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Clinical Impact
The present language
states:
(b) Clinician-Educators have
a substantial impact on preexisting educational, clinical, and administrative
practice at this institution. This standard is met when the candidate:
(i)
Ranks among the most distinguished educators or administrators at this
institution. Such cases must
include unambiguous and objective evidence of distinction, and document the
practices that have led to distinction.
and/or
(ii)
Through leadership, has achieved or maintained excellence in a significant
educational program (e.g., a clerkship, residency, or fellowship) or
administrative function (e.g., management of a clinic or multi-physician
practice, clinical laboratory, etc.).
Such cases must include unambiguous and objective evidence of achieving
or maintaining excellence, and document the practices that have led to
excellence.
and/or
(iii)
Has devised and/or implemented significant improvements in educational,
administrative, and/or clinical practices by, for example, curricular
revision, implementation of new programs and administrative practices,
creation of new educational or administrative tools, etc. Such impact should be documented
rigorously by describing in detail the preexisting practice, the revised
practice, and the impact the revisions have had.
Proposals
for promotion on the basis of (i), (ii), and/or (iii) must include written
statements from leading figures – educational, administrative, and/or
clinical, as approprate – in the candidate's field from outside this
institution. These statements
must analyze and evaluate the specific practices that have led to substantial
impact on preexisting educational, clinical, and administrative practice, and
cite the evidence for their conclusions. Great care must be taken to avoid the appearance of
gratitude or reward for faithful service as justification for promotion.
Following
are actual candidate's portions of eforms submitted in successful COAP cases
in which "internal impact" is invoked as a basis for promotion to
Associate Professor CE.
Disclaimer: The following information is drawn from
materials prepared by candidates for promotion to associate professor in the
Clinician-Educator track, and is presented with the candidates'
permission. It is intended to illustrate activities and materials that
might support promotion. In using these materials, please note the
following:
*The Provost (and, in some cases, the President) are the University officers
authorized to approve promotions. All levels of review below these
officers are advisory.
*Only Departments are empowered to propose promotions, and the Divisional
Dean is charged with transmitting such proposals to the Provost or returning
them to the Department.
*The judgment of the Department, Dean, and Provost will
therefore be critical to assessing qualification for promotion.
*Materials considered by the Department, Dean, and Provost will also (and
always) include confidential evaluations obtained from outside the
University. Materials considered by the Provost will include the
confidential evaluations of the Dean and Department, and those considered by
the Dean will include the confidential evaluations of the Department.
*Thus, the following materials are ONLY PART of a complete proposal for
promotion, whereas promotion is based on the ENTIRE proposal.
Therefore, it should not be assumed that a record comparable to that below
will necessarily result in promotion, or that a record not comparable to that
below will fail to result in promotion. The Departmental Chair is
likely to be the best source of advice as to whether promotion is feasible
and, when it is not, what additional activity may result in qualification for
promotion.
*This document has been prepared as a tool for use by assistant professors in
the Division of the Biological Sciences. Other individuals who may find
it informative are Department Chairmen, Section Heads, Committee Chairmen,
senior faculty and potential recruits. Its intent is to help guide
individuals and their departments as they think about promotion to Associate
Professor in the Clinician-Educator track. This document is not
intended to list the elements that every promotion proposal will be expected
to address. The following information is presented for information
purposes only and is not intended to create any contract or agreement, and
its contents are subject to addition, deletion, and change without prior
notice.
IMPACT ON CLINICAL PRACTICE:
a. Pre-existing practice.
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Primary amputation is
the most common treatment for critical limb ischemia. Even if some of these
amputations are prevented by revascularization procedures, the overall
improvement in quality of life and decrease in health care resource utilization
is immense. The predominant pre-existing practice at our institution has
been to either subject these patients with critical limb ischemia to
amputations or to revascularize them with traditional open-surgical
techniques.
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b. Intervention/innovation.
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Introduction of drug-eluting coronary stents, percutaneous
atherectomy devices, and catheter based thrombectomy catheters have made it
possible to attempt these limb-salvage procedures. I am an expert in the
use of such devices and because of my efforts at developing a collaborative
relationship with vascular surgeons, I have led the physicians at
University of Chicago in performing these limb-salvage procedures by
endovascular techniques rather than the riskier open-procedures. In the
last academic year, I performed 25 such procedures and saved many limbs
from potential amputations.
