West TN Medical News August 2015 by FW Publishing

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PHYSICIAN SPOTLIGHT PAGE 2

David Yakin, MD

Six West Tennessee Clinics Embark on Savings Program

Rural Clinics Seeing More Than Financial Benefits from CMS Program

FROM THE EDITOR:

By SUZANNE BOyD

The Times They Are a-Changin’

Undergoing transformative change, this industry has been tasked with fundamentally altering delivery methods and asked to meet heightened consumer expectations and increased demands for interaction and engagement. While the above statement is certainly representative of the healthcare industry … in this case, we are actually referencing the media’s role in the dissemination of information. The way we consume news has dramatically changed over the past decade. Yet, how, when and where we receive information is often a matter of personal choice. Some people love the feel of newsprint between their fingers. Others like to get information on their tablet. Still others want the highlights in 140 characters or less, giving them control of whether or not the topic is worthy of a click through to more information. Recognizing our readers embody these varied preferences, West Tennessee Medical News is excited to announce major changes to our product. If you love the monthly paper (and we certainly hope you do), no worries … you’ll still receive it faithfully each month in the mailbox. However, we’ve long realized the static nature of our websites left much to be desired from both an aesthetic standpoint and the ability to

Dr. Susan Lowry and Tammy Hazelwood, Administrator for Martin Medical Center, review data from the CMS Shared Savings Program that they are participating in as a part of an Accountable Care Organization.

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New Tennessee Laws Impacting Healthcare By CINDy SANDERS

A number of state laws impacting the healthcare industry in Tennessee have recently gone into effect. Following is a rundown of several key pieces of legislation that passed the 109th Tennessee General Assembly.

HB0033/SB0044: The Mabry Kate Webb Act (Effective May 18):

“The Mabry Kate Webb Act paves the way for expanded newborn screening that will include testing for very rare metabolic and heritable conditions,” explained Michelle Fiscus, MD, FAAP, president of the Tennessee Chapter of the American (CONTINUED ON PAGE 6)

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With the Affordable Care Act causing a shift in healthcare to look at not only quality in care, but ways to be more efficient in delivering healthcare, a Centers for Medicare and Medicaid initiative is making strides toward cutting down waste in the Medicare program and reducing healthcare costs for Medicare patients. Six West Tennessee primary care clinics have joined forces to participate in a three-year Shared Savings Program with hopes of reaping benefits for themselves, their practices and their patients. The Centers for Medicare and Medicaid Services (CMS) developed the Shared Savings Program under the Affordable Care Act. It is designed to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-ForService (FFS) beneficiaries and reduce unnecessary costs. Eligible providers, hospitals, and suppliers participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO). The program creates financial incentives for ACOs that lower their growth in healthcare costs while meeting performance standards on quality of care and putting patients first. Under the program, CMS specifies a Minimum Savings Rate (MSR) to account for the normal variation in expenditures based

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PhysicianSpotlight

Team Player

Even on the Sidelines, Yakin Stays in the Game By SUZANNE BOYD

Not many five-year-olds know what they truly want to be when they grow up but that was not the case for David Yakin, MD, an orthopedist with Sports Orthopedic and Spine in Jackson, Tennessee. For the native northerner, hockey and skiing may be a couple of his passions, but it was his dislike of living in cold weather that ultimately led him to become a southern boy. While he is hard pressed to find many hockey rinks in West Tennessee, the avid sports enthusiast has still found a way to stay in the game while not being on the field or the ice. Growing up outside of Pittsburg in Western Pennsylvania, Yakin knew at an early age he wanted to be a doctor and that desire grew as he did. “No one in my family was a doctor but I just somehow always thought that is what I would do,” said Yakin. “While I did excel in science and math throughout school and the idea of being a doctor grew more and more appealing to me as I got older, I really didn’t even know there was a difference between a family doctor and a specialist

Whether they play on the field or cheer from the stands, Dr. David Yakin enjoys helping athletes get back in the game.

until around medical school.” After graduating from a small Catholic High School, Yakin headed to the home of golf legend Arnold Palmer and

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AUGUST 2015

Rolling Rock beer, St. Vincent College in Latrobe, Pennsylvania where he majored in biology and minored in chemistry. While in college, he interned at a rehabilitation center that treated patients who had recently become paraplegic. “I was looking for a job and thought it would be interesting. It actually sparked my interest in orthopedics,” said Yakin. “Patients spent three to four months in the center after the accident that caused them to be paraplegic.” For medical school, Yakin went to Hahnemann University School of Medicine in Philadelphia. “There wasn’t a lot of exposure to orthopedics,” he said. “But one of my mentors was the team physician for the Philadelphia Flyer’s hockey team and we went to lots of games. I have always been an avid sports enthusiast and it was just a natural match with orthopedics so I geared my electives toward orthopedics.” After medical school, Yakin completed a one-year surgical internship in Pittsburgh at Allegheny General Hospital, during which he spent several months working in a neurosurgical intensive care unit that sparked his interest in neurosurgery. At the time, Allegheny was in the process of getting a neurosurgical program, which caused Yakin a dilemma – neurosurgery or orthopedics. After several months of deliberating, orthopedics won out. During his residency training at Hamot Medical Center in Erie, Pennsylvania, Yakin was exposed to what he calls ‘a little bit of everything’ on the orthopedic spectrum. He also met his future wife there. “While my main love was the sports side of things, I really liked the variety orthopedics offered. It wouldn’t suit me to just do one type of operation the rest of my life,” he said.

