FOCUS TOPICS CMO ROUNDTABLE • CARDIOVASCULAR CARE • GENOMIC MEDICINE • LEGISLATIVE AGENDAS
February 2019 >> $5
New Institute Chief Gives Tip of the Hat To Excellent Mentors Dr. John L. Jefferies, the head of Memphis’ new cardiovascular institute, credits his success to an impressive list of mentors, but his name belongs right along with them.
Profile on page 3.
TMA, THA Planning To Catch the Ears of State’s Lawmakers The Tennessee Medical Association plans to limit time on issues it supports and instead will spend much of its efforts establishing relationships with the new-look state legislature. Meanwhile, the Tennessee Hospital Association is focusing on three issues it considers key.
Stories on pages 7 and 13.
Many New Faces Are Popping Up In Array of Places
The Evolving Role of the CMO Chief Medical Officers Discuss Adjusting to a Changing Focus By BETH SIMKANIN
Over the past two decades, the role of Chief Medical Officer has evolved far beyond one of being a hospital-based, part-time position to one that is of considerable importance with responsibilities that include improving a hospital’s performance metrics, ensuring the highest quality of care and reducing costs through an efficient use of resources, while forging an alliance between providers and the hospital administration. This unwritten change in job description has come about largely because of a growing nationwide demand for quality, value-based healthcare. Hospital systems and physicians find it increasingly more difficult to function as separate entities. It is imperative for both groups to align their goals to provide safe and high-quality healthcare at a lower cost. It’s a tough job – the CMO essentially links all aspects of patient care – but, according to three Memphis-area CMOs, far from impossible. The (CONTINUED ON PAGE 8)
The CMO Roundtable, from left, Martin Croce, MD; Susan Nelson, MD; and Henry Sullivant, MD.
Genomic Medicine Making Impact Progress of Research Is Raising Hopes
By BETH SIMKANIN
There’s plenty of activity at Memphis-area hospitals and other healthcare facilities as new physicians and other staffers and are being added. The personnel updates are covered in Grand Rounds.
Benefitting from an increase in genomic research during the past decade, Memphis-area researchers have been able to make significant strides in pediatric genomic medicine. In fact, according to three local experts, there is recent evidence through research and clinical trials that genomics is beneficial for clinical use, especially in pediatric cancer patients. During the past four years researchers have been so successful in their efforts that Le Bonheur Children’s Hospital plans to add genomic sequencing to study pediatric diseases by 2020.
Coverage begins on page 13.
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Head of New Cardiovascular Institute Hopes to Build a ‘Destination Program’ Dr. John L. Jefferies Fueled by Impressive List of Mentors By LAWRENCE BUSER
This is a good time of the year for John L. Jefferies, MD. February is American Heart Month and last month was National Mentoring Month. He knows quite a bit about both. His list of mentors is a veritable who’s who in cardiology and as a heavily recruited expert in cardiomyopathy as well as cardiovascular genetics, his name is right there with them. Last July, Dr. Jefferies arrived in Memphis as the Jay M. Sullivan Distinguished Chair in Cardiovascular Medicine and Chief of Cardiology at the University of Tennessee Health Science Center (UTHSC). He also is head of the new cardiovascular institute – a collaboration between Methodist Le Bonheur Healthcare (MLH) and UTHSC. “Our long-term goals are to become an epicenter for cardiovascular care,” said Dr. Jefferies, a 1996 graduate of UTHSC College of Medicine. “We have so many resources available to us that we should really become a destination program for people with heart disease. We also want to drive cutting-edge research as much as possible and be a magnet to attract highlevel physicians, researchers and trainees. We have big goals, but I truly believe they are achievable.” As for his many mentors, he says: “I can’t repay them enough, and they’re still my mentors. They’re people I still talk to on a regular basis.” A native of La Follette, Tennessee, about 40 miles north of Knoxville, Dr. Jefferies was drawn to medicine as an undergraduate majoring in microbiology at the University of Tennessee. “I had a job as a patient-care assistant at a Knoxville hospital where I’d help get people up and out of bed, wheel them out in wheelchairs, that sort of thing,” he said. “I really got to know the patients and how appreciative they were of all the care they were being provided. I think that’s the time I knew that I wanted to go into medicine. I knew I wanted to help people.” After medical school at UTHSC, he did an internship and residency in both internal medicine and pediatrics at the University of Kentucky, earned a Masters of Public Health degree, and then did a fellowship in both pediatric and adult cardiology at the Baylor College of Medicine in Houston. Before returning to Memphis last summer, he was director of the Advanced Heart Failure and Cardiomyopathy Services in the Heart Institute at Cincinnati Children’s Hospital Medical Center.