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c. Outcome
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This success of endovascular thrombectomy procedures and
below-the-knee interventions by catheter based treatments has encouraged the
vascular surgeons to perform many of these revascularization procedures
endovascularly rather than by an open surgical technique. In addition,
cardiac surgeons who treat patients with advanced atherosclerosis that
increases morbidity in post-operative patients, prefer to refer patients
with critical limb ischemia to me for endovascular therapies instead of
getting open-surgical techniques by traditional vascular surgeons.
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d. Evidence
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á
Dr Jai Raman,
Director, Adult Cardio-thoracic Surgery, University of Chicago Hospital.
á
Dr
Giancarlo Piano, MD, in Section of Vascular Surgery, University of Chicago.
The impact of this intervention on this cohort of
patients is under study; an approximate estimate of patients saved from an
impending amputation is eight.
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IMPACT ON CLINICAL PRACTICE:
a. Pre-existing practice.
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When I
arrived at The University of Chicago the rodent colonies contained endemic viral
and parasitic infections, which resulted in frequent outbreaks in the
pathogen free animal colonies.
Soon after my arrival, the ARC began the process of cleaning up
these endemically infected colonies and initiated a new quarantine program
for rodents entering campus.
The goal of this project was to make all the rodent colonies free of
the infectious agents which are a concern to research. I was one of the team of ARC
veterinarians which initiated this process between 1998 – 2000,
however before it was fully implemented the other individuals left the
institution. I, therefore,
took over the entire program for elimination of the pathogenic rodent
agents from the colonies.
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b. Intervention/innovation.
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Upon my appointment as the Chief of Rodent Clinical
Services in 2000, I continued the process of cleaning up the rodent
colonies to be free of infectious diseases and began to implement the newly
established rodent quarantine program. The Division also invested a significant amount of money
in housing equipment and facility renovations to make this conversion to a
pathogen free campus possible.
The process of removing infectious agents from the
colony involves frequent microbiological testing of the colonies. We tested the colonies monthly to
find agents as early as possible. When an infectious agent was discovered in
the colony, the colony was quarantined and the investigator contacted to
develop a solution. Quarantine
and rederivation can be very disruptive to investigators research. I adopted a different
approach to dealing with the quarantine and clean up of the colonies than
some of my predecessors. I
believe it is equally important to allow investigators to continue their
research as it is to eliminating the infectious agents. Therefore, my approach to cleaning
up the colonies involved understanding how the ARCÕs efforts to eliminate
the agents would affect the investigators research and, when possible, try
to develop a solution that accomplished both objectives. This involved compromise on the
part of both groups, but resulted in a successful outcome for
everyone. Each problem in the
colony was handled on a case by case basis. This allowed investigators to continue some aspects of
their research, although some aspects of the research had to stop to
contain the agent. This
approach resulted in increased work for the investigators and the ARC
animal technicians through additional procedures to contain the agents in
the room. Leaving the agents
in the room also increased the risk of spread to another room in the
facility, therefore the ARC had to increase infectious disease surveillance
while the infected colony was present. In addition to the increased procedures, there was a
significant cost to this additional work.
In some cases
we were able to relocate the colony to a different location to allow the
investigator to work with the contaminated mice long term. The University also developed
a relationship with the animal facility at Michael Reese Hospital to allow
infected rodents to be housed at this location during the clean up
process. This was originally
designed by my predecessors to only remove mice from University facilities
to accomplish rederivation of the colony. However, I took a less restrictive approach and used this
facility to allow investigators to work with mice from other institutions
that were contaminated. This
allowed these studies to be conducted when no facility was available on the
University campus.
In the past, there was a strict policy prohibiting the
removal of any animals or tissues from quarantine and which prevented
investigator access. Although
these are still our guidelines, at times it is necessary to allow
exceptions to allow the research to be accomplished. This was especially true prior to
the creation of the new Dirty Quarantine Room described below. I have also allowed some research
studies to be conducted in the quarantine facility, allowing investigators
to do research here that otherwise would need to be done at another
institution.