As his residency training was coming to an end, Yakin got married and had to decide where he would practice. One major factor in his search for a practice to join was location. “Erie is beautiful two months out of the year. The rest of the time it is cold, dreary and you don’t see the sun for six months,” said Yakin. “Since we had no kids and no ties, we wanted to head south to get out of the cold. North Carolina and Georgia were on our radar when I got a call from Dr. Keith Nord, who had been in practice for a year in Jackson, Tennessee. We had never heard of Jackson, but we came down and met with Dr. Nord. We hit it off immediately and really saw eye to eye on lots of things. After another visit a few months later, we knew it was for us. After nearly 18 years, I would say it was not a bad decision.” Sports is more than just part of the clinic’s name since the practice serves as team physicians to several local high school and area college teams as well as the Southern League Jackson Generals, a minor league baseball team and AA affiliate of the Seattle Mariners. Yakin also got to feed his love of hockey while the clinic was the team physicians for the River Kings hockey team in Desoto County Mississippi. “I played hockey growing up and had served on the medical team for a semi-pro hockey team while in my residency. They even let me skate with them,” said Yakin. “When the opportunity arose to work with the River Kings, I jumped on it. After a while it just go to be too much with all the travel and the number of games, so we gave it up.” As team physicians for the Generals, someone from the clinic attends every home game. “We take care of anything they need and consult with their trainers,” said Yakin. “We evaluate players in their training room or the office. Baseball is a chronic repetitive injury sport, so things don’t happen on the field as much as they do in sports such as football. Pros demand so much out of their bodies and require so much precision in what they do that any small thing can make a huge difference in performance.” Although Yakin migrated to the South to escape the cold, he still gets his fair share of it through his passion for skiing. “I live to ski,” said Yakin. “I will ski anywhere and come winter, I’m on the slopes as much as I can. My daughter and son have been skiing since they were five and they are teenagers now. My partners share in my love of skiing so we try to take one big helicopter skiing adventure each year together.” westtnmedicalnews

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MedicalEconomics BY BILL APPLING

You May Not Like This, But There’s a Lesson to be Learned From… CVS? Many of you know I have a couple of adjunct professor positions at the University of Memphis. I have taught for over 15 years and also founded my healthcare management and consulting business almost 12 years ago. My favorite course to teach is strategic planning, a requirement for all graduating business seniors. I do not require a text book and all our work and case studies are done over the internet, so we can get up to date information and case studies. I think if the opportunity arose, this course would be a great one for physicians. As you read this article, you will see why I make this comment. Almost all the physicians I know dislike the phrase, “walk-in clinics.” (It’s like a four-letter word.) I have studied most of the walk-in clinics and found the CVS model to be the most interesting and the one which will most likely have the greatest impact. So many times the words “strategic thinking and planning” are used together when they are different. I came across a very interesting word recently: “tautology.” A tautology is an explanation that uses the same or similar terms to explain what it means, like calling strategic planning a process that creates strategies. Dr. Jeanne M. Liedtka, is a faculty member at the University of Virginia’s Darden Graduate School of Business and former chief learning officer at United Technologies. Dr. Liedtka says, “strategic intent provides the focus that allows individuals within an organization to marshal and leverage their energy to focus attention, to resist distraction, and to concentrate for as long as it takes to achieve a goal.” The concept implies both having an overarching goal or direction, and making that goal a conscious focus or, “the act of turning your mind toward” an outcome or object. Also,the intent to change -- a change that we are completely passionate about, that channels our every action for the future. While you might be an expert in interpreting the particular “business ecosystems” in which you operate, how well do you understand what is happening culturally or politically that might also influence your future? Liedtka suggests strategic thinkers ask this question: “Having seen the future that we want to create, what must we keep from our past, lose from that past and create in the present to get there? You learn from the past and use that learning to make predictions. You look at the present to assess the gap between where you are now and where you want to end up. While your focus is always on the future, you can only act in the present.” SWOT analysis (strengths, weaknesses, opportunities, threats) never ends for strategic thinkers. Strategic thinkers are able to spot and react to great opportunities as they arise. They understand that the world is dynamic and they are open to change to reach westtnmedicalnews

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their vision. Dr. Liedtka says, “strategic thinking mirrors the scientific method…it is both creative in nature.” As strategic thinkers, we create hypothesis, those questions that start “what if…? or “If… then?- questions that enable us to imagine multiple scenarios, analyze them as best we can based on the knowledge we’ve accumulated and then test the best hypothesis (experiment). As we act, we learn from our experience to create new hypothesis for future action. CVS, arguably the nation’s biggest healthcare company, has ambitious plans. And tobacco doesn’t fit in them. With 7,800 retail stores and a presence in almost every state, CVS Health has enormous reach. Although shoppers might think of CVS as a place to pick up toothpaste, Band-Aids or lipstick, it is also the country’s biggest operator of health clinics, the largest dispenser of prescription drugs and the secondlargest pharmacy benefits manager. With close to $140 billion in revenues in 2014 and about 97 percent of that from prescription drugs or pharmacy services, CVS is arguably the country biggest healthcare company, bigger than the drug makers and wholesalers, and bigger than the insurers. Even before the Affordable Care Act created millions of newly insured customers in the nearly $3 trillion healthcare industry, CVS saw there were more profits to be made handling prescription drugs than selling diapers. But their transformation from drugstore to a healthcare company began a decade ago. CVS already has more recently taken on a new advocacy role, that of public enemy of cigarettes. But with smoking rates on a steady decline, and cigarettes sales slumping, CVS also saw that

future profits lie not with “Big Tobacco” but in health and wellness. Larry Merlo, the CEO of CVS Health, is a former pharmacist and came into the company when it bought People’s Drug. Merlo said, “Hypertension, diabetes, osteoporosis, it’s the same story -- people don’t take their medications as prescribed. Pharmacists, who see patients more frequently than doctors do, can make sure patients stay on their drug regimens, keeping them out of the hospital and saving the healthcare system billions of dollars down the road.” The shift toward healthcare started in 2004, when CVS acquired Eckerd Stores and Eckerd Health Services, giving CVS a foothold in administering drug benefits to employees of big corporations and government agencies. Two years later, CVS acquired MinuteClinic, a pioneering in-store health clinic chain that was offering treatment for routine illnesses, basic screenings and vaccinations. CVS also expanded its highly profitable specialty pharmacy business, which focuses on expensive drugs that treat complex or rare diseases like cancer or HIV. It acquired Coram for $2.1 billion. Coram is a business that allows CVS to dispatch technicians to patients’ homes to administer pharmaceuticals through needles and catheters. And the acquisitions just keep on coming. The growth of CVS comes at a time when the way Americans access and pay for healthcare is evolving quickly. Merlo said, “Say you have diabetes, and you go into a pharmacy to get your insulin, how great is it if, in the same aisle, there’s a cookbook for people with diabetes? And there are some foods that are already approved for you, and a place to check your feet, and a clinician to check your eyes.”

