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Spotlight Interview: Drs. Michael Lattanzi, Michael Natter, and Tanya Wilcox
July 2019

Halfway Technologies and the EHR

A message from the chair, Dr. Steve Abramson

The electronic health record has been the subject of much discussion and criticism—and occasional humor, as in the accompanying cartoon by Michael Natter, featured in today’s Spotlight Interview. The mandate for electronic health records by physicians came from the Obama Administration with the goals of making medicine safer, empowering patients, and allowing providers to provide high-quality, cost-efficient care. Within 10 years the utilization by physicians has soared from 9% to 94%! This is a remarkable transformation from paper to computer—one which has become integral to the professional lives, and periodic frustrations, of doctors and nurses.

Over this period we have seen a quiet but disruptive revolution. Indeed, much attention has been given to the contribution of the EHR to physician “burnout,” and a misguided few have framed this as administrative exploitation of providers. Such condemnation misses the central advantage to providers and patients, namely that the EHR has improved communication among physicians, offered immediate access to lab and imaging results, and effected a higher level of care across health systems and populations through coordination and implementation of best practices.

And yet the EHR remains a challenging tool for many, particularly for more senior physicians like myself, brought up in the paper, shall we say Guttenberg, era. In 1975 Lewis Thomas introduced the phrase “halfway technologies” to describe new medical and surgical technologies of great promise that would take years of improvement to have the full desired impact on disease. In many ways, the accelerated universal introduction of the EHR has presented institutions and providers with a halfway technology—critically valuable but in need of continued improvements, as evidenced by periodic EPIC “upgrades,” which some have described as flying the plane as it is being built.

We are fortunate that MCIT, led by Nader Mherabi, Paul Testa, and Adam Szerencsy, is actively focusing on improving the EHR experience for NYU providers, with efforts intended to make EPIC more flexible, user friendly, and customizable. These include personalized sessions, site visits, and remote learning. Among the current links that may be useful is the Epic Tipsheet Website.

The Department of Medicine has also begun an initiative, led by Mark Pochapin and Katy Wesnousky, to work with the MCIT team to provide input on faculty and resident needs, and to assist with implementation of EPIC enhancements. Our goal is to work together to make the EHR a better tool for physicians to provide high-quality care for patients while maintaining our own professional satisfaction and quality of home life—bringing it beyond a halfway technology.

As part of this process, we will be reaching out to physician groups to get feedback. For those who are interested we encourage you to submit suggestions now via this link

Give feedback on your EHR Experience


 

Spotlight on Drs. Michael Lattanzi, Michael Natter, and Tanya Wilcox

In the latest spotlight interview, we talk with three of our talented medical residents—Drs. Michael Lattanzi, Michael Natter, and Tanya Wilcox—about their ongoing research, the rewards of patient care, and their plans for the future.

Drs. Lattanzi, Natter, and Wilcox presented their work at the most recent Grand Rounds Resident Research Showcase, held on May 22, 2019. Their projects were:

  • Michael Lattanzi, MD: "Single Cell Analysis of Urothelial Carcinoma Identifies Epithelial-Mesenchymal Transition as a Potential Mechanism for Immune Exclusion" (Mentor: Arjun Balar, MD)
  • Michael Natter, MD: "Why Medicine Needs Art" (Mentor: Lucy Bruell, MS)
  • Tanya Wilcox, MD: "Cardiovascular Risk Scores to Predict Perioperative Stroke in Non-Cardiac Surgery" (Mentor: Jeffrey Berger, MD)

“I am a Chief, I will always be a Chief”


With gratitude and fond regards to our 2018-2019 Internal Medicine Chief Residents: Katherine Riedy, Oscar Mitchell, Allison Guttmann, Jonathan Chun, Dana Zalkin, Rishi Pandya, Scott Statman, Hadas Reich, Andrew Lehr, and Daniel Sartori.

