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Brian Brown, MSN

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Identity as a Risk Factor Heart disease and the feminine mystique Despite the fact that heart disease is the number one killer of women in America and stroke the leading cause of disability, women often don’t identify with the very real dangers the disease holds for their gender ... 4

Nurses, Doctors Agree on Rx For Improved Work Environment What do nurses think of doctors? What do doctors think of nurses? More to the point, what do they admire about one another, what do they do to irritate one another, and what can they do to improve their working relationship? Medical News posed these questions to experienced doctors and nurses, and we hope their candid answers in these two stories help

to promote a better understanding between the disciplines. In order to receive the most frank and honest comments, we made an exception to our policy of not using unnamed sources. We offered the nurses and doctors anonymity so that they could talk most freely. Some of the opinions expressed here may sting, but they also may open some eyes and elicit productive discussion.

Doctors Say:

Nurses Say

Ask physicians about interactions with nurses and how the work environment might be improved, and they all agree with the nurses: communication and respect are primary. However, responses differ about how much autonomy the nurse should have in this relationship. A recurring topic was questioning a doctor in front of the patient.

When Medical News asked nurses what physicians could do to improve their working relationship, good lines of communication was one of the factors most mentioned. “I like the doctors the patients like – the ones who have some savvy or charisma in dealing with people,” was the response from one nurse. “The ones who communicate well with patients, patient families, nurses, everyone,” said a 25-year veteran ICU and recov-

(CONTINUED ON PAGE 6)

By GINGER PORTER

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Dustin Summers Executive Director, West Tennessee Physicians Alliance By SUZANNE BOyD

It is the dawn of a new era for the West Tennessee Physicians Alliance (WTPA) as long time Executive Director Tom Reed hands the reigns over to a fresh new face, Dustin Summers. With the changing of the guard, the Alliance, which has more than 100 doctors and more than 25 specialties, is looking to Sum-

mers, who has experience in healthcare policy and public health, to move the organization forward. Summers, a native of Paris, Tenn., always knew healthcare was in the cards for him; however it was not until he arrived in Washington D.C. for graduate school that he found his niche – healthcare systems and community

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NurseSpotlight

Brian Brown, MSN

Family Nurse Practitioner & Psychiatric Nurse Practitioner By SUZANNE BOyD

Editor’s note: This month, instead of our regular Physician Spotlight, in honor of nurses we focus on an outstanding nurse who represents the quality of care provided by the profession. Born in the crossroads of the Delta Blues, Clarksdale Mississippi, Brian Brown, MSN, grew up knowing he always wanted to be a physician. When the time came for him to make that decision a reality, nurse practitioners were on the rise as a profession and he found that direction a better fit with his philosophy of dealing with people. Today the family nurse practitioner who is also a psychiatric nurse practitioner is at the crossroads of Rock and Roll, Jackson, Tennessee and is bringing his holistic approach to his patients at Matrix Wellness Solutions. Brown earned a Bachelor of Social Work from the University of Mississippi. He received his Bachelor of Science in Nursing in Memphis at the UT Health Sciences Center, where he also earned his Master of Science in Nursing in 1998. “The program I chose for the master’s degree was a two level certification track in psychiatry and family medicine,” said Brown. “It was such an intense track that they stopped the dual track after four years.” After completing his education, Brown moved to Jackson to work with Pathways Behavioral Health Services. He also moonlighted for a Memphis psychiatrist doing inpatient work, which led to doing some psychiatric work in nursing homes. “Working in the nursing homes with patients really allowed me to take a

holistic approach to caring for patients, which was in line with my overall philosophy,” said Brown. Brown eventually took over the nursing home contracts on his own and started his own practice in 2002, Comprehensive Behavioral Health, which included an outpatient clinic and adolescent residential inpatient practice. Over the years, Brown says he has evolved into what he calls a hybrid practitioner, combining his psychiatric and family practice knowledge into one model. Three years ago he opened Matrix Wellness Solutions, a unique approach to healthcare that utilizes a wellness ap-

proach. “If we have a patient who is dealing with sadness, fatigue, insomnia, and weight gain, rather than immediately diagnosing it as depression and prescribing medication, we look at underlying causes for it,” said Brown. “With this holistic approach, we take a thorough history and look for laboratory abnormalities related to hormone imbalances that could be going on. For overall wellness purposes, we also look at advanced laboratory markers that would indicate cardiovascular risk, diabetes risk, and genetic risk. This gives us a very individualized picture about the person’s health and allows us to address those specific factors. We have found in our practice that most people want to treat the underlying hormone imbalance or other causes when we can find them. We feel we have a pretty unique model that no one else has.” In keeping with the wellness approach, Brown is always looking for innovative ways to address wellness concerns before they become big issues. Three years ago, he had an advanced lipid panel run. “My cholesterol had always been fine but because of my family history of heart disease, I had an advanced lipid panel run that Boston Heart Diagnostic and Cleveland Heart Diagnostic were utilizing,” said Brown. “What we discovered was that I had smaller lipid particles and bad genetics that put me at a higher risk for a heart attack and stroke. I immediately thought it was something we should be running at our outpatient wellness clinic. Boston Heart said we were one of the few clinics in West Tennessee and the only wellness clinic in the nation running their panels. Because of the wellness and prevention

benefits we gleaned for our patients, that opened the door for them to go into other clinics like ours throughout the nation.” For the past two years, Brown has been working on an intensive certification under his mentor, Neal Rouzier, MD, a leader and expert in the field of healthy aging who has been honored by The Academy for Preventive and Innovative Medicine for his contributions to evidence-based medicine in the specialty of hormone replacement therapy and preventive care. “I have completed 60 hours of classroom training and passed two of the four tests for this certification which I will complete in early 2015,” said Brown. “This places me in the top onehalf percent of prescribers in the nation for hormone replacement therapy and preventive aging care.” Taking a holistic approach to wellness allows Brown to incorporate his counseling experience into his practice. “To say I hang my shingle out and do therapy, is not correct,” said Brown. “But I do incorporate aspects of therapy into my practice everyday. For instance, if someone comes in with weight issues, we assess how that has evolved into a problem and deal with the life, work or home issues from as many angles we can.” Brown balances his busy practices with family. “We are very family oriented. Any chance I have, we are spending time as a family. We enjoy traveling and doing mission work through our church and other organizations,” said Brown. “For my wife, who is the high school principal of Trinity Christian Academy, and I, our jobs are our ministry so church, family and work are our world.”