It has been under my direction that the clean up of the
rodent barrier facilities was accomplished and have been maintained free of
the common infectious agents that affect rodents. In addition to obtaining the pathogen free status, we
have also developed several solutions to working within the limitations of
maintaining a pathogen free colony.
A couple of these are described below.
Return Barrier Facility:
A consequence of changing the mouse facilities to
pathogen free barrier facilities was that mice leaving the barrier were
unable to return to their original location. This resulted in several research projects which
required access to equipment outside the animal facilities to be limited to
non-survival projects. To
resolve this problem, I developed the Return Barrier Facility. This allowed investigators to
perform their research procedures outside the barrier facility but also
protected the main barrier facilities from potential outbreaks due to the
mice leaving the animal facility. Initially only a few investigators required the
use of this facility. However, the return facility is now in its third
location due to continued demand. The return barrier facility concept is of great
interest to other lab animal veterinarians and professionals that visit our
facilities.
Dirty Quarantine Room:
A room has recently been created in the quarantine
facility to allow investigators to bring in animals with suspicious or
problematic health status, which prevents them from entering the animal
facilities. This new room will
allow investigators to perform acute studies on the animals that would not
have been allowed in the past.
This will further enhance the flexibility of investigators to
perform animal based research on campus.
The
changes in the clinical rodent program at The University of Chicago have
been of both innovation, as described in the return facility, but also
intervention in cleaning up the rodent colonies on campus, creating the
dirty quarantine room and maintaining a pathogen free campus. The other intervention that was
implemented is the cultural change of working with the investigators more
closely to obtain workable solutions for all parties.
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c. Outcome.
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Animal colonies which are infected with various
infectious agents will introduce significant variables into the animal
research studies. Some of the
microbiologic agents that affect mice will actually create or eliminate
specific research models. This
is especially true of immunology research, in which the immunomodulatory
impact of some mouse pathogens will significantly interfere with research
results. Another impact of
eliminating the endemic pathogens from the animal facilities has been to
ease the movement of mice between collaborating investigators at other
institutions. Most
institutions will not accept rodents which are endemically infected with
pathogens without expensive and timely clean up of the animals.
It has been most important to balance the needs of the
research with the goal of cleaning up the colonies. To accomplish this balance I
developed a productive working relationship with the investigators by
listening to their needs and attempting to accommodate them whenever
possible. From these
discussions, we were able to add some unique solutions to the animal
facilities such as the Return Facility, and Dirty Quarantine Room. These solutions have allowed more
flexibility to the type of research performed at this institution.
The specific
examples and solutions described above are all based in a change in culture
in the Animal Resources Center that I have tried to initiate over the last
few years. This change
is one of accommodation of the needs to the researchers who utilize the facilities. The culture of the ARC didnÕt
always focus on this concept.
We routinely meet with faculty to develop solutions to their
research needs that do not fit into the current animal facilities.
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d. Evidence
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The evidence of the success of creating a pathogen free
campus, and workable solutions to allow investigators to still get their
work accomplished, has been the significant decrease in the number of
disease outbreaks that have occurred since this was accomplished. Most of the adventitious agents
detected in the colonies since the clean up have been due to contaminated
animals shipped from vendors.
The evidence for the success of changes to the ARC that have
allowed greater flexibility for research is difficult to assess but is best
measured by the satisfaction of the faculty who have worked with me over
the last few years. Many of
them have been asked to complete teaching and service evaluations and could
be contacted to attest to this impact. All the faculty who use animals were also sent an
ARC Survey from the DeanÕs Office and the ARC Faculty Advisory Committee
last year, the results are attached and show the majority of respondents
believe the leadership and management (question 3) of the ARC is good with
72% indicating highly positive response. The ARC Survey is included with these
materials.
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IMPACT ON CLINICAL PRACTICE:
a. Pre-existing practice
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Prostate cancer is the most common solid organ tumor in
men over the age of 50. Approximately 230,000 men are diagnosed annually with
nearly 40,000 deaths due to prostate cancer annually. The gold standard for
surgical intervention in the treatment of prostate cancer has been the
radical retropubic prostatectomy. This procedure is associated with
significant morbidity including but not limited to bleeding, incontinence,
sexual dysfunction and a prolonged
recuperative period.
