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D epartment


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. 6, Issue 2: Apr. 2017

Good Stewards Antibiotics save lives. COMMON REASONS ANTIBIOTIC But their power to do so PRESCRIBING GUIDELINES ARE NOT is increasingly threatened with the proliferation FOLLOWED of multidrug-resistant • Inaccurate belief that non-recommended organisms (MDROs). Overuse and use of broad agents may be more likely to cure an spectrum antimicrobials infection with unnecessary double • Concern for patient satisfaction; a common coverage can profoundly damage the human method by which clinicians are evaluated microbiome, which has • Fear of infection complications and related likely contributed to the adverse outcomes proliferation of MDROs. Antibiotic stewardship promotes wise use of this resource. Dr. Shorman credits the program’s success in part to support UTMC’s antibiotic from the administration, coordination with the microbiology lab, stewardship program has been energized under the direction and having a dedicated pharmacist. Looking ahead, the team of Dr. Mahmoud Shorman. The objectives of the program hopes to add another pharmacist and to begin using a clinical are three-fold: to optimize outcomes for patients who need surveillance system to monitor patients and protect them from antibiotics, to prevent collateral damage to patients’ microbiome, infections, drug interactions and other adverse events. and to reduce costs. “The goal is to get the right antibiotic on Now that the Joint Commission is requiring all its accredited board early, to use it as long as needed, and to stop as soon as it hospitals to have an antibiotic stewardship program, expertise is no longer needed,” says Dr. Shorman. Rapid testing to identify in this area is well sought after. UTMC’s highly qualified specific pathogens, autostop orders, and reassessing patients’ stewardship team will provide greater ability to optimize allergies to antibiotics are among the program’s initiatives. The antibiotic use and enhance care for all patients. plan is to incorporate these into the sepsis bundle, which will optimize that pathway.

Points of View

and more a matter of serial clicks. We are rapidly becoming a profession of “clickers.” However, mouse clicks are not as harmless as they seem. They could certainly be harmful if we perchance click on the wrong chart, the wrong medicine, or the wrong dose. Moreover, a single mouse click could delete a lot of important material (often accompanied by loud shouts of dismay from the user!) Thus, clicking the mouse is not merely a physical act, but the information being clicked has to be rapidly processed by the brain, and the correct choices have to be made. The ability to do things fast also means our brains have to process this information at ever increasing speeds. The demand for constant attention can be stressful because our brains are not meant to process information rapidly over extended periods of time. Nevertheless, despite all these “issues,” I feel really handicapped without my trustworthy mouse to point and click. Protest seems futile and I, for one, am resigned to keep “clicking” my way through life.

Computers have become such an integral part of our lives. As physicians, we seem to be spending an ever increasing proportion of our day in front of computer screens performing repetitive tasks. One of these repetitive tasks involves the computer mouse. Mouse clicks are supposed to make our life easier and expedite our work. If you are like me, Rajiv Dhand, MD, Chair you probably perform hundreds if not thousands of mouse clicks daily. In fact, I have never counted them because it is supposed to be a mindless, subconscious activity. You may have heard the oft repeated phrase, “It only requires a few more mouse clicks.” Entering data in the electronic medical records is now more 1

Reaching Out to Tomorrow’s Health Care Leaders Today

Introduction to Health Care Delivery is a class at UT-Knoxville designed for freshmen who have an interest in a career in health care. Originally directed by Dr. Richard Obenour, it has been led by Dr. Kim Morris for the last two years. The class typically enrolls 200 students and consists of panel discussions, lectures, and interactive sessions with a variety of health care providers. Most of the classes are in Wood Auditorium, though some are held on the UT campus. Dr. Morris said the course was initially tailored to pre-med students but now includes sessions about other health care professions, such as Pharmacy and Health Law. Physical therapy, occupational therapy, and Speech Pathology may be added in future. Some students who start out planning to go to medical school find it is not the best fit for them, but they still want to work in health care. Knowledge of other health-related fields can help them find their niche. “It’s good for students to learn early about all the possibilities in health and health care,” said Dr. Morris. Most students think about careers in areas they have been exposed to, but that is usually fairly limited. This course allows them to think about aspects of health care they would not learn about for years, if at all. “Some of our residents and medical students tell me they took this course when they were freshmen,” said Dr. Morris. It is gratifying to know this course is available for our future colleagues in health care.

