University Cardiology Survival Guide
Dr. Jeremy Mahlow is currently overseeing new physician orientation for the group. Please feel free to communicate with him about any orientation issues. We will assign a “new physician buddy” to each new physician that joins the group. Feel free to contact this person with any questions at any time for the first few months.
Any of the other partners should be willing to help out as well. Jason Raiford Davis is the practice manager. Stacy Kinder is his assistant. Hospital credentialing and orientation emails could be directed to Stacy Kinder.
University Health System Inc. (UHS) is the official employer. This entity is directly responsible for orientation process (Stacey is mainly a liaison between you and them). Organizational charts for UHS can be found at https://insite.utmck.edu/departments/human-resources/organizational-charts/.
Please budget 2 days to do orientation related activities (getting parking passes, computer login, ID badge, etc.) If you have patients scheduled to see you on your first day, arrive at least 2 days earlier as you need to have certain things “up and running” before seeing patients. Please make sure you know when your first patient is scheduled, and plan to arrive at UT 2 days earlier than that. Please see Dr. Mahlow and JayShree to get proper access to the computer software programs/websites.
UHS Cardiology (also known as University Cardiology, formerly Knoxville Cardiovascular Group or KCVG) is the only cardiology group at UT. We have about 25 cardiologists. There are about 6 interventionalists and 4 electrophysiologists. There are 9 general cardiology fellows and 1 interventional fellow. More information can be found at http://www.utcardiology.com/. UHS is employing the physicians that comprise University Cardiology.
There are three inpatient care cardiology services: the Acker, London, and Rawson services. The interventionalists rotate staffing the Acker (CCU) service, and the general cardiologists staff the London/Rawson services a week at a time. There are cardiology fellows, nurse practitioners, and often medical residents on each service. There are night shift nurse practitioners that cover the services at night, and we rarely get paged at night. There is an EP service with an EP doctor on call 24/7 by phone; there is also a CHF service with a CHF expert on call 24/7 by phone. Occasionally, patients with purely EP issues or purely CHF issues may go to the EP or CHF services after discussion with the attending on those services. New consults are distributed to the appropriate service by an office staff member who will communicate with the attending on call via PerfectServe.
The interventionalists manage all the STEMIs/temporary pacing wires/Impella/Balloon pumps that come in, and they cath all the inpatients that need urgent cath. Some non-interventionalists give all their outpatient caths to the interventionalists; most have a procedure day every other week. The EP attendings and some of the structural heart specialists have multiple procedure days every week.
Each doctor’s role is specified on the daily rounding list available each morning in the medical records room. Our schedules are also available online at uconcall.com/attendings, and your personal schedule can be synch’ed to your smartphone or desktop computer calendar. There is a schedule assigning duties to the EKG reader, echo reader, nuclear test reader, and TEE doctor. There is also a schedule assigning doctors to sign in at the cardiac rehabilitation center on the first floor (it takes 5 seconds to sign in there). Call schedules are done 6-12 months in advance. There is an online procedure to switch call with another partner. Paid time off and adjustments to your schedule should be requested through your medical assistant (MA). There is a procedure to assign outpatient ASAP visits to each doctor that will be handled through your MA.
University Cardiology is located in Building E, the Heart Lung Vascular Institute. We park in the parking garage next to this building, but you can park basically anywhere. Offices are on the 3rd floor. Stress tests are done on the second floor. Cardiac rehabilitation is on the first floor. A bridge to the hospital is on the second floor. The cath lab is on the other side of the bridge. The heart hospital is on the other side of the hospital and has four floors. The ER is on the first floor. The doctors lounge is in the basement. The inpatient computer system is called PowerChart. The outpatient computer system is called Centricity. Cath films and Echo exams are stored on Xcelera workstations, and radiology images can be accessed via the PACS system. Dr. Mahlow can help you get access to all of these from home if you like (and he has some helpful computer tools/scripts available on uconcall.com). Lifestar is a service that transports patients by helicopter. If you get paged to “9111” it is probably Lifestar wanting to transfer a STEMI. Lifestar (dial 9111) can also accept faxes for you and email those to you.
There is an echo tech available 24 hours a day. The rounding sheet has their pager number. Sometimes you will be asked to read stat echoes on call, and there is a way to do that from home (ask Dr. Mahlow).
Several physicians occasionally go to satellite clinics in areas such as Etowah, Jefferson City, etc.
