internal medicine

2 O 1 1

a n n u a l r e po rt Table o f Co ntents

Chair’s Report 2

Clinical Programs 4

Faculty Affairs 6

Veterans Affairs 8

Basic & Translational Research 10

Clinical Research 12

Graduate Medical Education 14

Patient Care 20

Research 38

Education 56

Outreach 62

Department Updates 73 Chair’s Repo rt John Carethers, MD Chair

CONTINUED RECOGNITION When U.S. News & World Report recently released their rankings of medical schools and medical school specialties, the U-M Department of Internal Medicine was ranked 6th overall nationally, tying our rank for last year, and a repeat of our highest rank in more than 10 years. U-M’s Medical School tied for 10th overall for research medical schools, and 8th overall for primary care medical schools. This recognition by our peers and others is a testament to our efforts to make U-M the best place for education and training, for clinical care, and for research.

This past year, 2011, was no exception. Some of our most notable efforts included:

MAKING U-M A DESTINATION leadership and extensive research efforts related to Our 2011 annual report’s theme is “Destination Internal metabolic diseases such as obesity (page 40). Medicine.” I wanted to feature our department’s participation in numerous Destination Programs, or RESEARCH GROWTH Centers of Excellence, that are being highlighted by Our research funding and efforts are still going the U-M Health System. These amazing multi- strong. Some of our research groups have moved or disciplinary programs are bringing the best of U-M’s are planning to move to U-M’s North Campus research and clinical care expertise together to create Research Complex to take advantage of NCRC’s the ideal patient experience (page 22). new facilities and their many advantages (page 50).

ADDRESSING NATIONAL EPIDEMICS BUILDING A STRONG FOUNDATION Two stories in this year’s report focus on how our Internal Medicine continues to play a vital part in department is contributing to groundbreaking work cultivating the next generation of clinicians and addressing health issues that are contributing to researchers through our extensive role in teaching at major health problems throughout the U.S. the U-M Medical School (page 58) and in our training population. One describes our work with U-M’s Sleep of 280 residents and fellows (page 14). Disorders Center (page 31) and the other details our

2 2011 Internal Medicine Annual Report PIONEERING ACOs HONORING FACULTY The Department of Internal Medicine Two Internal Medicine faculty Caroline Blaum, MD, Our department is pleased to announce that the is healthy, and continues to grow in and David Spahlinger, MD, have been dedicated to Laurence H. Baker Collegiate Professorship in its missions of research, education, exploring how Accountable Care Organizations Cancer Developmental Therapeutics in the Division of and clinical care. Our high national (ACOs) can save money while improving patient care Hematology/Oncology has been established in rankings speak volumes about the through demonstration projects at U-M. Their efforts recognition of Dr. Baker’s impressive contributions to great work that goes on here every have been so successful that U-M has been chosen medical oncology and his leadership in clinical cancer day. As “leaders and best,” our as the site of the Centers for Medicare & Medicaid research, patient care, and education at U-M (page department is setting a national Services Innovation Center’s Pioneer ACO Model 76). After four decades of extraordinary service to U-M trend by being at the forefront of (page 36). and the Division of Gastroenterology, Timothy T. innovation of medicine in everything Nostrant, MD, retired from active practice to join his that we do. Many of the stories in NEW APPOINTMENTS family in South Carolina. The department hosted a this report help illustrate how we’re Raymond Yung, MB, ChB, was appointed as Chief two-day event last fall to celebrate his career, making that possible. of the Division of Geriatric and Palliative Medicine and achievements, and many contributions at U-M (page Co-Director of the Geriatrics Center on Nov. 1, 2011. 77). He succeeds Jeffrey B. Halter, MD, who served as Chief of the Division of Geriatric Medicine since its A FEW FAREWELLS inception in 1984 and remains Director of the U-M Our department sadly lost two outstanding faculty Geriatrics Center (page 74). The Division of members this past year. Giles G. Bole, an emeritus Rheumatology announced the appointment of faculty and former Dean of the U-M Medical School Dinesh Khanna, MD, MS, as Director of the who specialized in arthritis research and rheuma- Scleroderma Program in July 2011. Khanna is tology, passed away on June 8, 2011. Galen B. Associate Professor of Medicine and Marvin and Toews, MD, FACP, a pioneering lung researcher who Betty Danto Research Professor (page 75). led our Division of Pulmonary and Critical Care Medicine for more than 20 years, passed away Oct. 12, 2011. They both contributed significantly to our department and will be dearly missed (page 78).

2011 Internal Medicine Annual Report 3 Clinical Pro grams Timothy J. Laing, MD Senior Associate Chair for Clinical Programs

fter several years of major growth our clinical programs remained relatively stable in Health System’s newest health center will A 2011. The amount of ambulatory care services provided dropped slightly while our also offer a new musculoskeletal program specialty care services both on- and off-site continued to grow. While our outpatient facilities combining the specialties of rheumatology, in Ann Arbor (Briarwood and Domino’s Farms), Livonia, and Brighton continue to perform orthopedic surgery, and physical medicine; well, there are new efforts to establish facilities in the Northville area. In addition to this, there eye care; radiology services; an infusion for are several other plans underway that will help us meet our patients’ growing needs and cancer and non-cancer treatment; and a improve their care experience. medical procedure unit.

NORTHVILLE EXPANSION center in Northville Township, near our TAUBMAN IMPROVEMENTS The U-M Health System is existing Livonia Center for Specialty Care. When the new C.S. Mott Children’s Hospital expanding its primary and and Von Voigtlander Women’s Hospital specialty patient care in The new facility will include 100,000 square opened this past December 2011, outpatient Metro Detroit with the feet of clinical and diagnostic space clinics for women, newborns, and children construction of a new dedicated to caring for adults and children. In moved there—opening up nearly 30,000 $39 million health addition to primary and specialty care, the square feet of space in the Taubman Center.

4 2011 Internal Medicine Annual Report The U-M Health System is investing $20.5 As part of this effort, there are plans to clinical focus areas involve Internal Medicine. higher quality care, while reducing growth in million to renovate, reorganize, and revitalize update and redesign 27,500 square feet on They include transplant, critical care expenditures through enhanced care this space. the third floor where many clinics run by the medicine, digestive diseases, cardiovascular coordination. Caroline Blaum, MD, Professor Department of Internal Medicine will be medicine, and oncology. of Internal Medicine and Geriatrics will serve The south end of the first floor will be renovated to improve the patient experience as the Medical Director of the U-M/IHA converted to a multidisciplinary Transplant and the efficiency of clinic operations. This PIONEER MODEL Pioneer ACO (page 36). Center clinic by the end of summer 2013. includes areas for gastroenterology, general It was also announced in 2011 that U-M will This will provide one-stop access to medicine, pulmonary medicine, nephrology, participate in the Pioneer Accountable Care It is through these many efforts to specialized care for patients who are waiting infectious diseases and overseas travel, Organization (ACO) model, in partnership with grow, improve, collaborate, and for or have received an organ transplant at medical genetics, and rheumatology. IHA Health Services Corporation. The Pioneer innovate that the U-M Department of UMHS. Also new will be an outpatient ACO Model is sponsored by the Centers for Internal Medicine continues to infusion area. This will be the third such clinic STRATEGIC PLAN Medicare & Medicaid Services (CMS) provide some of the best patient opened by UMHS to help meet rising The Health System released the core of the Innovation Center. U-M and IHA will work with care and clinical programs in the demand for such care. UMHS Strategic Plan and five of the seven CMS to provide Medicare beneficiaries with state and the nation.

2011 Internal Medicine Annual Report 5 Faculty Affairs Richard H. Simon, MD Associate Chair for Faculty Affairs

he Department of Internal Medicine has realized phenomenal growth over the past four academic progress and a general T academic years. We continue to increase the size of our clinical faculty while our research Performance Review Committee appraises faculty numbers are stable. The chart at right breaks down that growth by year and by faculty all aspects of their professional activities. To type. In total, the department has added 97 positions during this period. assist the faculty in improving their professional abilities, the Department has ADVANCING DIVERSE through initiatives that develop strategies to been developing leadership training PERSPECTIVES seek out and recruit the best faculty programs that among other areas The diversity of the faculty within the candidates from all demographic groups. emphasizes improving communication skills. Department of Internal Medicine has been We have been strongly supporting the general slowly expanding. The number of women DEVELOPING CAREERS efforts of the Medical School that launched a and under-represented minorities in our The Department continues to utilize peer new faculty career development website this higher academic ranks have been review committees to deliver constructive past year. This is just the first component of a increasing gradually. The effort to criticism to the faculty. A Promotions comprehensive faculty career development increase diversity continues Committee assesses faculty members’ program currently being created. The site

Number of Faculty Members by Track and Year

559 585 631 656

238 241 262 268

80 76 93 89

241 268 276 299

2008 2009 2010 2011 Clinical Instructional Research

6 2011 Internal Medicine Annual Report includes resources to help faculty with teaching, professional writing, acquiring research funding, and gaining prominence in their respective fields. There are plans to assemble networking groups so faculty can share experiences and advice with colleagues who hold similar interests and aspirations. Leadership development workshops are being established in partnership with the U-M Ross School of Business.

BUILDING DESTINATIONS This year, our annual report is highlighting the U-M Destination Programs (page 22). The core of these efforts relies heavily on the Department’s high-quality faculty who are a major driving force behind these programs, having laid the groundwork upon which they are built. It is the talents, ideas, and dedication of our faculty that are bringing these programs to life by linking cutting-edge research to improving patient care.

2011 Internal Medicine Annual Report 7 veterans affairs Richard H. Moseley, MD Chief, Medical Service, VA Ann Arbor Healthcare System; Senior Associate Chair for VA Programs

he VA Ann Arbor Healthcare System continued to experience a significant increase in an academic setting. Preliminary results from T both outpatient and inpatient activity in 2011. There was a four percent increase in total this collaboration show decreased unique patients, a five percent increase in outpatient visits, and an over three percent rise in readmission rates, shorter room turn-over the number of patient admissions. Through several ongoing initiatives and efforts, we’ve been time, improved prevention of catheter- able to keep our readmission rates steady, decrease length of stay, and continue to improve the associated urinary tract infections, and patient-care experience this past year. improved communication between physicians and nurses. As a result of this FACILITY IMPROVEMENTS unit of eight beds opening in the summer of preliminary success, the HOPE initiative was From a clinical standpoint, we have been 2012. Construction has started on the new asked to provide data to the Office of making many improvements to our facilities. 28-bed unit that is being added on our sixth Systems Redesign for a presentation by We were even joined by Michigan Governor floor. It is slated to open in early 2013. Robert Petzel, MD, VHA Under Secretary for Rick Snyder at the opening of our new Health, to Congress in April 2011. chemotherapy infusion center in the fall of INITIATIVES 2011. This $763,000 project, funded by HOPE Initiative SCAN-ECHO Initiative the American Recovery and Sanjay Saint, MD, MPH, Associate Chief Specialty Care Access Network - Extension Reinvestment Act of 2009, and Professor in the Division of General of Community Healthcare Outcomes features 16 treatment chairs Medicine, has been working with Eric (SCAN-ECHO) is a specialty care and a vast amount of Young, MD, VAAAHS Chief of Staff, to lead transformative initiative from the Office of improvements and the Hospital Outcomes Program of Specialty Care Services, Department of amenities for our Excellence (HOPE) Initiative, which is funded Veterans Affairs. Through this initiative, the patients and their by a Systems Improvement Capability Grant Ann Arbor VA Liver Clinic, directed by Grace families. Steps are from the VHA Office of Systems Redesign. Su, MD, Associate Professor in the Division also being taken to The HOPE initiative aims to create a stellar of Gastroenterology, is exploring innovative improve the situation inpatient service that could eventually new ways to provide state-of-the-art care for for short-term stays become a national and international model veterans with liver disease. Using with an observation for how inpatient care should be provided in videoconferencing, SCAN-ECHO providers

8 2011 Internal Medicine Annual Report can evaluate and treat veterans in rural areas and Programming of Pancreas with chronic liver diseases without the cost Development.” The project will study the and inconvenience of the patient traveling to processes by which certain conditions in the the VA facility. womb increase the potential for the fetus to develop glucose intolerance and type 2 NEW FACULTY diabetes during adult life. Although a primary William (Rick) Weitzel, MD, a Professor in developmental problem with beta cells has the Division of Nephrology recently joined the been described in the research literature, the VA faculty as a physician and a researcher. overall in utero process for the increased His clinical interests include end stage renal susceptibility to diabetes is not yet well disease and vascular access for dialysis. He understood. conducts research in many areas of medical device development for application in As the VAAAHS continues to evolve patients with renal and vascular diseases. to meet the changing health care needs of veterans today, our RESEARCH NEWS dedicated faculty continue to provide Ernesto Bernal-Mizrachi, MD, an expert care and develop exciting Associate Professor in the Division of new ideas that will make a difference Metabolism, Endocrinology & Diabetes and well into the future. the Larry D. Soderquist Professor, recently received a research grant to support a shared effort between U-M and the VA. He has secured more than $1.3 million in funding from the National Institute of Diabetes and Digestive and Kidney Diseases for a four-year project titled “Nutrient Signals

2011 Internal Medicine Annual Report 9 Basic and Translational Research Programs Benjamin L. Margolis, MD Associate Chair for Basic and Translational Research

hile the current funding forecast remains stable, there are many developments within the industry, foundations, and other federal and W health system, the medical school, and our department, that continue to promote basic state agencies, the school received $490.5 and translational research excellence that gets U-M recognized. million in fiscal year 2011. Those dollars fund U-M research projects on everything from NCRC OPPORTUNITIES some research programs to the NCRC. Our stem cells and genetics to specific diseases They include the continued development of first group from the cardiovascular center such as cancer, diabetes, heart disease, programming at the new North Campus moved there in October 2011 (see story on children’s health, depression, and a broad Research Complex (NCRC). Its high-tech page 50). range of rare disorders. Department of laboratory and research spaces are providing Internal Medicine researchers are well a wonderful opportunity to expand our FEDERAL FUNDING represented among this group. basic and translational research Federal funding also remains strong. programs. Having access to this Research at the U-M Medical School brought DIABETES RESEARCH valuable asset will also be a hundreds of millions of dollars into the state One of the newest large federally funded tremendous recruitment of Michigan in 2011. The school ranked sixth projects is a $3.5 million effort to study how tool as we add among all medical schools in total funding diabetes disrupts the basic function of programs that attract from the National Institutes of Heath and tissues in many areas of the body that is led even more talented second among medical schools affiliated with by kidney specialist Frank C. Brosius, MD, scientists to U-M. public universities. This is U-M’s fourth Chief of the Division of Nephrology (see page Due to restricted consecutive year in the top 10. 40). Just as diabetes impacts several space on our main systems of the body, the U-M research team campus, we have U-M medical researchers were awarded represents a varied group of experts. already started to $319.7 million in NIH funding in federal fiscal Brosius, along with diabetes and obesity actively relocate year 2011. From all sources, including specialist Charles Burant, MD, PhD;

10 2011 Internal Medicine Annual Report neurologist Eva L. Feldman, MD, PhD; ophthalmologist Thomas W. Gardner, MD, MS, of U-M’s Kellogg Eye Center and Assistant Professor of Internal Medicine Subramaniam Pennathur, MBBS, will lead the consortium of investigators.

Their study is using the infrastructure of the Michigan Metabolomics and Obesity Center. This center has developed technology for assessing the utilization of different metabolites by tissues in animals and in humans, which may be the basis for the development of complications of diabetes.

