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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

Resident Clinic Update

Vol. 7 Issue 2 Apr 2018

Dr. Juli Williams, Clinic Director (R), pictured with Internal Medicine Residents Drs. Sneha Thakur, Tyler McLaurine, and Blair Reynolds (L-R)

The resident clinic is undergoing many new and exciting changes! Over the last year, there has been a collaborative effort focusing on overhauling the “as needed” or “PRN” visits, launching the patient portal, and increasing the number of physical and wellness exams. In May, the PRN schedule was revamped to allow for more flexibility. Previously, patients with acute issues who needed to be seen within one to two days were added to openings in individual residents’ schedules. Now, each morning or afternoon clinic session has three to six 15-minute blocks reserved for PRNs. At the beginning of each clinic, residents divide the PRNs based on cancellations and acuity of the patient’s illness. PRN visits can vary from a mild viral gastroenteritis to a COPD exacerbation needing hospital admission. The resident clinic chief-elect, Dr. Henry Shiflett, views the new system as “a great success. It is a wonderful service to patients and reduces the number of urgent care and ER visits.” Dr. Juli Williams also echoes his sentiments, “The new system was a true collaboration amongst attendings, residents, office staff, and nurses. It has been warmly received.”

Points of View The increasing costs of prescription medications has once again become a matter for public concern. In my clinic, patients’ inability to pay for the high cost of their medications is becoming increasingly frequent. Many of my patients, especially those on fixed retirement incomes, must make difficult choices about affording their medications, often preferring to use only those medicines that are essential for life Rajiv Dhand, MD, Chair while omitting others needed to improve their quality of life. Public awareness about the high cost of prescription medicines has been heightened by the increase in prices of some previously marketed drugs and the extraordinary costs of some newly introduced 1

Our resident clinic director, Kay Rangnekar, doubles as our technology guru. Since her arrival, she made many improvements to the electronic medical record. Her most recent coup d’état was tweaking office note templates for annual physicals and wellness exams. The goal is to increase the number of physicals and wellness exams, in order to increase preventative screening measures. Ms. Rangnekar identified 180 patients who qualify for exams and are being contacted to schedule their clinic visits. Lastly, the patient portal is now up and running. This portal is a service provided to both Internal Medicine and OB/GYN patients and provides patients with the opportunity to view and download lab and diagnostic results. Ultimately, it allows for more accessibility between patients and physicians in between office visits. Nearly 3,570 patients have access to the patient portal, and approximately 245 patients frequently access the secure messaging service. In the last year, there have been many improvements in resident clinic. Thankfully, changes will continue to evolve as Dr. Shiflett is constantly reassessing needs in clinic. therapies (in excess of $100K/year). In the U.S., the government allows drug companies to set their own prices, often to a level that the public demand and market will bear. As a result, the public spends more on prescription drugs than any other high-income country. Pharmaceutical companies justify the cost of medications based on the high expenditure involved in research and development and the limited duration of patent protection afforded to a new product. There is no doubt that pharmaceutical companies have developed many life-saving therapies for chronic, serious illnesses. However, we must balance the cost of these life-saving treatments against the public’s ability to afford such therapies. The increasing cost of prescription drugs limits physician’s ability to treat their patients effectively, even those with adequate health insurance, because of the high out-of-pocket costs paid by consumers. The inability to afford medications becomes even more critical in patients who lack health insurance. continued on page 2

Increasing Admissions on Housestaff Medicine Learning Enhanced with a Variety of Patients

Housestaff Medicine Team 2 pictured during morning rounds

Historically, Housestaff Medicine Teams 1 & 2 admitted resident clinic patients, Dr. Juli Williams’ patients, and Faculty Internal Medicine patients. Depending on the team’s census, on admitting days the housestaff medicine senior would contact the ER notifying them if they were “open” or “closed” to unassigned patients. After the annual program review in the fall, residents suggested utilizing the UTH nurse practitioner (NP) quarterback as a way to funnel unassigned patients to housestaff medicine in lieu of the ER. This prompted a pilot that went live in November. Every morning, the admitting senior resident PerfectServes the UTH NP quarterback notifying them how many unassigned patients they would like to admit, if any, depending on the team census. At the front line of the pilot were Drs. Christina Kitsos and Blair Reynolds. Dr. Reynolds noted, “The steady flow of admissions provided ample teaching opportunities not only for the interns but medical students as well.” The UTH NPs were very cognizant and offered interesting teaching cases. Additionally, maintaining a steady census was easier--Dr. Christina Kitsos’ team admitted at least four patients each admitting day. Both HSM and UTH warmly received the pilot. At January’s monthly resident meeting, the decision was made to make the pilot the new norm.