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MedicalEconomics BY BILL APPLING

When the Center for Medicare & Medicaid Services (CMS) reports were released April 1, the information concerning the amount of money physicians were making, it brought on the obvious reaction from the medical community, including me. In fact, I decided to use the same title for this article that I used in my letter to the editor that appeared in the Commercial Appeal, on April 14. Physicians are all for transparency but the data which is used currently by CMS and the commercial payers is not accurately reflected. This type of data will cause patients to make inappropriate and potentially harmful treatment decisions. It will also result in unwarranted bias against physicians that can possibly destroy careers. There are other areas of healthcare where the data is also misleading. Providers know that clinical data (not just cost data) is the true measure of clinical outcomes and that they need the clinical data to improve outcomes. “The country is moving toward greater transparency in how healthcare institutions and providers charge patients and their insurance companies. Despite the attempt at clarity, the reimbursement data can mislead. The numbers may include staff payroll and equipment costs,” said Professor Cyril Chang, director of the Methodist Le Bonheur Center for Healthcare Economics at U of M’s business college. “A large part of the Medicare reimbursement okay expenses; medications, staff and equipment. Doctors are all for transparency, but comparing physicians’ outcomes with their peers and using quality measures are better strategies than using Medicare reimbursements,” said Keith Anderson, MD, board chairman of the Tennessee Medical Association. “Sinai is one of a growing number of health systems across the country that has begun tackling the social, economic and environmental conditions in the communities they serve as part of their programs to reduce hospitals re-admissions and improve outcomes.” (Modern Healthcare, February 3, 2014) “Cleveland Clinic CEO talks strategy, expansion and standardization.” (Modern Healthcare, February 3, 2014.) Earlier this year the first Independent Mid-South Information Exchange (MSHIE) was formed as a partnership between Pediatric Independent Practice Association (PIPA), and MSHIE Systems, LLC. MSHIE Systems is a joint venture between two local Memphis companies, PCS Medical Solutions, LLC and Cornerstone Technologies, LLC. The Mid-South Health Information Exchange represents the first project of its kind in the Mid-Mid-South: a health information exchange that will connect providers of one specialty (Pediatrics) at the individual practice level. “Other Exchanges have focused on multispecialty, and have involved westtnmedicalnews

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Misleading Doc Data connection at the hospital level,” said Dr. William Terrell, President of the Board of Governors of PIPA. PIPA made the decision a couple of years ago to move from a ‘messenger model IPA’ to ‘clinical model IPA.’ We identified that our technology was our greatest weakness. We have developed a great working relationship and are eager to move our partnership forward. Carmon Heilmann, president of PCS Medical Solutions and chief manager of MSHIE said, “The effort is unique. Other exchanges have connected providers to hospital data; however hospital systems contain only isolated incidents or care; when a patient receives treatment at the hospital.” By connecting to the practice EHR systems ( approximately 80 percent of the doctors in PIPA have EHRs), the MidSouth Health Information Exchange will contain much more of the patients medical record…the information that only exists in the patient’s chart at their doctors’ office. This represents a significant amount of clinical data available to providers and others. This will be real-time data (not claims or reimbursement data) to providers in the exchange showing the latest clinical findings for the patient whether the patient was last seen by that provider or not.

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This capability could also be extended to providers and facilities that aren’t

necessarily members of PIPA. For example, critical care facilities, hospitals and others.” Ultimately the HIE will provide a means to analyze these large quantities of patient data for the purpose of population health management and clinical integration. Identifying the highest risk patients and developing care plans and follow up for that group. Initially the exchange will focus on immunizations records and specific disease types that are important in the pediatric arena; asthma (Memphis ranked fourth in the country), juvenile diabetes, ADHD and others. Development of care plans for these areas will aid providers in implementing cost saving plans for their highest risk, ultimately the most expensive patients, from a cost of care perspective. Another unique aspect of this exchange is that PIPA will own a controlling interest in the local MSHIE. The exchange is physician driven. This will help keep the focus of the system on providing better care to their patients. MSHIE Systems is responsible for the development, implementation, training and maintenance of the exchange. “Professionals in practices around the country are harnessing their own data to manage patient populations more effectively,” said Keith Wisenberg, MBA,

CMPE. The concept, discussed in a growing number of circles, has major implications for healthcare providers. During the 2013 Colorado Health Symposium sponsored by the Colorado Health Foundation, Denver, attendees were asked how comfortable they were with payers gathering and using patient data to incentivize healthy behavior. Consider the fact, the speaker said, that retail companies identify repeat customers with cell phone roaming devices, access customer time spent in front of displays and use data on their buying to customize future coupons. If supermarkets track food purchases with loyalty cards, gyms tally facility use, and credit card companies record every purchase, it might not be long before employers and payers use that data to create a picture of your health and tailor insurance premiums accordingly. The question is not if you use it, but how to use it. (“The State of Medical Practice,” MGMA Connection, magazine.) 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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Identity as a Risk Factor Heart disease and the feminine mystique By CINDy SANDERS

Despite the fact that heart disease is the number one killer of women in America and stroke the leading cause of disability, women often don’t identify with the very real dangers the disease holds for their gender, according to Robert Wood Johnson Foundation Clinical Scholar Lisa Rosenbaum, MD. “We all know men drop dead of heart atDr. Lisa tacks … we don’t think of women dropping dead of Rosenbaum a heart attack,” the University of Pennsylvania cardiologist noted of the masculine attributes often attached to heart disease. Furthermore, women tend to fear other diseases, notably breast cancer, more than heart disease. The HealthyWomen 2010 survey, in partnership with the National Stroke Association and the American College of Emergency Physicians, found that women believe breast cancer is five times more prevalent than stroke, and 40 percent of those surveyed were ‘only somewhat’ or ‘not at all’ concerned about experiencing a stroke. Yet, stroke is significantly more prevalent in women than in men, and stroke kills twice

as many women as breast cancer each year. “There’s a certain sort of female solidarity around breast cancer,” Rosenbaum stated. In a perspective piece published earlier this year in the New England Journal of Medicine, Rosenbaum wrote about an encounter with a middle-age woman with high blood pressure and hyperlipidemia. When Rosenbaum asked the new patient what was the number one killer for women, she noted the patient “answered in a way that sticks with me: ‘I know the right answer is heart disease,’ she said, eyeing me as if facing an irresistible temptation, ‘but I’m still going to say breast cancer.’” Rosenbaum is quick to say breast cancer is a valid concern, but the emotions linked to the disease go beyond just the facts. She pointed to the controversy surrounding mammography as a clash between data and identity at the social level. Despite a recommendation from the U.S. Preventive Services Task Force to decrease mammography frequency for most women under age 50 based on decades of data, Rosenbaum wrote, “So intense was the outrage over these evidence-based recommendations that a provision was added to the Affordable Care Act specifying that insurers were to base coverage decisions on the previous screening guidelines.”

