March 2015 Newsletter

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Department of Medicine eNewsletter
March 2015
:: Interview
:: Department News
:: Department Events
:: Leadership Council Minutes
Leadership Council
March 2015
Richard Walsh

B. Arafah

K. Armitage

A. Askari

R. Bonomo

R. Chandra

F. Cominelli

F. Creighton

R. Folz

G. Gnanasekaran

S. Gravenstein

T. Hostetter

D. Hricik

N. Meropol

R. Salata

D. Simon

R. Walsh

J. Wright



Recorded by:
A. Staruch
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department interview
Sarah Augustine, MD, Associate Chief of Medicine at the Louis Stokes Cleveland VA Medical Center, talks about the importance of quality initiatives, shares her perspective on the changes taking place in medical training and discusses key aspects of an organizational culture that empower women in medicine to grow.


What are some of the latest quality initiatives you have been developing lately? How do you see them unfolding over the next few months?


Over the past 15-20 years, the Louis Stokes Cleveland VA Medical Center has taken on a leadership role in quality improvement initiatives. I oversee the General Medicine section, which includes Women's Health, Emergency Department, Inpatient Wards and Primary Care. In Women's Health, Phyllis Nsiah-Kumi, MD, was awarded a grant for a multidisciplinary breast care clinic for female veterans, including developing breast navigation services for patients with benign and malignant disease. Over the past year, we have been successful in introducing a breast clinic that now features a women's health breast specialist, surgical oncologist and radiologist. The grant will also fund breast navigation training for several of our staff members.



In the Emergency Department, one of the quality projects that Todd Smith, MD, is working on is minimizing door-to-doc time. Our current performance measure is 45 minutes. However, we were exceeding this time with our nonacute patients. What we have done is re-evaluated our space limitations and modified the old system of having providers assigned to rooms and being responsible for calling patients in. Instead, we started allowing the rooms to be available for anyone's use and had a third party call the patient in, so that the first available physician can see them right away. By changing the logistics, our flow improved immensely and we are now able to meet the 45-minute performance measure with our nonacute patients.


Another project of our Emergency Department has to do with the primary care clinic. A lot of patients with below acuity complaints were coming in seeking emergency care service instead of services of primary care physicians. The situation caused imbalance in the system with open unutilized appointments in primary care and long lines to the emergency room. We now have a new system in place where a triage nurse in the Emergency Department receives a report of open slots in primary care, once a patient's complaint is identified as low acuity, he or she is triaged directly to primary care service. We now have over 95 percent utilization of our open slots in primary care clinic as well as more efficient Emergency Department that can serve acute patients faster.

Finally, on the inpatient service side, Charles LoPresti, MD, initiated a flyer introducing physicians, describing their roles and dates of service to patients in our care.



What measures do you take to ensure these critical projects are sustainable over time?


The Emergency Department and primary care project has been going on for 18 months; it is a multidisciplinary project that would have failed without the support of our nurses and clerical staff. This required us to sit down wilth all parties involved in the project to get their input to ensure the project is successful. After implementing the project, we revisited it in a month to identify areas that needed further improvements. This follow-up was critical in ensuring the sustainability of the project and implementing it into the regular day of health care providers.



Do quality improvement projects take on a new role in the changing health care environment?


Health care quality is critical to our medical center. You would expect that if your family member walked into any physician office with the same complaint, he or she would receive the same quality of care. However, we all know from experience that this is not always the case. I strongly believe that we have quality measures to use as a system of checks and balances for the services we provide to patients.



We teach residents to be knowledgeable of quality measures and understand why they were put in place. At the same time, we do not want to allow the management of patients to be directed solely by quality measures. If a patient is not willing to take three new medications, despite recommendations and research findings, the point is not to push the patient, but rather adjust the care so that the patient cooperates best. You have to be willing to start a dialogue with your patient and be receptive to his or her side of the story. As a physician, you have to understand that you have to find a balance between quality requirements and a patient's comfort level. If we allow ourselves to be driven only by quality measures, we will be checking boxes for the sake of checking boxes, not for the sake of good patient care.



