Curriculum Vitae Ana Tuya Fulton, MD, FACP (Ana Cristina Tuya, MD)

Transcription

1 Curriculum Vitae Ana Tuya Fulton, MD, FACP (Ana Cristina Tuya, MD) December 13, 2016 PERSONAL INFORMATION Business Address: Butler 345 Blackstone Blvd, Center House Rear #211 Providence RI Business Phone: Business Fax: Business or EDUCATION Undergraduate The George Washington University Washington DC. Major in Psychology, BA. Graduation Summa Cum Laude Early Acceptance to The George Washington University School of Medicine. Medical School The George Washington University School of Medicine Washington DC. Awarded MD and graduated with distinction on May 20, POSTGRADUATE TRAINING Residency Brown University, Rhode Island, Rhode Island. Internal Medicine PGY Eddy Street JB 0100 Providence RI Chief Residency Brown University, Rhode Island. PGY 4 Internal Medicine. Fellowship Brown University, Rhode Island, Division of Geriatrics. Geriatric Medicine Fellowship Brown University Harriet W. Sheridan Center for Teaching and Learning Certificate I POSTGRADUATE HONORS AND AWARDS 2005 Haffenreffer Fellow in Medical Sciences in the Internal Medicine Program. Awarded for work done chief residency year 7/2004-6/ Chosen as Futures Program Participant for the 2006 American Medical Directors Association (AMDA) Annual Meeting 2007 Geriatric Academic Career Award (GACA) from HRSA awarded Three year funding for academic geriatricians. 1

2 2011 Recommended for Invited Fellowship to American College of Physicians. Elected a Fellow of the College March 1, John A. Hartford Foundation Featured Change AGEnt July 2016 MILITARY SERVICE Not applicable PROFESSIONAL LICENSES AND CERTIFICATION 2005 Certification in Internal Medicine by the ABIM 2006 Certification in Geriatric Medicine by the ABIM 2006 Doctor of Medicine, Rhode Island Department of Health DEA license state of Rhode Island ACADEMIC APPOINTMENTS Brown University. Assistant Professor of Medicine, Division of Geriatrics & Palliative Medicine Brown University. Assistant Professor of Medicine (Clinical), Division of Geriatrics & Palliative Medicine 2015-present Brown University. Associate Professor of Medicine (Clinical), Division of Geriatrics & Palliative Medicine 2015-present Brown University. Associate Professor of Psychiatry and Human Behavior (Clinical) HOSPITAL APPOINTMENTS 2006-present Admitting privileges at Rhode Island, Rhode Island 2006-present Admitting Privileges at The Miriam, Rhode Island Director of Education, Division of Geriatrics, Rhode Island 2008-present Privileges at Kent, Rhode Island 2008-present Chief of Internal Medicine, Butler present Director of Internal Medicine Education, Butler 2014-present Privileges at Memorial, Rhode Island 2014-present Privileges at Women & Infants, Rhode Island 2014-present Director of Geriatric Medicine, Care New England Health System 2016-present Chief of Geriatrics, Care New England Health System 2016-present Medical Director, Integra Community Care Network, LLC OTHER APPOINTMENTS Editor, Geriatrics for the Practicing Physician. Monthly column of Medicine and Health Rhode Island publication of the RI Medical Society Objective review committee (ORC) member for the review of grant applications received for the HRSA : Geriatric Education Centers (GEC) Member, Women s Health Advisory Committee to the Rhode Island Department of Health. Appointed March