“Consumers are saying: I want all of that at a place near my house that’s open on Saturdays, when it’s convenient for me. I want that place to post prices. It’s in CVS’s interest to pull in more and more pieces of the puzzle.” A typical CVS clinic brings in $500,000 a year representing just a fraction of CVS’s revenue; still the clinics are an important part of the company’s healthcare proposition. CVS is by far the leader. Wal-Mart has fewer than 100 clinics, compared with more than 900 in CVS’s portfolio. Walgreens, the secondlargest, has half as many as CVS. And CVS plans to add more clinics reaching 1,500 by 2017, the company has said. A study by the researchers at the RAND Corporation estimated that more than a quarter of emergency room visits could be handled at retail clinic and urgent care centers, creating savings of $4.4 billion a year. Helena B. Foukles leads CVS’s retail business said, “Customers quickly made the leap.” Foulkes pointed to a prominent snack corner at the front of one of the stores. “What you’ll see in our stores are brands that convey healthy without being edgy. Its Chobani yogurt, its KIND bars its lots of proteins and nuts.” At this point, there are no plans to stop selling high-fat or high-sugar snacks. But those things might be harder to spot in a CVS store. When asked where the Oreos were, Foulkes smiled. “You’ll find them, but you’ll have to look for them.” Bill Appling, FACMPE, ACHE, is founder and president of J William Appling, LLC. He is a national speaker, presenter and a published author. He serves as an adjunct professor at the University of Memphis and is on the boards of Hope House and Life Blood. For more information contact Bill at j.william.appling@ outlook.com.

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AUGUST 2015

Six West Tennessee Clinics Embark on Savings Program, continued fromp age 1 upon the number of Medicare fee-forservice beneficiaries assigned to the ACO. To form an ACO, there must be a minimum of 5000 beneficiaries covered. The MSR helps ensure that savings are a result of the ACO’s performance instead of normal variation in Medicare expenditures. Before an ACO can share in any savings generated, it must demonstrate that it met the quality performance standards for that year. In the first year of the three-year agreement period, ACOs satisfy the quality standard based on their complete and accurate reporting of data. Quality performance benchmarks are phased-in during the second and third performance years of the ACOs’ agreements. The ACO’s patients’ claims over the prior three-year period are utilized to set the baseline for the group. For 2015 there are 33 quality measures scored as 31 individual measures and 1 composite measure (which includes 2 individual component measures). These measures span four quality domains: Patient/Caregiver Experience, Care Coordination/Patient Safety, Preventive Health, and At-Risk Population. In 2012, the program’s first year, there were 89 ACOs participating in the program across 49 states plus Washington, D.C. and Puerto Rico. In 2015, the number had grown to 404 with more than half comprised of networks of individual practices. Only nine percent of the total ACOs in the program this year are rural health clinics, one of which is West Tennessee

AUGUST 2015

Clinical Partners, which was formed in 2015 and is comprised of six clinics from the independent physician’s association, West Tennessee Primary Care (WTPC). When forming the ACO, WTPC Executive Director Dustin Summers says he saw a natural match in the Primary Care Physicians group. The 20 physicians are from East Wood Clinic, Griffey Clinic, Paris/Henry County Medical Clinic located in Paris, Martin Medical Clinic, Milan Medical Clinic, and Northside Medical Clinic in Jackson. Imperium Health Management, LLC was utilized to set up the ACO and is consulting with the group on its participaDustin Summers tion in the Shared Savings Program. “This was an opportunity to strengthen the presence of our independent doctors across West Tennessee. We approached the clinics in the independent physician’s association about forming an ACO to participate in the program. Six joined initially but we hope to add the other practices in the future,” he said. “While Accountable Care Organizations are often an organization of multi-state, multi-specialty practices, that is not the case with ours. This group is unique in that they are all independent practices that already knew one another and had an ongoing relationship. The goal is to man-

age our more than 8200 Medicare patients in a more cost-effective manner in hopes of saving Medicare money with the incentive that Medicare will in turn share half of the savings with the doctor group.” The clinic administrators recognized the benefit this program could have for their clinics. While some were initially apprehensive about it, all were receptive to the idea that it could work in the development of sound fiscal policies. While participation in the program meant some modifications in the type and manner data is reported, participation has not caused an undue burden or increased paperwork. “I had read a lot about the ACOs and Shared Saving Programs and knew that there was not a lot of opportunity in the West Tennessee area for independent clinics so when Dustin and Imperium Healthcare came to us with their proposal, it was hard to pass up the chance to participate, especially when there was really no risk on our part,” said Tammy Hazelwood, administrator for Martin Medical Center. “This day and time you have to be willing to try new things to stay competitive and profitable. Now, we are working to see if we can make a difference. It has put another factor into the equation of clinical decision making for the provider. As a part of this program, they want to make the best decision for the patient both medically and financially.” “Joining the group helps me coordinate care that benefits my patients. We hope to get better prices for them along with higher standards of care” said Susan Lowry, MD, Martin Medical Clinic. “I had no reservations in joining. It is a chance to work with several outstanding colleagues to practice cost-effective medicine. I can work with several colleagues to pick service providers – nursing homes, home health agencies, hospice groups, hospitals, and dome companies to help control the costs to our Medicare patients and ultimately Medicare program itself.” Beneficiaries seeing healthcare providers in ACOs always have the freedom to choose doctors inside or outside of the ACO. Participating clinics in the ACO are required to post a notice in their waiting room that they are participating in the Shared Savings Program. CMS also sends a standard letter to their Medicare patients informing them of their doctor’s participation and that they have the right to opt out of having their data included in the program. For West Tennessee Clinical Partners, less than 10 percent of Medicare patients opted out. Quarterly reports give participating physicians and clinics information, based on claims data, they may not otherwise have that helps evaluate practice and referral patterns. “It is a great picture of the quality and cost of services we are utilizing. We can see what services or facilities cost Medicare more, which, in the end, may cost the patient more. We can then work with our patients to make sure they are getting the same level of care at the most efficient price,” said Summers. “It is an educational tool for our providers that lets us look at their practice patterns as