Faculty Spotlight Dr. Dan Ely – Medical Director, Positively Living In addition to Dr. Daniel Ely’s responsibilities as a core faculty member, he recently took on a new role as the Medical Director for Choice Health Network. Choice Health Network is a medical clinic that provides primary care and infectious disease care for vulnerable patients with HIV, Hepatitis C, or both in a safe, nonjudgmental environment. The clinic opened in January 2018 and was started by the not-for-profit organization, Positively Living. The clinic is staffed with a full time physician assistant and part time nurse practitioner as well as psychologists, case managers, peer navigators, and patient advocates. Like any other outpatient clinic, if a patient’s medical comorbidities become too complex, they can refer to subspecialists. As such, they frequently collaborate with the Knox County Health Department Center of Excellence and Dr. John Narro. This summer, they plan to expand by reaching out to rural communities through Telehealth. Additionally, the clinic provides other resources such as pre-exposure prophylaxis (PrEP) and are working with the state to start a needle exchange program. Dr. Ely’s passion for treating underserved patients was kindled during his residency at UT when HIV first emerged. Sadly, at that time there were no medications to treat HIV and patients ultimately died. Dr. Ely saw firsthand how the stigma, ignorance, and paranoia from society and the medical community negatively affected HIV positive patients. Choice Health Network is a unique clinic that addresses a growing need created by the opioid epidemic. Eventually, Dr. Ely hopes to extend this wonderful opportunity to residents.

Points of View

continued from page 1

In fact, barriers imposed by the high cost of prescriptions are proving detrimental to the health of our patients, and are a constant source of frustration for physicians who rely on these therapies to treat their patients with complex, chronic illnesses. An ageing populace with higher numbers of patients with more complex medical illnesses are likely to accentuate this divide between the cost of medications and their ability to pay for them. As physicians, we must actively support a health system that ensures affordable access to prescription drugs patient’s need to treat their illnesses. 2

Resident Spotlight Dr. Bill Lorson Dr. William “Bill” Lorson is our second year resident from Hilliard, Ohio. Throughout his undergraduate studies, Dr. Lorson was an active volunteer EMT and went on to attend the Ohio Fire Academy. During graduate school, he was also a firefighter in Indiana. While pursuing his love of medicine at Lincoln Memorial University, Dr. Lorson served as a training officer and eventually chief at the Cumberland Gap Volunteer Fire Department. Initially, firefighting piqued his interest because of the equipment and trucks, but he quickly realized he loved the adrenaline rush and firefighting also fulfilled his compassionate side for helping those in need. In addition to Dr. Lorson’s civic duties, he has a wide array of interests—from medical history to collecting fashionable socks. Artistically speaking, Dr. Lorson is a Renaissance man. He home brews, makes egg noodles and cinnamon rolls from scratch, makes pens on his lathe, and enjoys other wood working activities. Recently, he crafted an anatomically accurate heart out of wood complete with an electrophysiology (EP) diagnostic catheter. In July, he will apply for a cardiology fellowship. Dr. Bill Lorson pictured holding one of his handcrafted pens

Literary Rounds – “Where Medicine Mingles with the Muse” has been a monthly bright spot on the calendar for members of the UTMC community and the public since its inception in 2012. The program was the brainchild of Preston Medical Library’s Communications & Programs Coordinator and Poet-in-Residence, Donna Doyle. Donna’s vision of Literary Rounds came about when she and Dr. Ronald Lands were first working together on an elective Narrative Medicine rotation for residents and medical students. They recognized that integrating the arts in the health care environment can increase empathy, improve communication, and reduce stress. Opportunities to hear from and interact with poets, essayists, and other literary folks seemed like a perfect complement to the Narrative Medicine rotation. The events quickly became popular with a diverse audience from the hospital and the community. In addition to the positive effect on hospital staff, Donna was pleasantly surprised at how much the speakers were gratified to be able to present their work in a medical setting. Donna’s other projects have included Art Break, which displayed the artwork of hospital personnel, and local celebrations of National Poem in Your Pocket Day. The final Literary Rounds event took place on February 14, 2018, but Donna, who retired in March, hopes its effects will endure. She noted the majority of healthcare professionals who attended Literary Rounds responded “highly likely” to the evaluation item “This event will help me provide better care.” She said, “I feel especially pleased to know that Literary Rounds has had a positive impact on patient care as well as on how we care for each other.”