No matter where you stand on mammography, most healthcare professionals are united in agreeing lifestyle modifications and appropriate use of medications have been proven to prevent heart disease and save lives. However, Rosenbaum contends that facts alone aren’t enough. Instead, she said the healthcare community needs to find a way to tap into the emotional aspects of heart disease as successfully as has been done with breast cancer. In the her perspective piece, Rosenbaum wrote that although the first decade of educational campaigns such as Go Red for Women “led to a near doubling of women’s knowledge about heart disease, in the past few years, such efforts have failed to reap further gains.” She told Medical News, “Our default in medicine is to give people facts, and then we don’t know what to do when we hit the wall. We know how to disseminate facts … we don’t know how to change feelings.” Complicating the issue with heart disease is that in so many cases it is preventable, and therefore comes with builtin guilt. Risk factors, which have been well publicized, include smoking, obesity, high blood pressure, high cholesterol, and sedentary lifestyle. “All of these are embedded with a sense of not taking care of yourself,” Rosenbaum said. “You should have done something differently.” Conversely, breast cancer is imbued with a sense of having a terrible disease visited upon a victim, which is true. Also, because breast cancer kills more women at a younger age than heart disease,

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there are multiple media images of beautiful, strong heroines fighting and surviving … or succumbing … to a disease that attacks a body part that is so uniquely feminine. Rosenbaum pointed out Angelina Jolie’s message about breast cancer resonated with women across the nation who saw the actress as a lovely, brave, fierce role model. Again, she stated, it isn’t ‘bad’ that breast cancer has pushed its way to the front of female consciousness. It’s smart … and perhaps it’s the type of message the field of cardiology should consider to reach more women. However, Rosenbaum said it isn’t fair to ask healthcare providers to try to change identity beliefs in a brief office visit. Instead, she said the subject requires research regarding social values and group identity. Ultimately, Rosenbaum added, cultural messaging will likely come from a variety of sources including media outlets. Today, she said, “Our biggest challenge is translating what we know into better health of our population. The next phase of evidence based-medicine should be as much about figuring out how to communicate that evidence to our patients … to do that we have much to learn from the methodological approaches of the social sciences.” Rosenbaum added the starting point to address women’s perceptions of heart disease should be to conduct focus groups to evaluate where emotional beliefs currently stand and assess the impact of framing messaging in different ways. “This is decades worth of work,” she stressed, “to ultimately understand not just how they feel and where those feelings come from, but to evaluate whether there are appropriate interventions that help women adopt more heart-healthy behaviors.” While heart disease might have a decidedly masculine feel, there’s no reason why research can’t point to ways to soften the message and appeal on an emotional level to women, as well. After all, women are often identified with their capacity to love … the trick will be finding the right words to help a woman celebrate her big heart while being cognizant of the dangers that come with having an enlarged one.

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MedTenn 2014 Bringing Medicine Together By CINDy SANDERS

From April 24-27, physicians from across the state gathered in Middle Tennessee to discuss issues impacting medicine, attend targeted educational courses, vote on key policy resolutions, install new officers, network with colleagues, and support Alzheimer’s awareness during MedTenn 2014. The annual convention of the Tennessee Medical Association featured more than 20 speakers and 20 sessions over four days. TMA President Russ Miller said the theme of ‘bringing medicine together’ speaks to Russ Miller the association’s focus on collaborative practice and communication around patient-centered care. “We feel it’s very important to continue to advocate for doctors and patients to bring everyone together,” he said, adding the annual conference has become more of a true medical convention with a ‘big tent’ feel that includes other medical specialty societies. The multi-specialty meeting included coordinated events, education and activities with Cumberland Pediatric Foundation, Tennessee Academy of Ophthalmology, Tennessee Association for Long-Term Care Physicians, Tennessee Chapter of the American Acad-

emy of Pediatrics, Tennessee Chapter of the American College of Surgeons, Tennessee Geriatrics Society and Tennessee Psychiatric Association. The four-day conference included hot topics impacting patients and providers in Tennessee. Featured courses included ICD-10 implementation strategies, proper prescribing, workers compensation law changes, personalized medicine, depression secondary to critical illness, health reform, Medicaid expansion, and emerging payment and employment models. Miller noted TMA is keenly focused on the changing paradigm of payment for episodes of care. He added the change from volume to value isn’t threatening to physicians but is concerning in terms of how quality is counted and measured. “Doctors are always about quality and comparative data,” he stressed, adding it is important that decisions are based on clinical data and not just on claims data. The TMA is keeping a close eye on innovation grants tied to TennCare with the recognition that payment reform will ultimately expand to commercial payers, as well. “We realize the success of these pilots is directly in the hands of the physicians doing the work,” Miller said. “We’ve got to get it right at the onset. If we need to take a little extra time to make sure what we measure