John L. Jefferies
Along the way, he says, there were many mentors, such as Dr. Jacqueline Noonan, a pediatric cardiologist in Lexington, Kentucky, who characterized a genetic disorder now known as Noonan Syndrome. “I spent a lot of time with her during my residency training learning about heart disease, but she would also go to indigent areas of eastern Kentucky and treat people
for free,” says Dr. Jefferies. “She’d spend her whole day there and provide as much medical care as she could, at no charge. I thought that amount of dedication and altruistic behavior embodied what I wanted to become as a physician.” Another Kentucky cardiologist who made an impact on Dr. Jefferies was Dr. Roger Mills. “He really taught me the foundation of medicine: how to be a good doctor, how to be well read, how to do good examinations, how to order the rights tests and how to become an academic physician – someone who likes to take care of patients, but who also likes to teach and do research,” Dr. Jefferies says. “He strongly encouraged me to do research that would change the delivery of care. This allowed me to favorably impact care across the globe. “Then during my cardiology training in Houston I met Dr. Jeff Towbin who is an expert in heart failure among kids and also an expert in cardiovascular genetics. I learned a lot of what I do currently from him. He’s been a mentor to me for 25 years and, interestingly, he’s now the chief of pediatric cardiology at Le Bonheur.” There also is Dr. Douglas Mann at Washington University in St. Louis who
taught him about the importance of a strong work ethic and a willingness to put in long hours “if you really wanted to make a difference in medicine. If you want to write papers and do research you may be doing it on a Saturday because that’s the only time you have.” Dr. Frank Smart at Louisiana State University in New Orleans also made a lasting impression on him, which is evident when Dr. Jefferies speaks of the new cardiovascular institute collaboration between MLH and UTHSC and his own work in cardiology. “He taught me that idea about reaching for very high goals and striving to be transformative in medicine,” says Dr. Jefferies. “What can you do that really changes the current practice of what we do in medicine? That was something he and my other mentors taught me a lot about.” As an expert in cardiomyopathy and cardiovascular genetics, Dr. Jefferies has authored more than 200 peer-reviewed manuscripts and 20 book chapters, functioned as lead editor of two cardiovascular textbooks, and delivered more than 300 lectures nationally and internationally. “I see people from all over the world who come to me seeking guidance on car(CONTINUED ON PAGE 6)
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Genomic Medicine Making Impact, continued from page 1
Scientists began to perform genomic sequencing, the process of determining the complete DNA sequence of an organism’s genetic code at a single time, only two decades ago. Researchers sequence the genomes of patients to look for variations, which can cause certain medical risk factors in patients. To sequence a genome, physicians collect blood or saliva from the patient. Then, chemicals are used on the sample to break open the cells and gather the DNA that’s housed in them. Enzymes strip away surrounding proteins to isolate tiny strands of DNA. The genetic material is then placed in sophisticated machines, which read each of the 3 billion base pairs that make up a person’s genetic code. “Genomic sequencing is still in its infancy, but it’s growing quickly,” said Robert Williams, Ph.D., professor and chair of genetics, genomics and informatics at the University of Tennessee Health Science Center. “You aren’t seeing it done in the average clinical setting yet. There just isn’t much payoff clinically. It’s only been common to sequence within the last 10 years for active research purposes. St. Jude
is making major strides in cancer research with it through clinical trials.” Currently there are two ways genomic sequencing has been successful in clinical research: to learn more and assist in the diagnosis of certain diseases, such as specific subtypes of cancer, and to assist in medication dosage and certain targeted therapies for cancer patients. “Sequencing has made the greatest impact in cancer patients,” Dr. Williams said. “It’s helpful to know how a patient will handle a drug before they even take it. Physicians who treat certain types of cancer don’t have the luxury to tweak a patient’s dosage over a long period of time. They can’t afford to get it wrong.” An example is a phase III clinical trial called Total Therapy 17, which is in its second year at St. Jude Children’s Research Hospital. According to Scott Newman, Ph.D., group lead on bioinformatics analysis for St. Jude, the purpose of the clinical trial is to improve the cure rate and quality of life in children with acute lymphoblastic leukemia (ALL), a cancer of the blood and bone marrow that affects white blood cells, by adding targeted treatments that are tailored to each child’s type of ALL. According to Dr. Newman, this is the first big clinical trial at St. Jude where whole genomic transcriptome analysis is used for clinical care. Recently, Dr. Newman presented to the American Society of Human Genetics, a professional organization for human genetics specialists, a proof-of-principle study, which illustrated that nearly 80 percent of the 78 pediatric cancer patients studied had one clinically useful finding through genomic sequencing. Over the past four years, St. Jude has performed genomic sequencing and data analysis internally for research purposes through clinical trials. The information is gathered and shared on the St. Jude Cloud, which is an online data-sharing platform that provides researchers access to the world’s largest public repository of pediat-
