Villarosa A. Predictive ability of more than a 3-day pre-atrial fibrillation ablation cardiac computer tomography in detection of left atrial thrombus.

Presented at Society of Cardiovascular Computed Tomography 2023: Boston, MA July 27-30, 2023

• Kopstein M, Livesay J, Taylor J, Baljepally R. Plaque rupture cannot hide from OCT. Presented at Cardiovascular Innovations Foundation 2023: Austin, TX July 19-22, 2023

CE, Michotte JB, Lu Q, Reychler G, Vecellio L, de Andrade AD, Rouby JJ, Fink JB, Ehrmann S. Aerosol therapy in adult critically ill patients: a consensus statement regarding aerosol administration strategies during various modes of respiratory support. Ann Intensive Care. 2023 Jul 12;13(1):63.

• Li J, Liu K, Lyu S, Jing G, Dai B, Dhand R, Lin HL, Pelosi P, Berlinski A, Rello J, Torres A, Luyt

• Terry P, Dhand, R. The 2023 GOLD report: updated guidelines for inhaled pharmacological therapy in patients with stable COPD. Pulm Ther. 2023 Jul 20. doi: 10.1007/s41030-023-00233-z.

Online ahead of print.

Faculty Announcements

Special Recognition

New Faculty

The Department of Medicine would like to congratulate Dr. Francisco Soto on the invitation to become the Vice-Chair for the Pulmonary Vascular Disease Network with the American College of Chest Physicians (CHEST). He has plans to move into the Chair role after serving for two years as the Vice-Chair. Dr. Soto states that, “I am excited for the networking opportunities for our Pulmonary Hypertension Program as well as the fellowship program and the Pulmonary Critical Care Medicine Division”. There is also an opportunity to onboard an interested fellow in a leadership role within the network.

We are honored to have such a progressive researcher and practitioner as Dr. Soto on our faculty.

We are excited to welcome Dr. Ryan S. Alexander to the rank of Clinical Assistant Professor. He is licensed by the American Board of Internal Medicine and certified by the American Board of Preventive Medicine. Dr. Alexander is a graduate of LMU-DeBusk College of Osteopathic Medicine and completed a Master of Public Health at Yale University School of Public Health. He completed his residency in Preventive Medicine at Griffin Hospital, Yale University, in Derby, CT. Furthermore, he completed a fellowship in Addiction Medicine at Yale University School of Medicine.

We are happy to welcome Dr. R. Blake Lowe to the rank of Clinical Assistant Professor. He is licensed by the American Board of Internal Medicine, the American Board of Pediatrics, and the American Board of Obesity Medicine. Dr. Lowe is a graduate of Edward Via College of Osteopathic Medicine and completed a Master of Science in Food Science & Technology at University of Tennessee College of Agriculture. He completed his residency in internal medicine & pediatrics at Geisinger Medical Center in Scranton, PA and has worked as an assistant professor of medicine and pediatrics at Geisinger Commonwealth School of Medicine.

CME OPPORTUNITIES—MARK YOUR CALENDARS! hybrid attendance: half joining via Zoom or Microsoft Teams

• Cardiology Conferences, held weekly on Wednesdays in the Medicine Conference Room for .75 hour CME credit.

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

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

• Pulm/HTN Conferences, held on the 2nd Monday of the month at noon in different locations and are available for 1.00 hour CME credit.

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Ethics Case Rounds: “Granny Dumping” Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality.

“Liz” is a 34 y/o lady who was scheduled to have a heart valve replacement. She had a history of substance use disorder, endocarditis, noncompliance, and leaving AMA. She had been informed of the risks and benefits and had consented to the procedure. Her mother had been present for that discussion and was also in agreement. However, in the Operating Room just prior to being sedated for the procedure, Liz became agitated and aggressive. She said she changed her mind and wanted to leave against medical advice. She was sedated for safety and a time-sensitive ethics consult was requested.

