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D epartment

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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

Interventional Pulmonology

Pictured from Left to Right Dr. John Callison, Dr. Paul Branca, Dr. Michael McCormack and Dr. J. Francis Turner, Jr.

Interventional Pulmonology (IP) is an expanding area of interest in the specialty of Pulmonary and Critical Care Medicine. The origins of this specialty can be traced back to the introduction of rigid bronchoscopy by Gustav Killian in Germany and Chevalier Jackson in the United States. In 1962, Professor Shigeto Ikeda, a thoracic surgeon in Japan, developed a flexible bronchoscope and with the exhortation from Professor Ikeda to “Never Give Up,” the marriage of this specialty as art and science has continued to expand. Under the leadership of Dr. Dhand, the Department of Medicine is fortunate to have several physicians who are board certified in pulmonary and critical care medicine who specialize in the application of these techniques. Military medicine has always had a strong educational program in interventional techniques and pulmonary medicine. Owing to this, Dr. Michael McCormack obtained a wealth of experience during his training and, then, while serving as a military pulmonologist

Vol. 6 Issue 4 October 2017

in the Army. After completing a Pulmonary Medicine fellowship at Fitzsimons Army Medical Center and a Critical Care Medicine fellowship at University of Utah in Salt Lake City, he was an attending at the Tripler Army Medical Center in Honolulu, Hawaii, in addition to being the Chief of Pulmonary Outpatient Medicine for the Army Pacific Theater. Another Army veteran, Dr. J. Francis Turner, Jr, completed his Pulmonary and Critical Care fellowship at Fitzsimons Army Medical Center in Aurora, Colorado and was then named pulmonary function laboratory director and assistant director of the ICU. Subsequently, Dr. Turner was honored to become one of the first formally trained Interventional Pulmonology fellows in the United States, working at the R Adams Cowley Shock-Trauma Center at the University of Maryland and under the direct tutelage of Dr. Ko-Pen Wang, who invented transbronchial needle aspiration through the flexible bronchoscope at Johns Hopkins Hospital. Since his fellowship, Dr. Turner specializes in treating complex airway lesions and has been an IP director at both University and VA hospitals and was Director of IP at the National Naval Medical Center (Walter Reed National Military Medical Center) in 2008-2009. A member of the Board of Directors for the national governing body for interventional pulmonology (AABIP) for eight years, he is an editor and author of “Flexible Bronchoscopy,” the gold standard IP textbook (1). In addition to his teaching duties at UT, he is a consultant to the Chinese Association for Bronchology and Interventional Pulmonology and frequently travels to China and other countries to teach advanced pulmonary techniques. Dr. Paul Branca is our board certified interventional pulmonologist and member of the American Association for Bronchology. After completing his Pulmonary and Critical Care Medicine fellowship continued on page 2

Points of View

Quetel’s concept, and proposed the “law of deviation from average” which suggested the average was mediocre and introduced the concept of ranking individuals. According to this law, people above the average were “superior” to those who were below the average. In the late nineteenth century, Frederick Taylor, an American, proposed the application of averagarianism to industrial and business practices, and his vision (“Taylorism”) was embraced worldwide. Another American psychologist, Edward Thorndike, further advanced this practice, arguing in favor of a similar approach to education. He enthusiastically advocated for ranking in schools to sort students according to their deviation from an average. We continue to employ this ranking system for over one hundred years since the early twentieth century. Rose argues in his book that while averages are helpful for comparing groups of individuals with regard to their physical and mental health, personality or economic state, using them to compare between individuals has absolutely no factual or scientific basis. However, the concept of ranking has become so firmly ingrained

We believe so many concepts as firmly established “truths,” but they do not hold up to careful scrutiny. For example, we rely heavily on averages to determine grading and ranking of individuals. We constantly measure individuals by how close they are to an average or how much they rise above or fall below the “norm.” We employ such measures to compare performance in schools, for admission to Rajiv Dhand, MD, Chair colleges, and even to screen individuals for admission to our residency programs. In his book The End of Average, Todd Rose traces the origins of this concept. In the nineteenth century, Adolphe Quetel, a Belgian mathematician, first came up with the notion of an “average man” as an ideal. Later, a British mathematician, Sir Francis Galton, modified

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In the Cards: The Interventional Cardiology Fellowship at UTMCK