well as those of who we refer patients to. From this we can make adjustments designed to improve quality of care, efficiencies and thereby reduce costs.” Now in the third quarter in the program, Summers says the group is learning a lot. “In the first quarter report, we really looked at our providers’ numbers to get a perspective on where we stood and where we could see some improvement in practice patterns. We saw about what we expected for most things but in some services, it was an eye opening experience as to the vast disparity in terms of cost and quality of providers. The data will give us more information and will serve to illustrate the effectiveness of our physicians,” he said. “”With our second quarter numbers, we will be able to see if there have been any changes in provider behaviors that increase cost savings. We can see if changes are being made or if we need to further evaluate a service or an area.” Nationally the program seems to be working because last year many ACOs had higher quality and better patient experiences than published benchmarks and qualified for shared savings payments of $460 million. About half of ACOs earned bonuses for saving the government money during their first year of participation. While Summers anticipates the ACO will receive some financial benefit in its first year, how much, if any, will not be known until after the first quarter of 2016. “This first year is really a process of fact finding. We are looking internally and externally at how we can make improvements that benefit our Medicare population as well as all patients,” said Summers. “With this increased level of information for evaluating our practice patterns we can make more informed decisions in the care of Medicare beneficiaries. We hope to see trends in ancillary services that aid in our overall evaluation of how best to provide the highest quality of care in the more efficient and cost-effective manner. I think the program is ideal for every independent primary care doctor in West Tenn. as it increases the cost effectiveness of the practice and improves quality of care delivered.” ‘The information we have access to, as a participants, will definitely give us leeway to strengthen our clinical processes. We have always advised our providers to care for the patient and let the administrative staff worry with the financial side of healthcare. Now the providers are gaining access to information that can help them make better decisions for their patients based on quality of care as well as expense,” said Hazelwood. “The information that we are able to access as a part of this program allows us to better serve our patients. We can develop better clinical practices and help identify areas where we can help our patients stay healthier, while cutting expenses. Plus the ability to network and learn from other groups within West Tennessee Clinical Partners will allow us to be a better primary care provider. If we provide excellent care to our patients, while helping cut their healthcare expenses, we can both win.” westtnmedicalnews

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WHO’S TENDING OUR DOCTORS?

The Plight of Physicians-in-Training

Starting in medical school, stress and depression impact rising percentage of students; profession-wide, suicide claims a doctor a day By LYNNE JETER

On the night of June 21, 2012, Greg Miday, MD, scribbled a note before settling in for a hot soak with candles flickering, music playing – and a scalpel in hand: “This is just the end of the line for my particular train,” he wrote in a goodbye note. The following morning, his body was discovered, major arteries severed. Miday, 29, an instructor of medicine for the Washington University School of Medicine (WUSM) and a hospitalist with Barnes-Jewish Hospital, was days from beginning an oncology fellowship when he committed suicide. In his obituary, his parents – both MDs – wrote: “With all his talents and accomplishments, he struggled in a world that didn’t fully understand him.” “Greg knew it was a career killer to ask for (mental health) help,” said his mother, Karen Miday, MD, a psychiatrist from Ohio. “At the end, he must’ve felt there was no way out.” Every day, a medical student or doctor calls it quits in the most permanent way. Because of the stigma surrounding mental health issues, medical students remain wary of seeking help. “We must see change to de-stigmatize mental illness,” said Miday. “From the beginning, medical students should be allowed to seek help if they’re struggling. Unfortunately, medical people seem to be the most judgmental when it comes to mental illness.” Colin West, MD, PhD, co-director of the Mayo Clinic Department of Medicine Physician Well Being Program, told The New York Times: “If this is the way that students view each other – survival of the fittest – how do they view their patients who are depressed or struggling with mental illness?” Medical students are prone to maladaptive perfectionism and imposter syndrome disorders, cautioned Stuart Slavin, MD, MEd, director of curriculum for Saint Louis University School of Medicine, where he successfully implemented program changes to improve the wellbeing of medical students and received a national teaching award for restructuring medical education. “Maladaptive perfectionism is always setting the bar so high for yourself that you’re continually disappointed,” explained Slavin. “Imposter syndrome is the belief of being incompetent despite overwhelming objective evidence to the contrary. Both maladaptive perfectionism and imposter syndrome are particularly risky when medical graduates are starting residency. All of a sudden, they have their MD, they’re writing orders and making decisions for which they may feel terribly unprepared. They’re terrified of doing something wrong. Both can be setups for emotional distress and potentially suicide. The fear of being ‘discovered’ or disappointing those who have supported you along the way … suicide is westtnmedicalnews

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sadly an out as having potential advantages when you’re desperate.”

Haunting Actions

Because of their intrinsic knowledge of medicine, suicide success rates are alarmingly high among medical professionals. Nearly every physician knows of colleagues who took their own life. Many remain haunted by their actions.

Jay Bitar, MD, FACC, an interventional cardiologist at Cardiology Care Center in Lake Mary, Fla., recalled an intern – Brent Branham, MD – from Detroit, Mich., who committed suicide in 1985. “On the night Dr. Branham was on call Dr. Jay Bitar

(alone), he’d start having anxiety as my time to leave approached,” said Bitar, then Branham’s rounding resident on the infectious disease floor of a medical complex in downtown Detroit. When Branham’s onemonth rotation ended without incident, Bitar wrote a favorable evaluation. Two months later, as he was about to take night call on another medical floor, (CONTINUED ON PAGE 9)

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New Tennessee Laws Impacting Healthcare, continued from page 1 Academy of Pediatrics. “These tests are in addition to those already performed on every newborn baby in Tennessee.” She continued, “It is hopeful that earlier detection of children affected by these conditions will allow for better treatment opportunities and improved understanding of these life-threatening conditions. Testing is to begin within six months of the development of appropriate testing techniques and standards.”

HB0109/SB0367: Requirements for Radiological Services in an Ambulatory Setting (Effective July 1):

“The Tennessee Ambulatory Surgery Center Association (TASCA) lobbied this past legislative session for the passage of HB109/SB367 sponsored by Rep. Dawn White and Sen. Steve Dickerson,” noted TASCA Board Member Gina Throneberry, RN, MBA, CASC, CNOR. “Before the passage of this legislation, ambulatory surgical treatment centers (ASTCs) were required to obtain a radiologist to oversee the Gina radiological services of Throneberry the center. This was an expensive and unnecessary requirement due to the fact that ASTCs receive patients who have already been properly diagnosed in a physician’s office. When a

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AUGUST 2015

radiologist was not available or unwilling to oversee radiological services, the ASTC was cited.” Throneberry continued, “The passage of this legislation gives the governing board of the ASTC the authority to appoint a qualified individual to be responsible for ensuring that the radiological services are provided in accordance with applicable laws and rules. This revision also aligns the standard with the newly revised CMS standard.”