Fellowship, Connection, and Hope by Emily B. Martin, PhD, Assistant Professor of Medicine Imagine how patients feel when they learn they have been diagnosed with amyloidosis—a rare disease for which there is no cure. Imagine the fear and uncertainty…the loneliness. Although family members may be an invaluable support for patients, caregivers are often afraid, uncertain, and lonely as well. The amyloidosis research group at UTMC recognized the need for a support group for amyloidosis patients and their caregivers. With the help of Charlotte Haffner, an amyloidosis patient and heart/stem cell transplant survivor who works closely with the Amyloidosis Foundation, this group has come to life. Amyloidosis support group pictured from left to right: Sallie The goal of the group is to provide fellowship, shared experience, and Macy, Charlotte Haffner (amyloidosis patient who works for information on the latest diagnostic tests and therapies. The meetings also the Amyloidosis Foundation) and Emily Martin, PhD provide an unparalleled experience for our research team to interact with patients suffering from the disease we have studied for years. Generous financial support from the Amyloidosis Foundation has allowed us to invite world-renowned scientists to speak about their research and clinical trials, including an internationally-recognized Professor of Medicine from Tufts Medical Center and specialists from the Vanderbilt Amyloidosis Multidisciplinary Program. These meetings not only allow patients to connect with others that are undergoing similar challenges, but they also provide a sense of hope as they learn researchers are dedicated to fighting this disease. The first meeting was held in June 2016, with a second following in Oct 2016. Attendees have come from eastern and middle Tennessee, as well as several surrounding states. We plan to continue scheduling at least two meetings each year at UTMC. It has been a rewarding experience, and I am looking forward to our next meeting on April 29th, 2017!

Resident Spotlight – Dr. Lesley Jackson

Dr. Lesley Jackson is a vivacious second year internal medicine resident with a passion for global health. Her inspiration was kindled during the last six weeks of medical school, when she worked in Eldoret, Kenya, at Moi Teaching and Referral Hospital. She treated patients afflicted with tropical diseases as well as ubiquitous conditions such as pneumonia and meningitis. It was humbling, educational, and ignited a sense of purpose and passion. Over the last year and half, Dr. Jackson worked with the Graduate School of Medicine and the Internal Medicine Residency Program to establish a sustainable overseas global health elective accessible to future interested residents. This May, Dr. Jackson will travel to Mbale, Uganda, for four weeks. Uganda, a landlocked nation in East Africa, is one of the poorest countries on Earth and in desperate need of acute care as well as health education for providers. Dr. Jackson will work with the local medical students and residents. Together, they will teach and treat tropical disease, foster an understanding of healthcare costs in resource poor areas, and participate in sustainability projects so the benefits will continue to flourish for patients in need long after she returns to Knoxville. 2

Benevolence in Action Since June 23, 2013, East Knoxville Free Medical Clinic (EKFMC) has provided medical care to uninsured patients. Championed by Dr. Janet Purkey, EKFMC is based out of Magnolia Avenue Methodist Church every Monday between 12 pm and 6 pm. Approximately 15 patients are seen per week. It is not limited to primary care services, as it works closely with Knoxville Area Project Access (KAPA) to provide subspecialty services as well. The clinic is composed entirely of volunteers: physicians, case managers from Smokey Mountain Hospice, Spanish interpreters, even medical students. Initially, medical students volunteered. The first medical student to do so was our alumna, Dr. Jennifer Winbigler, who took histories and physicals. Since Dr. Janet Purkey pictured with several volunteers at EKFMC then, it was integrated into the third year medical student Internal Medicine Clerkship; however, any interested medical students are welcome to participate. EKFMC provides invaluable resources to an underserved population, while igniting passion in medical students to pursue public service. Alex Manole is a third year medical student at University of Tennessee Health Science Center. He volunteered during his core medicine clerkship between May and June 2016. It was an unforgettable experience. Despite prior experiences at free clinics, this was the first time he volunteered at a clinic based outside of a designed medical building. “The location illustrated an important point for me –you can serve your community anywhere.”

Faculty and Resident Awards and Honors Dr. Lesley Jackson - Golden Apple Teaching Award The College of Medicine Student Body and the Office of Medical Education and Student Affairs selected Lesley Jackson, MD to receive the Golden Apple – Internal Medicine Resident award for her contribution to the medical education of all students in the College of Medicine. She was honored at the UTHSC COM Caduceus Ball on March 18th, 2017. The Department of Medicine extends its congratulations to Lesley for receiving this prestigious award.

New Faculty Please join us in welcoming two new faculty members to the Department of Medicine. Dr. Simi Vincent attended medical school at the University of Medicine and Dentistry of New Jersey – (Robert Wood Johnson Medical School) in New Brunswick, New Jersey. He completed his internal medicine residency at Christiana Care Health Services in Newark, Delaware. Dr. Vincent completed a fellowship in clinical pharmacology at Vanderbilt University and a fellowship in infectious diseases at the University of Oklahoma Medical School. He joined University Infectious Disease in October 2016.

