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Diastole: Residents at rest

The Department of Internal Medicine’s Diastole blog encourages residents like Sarah Lee, M.D., to use writing as a chance to reflect and build resiliency.

The Department of Internal Medicine’s Diastole blog encourages residents like Sarah Lee, M.D., to use writing as a chance to reflect and build resiliency.

The patient lay in her hospital bed and stared into space, unable to make eye contact with the doctors who had come to help her.

Battling end-stage HIV/AIDS, the woman seemed unable to come to terms with her condition.

“I’m not sure if she could hear us, or if she was in denial and chose not to respond,” says Sarah Lee, M.D., a second-year resident in the Department of Internal Medicine. “It was frustrating and sad. That was my first year, and it was tough to deal with something like that so early on.”

Lucky for Lee, she had help. For the past two years, first-year residents have written reflective blog posts with the hopes of normalizing reflection and increasing resilience.

“That first year can be pretty jarring,” says Megan S. Lemay, M’11, assistant professor of medicine in the Division of Internal Medicine. “It is overwhelming for the best of us. As they face extremely difficult tasks, we are teaching the residents skills in resilience so that they can keep themselves well.”

Diastole, the relaxation phase of the heartbeat, is the perfect name for the blogs, Lemay says.

“If the heart does not take time to relax and then fill up, blood won’t be pumped out,” she says. “In the same way, if you don’t take time to relax and reflect, you have nothing to give.”

Interns have reflected on a variety of assigned topics, including the role model whose traits they want to emulate and the challenges they face in treating patients with mental illness. When Lee and her classmates were asked to reflect on their lowest and highest day in haiku form, she shared her experience with the non-verbal patient by writing,
She won’t look at me.
Only nods and sighs out loud.
Wonder what she feels.

Her haiku along with others from her fellow residents are featured in the latest issue of the Medical Literary Messenger, a web-based journal that strives to promote humanism and the healing arts through prose, poetry and photography.

“Sometimes it’s easier to try to forget a difficult experience,” Lee says. “But to share them, as well as your good ones, is healthy.”

Interns have also written about the embarrassment they feel when they make a mistake, the stresses of long hours and the sadness of losing a patient.

“They are identifying with each other and building empathy,” says Lemay, who is also an associate editor of the Messenger. “When they share their emotions the feedback they are getting is, ‘I didn’t realize anyone else felt that way.’”

The blogs are part of a larger resiliency program that includes monthly meetings and workshops that help interns cope with the demands of residency. Lemay oversees the blogs and meetings that are part of the overall resiliency curriculum created and run by Stephanie Call, M.D. M.S.P.H., program director, and Rebecca Miller, M.D., assistant professor.

“I don’t think people realize that taking the time to reflect on the challenges they face is normal,” Lemay says.

Lemay has been writing and publishing prose since she was a resident. When a patient she had been visiting throughout her first year passed away, she doubted her career choice.

“I wrote about it four months later as part of a workshop, and it lifted this burden from me,” she says. “It was extremely powerful.”

She hopes interns today experience similar benefits.

“I think 20 years ago the attitude was to suck it up,” Lee says. “But today, it’s OK to talk about what you are feeling. It’s great we can focus on our wellness too.”

By Janet Showalter


Medical Education Symposium 2018

List of symposium award recipients

Advances in patient care and science are not the only focus of research and innovation at the VCU School of Medicine. As a center for teaching and learning, the school also promotes work to better understand, enhance and continue improving the education process.

To bring more attention to this work, the school’s second annual Medical Education Symposium, celebrating scholarship and innovation, was held on April 4 in the McGlothlin Medical Education Center. Oral presentations, followed by a reception and poster session, provided an opportunity for medical school faculty and other medical educators on the MCV Campus to showcase and share with colleagues unique projects and practices for education innovation.

The symposium is designed “to promote an increased emphasis on scholarship in medical education,” says Terry Carter, Ed.D., the medical school’s associate dean for professional instruction and faculty development. “It’s a nice opportunity to see the breadth as well as depth of current medical innovation and scholarship at VCU.”

Presentations at the symposium included the use of holographic “enhanced reality” technology to help teach urogynecological surgical procedures, teamwork-building in first-year medical students and leadership-skill development among pediatric residents. Presenters and attendees alike expressed enthusiasm for the symposium as well as for being able to learn about the work of colleagues and to discover potential opportunities for collaboration and new ideas they might bring to their own disciplines and practices.

