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. 9 Issue 2 Apr. 2020
UT Medical Center’s Outpatient Psychiatry Clinic The Internal Medicine Clinic at the University of Tennessee Medical Center has been providing outpatient care for members of the East Tennessee community since July 2006. Internal Medicine and OB/GYN residents, under the supervision of their board-supervised attendings, provide quality primary care, acute care (through the PRN clinic), and hospital followup care (through the REACT clinic). The outpatient psychiatry clinic was added in 2018 in order to provide patients with more comprehensive care. Psychiatrist and Assistant Professor Dr. Paul Miller, sees patients 5 half-days per week and supervises the residents who see patients Friday mornings. The clinic also serves as the teaching setting for third-year medical students during their psychiatry rotation. Treatment is available for adults who are dealing with any of the major mental health issues including depression, anxiety, mood disorders, psychotic disorders, dementia, and addiction. TennCare is accepted, which removes a barrier that many patients face to getting mental health care. “Most, though not all, of our patients are on TennCare,” notes Dr. Miller. “It’s a busy clinic and there is a lot of need out there.” Perhaps one of the most important roles the clinic plays is to integrate medical and mental health outpatient care for people who have both medical and mental healthcare needs. People with psychiatric illness are more likely to have medical illnesses than the general population, and they have higher rates of death. They are also especially vulnerable to health care disparities, which may contribute to the fact that they often do not seek medical care until they are in crisis. Patients whose psychiatric problems and medical problems compound one another frequently lack enough resources to manage their health. Depression, fatigue, hopelessness, and anxiety can interfere with one’s ability, motivation, and trust to seek care and comply with recommendations. This is amplified for patients with delusions related to authority or to the
helping professions. Additionally, geographic, financial, insurance, and housing-related barriers can interfere with access to treatment. Dr. Miller espouses a holistic treatment philosophy, tailoring each plan of care to the needs of the individual patient, including the judicious use of medications. “We use a fairly conservative approach to prescribing,” he says. He and the residents strive to integrate nonpharmacological elements into patient care, noting that psychiatric medications are far more effective when used in conjunction with other modalities. These modalities -- primarily cognitive-behavioral therapy and other talk therapies – are mostly provided by way of referrals to practitioners in the community. “Developing a context for an individual’s symptoms is an essential part of mental health care,” said Dr. Miller. “Setting a reasonable expectation for medications while also developing a plan to address symptoms that may not respond to psychotropics is critical to delivering satisfactory care.”
Points of View
this department.” She remembers when there were only 8 residents, of which 5 were categorical and 3 were “flexible.” Now the program has grown to 42 residents; including the transitional years. Sissy knows that she and Kristi play a vital role in the health and well-being of the residents. Sissy reminisces about all of the changes that have occurred and the advances in technology over the last 40 years: such as fond memories of the electric typewriter (Selectrics) which was common-place in the office as well as how the Graduate School of Medicine was the first department to have an IBM Displaywriter installed. Sissy recounts that another difficult change in the workplace occurred after she was “left to keep the department alive, at the age of 22 years old, when
This feature is devoted to Melinda “Sissy” Ensor, our Residency Coordinator, for her 40 years of dedicated and enthusiastic service to the UTGSM. A native of Knoxville, TN, Sissy grew up in the city but moved to a farm in Blount County at 12 years old. She graduated from Lanier High School and took a few evening classes at UTK while doing administrative support work. On February 2nd, 1980, Dr. Alfred Beasley, Chair of Rajiv Dhand, MD, Chair the Department of Medicine and Dean of Graduate Medical Education, hired her. Sissy recalls, “I intended to work for the GSM for 3 to 4 years,” but she decided to stay because “the job is never boring and I found fulfillment within my role for
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Patient Follow-Up Appointments If “showing up is half the battle,” the Internal Medicine Resident Clinic is proving that a little help and a few reminders are the key to helping patients win. With the clinic’s new appointment reminder service, patients get a call 48 hours before their appointment and a text reminder the day of their appointment. This reminder system also offers to arrange transportation to the appointment for anyone with TennCare or a TennCare secondary insurer through CAC, ETHRA, taxis, and even Uber, if the patient cannot arrange their own transportation. The appointment cards in the Resident Clinic help the patients as well: printed on the back are phone numbers for transportation services provided by Amerigroup, Blue Care, and United Healthcare. Additionally, parking passes are provided on a case-by-case basis to patients that need to be seen frequently but cannot afford the $3 parking fee. Information regarding transportation options is also included in new patient packets and displayed in the waiting room and each exam room. With these interventions, the no-show rate at the Resident Clinic has dramatically decreased – from 62% in 2017, to 35% in 2018, to a current no-show rate of 18%!