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TMA Installs Volunteer Leadership The pomp and ceremony surrounding the presidential succession of the Tennessee Medical Association is always a highlight of the annual meeting. This year was certainly no exception as the gavel passed from Chris Young, MD, to Doug Springer, MD, who was installed as TMA’s 160th president with John Hale, MD, stepping into the presidentelect position. President: Douglas J. Springer, MD, FACP, FACG, is a gastroenterologist from Kingsport. Originally from Canada, he moved to Tennessee in 1978 as part of a young physicians’ program to move doctors to underserved areas of the state. Now a naturalized U.S. citizen, Springer has practiced his specialty for 35 years in Upper East Tennessee. A Fellow of the American College of Physicians and American College of Gastroenterology, Springer has been actively involved in several professional medical associations and is a past president of the Sullivan County Medical Society and past chair of TMA’s membership committee. He also has held professional service positions including reviewer for examinations for the American Board of Internal Medicine and chairman for the Department of Medicine at Indian Path Medical Center and Holston Valley Medical Center. Springer received his medical degree from the University of Calgary, Alberta, where he also completed his residency in Internal Medicine. He then undertook a fellowship in Gastroenterology at Queen’s University in Kingston, Ontario, Canada. He is board certiﬁed in both Internal Medicine and Gastroenterology. President-Elect: John W. Hale, Jr., MD, is a family medicine practitioner in Union City. Hale has been actively involved with the TMA since his student afﬁliation while at East Tennessee State University (ETSU). A three-time member of the TMA Board of Trustees, Hale has served in the House of Delegates (HOD) for 22 years. Immediately prior to his new position, Hale completed terms as speaker of the HOD and chair of TMA’s legislative committee. He is a past chair of the young physicians group and past AMA delegate in that role. Additionally, Hale has served as a past president and secretary of the Northwest Tennessee Academy of Medicine and is a past IMPACT board member. Hale earned his medical degree from ETSU’s Quillen College of Medicine and completed his residency at Jackson-Madison County Hospital.

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Doctors Say,

Nurses Say,

continued from page 1

“Some patients get the impression by little thing. He encourages nurses to use the nurse’s body language or interaction their training, but he believes they are with me that they are questioning my deconstrained by hospital policies. cision,” said a neurosurgeon with decades Other doctors blame electronic chartof service. “That causes a crisis with paing for communication problems between tient confidence. Nurses should respect nurses and doctors. An internal medicine the physician and understand that carryphysician for 36 years pined for the days ing out orders instills patient confidence. of written records. They don’t need to imply they know bet“I used to be able to ask if a patient ter.” had a problem in the night, This same physician if they pooped, if they had great respect for a slept—I defy anyone to Nurses are nurse’s intuition and find that in electronic afraid to speak up wanted them to “take charts now,” he said. more ownership” and feel they will get “Nurses need to be with patients. It able to present a in trouble. If they seemed the input simple history sex, complain, they could be would be welcomed age, presents with had there not been let go or get bad shifts, these symptoms, an audience. appearance, here is and I think that’s a This theme conpertinent history, here shame. tinued in the feedback are labs being done— gleaned from a seasoned like in the ER. Now we dermatologist, who advised are shotgunning people with questioning the doctor in front of 50 types of labs to see what falls the patient produces confusion on the part out.” of the patient and causes them to second The role of the nurse practitioner was guess everything. He said this advice also a hot topic. Repeatedly, it was expressed goes for physicians of other specialties. that supervising NPs should not imply “Double checking work and discussto doctors they know all that doctors do. ing opinions are fine if the issue is worked Also said was that the accountability of out respectfully privately and then prenurse practitioners was not there. One sented to the patient,” he said. 30-plus-year anesthesiologist recounted One general practitioner of 30-plus a story he heard from a colleague about years explained, “There will always be a patient who accessed a freestanding some bumping of heads, and everyone has clinic in a drugstore with severe abdomito remember they all have the patient’s nal pain. The NP administered antibiotics best interests at heart. for a UTI. The next day the patient was “I know there are doctors that tend near death in the ED with a ruptured dito be know-it-alls, and I know a lot feel verticulum. threatened when questioned. Nurses are “A physician in that spot would be in afraid to speak up and feel they will get in jeopardy of losing his license. The Board trouble. If they complain, they could be of Medical Examiners has a lot of criteria let go or get bad shifts, and I think that’s a and a long, arduous process for licensure shame,” he said. but the nursing board feels a nurse can Another doctor interviewed said, do anything a doctor can do by taking a “Like we could get nurses in trouble. The weekend course,” he said. hospital is always going to take the nurse’s An internist echoed his opinion, comside.” He cited the nursing shortage and paring 2500 nursing training hours with ways hospitals can discipline doctors as what he cited as 25,000 training hours for reasons for his statements. the standard beginning intern. Speaking Over and over there was a call for of statewide legislation proposed to allow nurses to use their training and clinical NPs to function without doctor oversight, skills. A six-year veteran in inpatient rehe said, “It is foolhardy to think nurse habilitation encouraged nurses not to be practitioners can function without physiafraid to use their clinical judgment to cian supervision.” problem-solve before calling a doctor, she Citing the need for nurse practitiosaid. “Have a proposed solution when you ners due to primary physician shortages, call me. Think it out and present it to me he continued, “We need to have a more so we can intervene.” symbiotic relationship. As a whole, my One hospitalist with experience in a peers respect NPs.” variety of areas expressed displeasure over There were lots of compliments the content of his messages while taking about “good” nurses, described as those call. who used their intuition and clinical “Sometimes I will get a call at 5 a.m. skills, took ownership in their jobs, went over whether to administer an over-thethe extra mile and were friendly and apcounter medication. If they were at home, proachable. A rehab physician said, “The they could do that. If a patient gets transones who are not just clocking in, passing ferred to another room, they will call meds and going home are the best to work me—and I ordered the transfer. It gets to with. It’s usually very obvious who those the point of harassment,” he said. “They nurses are that take extra steps with their have six patients, and I have 60.” patients.” He said the way the hospital uses A hospitalist said, “I am usually nurses can put stress on the physicianaround nurses who are bright, funny, nurse relationship, and that nurses should good to be around and good at what they not feel that they have to call for every do.”