3 2010 Guest Editor, Special Edition Nursing Home Care Medicine and Health Rhode Island present Member, Providence Community Transitions Coalition. Representing Butler 2012-present Participant, Lt Governor Workforce on developing the Rhode Island State Alzheimer s Plan based on the National Alzheimer s Plan 2014-present Member, Healthcentric Advisors Safe Transitions Advisory Board Peer Reviewer for the following medical journals or organizations: Journal of the American Geriatrics Society 2009-present HRSA, Geriatric Education Center Grants 2010 and ongoing as needed Annals of Internal Medicine, January 2011-present American Geriatrics Society Abstract Reviewer, 2011 Annual Meeting American Geriatrics Proposal Reviewer for 2015 & 2016 Annual meetings American Journal of Hospice and Palliative Care HOSPITAL COMMITTEES Member, Geriatric Medicine Fellowship committee, Rhode Island Member, Ethics Committee, Butler Member, Medication Safety Committee, Butler 2008-present Member, Clinical Leadership Committee, Butler 2008-present Chair, Infection Control Committee at Butler 2008-present Co-Chair, Medical Emergency Response Team Committee, Butler 2008-present Member, Medical Executive Committee, Butler 2009-present Member, Medical Equipment Committee at Butler 2009-present Co-Chair, Critical labs committee, Butler 2011-present Member, Fall Prevention Committee, Butler Member, Medical Administration Committee, Butler 2012-present Chair, Transitions of Care Committee, Butler 2014-present Member, Credentials Committee, Butler 2014-present Member, Senior Leadership Butler Member, Care management advisory group, Care New England Health System Member, Quality Council, Care New England Visiting Nurses Association UNIVERSITY AND RESEARCH COMMITTEES Member, Reynolds Foundation Grant Executive Committee, Brown University/Rhode Island Division of Geriatrics 2008 Chair, Residency Advisory Group Committee on Reynolds Foundation Grant, Brown University/Rhode Island Division of Geriatrics Member, Scholarly Concentration Committee, Brown University Member, Faculty Executive Committee, Brown University 3

4 Ex-officio member Medical Faculty Executive Committee Brown University Member, Reynolds Foundation Grant 2 Executive Committee, Brown University/Rhode Island Division of Geriatrics MEMBERSHIP IN SOCIETIES American Medical Association 2005-present American Geriatrics Society 2005-present American College of Physicians Rhode Island Medical Society Society for General Internal Medicine PUBLICATIONS LIST ORIGINAL PUBLICATIONS IN PEER-REVEWED JOURNALS 1. Tuya, A, Hohenhaus, M. Case presentations of the Brown University Department of Medicine Miriam Morbidity and Mortality Conference: A Case of Cardiac Sarcoidosis. Medicine and Health Rhode Island. November 2005, p Tuya A, Besdine RW. Geriatrics for the Practicing Physician: Using the Comprehensive Clinical Approach to Older Patients. Medicine and Health Rhode Island. January 2007; 90(1): Tuya A. Geriatrics for the Practicing Physician: Managing the Medication Portfolio & Avoiding Polypharmacy in the Older Adult. Medicine and Health Rhode Island. February 2007; 90(2): Tuya, A. Geriatrics for the Practicing Physician: The Management of Insomnia in the Older Adult. Medicine and Health Rhode Island.June 2007; 90(6): Tuya, A. Transitions of Care: A Topic for the Present and Future. Medicine and Health Rhode Island. July 2007; 90(7): Tuya, A. Teno, J. Feeding Tubes for Nursing Home Residents with Advanced Dementia: How to Approach Feeding Tube Decisions. Medicine and Health Rhode Island. January 2008; 91(1): Farrell, T. Tuya, A. Nutrition in the Older Adult. Medicine and Health Rhode Island. February 2008; 91(2): Starr, R. Fulton Tuya A. Case Presentation: Mr. J An 88-year-old man found on the floor, complaining of generalized weakness. Medicine and Health Rhode Island. June 2008; 91(6): Fulton Tuya A. Dementia Screening: Should We Screen Asymptomatic Older Adults? Medicine and Health Rhode Island. July 2008; 91(7): Fulton Tuya A. Treating Depression in the Older Adult. Medicine and Health Rhode Island. June 2009; 92(6): Fulton Tuya A. Geriatrics for the Practicing Physician A Pause for Reflection & Acknowledgement. Medicine and Health Rhode Island. October Epstein-Lubow G, Fulton Tuya, A, Gardner R, Gravenstein S, Miller I. Post- Transitions: Special Considerations for Individuals with Dementia. Medicine and Health Rhode Island. April 2010; 93(4):