HB0322/SB1331: Release of HIPAA Compliant, Limiteduse Data Sets (Effective May 6)

“This THA-proposed bill requires the commissioner of the Tennessee Department of Health to establish policies for the release of HIPAA-compliant, limiteduse data sets from claims data discharge reports of hospitals, ambulatory surgical treatment centers and outpatient diagnostic centers,” explained Beth Berry, senior vice president of Government Affairs for the Tennessee Hospital Association. “The Department of Health was willing to provide these data sets but was concerned the law was not clear enough to permit the data sharing. This law codifies the Department’s ability to provide the data.”

HB0699/SB1223: Telehealth Protections (Effective July 1)

“THA and a broad group of healthcare providers and payers were successful in passing legislation creating a strong telehealth environment in Tennessee,” Berry said of the new protections. She continued, “Developed by the group in response to overly-restrictive rules proposed by the state, the bill: • Creates a consistent definition of telehealth and telemedicine for all healthcare practitioners; • Defines criteria for a provider-patient relationship; • Provides that the standard of care for telehealth is identical to the standard of care in a traditional healthcare office visit; and • Prohibits healthcare provider licensing boards from placing additional restrictions on the practice of telehealth beyond those allowed in the bill.” The legislative staff at the Tennessee Department of Health noted the bill also allows a physician to prescribe via telemedicine, as long as all applicable prescribing statues (such as checking the Controlled Substance Monitoring Database) are met. However, pain management clinics and chronic nonmalignant pain treatment are excluded from application of this bill. TMA’s Vice President for Advocacy Yarnell Beatty said this new law helps preserve Tennessee as one of the most open states in which to practice telemedicine. He noted, “Tennessee is still mostly a rural state, and this bill should allow more access to care for patients to get the treatment and medications that they need.”

HB1157/SB1266: Pain Management Clinic Revisions (Effective July 1):

The legislative affairs staff of the Tennessee Department of Health explained, “This bill clarifies the regulations around certified pain clinics in Tennessee. It states that only doctors, advanced practice nurses and physician’s assistants, who are licensed in Tennessee with no restrictions

or encumbrances, can hold a pain clinic certificate or own a pain clinic. One of the owners of the pain clinic must be the certificate holder of that clinic and must meet eligibility requirements to be the certificate holder. By July 1, 2016 every certified pain clinic must have a medical director with advanced training in the field of pain management termed a ‘pain specialist.’”

Right to Try During the 109th General Assembly, state lawmakers approved HB0143/ SB0811 … more commonly known as the Tennessee Right to Try Act. The legislation is intended to provide terminally ill patients access to experimental drugs and devices that could have potential life-saving benefits. “Right to Try was an idea that was created by the Goldwater Institute in Arizona,” said Lindsay Boyd, director of Policy at the Beacon Center, a nonprofit, nonpartisan organization focused on public policy to eliminate government barriers perceived to interfere with individual rights. “So the credit goes to the Goldwater Institute for coming up with this really patient-driven reform that curbs the emphasis of protecting the industry and puts the emphasis back on protecting the patient.” Boyd first became aware of the initiative a couple of years ago before it had been introduced in any state houses. Lindsay Boyd In 2014, five states passed Right to Try laws. As of late June, Tennessee and 21 other states now have some version of Right to Try laws, another 18 states have introduced bills, and legislation also has been introduced nationally. The law affords protections for physicians, pharma companies and medical manufacturers while loosening the regulations on terminally ill patients. “We believe this strikes the perfect balance,” Boyd said. Insurers can cover the cost of treatment but don’t have to do so. Pharmaceutical companies can provide the experimental drugs for free or at cost (although they cannot make a profit) but don’t have to do so. The manufacturers also retain right of refusal if they believe a patient isn’t an appropriate candidate. “We wanted to make sure this was a ‘mandate light’ piece of legislation,” Boyd explained. “It’s a free will bill. It’s designed to open the access and open the conversation between the pharmaceutical company, patient and doctor.” She added, the law extends to medical devices, as well. Just as there are potential benefits to patients, Boyd said there are also benefits to manufacturers. “As we know, the approval process takes on average 10 years … and now it is jumping up toward 12 years,” she said of moving through the Food and Drug Administration cycle. Boyd said an ancillary hope of these laws is to open a dialogue about reforming the FDA process. “We’re sending patients to Europe to access drugs produced here. It’s really a backward process,” she said. In the meantime, by allowing patients who have exhausted other options early access to treatments that have already passed the Phase I clinical trial stage, manufacturers might be able to show efficacy more quickly and ultimately help expedite FDA authorization. However, Boyd noted, “If a drug drops out of that process at any point before it gets the FDA stamp of approval, it is no longer eligible to be a Right to Try drug.” To participate, patients must assume responsibility if any costs are involved and must sign a consent form waiving liability for their physician, the manufacturer, and their insurance company. Boyd said the law really represents a win/win. “That’s why we think this bill is really revolutionary and can be supported by everyone involved.” She concluded, “Ideally, we hope the law might save a life. That’s our ultimate goal. We don’t want to promise anyone false hope … but we do want to give patients hope where there was none before. We think it’s the least we can do for these patients.”

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WHO’S TENDING OUR DOCTORS?

Missouri Leads States on Medical Student Well-Being Advocacy

Proposed State Legislation Could be Model for Proactive Mental Health Measures at Medical Schools Nationally By LYNNE JETER

On an unusually chilly spring day, a fourth-year medical student in northern Missouri completed his mission with such surety that only dental records could identify his remains. “He was going to get it right this time,” lamented his father, who declined to have the family identified. His son, who died from a self-inflicted gunshot wound, was weeks away from earning a DO. More than 300 mourners were on hand for the premature burial Dr. Keith of the 26-year-old, inFrederick cluding state lawmakers attempting to push through legislation to deter the alarming rate of depressions and thoughts of suicide amid medical students in Missouri. Among them, Keith Frederick, DO, one of four doctors serving in the

Missouri Legislature, and a state representative (R-Jefferson City) who proposed House Bill 867, the “Show-Me Compassionate Medical Education Act” in the 2015 regular legislative session. By the time Frederick’s bill had churned through the legislative process and was awaiting a final look acknowledging the acceptance of Dr. Lisa a conference committee Moscoso report, a Senate filibuster over a Right-to-Work vote killed it, along with a couple of dozen bills awaiting similar action during the volatile last week of session. “This topic – a dirty little secret of medical education for decades – badly needs the light of day,” said Frederick. “One of the biggest problems is that medical schools say, ‘we’ve got this covered,’ but they don’t.”

