D epartment
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Con ne c ti ng T e c h n o lo g y , Ed uca t i o n a n d D i s cove ry w ith H um anis m in Me dicine
Vol. 11 Issue 2 Apr. 2022
Resident Reflections: Serving & Learning Through the COVID-19 Pandemic Four years of medical school followed by a minimum of three years of residency is the typical path for one to become a practicing physician. It means countless hours spent studying and understanding diseases, learning how to both diagnose and treat them, with the intent of applying that knowledge to a patient. Common pathologies such as heart failure, chronic obstructive pulmonary disease, diabetes, hypertension, and various presentations of sepsis are the bread-and-butter diseases one typically sees in an internal medicine residency and becomes proficient in managing. For many of us, having completed only a few months of residency training, these common pathologies were not so common. A different disease, one not yet found in medical textbooks, was running rampant, consuming hospital beds and resources, as well as creating a staffing shortage never seen before. This disease was also dissuading patients who would typically present to the hospital sick, to stay home because of fear of contracting this novel virus. This disease was COVID-19, and it affected our residents in many ways. Salem Karadsheh was a fresh intern, excited to start his residency here at UT Knoxville. He knew his internship would be different than previous residents due to the current COVID-19 pandemic. He recalls, “I had to adapt quickly to residency. There were times when my senior resident changed multiple times in a week due to senior residents getting sick. One week we had to resort to 4th call because so many residents were out quarantining. Despite these setbacks, I always felt
supported by my colleagues and attendings. The pandemic taught me to become a better learner, staying up to date on the latest treatments and guidelines to provide the best care to my patients. Although at first I was not able to see the broad pathologies I had hoped to encounter, I learned how to be a compassionate physician and have tough conversations with patients and their families.” Salem states his knowledge base has grown immensely since the beginning of residency, and he is excited to pass on his experiences to the incoming interns. Brandon Morris, one of the current PGY-2 residents, was greatly affected by the COVID-19 pandemic. He said the hardest part of COVID-19 was the uncertainty and unknown.
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Points of View
trainees or staff to any specific gender, race, religion, geography, or other stereotypes. We are dedicated to providing equal opportunity, inclusivity, and resources to all members of our department. We wish to promote a culture with respect for all individuals and an environment that recognizes the differences among members of our workforce and nurtures these differences in a collegial manner. To further promote our inclusiveness, we plan to introduce a new feature in our Newsletter that highlights our diversity and multiculturalism. Each quarter, we plan to interview one member of our department from different regions of the world about their country of origin, languages they speak, their beliefs, customs, festivals, foods, traditions and other notable achievements in medicine, science, literature, music, and the arts in their native lands. Hopefully, this will promote further conversation and desire to learn more about each other outside the workplace, in our clinics, in the hospital and among our neighbors. In turn, this will encourage better understanding and communication with our patients and colleagues from diverse backgrounds. We are willing and eager to embark on this important journey.
Diversity, Equity, & Inclusion In the month of January 2022, the Graduate School of Medicine hosted a number of events to highlight diversity, equity, and inclusion (DE&I) on our campus. The Dean, Dr. Hauptman, arranged for several speakers to give talks related to this topic in efforts to highlight and promote these ideals within our Rajiv Dhand, MD, Chair institution. This is a good start, but we recognize that, like many other institutions in the country, there is much that needs to be done and we have a long road ahead of us. In the Department of Medicine, we endeavor to build an environment where each member feels valued as an integral part of the program and we are committed to upholding greater DE&I among our faculty, trainees, and staff. We have a multi-cultural department with representation from many different continents of the world. For a start, we don’t limit our recruitment for faculty, 1
Resident Clinic Service Project Kay Rangnekar serves as the director for the UT Internal Medicine and OBGYN clinic and describes her staff as “the most generous people I have come across.” Ms. Rangnekar’s passion for service developed at a young age through her father, who was a Rotarian and whose motto was “service above self.” Kay continues to practice this motto through her role at the clinic and states, “Since joining in 2017, I have seen the generosity of my staff. They have always donated to the causes that we work for and help serve.” Some of the ways the clinic serves those in need is by passing out goody bags including soap, sanitary napkins, oral hygiene products, or canned food. “Anything the patient needs is given,” states Ms. Rangnekar. Additionally, a supply of peanut butter and crackers is kept in the office, and if a patient hasn’t eaten and is hungry, a staff member will go to the hospital cafeteria and bring food for him or her. Not only does Ms. Rangnekar and the clinic staff serve their patients while at work, but they are also active in serving the local community and each other. Examples of community service provided by Ms. Rangnekar include collecting canned food along with necessary items for Susannah’s House, a program for women recovering from addiction, and serving the residents at KARM for Thanksgiving. Additionally, the entire clinic staff is always ready to go above and beyond to serve each other during times of need such as an illness or death in the family. In the words of Ms. Rangnekar, “I am very proud and honored to work with such an amazing staff.”