Point of Care Ultra Sound
In a not-too-distant year of 1821, a physician described the potential incorporation of the stethoscope into medical practice as follows: “That it will ever come into general use, notwithstanding its value, is extremely doubtful; because its beneficial application requires much time, and gives a good bit of trouble, both to the patient and the practitioner; and because its hue and character are foreign, and opposed to all our habits and associations.” While point-of-care ultrasound (POCUS) initially faced similar doubts in its application, it has now become an integral part of patient care. POCUS has evolved from a binary decision-making tool (e.g., is there free intraperitoneal fluid in the trauma patient?), to now providing physiological interpretation, such as monitoring the resolution of thoracic “B-lines” in pulmonary edema after diuresis, and confirming the slight swelling of the inferior vena cava during fluid resuscitation. In patients presenting with shock, POCUS can rapidly identify possible contributors such as a large pericardial effusion or a severely reduced left (or right) ventricular systolic function. POCUS is rapid, accurate, repeatable, noninvasive procedure that does not carry the risks of radiation. It can be used in both stable and unstable patients, as well as inpatient and outpatient settings. The ability to perform repeated exams in critical patients is essential because initial negative sonographic exams may become positive as the disease progresses. Pitfalls of ultrasonography can occur from a variety of sources including the patient, the operator, or the ultrasound machine. Therefore, as POCUS becomes more common, it is imperative to train and evaluate physicians in its use, confirm their ability to combine the POCUS findings with the physical exam findings, and assess the incorporation of those findings into medical decision-making. As of July 2019, 12 physicians completed a training course on butterfly models and hand-held models to begin performing POCUS with patients in the ICU and Residents’ Clinic. Plans are underway to initiate a “Train the Trainers” program and hopefully the residents from the 2021-2022 academic year will be the first class to incorporate POCUS training in their residency at UTMC.
Resident Spotlight: Kat Coombes Dr. Kathryn “Kat” Coombes is a second year Internal Medicine resident. Her journey to medicine started when she was volunteering in her local ED at age 16. “I knew this was what I wanted to do,” she says. She grew up in San Diego, CA, and decided to attend the University of California-Santa Barbara for undergrad, majoring in biology and minoring in Spanish. Capitalizing on her love for Spanish and medicine, she lived in Chile for 6 months and completed a medical elective for women and children while abroad. This elective further ignited her joy for not just medicine, but serving the underserved. While in medical school at the American University of the Caribbean, Dr. Coombes volunteered locally in St. Maarten, educating women and girls about women’s health. Her ultimate passion in medicine, she says, is education. Dr. Coombes is eager to empower her patients with knowledge about their own health and chronic diseases to try to prevent complications. She also enjoys mentoring first-year residents and seeing them grow in confidence and knowledge throughout their first year of training, just as she saw herself grow last year. Dr. Coombes plans to pursue either outpatient medicine or an infectious disease fellowship in an underserved community upon completion of residency. Dr. Coombes met her husband, Dr. Tyler Coombes, while in medical school and they both chose UT for residency. They enjoy spending time exploring the breweries in Knoxville, playing with their puppy, Ranger, and planning their next adventure! 2
Faculty Announcements New Faculty
We are delighted to welcome Ms. Erin Campbell as an Instructor in the Division of Hematology and Oncology. Ms. Campbell graduated summa cum laude earning her Bachelor of Science degree in Biology from Western Kentucky University in Bowling Green, Kentucky. She earned her Master of Science in Genetic Counseling from the University of North Carolina in Greensboro, North Carolina. She joined the University Genetics Oncology Clinic in September 2018.
We are pleased to welcome Dr. Dante Pappano as a Clinical Assistant Professor in the Pediatric Clerkship. Dr. Pappano received his Doctor of Medicine from Washington University in St. Louis, Missouri. He completed a pediatrics residency at Yale-New Haven Children’s Hospital in New Haven, Connecticut. He completed fellowship training in neurology at Massachusetts General Hospital in Boston, Massachusetts and in pediatric emergency medicine at the University of Rochester Medical Center Strong Memorial Hospital in Rochester, New York. Dr. Pappano has been with East Tennessee Children’s Hospital since 2006.
We are pleased to introduce Cassandra Mosley as the Manager for the Department of Medicine. Cassandra has 3.5 years of experience as a business manager at the College of Medicine at ETSU. However, her recent experience includes 5.5 years as an accounting specialist within the finance department at UT Knoxville. She worked for the Assistant Bursar Dee Fortenberry and Renee Bumgarner on campus. Cassandra graduated with a Bachelor’s Degree in Business Administration and earned her Master of Science in Adult Educational Psychology at UTK. We are thrilled to welcome her onto the team and look forward to the enhancements she will bring to the department.
Guest Speakers We were delighted to have Joseph A. Lasky, MD, present his talk on “Idiopathic Pulmonary Fibrosis” at Medicine Grand Rounds Conference on January 14th, 2020.
We were excited to have Subramanyeswara Rao Arekapudi, MD, MPH, FACP, present “Immunotherapy and Management of Bladder Cancer” for a special faculty candidate lecture on January 20th, 2020.
Points of View
We were honored to have Daniel Ouellette, MD, present “Eosinophilic Lung Disease” at Medicine Grand Rounds Conference on February 11th, 2020. He also presented his talk on mechanical ventilation and liberation for our pulmonary / critical care fellows.