“This venue is great because it gives us an opportunity to find out what other people are doing here at VCU,” observed Kelly Lockeman, Ph.D., an assistant professor in the School of Medicine who is also director of evaluation and assessment for VCU’s Center for Interprofessional Education and Collaborative Care. She was particularly interested in the many initiatives centered on quality improvement. “So many departments are incorporating these efforts,” she said. “There are a lot of things going on that are striving to make the education more effective and even to figure out what ‘being effective’ means.”

Lauren Wingfield, M.D., a PGY-2 resident in emergency medicine, said the symposium “gives us a chance not only to show off what we are doing, but also to learn about what’s going on elsewhere in the hospital and to be able to incorporate that into our practice in the ER.”

The symposium included six oral presentations and 21 poster presentations selected from among more than 40 submissions. A panel of faculty with expertise in medical education served as judges.

Assistant Professor Nital Appelbaum, Ph.D., received the award for best faculty oral presentation for her talk “Why Residents’ Perceptions of the Clinical Learning Environment Matter.” She discussed how what’s known as the hidden curriculum, or “underlying norms and beliefs of a group that drive behavior” might affect whether residents and students feel supported and safe to express ideas or concerns. In turn, those perceptions might affect the efficacy of the learning environment and, ultimately, patient safety, she said. “We have a duty in medical education to not only ensure our trainees demonstrate competence in their specialty, but also to provide an environment that facilitates both work and learning processes, especially if we are to attain the goal of providing the best care to patients,” noted Appelbaum in her presentation.

The best trainee presentation award went to John Legge, M.D., a PGY-3 resident in adult neurology, whose poster outlined the education series developed in his department to introduce residents to the business and policy dynamics of health care. Traditionally, says Legge, this is information that medical education hasn’t covered. “It is something we have identified in all residency programs, not just neurology, as a weakness, and we are trying to bridge that gap,” he says. “The idea is for you to be able to walk out with more knowledge about business and policy and medicine than what you came in with.”

By Caroline Kettlewell


Honors Day celebrates student achievement and scholarship

During the busy days and years of medical school, Honors Day takes time to shine a light on some of the school’s brightest students and the scholarships that benefit them.

“In the life of a medical school, the opportunity to honor aspiring physicians is a fantastic experience,” says Dean of Medicine Peter F. Buckley, M.D.

The annual spring event traditionally recognizes those students whose outstanding performance has marked them with the distinction of having earned the highest grade in a course or clerkship or as the top student in their class.

Before Honors Day, Class of 1996 alumna Diane DeVita (far right) and her sister, Lynette Freeman (third from right), along with DeVita’s husband, John (far left), and their children, met Dean of Medicine Peter F. Buckley (top right) and the inaugural Freeman-Gayles Memorial Scholarship recipient, the Class of 2017’s Sarah Berg (center).

Before Honors Day, Class of 1996 alumna Diane DeVita (far right) and her sister, Lynette Freeman (third from right), along with DeVita’s husband, John (far left), and their children, met Dean of Medicine Peter F. Buckley (top right) and the inaugural Freeman-Gayles Memorial Scholarship recipient, the Class of 2017’s Sarah Berg (center). Photography: Skip Rowland

The day also serves as the chance to celebrate the dozens of privately endowed scholarships that have been established to benefit medical students. At the 2017 ceremony, the school awarded the Freeman-Gayles Memorial Scholarship for the first time.

Endowed by Class of 1996 alumna Diane DeVita and her sister, Lynette Freeman, the scholarship serves as a tribute to their parents, who died while DeVita was in her second year of medical school on the MCV Campus. While some schools may have required her to take a semester off, VCU allowed her to study from home and take her exams when she returned. It’s in this spirit of compassion that she and her sister hope to ease the financial burden for future students.

DeVita and Freeman, along with DeVita’s husband, John, and their children, attended Honors Day, after first enjoying lunch where they met scholarship’s inaugural recipient, Sarah Berg, who will graduate in May and train in emergency medicine at Barnes-Jewish Hospital in Missouri.

Honors Day also recognizes students who receive specialty awards, such as the four graduating students who produced this year’s top I2CRP capstone scholarly projects. The International/Inner City/Rural Preceptorship is a four-year program for students who declare an interest in and commitment to working with medical underserved populations in urban, rural or international settings.

Among this year’s recipients are Jacqueline Britz, for the project “Strengthening Early Childhood Programming in Underserved Communities in Virginia,” and Yael Tarshish for “Mental Health of Latina Mothers at Hayes E. Willis Health Center.” Both students have benefited from multiple scholarships, including the Aesculapian Scholarship, made possible through donations to the school’s Annual Fund.