Even though HB 867 nearly crossed the finish line, medical school deans balked early on. As originally drafted, the bill would have established an anonymous online survey to screen medical students for depression and provided for access to immediate help through an existing 24-hour hotline for students in crisis. It would have also required the state’s six medical schools – two public, four private – to conduct the screening. Results would have been made public after three years. Strong opposition came from the Washington University School of Medicine (WUSM) in St. Louis, consistently ranked among the nation’s top medical schools by U.S. News & World Report, and world-renowned for its 124-year history of groundbreaking research. “Washington University’s primary concern – voiced by all six Missouri medical schools – was a provision that would have required the State of Missouri to publish the rates of depression among

MD students at each of the state’s medical schools,” said Lisa Moscoso, MD, PhD, associate dean for students affairs at WUSM. “In its earliest form, House Bill 867 would’ve required the Missouri Department of Mental Health to determine rates of depression using a state-mandated survey tool, though student participation in the survey would’ve been optional. We noted that a voluntary survey instrument would give schools an unreliable view of the scope of any mental health challenges. We also worried that a government-mandated survey and reporting process for what is unquestionably a sensitive matter would undermine the culture of trust each school strives to build with its student body.” Frederick modified the bill while it was held for more than a month in the Social Services Committee, and then medical schools unofficially removed their opposition to the bill, which Frederick plans to (CONTINUED ON PAGE 8)

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Missouri Leads States, continued from page 7

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The performance icaid coverage to workers with disabilities period for the second wave of five (5) epiwho have incomes and/or assets that would sodes of care will not begin until January otherwise make them ineligible for current 1, 2016, but insurers are beginning to give TennCare coverage (generally 138% of the providers previews of their performance on poverty level). Under this new proposal, these future episodes on their current report Tennessee would allow disabled individuals cards. The second wave of episodes include: with family income up to 250% of the federal (1) acute COPD exacerbation; (2) screening poverty level to receive TennCare. One of and surveillance colonoscopy; (3) outpatient the aims of this new program is to eliminate and non-acute inpatient cholecystectomy; (4) the current financial disincentives for people acute PCI; and (5) non-acute PCI. The third with disabilities to work, while expanding wave of episodes of care will be(1) Upper GI access to healthcare. 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These proposed Tennessee include: (1) attention deficit hychanges include, among other things, a sur- peractivity disorder; (2) opposition defiance prising proposal to relax many of the techni- disorder; (3) coronary artery bypass graft; cal requirements that must be met to meet an (4) valve replacement and repair; (5) acute exception under the Stark Law for physicians exacerbation of congestive heart failure; and who contract with entities or persons with (6) bariatric surgery. Reports on these six whom they have a referral relationship, such (6) episodes will begin in mid-2016 and the as: (1) lease or personal services arrange- performance period for these episodes will ments would not have to be reduced into a begin January 2017. single agreement, a collection of documents would suffice; (2) there would be no requireTodd D. 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pre-file this fall. “The measure that was before the Senate in the final weeks of the session represented a reasonable approach to raise awareness about medical students’ mental health and to encourage Missouri medical schools to collaborate to identify best practices, particularly those efforts that are most effective at de-stigmatizing mental illness and encouraging students to seek support and services to cope with mental health issues,” said Moscoso. Margaret Wilson, DO, dean of A.T. Still University’s Kirksville School of Osteopathic Medicine in Kirksville, Mo., expressed concern about “confidentiality and potential to cause stigma to students.” Since modifications have been made, “the bill meets with my school’s support,” she said. In its final form, HB 867 dropped the requirement that medical schools undertake this study, but protected medical students and medical student organizations from interference or retribution from the medical schools when planning or conducting screening for depression or other mental health issues among medical students. Britani Kessler, MD, immediate past president of the American Medical Student Association (AMSA), traveled from Virginia to testify before the Social Services Committee that “mental wellness” is the organization’s most frequently clickedon website link. “The culture of the current medical education system is that you can’t show weakness,” said Kessler. “The rigors of

medical school make you sometimes think this sustained high level of stress is normal.” The AMSA Board of Trustees has expressed interest in launching a national pilot program to survey medical students anonymously at various intervals of their educational training. To Kessler’s knowledge, Missouri is the only state to have attempted to pass legislation relating to medical students’ mental well-being. “The purpose of the AMSA is to help pre-med and medical students learn things they aren’t taught in traditional medical education,” said Kessler. “We’re very feisty about medical education reform and making sure the social determinants of health are included.” Frederick said more changes are needed in medical education, like national award-winning modifications made to the four-year curriculum at Saint Louis University (SLU) School of Medicine in St. Louis, Mo., to reduce the damage rather than emphasize that medical students need to learn to cope with the existing medical education structure and harshness. “As SLU’s groundbreaking study revealed, medical education can greatly reduce the harm inflicted on medical students,” he said, “without adversely affecting achievement and board scores.” Editor’s Note: Please see series companion articles in this month’s edition: “Missouri Leads States on Medical Student Well-Being Advocacy” on page 5.

