D epartment
of
M edicine
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. 9 Issue 4 Oct. 2020
Resident Perspective on the COVID-19 Pandemic
Working as a resident during the coronavirus pandemic is a challenging and unique experience. The excitement of being on the front line is met every day by the stress of taking care of people who are critically ill with a novel virus, our knowledge of which is constantly evolving. The task of having to tell family members that their loved one, whom they cannot visit, is not doing well is sometimes mitigated by the relief of telling a family that their loved one’s condition has improved. This time has also allowed many of us to reaffirm the reason why we decided to pursue an occupation in medicine: to make a difference. Much of the stress we as residents experience on a day-to-day basis when caring for a patient with COVID-19, is the vast unknown. We may have thoughts such as whether we will be properly protected by the PPE we wear or whether we may expose our own family or household members when we return home. We don’t know whether
Points of View Social Determinants of Health
Rajiv Dhand, MD, Chair
My medical training appears so inadequate now. In medical school, I learned the structure and functions of the human body, the complex enzymatic reactions and genes that control our bodies’ systems and provide energy to fuel their activities. I learned about the derangements that occur in disease and the various cellular functions and genes that are affected in causing illness. I felt
patients diagnosed with COVID-19 will end up in critical condition on the ventilator. We also don’t know which treatments are best for these individuals, but we are always doing what is best to help them by reading up on the new developments regarding COVID-19. After discussions with many Internal Medicine residents here at UT, these past few months can best be described as an emotional rollercoaster. Despite this difficult season, we try to reflect and focus on the encouraging things that have come out of this. We remain determined to push through and do the absolute best we can, and we take pride in our comradery as a residency program. We stand united as we journey on through this pandemic together. And lastly, in the words of third-year Internal Medicine resident Sam Walker, “We remain hopeful for the patients we are caring for and for the world as a whole.”
very well equipped and confident knowing the various treatments (medical and surgical) for all these maladies. Imagine my excitement when this knowledge helped my patients to recover from their illnesses back to a state of health. My clinical practice was rooted in the firm belief, that there could be no more rewarding experience than service to my patients. Then the coronavirus swarmed all over the world in a pandemic unlike any other in the past 100 years. This faceless, voiceless, and yet merciless enemy has brought us to our knees. It strikes at will, claiming victims in a variety of geographic areas at random. Despite all our scientific and technological advancements, we are helpless and feel inept against the relentless march of the coronavirus. Even worse, this pandemic has exposed the continued on page 2 1
Infectious Disease Specialist Perspective on the COVID-19 Pandemic “By failing to prepare, you are preparing to fail.” - Benjamin Franklin. This quote, Dr. Mark Rasnake says, “has guided UT’s preparations for the COVID-19 pandemic. UT started stockpiling PPE in January and the hospital spared no expense-spending more for higher quality N95 masks, while other hospitals paid less and ended up disposing of their supplies due to poor quality.” UT has now weathered 2 waves of COVID-19 patients, the most recent being more representative of what other facilities in major cities, such as New York, were seeing in March. Dr. Rasnake believes the hospital and staff have responded: “amazingly well.” He attributes much of that to the involvement of a large pool of staff from every administrative level in planning UT’s response, as well as each participant trusting one another and the ownership participants took of their departments. When asked what may lie ahead in the coming months, Dr. Rasnake demurred: “Predictions are difficult. Things seem to be settling down, but we haven’t ruled out the possibility of a resurgence in the winter months along with other viral illnesses.” However, Dr. Rasnake noted that the southern hemisphere has seen a lesssevere flu season this year, partially due to increased social distancing, hand hygiene, and wearing masks. “We can also expect a vaccine in late 2020-early 2021. There are multiple promising trials for COVID vaccines being conducted.” Dr. Rasnake expressed his deep gratitude to hospital leadership and staff, who have been extremely flexible and thorough with all of the recent policy changes; Drs. Lubas and Norwood, who stepped forward to fulfill his duties as the residency PD when he was not able to; and the hospital residents, who “rolled up their sleeves and got to work” on the COVID units and have been extremely understanding of schedule and policy changes.