The Class of 2019’s Alvin Cho took home first place at the 2017 Medical Student Research Poster Session

The Class of 2019’s Alvin Cho took home first place at the 2017 Medical Student Research Poster Session for his poster “Effect of Gut Microbiome on Morphine Tolerance.”

In addition, Honors Day celebrated the 2017 Medical Student Research Poster Session, held in mid-April with 43 posters on display. The posters described research conducted by students covering a broad spectrum of topics in the basic and clinical sciences.

First place went to the Class of 2019’s Alvin Cho, whose poster “Effect of Gut Microbiome on Morphine Tolerance” highlighted his research over the winter with his mentor Hamid I. Akbarali, Ph.D., professor, Department of Pharmacology and Toxicology.

Other Honors Days awards spotlighted the newest inductees into the Alpha Omega Alpha Honor Society and the Leonard Tow Humanism in Medicine Award winner, the Class of 2017’s Braveen Ragunanthan.

Student Clinician Ceremony
The 2017 event ended with the Student Clinician Ceremony, an annual event previously held in the summer. Sponsored by the Arnold P. Gold Foundation for Humanism in Medicine, the ceremony is designed to provide guidance, information and support to rising third-year medical students as they prepare to begin their clinical rotations.

The transition from classrooms, simulations and research “to being front and center and seeing patients every day” brings on a new sense of responsibility, said Adam Bullock, M.D., FAAP, as he addressed the Class of 2019. The assistant professor is a pediatric emergency medicine physician with Children’s Hospital of Richmond at VCU and the 2017 Leonard Tow Humanism in Medicine Faculty Award recipient.

He encouraged students to listen to each patient’s individual story. “One of the most important questions you can ask is ‘What brings you in tonight? What are you afraid of?’”

Bullock elicited a laugh from the crowd when he joked about the grind of the medical profession and that “there is no ESPN ‘SportsCenter’ Top 10 best intubations of the day.” Instead, he told the students to ask themselves each day, “Did I help someone? Are they feeling better?” and therein will lie their motivation.

Part of the Student Clinician Ceremony also recognized outstanding residents through the Gold Foundation’s Humanism and Excellence in Teaching Award. Current fourth-year students chose five residents who were particularly strong role models for compassionate, relationship-centered care during the students’ third-year rotations.

Craig Kelman, M.D.
Department of Neurosurgery
2011 graduate of VCU School of Medicine
Advice: “Try to see patients in their own world. You are in a unique position to talk with them more than the residents. Get to know them.”

Tu Nguyen, M.D.
Department of Internal Medicine
2014 VCU School of Medicine
Advice: “Nurture your relationships with your family and friends, and find meaning in the relationships you cultivate with patients.”

Valerie Plant, M.D.
Department of Surgery
2012 graduate of VCU School of Medicine
Advice: “Be honest and choose a specialty you will love and enjoy. It will help with the tough times.”

Roxanne Sholevar, M.D.
Department of Psychiatry
Graduate of Sidney Kimmel Medical College at Thomas Jefferson University

Krista Terracina, M.D.
Department of Surgery
2011 graduate of Louisiana State University School of Medicine
Advice: “One night a week, spend 30 minutes with a patient, just talking. And remember the grandmother test – if it doesn’t meet the standard of care you would want for your grandmother (or daughter or other family member), it’s not right.”

By Polly Roberts


Peds ID Fellow Jeff Donowitz helps pinpoint problems, find cures

Peds ID Fellow Jeff Donowitz

Peds ID Fellow Jeff Donowitz recently wrapped up a two-year study that took him half a world away in a search for answers to problems of malnutrition, stunted growth and oral vaccine failure seen in millions of children.

A two-year research effort took Jeff Donowitz, M.D., half a world away in a search for answers to problems of malnutrition, stunted growth and oral vaccine failure seen in millions of children.

Now, armed with fresh data from the study, he’s ready to move forward, continuing his research on how overgrowth of bacteria in the small intestine is damaging the guts of children in low- and middle-income countries.

In 2014, Donowitz, an infectious diseases fellow in VCU’s Department of Pediatrics, was one of just seven pediatricians in the U.S. chosen by the Association of Medical School Pediatric Department Chairs for the Pediatric Scientist Development Program. Over the past two years, he traveled frequently to Dhaka, Bangladesh, seeking to identify a viable cure.

Donowitz’s interest in international public health medicine was ignited by trips to Haiti when he was younger. Later, as he was looking for potential research topics, his interest was piqued by environmental enteropathy, a low-level chronic inflammation in the GI tract that’s found in a large number of children living in unsanitary conditions.

“The effects of environmental enteropathy are very, very broad,” he says. “We have limited understanding of exactly what about it is affecting growth stunting, cognitive delays or oral vaccine failures, so that is partially what we are trying to figure out.”