View photos from the 2019 Internal Medicine Residency Graduation (password: elsa)

And with a warm welcome and best wishes for a successful year to our 2019-2020 Internal Medicine Chief Residents and all of our new interns!
Above, L-R: 2019-2020 chief residents Milna Rufin, Kelsey Luoma, Amy Ou, Christian Torres, Carl Drake, David Rhee, Gabriel Perreault, Cary Blum, Custon Nyabanga, and Tanya Wilcox
Below: 2019 PGY1s and program leadership


History Quiz Teaser

Some of the most important Supreme Court Cases since 1900 have involved issues relating to medicine and public health. Everyone is familiar with ROE v. WADE, but others—less well known—have also stirred enormous controversy when they were decided.

Here are four cases. What issues were involved?
JACOBSON V. MASSACHUSETTS (1905)
MULLER V. OREGON (1908)
GRISWOLD v. CONNECTICUT (1965)
CRUZON v. DIRECTOR, MISSOURI DEPARTMENT OF PUBLIC HEALTH (1990)

Scroll down for the answers.


Bridging the Gap: The NYU Transition to Residency Advantage

Q&A with Patrick Cocks, MD, and Marc Triola, MD

NYU School of Medicine has long been a leader in innovative educational strategies that weave together its trifold mission: to teach, to serve, and to discover.  With the announcement of a major grant from the American Medical Association, a project called the NYU Transition to Residency Advantage will now build upon this innovation by working to bridge the gap between medical school and residency. Drs. Patrick Cocks, the Abraham Sunshine Assistant Professor of Clinical Medicine and director of the Internal Medicine Residency Training Program, and Marc Triola, associate dean for Educational Informatics and director of the Institute for Innovations in Medical Education, tell us about the project.

Where did the idea for this project begin? Was it a natural progression from other work already being done here at NYU Langone Health?
For several years, NYU has worked to improve the UME-GME transition for our students and residents. The Three-Year MD pathway is an example of one such innovation that directly links medical school and residency training. From Day 1 of medical school, students in the three-year program are assigned a departmental advisor to support them throughout the entirety of their education and training. We recognized that a transition that bridges the UME-GME divide and includes robust coaching that starts in UME and continues into residency, a tailored training program, and enhanced assessment tools, are essential to optimizing the educational environment and enabling GME programs to shift away from one-size-fits-all education. This type of self-directed, learner-specific training focused on bringing out the best in each resident will improve outcomes, accelerate the path to competence and mastery, enhance patient safety and quality, address professionalism issues early, and counter the factors that contribute to stress and burnout.

In late 2018, the AMA announced a fantastic new grant program entitled the Reimagining Residency Initiative. Its aims are to support innovations that provide a meaningful and safe transition from UME to GME, establish new curricular content and experiences to enhance readiness for practice, and promote well-being in training. Leveraging our experience and the unique laboratory that NYU represents, we were successfully funded for our project: NYU Transition to Residency Advantage (TRA). We are one of eight projects to be awarded $1.8 million over five years.

How will the funding be used to implement your project?
A principal use of the grant will be to support 12 new GME Bridge Coaches from among GME faculty. Initially this will be within the residencies of Medicine, OBGyn, Emergency Medicine, Orthopedic Surgery, and Pathology. The GME Bridge Coaches will oversee and coach learners across the transition period post-match and into the intern year, thereby eliminating the discontinuous silos of UME and GME. These coaches will receive education on effective coaching strategies such as use of educational dashboards in trainee development as part of a new faculty curriculum that will be offered by NYU Langone’s Educator Community.

What do you anticipate the long-term impact to be on medical education and beyond?
The TRA project’s core goal is to improve the transition from medical school to residency and to preserve continuity in professional development, which is both a critical need and a missed opportunity. We feel that this unique “warm handover” approach will provide new insights that will improve the experience of our learners while enhancing the bi-directional coordination of UME and GME education and training efforts. Building on the effectiveness of coaching programs in addressing factors associated with burnout and improving wellness, the TRA project will also support the sense of mastery and meaning needed to achieve an optimal learning environment to support well-being among trainees. We also believe customized training opportunities and longitudinal coaching and career advising will better prepare trainees for the complex and ever-changing demands of practice.