Resident Spotlight – Dr. Megan Sears-Smith One of the bright spots in our second-year Internal Medicine residency class is Dr. Megan Sears-Smith. She is always quick with a smile and willing to lend a hand whenever needed. She attended East Tennessee State University where she double majored in biology and psychology. She later met her husband RI, who recently obtained his law degree, through the app Bumble. Dr. Sears-Smith eventually decided to pursue a residency in internal medicine, which landed her here at the UT Graduate School of Medicine. Dr. Sears-Smith and her husband live with their three dogs Honey, Daisy, and Sally. In her free time she enjoys hiking, traveling and camping: all activities in which her dogs are able to participate. After residency, she hopes to pursue a fellowship in hematology/oncology. This specialty allows Dr. Sears-Smith to continually expand her knowledge, as well as the opportunity to develop and maintain lifelong and meaningful relationships with her patients.
Points of View
continued from page 1
inequities in our health care system, which we knew existed all along but lurked beneath the surface. Now a harsh light shines on the racial, cultural, and socio-economic divides that exist in our country with regards to the frequency of acquiring coronavirus infection, preventing its spread, and getting appropriate testing and treatment. It is not just a matter of individuals having difficulty in accessing care or being denied lifesaving treatments, the disadvantaged face a real threat to their lives. The “social determinants of health” is no longer a phrase one reads in textbooks or newspaper articles, it encompasses a practical reality that has leapt and taken center stage in the struggle against the ruthless onslaught of a deadly virus that recognizes these inequities. The elderly, frail, poor, the undernourished, disadvantaged minorities, the under- or un-insured and individuals with prior illnesses are all at much greater risk of succumbing to the attack of this contagion. For illnesses that have no effective treatment, science and medicine do not offer much reprieve. Instead, we need to focus our energies on addressing the disparities and gaps in care delivery that exist in our health care system. For practitioners of medicine, the most important lesson we could learn from the current pandemic, is that promotion of health requires expanding our boundaries beyond those of the practice of traditional medicine. 2
Faculty/Staff Announcements New Faculty We are pleased to welcome Dr. Christopher Hill as a Clinical Assistant Professor in Internal Medicine. Dr. Hill received his Doctor of Medicine from James H. Quillen College of Medicine at East Tennessee State University in Johnson City, TN. He completed an Internal Medicine residency at the University of Tennessee Graduate School of Medicine. Dr. Hill was chief resident in the Graduate School of Medicine from 2018-2019. Since July of 2019, he has been a hospitalist with The University of Tennessee Medical Center.
We are delighted to welcome Dr. Lauren McCollum as a Clinical Assistant Professor in Neurology. Dr. McCollum attended medical school at the Perelman School of Medicine in Philadelphia, PA. She completed a residency in neurology at the Hospital of the University of Pennsylvania and fellowship in cognitive and behavioral neurology at Penn Memory Center. Dr. McCollum received an Alzheimer’s Association Clinician Scientist Fellowship Award during her first year of fellowship. Based on work from this project, she has had abstracts accepted at both the American Academy of Neurology (AAN) Annual Meeting and the Alzheimer’s Association International Conference (AAIC) for platform presentations. Dr. McCollum will utilize her rank as Clinical Assistant Professor to assist patients with Alzheimer’s disease and related dementias at the Pat Summitt Clinic.
Faculty Promotions It can be challenging enough to juggle a work-life balance in the corporate sector, but being a physician adds another layer of stress and accountability. Since the University of Tennessee Medical Center is a teaching hospital, each of our faculty members are expected to contribute to teaching the next generation of doctors, submit publications to current medical journals, and participate in research projects all while continuing to treat and care for patients in the hospital and specialty clinics. Each of the faculty members below have consistently exceeded these expectations and continue to give their heart and soul to the medical profession. • Associate Professor - Mark Rasnake, MD • Associate Professor - Daphne Norwood, MD, PF, FACP • Associate Professor - Emily Martin, PhD • Associate Professor - Annette Mendola, PhD • Clinical Associate Professor - Raj Baljepally, MD
Faculty Awards/Honors Dr. Janet Purkey, Associate Professor of Medicine, was awarded the Bland W. Cannon Teaching Award. The Bland W. Cannon Teaching Award is awarded to faculty members of the UT College of Medicine who demonstrate and teach those traits which Bland W. Cannon, M.D. believed to be necessary in becoming a dedicated and accomplished physician. These traits, in addition to a high level of scientific and medical competency, include humanism, respect, empathy, and compassion for the patient. Dr. Purkey graciously thanked the Cannon family for such an honor: Dear Cannon Family, Please accept my sincere thanks for awarding me the Bland W Cannon Teaching Award. I am humbled by this recognition. I work alongside many dedicated physicians and surgeons who strive to pass along the traits Dr Cannon valued to “our” young student doctors. Dr Cannon was a master physician who accomplished much in his 64 years. I have no doubt his former patients remember him fondly—for the same reasons you set forth in this award—compassion, humanism, empathy, and respect for each person. Being the recipient of this award is a huge honor bolstering my energy to share the marvelous world of medicine to the brightest, most hard-working young people. They are dedicated to becoming competent, accomplished physicians. Thank you. Kind regards, Janet L Purkey MD