The Times They Are a-Changin’, continued from page 1 adequately offer information between print cycles. Additionally, the editorial and publishing teams have looked at various solutions to quickly alert our readers to major breaking news stories and to have a platform to put important information in your hands in the immediate fashion audiences have come to require. To achieve these goals and meet your personal expectations, we are debuting our new website this month and offering you the flexibility of following us on social media platforms to receive updates. Knowing how many journals, magazines and e-mails you receive on a daily basis, we promise not to flood your devices with a constant stream of data. Instead, we will format key information into brief updates and breaking news alerts as warranted. For many of you, we already have your email addresses on file so you will automatically receive an e-blast. If you aren’t currently receiving electronic notifications from us, feel free to contact me at pharris@medicalnewsinc.com with your email address, and I’ll make sure you are added. You can also make such a request online at www.westtnmedicalnews.com. Our mission … as it has always been … is to make sure we get the latest clini-

cal, business, research and regulatory news in your hands, in addition to updating you on industry events and happenings among colleagues. The new format of the website makes it easier than ever for you to see the latest information in each of these categories, find related content, and share articles on your own social media platforms. Additionally, the design was created to be scalable to desktop, tablet and smartphone formats. As Bob Dylan aptly noted – The Times They Are a-Changin’ – and we’re excited to embrace that change with enhanced capabilities to deliver the best possible product to you in a manner that suits your busy life. We hope you enjoy the new look, flexible formats, and ability to receive industry updates in between print cycles. Please feel free to share your thoughts and comments with us. As always, we’re open to suggestions on how to continue to improve our publication and our performance. Sincerely, Pam Harris Publisher/Editor www.westtnmedicalnews.com westtnmedicalnews

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Head Injuries in Baseball ‘Greatly Addressed’ Redbirds’ Trainer Says New Helmets Have Made Big Difference By RON COBB

While most of the conversation about head injuries in sports has focused on football, a ripple effect has been felt in other athletic arenas. That includes baseball. “It’s definitely a worry in baseball, and it’s something that has been addressed greatly the last few years,” said Jeremy Clipperton, athletic trainer for the Memphis Redbirds. “You don’t hear about it as much in baseball because it’s not like football where it’s more of a contact sport, but it happens Jeremy and it’s definitely been adClipperton dressed.” Clipperton has been a trainer for 16 years, including the past four with the Red-

birds. He has been named Trainer of the Year three times in the minor leagues during stints with the Kansas City Royals, Seattle Mariners and St. Louis Cardinals organizations. Possibly the most Dr. Barry important change he has Phillips seen for players’ protection is the new, improved helmets. “They’re so much better now for blows to the head,” he said. “Blows that I saw even five years ago that would keep a guy out for two weeks, now they don’t even feel it because the helmets are so much better made now.” Just as in football, Clipperton and team physician Barry Phillips have protocols to follow when head injuries are suspected. “There’s a lot of checks and balances

now,” Clipperton said. “We have a protocol designated to us by Major League Baseball. You automatically have to go through Scat 3 tests with a guy. Then each club has an individual doctor who’s designated. By that I mean each organization, like the St. Louis Cardinals that we then confer to. The doctor then confers with the MLB doctor in New York before a player can return to play from any type of head injury. “So they’ve really taken the judgment out of it and there are definite tests you have to do before a guy can return.” And in the minor leagues, Clipperton said, there’s no rush. “It’s a totally different animal here,” he said. “In the minor leagues, the emphasis isn’t on winning, it’s on getting these players ready to play at the next level. For me, the next level is the St. Louis Cardinals. They want these guys healthy when they go up to

help the Cardinals.” Phillips, also the team physician for University of Memphis sports, said the days are long gone when a doctor or trainer on a football sideline could look a player over quickly, ask him if he was OK and then send him back in. “I think we always have done a pretty good job,” he said, “but now the concussion protocols change pretty much every year. There’s a whole lot more science to it, which is good. “I think the SEC is even talking about having a doctor up in the booth evaluating if anybody has any concussion symptoms and then call the team doctor and say, ‘Hey, that guy doesn’t look right.’ If you’re on the sideline, sometimes you’re checking one guy and you miss several plays. So it could be a good idea.”

The Plight of Physicians-in-Training, continued from page 5 Branham had a meltdown at the nurses station. A psychiatrist called to evaluate Branham determined he wasn’t suicidal and recommended the night off, calling for further psychiatric evaluation. Branham didn’t return home that night. Instead, he checked into a hotel room, injected himself with insulin he’d stolen from the hospital, and lapsed into a hypoglycemic coma. “The next morning, when the hotel maid found him unconscious, he’d already sustained permanent brain damage,” lamented Bitar. “He lived for a few months in a vegetative state before succumbing.” Over the years, Bitar has wondered what went wrong, how the signs were missed, who was to blame, and if actions could have been taken to positively impact Branham. “Each one of us has a Brent Branham inside,” said Bitar. “The system is quick to weed out physicians who cannot survive long, sleepless nights, withstand the pressure, and take abuse from senior staff … with pride. The system of residency training doesn’t address collateral damage like the physician’s marriage getting destroyed, or when the children become neglected, or when the physician’s physical or mental health is permanently degraded.” After hearing about a nearby physician who committed suicide, Pauline Chen, MD, wrote in The New York Times that his death came up repeatedly in conversations for days afterward. “It wasn’t the details of his life that haunted us; it was the details of his death,” she noted. “He’d locked himself in a room in the hospital, placed a large needle in his vein and injected himself with a drug that so effectively paralyzed his muscles, he was unable to breathe. Or call for help.” Pam Wible, MD, a family physician from Oregon and a national voice for physician suicide prevention, pointed out the ripple effects of such tragedies. A year after Kaitlyn Elkins, a third-year medical student at Wake Forest School of Medicine, died by asphyxiation due to helium westtnmedicalnews

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inhalation, Wible attended the funeral of Kaitlyn’s mother, who chose the same method to end her life. Miday was so devastated by her son’s suicide that “the first year after Greg died, I don’t think I could string three words together,” she said. Wible admitted: “Many of us have considered suicide, but we’re so resilient that we smile and head back into the next room to see the next patient.”

go further to require specific strategies to promote mental health among all trainees,” according to an article published March 4 in JAMA Psychiatry by Matthew Goldman, MD, of Columbia University Medical Center and New York State Psychiatric Institute and colleagues. Depression and burnout are separate entities, some medical professionals cautioned, noting that some overlap exists.

West believes that mental health wellness begins eroding with “first-years”: “We have to assume that starting in medical school, a pipeline of experiences leads to an increased risk of suicide,” he said. “That’s where we need to start.” Editor’s Note: Please see series companion article in this month’s edition: “Missouri Leads States on Medical Student Well-Being Advocacy” on page 7.