Peds ID Fellow Jeff Donowitz

A Bangladeshi child reminds Donowitz not to step in the open sewer. Environmental enteropathy is a low-level chronic inflammation in the GI tract that’s found in a large number of children living in unsanitary conditions.

His fellowship afforded him the opportunity to examine the issue under the mentorship of William Petri, M.D., Ph.D., the respected chief of Infectious Diseases and International Health at the University of Virginia. Bangladesh has world-class research facilities, including the International Centre for Diarrhoeal Disease Research, Bangladesh, notes Donowitz.

He hypothesized that small intestine bacterial overgrowth (SIBO) could, in part, explain those problems in poor communities. “When I started, there were only a few studies looking at SIBO in low-income countries, and most of them were just describing that it was there in large numbers. That’s where I got into the field.”

In his two-year fellowship, Donowitz says his hypothesis proved credible. Overgrowth, which was found in one in six children tested, was indeed associated with inflammation in the GI tract.

But other findings surprised him. “I had thought maybe SIBO was related to diarrheal disease but what we showed was that it’s really related to poor sanitation. So what is it about poor sanitation that leads to overgrowth in these children?”

Donowitz has a hypothesis about that, which he is exploring in a new, larger study of 275 Bangladeshi children who he is following from birth to age 2. “We’ll be measuring SIBO at multiple time points.” With that, he hopes to identify opportunities when treatment will be beneficial for the large numbers of children affected by SIBO.

Peds ID Fellow Jeff Donowitz

Armed with his study data, Donowitz is ready to move forward, continuing his research on how overgrowth of bacteria in the small intestine is damaging the guts of children in low- and middle-income countries.

“The nice thing about SIBO is that you can treat it with relatively low-cost antibiotics,” he notes. “But the downside to that is antimicrobial resistance. The idea of giving antibiotics on a large scale to a lot of people is not very attractive.”

Not only is Donowitz advancing knowledge about childhood disease, he’s proved to himself that he can secure funding. That’s important, as this fall he’ll be submitting grant requests to continue his work.

Donowitz has a message to prospective researchers. “I think a lot of times, young, smart people get put off of it because they hear that funding is hard to come by. Don’t be dissuaded by the first person who says there’s no money in it. It’s extremely rewarding.”

By Lisa Crutchfield


“The best year of my life:” Neurosurgery resident conducts brain tumor research in New Zealand

Lisa Feldman, M.D.

Supported by the most prestigious fellowship in neurosurgery, resident Lisa Feldman spent a year doing research in New Zealand.

As a sixth-year neurosurgery resident, Lisa Feldman, M.D., Ph.D., aches for her patients battling aggressive brain tumors.

Despite surgery, chemotherapy and radiation treatments, the average life expectancy for patients diagnosed with glioblastoma multiforme, the most aggressive type of brain tumor, is 15 months.

“We have to do better than that,” she said. “It’s so frustrating. I see so many patients suffering.”

Thanks to a prestigious fellowship and numerous collaboration efforts, Feldman is feeling optimistic about the future. The Chicago native was selected last year for the William P. Van Wagenen Fellowship, which awarded her a $120,000 stipend and $15,000 in research support. She used the funds to travel to New Zealand, where she studied perfluorocarbons as a new oxygen delivery therapy in hopes of reversing the death of healthy cells that results from radiation treatment of brain cancers.

“Our preliminary findings are very exciting,” said Feldman, who just returned to Richmond. “We are discovering that nanoparticles do improve tumor sensitivity to radiation.”

Feldman worked alongside physicians, scientists and researchers at the University of Auckland and the Malaghan Institute of Medical Research in Wellington. She is also collaborating with Washington University in St. Louis and her home Neurosurgery Department on the MCV Campus.

“The year I spent in New Zealand was extraordinary in that I had the opportunity to work with some of the brightest minds in the world,” she said. “It was the best year of my life.”

The teams have landed two more grants from the local government in New Zealand and the University of Otago to replicate their findings. Feldman is hopeful the next step will be clinical trials.

“Now that I’m back, we have weekly Skype calls,” she said. “Collaboration is absolutely crucial. There’s no way we could dream of accomplishing this without working together.”

Lisa Feldman, M.D.

In addition to studying how perfluorocarbons could help patients battling aggressive brain tumors, Feldman also spent time exploring New Zealand and says, “The country is absolutely breathtakingly gorgeous.”

Feldman is the Department of Neurosurgery’s first Van Wagenen Fellowship winner. The fellowship was established by the estate of Van Wagenen, one of the founders and first president of the Harvey Cushing Society, now the American Association of Neurological Surgeons.