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Faculty Awards/Honors continued from page 3 Paul J. Hauptman, MD, Dean of the University of Tennessee Graduate School of Medicine, honored Mark Rasnake, MD, Associate Professor of Medicine, with Exemplary Service Recognition Award. This honor was bestowed in recognition of his outstanding service to the UTGSM and The University of Tennessee Medical Center community during the ongoing COVID-19 pandemic. Dr. Mark Rasnake was also featured on WATE 6 news in Knoxville as a community hero for being a hardworking physician on the frontlines at the University of Tennessee Medical Center during the COVID19 pandemic. WATE 6 uploaded their news story that you can watch here: https://youtu.be/PbRTLzGzeMM Link to the WATE 6 article is available at: https://www.wate.com/community/wate-6-on-your-side-heroes/physician-working-hard-to-keep-communitysafe-during-pandemic/ Dr. Rajiv Dhand, Professor of Medicine and Chair of the department, was interviewed by Dr. Frank Adams, a pulmonary specialist at NYU Langone Health, as a guest expert on Doctor Radio for the weekly live radio Pulmonology Program, Channel 110 Sirius XM. They had a wide-ranging discussion about transmission of SARS-CoV-2 virus and methods to prevent its spread as reviewed in Dr. Dhand’s recent paper in the American Journal of Respiratory and Critical Care Medicine entitled “Coughs and sneezes: Their role in the transmission of viral respiratory infections, including SARS-Cov-2.” This paper has been downloaded over 7,000 times and is available at: https://www.atsjournals.org/doi/10.1164/rccm.202004-1263PP The American Thoracic Society issued a press release for Dr. Dhand’s recent paper in the American Journal of Respiratory and Critical Care Medicine entitled “Coughs and sneezes: Their role in the transmission of viral respiratory infections, including SARS-Cov-2. A link to press release is below: https://www.thoracic.org/about/ newsroom/press-releases/journal/2020/new-article-clarifies-details-of-covid-19-respiratory-transmission.php John Parkinson, The Senior Editor of Contagion Live – Infectious Diseases Today, interviewed Dr. Rajiv Dhand, regarding his recent paper in the American Journal of Respiratory and Critical Care Medicine entitled “Coughs and sneezes: Their role in the transmission of viral respiratory infections, including SARS-Cov-2.” Both segments of the interview are available to watch here: https://www.contagionlive.com/news/who-should-be-wearing-face-masks https://www.contagionlive.com/news/the-dangers-of-respiratory-droplets-to-frontline-health-care-providers “Dr. Terry is helping workers as an expert witness” “Hundreds of workers fell ill after cleaning up America’s largest industrial disaster without proper gear. At least 50 people have died. Twelve years later, they’re still waiting for help”. This story was produced through a partnership between Southerly and the Guardian, with support from the Economic Hardship Reporting Project. The Kingston Fossil Plant coal fly ash slurry spill was an environmental and industrial disaster that occurred on Monday December 22, 2008, when a dike ruptured at a coal ash pond at the Tennessee Valley Authority’s Kingston Fossil Plant in Roane County, Tennessee, releasing 1.1 billion US gallons of coal fly ash. Over 50 people who cleaned up the ash at the power plant near Kingston have died with ailments that can be linked to exposure to toxic elements of coal ash, and more than 400 are sick or dying. Many of them are unemployed, on disability, or were forced to take early retirement, their bank accounts drained from years of exorbitant out-of-pocket medical bills. Dr. Paul Terry, an epidemiologist at the University of Tennessee who is helping the workers as an expert witness, found plenty of proof the toxins and metals in coal ash are capable of causing the diseases – blood cancers, lung and brain cancers, chronic breathing ailments, leukemia and coronary heart disease, to name a few – from which the laborers are dead or suffering. Terry is quoted in the article as stating, “all of the diseases that were looked at by us were plausibly related to coal ash exposure. Particularly the protracted exposure they had over time without any protection like masks. They weren’t five miles away living in a house. They were in the middle of the dust, some people for years. Link to the article: https://www.theguardian.com/us-news/2020/aug/17/coal-spill-workers-sick-dying-tva
CME OPPORTUNITIES—Mark Your Calendars! • Cardiology Grand Rounds, held weekly on Wednesdays for .75 hour CME credit. • Medicine Grand Rounds, held on the 2nd and 4th Tuesdays of each month for 1.00 hour CME credit. • Ethics Case Rounds, held on the 4th Thursday of the month at noon in Wood Auditorium, are available for 1.00 hour CME credit. 4
Ethics Case Rounds A Patient with an Intellectual Disability
In Touch
Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality.