The computer system is frustrating at times, but it is so everywhere. Many helpful utilities are available at uconcall.com. On the inpatient side, everything is electronic- no more paper chart. On the outpatient side, we have Centricity. You will have a Desktop view in Centricity. The bottom half of the screen will contain chart documents- these are part of the permanent patient record and must be signed, looked at, or acted upon. The top half of the screen contains alerts. Alerts are a great way to communicate with your MA or other partners, but they are NOT part of the permanent record and they disappear (untraceably so) after 30 days. Thus, if you said something important in an alert (“refer patient to pulmonology to evaluate their mass on chest X-ray”), make sure either you or your MA converts that alert into some kind of permanent chart document.
We have a master list in records room that is updated by staff before 6am every morning. You can either write new patients on the master list or use the electronic hospital list system (see Dr. Mahlow for that). The list has patients, locations, physicians and ICD 10 codes. The list also designates who is on various tasks for the day (echo, PET, office nuke, EKG, TEE, EP, interventions); these schedules are made long in advance, but helpful to know on rounding list who’s doing what.
Call is divided into 12 hour blocks (day call 6a-6p, night call 6p-6a). You do not have to be in house for all hours of call. Unless called for emergency earlier, most of our physicians come in for day call between 6:30 and 7:30am, depending on personal style/preference (you can call our records room to see how many morning consults you have and adjust accordingly). For night call, most of our physicians stay at home (especially if we have a Fellow on call), but we do have call room with a TV in the office.
If you are not on an inpatient service, then you will not have to make hospital rounds; you can focus on your clinic and outpatient duties.
Sometimes a patient on the inpatient list may have a “W/S.” This means that it is a Dr. Wehber patient, but since Dr. Wehber is out that day, Dr. Shepple has been assigned to see the patient. EP consults are handled this way too: “W/M” might mean that both Dr. Wehber and Dr. Mahlow are following the patient (Dr. Mahlow is the EP consultant).
We have become much more of a consultative service rather than an “admission” service, especially in regard to patients through our own ED. You will learn the many reasons behind this. Interventionalists admit STEMIs, and some STEMIs are “auto-accepted” by lifestar which means you must see them in the cath lab. If is not a true STEMI then you can ask another service to admit the patient after your initial evaluation is complete. Cardiac arrests (unless it’s a STEMI) are generally admitted by critical care medicine. If you admit a STEMI/cardiac arrest, then you will consult critical care anyway and they are very helpful (manage vent, hypothermia, other ancillary issues). You will get called frequently by ED in patients that have elevated troponins but are not STEMIs; this is more of a “pass or play” option. If it sounds like a true straightforward ACS without other complicating medical features and you are going to cath patient early, then many of us will go ahead and admit that patient ourselves. But the lion’s share of patients will be admitted to UTH (UT Hospitalist service), Housestaff Medicine (IM Residents), or UFP (University Family Physicans service which also has residents).
The transfers from outside facilities are a little different and more controversial within our group. The prevailing thought in past has been accept the patient and get them here, and then if looks like noncardiac issue, consult UTH and can even ask them to take on their service as primary. We have a lot of patients in the hinterlands and we don’t want to throw up roadblocks to getting our patients here. That being said, this thought process has been evolving some too and there is some push to try to get more of those patients admitted to medicine service (you will grow to know the Afib/RVR, hypotensive with trop leak that gets here and is a septic train wreck). It’s your discretion, but we don’t want to be blocking transfers on patients with legitimate cardiac issues obviously. If you are called to accept a patient and you think they should go to the medicine service, you can just tell that to the operator or to Lifestar and they will make all the arrangements most of the time for you (so you don’t always need to call the medicine service yourself).
Almost always you will have a fellow, resident, or intern (or some combination) on call with you. The fellows do about a 14 or 15 hour shift of day call that lasts until the evening. There are generally nurse practicioners that work at night and handle most of the cross cover and consults (although they will call you with questions). Currently the fellows are on call from 6 AM to 8 PM, the NPs are on from 8 PM to 6 AM.
As stated above, all hospital rounds will be managed by the various inpatient services, although the EP physicians will round on their patients.
If you have consulted on a patient who is stable from cardiology standpoint but is remaining in hospital for other issues, you can at your own discretion choose to “sign off” that patient (try to indicate that in your note so the primary service knows- although a few of our colleagues often don’t do this, which inevitably leads to a frustrating call to the on call doctor a few days later). You should also write an order in PowerChart called “Cardiology Sign Off” when this happens. When you sign off a patient, write a “P” (for pass) next to patient’s name on our office rounding list in our records room (more on that below). On Fridays, you can also put a “WP” which means “Weekend Pass.” This means that you will still see the patient on Monday, but the weekend rounding team doesn’t need to see them unless they are paged.