“This is a big deal,” said R. Scott Graham, M’92, H’98, director of the Department of Neurosurgery’s residency program. “It’s the most prestigious fellowship to win in neurosurgery.

“Lisa has the perfect personality to get an award like this because she is so collaborative. She’s good at searching out people who have the skills that match her interests. She knows that you can accomplish so much more as a team than on your own.”

Feldman, 38, holds a bachelor’s degree in psychology from McGill University in Montreal. While conducting research for her Ph.D. in neuroscience at Montreal Neurological Institute, she regularly performed brain surgery on lab mice. It wasn’t long before she had an epiphany.

“I realized I really enjoyed operating,” she said. “I enjoyed the procedure. That’s what motivated me to go to medical school. I thought it would be much more fulfilling to help people.”

She earned her medical degree from Rush Medical College in Chicago in 2010 before coming to the MCV Campus for her residency. She is currently completely a three-month rotation at McGuire VA Medical Center, where she is mainly performing spine surgery. She will return to the MCV Campus in September to concentrate on brain surgery.

“That’s where my passion is – coming up with better ways to help my patients,” said Feldman, who will complete her residency in July 2018. “I am so grateful for all the opportunities I’ve had here. I’ve learned so much. It’s a dream come true.”

By Janet Showalter


Walk the Walk 2016

GME Match Map 2016From all over the country: 140 new interns begin training at VCU Health this summer, hailing from 25 different states and 53 different medical schools.

Each summer, academic medical centers around the country welcome a new class of interns into their teaching hospitals. These recent M.D. graduates are embarking on three to seven years of additional training in the specialty of their choice.

From Boston to Tucson to Seattle, 140 new interns have arrived at VCU Health from 25 states.

“We’re really proud of the caliber of this year’s recruits,” said Mary-Alice O’Donnell, Ph.D., associate dean for graduate medical education. “I’ve heard from many program directors who are enthusiastic about the interdisciplinary team spirit and patient focus this group will bring.”

Of the 140 interns, 43 completed their medical degrees at the VCU School of Medicine. But the remaining 97 interns hail from 53 different medical schools. They bring with them certain core competencies along with experiences and expectations that are based on what they’ve learned at more than four dozen medical centers.

GME Match Map 2016“Nationwide, communication failures are the leading cause of medical errors,” Ryan Vega, M.D., H’14, told the interns.

To be sure that they are on the same page in terms of what’s expected at VCU Health, the GME office organizes a three-day orientation called Walk the Walk. It differs from orientation programs at other medical centers where newly arrived interns are often trained in specialty specific programs. Instead, for seven years, O’Donnell has trained new arrivals in interdisciplinary teams.

Highlighting Handoffs
A session this year emphasized how to transfer care and responsibility of a patient to the next shift of caregivers, a process known as the handoff. The session was led by Ryan Vega, M.D., H’14, who completed residency training in internal medicine at VCU in 2014 and serving as the first chief resident for quality and safety at the McGuire VA Medical Center in 2014-15.

“Nationwide, communication failures are the leading cause of medical errors,” Vega told the interns.

Walk the Walk 2016This summer, 140 new interns participated in interdisciplinary orientation program so that everyone is on the same page. One of this year’s sessions tackled a leading cause of medical errors in hospitals across the country: handoffs.

To address the issue, VCU Health has adopted the I-PASS system developed by Boston Children’s Hospital. It’s a guideline for structured communication that uses a mnemonic to help health care providers move through the handoff process. (See chart below.) A 2014 study published in the New England Journal of Medicine reported the system can greatly increase patient safety without significantly burdening existing clinical workflows.

Vega estimates that VCU Health has applied the system more broadly at an institutional level than any other medical center in the country. Seven departments have completed a yearlong training, it’s built into patients’ electronic medical records and this is the second class of interns to train in the process.

“If we’re going to becoming the safest hospital in the nation,” Ryan emphasized, “structured communication is a route to eliminating medical errors.”

I Illness Severity Stable, “Watcher,” Unstable
P Patient Summary Summary statement; events leading up to admission; hospital course; ongoing assessment; plan
A Action List To do list; timeline and ownership
S Situation Awareness & Contingency Planning Know what’s going on; plan for what might happen
S Synthesis by Receiver Receiver summarizes what was heard; asks questions; restates key action/to do items

© 2016 I-PASS Study Group/Children’s Hospital Boston
All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu

By Erin Lucero

Virginia Commonwealth University
VCU Medical Center
School of Medicine
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Updated: 04/29/2016