5 13. Fulton Tuya, A. If you are over 65 Can you have your cake and eat it too? Medicine and Health Rhode Island. June 2010; 93(6): Fulton Tuya A. Nursing Home Care: An Introduction. Medicine and Health Rhode Island. December 2010; 93(12): Fulton Tuya A, Epstein-Lubow G. Family Caregiving at End of Life. Medicine and Health Rhode Island. February 2011; 94(2): Fulton Tuya A. Exciting News in the Area of Prevention and Screening. Medicine and Health Rhode Island. March 2011; 94(3): Rhodes-Kropf J, Huai C, Castillo EH, Fulton Tuya A. Managing the Patient with Dementia in Long-Term Care. Clinics in Geriatric Medicine. May 2011; 27(2): Fulton Tuya A, Rhodes-Kropf J, Corcoran AM, Chau D, Castillo EH. Palliative Care for Patients with Dementia in Long-Term Care. Clinics in Geriatric Medicine. May 2011; 27(2): Fulton Tuya A. The Farewell Column: Geriatrics for the Practicing Physician. Medicine and Health Rhode Island. June 2011; 94(6): Epstein-Lubow, G, Fulton Tuya A. Post- Transitions for Individuals with Moderate to Severe Cognitive Impairment. Annals of Long-Term Care: Clinical Care and Aging. 2012; 20(3): McNicoll L, Fulton Tuya A, Ritter D, Besdine R. Cadaver Treasure Hunt: Introducing Geriatrics Concepts in the Anatomy Class. J American Geriatrics Society. 2012; 60(5); Teno JM, Gozalo P, Mitchell SL, Kuo S, Fulton AT, Mor V. Feeding tubes and the Prevention or Healing of Pressure Ulcers. Arch Intern Med. 2012; 172(9): Fulton Tuya A, Sullivan James K, Price Lawrence. Concurrent Care at an Academic Psychiatric. Psychiatric Services. 2013; 64(3): Fulton Tuya A, Gozalo P, Mitchell SL, Mor V, Teno JM. Intensive Care Utilization among Nursing Home Residents with Advanced Cognitive Impairment. Submitted to Journal of Palliative Medicine. 2014; 17(3): Teno Joan M, Meltzer D, Fulton Tuya A, Mitchell S, Gozalo P, Mor V. The role of physician specialty and severely demented hospitalized nursing home residents treatment. Health Affairs. 2014; 33(4): Epstein-Lubow G, Fulton AT, Marino LJ, Teno J: Hospice Referral after Inpatient Treatment of Individuals with Advanced Dementia from a Nursing Home. American Journal Hospice and Palliative Care Jun; 32(4): OTHER PUBLICATIONS IN PEER-REVIEWED JOURNALS 1. Fulton Tuya A, Teno JM. What if feeding tubes actually cause harm to patients with advanced cognitive impairment. Editorial. Aging Health. October 2011; 7(5): BOOKS AND BOOK CHAPTERS 1. Fulton Tuya A. Dysphagia. In: 5 Minute Clinical Consult Editions. Lippincott Williams & Wilkins. 5

6 2. Fulton Tuya A, Teno JM. Advance Care Planning: Focus on communication and care planning rather than on building the perfect form. In Rogne L, McCune Lauraine S. (Eds.), Advance Care Planning: Communication about matters of life and death (33-44) New York, NY: Springer PUBLISHED ABSTRACTS 1. Tuya AC, Gifford DR. The Clinical Utility of SPECT in the Diagnosis of Alzheimer s Disease. J Am Geriatr Soc 2005; 53(supplement): S McNicoll L, Nanda A, Fulton Tuya A, Curtin A, Dexter C, Hurley M, Roach R, McMackin N, Besdine R. Novel Program for Faculty Development of Geriatrics Educator Clinicians. [abstract] J Am Geriatr Soc 2009; 57(supplement): S Ragsdale L, Gutman D, Tuya A. High-fidelity Medical Simulation for Geriatrics Emergency Medicine Training. J Am Geriatr Soc 2008; 56(supplement): S Epstein-Lubow G, Fulton Tuya A. Improving the Post- Transition for Geriatric Inpatients: Special Considerations for Cognitive Impairment. Am J Geriatr Psychiatry 2011; 19(3): S Fulton Tuya A, Price LH, Sullivan JK, Perez-Carter I. Falls in Geriatric Inpatients in a Psychiatric. J Am Geriatr Soc 2014; 62(supplement 1): S210. ABSTRACT PRESENTATIONS 1. POSTER presentation, The clinical utility of SPECT in the diagnosing of Alzheimer s Disease, at the National American Geriatrics Society Annual Meeting, 2005 Orlando, Florida, USA. 2. POSTER presentation, High-fidelity Medical Simulation for Geriatrics Emergency Medicine Training. Ragsdale L, Gutman D, Fulton Tuya A, at the National American Geriatrics Society Annual Meeting, 2008, Washington DC. 3, SYMPOSIUM Fulton Tuya A, Epstein-Lubow G. Improving the Post- Transition for Geriatric Inpatients: Special Considerations for Cognitive Impairment. American Association for Geriatric Psychiatry Annual Meeting, March 20, San Antonio, TX, USA. 4. Fulton Tuya A, Gozalo P, Mitchell S, Mor V, Teno JM. Intensive care use among nursing home residents with advanced cognitive impairment. Accepted for poster presentation. Gerontological Society Annual Meeting, November Boston, MA, USA. 5. Teno Joan M, Gozalo P, Mitchell S, Kuo S, Fulton Tuya A, Mor Vince. Does Percutaneous Gastrostomy Tubes Prevent or Heal Decubitus Ulcers In Advanced Cognitive Impairment? Accepted for Paper presentation. American Academy of Hospice and Palliative Medicine & Hospice and Palliative Nurses Association Annual Assembly, March 7-10, 2012 in Denver, CO, USA. 6. Epstein-Lubow G, Fulton Tuya A, Marino L, Teno J. Palliative Care Referral following Inpatient Psychiatry Treatment for Advanced Dementia. Poster presentation. American Association for Geriatric Psychiatry Annual Meeting, March 15, Los Angeles, CA, USA. 6