New Resident Rotation: Serving the Underserved
“Hey Mrs. Purkey, would you look at my wife? She doesn’t have insurance, but she has a breast lump.” This question would mark the beginning of a journey taken by an East Tennessean woman to ultimately survive a battle with breast cancer due, in part, to the help of the East Knoxville Free Medical Clinic (EKFMC) and the passionate volunteers who serve there. With roots stemming from local church members who originally gathered on Mondays to provide meals to the hungry and homeless, the EKFMC fills a care gap of almost a 3-mile radius in the city of Knoxville. Since its formal inception in 2013, this clinic has provided care to countless underserved citizens of East Tennessee and has also provided a priceless window into care of the underserved for Medical Students and Residents alike who also happen to be training in the area. Dr. Janet Purkey, who leads the clinic, highlights simple factors such as limited transportation that can drastically alter the quality of care someone receives. She states, “I have learned that an all-day bus pass is an amazing gift to someone who doesn’t drive.” Current third-year medical students rotating with UT Internal Medicine get an opportunity to serve within the clinic and this opportunity has been expanded now to residents as a part of the new “Social Determinants of Health” rotation. With this involvement, the capabilities of the clinic continue to grow and may also slowly incorporate other high-value care to the underserved such as basic dental care, dermatologic, and ultrasound services within the clinic. Overall, the EKFMC provides a wonderful service to the community and residents look forward to furthering its impact.
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Resident Spotlight: Laylan Shali, MD Dr. Laylan Shali is the inpatient medicine chief for the Internal Medicine Residency Program here at UTMC. She is a first-generation Kurdish immigrant. Her father is known for his extensive service within the Kurdish community. This shaped her view of medicine and is the foundation of her passion for assisting the medically underserved. In fact, she states, “I got into medicine because of healthcare disparities.” Initially, Dr. Shali started a safety improvement project as a PGY-2, highlighting gaps in education about health disparities. This has since developed into a new PGY-3 rotation focusing on clinics in Knoxville, including the Free Medical Clinic of America and East Knoxville Free Medical Clinic, among others. Her passion also evolved into a research project, “Social Determinants of Health”, which highlights how environment and upbringing shape perception of healthcare. She hopes to continue to emphasize healthcare disparities and help those communities in need while pursuing a fellowship in Cardiology at UTMC.
Resident Recognition: Chad Hughett, DO It is with great pleasure that we congratulate Dr. Chad Hughett for being selected to attend the upcoming Healthcare in Appalachia Conference: Practical Approaches to Addressing the Unique Needs of our Region on April 28th – 30th, 2022. When asked why he wanted to attend the conference and what he could gain from this experience, he wrote the following testimony. “I grew up in rural East Tennessee (Scott County) and know personally what difficulties some of these patients have to deal with and try to overcome. I want to attend this conference as I believe understanding my patients hardships here in East Tennessee will allow me to be a better physician and advocate for them. Appalachian Tennessee is notorious for isolated rural areas and a high poverty rate, making difficult and unique situations for patient care. I hope to learn how to better navigate these difficult situations to provide better patient care for the people of East Tennessee. I believe this conference will educate me and help provide first-hand experience on what these patients go through and resources I can use to help counteract these problems. I will be practicing in Powell, TN as an outpatient primary care physician after graduation. The information gathered at this conference will hopefully make me a better, more compassionate, and well-rounded physician. My plan is to use what I learn to build a foundation on healthcare in this area and continue to build this knowledge during my practice in this area. I will also continue to serve in the Army National Guard after graduation, along with my full-time outpatient primary care job.”