Interventional cardiology applies non-surgical techniques such as angioplasty and stenting to treat cardiovascular diseases. The Interventional Cardiology fellowship, now in its second year and now under the direction of Dr. J. Christopher Scott, is a one-year program designed to train physicians to become certified as a primary operator in Invasive and Interventional Cardiovascular Medicine. The fellowship began under the direction of Dr. Dale Wortham, who retired last year after a distinguished career. Interventional cardiology has grown immensely since it developed in the early 1980s. “At that time there were no fellowship programs; physicians would learn new techniques at conferences and trainings, then apply them in their own practice,” recalled Dr. Scott. In time, best Dr. Steven Dolacky pictured with Drs. Kevin Ogyauo, Interventional practices emerged, and in 1999 the first board certification Cardiology Fellow (center), and Carmelo Venero (left) exam was offered. “The options we can offer patients safely have grown a great deal,” Dr. Scott noted. “Research in Cardiology is advancing rapidly, so there is tremendous interest in the field.” He observes a one-person fellowship such as this is like an apprenticeship, in that the fellow gains expertise by practicing alongside seasoned subspecialists. Dr. Steven Dolacky believes a key strength of the fellowship is the diversity of practice styles among the faculty. “The atmosphere is extremely collegial here,” he said. “Everyone has a slightly different way of approaching a problem, and as a result we all learn from each other.” Dr. Dolacky completed the Cardiology fellowship here, and has returned to join the faculty after completing a fellowship in Interventional Cardiology at Albany Medical Center. The presence of a subspecialty fellowship creates opportunities for medical learners at all levels, from medical students to Internal Medicine residents to general Cardiology fellows. It also makes the residency program more attractive to prospective residents. “Even if residents aren’t planning to specialize in Cardiology, the fact that we offer this level of training says something very positive about the learning environment here,” says Dr. Scott.

Interventional Pulmonology

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at Vanderbilt University, he started at UT in 2000. He is a principal investigator in the Evaluation of the IBV® Valve for Emphysema to Improve Lung Function (EMPROVE) clinical trial. This multicenter, prospective, randomized, controlled study seeks to determine the safety and long-term effectiveness of the Spiration® valve in patients with emphysema. The IBV® valve is a one-way bronchial valve to redirect airflow from diseased to healthier areas of the lung. In addition to research, Dr. Branca is skilled in the art of bronchial thermoplasty for the treatment of asthma, an option for poorly controlled asthmatics on maximum medical therapy. Like Dr. Branca, Dr. John C. Callison, Jr. completed his Pulmonary & Critical Care Medicine fellowship at Vanderbilt University. During his fellowship, he won the Thomas L. Petty Award at the Annual Aspen Lung Conference for his work on lung cancer. Dr. Callison is an active participant in UT’s Chest Service. This multidisciplinary service coordinates care among various specialists to determine the best treatment options for patients with lung cancer. In particular, he enjoys chasing down difficult to diagnose lesions with the assistance of navigational bronchoscopy, which uses GPS-like technology to create a map allowing access to more difficult to reach lesions for biopsy. However, his most memorable patient encounters involve foreign body extractions. Once he extracted an almond, cashew, and peanut from one patient’s right mainstem bronchus and extracted an accidentally aspirated washer from a tire bumper from a different patient. The ability to perform these advanced intervention techniques greatly expands the scope of specialized services provided by our pulmonary and critical care medicine physicians. With rapidly expanding technology, the future is bright. References: 1. Wang KP, Mehta A, Turner JF, (Ed). Flexible Bronchoscopy, 3rd edition. Blackwell Science, - publication, ©2012.

Points of View

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in our educational system at all levels that we unquestioningly follow it to this day. I, for one, after reading this book, hope to be more openminded about an individual’s performance and talents as we prepare our next “rank list.”

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New and Improved! Core Medicine Clerkship now Includes Ambulatory Medicine

Alex Galloway, M3 is shown with Dr Amy Barnett seeing one of her favorite patients. It completed the circle for this student as Alex had seen this gentleman a week before in the ED with his housestaff team. Alex reminded the patient he had unwrapped the dressing before as he asked permission to look at the leg with Dr Barnett. Dr Barnett takes advantage of this visit to teach Alex finer points of caring for chronic venous stasis complications.