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b. Intervention/innovation
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Developed a minimally invasive program at the University
of Chicago for the treatment of prostate cancer. This initially began with
the development of a program for the administration of radiation seed
implants in 1998. This afforded the patients an out-patient procedure for
treating their cancer with less side effects and quicker recovery. In
February 2003, the robotic prostatectomy program was developed here in
Chicago with the University of Chicago being the pioneering program in
Chicago and the United States.
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c. Outcome
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The University of Chicago has become the leading center
in Chicago in performing the robotic assisted laparoscopic prostatectomy,
performing greater than 1200 cases in the last four years. The number of
prostatectomies performed at UCMC has increased from 150 cases in 2002, to
500 cases in 2006.
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d. Evidence
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This surgical procedure gives the patient a certain
level of comfort in the knowledge that his cancer is completely removed
with less blood loss, increased likelihood for preservation of sexual function
and quicker return to continence. The total recuperative time has been
halved with this procedure, all the while maintaining comparable cancer
control rates when compared to the open surgical procedure. I am the
urologist in the greater Chicago-land area with the largest experience in
robotic prostatectomies having performed nearly 700 cases. I am known
regionally and nationally as one of the premier surgeons performing the
robotically assisted radical prostatectomy.
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IMPACT ON CLINICAL PRACTICE:
a. Pre-existing practice.
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1. Disjointed care for patients admitted with infected
diabetic foot ulcers resulted in low levels of knowledge about and
satisfaction with caring for these patients in our system.
2. Stress ulcer prophylaxis was inappropriately high in
general medicine patients resulting in over prescribing during the hospital
stay and unnecessary continuation of prescriptions upon discharge.
3. The approach to nursing assessment and management of
pain in inpatient general medicine was sub-optimal which was reflected in
lower than desired patient satisfaction scores.
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b. Intervention/innovation.
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1. Led a multi-disciplinary team (general medicine,
infectious disease, orthopedics) development of a care pathway and
educational intervention.
2. Developed a practice based learning educational
session with resident leadership to reduce inappropriate prophylaxis.
3. I co-led an intervention pilot on one of two general
medicine wards (5NE) to standardize a nursing assessment and management
approach for patients with pain, with a particular emphasis on the use of
prn medication. Comparison in
patient self-reported satisfaction with pain management between the pilot
and control ward served as the primary outcome.
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c. Outcome
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1. Significant improvements in comfort and satisfaction
with caring for patients with infected diabetic foot lesions.
2. Significant reductions in inappropriate in-hospital and
at discharge prescriptions for stress ulcer prophylaxis.
3. Preliminary results have just become available and
suggest significant improvement in both average patient self-reported
satisfaction as well as percent of patients rating satisfaction as 5/5.
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d. Evidence
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1. Significant improvement in physiciansÕ knowledge and
comfort with caring for patients with infected diabetic foot lesions. Improved satisfaction with surgical
support among internal medicine physicians caring for patients with infected
diabetic foot lesions. Results
published in Journal of Clinical Outcomes Management.
2. 6 months after intervention, in-hospital
inappropriate usage was reduced from 59% to 33%, p=0.007 and at-discharge
inappropriate usage was reduced from 25% to 7%, p=0.009. Related results presented at
American Thoracic Society, Society of General Internal Medicine, and
Society of Hospital Medicine.
Paper accepted for publication in Journal of General Internal
Medicine.
3. Primary outcome results have just become available
showing that the average satisfaction on intervention ward was 4.795 (1-5
scale) as compared to 4.26 on the control ward. Additionally, 82% of patients on intervention ward rated
their satisfaction as 5/5 while only 60% of patients on the control ward
rated their satisfaction as 5/5.
Statistical analysis and comparison of demographics are
underway. If statistics
support significant improvement, we hope to submit an abstract of these
results; expand the pilot and continue data collection and analysis; and if
results continue to be positive, submit a paper describing the
implementation methods of this intervention. Results accepted for presentation at 2006 Society of
Hospital Medicine Annual Meeting.
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IMPACT ON CLINICAL PRACTICE:
a. Pre-existing practice.