7 7. Fulton Tuya A, Sullivan JK, Price LH, Carter Perez I. Falls in Geriatric Inpatients in a Psychiatric. Poster presentation. American Geriatrics Annual Meeting, May 16, Orlando, Florida, USA. 8. Poster presentation. Integrating Palliative Care & Geriatrics into Primary Care within an ACO. Fulton Tuya A, Lally K. Center to Advance Palliative Care. National Seminar 2016, Orlando Florida, October 27, Poster presentation. ACO s and the Seriously Ill: Integrating Geriatrics and Palliative Care. Fulton Tuya A, Lally K. Institute for Healthcare Improvement National Forum Orlando, Florida, December 5, SCHOLARLY WORK PUBLISHED IN OTHER MEDIA 1. Resources for Geriatrics Education public website on Brown Center for Gerontology Web page, with mirror site on Brown Internal Medicine Residency Intranet page. URL: (merged into other web page by Center for Gerontology 2013 up from ) 2. Comprehensive Curriculum outlines with suggested exam questions for The Warren Alpert Medical School of Brown University: Suggested aging content for Endocrine, Renal, Hematology, and Gastroenterology courses INVITED PRESENTATIONS INTERNATIONAL 11/2015 Webinar; Institute for Healthcare Improvement series on Advancing Palliative Care in the Era of Value Based Care. Expedition lecture #5: Building Collaborations between Geriatrics and Palliative Care. Presented on November 11, /2016 Minicourse Workshop lead for Institute for Healthcare Improvement s 17th Annual Summit on Improving Patient Care in the Office Practice and the Community on Flipping Healthcare: Operationalizing What Matters Most. Orlando Florida. Presented on March 20, NATIONAL 03/2011 Improving the Post- Transition for Geriatric Inpatients: Special Considerations for Cognitive Impairment. Symposium at American Association for Geriatric Psychiatry Annual Meeting, March 20, 2011 San Antonio, Texas 04/2014 Advanced care planning: Communicating about life and death. Association for Death Education and Counseling. Annual meeting, Baltimore MD. Panel presentation. 11/2015 The Role of Payer-Provider Partnerships in Improving Access to Palliative Care. Center to Improve Palliative Care annual meeting, San Antonio Texas. Panel presentation and symposium. 6/2016 Webinar: Butler : Bridging the Divide: An Inpatient Psychiatric s Approach to Improving Transitions of Care. 7