As you can see from some of the events of the past year, Internal Medicine’s basic and translational research programs are continuing to grow and flourish. We are hopeful that these developments will allow our faculty to make scientific breakthroughs that can truly transform and improve patient care.

2011 Internal Medicine Annual Report 11 Clinical Research Programs Anna S. F. Lok, MBBS, MD Associate Chair for Clinical Research

here were many exciting developments in clinical research for the Department of Internal REVIVE-IT STUDY T Medicine on both a global and local level this past year. The U-M Cardiovascular Center and the University of Pittsburgh were awarded $13.3 MAKING PROGRESS IN PEKING provided us with a chance to meet with our million by the National Heart, Lung, and Blood In September 2011, James O. Chinese partners. We all gained a better Institute and HeartWare, a maker of left Woolliscroft, MD, Dean of the U-M Medical understanding of the facilities, workflow, and ventricular assist devices, to conduct a clinical School led a delegation of Medical School culture at our collaborating sites. There is study comparing whether patients with heart researchers on a trip to Peking University tremendous enthusiasm and energy around failure less advanced than that of current Health Science Center (PUHSC) in Beijing, the collaboration. I personally came away LVAD recipients and ineligible for a heart China, for a symposium celebrating the with great confidence that our project will transplant do better with implanted devices one-year anniversary of the schools’ work, and that we can rely on our Peking than with current medical therapy. Joint Institute for Translational and University colleagues to give it their best Clinical Research. Researchers effort. Given that PUHSC has about 10 REVIVE-IT principal investigators from U-M visited laboratories, made patients for every one of ours, there is include Keith Aaronson, MD, MS, Medical progress on established tremendous potential to advance clinical Director of the Heart Transplant Program and projects, and discussed research through this partnership. Center for Circulatory Support; and Francis opportunities for the A. Pagani, MD, PhD, Surgical Director of future. In addition to investigators from the Joint U-M’s Heart Transplant Program and the Institute projects, the University of Michigan Center for Circulatory Support. This exciting For Department of Internal team was joined by faculty from the Medical pilot study will include 100 patients from Medicine researchers already School, Dental School, School of Nursing, selected hospitals across the United States, engaged in Joint Institute and School of Public Health, who are including U-M and Pittsburgh. projects focused on heart, interested in establishing collaborations with liver, and lung disease, this was a colleagues at PUHSC. CLINICAL RESEARCH SUPPORT chance to move them forward. We continued to provide guidance and The three-day symposium improve our clinical research support systems

12 2011 Internal Medicine Annual Report in 2011. Many of our clinical research The Department of Internal Medicine coordinators and technicians expressed a began many promising projects and need for more formal training and a systematic helpful programs during 2011. We orientation. We started a Study Coordinator hope that these efforts will allow us Network, which now has more than 100 to continue to grow clinical research members that meet at annual luncheons and at U-M, provide and evaluate new have quarterly forums on focused topics to treatments, and remain leaders in provide training for new coordinators or new patient care. research policies and to share best practices. A study coordinator committee that meets monthly was also established.

We also continue to provide Internal Medicine faculty with proper training and resources so they can efficiently conduct research studies while remaining compliant with changing rules and regulations and protecting our patients. Through our partnership with the Michigan Institute for Clinical & Health Research, we’ve been providing new faculty orientations that give an overview of the responsibilities of principal investigators and the many resources at U-M. We also work closely with them on providing supplemental funding for faculty who successfully secure pilot grants. REVIVE-IT principal investigators Keith Aaronson, MD, and Francis S. Pagani, MD, PhD, with Heartware’s implantable left ventricular assist device, a device to be used in the early 2011 Internal Medicine Annual Report treatment of heart failure. 13 Graduate Medical Education John Del Valle, MD Senior Associate Chair, Graduate Medical Education

his year was marked by our continued growth, pursuit of excellence, and adjustment to new MD; Sophia Califano, MD; Anneliese T changes. Flynn, MD; and Javier Valle, MD. In the Medicine-Pediatrics program, the Chief INCOMING RESIDENTS graduates for the Physician Scientist track. Resident is David Stewart, MD. These The number, diversity, and caliber of our Three of the incoming interns are with us for residents were selected based on their residency candidates continues to climb. The one preliminary year of training before joining outstanding performance during their Internal Medicine Residency Program the Neurology residency program and eight residency period and strong commitment to welcomed 53 incoming interns in June 2011, are members of the combined Medicine- their respective programs. including 13 graduates of the U-M Medical Pediatrics program, directed by Michael School along with other top tier medical Lukela, MD. NEW PROGRAM DIRECTORS schools. Of this group, 32 percent are Our residency program remains one of the newly elected members of the This select group came from more than top programs in the country, thanks to the Alpha Omega Alpha Honor 2,700 applicants—an increase from years expert guidance of our program directors, Medical Society and 16 past; of which, approximately 480 medicine including two recently named ones, to individuals have and medicine-pediatric candidates enhance and refine our educational offerings. earned additional interviewed with our faculty and program advance degrees. leadership from November 2010 through Anna Booher, MD, has been appointed to The program January 2011. the Internal Medicine Residency Program as also recruited Assistant Program Director for Career six outstanding CHIEF MEDICAL RESIDENTS Development. She completed her residency MD, PhD Every year the Department of Internal training here at the University of Michigan, Medicine and Medicine-Pediatrics Residency including a year as a chief resident, and is Programs assign new Chief Medical now a member of the Cardiology Faculty. Her Residents to an administrative role in their clinical interests include echocardiography, respective programs. For 2011, the CMRs general cardiology, and aortic disease. Dr. for Internal Medicine are Timothy Bodnar, Booher will be working with our residents on

14 2011 Internal Medicine Annual Report career development through mentoring, Physician-Scientist Program. We welcome 2011 Residents/Clinical Fellows retreats, and other educational activities. In Subramaniam Pennathur, MBBS, as the addition, she will assist with resident advising new Director for both the fellowship and the Allergy 4 and recruitment. program. Cardiology (Core) 20 Cardiology EP 4 Adam Tremblay, MD, has increased his ACGME CHANGES Cardiology Interventional 3 involvement with the residency program to Our program instituted the Accreditation MEND 6 now serve as the Associate Program Director Council on Graduate Medical Education’s for Outpatient Programs. He completed his major duty hour change in July 2011. This Internal Medicine CORE 130 residency training here at the University of has led to many changes in our program Med/Peds 33 Michigan and is currently a member of the structure. Everyone has worked extremely GI 21 General Medicine faculty. He has been hard to adjust to the changes. As we finish Geriatrics 6 working with the training program for a few our first year of this new approach, we Hospice/Palliative Care 3 years to coordinate the medicine services at continue to evaluate its impact and make HemOnc 18 the VA hospital and will continue to do so. Dr. refinements as needed to our call structure Tremblay will work with the training program and teaching methods. Infectious Diseases 4 to facilitate direction of the resident primary Nephrology 8 care clinical experience through our on-site, Pulmonary 12 VA and community-based general medicine Rheumatology 8 clinics. He will also be involved with resident advising and recruitment. Total Residents/Fellows: 280

NEW LEADERSHIP I would also like to thank James Beck, MD, for his many contributions as the Director of the Internal Medicine Fellowship and the

2011 Internal Medicine Annual Report 15 Department of Internal Medicine Division Chiefs

Front row (left to right): Peter Arvan, MD, PhD (Metabolism, Endocrinology & Diabetes); Frank Brosius III, MD (Nephrology); John Carethers, MD (Chair of Internal Medicine); David Pinsky, MD (Cardiovascular Medicine); and Powel Kazanjian, MD (Infectious Diseases). Back row (left to right): Chung Owyang, MD (Gastroenterology); Raymond Yung, MB, ChB (Geriatric & Palliative Medicine); David Fox, MD (Rheumatology); Theodore Standiford, MD (Pulmonary & Critical Care Medicine); Kathleen Cooney, MD (Hematology & Oncology); Laurence McMahon, Jr., MD, MPH (General Medicine); Eric Fearon, MD, PhD (Molecular Medicine & Genetics). Not shown: James Baker, Jr., MD (Allergy & Clinical Immunology)

16 2011 Internal Medicine Annual Report Department of Internal Medicine Associate Chairs

(left to right): Benjamin L. Margolis, MD (Basic & Translational Research); Timothy J. Laing, MD (Clinical Programs); Cyril Grum, MD (Undergraduate Medical Education); John Del Valle, MD (Graduate Medical Education); John Carethers, MD (Chair of Internal Medicine); Richard H. Simon, MD (Faculty Affairs); Richard H. Moseley, MD (VA Programs); Anna S. F. Lok, MBBS, MD (Clinical Research); and Musty Habhab (Department Administrator)

2011 Internal Medicine Annual Report 17 Department of Internal Medicine Chief Medical Residents

John Carethers, MD, Chair of Internal Medicine (center) with Chief Medical Residents (l to r): Anneliese Flynn, MD; Javier Valle, MD; Timothy Bodnar, MD; and Sophia Califuno, MD

18 2011 Internal Medicine Annual Report 2011 DEPARTMENT OF INTERNAL MEDICINE AWARDS

The Dr. Jacob P. Deerhake The John G. Frohna Award for The Chairman’s Award for Community Service Award Outstanding Teaching in Medicine- Outstanding Service to the Catherine S. Bonham, MD Pediatrics Department Fausta A. Ditah, MD Namita Sachdev, MD Kathleen A. Cooney, MD

The H. Marvin Pollard Award for The Jerome W. Conn Award for The Richard Judge Award for Outstanding Teaching of Residents Excellence in Research Excellence in Medical Student Award Thomas Duen-Shyr Wang, MD, PhD Teaching Theodore J. Iwashyna, PhD, MD Mary Kleaveland, MD, MPH The Paul De Kruif Lifetime The Excellence in Continuity General Achievement Award Special Recognition for Contributions Internal Medicine Teaching Award Galen Toews, MD to the Medical Student Teaching Barbara Soyster, MD Program award Seetha Monrad, MD

2011 Internal Medicine Annual Report 19 patient care DESTINATION: MICHIGAN How Internal Medicine Is Helping to Put UMHS on the Map

ny patient faced with a serious disease or condition would want access to top specialists complexity of the conditions served, each A in the field and to the most advanced treatment options available. While both of these clinic is staffed by a team of specialists from options have always been available at Michigan, the University of Michigan Health System all areas related to the disease that work (UMHS) has taken this idea to heart and stepped it up a notch with the concept of Destination together to diagnose and provide the best Programs. Internally at U-M, the term Destination Programs is being used to describe a group of treatment plan possible for the individual multidisciplinary clinics that are serving as models for exceptional care delivery. To the world at patient all in one location—and, in some large, they represent the very best of what UMHS has to offer: Faculty experts providing cases, all in the same day. multispecialty care through innovative clinical programs and cutting-edge research—all focused on providing the best patient care possible. For instance, U-M’s Multidisciplinary Aortic Program serves patients with aortic diseases The first cohort of seven Destination COORDINATED, MULTISPECIALTY including aneurysms, dissection, and Programs was selected and launched PATIENT CARE stenosis. Anna Booher, MD, an Assistant in September 2008. Through In order to become a true destination, UMHS Professor in the Division of Cardiovascular 2011, the list has grown to 19 has made a system-wide commitment to Medicine, who provides care for the programs, 12 of which creating the ideal patient experience. As diagnosis and management of non-surgical involve the leadership or models of this effort, the Destination Programs cases in the program explains, “If any of my participation of provide patient care representatives to help patients do require surgery, it’s a seamless Department of Internal organize the flow of patient activities. They process. They have access to both excellent Medicine faculty (see work directly with patients and coordinate surgeons and cardiologists for longer term highlight box on schedules with many departments and care and follow up. We all work together as page 28). services to ensure each patient receives the their team. The program brings together care needed during their time in Ann Arbor. specialists from cardiac surgery, They also help with accommodations and cardiovascular medicine, hypertension, travel planning if needed. vascular surgery, and vascular/interventional radiology that work together to formulate a This streamlined patient experience is also, in comprehensive plan for each patient, which part, made possible by the structure of the may include an intervention, surgery, or a multidisciplinary clinics. Due to the medical approach.”

22 2011 Internal Medicine Annual Report The Multidisciplinary Interstitial (Fibrotic) “We’ve been doing this for more than 20 Lung Disease (ILD) Program, co-directed by years now and have established the standard Professor Fernando J. of care for diagnosis in these Anna Bo Martinez, MD, MS, and ohe disorders used globally. As r, M Associate Professor D our clinic has grown and Kevin R. Flaherty, become more MD, MS from the multidisciplinary, we Division of can provide the Pulmonary and most com- Critical Care prehensive Medicine, approach to encompasses a diagnosis and broad range of introduction of lung diseases innovative involving the therapies for these inflammation and complex diseases. scarring of lung tissue. Through new thera- A multi-specialty peutic studies and our approach to the diagnosis broad range of services, we and treatment of ILD is required can provide patients with to most effectively care for these patients. information regarding what they have, how The program has a bi-weekly meeting bad it is, what will likely happen over time where cases are reviewed by clinicians, and how to best treat it—all in one place,” thoracic radiologists, cardiologists, and explains Martinez. pulmonary pathologists in order to discuss diagnosis and treatment options, including Similarly, patients facing liver cancer can be the need for further testing. seen during a single visit by physicians from

Kevin R. Flaherty, MD, MS (standing) and Fernando J. Martinez, MD, MS co-direct the 2011 Internal Medicine Annual Report Multidisciplinary Interstitial (Fibrotic) Lung Disease (ILD) Program 23 all of the appropriate disciplines at U-M’s information, treatment to date, and techniques in catheter ablation at U-M that Multidisciplinary Liver Cancer Program where coordination of other needed studies. An have made a significant impact on the Michael Volk, MD, MS, an Assistant individual treatment plan is then created for treatment of arrhythmias worldwide,” Professor in the Division of Gastroenterology each patient. explains Oral. “Today, our center performs provides care. Following an evaluation with a around 1,000 of these procedures a year and surgeon, medical oncologist, and/or EXCEPTIONAL CLINICAL uses the latest research and technology to hepatologist, each case is reviewed by at the PROGRAMS offer the newest treatments available,” he Multidisciplinary Liver Tumor Conference—a While UMHS is home to many exceptional adds. weekly discussion of patients’ cases by clinical programs, the Destination Programs surgeons, liver specialists, medical are prime examples of the vast expertise, The Blood and Marrow Transplantation (BMT) and radiation oncologists, and experience, specialized care, and resources Program at U-M is one of the largest in the radiologists—for careful available at Michigan. country. “More than 200 adult BMT consideration of all procedures are performed each year to radiological studies, Expertise & Experience replace damaged or destroyed bone marrow pathologic U-M’s Heart Rhythm Center (Arrhythmia with healthy bone marrow stem cells to treat Program) directed by Hakan Oral, MD, a patients with leukemia, lymphoma, Professor in the Division of Cardiovascular myelodysplasia, neuroblastoma, bone and Medicine, has been a national and soft-tissue sarcomas, brain tumors, and international leader in the treatment of other conditions,” explains Daniel Couriel, arrhythmias (abnormal heart rhythms) for MD, a Professor in the Division of more than 30 years and is still at the forefront Hematology & Oncology, who directs the of the field in caring for this common yet life Adult Bone and Marrow Transplant Program. threatening condition. “My mentor and the “Now with our updated and expanded facility center’s first Director,Fred Morady, MD, a in C.S. Mott Children’s Hospital, we also offer Professor in the Division of Cardiovascular one of the best transplant facilities in the Medicine, pioneered groundbreaking State of Michigan.”