Publisher Rajiv Dhand, MD, Chair, Department of Medicine and Associate Dean of Clinical Affairs
Vol. 9, Issue 4: October 2020
“Elinor” is a 45-year-old woman who has lived in a local community home for 12 years. Her medical issues include cerebral palsy with intellectual disability and diabetes mellitus type II. She has recently been diagnosed with ductal carcinoma (in situ). Her cognitive abilities are similar to an 8-year-old child’s. She has a sociable, easygoing manner and is friends with all of her housemates. She loves to eat, loves to dance, and likes anything with rainbows on it. She can become anxious when her routines are disrupted, especially with medical appointments, but this is generally manageable with coaching. She appears to enjoy an excellent quality of life. Elinor’s decision-making capacity is limited. She does not have a Conservator or Power of Attorney, but has a “Circle of Support” that includes the Director of Nursing and the Program Coordinator at her community home, a Community Resources Specialist at The Arc of Tennessee*, and her brother (and only known family member), Jim. Jim seems to care about Elinor but has not been especially engaged. During her years at the community home, he has not visited often and sometimes neglected to visit when promised. Nonetheless, Elinor adores him and does not appear hurt at Jim’s limited involvement. Approximately 1-3 percent of the global population identify as living with an intellectual or developmental disability (IDD). Since adults with IDD vary widely in their needs and abilities, an individualized approach to care is necessary to ensure that patients’ needs are met, and their preferences are respected. Focusing too closely on the abilities of people with IDD risks leaving them vulnerable to harm, while focusing too closely on their need for support risks leaving them vulnerable to paternalism. Actively collaborating with IDD patients, involving their caregivers, and consulting with relevant professionals improves care substantially. A care planning meeting was held with Elinor’s physicians, her Circle of Support, and the Director of Clinical Ethics. Jim was invited but did not attend. Her physicians explained the various treatment options for Elinor, considering her medical and mental health needs. All present agreed on a plan of care for treating her cancer. The group discussed strategies for helping Elinor understand what would happen, what she would need to do, and how to manage her anxiety. The next step was to discuss the plan of care with Elinor herself. However, she still needed a surrogate decision maker, and there were concerns that Jim (as Elinor’s next of kin) might not be a reliable surrogate. Staff from her community home would not be eligible to serve as surrogate if Jim was unable, unwilling, or did not respond. However, the Community Resource Specialist would be eligible to serve in that role. He confirmed that he would be willing to do so if needed. Jim was willing to assume the role of surrogate decision maker and agreed with the plan of care. A Physician Identification of Surrogate form was completed, and he consented to treatment on her behalf. Happily, Elinor tolerated treatment well and has been doing well since. * The Arc is an independent nonprofit advocacy organization for people with IDD.
Comments on this case may be sent to amendola@utmck.edu References • Craigie J, Bach M, Gurbai S, et al. Legal capacity, mental capacity and supported decision-making: Report from a panel event. Int J Law Psychiatry. 2019; 62:160-168. • Fisher K, Robichaux C, Sauerland J, Stokes F. A nurses’ ethical commitment to people with intellectual and developmental disabilities [published online ahead of print, 2020 Mar 31]. Nurs Ethics. 2020
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
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Editor Annette Mendola, PhD Administrative Director Jenny Roark Contributors Jenny Roark Robin Underwood Kristin O'Connor, MD Rajiv Dhand, MD Kandi Hodges Annette Mendola, PhD Cassandra Mosley Megan Sears-Smith, DO Elana Smith 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