“

”

MAY 2014

continued from page 1

ery nurse and nurse educator. She said Blanket concerns have to do with the this goes for physicians, regardless of age stressed health care system, such as nurse and gender. shortages, new reporting practices and inIndeed, communication and respect creases in policies and procedures. Nurses were key issues mentioned in every insay it is always helpful if doctors underterview. The nurse quoted in the above stand the limited staff and limitations put paragraph said she has prayed for doctors on nurses by competing demands. to ask her opinion. “I am at the bedside “I realize there are not enough ex24/7. I know the specialty patients I take perienced nurses anymore. I know the care of well. We could take much better newer ones will call a lot in the middle of care of the patient if doctors would just ask the night and we are using less supervisory me my opinion, listen and communicate.” docs in my area,” one NICU nurse said. As for most of the nurses interviewed, “But I have 25 years’ experience. If I call internists and family practice physicians you in the middle of the night because I were preferred to specialists because of have a concern, it is something. It’s not the respect they have for nurses and their my call whether we save this baby or not. people skills. The most temperamental You are the professional. It’s your call.” specialty described was surgery. A growing number of physicians and “One highly respected doctor has nurses are becoming efficient at new eleccalled us ‘nothing more than trained montronic charting and reporting systems. keys,’” said an almost 30-year nursing vetOne nurse said that new computerized eran currently working in an ambulatory charting systems, although a learning surgery center. “If you would not talk to curve at first, will help streamline healthyour wife, daughter or mother in the rude care – making treating patients safer and manner you find yourself talking to me, interpreting orders easier. Another exthen do not talk to me in that manner.” plained that verbal orders are hard to do One hospital surgeon was described as with new computer systems, and said she “berating nurses and residents over pretty wishes that physicians would adhere to the much everything. He is intentionally intimnew electronic guidelines. idating and downright mean to everyNurses also pointed out they one he deems not as important also have their physician heas himself,” by a 16-year roes. A nurse practitioner pre-op nurse with 33 in psychiatry had a difIf you would not years cumulative ficult patient threaten hospital experience. her and then file a talk to your wife, She described ingrievance against daughter or mother stances of whining, her and threaten in the rude manner complaining and to kill her. The temper tantrums psychiatrist told you ﬁnd yourself from many docher to walk away talking to me, then do tors, resulting in a from the situation not talk to me in that real lack of respect and let him handle for the doctor and it, telling her he had manner. decrease in productivher covered and it was ity by the staff. ultimately his responsibil“I have definitely had ity as the attending. It meant some doctors who have had a sense a lot to her and she felt much safer. of entitlement, and are rude or arrogant,” A 24-year oncology nurse explained said a nurse practitioner with 10 years’ she was extremely happy where she experience. “Or, they don’t see the value worked. of nurses and nurse practitioners. NPs are “I work with some of the most inthere for the benefit of the patient. It’s not telligent people in the world, world-rethat we want to be a physician. If that was nowned, and they are not too big to talk to the case we would have gone to medical patients, patient families, or nurses,” she school.” said. “They are very respectful of everyA MED/SURG nurse of 16 years one and it facilitates the best patient care said she knows all specialties are busy, but possible.” she would like more physician communiSelf-sufficient, kind, friendly, quick to cation with patient families. She has been thank those who help him and very comon both sides, recently losing a family plimentary is the way one pre-op nurse member after several months-long hospidescribed her favorite anesthesiologist. tal stays. She said at first, she would keep “Typically, the doctors who get the her profession a secret from her loved best work from nurses are the ones who one’s doctors, but eventually her nursing treat them with kindness and respect,” she experience would be found out. Commusaid. “They show occasional appreciation nication would improve after that, and she or interest in you as a person or your life thinks that openness in communication outside work. It’s validation.” should be the same for everyone. Communication between physician colleagues is important to the hospital REPRINTS: Want a reprint of a nurse, said a 27-year nursing veteran. Medical News article to frame? A PDF There can be conflicting discharge orto enhance your marketing materials? ders, different medication choices, or one Email subscribe@medicalnewsinc.com doctor may start one thing and another for information. physician discontinue it. In these cases her concern is consistency.

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Hey Doc, It’s About People By TIM NICHOLSON

You’ve been there. On a flight between somewhere and home, seated next to a stranger on their way to some other place. Conversations are usually light if they happen at all. We’re often trying to catch a nap or speeding our way through some sort of work on the laptop before touchdown. But this time I was seated next to a doctor who was winding down a practice he’d only recently sold and headed into what he called “halftime.” His plan was to start a new career. I couldn’t help asking him what he found the most rewarding about the one he was exiting. The doctor had been the chief medical officer of a fifteen physician general practice with some areas of specialization but his primary focus was family medicine. I asked, “What do you think have been the top medical advances during you tenure?” His answer was winding until he decided to focus on the most recent 10 years or so and people.

He was hopeful about the big picture advances like the 2003 announcement that scientists had completed a draft sequencing of the human genome, or all the genes that make up our DNA. The doctor appreciated the increased application of minimally invasive surgeries, laparoscopic surgery has become the norm for many operations, including gall bladder removal, hernia repair and appendectomies among other things. And, medications like those that address sexual dysfunction, “in the way that Viagra is used to treat erectile dysfunction,” he said. I thought out loud, ”That’s quite a journey from mapping the human genome to the bedroom. Do those things have anything in common?” His answer was quick, “people.” Of course, people. It turns out that “relationship” is the thing he will miss most about practicing medicine. He made the connection this way:

Update on ICD-10 Physicians in Tennessee have been encouraged by the Tennessee Medical Association (TMA) to “continue improving clinical documentation” in preparation for ICD-10 changes despite the fact that the U.S. Senate on the last day of March voted to delay the implementation of ICD-10 until October 1, 2015. The Senate vote of 64-35 led to the passage of a House-approved measure that would delay a scheduled 24 percent cut to Medicare physician reimbursement rates and push the ICD-10 compliance deadline to 2015. A statement issued by the TMA shortly after the Senate’s action stated, “We encourage physicians to continue improving clinical documentation to not only transition into ICD-10, but also meet new requirements for value-based reimbursement, ACOs and other emerging payment models. TMA will continue supporting Tennessee’s medical practices in these efforts through education, legislative advocacy, special events and other programs “For the past three years, TMA has provided education and other resources to help our members fully prepare for the October 2014 deadline. Practices that were on track to successfully transition are now ahead of the curve. For others, this latest delay means more time to prepare.” U.S. healthcare organizations are working to transition from ICD-9 to ICD10 code sets to accommodate codes for new diseases and procedures. The switch means that healthcare providers and insurers will have to change out about 14,000 codes for about 69,000 codes. Before Congress’ action last month, the ICD-9-CM code sets that currently are used to report medical diagnoses and inpatient procedures would have been replaced by ICD-10. The looming changes raised the question, would the Memphis medical community be ready for the change? westtnmedicalnews