24 Hakan Oral, MD, Director of the Heart Rhythym Center 2011 Internal Medicine Annual Report Specialized Care and Resources annually—with these rare tumors. Most clinics available for patients with adrenal The Multidisciplinary Sarcoma Program community-based practices see fewer than cancer in the world.” plays a vital role in the region due 10 cases a year. Gary Ham to the rarity of sarcomas—a me U-M’s Kidney Transplant Program for adults r, M D family of cancers that , The Multidisciplinary is the first, the largest, and the most Ph arise in the body’s D Endocrine Oncology advanced in Michigan. It’s considered among connective tissues Program directed by the leading programs in the nation in terms of that affect less than Gary Hammer, volume, patient survival, and transplant graft one percent of MD, PhD, a survival. “Because of our high volume, adults with cancer. Professor in the decades of experience, cutting-edge If a patient has a Division of therapies and multidisciplinary team of sarcoma, they Metabolism, specialists, we can perform transplants on need a hospital Endocrinology, and patients who have been turned down by with a dedicated Diabetes, is other centers, including people who are program capable of composed of two ‘sensitized’ due to high amounts of diagnosing and multidisciplinary antibodies circulating in their blood,” explains effectively treating this clinics, the Adrenal Milagros D. Samaniego, MD, FACP, FASN, type of cancer. The Cancer Clinic and the a Professor in the Division of Nephrology and Multidisciplinary Sarcoma Thyroid Cancer Clinic, that the Director of the Kidney and Kidney/ Clinic, which is co-directed by also serve a very specific niche for Pancreas Transplant Programs at U-M. “Our Scott Schuetze, MD, PhD, an Associate patients. “There are only about 500–600 Michigan Sensitized Candidate Program is Professor from the Division of Hematology & cases of adrenal cancer diagnosed in the able to perform kidney transplants on Oncology, with J. Sybil Biermann, MD, an United States each year,” explains Hammer. patients who otherwise might be left with no Associate Professor from the Department of “It’s a rare cancer that requires specialized other options. We can desensitize them by Orthopaedic Surgery, cares for a large care and experience. Our program is one of removing these antibodies using medications volume of patients—about 250 new cases the only fully integrated, interdisciplinary and a process similar to dialysis, improving

2011 Internal Medicine Annual Report 25 the chances that a donated kidney will not be criteria to more accurately diagnose primary rejected by their body.” liver tumors. They also have robust federally funded research programs in primary liver MAKING PATIENT CARE BETTER tumors and are considered worldwide TODAY AND TOMORROW pioneers in radiation therapy for primary liver Another area where few can compete with tumors. About 15 percent of the program’s Michigan in the region is the impact of our patients come from outside of Michigan. Their strong research programs on patient care. clinical research and the clinical research at Many patients come to U-M, and in particular the Comprehensive Cancer Center is a big to the Destination Programs, for access to draw for many in the region. advanced treatments and clinical trials that are not available anywhere else. In addition, While over at the Cardiovascular Center, translational research and data collection U-M’s Multidisciplinary Aortic Program is taking place through the Destination Programs currently the only program in Michigan is helping to shape the future of patient care. offering two alternatives for aortic valve replacement for patients who are not good Clinical Trials candidates for open-heart surgery: the At any given moment, there are hundreds of Medtronic CoreValve trial and the Edwards clinical trials going on at U-M that are testing SAPIEN Heart Valve trial. new, more effective drugs, therapies, and devices to create better treatments, In spring 2011, physicians performed U-M’s outcomes, and quality of life for patients. first minimally invasive aortic valve replacement with the implantation of the “Every day we are applying our research Medtronic CoreValve Transcathetic Aortic strengths to our patients’ care,” explains Volk. Valve prosthesis on three patients. The U-M U-M’s Multidisciplinary Liver Cancer Program study team is lead by Internal Medicine actually developed the radiological (imaging) faculty Stanley J. Chetcuti, MD, and Paul

26 The U-M Comprehensive Cancer Center 2011 Internal Medicine Annual Report Michael Grossman, MD, Associate study will include 100 patients from selected Division of Cardiovascular Medicine. Because Professors from the Division of hospitals across the United States, including patients with chronic atrial fibrillation can be Cardiovascular Medicine with U-M and Pittsburgh. difficult to treat, the center is investigating Stanle y J. C colleagues G. Michael Deeb, he viable options other than ablation to treat this tcu MD, and Himanshu J. ti Bridging Bench to condition. They’re currently working with , M Patel, MD, from the D Bedside cutting-edge technologies to utilize the Department of Everywhere you turn molecule to find other options. “We have been Surgery. at U-M, there are successful at generating heart cells from a labs and centers patient with an abnormal heart rhythm in order In a new REVIVE- working behind- to study the molecular mechanisms of those IT clinical study the-scenes and cells. We do this by reprogramming the announced in around-the-clock patient’s skin cells to become stem cells and 2011, researchers to discover the then we modify their genetic makeup so they will compare next big become heart cells. This is a very exciting whether patients breakthrough in breakthrough with many future possibilities,” with heart failure less patient care. The explains Jalife. “Our team is also using advanced than that of Destination Programs mathematical modeling software to create current left ventricular are instrumental in maps of electrical activity in the heart muscle. assist device (LVAD) promoting translational This research could lead to more precise recipients and ineligible for a heart research, the interactive process treatment of areas of the heart muscle where transplant do better with implanted LVAD between scientists and clinicians working abnormal rhythms might originate,” he adds. devices than with current medical therapy. together to inform the bedside about the Principal investigators from U-M include bench and vice versa. As part of the Blood and Marrow Keith Aaronson, MD, MS, a Professor in Transplantation Program, U-M’s the Division of Cardiovascular Medicine, and Dr. Oral’s Heart Rhythm Center works closely Extracorporeal Photopheresis Program Francis A. Pagani, MD, PhD, a Professor with the Center for Arrhythmia Research led directed by Couriel is the largest in the world. from the Department of Surgery. The pilot by José Jalife, MD, a Professor from the It researches graft-versus-host disease, a

2011 Internal Medicine Annual Report The U-M Cardiovascular Center 27 U-M’S 2011 disorder caused when a newly transplanted Joel Rubenstein, MD, an Assistant DESTINATION PROGRAMS immune system attacks the patient’s skin Professor in the Division of Gastroenterology, and organs—one of the most common and is a recognized expert in the diagnosis and Multidisciplinary Aortic Disease Program dangerous consequences of allogeneic management of Barrett’s esophagus, a Multidisciplinary Bladder Cancer Program transplantation (when stem cells are donated precancerous lesion associated with Blood and Marrow Transplantation Program from a genetically matched family member esophageal cancer. His research with the Congenital Heart Program (usually a brother or sister). This research is Esophageal Cancer Program is helping to Cerebrovascular Disorders Program helping to provide cutting-edge therapies to develop efficient management strategies for Cranial Base Program transplant patients with graft-versus-host identifying Barrett’s esophagus. These efforts Craniofacial Anomalies Program disease, as well as lung transplant patients will help identify esophageal cancer early Multidisciplinary Endocrine Cancer Program facing organ rejection. when it can be more effectively treated and Multidisciplinary Esophageal Cancer Program reduce deaths from esophageal cancer. Fetal Diagnosis and Treatment Center The ongoing work being conducted in Head and Neck Cancer Program Hammer’s laboratory has led to the “In addition to providing enhanced patient Heart Rhythm Center (Arrhythmia Program) development of new national and care and training opportunities at U-M, the Interstitial (Fibrotic) Lung Disease Program international therapeutic trials with biological- Destination Programs are helping to provide Multidisciplinary Liver Cancer Program based therapies for adrenal cancer that a strong bond, better communication, and Michigan Sensitized Candidate Program (MISCAP) target the molecular defects in cancer stem coordinated research between disciplines,” Multidisciplinary Pancreatic Cancer cells while sparing normal tissue. “Because explains James Scheiman, MD, a Multidisciplinary Sarcoma Program we have a cohesive group of scientists and Professor in the Division of Gastroenterology Skin Cancer Program clinicians interested in adrenal biology and who serves as the GI lead in the Thoracic Insufficiency and Respiratory Support Program clinical care at U-M, it’s been relatively easy Multidisciplinary Pancreatic Cancer Program to work together to ask clinically pertinent and has an active research program in early The Department of Internal Medicine is involved in questions that are backed by basic science,” diagnosis of pancreatic cancer. Since programs shown in bold. Hammer says. “Our research and clinical current diagnostic techniques can’t reliably trials are working toward creating less toxic distinguish between pancreatic cancer and treatments for cancer patients.” inflammation, his research is exploring how

28 2011 Internal Medicine Annual Report to detect a disease signature for pancreatic Data Collection cancer through optical spectroscopy. “We In addition to the research taking place at The Aortic Program houses and manages hope to develop a device to be the International Registry of Aortic Dissection Jame U-M, the size, scope, and s Sch used during minimally eim specialization of many of the to help us understand more about this an invasive endoscopies , M aspect of aortic disease. Researchers can D Destination Programs is that could identify also providing valuable review the registry data and look for trends in cancerous changes data and guidelines this disease process. “Our group also in pancreatic tissue. that are impacting recently established a Bicuspid Aortic Valve This would allow research and registry that is looking at patients with this for earlier cancer patient care on a congenital disease to identify its long-term treatment when global scale. effects,” explains Booher. needed and prevent Data and A FUTURE MODEL unnecessary evaluation provided The overall concept of the Destination surgeries when no by Martinez and Programs was created with the goal of cancer is detected,” Flaherty from the making UMHS a global destination for he explains. Multidisciplinary exceptional health care. After just a few short Interstitial (Fibrotic) Lung years, those involved feel like they’re on the Michelle Anderson, MD, an Disease Program was used right track. Assistant Professor in the Division to create the international of Gastroenterology, also contributes to the guidelines for the diagnosis and management “We’re serving an important role as models Pancreatic Cancer Program through her of idiopathic pulmonary fibrosis published by right now. Ideally, the whole U-M Health research on the discovery of markers to the American Thoracic Society, European System should eventually be a Destination detect pancreatic cancer at an earlier stage Respiratory Society, Japanese Respiratory Program. It will take time, but we’re headed through minimally invasive approaches such Society, and the Latin American Thoracic in that direction,” says Samaniego. Hammer, as endoscopic biopsies and blood tests. Association. whose Endocrine Oncology Program was

2011 Internal Medicine Annual Report 29 one of the very first Destination Programs, If they can continue to combine the best feels that “The Destination Programs are bench-to-bedside research and faculty serving as ambassadors of what U-M does expertise with multidisciplinary care and ideal best—they represent and, most importantly, patient experiences, there’s no doubt that the deliver a strong commitment to patient care, Destination Programs will continue to serve access to multiple experts, and cutting-edge as models for the future of health care care grounded in science. That really is the delivery at U-M and beyond. Michigan Difference.”

“The Destination Programs are serving as ambassadors of what U-M does best—they represent and, most importantly, deliver a strong commitment to patient care, access to multiple experts, and cutting-edge care grounded in science. That really is the Michigan Difference.”

30 2011 Internal Medicine Annual Report The University of Michigan Sleep Disorders Center: Helping Patients Get a Good Night’s Sleep

pproximately 50 to 70 million Americans suffer from sleep disorders, and the “When people don’t receive an adequate A number keeps on growing. The effects of chronic sleep deprivation can amount of sleep, neither their brains nor be diverse and life-threatening. Lack of sleep is associated with motor Ron C their bodies function well during herv vehicle crashes, workplace accidents, and injuries. It is also linked in, the day,” says Chervin. MD , M “Lack of sleep impacts with impairments in cognitive performance and with serious S physical ills, including heart disease, diabetes, depression, our thinking, our ability and obesity. to process memories and to modulate According to Ron Chervin, MD, In parts of emotions, our MS, Professor of Neurology and Scandinavia, for motor coordi- Director of the Sleep Disorders instance, children nation, and our Center at U-M, sleep get two more sensory function. deprivation is one of the most hours of sleep per Studies conducted serious health issues facing night on average more than a the nation. “Americans,” he than American decade ago notes, “are sleeping less children do.” demonstrate that a per night with each rat prevented from passing generation. Chervin attributes this sleeping will die in about We’re sleeping about national sleep crisis to a two weeks from multi-organ two hours less than chronic busyness in our society and immune system failure.” we did before the and a refusal to prioritize sleep, as well as to invention of the the absence of sleep education in our Providing High-Quality light bulb in 1879, schools. Many schools now educate Clinical Care and we’re on the students about proper nutrition, but they At the University of Michigan Sleep Disorders low end of the don’t emphasize the importance of getting Center, physicians are helping patients with total sleeping time an adequate night’s sleep for learning and sleep disorders get a better night’s rest. One scale worldwide. overall physical well-being, he says. of the nation’s largest academic sleep

Helena Schotland, MD, created the Michigan CPAP bank at the U-M Sleep Center. The program checks, cleans, and redistributes unused CPAP equipment to patients who otherwise might not have access. CPAP machines are 2011 Internal Medicine Annual Report often given to patients with sleep apnea and other conditions that make breathing during sleep difficult. 31 medicine programs, the Center includes “We have, for instance, a terrific unique multidisciplinary clinics, three multidisciplinary clinic for patients with state-of-the-art sleep laboratories, and the obstructive sleep apnea, who cannot interdepartmental U-M Center for Sleep tolerate treatment with CPAP,” says Helena Science (CSS), which is devoted to improving Schotland, MD, an Assistant Professor in the treatment for and educating the public about Division of Pulmonary and Critical Care sleep disorders. Comprising 45 faculty Medicine. In the Alternatives to CPAP Clinic, members from 15 departments, CSS patients are evaluated by a team comprised conducts research in laboratories and clinics of a sleep medicine specialist, an otolaryn- across the campus. gologist, an oral and maxillofacial surgeon, and sometimes a dentist. The team works One of the most powerful aspects of the sleep together to create a therapy regimen for each program at U-M is its interdisciplinary patient, which might involve surgery to enlarge approach to understanding, diagnosing, and the airway, nasal surgery, or the use of an oral treating sleep disorders. In the Center’s appliance that fits within the mouth. multidisciplinary clinics, patients are seen by faculty from a variety of disciplines, including Another interdisciplinary clinic—the internal medicine, neurology, pulmonary Behavioral Sleep Medicine Clinic (Insomnia medicine, psychology, child psychology, Clinic)—emphasizes cognitive-behavioral behavioral/developmental pediatrics, pediatric therapy as opposed to the long-term use of neurology, pediatric pulmonary medicine, medications in the treatment of patients with otolaryngology, oral and maxillofacial surgery, chronic insomnia. In this program, a sleep and dentistry. These specialists work together specialist works with a psychologist who to develop the most effective treatment specializes in sleep problems to develop regimen for each individual patient. assessment and treatment plans that often need to address multiple underlying issues. Treatment often involves helping patients to

32 A patient being evaluated in one of U-M’s sleep laboratories. 2011 Internal Medicine Annual Report change beliefs that impair their ability to cognitive-behavioral therapy can be highly going to sleep (and sometimes even fear sleep, optimize their sleep schedules, and effective for the long-term treatment of sleep), often staying up all night. And when gain new understanding of sleep insomnia, and sometimes offers they finally do fall asleep, their sleep is Qurr atul A practices at home that will . Sh more long-lasting benefit frequently disrupted by nightmares, dream am foster good sleep. im than sleeping pills,” says enactment behaviors, or night terrors.” -U zz Chervin. a m “When working with a PTSD sufferers are often referred to the n , patients, I try to M The VA Medical clinic after they’ve completed a cognitive- make it very clear D Center also features behavioral therapy program, but continue to that beds are for a Sleep Disorders experience sleep problems. “When PTSD just two Clinic, where sleep sufferers complete a therapy program and activities—sleep specialists treat still have difficulty with nightmares,” says and sex—and veterans with Shamim-Uzzaman, “we may use a bedrooms should many types of medication called Prazosin, which has be quiet, dark, and sleep disorders, proven to be beneficial for these patients.” comfortable,” says including sleep Schotland. “I also disturbances caused by The Center also features three large sleep coach patients to leave post-traumatic stress laboratories with private bedrooms and the bedroom and engage in disorder (PTSD). “Many PTSD bathrooms for patients, where a staff of more a quiet activity when they can’t sufferers develop sleep-related than 50 technologists conduct sleep studies. go to sleep and to only return when they feel problems, such as severe nightmares and About 6,000 nocturnal studies are conducted drowsy.” night terrors, related to their traumatic each year. The third sleep laboratory, opened experiences,” says Qurratul A. Shamim- in May 2012 at Domino’s Farms, is designed According to Drs. Schotland and Chervin, Uzzaman, MD, Clinical Instructor, to provide additional, state-of-the-art facilities these kinds of behavioral approaches can be Departments of Internal Medicine and for daytime sleep clinic visits and nocturnal just as effective as medication in treating Neurology and Director of the AAVA Sleep sleep studies. This will shorten wait times for insomnia. “Studies have shown that Medicine Program. “As a result, many avoid clinical sleep services.