Dr. Naveen Raj attended medical school at Nova Southeastern University in Davie, Florida. He completed his residency in internal medicine at Mt. Sinai Medical Center in Miami Beach, Florida. He completed a fellowship in rheumatology at Larkin Hospital/ Nova Southeastern University in South Miami, Florida. Dr. Raj joined University Rheumatology in October 2016.

Guest Speakers We were honored to have Dr. Marin H. Kollef, FACP, FCCP, present both the Department of Medicine Grand Rounds, “Ventilator-Associated Pneumonia (VAP): An Update,” and Research Conference, “End of Life Issues and Moving Critical Care Research to the Emergency Department,” on Tuesday, March 28, 2017. Dr. Kollef is Golman Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at Washington University School of Medicine in St. Louis, Missouri. He is director of the Medical Intensive Care Unit and director of Respiratory Care Services at Barnes-Jewish Hospital. Dr. Kollef serves on the editorial board and is a reviewer for several prestigious journals. He has authored in excess of 300 peer-reviewed manuscripts as well as more than 300 letters, case reports, editorials and invited publications. He has presented numerous lectures on topics including sepsis, antibiotic resistance and antibiotic management of gram-negative infections. 3

CME Opportunities—Mark Your Calendars! • 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, are available for 1.00 hour CME credit.

Ethics Case Rounds - “I want to live. I am afraid to die.” Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality. Dilon came to UTMC in septic shock. He had arrived in the US 15 years ago and worked in a poultry production plant until he lost an arm in an accident. While hospitalized for his injury, he was found to have diabetes, hypertension, and renal failure. He received outpatient dialysis for a while; however, clinics have stopped dialyzing him because he has no ability to pay and is not eligible to apply for benefits. Since then, he has been getting dialysis on an emergent basis through the ED. His health has worsened over time; now bedbound, he is facing the end of life. A friend of a friend, Mireille, has been taking care of him but is unwilling to continue to do so without additional help. His sepsis cleared and discharge planning underway, Dilon considered hospice but then changed his mind. He asked to be sent to another state that might have a facility that would provide dialysis for him. If that is not possible, he asks to go back to Mireille’s home and return to UT ED by ambulance for dialysis “even only once a week I will be grateful.” The team requested an Ethics consult. None of the options were good. Then they considered a novel approach – could scheduled dialysis through the ED be a possibility? Scheduled dialysis is expensive, at roughly $82,000 per patient per year.1 But frequent, unscheduled dialysis in an emergency setting is far more expensive – one estimate is $200,000 per patient per year – due to the attendant health problems associated with it.3 Additionally, it “… places patient’s lives at risk, and it results in more ER visits, more hospitalizations, and more blood transfusions than does scheduled dialysis”3 However, even regular dialysis will not save Dilon’s life … or address his fear of death. It will not provide him a place to stay or daily care. Tragically, Dilon is dying. While he is entitled, via the Emergency Medical Treatment & Labor Act (EMTALA), to receive emergency lifesaving treatment, to encourage aggressive treatment at EOL while his basic physical and emotional needs cannot be met would not be humane. Providing high-cost, low-benefit treatment at the end of life, while not providing lower-cost preventative and maintenance care, is not a sustainable practice. The Ethics team recommended no arrangements be made vis-à-vis use of the ED as an outpatient dialysis clinic, though if Dilon plans to go to an ED for emergency dialysis, he should not be intimidated, shamed, or otherwise dissuaded from doing so. They recommended including all appropriate and available palliative measures – with or without hospice – and encouraged Mireille to decide what she was willing to provide for Dilon and under what conditions. Mireille agreed to take Dilon back, but only with the additional help of hospice. He agreed to this plan and had dialysis the day he left. He died in his sleep a few days later.

In Touch Vol. 6, Issue 2: April 2017

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 Azaria Ehlers, MD Kimberly Givens 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.

References 1. National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC), (2009). Costs per Patient. U.S. Department of Health and Human Services. Retrieved from 2. Raghavan, R. (2012). When access to chronic dialysis is limited: One center’s approach to emergent dialysis. Seminars in Dialysis, 25(3), 267–271. 3. Raghavan, R., & Nuila, R. N. (2011). Survivors – Dialysis, immigration, and the U.S. law. New England Journal of Medicine, 364(23), 2183–2185.

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In Touch Newsletter - April 2017  
In Touch Newsletter - April 2017  

A quarterly newsletter for the Department of Medicine at the University of Tennessee Graduate School of Medicine.