Resident Reflections: Serving & Learning Through the COVID-19 Pandemic
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He recalled, “It was tough to not get burnt out. We all thought the COVID-19 surge was over after the first year, then another wave hit. We were getting pulled from specialty rotations and having to cover other shifts. I had to focus on work life balance and find different avenues to help de-stress.” When he was not at work, he consciously tried to be in the moment with his family and girlfriend. He said it was important to keep work life at the hospital and not bring it home. He said once he was able to disassociate the two, he was able to let his mind relax. Additionally, he focused more on his golf game and was able to bond with co-residents who shared similar interests. Brandon says it is important to find a career that makes you happy and keeps you engaged. For him, he has found this passion in primary care. He states the COVID-19 pandemic and the challenges it presented have made him an overall better well-rounded physician. COVID-19 was devastating to many patients and their families. It also took a physical and mental toll on residents. For Salem and Brandon, it caused them to experience unforeseen challenges. It presented additional stressors on top of the rigors of residency. They had to learn how to become better communicators to their patients, family members, and colleagues. They had to learn how to compartmentalize their emotions, while providing a strong professional front. Although the future of COVID-19 is still unclear; it is important to remember that we are not alone. The support system here at UT Knoxville is unapparelled, and we will always have each other to lean on. 4
Faculty & Staff Announcements: New Faculty We are elated to welcome Dr. William Austin Nunemaker for appointment to the rank of Clinical Assistant Professor. Dr. Nunemaker completed medical school at Lincoln Memorial University-DeBusk College of Osteopathic Medicine in Harrogate, TN. He completed a residency in Internal Medicine at the University of Tennessee Graduate School of Medicine. He currently serves as a Hospitalist with the University of Tennessee Medical Center.
We are delighted to welcome Dr. Benjamin Chapman Verzi for appointment to the rank of Clinical Assistant Professor. Dr. Verzi completed medical school at the University of Tennessee Health Science Center. He completed a residency in Internal Medicine at the University of Tennessee Graduate School of Medicine. He currently serves as a Hospitalist with the University of Tennessee Medical Center.
In Memoriam of Alfred Beasley, MD: It is with great sorrow that we announce the passing of Alfred Beasley, MD. He was the beloved Chair of Medicine from 1967 until 1997, and endearing friend to all. Although he will be greatly missed by many, the legacy and love of Dr. Alfred Beasley will live on. Dr. Beasley devoted his life to the practice of medicine and was passionate about teaching medicine and ethics to the next generation. He graduated from UT College of Medicine in Memphis in 1959, served internship and residency at UT Hospital Knoxville. He was drafted and served in the United States Navy as a flight surgeon during the Cuban Missile Crisis. He later completed his Internal Medicine Fellowship and Cardiology Fellowship at Emory University in Atlanta, GA. In 1967 he returned to the UT Medical Center to serve as the Chief of Medicine. He later became Professor and Program Director for the Medical Residency program, and then Director of Medical Education at UT Knoxville for many years. Dr. Beasley was instrumental in the formation of UT Medical Center’s biomedical ethics program, and co-authored a book entitled Ethical Analysis of Clinical Medicine: A Guide to Self-Evaluation. He loved his church – First United Methodist, sang in the choir, frequently taught the Christian Forum Sunday school class, and served in many leadership roles In lieu of flowers, memorials may be made to the Alfred D. Beasley, MD Endowment, by check or by visiting www.utmedicalcenter.org/give-now. Checks should be made payable to: UT Foundation c/o UT Medical Center Development Office 2121 Medical Center Way, Suite 110 Knoxville, TN 37920. Gifts may also be made to First Methodist Church, or a charity of your choice.
CME OPPORTUNITIES—MARK YOUR CALENDARS! • 9th Annual Primary Care CME Conference, offering up to 7.0 hours of CME credit this year. The conference will be held in-person at the Marriott Knoxville Downtown on March 4, 2023. We hope you can join us for this informative event. View course information, agenda, and fees at: Primary Care CME Details • Cardiology Conferences, held weekly on Wednesdays from 12:15 – 1:00pm in the Medicine Conference Room and are available for 0.75 hour CME credit. • Medicine Grand Rounds, held on the 2nd & 4th Tuesdays each month from 8:00-9:00am in the Medicine Conference Room and are available for 1.00 hour CME credit. • Ethics Case Rounds, held on the 4th Thursday of each month from 12:00-1:00pm in Wood Auditorium and are available for 1.00 hour CME credit. • Pulmonary/HTN Conferences, held on the 2nd Monday each month from 12:00 – 1:00pm, in different locations and are available for 1.00 hour CME credit. 3
“What have we got to lose?” Ethics, Ivermectin, and the Right to Try Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality.