The health care reform has undoubtedly impacted training programs. At what level should quality initiatives be introduced in the current day and age?


I do not think we introduce quality early enough in medical education; it needs to be robustly integrated into the curriculum of medical schools. At the Louis Stokes Cleveland VA Medical Center, we teach a progressive quality curriculum over the three years of training. The intern portion of the curriculum is the introduction of quality and quality measures as they relate to today's health care system. We then teach our residents the implications of efficiency, flow, waste, etc. We establish a common language among our trainees as our COE residents go through Weatherhead School of Management's Six Sigma training. We need to instill the importance of health care quality in our trainees, and ensure that residents understand that this is the way health care will be practiced in the future and be able to navigate this system.



You have been recognized with numerous teaching and leadership awards. In your perspective, what are the key qualities essential for a good teacher nowadays?


One of the most important things for me in residency education is to be a role model. I want to treat patients the way I would expect my family members to be treated and I always use that as my litmus test. Our residents are really smart, talented and knowledgeable of latest studies and are able to apply the latest research findings to clinical care. One area I feel I can make an impact on is showing effective doctor-patient communication through my own practice. This does not only concern medical diagnosis, but also has to do with understanding factors outside of patients' hospitalization responsible for their problematic behavior. It is essential to construct a dialogue with patients so that they understand we as doctors do not only care about what happens to them in the hospital, but are also concerned about their environment at home. We do not have a formal curriculum for this kind of doctor-patient communication; the only way we can pass these skills on to our trainees is through role modeling.



I also think it is critical to allow our residents to have as much autonomy as possible while providing support and help when they need it. I always tell residents they can construct a plan of care for a patient as long as they can justify the treatment based on medical history, physical exam and objective data. There are many ways to take care of a patient; our trainees need to be able to develop their own management style and be confident about it.



What are some of the critical changes that will take place in education that we will need to be prepared to address in the next few years?


I support the duty hour restrictions, as I do not believe that working over 80 hours a week can make somebody a better doctor. However, the duty hour restrictions also impact the clinical exposure due to the limited number of patients seen by trainees. In a perfect world, residency training would be extended to four years; however, I do not think this is something that is realistic considering GME funding climate. I feel we are not giving our trainees enough clinical exposure before we send them out into the world to be licensed independent practitioners. Our trainees are eager to learn, but we have tied their hands to some extent. As a result, I am witnessing more residents work one year as hospitalists to get the additional clinical exposure before entering a fellowship program or going into primary care.



As a female physician in a leadership position,do you believe there still exists a glass ceiling for women in medicine?


I think the glass ceiling is still there, though it has become higher. I think I'm in a very unique position as I've received a lot of support from my male colleagues and mentors early on. This incredibly supportive environment is very rare and because of it I personally do not feel like I have factors impeding my professional growth.



I have found that you have to have a certain level of skills in order to advance in leadership. I think a lot of it comes down to communication and engagement of people; these skills are very natural for women to develop. At the same time, however, we make choices about personal life and work life, and as women, we are more sensitive about maintaining this balance. Because of our accommodating environment here at the VA, female section chiefs and I are confident that our home life is not going to suffer because of our workload. We find ways to work around it by working remotely from home at night, getting to work earlier in the morning or working over weekends. At the same time, if I need to leave work at 5:00 p.m. to pick up my children from an activity, I can do so, even though I will have to shift my workday later to compensate for it. We are very grateful to have this supportive environment, but I think it is a rare oasis.



What are the key components of the culture that would enable women in medicine to grow?