2011 Internal Medicine Annual Report 33 In addition to clinical care, the Center is inattention, and attention-deficit/hyperactivity on cognitive tests often improved one year involved in educating both physicians and the disorder. These studies suggest that after the procedure was performed.” general public about sleep disorders and the neurobehavioral disorders in children can be Another study conducted by U-M Medical importance of sleep. One area Center faculty caused by undiagnosed sleep disorders and School researchers demonstrated that urban are focused on is including a discussion of when the sleep disorders are treated, the schoolchildren who display aggressive sleep during routine primary care visits. behavior often improves. behaviors are much more likely to experience “Oftentimes, sleep disorders are overlooked,” daytime sleepiness than schoolchildren who says Shamim-Uzzaman. “Sleep apnea may “We have found, for instance, that there is a don’t bully. According to the researchers, this affect up to 18 million Americans, and is strong link between snoring in children and sleepiness could be caused by a sleep associated with both hypertension and stroke; hyperactivity. Our data suggest that as much disorder, such as SDB, or it could be caused yet this disorder often goes undiagnosed for as 15 to 20 percent of children with by other factors, such as not getting enough years. We’re educating doctors to screen for hyperactivity would stand to benefit if their sleep because of a chaotic home this and other sleep problems as part of the snoring and any underlying sleep apnea were environment or stimulus from electronic routine check-up.” treated,” says Chervin. devices. Although further research is needed, the study suggests that aggressive behavior Advancing Treatment through In one study, U-M researchers looked in children might be reduced by efforts to Research carefully at behavior and cognition in help them get an adequate night’s sleep. Performing research that might lead to children with sleep-disordered breathing improved treatments for sleep disorders is (SDB) before and after they had their Center researchers are also working to another important aspect of the Center’s adenoids and tonsils removed. “Children improve understanding of sleep disorders in activities. Center faculty, for instance, have scheduled for an adenotonsillectomy often adults. For instance, a collaborative research conducted a number of important have SDB along with significant behavioral project led by Associate Professor of investigations on the relationship between issues and cognitive impairment,” says Neurology Louise O’Brien, PhD, involves sleep disorders in children and disruptive Chervin. “Our study showed that their both the Center and the Department of behavior disorders, such as hyperactivity, behavioral disturbances and performance Obstetrics and Gynecology. Results show

34 2011 Internal Medicine Annual Report that one out of three pregnant women These and other groundbreaking studies experience frequent snoring, a major have significantly advanced our symptom of sleep-disordered breathing, by understanding of sleep, its disorders, and the their third trimester. Findings demonstrate harmful effects of sleeplessness on the mind that this snoring is associated with increased and body. “Sleep medicine is a new, rapidly risk for gestational hypertension and growing, and exciting field that already helps pre-eclampsia, two blood pressure disorders so many people,” says Chervin. “Our seen by obstetricians every day. Research by research aims are to innovate evaluations Dr. O’Brien’s team has also shown that and treatments that are even more effective.” restless leg syndrome, a disorder in which there is a need to move the legs to stop unpleasant sensations, is common in late “There is no more exciting place to do this than the pregnancy (35 percent) and predictive of University of Michigan. With the support of a large, diverse, poor sleep quality and daytime functioning. and talented faculty (including many from the Department of Given that blood pressure disorders during Internal Medicine); significant research funding from the pregnancy can raise fetal morbidity and mortality, and cost the health care system federal government; and generous contributions from millions of dollars each year, studies are now Michigan residents who are committed to helping to underway to determine the effect of maternal sleep problems on newborns, or the children advance human health through improving sleep, we hope to they are destined to become. Treatment have substantial positive impact on local, national, and intervention studies are in progress to assess whether improvement in maternal sleep has international sleep health.” a positive effect on both the health of the mother as well as her baby.

2011 Internal Medicine Annual Report 35 Cutting Costs While Improving Care: Internal Medicine Faculty to Lead Pioneer Accountable Care Organization at U-M

n late 2011, it was announced that the University of Michigan Health System will be David Spahlinger, MD, Senior Associate Iparticipating in the Pioneer Accountable Care Organization (ACO) model, a transformative Dean for Clinical Affairs and Director of the new initiative sponsored by the Centers for Medicare & Medicaid Services (CMS) Innovation U-M Faculty Group Practice, says the results Center. In partnership with IHA Health Services Corporation, an Ann Arbor, Mich.-based of the Demonstration show there are ways to multi-specialty group practice, U-M will work with CMS to provide Medicare beneficiaries cut costs but also improve quality of care. with higher quality care, while reducing growth in Medicare expenditures through enhanced “U-M achieved both of the project’s aims: to care coordination. Caroline Blaum, MD, Professor of Internal Medicine and Geriatrics, will provide the highest-quality care and reduce serve as the Medical Director of the U-M/IHA Pioneer ACO. health care spending growth for all traditional Medicare patients, including those with costly The Pioneer ACO Model is designed to BUILDING ON OUR SUCCESS chronic illnesses,” he explains. encourage the development of ACOs, where This new effort will build upon U-M’s recent groups of doctors and other healthcare success with the Medicare Physician Group AND NEW PROGRAMS AND providers work together to provide high Practice Demonstration. During that five-year INITIATIVES quality care for their patients. U-M and project, U-M’s Faculty Group Practice, which The Medicare Physician Group Practice IHA are among top health care includes nearly 1,600 U-M faculty physicians Demonstration at U-M began by focusing on organizations from around the who care for patients at the three U-M the quality of care for patients with diabetes, country, that were chosen by hospitals and 40 U-M health centers, saved but expanded in its second year to include CMS to test the Medicare more than $22 million on the cost congestive heart failure and coronary artery effectiveness of several of care for patients. Of the ten groups that disease—both chronic heart conditions that models of payment in participated, U-M was one of only two that carry a very high risk of emergency helping organizations earned shared savings during all five years of hospitalization and other higher-cost care if make a rapid the demonstration. And in the last year of the not managed appropriately. Since the third transition to higher project, U-M scored a 98 percent grade on year, the project has included hypertension— quality care at a quality measures. U-M’s Faculty Group another high-risk and costly condition—and lower cost to Practice also currently is participating in a breast and colorectal cancer screenings. Medicare. similar project known as the PGP Transition Demonstration.

36 2011 Internal Medicine Annual Report U-M has also launched a number of new multiple locations and settings. Many of we provide our patients and their families.” well as for reducing growth in Medicare programs to help improve care for all the programs and innovations put in place Under the Pioneer ACO Model, CMS will expenditures for the same patient population. patients, including transitional care programs involved not only physicians but also provide incentives for participating health designed to assist patients with hospital pharmacists, nurses, social workers, care care providers who form an organization to “U-M has already had longstanding discharge information and follow-up activity. managers, and others who are involved in coordinate care for patients. Providers who partnerships with IHA. They’re one of the Also started were complex care coordination the care of Medicare patients at all U-M band together through this model will be largest, fully integrated multi-specialty groups programs designed to reduce unnecessary facilities. required to meet quality standards based in southeast Michigan. We’re looking forward treatments, readmissions, handoffs, and wait upon, among other measures, patient to a successful collaboration that will give both times, as well as a medical home program “By virtue of our Demonstration’s success, outcomes and care coordination among the of our organizations a voice in how ACOs are where a patient and his or her personal U-M already has set up an ACO,” explains provider team. Robust quality measures and developed over time,” adds Blaum. physician partner to identify, provide, and Blaum. “The Pioneer model will help us build other criteria will be used to reward ACOs for coordinate all needed services across upon this experience and allow us to continue providing beneficiaries with a positive patient to improve the quality and efficiency of care experience and better health outcomes, as

2011 Internal Medicine Annual Report 37 research Metabo lic Syndrome How Internal Medicine researchers are chipping away at this pervasive and pernicious cluster of high glucose, high blood pressure, dyslipidemia, and central obesity

n many ways, metabolic syndrome—the grouping of factors that increase risk for type 2 inflammation, the production of reactive Idiabetes, heart disease, and stroke—is a paradox. On one hand, almost any grade-schooler oxygen species, and other processes that could tell you how to tackle it: Eat better and exercise. On the other, we don’t truly know why result in insulin resistance. This can really this is so hard to do—nor do we know why the 35 percent of us who meet the criteria for damage tissues. ” metabolic syndrome are more prone to an array of complications in tissues as varied as the kidneys, eyes, nerves, heart, liver, and joints. Looking at this process at a granular level in terms of what happens to these excess But researchers throughout Internal Medicine What happens on a conceptual level is nutrients, which metabolic pathways they are hoping to remedy that. They are looking characterized by Charles Burant, MD, PhD, influence, and how this results in tissue in unprecedented scope and detail at Professor of Internal Medicine (Metabolism, damage is the subject of a number of everything from the root causes of obesity to Endocrinology, & Diabetes [MEND]), research efforts, including a $3.5 million how metabolic syndrome instigates tissue Molecular & Integrative Physiology, and multi-disciplinary DP3 grant from the National damage to how lifestyle interventions can Environmental Health Sciences; Dr. Robert C. Institute of Diabetes and Digestive and change disease progression. and Veronica Atkins Professor of Metabolism; Kidney Disease. This grant will allow and Director of the Michigan Nutrition researchers from Internal Medicine and Molecular Underpinnings Obesity Research Center. “Metabolic departments like Ophthalmology and of Metabolic Syndrome and syndrome is simply a physiological response Neurology to determine what it is about this Its Complications to too much nutrition,” he says. “When specific “milieu” that leads to complications— The thing about metabolic syndrome is that you’ve gotten to a point where you can’t and what can be done to prevent it. because it’s not a disease in its own right, it store any more fats and sugars, bad things can be easy to ignore. The danger in this, start happening. You start getting Tissue-Specific many researchers point out, is that the same metabolites being made within tissues that Complications kinds of organ damage that happen in are associated with the over-activation of The Kidneys diabetes are already beginning in the various pathways. These pathways normally One of the divisions working hard on these glucose-rich milieu of metabolic syndrome. play very important roles in the cell. But when questions is Nephrology, including Frank they are chronically activated, it leads to Brosius, MD, Chief of Nephrology and

40 2011 Internal Medicine Annual Report Professor of Internal Medicine and complications. And second, that the situation there because of a block in the cycle. They Molecular & Integrative Physiology; is actually reversed in the tissues of the nerves want both to understand the disease Subramaniam Pennathur, and retina. “This was surprising,” mechanisms and to develop a , MD er, MD MBBS, Assistant Professor sius says Brosius. “The paradigm metabolomic profile that will identify retzl ro s K k B ia of Internal Medicine; and an in complications research which patients are prone to tth Fr a Matthias Kretzler, has been that all the kidney injury. That way they M MD, Professor of microvascular can intervene before Internal Medicine complication-prone activation of the harmful and Computational tissues—the eyes, pathways occurs. Medicine & nerves, and Bioinformatics. kidneys—were Another pathway they’re Using both likely to have the exploring came to light bottom-up same underlying through genetic analyses (metabolomic) and mechanism of of kidney biopsies and top-down disease. So we was later validated in (genomic) would have predicted mouse models. They found approaches, they’re increased glucose that increased activation of generating important new metabolites in all three the JAK/STAT signaling pathway insights. tissue types.” in diabetes resulted directly in kidney scarring and dysfunction. This is For example, by comparing the metabolic To figure out what’s happening, they’re a valuable finding because there are already byproducts of hyperglycemic patients with conducting flux experiments in which they’ll JAK/STAT inhibitors on the market for other advanced kidney complications to those follow labeled glucose through the entire conditions that might hold promise for without, they’ve identified two unexpected glucose metabolic pathway to see whether nephropathy patients. things. First, that glucose metabolism seems metabolism is truly revved up in the kidneys to be ramped up in the kidneys of those with or whether metabolites are just building up

2011 Internal Medicine Annual Report 41 “The exciting part of these insights is the “There’s clear evidence that they can To clarify how glucose fluctuations contribute personalized medicine aspect,” says develop myocardial dysfunction or cardiac to this risk, Pop-Busui is heading an R01 with Pennathur. “Ideally, we’d like to be able to failure without having coronary co-investigators from Internal oy, MD do multiple panels on patients and be able artery disease or vern Medicine, Radiology, and Du to tell them which of their pathways are hypertension. We don’t ire Biostatistics, among la altered and therefore which set of drugs will really understand why C them, Claire prevent complications in their particular that’s happening.” Duvernoy, MD, case.” Associate Professor But it starts early. of Internal The Heart In a study she Medicine, Chief of Along with the microvascular conducted with Cardiology at the complications of metabolic Melvyn VA Ann Arbor syndrome are the Rubenfire, MD, Healthcare cardiovascular changes, Professor of System, and which are being addressed Internal Medicine founder of the by a number of Internal and Director of Women’s Heart Medicine researchers, Preventive Cardiology, Program. With the use among them Rodica they found cardiac risk of continuous glucose Pop-Busui, MD, PhD, factors already developing in monitoring and a number of Associate Professor of patients with metabolic state-of-the-art imaging Internal Medicine (MEND) and syndrome. “We found significantly altered techniques, the team aims to determine how Co-Director of the Michigan cardiac nerve function and tone,” she says. the heart’s nerves, function, and metabolism Peripheral Neuropathy Center. “There’s an “This can have detrimental consequences are damaged by changes in glucose. “Is it the interesting difference between down the road in terms of cardiac structure, time spent with high or low blood glucose that hyperglycemic patients and those in the function, and the development of is the problem—or is it the rate of change general population,” says Pop-Busui. arrhythmias.” between these states that’s doing most of the