Seeking Solutions

Missouri jumped ahead as arguably the first state to introduce legislation aimed at facilitating change at the medical school level. Keith Frederick, DO, one of four doctors serving in the Missouri Legislature, and a state representative (R-Jefferson City), proposed the “ShowMe Compassionate Medical Education Act” in the 2015 regular legislative session. House Bill 867 raises awareness about medical students’ mental health and encourages Missouri medical schools to collaborate to identify best practices, particularly those efforts most effective at de-stigmatizing mental illness and encouraging students to seek support and services to cope with mental health issues. In June, the American Medical Association (AMA) launched an ambitious new initiative to address physician burnout, a step toward addressing mental health wellness in the profession. The interactive practice transformation series, AMA STEPS Forward, was developed after research revealed the overall burnout rate of U.S. physicians approaching 40 percent. That’s “more than 10 percentage points higher than the general population, which is why the AMA is taking a hands-on approach to meeting their dayto-day concerns,” said AMA CEO James L. Madara, MD. The Accreditation Council for Graduate Medical Education requires that programs assess fatigue and burnout among trainees and provide access to confidential counseling, “but these regulations should

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GrandRounds NHC Homecare in Milan Names Administrator MILAN - Matt Curtis was recently named administrator of NHC Homecare in Milan. He has worked in homecare for 7 years in both West and Middle Tennessee and has a BA in Health and Human Performance from The University of Tennessee at Matt Curtis Martin and his master’s in Healthcare Administration from Bethel University. He is originally from Trenton, Tenn. but now resides in Milan with his wife, Julie, and daughter, Scarlett. Curtis said that healthcare is always changing and he believes it is very important to educate the community on the resources available and that he’s excited to continue the reputation that NHC has established in West Tennessee.

TMA Survey Reveals Doctors’ Frustrations with Medical Specialty Board Processes NASHVILLE - A statewide survey by the Tennessee Medical Association regarding physicians’ required maintenance of certification (MOC) by various medical specialty boards, found most Tennessee physicians feel the cost and effort associated with certification and/ or recertification of a medical specialty is unreasonable and does not produce a measurable return on investment in

terms of patient care. For years the MOC process has stirred controversy in the medical community from some physicians who have grown weary of what they consider excessive fees and overly frequent testing requirements. The TMA House of Delegates passed a resolution in April 2015 calling for the Board of Trustees to report the findings of the survey, which was conducted in 2014, and study the results to determine what, if any, national advocacy efforts it can support to improve the MOC process. MOC is not a state-level issue. The TMA would like to see more reasonable use of testing, certification and recertification focused on keeping doctors current with clinical best practices that produce efficient, quality care, said John W. Hale, Jr., MD, a family physician in Union City, and President of TMA.

New Medical Director of Palliative Care at JMCGH JACKSON — West Tennessee Healthcare is excited to announce Kevin Joe Wheatley, M.D., FAAFP, as its new Medical Director of Palliative Care at Jackson-Madison County General Hospital. Wheatley is a graduate of James H. Quil- Dr. Kevin Joe Wheatley len College of Medicine at East Tennessee State University in Johnson City, TN. He completed his

residency training with the University of Tennessee Family Medicine in Jackson, Tenn. Wheatley obtained his hospice and palliative fellowship training at the University of Tennessee in Memphis, TN. Palliative care, also known as palliative medicine, is specialized medical care for people living with a serious illness. It focuses on providing relief from the symptoms and stress of a serious illness no matter the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of palliative care doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. Wheatley assumed his new role as Medical Director of Palliative Care at JMCGH in July. He will also assist with medical duties at Hospice of West Tennessee. Dr. Clyde Smith will continue to serve as Medical Director of Hospice of West Tennessee and Dr. Smith and Dr. Edward Koonce will continue to work in the hospital’s palliative care program.

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GrandRounds Jackson-Madison County General Hospital Receives ACC Award for Cardiac Care JACKSON — Jackson-Madison County General Hospital has received the American College of Cardiology’s NCDR ACTION Registry–GWTG Platinum Performance Achievement Award for 2015. Jackson-Madison County General Hospital is one of only 319 hospitals nationwide to receive the honor. This is the second year in a row JacksonMadison County General Hospital has received this recognition. The award recognizes JacksonMadison County General Hospital’s commitment and success in implementing a higher standard of care for heart attack patients and signifies that Jackson-Madison County General Hospital has reached an aggressive goal of treating these patients to standard levels of care as outlined by the American College of Cardiology/American Heart Association clinical guidelines and recommendations. To receive the ACTION Registry– GWTG Platinum Performance Achievement Award, Jackson-Madison County General Hospital consistently followed the treatment guidelines in the ACTION Registry–GWTG Premier for eight consecutive quarters and met a performance standard of 90 percent for specific performance measures. Full partici-

pation in the registry engages hospitals in a robust quality improvement process using data to drive improvements in adherence to guideline recommendations and overall quality of care provided to heart attack patients. Deann Montchal, Vice President of Hospital Services at West Tennessee Healthcare said the award is a proud achievement for the hospital and reflects the hard work and dedication of the staff.

Baptist Medical Group Woman’s Clinic Physician Receives Honor UNION CITY - Recently, Paul B. Nieves, MD, obstetrician and gynecologist at Baptist Medical Group-The Woman’s Clinic in Union City, received the 2014-2015 Clinical Adjunct Faculty Award for Excellence in Teaching from the College of Osteopathic Medicine at Des Moines University of Des Moines, Iowa. Students and fellow clinical faculty identify candidates for this honor. The award is given to clinicians who have achieved the high standards of clinical practice and teaching to students from the Des Moines University College of Osteopathic Medicine during the previous year according to Dr. J.D. Polk, Dean for the College.

Baptist Memorial-Union City Holds Crash Course Nurse Camp UNION CITY - Baptist Memorial Hospital-Union City offered its Crash Course Nurse Camp to area high school students June 1-5 and July 6-10. Forty-four students participated. Crash Course Nurse Camp is a summer day camp that exposes students to the healthcare industry, primarily nursing. According to Lori Brown, chief nursing officer at BMH-UC, the goal of Crash Course Nurse Camp is to promote the nursing profession to young people so that they select appropriate high school course work and can begin setting goals for their future careers. During Crash Course Nurse Camp, students learn about the educational requirements, skills, typical job duties and personal qualities of nurses. They participate in interactive, hands-on activities that highlight the skills, equipment, technology and resources used by nurses and other health professionals. The application process includes a student application, short essay, counselor recommendation and teacher recommendation. Students in home school settings may submit letters of recommendation from community members. Students interested in completing an application should contact their guidance counselors or visit www.crashcoursecamp.com.

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