Weekend coverage will also involve reading inpatient nuclear stress tests (here we do Lexiscan PETs and have great reading software we’ll teach you), EKG reading and echo reading. The EKGs are split between the doctors not on day call that day. Friday day call doc will read (on Saturday morning) the echos done Friday night; Saturday day call reads Saturday echos, Sunday day call reads Sunday echos. All of your duties will be on uconcall.com/attendings.
This is something that most of us straight out of fellowship were completely unprepared for, but you will pick it up surprisingly quickly. When you learn our Centricity office EMR system, you will learn how to bill your office visits in the computer. Our staff handles imaging billing which is great.
Our hospital charges are now done either on paper or on computer, but the computer system is greatly encouraged. You will get a rounding list, write your name at top, and highlight the patients you see and write the appropriate CPT code(s) and ICD 10 code(s) (try to have three ICD10 codes). You will give you MA that paper each day. Or, you can use the computer to submit the charges- Dr. Mahlow will orient you on that.
The choice of what level to bill office and hospital visits is complex, controversial and variable based on physician. More on this in person.
If you will be out of the office, make sure you assign all your patients to other physicians (for example if Dr. Shepple is out of town, he will write “S/M” next to his patients to assign them to Mahlow. This is less of an issue now that our patients are managed by the inpatient services, but may be an issue for the EP and CHF attendings. Please directly communicate about each patient with the attending that you sign them out to.
Medical Staff meetings are quarterly at 6pm in the Garden Plaza portion of the hospital. These meetings typically last an hour, and great food is served. Our own group also meets at least quarterly (dinner NOT served), and these meetings typically start at 5pm on a Wednesday and last 90 minutes (or hopefully less).Cath conference is every Monday at 4:30PM. This is multi-disciplinary with cases sometimes presented by the fellows but also presented by Attendings. CT Surgery is typically present. During this conference, we typically show cath films and/or echo and/or nuclear images. I would say that 3-5 Attendings are usually present (in other words, not everyone comes to this).Journal Club for the fellows is usually monthly on a Thursday at 5pm. One of the drug reps usually provides a light dinner for this. Attendings chair Journal Club on a rotating basis. That month’s Attending is welcome and encouraged to choose to articles that he or she finds of special interest.
In hospital, phones have 4 digit extensions. You will quickly learn which ones go where (9111 is UT LifeStar, who pages out STEMIs in addition to many of our transfers). If calling a hospital number from outside line, the prefix is 305- then four digit extension. In hospital, dial 29 to get an outside line. In office, dial 4- then four digit extension when calling the hospital. Our office phones have 3 digit extensions; the only ones I know are my MAs, and the records room (129). When dialing an office extension from outside line, the prefix is 246-7___. The great majority of communication among our partners and MAs is via mobile phone or the PerfectServe App.
You will learn this on the fly, but here’s a brief primer… The Heart Hospital is the West tower (8 floors): 2 is CVICU, 4 is primary cardiology floor, 6 is neuro ICU, 7 is mixture of CT surgery and other cardiology patients, 8 is vascular. Patients with a sheath still in place must go to 7 West, CVICU or CVR (cardiovascular recovery, adjacent to cath lab). The East Tower has 12 floors. 4 East has the COU (clinical observation unit) where a lot of chest pain/rule outs go. The South Tower has 7 floors. 2 south is cath lab. MCC (medical critical care) and step down are on 5 south. The North Tower houses Surgical ICUs mostly on 2 North (Trauma, Surgery etc) and 1 unit on 4 North.
Each physician has an initial +/- a number that we use on the patient list and schedules. Don’t try to make sense of it, some are first names, some are last, some are extensions…
A3- John Acker
B- Stuart Bresee (PCI)
B2- Mike Bailey (EP)
J- Jim Cox (EP)
J2- Jeff Johnson
R- Raj Baljepally (PCI)
L- Joe Liu
H- Jeff Hirsh
H2- Russ Huntsinger
M2- Matt Chua (Sevierville)
O- Tjuan Overly (PCI)
C2- Jay Crook
G- Gayathri Baljepally
V- Carmelo Venero (PCI)
V2- Tony Villarosa
M- Jeremy Mahlow (EP)
S- Ben Shepple
D- Steve Dolacky (PCI)
P- David Perkel
M3- Muddassir Mehmood (CHF)
K- KayLeigh Litton (PCI)
K2- Anne Kassira
W- Amy Wehber
T- Roger Thompson
R3- Morgan Randall (PCI)
Interventionalists (7): Dolacky, Bresee, Raj Baljepally, Overly, Venero, Randall
EPs (4): Cox, Hirsh, Mahlow, Bailey
General (8): everyone else