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Since so many people and organizations would have been affected, that question was an important one. The users of the codes include practitioners, insurance carriers, government regulatory bodies and healthcare research personnel. Other entities that would have been impacted include hospitals, pharmacies, physical therapy providers, home healthcare providers and skilled nursing facilities. The TMA expects all practices in the state to incur additional testing timelines and costs. The organization says it will communicate related updates as they are available. TMA expects the transition from ICD-9 to ICD-10 to bring drastic changes to a physician’s practice. It forecasts the increase in coding will jump from 16,000 to 68,000 alone. All “covered entities” – as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) – will be required to adopt ICD-10 codes for use in all HIPAA transactions. To avoid disruptions in patient care and reimbursement, TMA suggests physicians must be prepared. A successful transition from ICD-9 codes to ICD-10 codes will require significant planning. At minimum, organizations should consider the following: • Ensure top leadership understands the scope and significance of the ICD-10 implementation and transition • Assign responsibility and decisionmaking authority for managing the transition • Plan a comprehensive and realistic budget • Ensure involvement and commitment of all internal and external stakeholders, and • Adhere to a well-defined timeline. The TMA says it can help with this transition through online courses, access to experts and ICD-10 transition toolkit and software.

Experts say sequencing each person’s genome would be beneficial to prevent a variety of heart ailments and even obesity. “Just knowing they have a higher risk of obesity could be enough motivation for patients to lead a healthier lifestyle,” he said, adding that it was one of the Top 3 issues his clinic addressed with patients. Laparoscopic surgery matters because patients generally endure less pain, smaller scars and a shorter recovery period. “Patient types who might have tried to live with their conditions in the past were more inclined to seek treatment now. They feared missing work and losing jobs. Less recovery time means less time off the job.” The pilot interrupted our chat to announce our descent into Memphis. So I asked, “Our time together is limited. I get the people part of the genome and surgical advances but where’s the people part intersect with Viagra?” I felt like an eighth grader. “Relationships are about people. Medications like Viagra have helped to restore intimate relationships between husbands and wives.” He smiled and said, “These medications aren’t about feeling manly like some TV commercial might suggest. I’ve prescribed them to couples that had drifted apart. During counseling sessions I’d learned that they were no longer having sex and that it was often about the husband’s being physically incapable of performing. Men and women have written to tell me that a prescription to address erectile dysfunction

saved their marriage.” Relationships. People. Of course, it’s why any advance in medicine is relevant. And it’s also why social media matters. People want access to information that might be helpful in treatment of a condition they’re trying to manage or that might inform their ability to be useful to a friend or family member who suffers a medical condition. Access to information from a trusted voice, like their doctor, could be the advance in medicine that makes the biggest difference in the life of someone in your patient community. Map their genome? You may not be doing a personalized sequencing but we’re all learning from those who are. Prescribe the right medication? Sure, that’s most likely within your realm of authority. Sharing information that’s helpful? You can. You’re one of the most important people or relationships in a patient’s life. And advances in the use of social media for that purpose have made it one of (what may someday prove to be among) the top advances in medicine. Tim C. Nicholson is the President of Bigfish, LLC. His Memphis-based firm connects physicians, clinics and hospitals to patients and one another through healthcare social media solutions, branding initiatives and websites. His column, “Hey Doc”, appears here monthly. Find him on twitter @timbigfish or email tim@gobigfishgo.com

Healthcare Law Commercial Litigation Business Law Estate Planning

TODD D. SIROKY, ATTORNEY 316 South Shannon Street Jackson, TN 38301 731-300-3636 www.sirokylaw.com MAY 2014

Healthcare Leader: Dustin Summers, continued from page 1 health. “I graduated from the University of Tennessee-Martin, then moved to Washington, DC, by way of Nashville, to pursue a master’s degree in public health at George Washington University with a focus on global health,” said Summers. “Although I was primarily studying what was happening in Africa and Asia, there were many parallels to what we see in the South and other rural areas of the United States. While in school, I also worked in a variety of capacities at organizations that focused on various aspects of healthcare,

and along the way, I was able to develop the organizational management skills that I believe will be an asset to the WTPA. When the opportunity to return to West Tennessee became available, I jumped at the chance to take on this new challenge.” Taking over as executive director for WTPA, allows Summers to pull from his experiences in the non-profit field as well as development and fundraising. “I have had the opportunity to work with a wide variety of people from all across the country, and a large portion of my pro-

fessional background has been shaped by experiences that have allowed me to develop both external and internal communication skills. I also feel that I have an understanding as to how overarching health policies can affect practitioners and hospitals at the community level.” Summers also recognizes the value of the expertise already in place at the WTPA. “I know working with Tom through the end of May is a huge benefit to me as he has such a wealth of knowledge regarding the local medical commu-

MedTenn 2014, continued from page 5 matters, it will benefit the patient and profession.” From a public health standpoint, Miller said, “There are a couple of issues that need resolution in short order.” One, he continued, is Tennessee’s prescription drug problem. “I think we’ve got awareness at a high level,” he said of past efforts to draw notice to the problem. “Now, our attention is more focused on providing solutions to the misuse and abuse of prescription drugs.” TMA has been closely involved in crafting continuing medical education seminars tied to prescription drugs and opioid use in the state. The latest CME iteration was launched during MedTenn ’14 in response to recent legislative requirements pertaining to controlled drug prescribing and licensure renewal. The two-hour course also will be presented around the state in the coming weeks. Another public health issue on the front burner is the expansion of Medicaid in Tennessee. “As doctors in Tennessee, TMA believes it’s the right thing to do at the end of the day. It’s documented that people with access to healthcare and health insurance lead longer, healthier, more productive lives,” Miller said. He continued, “Healthcare supports expansion … politics has to figure out how to pay for it. Our position comes from what’s right for patients, but we’re going to continue to work with legislators to find a solution we can all live with.”

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In addition to tackling the serious business of medicine, attendees also got to have a little fun and give back at the same time. Miller noted TMA opted to forego the traditional banquet following the presidential gavel exchange in favor of a fundraiser this year benefitting the Pat Summitt Foundation, which provides grant funding in the

fight against Alzheimer’s disease. Miller said physicians generously give of their time and resources throughout the year. The TMA team thought it was highly appropriate to support that spirit by giving back as an organization to a medical issue impacting millions of families across the country.