“Paula,” a 70 y/o lady, presented to University of Tennessee Medical Center after several days of fever, malaise, and shortness of breath. She tested positive for COVID-19 and required intubation shortly after admission. She received full courses of Dexamethasone and Remdesivir, but unfortunately her condition continued to worsen. Her brother “John” was her health care agent. John had been reading about treatment for COVID-19 and was hopeful about the potential for Ivermectin to improve her chance to recover. The ICU attending explained that Ivermectin was not part of the standard of care for COVID-19 as it had not been shown to be effective for these patients in the ICU. John felt concerned that Paula was not improving with the standard of care and wanted to try anything that might help. He said he was requesting Ivermectin under Tennessee’s “Right to Try” law. He noted that Ivermectin has been safely used in humans for many years. Since it is safe, he could not understand why a physician would not use it if a patient or family member wanted it. Right to Try and Off-label Use Right to Try laws allow patients with life-threatening conditions to try medications that have passed Phase One safety trials and have not been approved by the FDA for any use. Qualified patients must not be eligible for a clinical trial involving that drug and must have exhausted all other treatment options. Right to Try laws do not require manufacturers to provide the medication requested, providers to prescribe it, or for any entity to pay for it. In contrast, off-label use involves prescribing an FDA-approved medication for an indication, a population, or using a dosage that has not been approved by the FDA. It is a common practice in every medical specialty. The strength of the evidence for benefit should guide off-label use. Medications that are new, have known serious side effects, are costly, or are proposed for novel use warrant careful scrutiny for off-label use. Medications with very low certainty of benefit should be limited to research protocols. Since Ivermectin is approved by the FDA for treatment of parasites, it would not be available under Right to Try, but could be considered for off-label use. “What have we got to lose?” The attending explained the current state of research does not show that Ivermectin is beneficial for treatment of COVID-19 patients in the ICU. He said it is unwise to add medications to a complex picture unless there is a reasonable expectation for benefit, since all medications have side effects and could worsen her condition. He also noted that doses that would suppress viral load would be much higher than doses used for parasites, again with potential for harm. He said he was continuing to watch the research and was receptive to including Ivermectin if future evidence shows safety and efficacy. Paula had a lengthy hospital course, marked by improvements and setbacks. Ultimately, she improved, got stronger, and was able to be discharged to the care of her brother and sister-in-law. Comments on this case may be sent to amendola@utmck.edu
References • DeTora LM. What is safety?: Miracles, benefit-risk assessments, and the “right to try”. Int J Clin Pract. 2017 Jul;71(7). doi: 10.1111/ijcp.12966. Epub 2017 Jun 8. PMID: 28594475 • https://www.fda.gov/patients/learn-about-expanded-access-and-other-treatment-options/right-try • Largent EA, Miller FG, Pearson SD. Going Off-label Without Venturing Off-Course: Evidence and Ethical Offlabel Prescribing. Arch Intern Med. 2009;169(19):1745–1747. doi:10.1001/archinternmed.2009.314
Presentations, Publications, Awards
Department of Medicine faculty, residents, and fellows share their knowledge and experience by publishing and presenting across the world. For a list of our most recent accomplishments, visit http://gsm.utmck.edu/internalmed/scholars.cfm.
Thank You For Your Support
For information about philanthropic giving to the UT Graduate School of Medicine, Department of Medicine, please contact the Development Office at 865-305-6611 or development@utmck.edu. If you would like more information about any of the topics in this issue of In Touch, please contact the Department of Medicine at 865-305-9340 or visit http://gsm.utmck.edu/internalmed/main.cfm. We look forward to your input. Thank you.
Stay In Touch!
Alumni, please update your contact information by completing the simple form at http://gsm.utmck.edu/internalmed/alumni.cfm or by calling the Department of Medicine at 865-305-9340. Thank you! 5
In Touch Vol. 11 Issue 2: April 2022
Publisher Rajiv Dhand, MD, Chair, Department of Medicine and Associate Dean of Clinical Affairs Editor Annette Mendola, PhD Administrative Director Jenny Roark Contributors Jenny Roark Robin Underwood Rajiv Dhand, MD Kandi Hodges Annette Mendola, PhD Cassandra Mosley James Drew, MD Marc Oropilla, DO Megan Sears-Smith, DO Shawna Stephens, DO Ashley Gutierrez-Santana, MD Design J Squared Graphics In Touch is produced by the University of Tennessee Graduate School of Medicine, Department of Medicine. The mission of the newsletter is to build pride in the Department of Medicine by communicating the accessible, collaborative and human aspects of the department while highlighting pertinent achievements and activities. Contact Us In Touch University of Tennessee Graduate School of Medicine Department of Medicine 1924 Alcoa Highway, U-114 Knoxville, TN 37920 Telephone: 865-305-9340 E-mail: InTouchNewsletter@utmck.edu Web: http://gsm.utmck.edu/ internalmed/main.cfm The University of Tennessee is an EEO/AA/Title VI/ Title IX/Section 504/ADA/ ADEA institution in the provision of its education and employment programs and services. Disclaimer: quotes/ interviews are edited for length and clarity