42 Rodica Pop-Busui, MD, PhD 2011 Internal Medicine Annual Report damage?” says Pop-Busui. By clarifying this, To address this, he’s working not only on of the same features of the metabolic her team hopes to determine the level of lifestyle interventions but on testing drug syndrome despite having partial to almost control required to prevent cardiac therapies that may halt disease complete loss of fat tissue. She has been , MD Oral complications. Elif progression. Among these one of the key international players in was a recent Phase II shepherding leptin therapy to the final stage The Liver study of GS-9450, a of FDA approval last year, and she hopes Nonalcoholic fatty selective caspase that once it is approved for lipodystrophy, it liver disease is yet inhibitor that is may also help reverse the progression of fatty another complica- showing promise in liver disease in a subgroup of patients with tion that is both reducing low levels of leptin. associated with inflammation and and can be patients’ liver test Also bringing her expertise to bear on these exacerbated by abnormalities. issues is Elizabeth Speliotes, MD, PhD, metabolic syn- MPH, Assistant Professor of Internal Medicine drome. “Research He is also (Gastroenterology) and Computational from our group and collaborating with Elif Medicine & Bioinformatics. She is using others has shown that Oral, MD, Associate genome-wide association studies to identify patients with fatty liver Professor of Internal genes associated with fatty liver disease and who also have components Medicine (MEND) and obesity in the hopes of determining which of metabolic syndrome have the Director of the MEND Obesity and traits share a common genetic cause. “We most severe form of the disease with the Metabolic Disorders Program, on her R01 know that not everybody who becomes most fibrosis/scarring,” saysHari studying the role of the fat-derived hormone obese gets complications from obesity, and Conjeevaram, MBBS, Associate Professor leptin in fatty liver disease. This work builds not everybody who develops fat in their liver of Internal Medicine (Gastroenterology) and on Oral’s large body of work proving the goes on to develop cirrhosis or metabolic Director of the GI Fellowship Training efficacy of leptin in treating patients with syndrome-related abnormalities,” she says. Program. lipodystrophy, who paradoxically have many “We’re trying to get to the genetic root of why

2011 Internal Medicine Annual Report 43 some people will get more of these accompanies metabolic syndrome. One of changes,” he says. “Then we could consider abnormalities as they gain weight compared these is Blake Roessler, MD, Professor of treating their knees with hormone inhibitors, to others.” Internal Medicine (Rheumatology). Roessler is some of which are already on the market.” Bla ke Roe ssle doing this by rethinking how fat is viewed r, M D Thus far she and her colleagues with respect to the joints. “The prevailing Another source of joint pain tied closely to have identified and are working thought has been that obesity puts people at metabolic syndrome is gout. This is the to characterize more than 90 risk for, say, knee osteoarthritis based simply purview of Puja Khanna, MD, MPH, loci associated with body- on body mass,” he says. “If you’re bigger, Assistant Professor of Internal Medicine mass index or fatty liver you’d put more load on the knee, and it (Rheumatology), who was recruited to U-M in disease. They’ve found would fail prematurely like any mechanical 2011 to set up a Center of Excellence for that some genetic variants device.” But it turns out that’s too simplistic a Gout. “Once known as ‘the disease of kings,’ that promote fat in the liver view, since large, lean people are actually gout is now the disease of the common also affect characteristics protected from knee osteoarthritis. man,” says Khanna. “It used to be that only of the metabolic syndrome, royalty had access to the excessive amounts while others do not. “This is So, he’s looking at fat not as a source of of meat and alcohol, and the sedentary exciting because it suggests mass, but in terms of anatomic location and lifestyle that contribute to gout. But not any that we can genetically function. With this approach, his team has more.” Due to the rise in obesity, impaired dissociate epidemiologically shown in culture that the fat-derived glucose tolerance, and chronic kidney correlated traits,” she says. “With this hormones leptin and interleukin 6 increase the disease, gout now affects some 8.2 million information we hope in the future to be activity of two biochemical pathways affecting Americans, and it’s showing up in ever- able to subclassify people into disease-risk bone and cartilage formation. He’s now younger patients. categories so we can personalize their looking at the levels of these hormones within treatment.” the joints—in intra-articular fat and synovial Gout’s signature attacks of acute fluid—to see if higher levels are correlated with inflammatory arthritis are caused by the The Joints more advanced disease. “If this turns out to deposition of uric acid crystals in the joints Researchers are also making strides in be the case, we’d like to identify high-risk and soft tissues. What starts as painful addressing the joint pain that so often patients before they develop arthritic flares can become chronic if poorly

44 2011 Internal Medicine Annual Report managed, leaving some sufferers in Integrative Physiology, and Marilyn H. Vincent affects the development of this area and can wheelchairs with daily pain they rate 10 out Professor of Diabetes Research. He is looking actually program us for metabolic syndrome of 10, says Khanna. She is in detail at why we eat to excess later in life. His lab is exploring the Martin working to reverse both the Mye by exploring leptin’s role in mechanisms by which this happens. rs Jr. personal suffering and , M energy balance and body D , P lost productivity h weight. Another area he’s looking at is the lateral D attributable to gout hypothalamic area, which influences the with a focus on His approach has reward value of food. By understanding how outcomes been to identify this works, he’d ultimately like to be able to research, the populations of turn off the desire to eat beyond the point of development of neurons in the brain feeling full. treatment that express the guidelines, and leptin receptor then He’s also looking at a group of neurons that drug trials. try to figure out express the neurotransmitter NOS1. By “Michigan has an what they do in a knocking out their leptin receptors to see amazing tradition of step-wise fashion. He how that would affect reproduction, Myers cutting-edge bench works largely on mouse wound up creating mice that were, as he research in gout,” she models but is collaborating puts it, “very diabetic, very obese, very says. “We’re working to with Elif Oral in studies of sluggish, and very hungry.” He’s hoping this ensure this is translated human lipodystrophy patients. surprising finding might one day pave the bedside.” way for a drug target that could regulate food His lab published work on three areas of the intake and energy balance. Root Causes brain last year with long-term implications Moving away from complications to the for understanding obesity. The first is the The groundbreaking nature of Myers’ work biochemical roots of obesity, one findsMartin arcuate nucleus, which controls satiety. It was recognized last year with the Ernst Myers, Jr., MD, PhD, Associate Professor of turns out that over- or under-nutrition in Oppenheimer Award, endocrinology’s highest Internal Medicine (MEND) and Molecular & utero for humans (or postnatally in mice) honor for a young investigator.

2011 Internal Medicine Annual Report 45 While Myers is looking at the causal reasons Auchus was recruited to U-M last second, the macrophages were qualitatively mechanisms of common forms of metabolic year—to develop a platform for different. They were in an activated state that R syndrome, one of his endocrinology “steroidomics”—sensitive metabolomics- produced a lot more inflammatory proteins.” ichard A uch colleagues is looking at a less- based tests for steroids and their us , M D common but long-overlooked intermediates. He hopes to help clinicians The reason, it turns out, was that the old , P h D source—benign adrenal more readily identify this newly appreciated macrophages didn’t produce enough of the tumors. Richard Auchus, subset of people whose metabolic syndrome inflammation-suppressor PPAR-gamma. MD, PhD, Professor of could be improved with adrenal-tumor surgery However, by using a diabetes drug known to Internal Medicine and or targeted therapies. stimulate PPAR-gamma production, Yung’s Director of the MEND team was able to reduce the inflammation Fellowship Program, has The Role of Aging generated by these older cells. shown that there is a small A unique spin on the question of obesity and but important group of its associated morbidities comes from Yung quips that it’s not quite the fountain of patients with tumors that Raymond Yung, MB, ChB, Chief of Geriatric youth, but he hopes that as he and others rev up cortisol production & Palliative Medicine, Professor of Internal come to understand these processes better, and lead to the symptoms of Medicine, and Director of the Institute of they may be able to reduce the disease metabolic syndrome. Gerontology. He was interested in whether burden of aging. age-related obesity was distinct from These patients have typically fallen diet-induced obesity in terms of generating A Sustainable Lifestyle through the cracks because they don’t the inflammation characteristic of metabolic Change produce enough cortisol to meet the syndrome. Since reducing the disease burden is traditional criteria for Cushing’s syndrome. ultimately what all these physician- This is, in part, because their tumors make The answer, he discovered, was yes. By researchers are interested in, each not just cortisol, but intermediates on the looking at the belly fat of mice, his team acknowledges that however hard they may pathway to cortisol production, which have noticed striking differences in the immune work to manage individual aspects of similar biological effects but aren’t measured cells of older animals. “First, the number of metabolic syndrome, the closest thing to a with current techniques. This is one of the T-cells was increased,” says Yung. “And, magic bullet is lifestyle change.

46 2011 Internal Medicine Annual Report No one knows this better than Charles says Burant. “If people can get through the metabolic syndrome in Quito, Ecuador. Burant and his MEND colleagues Amy first couple days, they aren’t that hungry.” Closer to home, she’s running a number of Rothberg, MD, Assistant Professor of Most patients lose about 20 percent of their studies on how patients can be Andrew K Internal Medicine and Medical Director of the body weight over three to four months, and supported in controlling their blood raft son MEND Weight Management Clinic, and dieticians work hard to help them keep it off. glucose and maintaining a , M D Andrew Kraftson, MD, Instructor of Internal healthy lifestyle between Medicine and Co-Director of the Post- Thanks to the many resources available at doctor visits. Bariatric Surgery Clinic. Their work in the U-M—like the Nutrition Center, the Metabolic weight-loss clinic has shown that taking Fitness Program, and the Laboratory for In a study of VA patients, people from an average of about 3,000 to Physical Activity and Exercise Intervention Heisler demonstrated that 800 calories a day reverses almost every Research—several departmental reciprocal peer support aspect of the metabolic syndrome. “Once researchers, including Pop-Busui, Duvernoy, could be more effective you start relieving cells of the stress of too Oral, Rubenfire, and Conjeevaram, are than nurse care much nutrition,” says Burant, “things heal looking at how diet and exercise affect their management in helping pretty quickly.” His team has learned they systems of interest. patients control their blood have to cut patients’ diabetes drugs in half sugar. In studies at the on the first day and are ultimately able to Others are looking at how these kinds of Community stop medications for conditions ranging from lifestyle changes can be fostered among high blood pressure to depression. They’ve traditionally hard-to-reach audiences. One of also seen anecdotally that patients’ joint pain these is Michele Heisler, MD, MPA, improves—even before there’s a lot of real Associate Professor of Internal Medicine weight loss. They think this is the result of (General Medicine) and Health Behavior & decreased inflammation. Health Education, and Research Scientist at the VA Center for Clinical Management However compelling the benefits, the trick is Research. On the global stage, Heisler to get people to follow the program. “We co-mentors a team of medical students generally have a very happy clinic population,” assessing quality of care for patients with

2011 Internal Medicine Annual Report 47 Health and Social Services Center (CHASS), “What we saw was summarily disappointing; benefits appear to be sustained into high Kim Ea a federally qualified health center that I was shocked at how poor the effort had school. The program is now expanding to 21 gle, MD serves the pre-dominantly Latino been to sustain childhood health in a schools in Detroit and elsewhere in the state. and African-American meaningful way.” communities of southwest Why Here? Detroit, she is demonstrating So he returned to U-M determined to make What is it about the department that has how community health a change. By building a team from the positioned it to chip away at metabolic workers and web-based University, its health system, and local middle syndrome from such a variety of angles? Two educa-tional tools can be schools and community groups, Eagle words: expertise and infrastructure. used to improve patient helped launch Project Healthy Schools. It outcomes. aims to change the culture in which sixth “The department has done a great job of graders form the habits that can prevent investing in resources that help us combine Equally promising is work metabolic syndrome. “Our goals for the kids our expertise in phenotyping, animal models, being done among middle- are simple,” says Eagle. “Eat more fruits and metabolomics, and so forth to really school students by Kim vegetables; exercise; and reduce sugary understand the basis of obesity and Eagle, MD, Albion Walter drinks, fatty foods, and screen time.” The metabolic syndrome,” says Burant. “This is Hewlett Professor of Internal program features engaging educational critical because, as I tell my patients, 68 Medicine, Chief of Clinical modules, health-promoting school events, percent of us in this country are either Cardiovascular Medicine, and Director of the and changes to the school’s food offerings. overweight or obese—right now, the thin Cardiovascular Center. While somewhat people are the ‘abnormal’ ones.” outside his usual research umbrella, the topic The results have been impressive. His team of childhood obesity drew him in while has followed 550 students in Ann Arbor for The department is doing everything it can to serving on an NIH advisory council. “Our three years, and found an improvement in change that. committee asked the NIH to bring in the self-reported behaviors as well as nation’s top intervention experts,” says Eagle. cardiovascular risk factors—and these

48 2011 Internal Medicine Annual Report Sampling of Research Relevant to Metabolic Syndrome by Internal Medicine and Collaborators

Topic Researchers Affiliation Approach Key Advancement Causes of Obesity and/or Martin Myers, Jr., MD, PhD Metabolism, Endocrinology & Action of leptin in the brain Identified set of neurons expressing NOS1 implicated in all facets of metabolic Metabolic Syndrome Diabetes (MEND) syndrome Elizabeth Speliotes, MD, PhD, MPH Gastroenterology Genetic determinants of obesity Identified 90 loci associated with obesity & fatty liver disease Richard Auchus, MD, PhD MEND Cortisol overproduction by benign adrenal tumors Using steroidomics to identify patients with “subclinical” syndrome-causing tumors Raymond Yung, MB, ChB Geriatric & Palliative Medicine Role of age-related obesity in inflammation Discovered distinctive immune-cell changes in the fat of older animals responsible for inflammation Kidney Complications Matthias Kretzler, MD Nephrology Genome-wide analysis of disease mechanisms using implicated Jak/STAT signaling pathway in diabetic kidney disease, plausible the C-PROBE cohort from the O’Brien Renal Center, a new drug target multi-institutional network of tissue samples and patient records he helped create Frank Brosius, MD Nephrology Genetically modified mouse models of nephropathy implicated Jak/STAT signaling pathway in diabetic kidney disease, plausible new drug target Subramaniam Pennathur, MBBS Nephrology Metabolomics of nephropathy Identified distinctive patterns of glucose metabolism that predict kidney complications; showed that these patterns vary among microvascular complication-prone tissues Cardiac Complications Rodica Pop-Busui, MD, PhD MEND Natural history of cardiac failure in diabetes Clarifying the role of wide glucose fluctuations & cardiovascular autonomic neuropathy in the progression of the heart’s metabolic & functional changes in diabetes Demonstrated early cardiovascular damage associated with metabolic syndrome. Reduced cardiovascular autonomic dysfunction & oxidative stress through Mediterranean diet & exercise Melvyn Rubenfire, MD Cardiovascular Medicine Lifestyle interventions through the Metabolic demonstrated early cardiovascular damage associated with metabolic syndrome. Fitness Program Reduced cardiovascular autonomic dysfunction & oxidative stress through Mediterranean diet & exercise Claire Duvernoy, MD Cardiovascular Medicine Coronary flow reserve (CFR) as risk indicator Demonstrated that obesity is a pro-inflammatory state associated with reduced CFR. Showed CFR improvements from weight loss Fatty Liver Disease Elif Oral, MD MEND Role of leptin in lipodystrophy & fatty liver disease Using leptin to treat lipodystrophy & fatty liver disease Hari Conjeevaram, MBBS Gastroenterology Drug therapies & lifestyle interventions Using leptin to treat fatty liver disease Elizabeth Speliotes, MD, PhD, MPH Gastroenterology Genetic determinants of fatty liver disease Identified 90 loci associated with obesity & fatty liver disease Joint Pain Blake Roessler, MD Rheumatology Functional contribution of intra-articular fat to joint pain shown that two fat-derived hormones affect bone & cartilage formation pathways Puja Khanna, MD, MPH Rheumatology Treatment guidelines & clinical trials for gout Developing Center of Excellence for Gout at U-M Lifestyle Interventions Charles Burant, MD, PhD MEND Combining metabolomics with lifestyle research Revealing metabolic changes that lead to disease – & mechanisms through which diet & drugs may impact it Michele Heisler, MD, MPA General Medicine Encouraging patient self-management in high-risk demonstrated value of peer support & related interventions in blood-glucose control groups Kim Eagle, MD Cardiovascular Medicine Childhood obesity Launched Project Healthy Schools to improve middle school behaviors & cardiovascular risk factors Hari Conjeevaram; Elif Oral; Claire Duvernoy; see above Impact of lifestyle interventions on specific systems Melvyn Rubenfire; Rodica Pop-Busui