In the discussion that followed, the team agreed that Liz would die sooner or later without surgery and was at very high risk for stroke in the meantime. Team members who were present in the OR said she had been restless and complaining of discomfort from the central line but did not voice a change in goals of care or recognition that she would die without surgery. The surgeon felt the Liz’s refusal was not an authentic, capacitated refusal and thought they should proceed. Other members of the team felt uncomfortable proceeding over her objections. A decision was reached to postpone the procedure in order to allow Liz to wake up fully and repeat the informed consent process. The surgeon said he would perform the valve replacement later that day if she consented.

Steps to take when a patient refuses a time-sensitive, potentially lifesaving intervention include (a) assessing the patient’s decision-making capacity, including the seriousness and imminence of the consequences of refusing, (b) identifying (and removing, if possible) any barriers to authentic decision making, (c) assessing the risks, efficacy, and time-sensitivity of the intervention, and (d) considering the logistics and likely sequelae (including emotional sequelae) of proceeding against the patient’s refusal.

While Liz was waking up, her nurse spoke with her mother about post-op expectations, including the importance of participating in physical therapy, which can be uncomfortable. Her mother was skeptical about Liz participating in post-op care, saying she did not cope well with pain and didn’t like being told what to do.

Her mother agreed that Liz’s refusal was not an authentic choice, but rather reflected her inability to tolerate discomfort. She was initially in favor of proceeding with surgery over Liz’s objections “even if you have to restrain her”, since the risks of delay were so high. However, she changed her mind when she considered that her recovery would not go well unless she participated in therapy.

When Liz awoke, the surgeon spoke with her about the procedure. Liz agreed to surgery and did not remember refusing. Later that afternoon, however, she became agitated and again refused surgery and said she was leaving against medical advice. She said the line in her neck was painful and she was “over this”. She was not amenable to repositioning or medications for pain. Despite encouragement to stay from her physician, nurses, and family, she signed herself out against medical advice. She agreed to return to the hospital if her symptoms recurred, but unfortunately was lost to follow up.

Comments on this case may be sent to amendola@utmck.edu References • Beal ML, Oxman DA, Becker MA. Non-urgent Surgical Intervention Over Objection in a Patient Who Lacks Capacity: A Case Report. Psychosomatics. 2020 May-Jun;61(3):277-280. doi: 10.1016/j.psym.2019.07.005.

Epub 2019 Jul 24.

• Waisel DB, Lamiani G, Sandrock NJ, Pascucci R, Truog RD, Meyer EC. Anesthesiology trainees face ethical, practical, and relational challenges in obtaining informed consent. Anesthesiology. 2009 Mar;110(3):480-6. doi: 10.1097/ALN.0b013e318197ff46.

Presentations, Publications, Awards

Department of Medicine faculty, residents, and fellows share their knowledge and experience by publishing and presenting across the world. For a list of our most recent accomplishments, visit http://gsm.utmck.edu/internalmed/scholars.cfm.

Thank You For Your Support

For information about philanthropic giving to the UT Graduate School of Medicine, Department of Medicine, please contact the Development Office at 865-305-6611 or development@utmck.edu.

If you would like more information about any of the topics in this issue of In Touch, please contact the Department of Medicine at 865-305-9340 or visit http://gsm.utmck.edu/internalmed/main.cfm.

We look forward to your input. Thank you.

Stay In Touch!

Alumni, please update your contact information by completing the simple form at http://gsm.utmck.edu/internalmed/alumni.cfm or by calling the Department of Medicine at 865-305-9340. Thank you!

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In Touch Vol. 12 Issue 4: October 2023

Publisher Rajiv Dhand, MD, Chair, Department of Medicine and Associate Dean of Clinical Affairs Editor Annette Mendola, PhD Administrative Director Jenny Roark Contributors Jenny Roark Robin Underwood Rajiv Dhand, MD Annette Mendola, PhD Cassandra Mosley Shawna Stephens, DO Ashley Gutierrez-Santana, MD Erin Hamric, DO Logan Shaver, DO 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.

Disclaimer: quotes/ interviews are edited for length and clarity