Flexibility is key. It is inspiring to belong to a workplace where leadership wants you to work hard and still be happy outside of work. As in any organization, it is important to understand the factors that drive each person. Establishing a level of understanding for creating a family and taking time off to have children is very motivating for women to work even harder when they come back. Often times a simple rearrangement of schedules is all it takes to give that little bit of flexibility to accommodate for appointments, pregnancies or daycare. Here at the VA, we have a unique culture that not only can offer flexibility to women, but also to our male faculty and staff. We need to understand that life goes on outside the hospital and be supportive of each other. In return, this caring culture attracts outstanding professionals who want to work in an environment where they are recognized and valued as individuals.

department news report

Division of Cardiovascular Medicine


Saptarsi Haldar, MD, was awarded a $3.2 million multi-PI R01 grant from NIH to study epigenetic mechanisms in heart failure pathogenesis.
In addition, Dr. Haldar received a new accelerator grant from the NHLBI's National Center for Accelerated Innovation for first-phase preclinical development of BET bromodomain inhibition as a novel therapy for human heart failure.




Jay Sahadevan, MD, and Albert Waldo, MD, were awarded $50,000 from the Ohio Third Frontier in the Technology Validation category. The funding will be used for the development of an endocardial catheter that will work with novel algorithms to detect sources sustaining atrial fibrillation.





Schedule a clinical appointment with Cardiovascular Medicine physicians






Division of General Internal Medicine


Attila Nemeth, MD, was elected Fellow to the Society of Hospital Medicine. Dr. Nemeth demonstrated an outstanding level of commitment to hospital medicine, system change and quality improvement principles.



Clifford Packer, MD, along with his team was named the winner of the Costs of Care and ABIM Foundation Teaching Value and Choosing Wisely Challenge. The challenge sought to identify the most promising innovations and bright ideas for teaching high-value care and stewardship to medical students, trainees and faculty. Dr. Packer's project modified the traditional SOAP note template to include a discussion of value. By embedding value consideration into a routine practice, students reported greater comfort with initiating discussions about overuse with their clinical teams.






Division of Hematology & Oncology

Basem William, MD, was elected Fellow in the American College of Physicians. This accomplishment honors Dr. William's commitment and dedication to internal medicine.







Division of Infectious Diseases & HIV Medicine

Robert Bonomo, MD, published an article entitled "Structural Basis of Activity Against Aztreonam and Extended Spectrum Cephalosporins for Two Cabapenem-Hydrolyzing Class D β-Lactamases from Acinetobacter Baumannii" in the Journal of Biochemistry. The results of Dr. Bonomo's team reveal worrying trends in the past enhancements of substrate spectrum of D β-lactamases and provide a possible map for β-lactam improvement.

Henry Boom, MD, published an article entitled "Polymorphisms in TICAM2 and IL1B are associated with TB" in Genes and Immunity Journal. After examining 29 genes in pathways that mediate immune suppression to Mycobacterium tuberculosis in subjects from Uganda, researchers discovered the association between TICAM2 polymorphisms and TB and between IL18 and pediatric TB.

The American Geriatrics Society (AGS) selected an abstract submitted by Robin Jump, MD, for presentation at the Teachers Methods and Materials Swap for Geriatrics Education during the AGS meeting. The abstract entitled "Preliminary Outcomes from an Educational Intervention to Promote Antimicrobial Stewardship and Improve the Care of Older Adults with Infections" describes a five-hour case-based curriculum about infections common among older adults. The cases stress antimicrobial stewardship. Outcomes from an accompanying survey indicated that the case-based educational intervention improved provider knowledge and confidence to care for older adults with infections.
In addition, Dr. Jump's research on infectious diseases in older adults culminated in an article entitled "Clostridium Difficile in the Long-Term Care Facility: Prevention and Management" published in Current Geriatrics Reports and an article entitled "Knowledge, Beliefs, and Confidence regarding Infections and Antimicrobial Stewardship: A Survey of Veterans Affairs Providers Who Care for Older Adults" published in the American Journal of Infectious Control.


Michael Lederman, MD, and Benigno Rodriguez, MD, discovered that a common herpes drug can reduce HIV-1 levels. The article entitled "Valacyclovir Decreases Plasma HIV-1 RNA in HSV-2 Seronegative Individuals: A Randomized Placebo-Controlled Crossover Trial" published in Clinical Infectious Diseases shows that there are new promising avenues for the development of HIV-fighting drugs.