2011 Internal Medicine Annual Report 49 The No rth Campus Research Complex: Using Space as a Research Tool

y now, most University of Michigan watchers have read something about the North “The facility is interconnected in a way that is BCampus Research Complex (NCRC), the 174-acre former Pfizer campus that U-M unusual on an academic campus,” says purchased in 2009 to “ignite improvements to humanity’s health and well-being.” The idea Canter. “Every building, bar one or two, you was a grand one: to replace research as usual with approaches even more innovative and could walk to without going outside. The impactful. facility is connected by corridors; it’s connected with social spaces—coffee bars, Can a facility really make that kind of a each other. This is what originally attracted high tables, conference rooms. Most university difference? It depends on how it’s used, say Canter to the NCRC team. “Despite the fact buildings grow up as a series of separate planners. The key is not just using it as that the Medical School and Health System entities, yet studies have shown that proximity overflow space, but using it to add value in had committed to the cost of purchasing and and accessibility are keys to collaboration. subtle but powerful ways. “This is a running the facility,” says Canter, “other This facility is designed for that.” remarkable window of time when space is a schools were talked about in the same tool,” says David Canter, MB, ChB, NCRC sentence as being involved. It was going to A series of high-tech core scientific services Executive Director, “a tool for helping be Engineering, Information, LS&A, Dentistry, will also help bring research to the next level. interesting, imaginative programs come to Public Health, Pharmacy, and so on. It would This includes DNA sequencing, bioinformatics, life.” be that rare set of buildings that wasn’t allied methods support, microscopy, phenotyping, to one particular school. It was too and the like. “We ultimately want to co-locate This can happen in a variety of ways—from interesting to pass by.” all the scientific services in a central mall clustering dispersed researchers working on environment,” says Joan Keiser, PhD, NCRC similar topics to configuring the space so that But it’s not just researchers from various Director. “One barrier to researchers using key thinkers regularly cross each other’s disciplines that will mix. It’s mixing technology core services is just not knowing they’re paths. developers with technology users, lab available.” This would make it virtually researchers with data miners, faculty with one-stop shopping. This is precisely the plan. Collaboration, industry, junior with senior, and basic with already a cultural hallmark of U-M, would get translational—all in a space designed for But cutting-edge scientific services and a structural boost by having disparate interaction. collaborative spaces are only part of the researchers working “cheek to jowl” with picture. The space means different things to

50 2011 Internal Medicine Annual Report different people, and this is perhaps best A large part of this group is from the Center cardiac electrophysiology-type studies. In exemplified by some of the Internal Medicine- for Arrhythmia Research, directed by José addition, they’re set up in concentric circles— affiliated groups who in 2011 planted their Jalife, MD, Professor of Internal Medicine the labs surround the animal care facilities, life, MD flags at the NCRC. and Molecular & Integrative Physiology, and and the offices surround the labs. é Ja Jos Cyrus and Jane Farrehi Professor of Everything is totally seamless and Cardiovascular Research Cardiovascular Research. For Jalife’s group, convenient.” Center: the move was a natural. Recruited as a Convenient Location with Room to group of 35, they’d been located off campus They’re using this space to Grow in leased space that was several miles from break important new The first lab-based researchers to set up shop their collaborators in Engineering and the ground, particularly with at the NCRC were from the recently Medical School. The NCRC space brought stem cells. “What we’re established Cardiovascular Research Center them closer to colleagues and gave them doing now,” says Jalife, “is (CVRC), which includes members of the critical room to grow. This allowed the generating stem cells, not Cardiovascular Center and encompasses recruitment last year of another leading from embryos, but from the researchers from Internal Medicine, Pediatric arrhythmia expert, Héctor Valdivia, MD, skin of patients. We can Cardiology, Cardiac Surgery, Vascular Surgery, PhD, Professor of Internal Medicine and convert their skin cells into Pharmacology, Molecular & Integrative Frank Norman Wilson Professor of stem cells, then convert the Physiology, and the College of Engineering. Cardiovascular Medicine, and his group of 10 stem cells to heart cells.” While a number of CVRC researchers remain researchers from the University of Wisconsin. Ultimately, he hopes to use this on the medical campus, some 100 are now at process to study converted heart cells the NCRC studying the mechanisms of “The space is ideal for what Héctor and the from, for example, patients with hypertrophic cardiac muscle function and rhythm as well as rest of us do,” says Jalife. “Our labs are cardiomyopathy and their siblings to try to vascular biology. designed specifically for molecular biology and understand the genetic contributions to this

2011 Internal Medicine Annual Report 51 and other causes of cardiac arrhythmia and and Computational Medicine & Bioinformatics, Bioinformatics, Internal Medicine (Molecular sudden death. in identifying the genetic underpinnings of Medicine & Genetics), Human Genetics, rare nephrotic syndromes. Guan and Public Health. He’s seen kovitz Mar Department of will mine large data sets vid firsthand how incorporating Da Computational Medicine & (including those Kretzler bioinformatics into Bioinformatics: helped establish) for Internal Medicine Recruitment and Reach relevant pathways, research can be Another group with deep connections to and Kretzler will use transformative. Internal Medicine that has set up an outpost transgenic mice to at the NCRC is the newly formed Department test her He tells the story of Computational Medicine & Bioinformatics predictions. of a senior (DCM&B). It is chaired by Brian Athey, PhD, research leader in Professor of Internal Medicine (Allergy) and The NCRC gives Infectious Psychiatry. the DCM&B room Diseases, David to accommodate Markovitz, MD, Charged with developing novel informatics the 10 or so faculty Professor of Internal and computationally based methods, tools, they plan to hire over Medicine, who’d been and algorithms, the department has made the the next few years. It is seeking NIH funding for NCRC home to both its Bioinformatics Core also serving in some ways as years for a special aspect of and its first two recruits. Among these is a natural testbed as they his work on endogenous Yuanfang Guan, PhD, Research Investigator contemplate whether the rest of the retroviruses. “These are distant relatives of of Computational Medicine & Bioinformatics department will move. The idea of coming in HIV that account for an amazing and Internal Medicine (Nephrology). A perfect regular contact with a whole new set of proportion—around 8 percent—of the DNA example of the way in which the two potential collaborators excites Gilbert in our genome,” says Omenn. “People departments reinforce each other, Guan is Omenn, MD, PhD, Director of the Center for thought they were just relics, but David had collaborating with Matthias Kretzler, MD, Computational Medicine & Bioinformatics, evidence that some of these sequences Professor of Internal Medicine (Nephrology) and Professor of Computational Medicine & were activated in Hodgkin’s lymphoma,

52 2011 Internal Medicine Annual Report breast cancers, and perhaps other diseases. North America and didn’t even know it,” says that tend to pick up where other health- It was out-of-the-box, high-risk stuff that Canter. This is because it was a series of services researchers leave off. “A clear peer review doesn’t reward. Then the NIH successful individual groups without a larger example,” says An, “is Rod Hayward and his announced a new class of grant—the sense of identity. team in the VA Center for Clinical Transformative R01 grant—which was Management Research. One of their goals is perfect for him. So we helped him design The IHPI hopes to change that. “This is a to optimize care by personalizing treatments. these cutting-edge experiments with place where we can aggregate and share So they do a lot of work—epidemiological, high-throughput DNA and RNA sequencing that incredible wealth of expertise, creativity, statistical, meta-analytical, and methods, and, lo and behold, he got the and innovation from throughout the programming—to develop a mathematical grant—a $ 6.9 million, potentially paradigm- University,” says IHPI Interim Director model that shows how treating people in a changing grant.” Rodney Hayward, MD, Professor of Internal more individualized way could, say, double Medicine (General Medicine) and Public the efficiency of health care. Then we can Institute for Healthcare Health, and Senior Investigator at the VA come in and develop the tools that help Policy & Innovation: Center for Clinical Management Research. doctors and patients do it.” Identity and Influence Another group that plans to use the NCRC to How will they do that? First, he says, by Because of the nature of his work, An already intensify its research impact is the Institute for assembling a critical mass of co-located collaborates with some 20 health-services Healthcare Policy & Innovation (IHPI). Formally faculty along with a large cohort of others research groups spread across the approved by the Regents in May 2011, the who will use flexible touch-down spaces to University. He’s eager to have a centralized IHPI is bringing more than 150 health-services regularly drop in and work. place that will help him strengthen existing and health-care policy investigators and 250 collaborations and form new ones. research staff from across the University and This cluster of relevant researchers is partner institutions into a more cohesive and especially attractive to Lawrence An, MD, The second way researchers will share interconnected unit. Associate Professor of Internal Medicine expertise is through the use of advanced (General Medicine) and Director of the Center research cores, says Laurence McMahon, “The University already had one of the largest for Health Communications Research. His Jr., MD, MPH, Chief of General Medicine, collections of health-systems researchers in group works to develop communication tools Professor of Internal Medicine and Public

2011 Internal Medicine Annual Report 53 Health, and member of the interim IHPI be better able to translate our work to the bringing diverse groups together to work on leadership team. He’s especially enthusiastic local and national stage. I believe we will translational goals. He sees groups from about the data management core, which become known for doing some of the most Internal Medicine, Engineering, Urology, Laure nce M cM will provide access to and expertise rigorous and important health-services Surgery, Pathology, and Pharmacy working ah on in manipulating large databases research in the nation. And through IHPI, we together on cancer stem cells, detection of , Jr ., like Medicare’s, as well as the can communicate that work more effectively, circulating tumor cells, and drug discovery. M D , methods core, which will offer and partner with private and public entities M P advanced quantitative and that can use our work.” But even beyond working across divisions H qualitative approaches to and colleges, Wicha envisions entirely new health-services research. “I see the IHPI becoming like the U-M research models based on partnerships with consumer confidence index,” says Canter. pharmaceutical companies. “There are two important “Recommendations will not bear the label of goals for all this,” says Eve an individual researcher; they will carry the And this is not just a vision. “Already our Kerr, MD, MPH, Professor voice of 400 researchers known for the cancer stem-cell group is working with a of Internal Medicine (General quality and thoughtfulness of their work. The company called MedImmune,” says Wicha. Medicine), Director of the VA Institute will have that kind of gravitas.” “We’ve worked out a new kind of deal. The Center for Clinical Management company will fund selected research projects, Research, and member of the Translational Oncology: and we’ll share the intellectual property. I think interim IHPI leadership team. “The New Models for Funding and this is the future funding model—a lab that’s first is synergy. When we assemble people Translation supported partially by the NIH and partially by with different expertise, perspectives, and The Translational Oncology Program also has these new arrangements with pharmaceutical experience, we bring together ideas that by big plans for the NCRC. Max Wicha, MD, companies. From our perspective, it’s not just themselves may be very good but in Distinguished Professor of Oncology, funding; it helps get our ideas and drugs into combination could be game-changing.” Professor of Internal Medicine (Hematology the clinic—that’s what we really want to do.” “The second area is impact. By being a voice and Oncology), and Director of the U-M The NCRC couldn’t be better suited to this for U-M in health-services research, we will Cancer Center, says he’s enthusiastic about task. Not only was it originally set up as a

54 2011 Internal Medicine Annual Report space for pharmaceutical R&D, it now also includes space to co-locate public and private partners. There is even a Venture Accelerator designed to nurture any spin-off companies that emerge from University research.

The Road Ahead As 2011 closed, the NCRC reached an interesting milestone—its first 1,000 faculty and staff had moved in. With 2,000 left to go, many leaders throughout the Health System and University were already hard at work considering who the next 1,000 should be. They hope the final mix will be a potent one—not merely in terms of advancing U-M’s research agenda or even rallying the region’s economy, but in truly igniting improvements to human health.

2011 Internal Medicine Annual Report 55 education BUILDING A SOLID FOUNDATION Internal Medicine’s Vital Role in Undergraduate Medical Education

Cyril Grum, MD, a Professor in the Division of Pulmonary and Critical Care Medicine and the Senior Associate Chair of Undergraduate Programs for the Department of Internal Medicine is passionate about education and the role that Internal Medicine plays in training the next generation of clinicians and researchers at U-M. “It is a third of our mission: Education, patient care, and research. Faculty provide spectacular mentorship to medical students both during their basic science years [first and second years] and during their clinical years [third and fourth years],” he explains.

In the latest U.S. News & World Report Putting the Patient into rankings of medical schools, U-M’s Medical Patient Care School tied for 10th overall for research In addition to his role as the Associate Chair medical schools, and 8th overall for primary for Undergraduate Programs, Dr. Grum is also care medical schools. “Our department the Clinical Director for U-M’s third- and should really be proud of this recognition. fourth-year medical students. It is during these Internal Medicine faculty deliver more than a years students learn the art and science of quarter of the entire four-year curriculum and medicine by taking care of patients. Dr. Grum our faculty hold key leadership positions has the pleasure of leading them into the within the Medical School,” Grum adds. “The brave new world of clerkships and related quality of our faculty’s teaching and the vast student curriculum. “It’s a real eye-opening amount of clinical opportunities we provide experience for the students—being on the ensure that U-M’s medical students are front lines—but they love it. I have never heard extremely well-prepared to become doctors. one of them wish to go back to the first two Our graduates are considered top recruits for years of course work. I think the joy of taking some of the best graduate residency care of patients is unlike any other. That’s why programs across the country.” most of us went into the profession of medicine: to take care of patients and to be their doctors,” he explains.

58 2011 Internal Medicine Annual Report This direct interaction between medical about medicine. They work closely These conditions address both acute illnesses students and patients has been an important with our faculty and house staff to gain the and chronic diseases and require a variety of and long-standing tradition at Michigan. expertise and professional attributes that communication and technical skills. “No The Medical School was one of the first to will make them excellent physicians,” matter what specialty a student eventually successfully introduce the concept of the explains Grum. selects as their career choice, this Internal clinical clerkship in 1899. Because U-M Medicine training is providing the foundation owned its own hospital, clerkships could be New Initiatives for good, solid, and well-rounded patient set up directly at that hospital. Other medical The Department of Internal Medicine has also care,” explains Grum. schools had previously tried to incorporate started several new initiatives this past year to clerkships into their curriculum, but privately make the clerkship even better: Formal mid-clerkship feedback evaluations owned hospitals would not allow medical to review each student’s progress students to work with their patients. Today, Increased faculty observation of M3 physical (how many patients and how Michigan’s clerkships consist of a sequence exams were added to the curriculum to many conditions/ of seven clinical rotations that are completed augment the extensive training students diseases they’ve in family medicine, internal medicine, already receive during first and second years. seen, etc.) have neurology, obstetrics and gynecology, Students are now working with faculty in also been pediatrics, psychiatry, and surgery. The clinics conducting physical exams to bolster introduced. Department of Internal Medicine’s 12-week their knowledge and access new skills. This ensures clerkship is the longest and most extensive that of all of them. The twelve conditions that every student students should see were recently revised. They now are right “I strongly believe students learn best while are 1) chest pain, 2) dyspnea, 3) anemia or GI on track participating in the care of patients, and the bleeding, 4) abdominal pain or liver disease, 5) to gain clinical years are marked by extensive preventive care, 6) fever, 7) hypertension, 8) the practical application. Through this diabetes, 9) kidney failure, 10) joint or back apprenticeship, they need to focus on pain, 11) smoking cessation or nutrition learning about the patients in order to learn counseling, and 12) a geriatric assessment.