Third-year medical students rotating here at UTMC during their Core Medicine Clerkship will benefit from new learning opportunities, thanks to the addition of an ambulatory medicine component to the rotation. The clerkship used to take place almost exclusively in the hospital, with little if any exposure to ambulatory medicine. “Any lengthy exposure to ambulatory medicine didn’t happen until fourth year, when students have already settled on a specialty,” said Dr. Janet Purkey, clerkship director. Now the fourth year ambulatory medicine block has been replaced with 2 weeks each in geriatric and palliative care, and the eight week block of M3 Core Medicine Clerkship has been reconfigured to six weeks in the hospital and two weeks in an ambulatory setting. Students are placed in several office specialties, including general internal medicine, cardiology, nephrology, and integrative medicine. Students who have an interest may request a particular specialty; often this can be accommodated. Dr. Purkey also makes sure everyone has an opportunity to get to the Monday afternoon Free Clinic at least once, though this is not required. Other parts of the clerkship have been retained. “Of course, we still do Sim lab, which is an invaluable part of medical education,” she said. Dr. Purkey sees the addition of ambulatory medicine as a very positive change. “It makes a big impact on their future, particularly if they find they love office medicine,” she said. Dr. Purkey encourages anyone who would like to serve as a preceptor for medical students to contact her.

Resident Spotlight – The Price is Right. Dr. Adam Price is our tranquil, third year resident from Middlesboro, Kentucky. He attended East Tennessee State University (ETSU) for medical school, as he wanted to stay closest to home. For residency, he chose Knoxville based on our reputation from our alumni, Drs. Reem Hussein and T.J. Mitchell. His most memorable experience during residency was the ICU. Currently, Dr. Price is interviewing for a nephrology fellowship. During his fourth year of medical school, an elective nephrology rotation captured his interest. He enjoys the complex pathophysiology, mix between outpatient and inpatient, and opportunity for patient continuity. Dr. Price’s favorite part of the nephron is the Loop of Henle because of its concentrating power while his least favorite electrolyte is potassium because it creates late night phone calls in the ICU for emergent dialysis. Like his mentor, Dr. Nesbit, he is wary of the infamous bumex-albumin drips. Opinions regarding the use of these drips vary among attendings. When he is not calculating delta delta gaps, he is in the kitchen whipping up a batch of his famous chicken enchiladas or reading a mystery novel while munching on homemade pumpkin bread.

Faculty and Resident Awards and Honors We wish to congratulate Dr. Rajiv Dhand on being elected president of the International Society for Aerosols in Medicine (ISAM). ISAM is an international, non-profit organization that stimulates and fosters interdisciplinary cooperation and exchange of information in all aspects of aerosol research in medicine including the health effects of inhaled aerosols and pulmonary drug delivery. We anticipate Dr. Dhand achieving many great things in his role as president of ISAM.

We also wish to congratulate Stephen Kennel, PhD for his promotion to Professor of Medicine and Radiology in UT Health Science Center College of Medicine – Knoxville, Graduate School of Medicine, effective July 1, 2017.

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New Faculty We are pleased to welcome Dr. Steve Dolacky as a Clinical Assistant Professor in the Division of Cardiology. Dr. Dolacky attended medical school at the American University of the Caribbean in St. Maarten, Netherlands Antilles. He completed his residency in internal medicine at the University of Connecticut. He completed a fellowship in cardiovascular disease at UT Medical Center and a fellow ship in Interventional Cardiology at Albany Medical Center. Dr. Dolacky joined University Cardiology in July.

in epilepsy and clinical neurophysiology at the Cleveland Clinic Foundation in Cleveland, Ohio. He began working in the Knoxville Neurology Clinic on Sutherland Avenue in June and transitioned to the Pat Summit Clinic in mid-July. We are delighted to welcome Dr. Francisco Soto as an Associate Professor in the Division of Pulmonary and Critical Care Medicine. Dr. Soto attended medical school at the Universidad del Valle in Cali, Colombia. He completed residency in internal medicine at the University of Illinois at Chicago. He completed a fellowship in pulmonary, critical care and sleep medicine at Baylor College of Medicine. Dr. Soto joined University Pulmonary and Critical Care in August.

We are delighted to welcome Dr. David Perkel as a Clinical Assistant Professor in the Division of Cardiology. Dr. Perkel attended medical school at the University of Southern California Keck School of Medicine in Los Angeles, California. He completed a residency in internal medicine at Cedars-Sinai Medical Center/West Los Angeles Veteran’s Administration and completed a fellowship in cardiovascular disease at the University of Tennessee Medical Center. He also joined University Cardiology in July.