Faculty Honors

Special Thanks to our Alumni

We wish to congratulate Drs. Rajiv Dhand and J. Francis Turner, Jr. on becoming inaugural American Thoracic Society Fellows. The ATS Fellowship was offered for the first time this year. This distinctive designation recognizes select members for their accomplishments, dedication, and contribution to the Society in the fields of pulmonary, critical care, and sleep medicine.

We would like to thank all of the alumni who generously donated in response to Sissy Ensor’s recent request. We greatly appreciate your philanthropy and hope you will continue to support the residents’ education in the future. For those still interested in donating, please call the department at 865-305-9341.

CME Opportunities—Mark Your Calendars! Please join us this Friday!! • Weekly Cardiology Conferences, generally held on Wednesdays each week for .75 hour CME credit.

The 6th Annual Medicine CME Conference, The Rhythm and Blooms of Internal Medicine, offering 10.25 hours of CME credit, will be held April 6-7, 2018, at the Holiday Inn World’s Fair Site. We hope you can join us for this informative event.

• Medicine Grand Rounds, which are generally held on the 2nd and 4th Tuesdays of each month for 1.00 hour CME credit.

Registration available onsite! View course information, agenda, and fees at: http://gsm.utmck.edu/cme/courses/2018/medicine/ main.cfm

• 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. 3

Ethics Case Rounds - Respecting the Jehovah’s Witness Patient” Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality. “Linda” is a warm, friendly 78 year-old lady who was admitted for internal bleeding. She has end-stage renal disease (ESRD) and is scrupulous about getting to dialysis three times weekly. She was in otherwise good health. She is widowed, with three sons who live out of state. Her granddaughter lives in town and is her power of attorney. Linda is one of Jehovah’s Witnesses. She has a living will that authorizes all life-sustaining measures except blood and certain blood products, even if these are needed to save her life. She had full decision making capacity and affirmed what was in her living will, saying “I’ll take anything modern medicine can give me, except for blood” that can restore a quality of life in which she could read, watch television, and get around “at least in a wheelchair.” She said she would not want to be maintained if she was in a bedbound state, unable to interact with others. Linda’s physicians and nurses are committed to respecting her wishes, though they have concerns about how to do so in this situation. Dialysis can be dangerous with hematocrit and hemoglobin levels as low as Linda’s have become. At the same time, skipping or shortening dialysis sessions carries its own set of dangers for patients with ESRD. Accordingly, the issue of blood transfusion has been discussed multiple times this admission. The fact that staff keep discussing blood transfusion and the risks associated with declining it have resulted in Linda feeling as if she is being pressured to allow blood transfusions. There are other products used to treat anemia that are acceptable to many of Jehovah’s Witnesses. However, these take time to work. Linda was already receiving those that were listed as acceptable on her living will and appropriate for her condition. In the present situation, they may not work quickly enough to make dialysis safe. For several days, Linda was not able to tolerate a full round of dialysis. As a result, she became volume overloaded and encephalopathic, and was transferred to the ICU. Without a blood transfusion, she could be facing end of life. Some of her providers became concerned Linda might not have fully understood the risks of refusing transfusion when her granddaughter said the products used in place of blood are “every bit as good as blood ... probably even better, because blood transfusion is risky.” Given the question of blood transfusion had been addressed and clarified multiple times this admission, the ethics recommendation was not to include it again for routine consents. If it needs to be discussed, begin the conversation by acknowledging Linda’s living will, her goals of care, and her consistent refusal of blood transfusions. Education on alternatives to blood products is unlikely to have changed decision making in this case, though it would be useful for all involved to learn more about them after this situation has resolved. Her physicians will attempt dialysis as long as it is safe, and her condition while on dialysis will be carefully monitored. If she shows signs of being in danger, it will be stopped and attempted again later if safe. Her granddaughter agreed with the plan, saying “I hope this isn’t her time, but if it is, we accept that.” Linda’s condition improved slowly. When her encephalopathy cleared, she too agreed with the plan of care. After several days in the ICU she went to the floor, and later was discharged to a rehab facility with plans to go home when she was ready. Comments on this case may be sent to amendola@utmck.edu References 1. Bock, GL. “Jehovah’s Witnesses and autonomy: Honouring the refusal of blood transfusions” Journal of Medical Ethics 2012; 38: 652-656. 2. Panico, ML, Jenq, GY, and Brewster, UC. “When a patient refuses life-saving care: Issues raised when treating a Jehovah’s Witness” Am J Kidney Dis 2011 58(4): 647-653.

In Touch Vol. 7, Issue 2: April 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 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. 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

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

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.