2011 Internal Medicine Annual Report 59 INTERNAL MEDICINE FACULTY LEADING THE U-M MEDICAL SCHOOL James Woolliscroft, MD Dean

necessary skills and meet the curriculum students that makes 22 percent of graduates Joseph Kolars, MD requirements that are needed. selecting Internal Medicine as their specialty. Senior Associate Dean for Education and These are top-notch students. Ten of the 34 Global Initiatives The department has also put a premium on also hold advanced degrees such as a PhD Monica Lypson, MD providing students with rapid feedback as or Master’s degree and five were inducted Assistant Dean for Graduate Medical well. “We are now getting grades and into the Alpha Omega Honor Society, the Education, Interim Associate Dean for evaluations out much faster to students than only national honor medical society in the Diversity ever before. One hundred percent of our world,” says Grum. Steven Gay, MD, MS grades were out in four weeks or less. This is Assistant Dean for Admissions much better than the national average. It’s It also appears that Dr. Grum’s passion for also a culture shift for the faculty. It’s teaching is not lost on his students. He was Rajesh Mangrulkar, MD reinforcing our commitment to education, named the Class Marshal by the Medical Assistant Dean for Educational Innovation putting it on par with our clinical School class of 2011. Class Marshals that and Technology Implementation responsibilities,” adds Grum. are nominated and voted on by the students Roger Grekin, MD in recognition of their contributions to the Curriculum Director for the first two years A Lasting Impression class have the honor of leading the class Cyril Grum, MD It appears that Internal Medicine’s impact on processional into the auditorium on Curriculum Director for third and fourth medical education at U-M is making a strong graduation day. This was his 13th year years impression on the next generation. “This past leading the class since 1990. There will most year the Medical School had the highest likely be many more. Robert Lash, MD number of graduating students selecting Director, Clinical Foundations of Medicine Internal Medicine (25) and Medicine- Arno Kumagai, MD Pediatrics (9) as a career—there were 34 Director, Social and Behavioral Issues in students total. Of the 154 graduating medical Medicine

60 2011 Internal Medicine Annual Report 2011 Education + Teaching AWARDS

Student Awards Faculty and House Officer Kevin R. Flaherty, MD, MS, was presented The William Dodd Robinson Award was Teaching Awards with the Medical School Community Service given by the faculty of the Department of The Galens Medical Society awards Bronze Award. Cary En gleb Internal Medicine to graduating seniors Beepers to house officers who they feel have erg , M Stephanie Videka Sherman and William been exemplar in their teaching duties Cary Engleberg, MD, DTM&H, D , D T John Zacharias for their outstanding towards medical students. This year, five from Internal Medicine’s M & performance in the junior medicine clerkship were awarded to house officers in Internal Division of Infectious H and senior electives in internal medicine. Medicine and Medicine-Pediatrics: Sophie Diseases, was honored with Califano, MD; Carl Hammaker, MD; Eric a Lifetime Achievement in The Eli G. Rochelson Memorial Award was Riles, MD; Jessica Tsui, MD; and Javier Medical Education award given to Melissa Isabelle Lygizos for the Valle, MD. from the Medical School most outstanding performance in pulmonary for his efforts and and critical care medicine by a graduating The Galens Medical Society Silver Shovel achievements in medical medical student. Award went to Sandro K. Cinti, MD, as the education at Michigan and faculty member voted to be the most abroad over the last 25 outstanding clinical teacher. years.

The Kaiser-Permanente Award for Excellence in Teaching was presented to two Internal Medicine faculty this year: Kim Eagle, MD, received the award for pre-clinical teaching and Sandro K. Cinti, MD, received the award for clinical teaching. The Kaiser Award is the highest teaching award at the Medical School, recognizing faculty for dedication to quality teaching, enthusiasm, and efforts to improve the experience of each student.

2011 Internal Medicine Annual Report 61 outreach At the Forefront of the Field: Top Gastroenterology Journal Comes to Michigan

n July 2011, the University of Michigan Istarted its five-year term as the editorial Bishr team behind Gastroenterology, the Oma ry, most prominent journal in the field MD , P of gastrointestinal disease. The hD new Editor-in-Chief is Bishr Omary, MD, PhD, the Chair of the Department of Molecular & Integrative Physiology, Professor of Internal Medicine, and H. Marvin Pollard Professor of Gastroenterology. His editorial experiences include serving as Associate Editor of Gastroenterology from 2006 to 2011 and Molecular Biology of the Cell from 2004 to 2011.

“We have a wonderful team that works so well together. It’s also fun and exciting to be at the forefront of what’s going on in the field.”

64 2011 Internal Medicine Annual Report “This is a ‘society’ journal that is published by Gastroenterology delivers up-to-date and the American Gastroenterological authoritative coverage of both basic and Association, and the editorial team rotates clinical gastroenterology (www.gastrojournal. every five years. The Society selected U-M as org/). Regular features include articles by the new team due to the strength of its leading authorities and reports on the latest Division of Gastroenterology and the research treatments for diseases. It also bridges the here. It’s a great honor for us and an gap between basic and clinical science by opportunity for the faculty—nine out of the publishing comprehensive reviews and 16 editors are from Michigan (see page 64) perspectives on important topics such as and it brings instant visibility to the institution. pancreatitis and liver disease. It’s a highly respected journal that’s read internationally,” explains Omary. Being the Gastroenterology is ranked first of 71 journals editor of a major journal also takes a great in the Gastroenterology and Hepatology commitment. Dr. Omary estimates that he is category on the 2011 Journal Citation now spending an additional 20 hours a week Reports® and its impact factor has been on top of his usual duties on this task. “I between 12 and 13 during the past few wouldn’t trade it. We have a wonderful team years, and only 12 percent of submitted that works so well together. It’s also fun and manuscripts are ultimately accepted. Its exciting to be at the forefront of what’s going immediacy index, which is a measure of how on in the field.” he adds. topical and urgent work published Gastroenterology is, is 2.9, the highest in the About Gastroenterology field.Gastroenterology is circulated to 19,000 As the official journal of the American individuals and institutions worldwide. Gastroenterological Association Institute,

2011 Internal Medicine Annual Report 65 Gastroenterology Malcolm J. Low Special Section Editors: Thomas D. Wang Board of Editors University of Michigan Medical School Covering the Cover University of Michigan Medical School Jean-Michel Pawlotsky Anson W. Lowe Editor-in-Chief: University of Paris–Est Stanford University Selected Summaries M. Bishr Omary Philip S. Schoenfeld Richard H. Moseley University of Michigan Medical School Linda C. Samuelson University of Michigan Medical School University of Michigan Medical School University of Michigan Medical School Senior Associate Editors: Print and Digital Media Reviews Bruce E. Sands Press Highlights John M. Carethers Joel H. Rubenstein Mount Sinai School of Medicine Grace L. Su University of Michigan Medical School University of Michigan Medical School Detlef Schuppan University of Michigan Medical School Anna S. Lok Johannes Gutenberg, University of Mainz Reviews in Basic and Clinical University of Michigan Medical School Mentoring, Education, Diane M. Simeone Gastroenterology and Hepatology and Training Corner Chung Owyang University of Michigan Medical School Robert F. Schwabe John Del Valle University of Michigan Medical School Columbia University Jerrold R. Turner University of Michigan Medical School Associate Editors: The University of Chicago John W. Wiley University of Michigan Medical School Jonathan Braun John A. Williams Clinical Challenges and Images in GI University of California, Los Angeles University of Michigan Medical School Grace Elta University of Michigan Medical School Biostatistical Editors: Douglas A. Corley Julie A. Douglas Online Editor: Robert J. Fontana Kaiser Permanente, Division of Research University of Michigan Medical School John F. Kuemmerle University of Michigan Medical School William L. Hasler Medical College of Virginia Campus, Virginia Cathie Spino University of Michigan Medical School Commonwealth University Imaging and Advanced Technology University of Michigan School of Public David Lieberman Ralf Kiesslich Health Oregon Health and Science University Johannes Gutenberg, University of Mainz

66 2011 Internal Medicine Annual Report A New Chapter for Continuing Medical Education at Internal Medicine

Tremendous Changes at U-M he year 2011 marked a tremendous amount of change for continuing medical education T (CME) at the University of Michigan. The U-M Medical School stopped accepting any pharmaceutical funding for its CME offerings on January 1, 2011. They were the first in the country to do this and there were a lot of concerns about what the consequences would be. Would this result in less CME offerings? Less public outreach for U-M? How would this affect the care of patients throughout the state and region?

All practicing physicians in the state of In 2011, the Office of CME Michigan must complete 50 hours of dissolved and oversight of the continuing medical education a year to CME activities of the Medical maintain certification. U-M has always been School shifted to the Office of the state’s leading provider of CME Continuous Professional opportunities and the Department of Internal Development (OCPD). The Medicine has traditionally offered the most OCPD now designates AMA CME course offerings. PRA Category 1 Credit™ for the Medical School’s more than 300 The loss of industry funding did result in a CME activities per year (e.g., major reduction in the number of CME events grand rounds, journal clubs, and for community physicians offered by the courses). Individual departments Medical School. In 2010, there were 54 are now responsible for the course offerings (38 of which were provided production and finances of all of by the Department of Internal Medicine). For the CME activities they sponsor, 2011, that number dropped by nearly 50 including all of the marketing and percent to 28 total (20 of which are provided event planning activities. by the Department of Internal Medicine).

Internal Medicine CME Team: Allison Picinotti, James Froehlich, MD, MPH, and 2011 Internal Medicine Annual Report Jennifer Goodwine 67 Internal Medicine’s Medicine’s CME Medical Director, James The team was able to go ahead with the 13 Next Steps Froehlich, MD, MPH, an Associate courses that had been planned for 2012 In the wake of these funding and structural Professor in the Division of Cardiovascular (listed at right). They are now in the process changes, both the Medical School and the Medicine, implementing: of planning for next year, which involves individual departments started closely re-evaluating CME budgets, as well as examining their approach to CME. The • Online registration processes identifying missed opportunities and events Division Chiefs came to the Chair of the • Marketing strategies that could be combined. They also plan to Department of Internal Medicine, John • Redesigning marketing materials videotape future courses so they can be Carethers, MD, with their concerns about • Refining data collection offered online to physicians and other health the future of CME. An Internal Medicine CME • Streamlining mailing lists care providers nationwide, and even reach Steering Committee was created to explore • Hiring a program coordinator, our alumni and former fellows. This will allow how to best respond to these new changes. Jennifer Goodwine them to reach largely untapped markets that Given the department’s size and amount of would be interested in taking our CME offerings, it was decided that Internal “Our Internal Medicine CME team is the first offerings but not able to travel to Michigan. In Medicine would need to create its own CME of its kind in the U-M Health System,” addition, they are also exploring alternative team and office to best meet the needs of its explains Froehlich. “We’ve been focusing on funding sources that include non- 12 divisions. developing strategies and refining processes. pharmaceutical corporate sponsors. Given all of the recent changes, everyone at In late 2011, Allison Picinotti, formerly the Michigan is re-evaluating why and how they As for the questions and concerns about Marketing and Development Manager for the offer CME—its purpose, funding, and CME at Michigan, many of them still remain, Division of Metabolism, Endocrinology and structure.” but for now the new team is positive about Diabetes/U-M Comprehensive Diabetes the future. “Right now, everyone here is Center, was brought on board as Internal “We are excited to build a successful CME excited about having this new office. We’re Medicine’s first CME Program Manager to program. We have done a lot of work over the hopeful that our work and focus will actually create the new program from the ground up. past five months but we still have more to do. end up working even better than the old She has been extremely busy in her first few There are a lot of new strategies we want to CME formula for the Department of Internal months working closely with Internal incorporate into the program” adds Picinotti. Medicine,” adds Picinotti.

68 2011 Internal Medicine Annual Report The new Department of Internal Medicine CME Office website can be found at: www.med.umich.edu/intmed/cme

2012 CME Courses • 16th Annual Common Problems in Office Practice • Pathogenesis and Management of Systemic Sclerosis: An Update • Advanced Liver Disease and Liver Transplantation Update 2012 • Update on Arrhythmias & Syncope: What’s New in Arrhythmia Management 2012 • Northern Michigan GI-Liver Wrap-up • 30th Annual Internal Medicine Update • 25th Annual Cardiology Update • Clinical Issues in the Care of Older Adults: Updates in Medication Management • 25th Annual Update in Pulmonary & Critical Care Medicine • Updates in Nephrology for the Primary Care Provider • Endocrinology & Diabetes Update • 9th Annual IBD Update for the Practicing Physician • 15th Annual Liver Disease Wrap-up

2011 Internal Medicine Annual Report 69 MEDICINE, SHE WROTE

Preeti N. Malani, MD, MSJ, an Associate Professor in the Divisions of Infectious Diseases and Geriatric Medicine, didn’t always plan on being a physician. Her first love was writing.

She started out writing for her high school newspaper. As an undergraduate at U-M, she wrote for the Michigan Daily and majored in communication with a self-designed focus on medical journalism. She went on to complete a master’s degree in journalism at Northwestern University’s Medill School of Journalism.

A CHANGE IN DIRECTION While fascinated by the field of medicine, she was undecided about it as a career until she covered a story for the Dayton Daily News about a young man who had died in a motorcycle accident. His family had donated his organs. This act benefited the lives of five people. While researching this story, the medicine, and the medical professionals involved, she explains, “I thought to myself, I want to be a part of this. I don’t want to just write about this, I want to do this.”

70 2011 Internal Medicine Annual Report Malani went back to medical school and She now serves as the Associate Editor for As for the future, Malani has no plans to alter earned her M.D. degree from Wayne State Infection Control and Hospital Epidemiology her combined career path. If anything, she University School of Medicine and completed and the Assistant Deputy Editor at Clinical hopes someday to be the Editor-in-Chief of a her internal medicine residency and infectious Infectious Diseases, a leading journal with a top tier journal and also pursue her interests diseases fellowship at the University of broad international readership. She is also in nonmedical writing. Michigan, where she also received a master’s Co-Editor of the third edition of Practical degree in clinical research design and Healthcare Epidemiology and the second statistical analysis. She completed fellowship edition of Best Practices in Infection “Working behind the scenes on a top journal, training in geriatric medicine at the Oregon Prevention and Control: An International Health and Science University. She came Perspective. you really need to be in the clinical loop to back to join the faculty of the U-M Department of Internal Medicine in 2004. Malani also finds that she’s regularly applying maintain quality. You’re communicating to the these skills in both clinical and research THE BEST OF BOTH WORLDS settings. “I feel that my journalism background entire field—changing practice and improving Even though her career path took a twist that actually helps a lot with my clinical work. care. That’s what I love. I don’t want to give brought her here, Malani regularly I know how to ask the right questions, how incorporates her passion and talent for to interview my patients, how to investigate that up.” writing into her work. In fact, she still answers. I also use my editorial experience dedicates about 25 percent of her time to it. to help colleagues communicate about their She worked for the Journal of the American research. I teach junior faculty how to craft a Medical Association throughout graduate story. I ask them ‘What’s going on?’ ‘What’s school and medical school and still your angle?’ ‘What can you tell me that will contributes to their media and books section. help me do my work?’” she explains.