Amy Ray, MD, was chosen by the Gerontological Society of America to participate in the 2015 Immunization Champions, Advocates, and Mentors Program (ICAMP) Provider Champion Training Pilot. ICAMP is intended to mobilize and assist health care professionals in their efforts to immunize adult patients to protect against vaccine-preventable diseases and disability, increase immunization rates, and reach the Healthy People 2020 goals for adult immunization. ICAMP is developed by GSA and supported by Pfizer. Dr. Ray will be part of the pilot study to evaluate a toolkit designed to improve adult immunization rates.
In addition, Dr. Ray was recommended by UH leadership to receive the 2015 YWCA Women of Professional Excellence Award. Established in 1977, the Women of Achievement Awards are considered some of the most prestigious honors for women in Cleveland. Recipients are selected by their employers for their professional accomplishments, dedication to their organization and commitment to the community. Women nominated for the award exemplify high professional standards and evidence of career and personal growth; make significant contributions to the effective, efficient operation of their organization; display a willingness to support and mentor others in their organizations and positively impact the community.

Carlos Subauste, MD, received a $200,000 grant from NIH Center for Accelerated Innovation for his project entitled "Inhibition of CD40-TRAF signaling for the treatment of vascular inflammatory disorders." Dr. Subauste discovered a compound that inhibits CD40 signaling, exhibits anti-inflammatory activity in vitro and in vivo, yet does not appear to impair cell-mediated immunity in vivo. The funding will be used to generate and test analogues of the compound.

Division of Nephrology & Hypertension

Joshua Augustine, MD, received the 2015 Person of the Year Award from the Kidney Foundation of Ohio. This award was presented for Dr. Augustine's exemplary service and dedication to the mission of the organization.

Donald Hricik, MD, will receive the American Society of Transplantation's Lifetime Achievement Award at the American Transplant Congress. This recognition celebrates Dr. Hricik's outstanding medical contributions and dedication to the field of transplantation.

department conferences & events

Team Science Challenge

The purpose of Team Science Challenge is advancing modern medical research. The awards from the Department of Medicine will provide support for developing a major research proposal to a multidisciplinary team.

Application Deadline: May 1, 2015
Submission: Send applications in PDF format to Martha Salata


Research Day 2015

When: Friday, May 15

When: 12:00 - 3:30 p.m.

Where: Wolstein Research Building Atrium and Lobby

Abstracts Deadline: Monday, May 4

Register for the event

Submit your abstract




Grand Rounds

When: Tuesdays, 12:00 - 1:00 p.m.

Where: Kulas Auditorium, Lakeside, 5th Floor


April 7

"Candidemia: Antifungal Stewardship and the Importance of Rapid Diagnosis" by Michael Pfaller, MD


April 14

"Screening, Treatment and Prevention of Rheumatic Heart Disease in Uganda" by Chris Longenecker, MD


April 21

"Bariatric and Metabolic Surgery in 2015" by Mujjahid Abbas, MD


April 28

"Biventricular Pacing in 2015" by Anselma Intini, MD


department leadership council minutes

Leadership Council

Dr. Walsh updated the council members on enhancements to the Electronic Health Record (EHR). Personnel from the IT department will meet with divisions to go over these changes. Faculty members are encouraged to attend the division meetings on this topic.


Leadership Council

Dr. Walsh announced that he will be stepping down as Chair of the Department of Medicine and Physician-In-Chief of University Hospitals Case Medical Center effective July 1, 2015. Dr. Robert Salata will serve as the Interim Chair of the department. A national search will take place for the position. Members of the council thanked Dr. Walsh for his tenure as Chair and Dr. Cominelli proposed to name the department's annual Research Day after Dr. Walsh.


Leadership Council

Dr. Salata asked for council members' support as he takes on the role of Interim Chair. He will be in contact with Division Chiefs to go over data that will be needed for the department's strategic plan.