We are pleased to welcome Dr. Nathan Smith as a Clinical Assistant Professor in the Division of Internal Medicine. Dr. Smith attended medical school at the University of Tennessee College of Medicine in Memphis. He completed residency in internal medicine at the University of Tennessee Graduate School of Medicine in Knoxville where he served as Chief Resident. He currently practices with UT Hospitalists.

We are excited Dr. Bruce LeForce has joined the faculty as a Clinical Assistant Professor in the Division of Neurology. Dr. LeForce attended medical school at the University of Louisville in Louisville, Kentucky. He completed an internship in internal medicine and a residency in neurology at Wilford Hall Medical Center on Lackland Air Force Base in San Antonio, Texas. He completed a fellowship

New Staff Ann Bowman recently joined the department as an administrative assistant II. She has her Bachelor’s degree in French. She has a background in nonprofit funding raising and most recently served at Big Brothers and Big Sisters. Ann has four sons and enjoys gardening, reading and UT sports. We look forward to the creative ideas she will bring to the department.

CME Opportunities—Mark Your Calendars! • Weekly Cardiology Conferences, generally held on Wednesdays each week for .75 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.

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


Ethics Case Rounds - Seeking Balance in the ICU Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality. Vernon is an 80-year-old gentleman who lives in Kentucky with his wife of 60+ years, Dotty. They have 3 surviving children and many grandchildren, but only one daughter, Maggie, lives locally. Vernon has diabetes, chronic kidney disease, and chronic pain. He has been increasingly limited in what he can do due to neuropathy and visual impairments, and Dotty has some dementia, but they get by with Maggie’s help. He was transferred to UTMC after an overdose of pain medication, which the family maintained was unintentional. His prognosis was grim; he was intubated, unresponsive and in multi-organ system failure. Maggie says they want “everything done” for Vernon, and became angry when his poor prognosis was discussed. After two weeks of very little progress, they decided on tracheostomy and PEG tube. Dotty and Maggie visited several times a week. They were polite but reserved. Dotty had a sweet, passive demeanor, while Maggie often seemed distrustful, even hostile. Maggie says her dad “absolutely would not” want to live in a nursing home “and mom and I would never put him in one.” They are hopeful he will return home; “We are just waiting on the Lord.” They were not receptive to care planning discussions, but did accept social visits, and appreciated sharing family stories. One of the chaplains tried to stop by whenever they were there. Over time, family seemed more comfortable with the staff. However, they remained steadfast in the plan to bring him home, answering concerns with “we’ll manage.” Team members recognized that Vernon’s family’s Appalachian culture could be a factor in conversations about his care. As a group, Appalachians are “proud, private, and take care of their own.” It can take some time to earn their trust. Team members realized they needed to gain Dotty’s and Maggie’s trust before they could accept the information about Vernon they were trying to give them. One afternoon in a side conversation, Maggie said she knew her father would never be able to go home, but that she had to protect her mother. “Mommy will never be able to let go of Daddy, he’s been her whole life.” She admitted to “praying he would just go to sleep” if he wasn’t going to get better. Privately, Dotty confided that she has been “holding on for Maggie. She can’t face her Daddy leaving us. We’ll just have to wait until the Lord is ready for him.” Another family meeting was held. A chaplain opened the meeting with prayer. The staff talked about some of the things Dotty and Maggie had shared about Vernon and their family. Then the physician explained, as before, that she was worried that he would never get any better. Maggie asked if he could “just come home with us,” but understood when told he probably could not survive the trip. Dotty asked if the doctors could take him off the machines and let him go. After additional discussion, they asked for comfort measures, including terminal extubation. Vernon died peacefully a few hours later. Maggie thanked the staff, saying, “You all have been a blessing.” Comments on this case may be sent to amendola@utmck.edu References 1. Behringer, B, and Friedell, GH. “Appalachia: Where place matters in health” Preventing Chronic Disease [serial online] (2006) vol 3 no 4. 2. Carter, MA, and Klugman, CM. “Cultural Engagement in Clinical Ethics: A Model for Ethics Consultation” Cambridge Quarterly for Healthcare Ethics (2001) 10, 16-33. 3. Wojtasiewicz, M. E. C. 2006. “Damage compounded: Disparities, distrust, and disparate impact in end-of-life conflict resolution policies.” American Journal of Bioethics 6(5): 8–12.

In Touch Vol. 6, Issue 4: October 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. 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! 5

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.

In Touch October 2017  

In Touch is a newsletter for alumni and friends of the Department of Medicine at the University of Tennessee Graduate School of Medicine.

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