8 Presented on June 23, Audience across 6 New England States, 200+ attendees. LOCAL 11/2006 Whole Patient Program. Presented to freshman PLME undergraduate students who are in the 8-year combined baccalaureate/md program at Brown. The Whole Patient Program is a dinner plus speaker event. The physician brings along a patient so that both can discuss the doctor/patient relationship as it relates to the patient s health care 04/2009 The Elusive UTI. Geriatric Psychiatry Grand rounds at Butler 07/ /2011 Brown Summer Studies Course. Career discussion with high school students in the So You Want to be a Doctor Course 12/2010 Geriatric Psychiatry Grand Rounds at Butler Falls Prevention and Assessment 03/2011 Geriatric Psychiatry Grand Rounds at Butler Improving the Post- Transition for Geriatric Inpatients: Special Considerations for Cognitive Impairment 10/2011 Transitions of Care presentation; invited speaker to Butler Clinical Quality Council yearly conference 05/2012 Transitions of Care presentation; invited speaker to Geriatrics Division Fundamentals lecture series, Rhode Island 06/2012 Rethinking Alzheimer s disease; invited speaker to Butler Medical Staff Association Meeting 07/2013 Brown Summer Studies Course. Career discussion with high school students in the So You Want to be a Doctor Course 07/2014 Brown Summer Studies Course. Career discussion with high school students in the So You Want to be a Doctor Course 12/2014 Senior Net View Community Meeting Guest speaker, Creating an Innovative Health System Wide Program for Older Adults at Care New England 6/2015 Kent Grand Rounds Geriatric Medicine Across Care New England 12/2016 Webinar. RI-GEC and NE-QIO. Conversations & Goals of Care: Introduction to Palliative Care & Hospice. MEDIA PRESENTATIONS 08/2007 Guest on Nuestra Salud on Latino Public Radio Discussed Geriatrics, prevention, and health issues relevant to older Hispanics. 09/2011 Guest on NBC Channel 10 news Providence RI. Inteviewed to discuss end stage dementia and effects on caregivers. 09/2011 Guest on WPRO Gene Valecenti radio program interviewed to discuss end stage dementia and caregiver stress 8

9 GRANTS COMPLETED: 1. 07/ / Assistant Director to the Reynolds Foundation Grant under PI, Richard Besdine, MD, Funding amount: 2,000, / / Geriatric Academic Career Award (GACA) from the Department of Health and Human Services (HRSA). Funding amount: 50,000/year for salary support to advance academic career of junior faculty Hartford Scholar Hartford Foundation Center of Excellence Grant to Brown University. Funding amount: 30,000 to Division of Geriatrics at Rhode Island 4. 02/ /2014: Co-Investigator "Needs assessment of patients and family members regarding prevention of psychiatric hospitalization for dementia." Supported by the Surdna Foundation and Butler, and in coordination with Dr. Joan Teno and the Center for Gerontology and Health Care Research at Brown. PI: Gary Epstein-Lubow, MD. Funding amount: 25, /2014 Hartford Foundation Change AGEnts action award - Designing a New System-wide Geriatric Medicine Program for Care New England. 1 year award, 10,000. CURRENT: 1. 07/ /2017: Co-Investigator and Director of Psychiatry Curriculum in Donald W. Reynolds Foundation - Next Steps in Physicians Training in Geriatrics. PI: Richard W. Besdine, MD. Funding Amount: 1,000, / /2018: Care New England (CNE) Site Director, Co-Project Director for CNE on Geriatric Workforce Enhancement Program from the Department of Health and Human Services (HRSA) for RI-GWEP project. Funding amount: 850,000/year to University of Rhode Island Geriatric Education Center and multiple partners for a geriatric workforce enhancement program to integrate primary care and geriatrics across the state of RI. TEACHING ROLES Director of the Geriatric Rotation for Internal Medicine Compulsory Intern rotation, Rhode Island Coordinated the rotation schedule (3-4 residents/month, each with an individualized schedule with multiple sites/preceptors), organized and planned for all lecture series, shadowing experiences, and clinical work. Participated in, gave lectures and evaluated all parts of the curriculum for ongoing improvement over time present Continuity Clinic Preceptor for Internal Medicine Residents, Rhode Island Volunteer to the program; second and third year residents assigned to participate in my outpatient, later inpatient practice for continuity. One resident, Christopher Jones, later went on to do Geriatrics fellowship Site preceptor; Geriatric medicine fellows at Butler on consultative medicine in the geriatric psychiatry patient 9