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1. Prior to
my arrival in 2000 there was very little clinical genetics activity. Dr Bill Dobyns had arrived several
years before me and had started genetics clinics which had not been present
in a formalized way in the past.
2. Sotos
syndrome is an autosomal dominant condition of overgrowth and developmental
delays with specific dysmorphic features. The genetic basis of Sotos syndrome was described
several years ago. The
condition is relatively rare and few physicians have significant experience
with the condition making it difficult to accurately recognize and
diagnose.
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b. Intervention/innovation.
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1. I
developed general genetics services on the in-patient and out-patient arena
and have built the service into its current form. The clinic has referrals from primary care doctors,
pediatricians and other sub-specialists. I also developed genetic services in the craniofacial
clinic. I helped to develop
the neurogenetics clinic as described. I developed relationships with two private hospitals in
the community for which we now provide genetic counseling services to their
pre-natal care programs.
2. I
collaborated with a group in Europe to collect patients with Sotos syndrome
with mutations in the gene and deletions of the gene. Clinical information was collected
and collated so that accurate clinical descriptions of the syndrome could
be made. Correlations with
genetic findings allowed further description of the genotype-phenotype
correlation. The mechanism of
deletions was defined and incidence of deletion reported. Finally, I developed a clinical,
scored checklist for Sotos syndrome and defined a score cut off with
correlation to the findings of genetic testing.
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c. Outcome.
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1. Clinical
genetics is now recognized and utilized by many services within the
hospital.
2. The
results of the clinical correlation, genotype-phenotype studies and
deletion mechanism were reported in a total of three manuscripts. These studies provided more detailed
description of the condition to aid clinicians in recognizing the disorder
and being confident in the accuracy of the diagnosis. The mechanism of deletions was
defined. A clinical scored
checklist was developed and was successful in predicting the outcome of
genetic testing. These results
will improve the utilization of the testing and improve the cost utility of
genetic testing for Sotos syndrome.
This should decrease the number of genetic tests ordered on patients
with low risk of having Sotos syndrome or a positive genetic test.
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d. Evidence
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1. Faculty
who could attest to the changes in clinical genetics services would include
Dr Kwong Lee and Dr Bill Meadows of the neonatology division and Dr Joel
Schwab of general pediatrics.
2. The
outcome of all of the studies were accepted for publication in three
different manuscripts (please see list of manuscripts).
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IMPACT ON CLINICAL PRACTICE:
a. Pre-existing practice.
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On the General Medicine wards in the hospital setting there
were gaps in knowledge, education and quality regarding the care of the
hospitalized older medical patient at the U of C particularly in the areas
of medication review, pain assessment, identification of the frail or
vulnerable aging patient, delirium ID/ prevention and hospital discharge.
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b. Intervention/innovation
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The CHAMP faculty development program with my role as
the program director has trained approximately half of the internist
faculty to date. The CHAMP program has an evaluation scheme that not only
looks at impact on education and teaching but links CHAMP course objectives
to clinical care outcomes for the vulnerable or frail older hospitalized
patient at the U of C through an ongoing hospitalistÕs research program
lead by Dr. Meltzer.
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c. Outcome
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The narrowing the gaps in knowledge on care of the aging medical
patient appear to have effect on the actual care the aging hospitalized U
of C medical patient is receiving specifically with regard to discharge.
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d. Evidence.
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Preliminary data suggests that patients cared for by
medicine attendings who complete the CHAMP course are less likely to die
during hospitalization vs. patients cared for by non-CHAMP attendings. This survival effect is seen in
older patients.
Patients cared for by attendings who complete the CHAMP
course are less likely to die during hospitalization vs. patients cared for
by the attendings before they participated in the CHAMP course.
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IMPACT ON CLINICAL PRACTICE:
a. Pre-existing practice.
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In 2005 the University of Chicago took over as
the team physicians and hospital for the Chicago BlackhawkÕs National
Hockey League team. The
section of general internal medicine had not been involved in the care of a
professional sports team prior to that. My goal as the lead internist was to prevent loss of
game time for a player with a medical illness (a non-orthopedic or non-game
related injury).
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b. Intervention/innovation.