Flashback Photo

The photo above features the Class of 2003-2004 from our Internal Medicine Residency Program. Do you recognize a colleague? Are you in the photo yourself? We’d love to identify all of the alumni in the photo who are still at NYU Langone.

Click on the photo for a closer look. Send your comments and guesses to DOMCommunications@nyumc.org

 

Department of Medicine Annual Awards

Congratulations to the winners of this year’s Department of Medicine awards, presented at Grand Rounds on Wednesday, June 12, 2019. Dr. Abramson also presented the annual “State of the Department” at the meeting.

PGY1 of the Year: Alexandria Imperato, MD
PGY2 of the Year: John Bostrom, MD
PGY3 of the Year: Jason Ng, MD

Teacher of the Year, Inpatient: Scott Schafler, MD
Teacher of the Year, Outpatient: Richard Greene, MD
Teacher of the Year, ICUs: David Fridman, MD

Fellow Awards:
Cardiology: Gregory Katz, MD
Endocrinology, Diabetes and Metabolism: David Carruthers, MD and Chelsey Baldwin, MD
Gastroenterology: Maureen Whitsett, MD
Geriatric Medicine: He “Helen” Sun, MD
Hospice and Palliative Care: Sheena Zapata, MD
Hematology and Medical Oncology: Rafael Winograd, MD
Infectious Diseases and Immunology: Seth Blumberg, MD
Nephrology: David Packer, MD
Pulmonary, Critical Care, and Sleep Medicine: David Ellenberg, MD
Rheumatology: Ruth Fernandez Ruiz, MD

Faculty Awards:
Cardiology: Robert M. Donnino, MD
Endocrinology, Diabetes and Metabolism: Nidhi Agrawal, MD
Gastroenterology: Scott M. Smukalla, MD
Geriatric Medicine: Nina Blachman, MD (shown above with Drs. Caroline Blaum, Daniel Sartori, and Steven Abramson)
Hospice and Palliative Care: Susan Cohen, MD
Hematology: Tibor Moskovits, MD
Medical Oncology: Joshua Sabari, MD
Infectious Diseases and Immunology: Neil Steigbiegl, MD
Nephrology: Jeffrey Michael, MD
Pulmonary, Critical Care, and Sleep Medicine: Luis F. Angel, MD
Rheumatology: Michael Toprover, MD

Teacher of the Year, NYU Langone-Brooklyn: Eric Bondarsky, MD


History Quiz: Controversy and the Supreme Court

Above we mentioned four controversial cases related to health and medicine that made it to the Supreme Court:

JACOBSON V. MASSACHUSETTS (1905)
MULLER V. OREGON (1908)
GRISWOLD v. CONNECTICUT (1965)
CRUZON v. DIRECTOR, MISSOURI DEPARTMENT OF PUBLIC HEALTH (1990)

How did you fare with your knowledge of these milestones?

JACOBSON v. MASSACHUSETTS
The case involved the state power of Massachusetts to require individuals to be vaccinated or face penalties during a “public health emergency”—in this instance an outbreak of smallpox. Henning Jacobson, a minister, refused to be vaccinated, claiming a previous vaccination had made him ill. He also refused to pay a $5 fine for his refusal, claiming that the state had violated his 14th Amendment constitutional protections. In a landmark decision, the Supreme Court ruled (7-2) that one’s personal liberties must give way to the collective good during a health emergency. In the words of Justice John Marshall Harlan, “the liberty secured by the Constitution … does not import an absolute right in each person to be at all times, and in all circumstances, wholly freed from restraint… It is within the police power of the state to enact a compulsory vaccination law.”