The Economic Impact of Tennessee Physicians A report released last month by the America Medical Association in conjunction with state medical societies underscores the enormous influence physicians have on national and state economies. Looking at approximately 720,000 physicians in the United States primarily engaged in patient care (as opposed to physicians focused on research and teaching), the study found physicians create healthy communities in ways that extend far beyond the delivery of medical care. Nationally, patient care physicians contributed $1.6 trillion in economic activity and supported 10 million jobs in 2012. “Physicians carry tremendous responsibility as skilled healers, trusted confidants and patient advocates, but their positive impact isn’t confined to the exam room,” said AMA President Ardis Dee Hoven, MD. “The new AMA study illustrates that physicians are strong economic drivers that are woven into their local communities by the jobs, commerce and taxes they generate.” She added those dollars support schools, housing, transportation and other public services in local communities. In Tennessee, patient care physicians support more than 143,000 jobs and more than $11.7 billion in wages and benefits. Additionally, those physicians contribute to a total of $618.8 million in local and state tax revenues and generate $20.1 billion in economic activity for Tennessee. On average, each physician supported 10.21 jobs with an average of more than $834,000 in total wages and benefits, contributed more than $44,000 in local and state tax revenues, and generated more than $1.4 million in direct and indirect economic output.

nity. The clinical administrators I get to work with through the Alliance also made this job very attractive to me.” As the only employee of WTPA, Summers role is to work closely with the organization’s Board of Directors, which is comprised of six physicians and for the first time in the 30-year history of the Alliance, a clinical administrator. He also serves as an advocate for the member physicians and clinics with hospitals, insurance companies and the community. His health policy background allows him to serve as a resource for healthcare policy changes that may be coming on the state and national level. Summers sees his biggest challenge in the degree of national uncertainty surrounding healthcare reform. “The last five years have seen a major change in the way healthcare will be delivered and accessed in the future. One of the greatest challenges will be found in how we as an organization navigate those waters and provide quality and affordable care to the community. This is a challenge for all medical practitioners and healthcare organizations. However, I am confident that the WTPA will only strengthen its presence in this regard throughout the area, region and state.” As he becomes immersed in his new job, Summers wants to increase the presence WTPA has, not only in Jackson, but across West Tennessee. “I want to build our presence as a healthcare network,” said Summers. “I am hoping to immediately improve the coordination and communication within our organization and between the WTPA and the Jackson community. The strength of our organization is in the individual doctors and clinics that comprise the WTPA. With over 100 physicians representing over 25 medical specialties, we cover everything from primary care to advanced specialization. As the WTPA grows and develops, I hope that we will be able to position ourselves as an organization that represents quality care and dependable service throughout Jackson and West Tennessee.” For Summers, relocating to West Tennessee is coming home. With his parents, three brothers, niece and nephew just a few hours away in Paris, he is enjoying spending time with them. An avid baseball fan who played all four years in college, Summers plans to take in as many Jackson General games he can. “When I moved to DC, I knew no one. I worked a fulltime job while going to graduate school, and I did my best to make the most of my experience,” said Summers. “In a very short amount of time, I was able to have many unique opportunities and to be involved in things I never even dreamed possible while growing up in Paris. All of those experiences led me to be the Executive Director for an outstanding organization that I think I can have an even greater impact on healthcare in Jackson and throughout West Tennessee.”

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SANS Cyberthreat White Paper Shows Dark Clouds on HIT Horizon Widespread security issues put systems, patients at risk Consider yourself warned. A white paper released earlier this year by SANS, a global leader in cybersecurity research, training and certification, painted a bleak picture of where those in the healthcare industry currently stand in terms of keeping protected information safe and secure. The report was created using healthcare-specific data provided by Norse, a live threat intelligence and security solutions firm, from September 2012-October 2013. The eye-opening results underscored the vulnerability of providers, payers, business associates and patients. Authored by Barbara Filkins, a senior SANS analyst and healthcare specialist, the report detailed the widespread problem. In analyzing the Norse data collected during the 13-month sample, the intelligence found: • 49,917 unique malicious events, • 723 unique malicious source IP addresses, and • 375 US-based healthcare-related organizations compromised … averaging about one a day. Filkins wrote, “The data analyzed was alarming. It not only confirmed how vulnerable the industry had become, it also revealed how far behind industry-related cybersecurity strategies and controls have fallen.” Furthermore, the analysis made it clear that the threats aren’t unique to any one type of healthcare company, but providers are seemingly the most vulnerable. In looking at the sectors compromised by malicious traffic, healthcare providers led the way with 72 percent. Business associates accounted for 9.9 percent of the malicious traffic, health plans 6.1 percent, healthcare clearinghouses 0.5 percent, pharmaceuticals 2.9 percent, and other related entities 8.5 percent. Most alarming, noted Filkins, was the level of activity found in what was just a sample set. Speaking to Medical News from her California office, Filkins said ‘malicious events’ are defined as an outside threat or event that might have penetrated the system and could range from hijacking contacts to pushing sensitive information outward. She noted that many companies, practices and facilities have policies in place warning employees not to click on an unknown email or link. (And who hasn’t received a suspicious link under the guise of coming from a friend or colleague?) Yet, she said, “People need to be looking at not only what comes into their network, but what goes out of their network.” To find and address malware typically requires a HIT professional. “A lot of times an attacker will use a very common protocol so it might look like someone is westtnmedicalnews

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The Cost of Failure

them more secure.’”

By CINDY SANDERS

Measures to Improve Security

browsing the web, but you might have to dig a little deeper under the covers,” she noted of finding and locating problems. “A lot of these events continued not just for days … but for months,” she added.