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I surmised that a likely source for medical illness would be from
infectious disease. So I had
the medical director and lead infection control practitioner from the
University of Chicago Hospitals tour the training room and locker room at
the United Center to give their recommendations. We implemented their plan, including an immunization
program, strict rules on preventing the sharing of towels, razors, and
shower shoes, and installation of alcohol based cleanser dispensers.
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c. Outcome.
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Limited games were lost to medical illness in
2005-6. (Most games lost were
due to orthopedic issues and game-time injuries.) Given we were not caring for the team in prior years, no
specific data comparisons can be made.
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d. Evidence
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The Head Athletic Trainer (Mike Gapski), Assistant Athletic Trainer
(Jeff Thomas), and Team Physician (Dr. Michael Terry in the Department of
Surgery, section of Orthopaedic Surgery) can be contacted for evidence.
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IMPACT ON CLINICAL PRACTICE:
a. Pre-existing practice. Describe the
situation before your impact.
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Due to payment issues, it is often difficult for
patients who would benefit from neurocognitive evaluation to receive these
services.
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b. Intervention/innovation. Describe what you
did to change the pre-existing situation.
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I have co-developed programs that foster greater use of
screenings, conducted during or in tandem with clinic visits in DBP or
Pediatric Neurology, to provide needed evaluations and recommendations for educational
programming at no to minimal cost.
These programs rely on the use of trainees under supervision to
maximize cost efficiency.
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c. Outcome
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As discussed in the training innovations section, ongoing
investigation of the success of this project is taking place.
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d. Evidence
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Michael Msall, M.D. and James Tonsgard, M.D. are faculty
involved in this project, who can attest to its success and need.
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IMPACT ON CLINICAL PRACTICE:
a. Pre-existing practice.
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Imaging-guided radiofrequency ablation of
musculoskeletal tumors was not offered in the Department of Radiology at
the University of Chicago.
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b. Intervention/innovation.
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I researched the procedure, which had been performed at
other institutions. I
subsequently obtained the necessary equipment and performed radiofrequency
ablation of osteoid osteomas (benign but painful bone tumors) in several
patients.
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c. Outcome.
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The section of Musculoskeletal Radiology now performs
several ablations per year.
Although the vast majority of ablations are performed on patients
with osteoid osteoma, we have also used the procedure to successfully treat
patients with eosinophilic granuloma of bone as well as patients with
painful bone metastases refractory to other treatment.
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d. Evidence
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CT-guided radiofrequency ablation is now the treatment
of choice for patients with osteoid osteoma at the University of Chicago.
The orthopaedic oncologists here now refer such patients to the
Musculoskeletal Radiology Section rather than performing surgery in most
cases. Most patients do not
require hospitalization following the procedure and obtain rapid
symptomatic relief. Our
success rate has been greater than 90% for permanent relief of pain
following only one ablation.
Dr. Terrance Peabody of the Department of Orthopaedic Surgery can
attest to the beneficial impact of this procedure.
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IMPACT ON CLINICAL PRACTICE:
a. Pre-existing practice. Describe the
situation before your impact.
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1. No local regional tumor therapy
2. No VIR clinic and inpatient service
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b. Intervention/innovation. Describe what
you did to change the pre-existing situation.
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1. Provide local regional cancer therapy, including
chemoembolization and ablative therapy
2. Assisted in development of VIR clinic and inpatient
service
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c. Outcome. Describe the impact of your
intervention or innovation on the pre-existing situation
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1. Local regional cancer therapy has complemented other
types of cancer treatments at our institution. This has enhanced patient care in general.
2. The presence of VIR clinic and inpatient service has
enhanced patient care and house staff education.
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d. Evidence
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1.Local regional cancer therapy attracts many patients
to the hospital, with me as the primary contact. In addition, physicians from other services such as
hepatology and oncology have referred their patients for local regional
therapy.
2. As demonstrated recently in our exhibit in The
University of Chicago 2006 Quality Fair (entitled: Clinical Impact of
Routing Physician Rounds in VIR Patients), the inpatient service has had a
positive impact on patient care.
The VIR clinic has also improved patient care and house staff
education. We have a quality
improvement project currently on-going regarding VIR clinic visit impact on
patientÕs care and satisfaction.
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