MULLER v. OREGON (1908)
In the early 1900s, the Oregon state legislature passed a law limiting the number of hours that women could work in most occupations outside the home to ten-per-day. The law, which did not restrict the hours a man could work, was based on the widespread belief that women were not only physically weaker than men, but that their primary duties in bearing and raising children had to be protected in order to safeguard the family unit. In a unanimous decision, the Supreme Court upheld the Oregon law, stating that a woman’s “physical structure and a proper discharge of her maternal functions—having in view not merely her own health, but the well-being of the race—justify legislation to protect her from greed as well as the passion of man.”
        In 1908, Muller was seen as a great victory for women and for public health. Times certainly have changed.

GRISWOLD v. CONNECTICUT (1965)
Like a number of other states in this era, Connecticut had a law on the books from 1879 banning the use of contraceptives, even among married couples, and punishing those who used any form of birth control or assisted others in doing so. In a 7-2 decision, the Supreme Court struck down the law on grounds that it violated marital privacy. But several justices went further, contending that the Bill of Rights had created a fundamental (if unstated) right to privacy with respect to other intimate practices. Griswold would be cited from this point forward in cases regarding birth control, abortion, same sex marriage, and in the striking down of state sodomy laws.

CRUZON V. DIRECTOR, MISSOURI DEPARTMENT OF PUBLIC HEALTH (1990)
By the late 1980s, several cases involving the criteria for removing life-sustaining treatment for hospital patients were working their way through the courts. Cruzon was the first to be decided at the highest level. It involved the victim of a car accident, Nany Cruzon, who had been on life-support in a Missouri state hospital for five years. When her parents got a court order to remove their daughter’s feeding tube, claiming she had told a friend that she would not have wanted to be kept alive this way, the state of Missouri appealed on grounds that the story was insufficient to justify ending her life. In a 5-4 decision, the Supreme Court decided in the state’s favor, ruling that “clear and convincing evidence” of an individual’s desire to end life support must be provided in cases like Cruzon’s, where the state opposes the decision to terminate. Known as the first “right to die” case, Cruzon spurred national interest in the now-common living will.



 

Featured Student Essay

"The Culture of Care" by Eileen Jiang
Winner of the Clerkship Award for Outstanding Essay in Medical Humanism