2011 Internal Medicine Annual Report 71 American Society for Clinical Investigation Association of American Members Physicians Members

Peter Arvan, MD, PhD Joel Howell, MD, PhD Kenneth Pienta, MD Peter Arvan, MD, PhD David Markovitz, MD Ariel Barkan, MD Patrick Hu, MD, PhD David Pinsky, MD John Carethers, MD Juanita Merchant, MD, PhD Ernesto Bernal-Mizrachi, MD H. David Humes, MD Bertram Pitt, MD C. William Castor, Jr., MD Fred Morady, MD George Brewer, MD Mariana Kaplan, MD Pavan Reddy, MD Kathleen Cho, MD Martin Myers, MD, PhD* Ronald Buckanovich, MD, PhD* Eve Kerr, MD, MPH Bruce Richardson, MD, PhD Kathleen Collins, MD, PhD* Akinlolu Ojo, MD, PhD* John Carethers, MD Alisa Koch, MD Theodora Ross, MD, PhD Stefan Fajans, MD M. Bishr Omary, MD, PhD C. William Castor, Jr., MD Ronald Koenig, MD, PhD Sanjay Saint, MD, MPH Eric Fearon, MD, PhD Gilbert Omenn, MD, PhD Kathleen Cho, MD Matthias Kretzler, MD Alan Saltiel, PhD David Fox, MD Chung Owyang, MD Kathleen Collins, MD, PhD Benjamin Margolis, MD Jim Shayman, MD Thomas Gelehrter, MD Marc Peters-Golden, MD Daniel Eitzman, MD David Markovitz, MD Robert Sitrin, MD David Ginsburg, MD David Pinsky, MD Stefan Fajans, MD Laurence McMahon, Jr., MD, MPH Theodore Standiford, MD Gary Hammer, MD, PhD* Bertram Pitt, MD Eric Fearon, MD, PhD Juanita Merchant, MD, PhD Andrea Todisco, MD Daniel Hayes, MD Jim Shayman, MD David Fox, MD David Miller, MD, PhD* Thomas Wang, MD, PhD H. David Humes, MD Theodore Standiford, MD Thomas Gelehrter, MD Fred Morady, MD Stephen Weiss, MD Jose Jalife, MD Galen Toews, MD David Ginsburg, MD Martin Myers, MD, PhD Max Wicha, MD Stevo Julius, MD Joel Weinberg, MD Thomas Glaser, MD, PhD Akinlolu Ojo, MD, PhD Roger Wiggins, MB, BChir Alisa Koch, MD Stephen Weiss, MD Stephen Gruber, MD, PhD M. Bishr Omary, MD, PhD John Williams, MD, PhD Ronald Koenig, MD, PhD Max Wicha, MD Jeffrey Halter, MD Chung Owyang, MD Xiaochun Yu, MD, PhD Anna Lok, MBBS, MD* Roger Wiggins, MB, Bchir Gary Hammer, MD, PhD Marc Peters-Golden, MD Malcolm Low, MD John Williams, MD, PhD Benjamin Margolis, MD

* New Member in 2011–2012

72 2011 Internal Medicine Annual Report

NEW APPOINTMENTS

Raymond Yung named Chief and all aspects of the clinical, research and A specialist in the care of older adults with of Division of Geriatric and education missions of the Division, including arthritis, Yung is a sought-after clinician who Palliative Medicine fellowships in geriatric medicine and palliative has been recognized in Best Doctors in Raymond Yung, MB, ChB, was appointed care medicine. With Yung’s appointment, the America. He is a member of both the as Chief of the Division of Geriatric and Geriatric Medicine Division has been geriatric and rheumatologic societies and is a Palliative Medicine in the Department of renamed the Geriatric and Palliative Medicine regular reviewer of manuscripts and grants. Internal Medicine and Co-Director of the Division. This change highlights the Division’s He also serves as the associate director for Geriatrics Center at the University of role in geriatric palliative care and the research for the Geriatrics Research, Michigan on Nov. 1, 2011. Hospice and Palliative Medicine fellowship, Education and Clinical Care Center (GRECC) and the commitment to advancing palliative of the Ann Arbor VA Health System. Yung is He succeeds Jeffrey B. Halter, MD, who medicine as a core mission. nationally recognized for his research on served as Chief of the Division of Geriatric inflammation and aging. He joined the U-M Medicine since its inception in 1984 and “Ray is an outstanding clinician, researcher, faculty in 1996. remains Director of the U-M Geriatrics and educator, and is ideally suited to Center. shepherd the Division for the foreseeable future,” says John Carethers, Chair of the Yung is a U-M professor of Internal Medicine Department of Internal Medicine. “He will who is board-certified in both geriatric work closely with Geriatrics Center Director medicine and rheumatology. As Division Jeff Halter, who has guided and grown the Chief, he is responsible for faculty matters Division to its highly recognized national stature.”

74 2011 Internal Medicine Annual Report Scleroderma Program Khanna was most recently Assistant welcomes Dinesh Khanna, MD, Professor of Medicine at UCLA and Director as new director of its scleroderma clinic. The author of more U-M’s Division of Rheumatology, Department than 120 peer-reviewed publications and of Internal Medicine, announced the book chapters, Khanna is also the recipient appointment of Dinesh Khanna, MD, MS, of the 2011 “Best Doctor of the Year” award as Director of the Scleroderma Program in from the National Scleroderma Foundation. July 2011. Khanna is Associate Professor of He is currently funded by the National Medicine and Marvin and Betty Danto Institutes of Health and is leading efforts to Research Professor. develop guidelines for the management of scleroderma and gout. The Scleroderma Program is a multidisciplinary group of caregivers, scientists, and clinical researchers dedicated to advancing knowledge about scleroderma and related conditions. Scleroderma, meaning “hard skin,” causes abnormal growth of connective tissue, which affects the skin and internal organs.

2011 Internal Medicine Annual Report 75 Laurence H. Baker Collegiate Professorship in Cancer Developmental Therapeutics Established

he U-M Department of Internal Medicine is pleased to announce the completion of Society of Clinical Oncology Distinguished T the Laurence H. Baker Collegiate Professorship in Cancer Developmental Service Award for Scientific Leadership and Therapeutics in the Division of Hematology & Oncology. Statesman Award, the American Cancer Society Distinguished Service Award, the This professorship recognizes leading one of the largest federally funded Sarcoma Foundation of America Nobility in the importance of Dr. Baker’s cancer clinical trials cooperative groups in the Science Award, and the Jeffrey A. Gottlieb impressive contributions to world. Additionally, he is an internationally Memorial Award for Outstanding medical oncology and his recognized authority in early and late stage Achievement in Cancer Therapeutic leadership in clinical cancer translational research and survivorship in Research. research, patient care, and sarcomas. education at the University Through this named permanent endowed of Michigan. He has Dr. Baker serves as a scientific consultant to professorship, the Division of Hematology/ devoted his career to the the National Cancer Institute as well as many Oncology and the Department of Internal improvement of cancer university cancer center scientific advisory Medicine wish to honor Dr. Baker for his care with a multidisciplinary boards. He has authored more than 200 myriad contributions to the University of team approach focused on articles in peer-reviewed journals and more Michigan and the field of cancer the patient, innovative clinical than 50 books or book chapters. He is the developmental therapeutics. trials, and the integration of recipient of numerous awards, including the laboratory and clinical research University of Michigan Dean’s Award for findings to advance new treatments Achievement in Clinical and Health Sciences and developmental therapeutics. Dr. Research and Token of Appreciation from Baker has been Chair of SWOG since 2005, Medical Students Award, the American

76 2011 Internal Medicine Annual Report Timothy T. Nostrant, MD, retires

fter four decades of service to the University of Michigan and the field of gastroenterology, Outstanding Clinician Award from the Dean’s A Dr. Timothy T. Nostrant retired from active practice to join his family in South Carolina. A Office in 2008. two-day event celebrating his career and achievements took place on September 23–24, 2011, at U-M. Throughout his career, Dr. Nostrant was also recognized nationally Dr. Nostrant joined the Department of Gastroenterology, and Acting Division Chief for as an authority in clinical Medicine as a House Officer in 1973 and Gastroenterology. He was the lead physician gastroenterology and a completed his Gastroenterology fellowship in and architect for the Faculty Diagnostic Unit, serious educator. He 1979, whereupon he became a faculty which was designed to serve as a national participated in over 70 member at U-M. From the very start, he model for the development of the Clinician visiting professorships, exhibited the attributes of a master clinician: Scholar Track. Its multi-subspecialty approach seminars, and extramural trusted by his patients, respected by his to consultations has become a blueprint for invited presentations. He colleagues, and admired by his students. His other departments within U-M. In the 1980s, authored over 100 peer tremendous clinical knowledge and expertise, Dr. Nostrant recognized that endoscopy review papers on digestive made him the “go-to” person in the Division would become one of the major diagnostic disorders and has been a for any GI problems. tools in gastroenterology. With this in mind, he member of the editorial board convinced U-M to build the Medical for several gastro-intestinal He guided the creation of the infrastructure Procedures Unit, which is the model for all journals. At the state level, Dr. and foundation of the clinical operations for endoscopy units in the nation today. Nostrant served as the President of the Division of Gastroenterology. In the early the Detroit Gastro-enterology Society 1980s, he spearheaded and developed Over the years, Dr. Nostrant trained more than and as Governor of the Michigan chapter clinical procedures and systems, many of 300 fellows who are now practicing in 33 of the American College of Gastroenterology. which are still in place. His talents as a states. His clinical knowledge and judgment On a national level, he served on several clinician and administrator led Dr. Nostrant to have made him one of the most popular committees for both the American serve in a broad spectrum of clinical roles clinical gastroenterologists in the state of Gastroenterological Association and the including Physician Leader, Outpatient Clinic Michigan. He received numerous awards for American College of Gastroenterology. Director, Inpatient Chief for the Division of his teaching contributions, including the

2011 Internal Medicine Annual Report 77 IN MEMORIUM

Giles G. Bole Giles G. Bole, a former dean of the dean until 1990. In 1990 Bole was appointed the end of Bole’s tenure as Dean, the Medical Medical School who specialized interim dean of the Medical School and was School commissioned a cultural diversity in arthritis research and formally named dean in July 1991. The audit, helping the School to critically assess rheumatology, passed away Medical School was recognized in several itself and develop new ways of integrating the in June 2011. He was 82 notable ways during Bole’s tenure, receiving a values associated with diversity into the years of age. Robert Wood Johnson Clinical Scholars School’s culture. Bole’s leadership brought Program Grant and being re-designated one about improvement and growth in the physical Dr. Bole spent nearly his of the top members of the NIH Medical plant of the Medical School and the entire entire academic career at Science Training Program. The School also U-M Medical Center. the University of Michigan, was re-funded with the largest General Clinical earning his BS in 1949 and Research Grant provided by the National The Medical Science Research Building his MD in 1953. In 1959 he Institutes of Health. The Medical School III was built, and the older Medical joined the Medical School moved up from sixteenth to ninth in the U.S. Science Buildings I and II were renovated faculty and from 1969 to News & World Report rankings of research- and remodeled. The Medical School 1986 was director of the intensive medical schools, and in 1996 it administration worked with the Michigan Rackham Arthritis Research ranked ninth in total research funding from the delegation in Congress to obtain funding for Unit. In 1975, Bole became chief NIH. Bole also oversaw the appointment of 12 the remodeling and reconstruction of the of the Rheuma-tology Division in department chairs, as well as the appointment Ann Arbor VA Medical Center. In July 1996, the Department of Internal Medicine, a of the director of the NIH General Clinical Bole announced his intention to step down position he held until 1986 when he joined Research Center and co-directors of the from the Deanship and return to the faculty; the Dean’s Office. He served as the Medical Mental Health Research Institute. In 1992, he was named Dean Emeritus of the Medical School’s associate dean for clinical affairs, the School started using a radically new School shortly thereafter. He retired from U-M then as senior associate dean and executive curriculum, and to better serve the students, in 2003. associate class size was reduced from 207 to 170. Near

78 2011 Internal Medicine Annual Report Galen B. Toews Galen B. Toews, MD, FACP, a pioneering divisions throughout the country followed recognition of his major contributions to lung researcher who led the Division of his template for patient-oriented research the areas of research, education, Pulmonary and Critical Care Medicine at the training. clinical care, and service, Toews University of Michigan Health System for was awarded the Paul De Kruif more than 20 years, passed away in Toews graduated from the University of Lifetime Achievement Award October, 2011, after stepping down in Oklahoma School of Medicine in 1971 and from the U-M Department of September due to illness. completed an internship and residency in Internal Medicine in 2011. internal medicine at Parkland Memorial Toews was a leader in the field of respiratory Hospital in Dallas, Texas. He served as an research for more than 30 years. Based Army doctor at Fort Polk in Louisiana and on his contributions to the field, he was then completed pulmonary and immunology nominated by his colleagues for the fellowships at The University of Texas Distinguished Achievement Award from the Southwestern Medical Center before joining American Thoracic Society. His research the faculty there in 1979. In 1987, he was focused on the body’s immune response appointed the Chief of the Division of and the role it played in human lung disease, Pulmonary and Critical Care Medicine in the including idiopathic pulmonary fibrosis Department of Internal Medicine at U-M. He (IPF). Toews was also known for fostering was promoted to full professor in 1991 and collaboration between basic science served as Associate Dean for Research at research and clinical investigators. His efforts the U-M Medical School from 2006–2008. In helped to make U-M one of the premier 2002, he was given the Michigan Thoracic institutions for the diagnosis and treatment Society’s Bruce H. Douglas Award for of IPF and other lung diseases. Pulmonary contributions to pulmonary medicine. In

2011 Internal Medicine Annual Report 79 For more information about the University of Michigan Department of Internal Medicine, go to: www.med.umich.edu/intmed

For detailed information about individual divisions, please visit their website:

Allergy and Clinical Immunology: www.med.umich.edu/intmed/allergy Cardiovascular Medicine: www.med.umich.edu/cvc Gastroenterology: www.med.umich.edu/gi General Medicine: www.med.umich.edu/intmed/genmed Geriatric Medicine: www.med.umich.edu/geriatrics Hematology & Oncology: www.med.umich.edu/intmed/hemonc Infectious Diseases: www.med.umich.edu/intmed/infectious Metabolism, Endocrinology & Diabetes: www.med.umich.edu/intmed/endocrinology Molecular Medicine & Genetics: www.umich.edu/~mmgmed Nephrology: www.med.umich.edu/intmed/nephrology Pulmonary & Critical Care Medicine: www.med.umich.edu/intmed/pulmonary Rheumatology: www.med.umich.edu/intmed/rheumatology

University of Michigan Department of Internal Medicine 3110 Taubman Center, SPC 5368 1500 East Medical Center Drive Ann Arbor, MI 48109 (734) 936-4340

80 2011 Internal Medicine Annual Report