Locking the Front Door, Leaving the Back Wide Open

Oftentimes the point of entry for attackers was not the main information system. Instead, those with malicious intent entered through peripheral surfaces like network printers, call contact software, routers, medical devices, and … ironically … security cameras. While the main system was securely locked and password protected, many times, Filkins said, the default password remains on these add-on surfaces. Finding the admin password, she continued, is as easy as doing a quick Internet search for the device in question. “There are some very basic things that can be done to get started with protection,” Filkins noted. The most obvious … but clearly overlooked … is to change those default passwords. However, she continued, changing to an easily deciphered password isn’t much help. Avoid using your children’s names, street address, pet names, combined physician names, name of the practice, or other easily discernable choices. The best passwords, Filkins said, include numbers and unique characters. Mobile devices can also cause headaches … in part because of unrealistic expectations and policies. “Everyone uses mobile devices,” Filkins stated. “Rather than trying to bury that and say, ‘oh, we never use mobile devices,’ maybe relax the punitive policies and instead say, ‘let’s get honest and figure out how to make

“Know what’s on your network,” Filkins said. “Make sure your network is configured properly and devices are configured properly.” She added it’s important to know who is using what and how it’s being used. Having a strong password policy is critical to proper configuration. “Think like an attacker,” she continued. “And if you can’t do it, get someone who can.” There are numerous resources and companies that can help with this task. It boils down to being aware, Filkins noted. “It’s basic awareness but in a digital world.” She continued, “Know what your network pathways are for your organization.” Filkins said that often there’s an emphasis on protection for “bad things coming in” … but if something does penetrate the system, there isn’t much monitoring of outbound traffic. Egress filtering is as important as ingress protection.

The healthcare industry is particularly attractive to cyber attackers because of the type of information housed on servers. With medical identity theft, the victim is responsible for costs related to a compromised medical insurance record. A survey by the Ponemon Institute last year estimated that cost to be $12 billion in 2013. Security breaches also represent major costs to the compromised entity. Steep fines, incidence handling, victim notification, credit monitoring for victims, and potential legal action represent direct outof-pocket expenditures. In addition, a data breach could also significantly harm reputation and future business opportunities. The greatest cost, however, is to a patient who winds up with inaccuracies in his medical record that could result in a misdiagnosis or wrongly prescribed medication.

The Takeaway

“Today compliance does not equal security,” Filkins wrote. “Organizations may think they’re compliant, but this data shows that they are not secure.”

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GrandRounds Senior Expo 2014 in Jackson The SW Area Agency on Aging & Disability’s Senior Expo will be held on Thursday, May 22, 2014, at the Carl Perkins Civic Center in Jackson. They expect an attendance of 300-400. The overall theme is “Safe Today, Healthy Tomorrow”. In addition, there will be a County Fair with a “Hee Haw” show for the entertainment. There will be “Fair Food” and lots of fun things going on. For more information, call Terrie Adkins, LPN, at 731-668-6414.

The Jackson Clinic Announces Addition of New Internal Medicine/ Geriatrics Physician The Jackson Clinic recently added Dr. Ernesto P. Chioco to their Internal Medicine and Geriatrics Department. Dr. Chioco joins Dr. Keith H. Kirby, Dr. Dulce Flor E. Madrid and Dr. Cindi R. Swaim Dr. Ernesto P. Chioco at 3568 Chere Carol Road in Humboldt. Dr. Chioco received his Doctor of Medicine degree from Far Eastern University, Manila, Philippines. He completed his residency at Bergen Pines County Hospital,

Babies Born At Jackson-Madison County General Hospital Receive Safe Sleep Sacks Infants born at Jackson-Madison County General Hospital now go home with a gift from Ayers Children’s Medical Center, which will hopefully decrease their chances of SIDS (Sudden Infant Death Syndrome). Infants receive take-home sleep sacks plus information and teaching with safe sleeping tips. The information includes the ABC’s of Safe Sleep including: Babies Should Sleep Alone, on their BACK, in a CRIB. The hospital chose sleep sacks because they encourage babies to be both warm and safe during sleep said Deena Kail, Administrative Director of Ayers Children’s Medical Center and the West Tennessee Women’s Center at General Hospital. Statistics show that more than 4,500 babies die unexpectedly each year in the United States, often due to suffocation from fluffy bedding or a sleeping adult and many times the direct cause is never discovered. Thirty-two -year-old Sandy Alexander of Jackson had gone back to work for only two days when she got a call that her baby, Grant, had died of SIDS. Sandy says she was determined that other mothers would not have go through the same tragedy that she experienced. She has made it her mission to educate other parents and caregivers about safe sleep practices for babies. Alexander was instrumental in persuading Ayers Children’s Medical Center to send every newborn home with a safe sleep sack. Alexander recently produced a public service announcement for local radio and television stations as the next step in an ongoing campaign to reduced sleep-related infant deaths. Her story can be seen by visiting www. youtube.com/user/TNDeptofHealth. The safe sleep sacks at Jackson-Madison County General Hospital are made possible by the Ayers Children’s Medical Center Fund at the West Tennessee Healthcare Foundation. If you would like to support this fund visit www.wthfoundation.org/give and type in sleep sacks under designation. 10

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Paramus, New Jersey and his internship at Veteran’s Memorial Medical Center, Quezon City, Philippines. He completed a fellowship in geriatrics at Westchester County Medical Center, Valhalla, New York. Dr. Chioco is Board Certified, American Board of Internal Medicine and Geriatrics. Internists handle the non-surgical treatment of diseases that affect the internal organs of the body and provide ongoing, comprehensive medical care for older patients. Internists tend to be consultants to other doctors focusing on diagnostic problems that need secondary opinions. By working hand in hand with a patient’s primary care physician, comprehensive and thorough medical attention is achieved. Geriatrics is the branch of medicine that focuses on health promotion, the prevention and treatment of disease and disability in later life. A geriatrician is a medical doctor who is specially trained to prevent and manage the unique and, oftentimes, multiple health concerns of older adults. They are able to treat older patients, manage multiple disease symptoms, and develop care plans that address the special needs of older adults.

Reduced Pain for Joint Replacement at JMCGH Patients undergoing joint replacements at Jackson-Madison County General Hospital have seen reductions in post operative pain with a new pain medication. Exparel is an anesthetic injection that can be administered by physicians into the wound site following joint replacement. Exparel is a medication that allows the orthopedic surgeon to significantly prolong the effect of numbing medicine directly at the operative site for up to 72 hours. Surgery Executive Director Rene’ Hampton says this new patient focused pain control has been used at Jackson-General for only three months and has already proven to help patients in a variety of ways including shorter hospital stays, less narcotic pain medicine and earlier physical therapy. Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.

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