No change in a physician’s career is greater than the transformation from graduate student to clinician during Medical School’s clinical clerkships. Students are often too busy to reflect during this time, worried more about patients, learning, tests, and assignments. Based on a personal experience as a student, Dr. Martin Blaser, then Chair of Medicine, created one more assignment in 2000: write and submit a personal reflection while on the Medicine Clerkship. Students are free to pursue their own interests, and the resulting essays have yielded remarkable work. Essays reveal inner thoughts and struggles, and in many cases, insights and improved understanding, as students become doctors. We hope that these essays will remind you of your career, meaningful patient experiences, and allow you to relive the process of becoming a doctor through the eyes of our students.

~~~~~

“Ni hui shuo zhong wen ma?”

As someone who grew up in a Mandarin-speaking household, there is something very special about taking care of Chinese patients. With a nod, I feel suddenly ushered behind the curtain into a more intimate world where the space between people feels closer, relationships feel warmer, and speech flows more freely. There is often such an expression of relief on the faces of patients when they are finally greeted in their native tongue and I relish the way plans for diagnosis or treatment seem to readily come together when carried on the foundation of shared language. However, the familiar also has a power to bring forward like a flood all the concerns that had been previously bubbling behind the surface. All at once it is more than I expected, and all words are swept away.

You know me. I know you. We share a common understanding from a shared background and culture, so you can be frank with us. Tell us honestly, what should we do? This is the undercurrent of the past hour’s discussion. He stares at me and I look back at him, the son of my latest patient. The patient is eighty-three years old with a likely new diagnosis of lung cancer and worried about the pain of a biopsy needed for confirmation and treatment. She has told me that she’s lived a full life already and only wants to be ensured of comfort. However, her family is hoping for more time, so we circle back and forth in discussions of uncertainty. I try to talk about possibilities, laying out the options before them, but the family is holding out for an absolute that I cannot provide. Suddenly, that cozy sphere of intimacy is too tight and too close. I am overwhelmed by the faith and trust that is placed in me as well as the heightened expectation that comes from greater familiarity. I feel at a loss for how to answer. The words stick in my throat and I struggle to find the right phrases to convey that there are no certainties to be had as we struggle to find a path forward.

Other times, I am caught off guard by the depths of what my patients are willing to confide in me. With red-rimmed eyes and hushed tones, a husband tells me about fears for his wife who has been recently diagnosed with metastatic breast cancer. She is in her late forties and lies slumped over a table nauseous and exhausted, with yellowed skin and eyes due to complications from her first round of chemotherapy. She perks up as her husband shows me pictures of their children, two smiling girls of five and seven, and mentions missing them. However, the couple hasn’t had them visit for fear of them seeing how serious their mother’s condition really is. This situation is realized for another family as a daughter savors the time she has left with her mother who is barely fifty but dying of cholangiocarcinoma. She says her mother is the only family she has left in the whole world and that she is trying to be brave and hold herself together. At the same time, she expresses injustice at the situation. Her mother had always been so good, always putting others before herself. Why did such a thing have to happen to her? At these times, I find myself desperately wanting to answer the depths of emotions that have been entrusted to me. However, my mind inevitably blanks. There are no words. For in the face of such suffering and anguish, what can really be said? Yet for what little I feel I can offer to these families, I receive more gratitude than should be due. What is even more humbling is that as I struggle to find the right words to comfort them, these families show an incredible amount of concern for me, thanking for me for doing a good job and reminding me to also take breaks to rest.

Over the past months, it has been a great privilege to work with my Chinese patients and to share in some of hardest periods of their lives. Learning about their stories through the lens of shared language, background, and culture brings home the realities and sorrows of illness and mortality, as their faces blend with those of my parents and grandparents. They remind me of the very personal aspect of medicine and show that at its heart, it’s not just a practice of treating disease, but also a process of journeying with patients and their families through some of the most broken moments of their lives. Sometimes, this starts with just a few familiar and comforting words.

~~~~~~~~

Eileen Jiang is a recent graduate of NYU School of Medicine from the Three Year Pathway Program. Originally from New Jersey, she attended Columbia College with a major in Biology. Prior to starting to medical school, she worked as a research technician at Memorial Sloan Kettering Cancer Center studying pediatric oncology. She recently married a fellow NYU medical school graduate and just finished up her honeymoon in Asia. She is excited to be returning to NYU this July to start her residency in Pediatrics.

Highlights from Dr. Abramson's State of the Department Presentation
(Grand Rounds, June 12, 2019)

School-Wide Awards and Recognition:
 2018-2019 Academic Year

Sondra R. Zabar, MD
New York University 2018-2019 Distinguished Teaching Award
Professor
Director, DGIMCI
Director, Standardized Patient Program

David Kudlowitz, MD
Distinguished Teacher in the Clinical Sciences
Instructor

David T. Stern, MD, PhD
Master Educator
Dean's Honors Day

Professor of Medicine
Vice Chair for Education, Faculty and Academic Affairs

Ann Marie Schmidt, MD
Master Scientist
Dean's Honors Day

Dr. Iven Young Professor of Endocrinology

Leadership Recruits

Mark J. Mulligan, MD
Professor, Medicine & Microbiology
Director, NYU Langone Vaccine Center
Director, Division of Infectious Diseases and Immunology

David M. Charytan, MD
Norman S. Wikler Associate Professor of Medicine
Director, Division of Nephrology

New Appointments

Andrew B. Wallach, MD
Clinical Director, Ambulatory Care
Clinical Chief, Office of Ambulatory Care
Senior Advisor, Division of Medical and Professional Affairs, NYC Health + Hospitals/Bellevue

Craig Thompson, MD
Director, Cardiac Catherization Laboratory, Tisch
Director, Interventional Cardiology, NYULH

PHOTOS & EVENTS

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