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her supervisor retired.” Unfortunately, she has had a few personal setbacks over the years but nothing as serious as her car wreck last year. Sissy acknowledges that, “I still wake up every day with pain and am finding new things that are bothersome.” However, despite all the hurdles, Sissy is “amazed and proud of all that she has accomplished during her time here at UT.” In closing, Sissy would like to ask past residents to consider “paying it forward” by sending in donations towards providing additional resources for the current residents so that we can continue to have a very high success rate in the ABIM board examination each year. We are extremely thankful to Sissy for her many years of extraordinary service to the department.
Primary Care CME Conference is canceled for 2020 All CME conferences are suspended at this time due to covid-19 • Primary Care CME Conference, offering up to 10.25 hours of CME credit, will be held April 9, 2021 @ Hilton Knoxville Airport in Alcoa, TN. We hope you can join us for this informative event. Registration available onsite! View course information, agenda, and fees at: http://gsm.utmck.edu/cme/courses/primarycare/main.cfm • • • •
Cardiology Conferences, held weekly on Wednesdays for .75 hour CME credit. Medicine Grand Rounds, held on the 2nd, 4th, & some 5th Tuesdays 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. Pulmonary Hypertension conferences, held on the 2nd Monday of the month at noon on the HLVI 1st floor education room, are available for 1.00 hour CME credit. 3
Ethics: Medically and Psychiatrically Complex Patients Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality. “Ronnie” is a 46-year-old woman who was admitted in hypertensive crisis. Her medical history includes end-stage renal disease requiring dialysis, congestive heart failure, and schizophrenia. She has a history of refusing dialysis and medications. She has had several weeks-long hospitalizations within the year for similar problems. She has family in Memphis, including a favorite brother, but few contacts here besides a few trusted staff members at Helen Ross McNabb. She came to East Tennessee several years ago because of delusions that she is part owner of Dollywood. She was intermittently homeless here, but did not want to return to Memphis. Developing a safe discharge was challenging because placement for people who have both medical and psychiatric needs is difficult, as most agencies are not able to meet both kinds of needs. Ronnie’s paranoia and noncompliance put her at high risk of death. She insisted she could take care of herself on her own. However, she did not have housing, and she expressed disbelief when told that she could become sick or die without dialysis. She did have resources to draw on: family who was willing to be involved, a good relationship with some members of the UTMC staff, and a good relationship with several members of the Helen Ross McNabb staff. A residential mental health facility was identified that could potentially meet her needs … if she could stay healthy and psychiatrically stable. Facility staff requested an ethics consult as part of evaluating whether they could accept her for discharge. Identifying and partnering with community organizations and agencies that serve vulnerable populations can magnify the ability of each entity to better care for patients. This permits the sharing of information, maximizes efficient use of resources, creates goodwill, and provides inter-institutional support. A meeting was held between the health facility staff, UTMCK’s psychiatry, case management, and ethics staff; and Ronnie’s brother. All agreed Ronnie could not reliably understand relevant medical information or reason through options, and thus lacked reliable decision-making capacity. All noted that Ronnie seemed to tolerate dialysis when psychiatrically stable, but that when one element of her medical or psychiatric wellbeing became disrupted, she decompensated quickly. The team developed a care plan including use of a long-acting injectable antipsychotic medication, identification of her brother as her surrogate, and planned responses for when she decompensated medically or psychiatrically. Ronnie was pleased with the plan, including the long-acting antipsychotic. However, as the day of discharge approached, she said she changed her mind about the injection, because “it made me have a miscarriage last time” (the pregnancy was a delusion; there was no miscarriage). Following the care plan, the team reached out to her brother and staff members she has trusted. Fortunately, they were able to encourage her to accept the injection. If she had continued to refuse, the team would have needed to evaluate her decision-making capacity and consider whether overriding her refusal was in her best interests. She was able to be discharged to the residential facility where she did well for more than a year. She had a brief re-admission after missing two dialysis sessions, but she then returned to her facility. Comments on this case may be sent to firstname.lastname@example.org References • Guidry-Grimes, L. “Homeless, Ill, and Psychiatrically Complex: The Grueling Carousel of Cassandra Lee” Hastings Center Report 49, no 4 (2019): 8-13. • McKlindon, DD, Nathanson, P., and Feudtner, C. “Responding to Moral Distress and Ethical Concerns at the Intersection of Medical Illness and Unmet Mental Health Needs” Journal of Clinical Ethics 28, no 3 (2017): 222-227.
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 email@example.com. 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
In Touch Vol. 9, Issue 2: April 2020
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 Kristin O’Conner, MD Rajiv Dhand, MD Kandi Hodges Annette Mendola, PhD Kimberly Givens Megan Sears-Smith, MD 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. Disclaimer: quotes/ interviews are edited for length and clarity
A newsletter for the Department of Medicine at the University of Tennessee Graduate School of Medicine in Knoxville, TN.