10 /2016 Director of Internal Medicine Education at Butler Implemented and organized the creation of various ongoing educational programs at Butler hospital since taking on the role of Chief of Internal Medicine & Director of Education. First was the establishment of a regular educational program in the monthly physician meeting series Updates in Internal Medicine. Additionally, a multi-disciplinary in-service program was formalized to deliver similar pertinent updates in internal medicine and case based learning to the staff on the inpatient units. Ad hoc lectures, case based teaching and lectures within the psychiatry residency lecture series also done on a regular, annual basis present Faculty Geriatric Anatomy Workshop Series Clinical correlations session for first year medical students. Participated as one of the faculty in the 2-3 sessions per academic year. Geriatrics faculty attends the anatomy lab and rotate at 4-5 tables to describe anatomical findings in the setting of clinical correlations Coordinator of Geriatric Anatomy Workshop Series Medical Student 1 st year Anatomy Engage faculty to participate, provide the ongoing education and evaluation of the program and participate in the workshops as well Doctoring mentor Volunteer site for any interested medical students for the clinical, shadowing experience /2016 Rotation director Consultative Internal Medicine Elective for 4 th year Psychiatry Residents For fourth year psychiatry residents who would like additional internal medicine experience from the specific perspective of treating inpatients on psychiatric units 2013-present with acute and chronic co-morbidities. Director of Psychiatry Curriculum in Donald W. Reynolds Foundation - Next Steps in Physicians Training in Geriatrics Co-investigator on the grant project. Designated director of psychiatry curriculum. Identify content needs, and to develop educational curriculum for all psychiatry residents to receive during the first year of the grant (19 hours total). Educational effort was coordinated, organized, and almost all lectures delivered by me /2016 Preceptor & rotation director consultative internal medicine rotation for geriatric psychiatry fellows Month-long rotation to participate in geriatric medicine consultations on the 2014-present 2014-present inpatient geriatric psychiatry unit at Butler hospital. Rotation director Kent Family Medicine Residency Geriatrics rotation Month long rotation for 2 nd or 3 rd year family medicine residents in geriatric medicine based at Butler hospital with rotations throughout CNE geriatrics efforts Rotation director Kent Internal Medicine Residency Geriatrics rotation Month long rotation for 2 nd or 3 rd year family medicine residents in geriatric medicine based at Butler hospital with rotations throughout CNE geriatrics efforts LECTURES 10

11 8/2006 Comprehensive Geriatric Assessment. Presented to the internal medicine housestaff at noon conference, Rhode Island 02/2008 History and Physical of the Geriatric Patient. Noon conference to the Medicine housestaff, VA Medical Center 08/2008 Medical Emergencies. Psychiatry Residents, Butler. 11/2010 Medical Emergencies. Psychiatry Residents, Butler. 11/ /2012 Metabolic syndrome. Psychiatry residency at Butler hospital 07/2011 Medical emergencies, Psychiatry Residents, Butler 07/2013 Medical emergencies, Psychiatry Residents, Butler 10/2013 Reynolds 2 PGY 4 s Psychiatry CNS changes with Age, Butler 11/2013 Introduction to Geriatrics What is a Geriatrician to IM and FM residents at Kent, Warwick RI 01/2014 Reynolds 2 PGY 4 s Psychiatry Dementia, Butler 02/2014 Reynolds 2 PGY 4 s Psychiatry Hospice, Palliative Care and goal setting, Butler 03/2014 Reynolds 2 PGY 4 s Psychiatry Pharmacology, Butler 06/2014 Reynolds 2 PGY 4 s Psychiatry Sleep and Sleep disorders of Aging, Butler 11/2014 Reynolds 2 PGY 4 s Psychiatry CNS changes with Aging, Butler 11/2014 Basic Geriatrics and Polypharmacy Kent IM residents, Kent 12/2014 Reynolds 2 PGY 4 s Psychiatry Delirium in Older Adults, Butler 2/2015 Reynolds 2 PGY 4 s Psychiatry Pharmacology, Butler 5/2015 Reynolds 2 PGY 4 s Psychiatry Dementia, Butler 6/2015 Reynolds 2 PGY 4 s Psychiatry Hospice, Palliative Care and goal setting, Butler 11/2015 Delirium Kent IM residency noon conference, Kent 1/2016 Dementia Kent FM residency noon conference, Kent 5/2016 Goals of care conversations, role play Psychiatry 4 th year residents, Butler 8/2016 Goals of care conversations, role play Psychiatry all residents, Butler 9/2016 Medication management and Polypharmacy Psychiatry 4 th year residents, Butler 9/2016 Goals of care conversations, role play MHRI Internal Medicine residency noon conference, MHRI 11