ric cancer genome data. cent of the population is African-Ameri“We hope that by providing this data, can,” Dr. Brown said. “African-American we can generate more information about DNA isn’t represented in many databases rare cancers in order to be able to treat around the country. Our biorepository is a them in the future,” Dr. Newman said. valuable resource.” A little over three years ago, Le The vetting process to access samples Bonheur Children’s Hospital began its is rigorous, and researchers must share Biorepository and Integrative Genomics their findings with Le Bonheur. Dr. Initiative, which collects DNA samples Brown said the samples are used only for of patients, with their research purposes. family’s consent, to help Additionally, Le Bonphysicians and researchheur has a community ers study the influence outreach initiative to eduof genes on pediatric discate the Memphis comeases and how well they munity on genetics and respond to treatment. genomics. Chester Brown, MD, “This is an acaPh.D., genetics division demic endeavor,” Dr. chief at Le Bonheur, said Brown said. “We must the initiative is an excelhave community engagelent resource for the ment and involvement. hospital to gain access We’ve started genomics to research on diseases and genetics education affecting children. in the Memphis commuChester Brown According to Dr. nity, including at White Brown and Dr. Williams, Station High School and the biorepository is a useful resource many local churches, to educate the averworldwide based on the demographics of age person on the advantages of this type Memphis. of research.” “Memphis is unique because 64 perDr. Brown said Le Bonheur also holds genomic education seminars to educate physicians and medical students on genetics issues such as genetic testing and ethical concerns. Dr. Brown said the next step for Le Bonheur is to perform genomic sequencing and analysis internally. He said external funding has been secured, and he›s hopeful that Le Bonheur will be able to have the machines and storage available by next year. All three genomics experts say that even though genomic sequencing isn’t currently available in an average clinical setting, it will be in the future and the cost will be minimal. According to the National Human Genome Research Institute, the first whole genome sequencing cost $2.7 billion and was completed in 2003. According to Williams, 16 years later, the cost is around $1,500 and is expected to go down. “I expect that one day everyone will be sequenced at birth,” Dr. Williams said. “All of the data won’t be useful right away, but it will help each individual live a better life. It will help physicians treat patients 800.971.8871 over their entire lifetime.”
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Head of Cardiovascular Institute Aiming High, continued from page 3 Institute Lands Third Prominent Physician The University of Tennessee Health Science Center and Methodist Le Bonheur Healthcare have successfully recruited the third of three nationally prominent cardiovascular physicians to lead a new cardiovascular institute in Memphis. The agreement was announced in late January. Chittoor Sai Sudhakar, MD, is the new division chief of Cardiac Surgery in the UTHSC College of Medicine’s Department of Surgery, the Methodist Endowed Professor of Cardiac Surgery, and co-director of the Methodist Le Bonheur Adult Cardiac Service Line. Dr. Sudhakar joins John L. Jefferies, MD, MPH, who in June was appointed the Jay M. Sullivan Endowed Chair in Cardiovascular Medicine and chief of the Division of Cardiology in the College of Medicine at UTHSC. They will be co-directors for a new UTHSC-Methodist Cardiac Institute, which will offer all areas of cardiovascular medicine. Dr. Jefferies formerly served as director of the Advanced Heart Failure and Cardiomyopathy Services at the Heart Institute at Cincinnati Children’s Hospital Medical Center. He brings a track record of program development, leadership, clinical excellence, and academic achievement from his previous position as division director for Cardiothoracic Surgery at Baylor Scott & White Health System, Central Division, Scott & White Medical Chittoor Sai Sudhakar Center in Temple, Texas, and as surgical director of the Heart Transplant and Mechanical Circulatory Support Program at The Ohio State University Medical Center in Columbus, Ohio. Zhongjie Sun, MD, PhD, FAHA, a distinguished cardiovascular investigator, rounds out the leadership team as the chair of the Department of Physiology in the College of Medicine at UTHSC and deputy director of the Cardiac Institute. Dr. Sun came to UTHSC in April from the University of Oklahoma College of Medicine, where he was a professor of physiology, vice chair of research, chair of the research committee, and director of the Robert & Mary Cade Laboratory at the University of Oklahoma Health Sciences Center. “UTHSC and Methodist are very heavily invested in making this a nationally and internationally recognized program,” Dr. Jefferies said. “My role will be to lay the groundwork to further develop this institute, expand the number of services offered, and develop Centers of Excellence in distinct areas of cardiovascular medicine.” He said organizers of the institute anticipate national and international referrals coming to Memphis. Zhongjie Sun
diomyopathy and heart failure,” he said. “They make these long journeys because they see the work that I have done and feel that we can offer something additive and unique to their care. I see both children and adults. Some of these patients have followed me from my prior institutions in Houston and Cincinnati. Since I’ve been in Memphis I’ve developed a unique relationship with St. Jude.” While only about 10 percent of practice is in pediatric cardiology, Dr. Jefferies sees patients from St. Jude who are longterm survivors from childhood cancer who have lived through the drugs and radiation therapy used to treat their cancer. “But that actually predisposes people to developing heart disease – an area of medicine called cardio-oncology – so I have a strong research partnership with St. Jude, and that’s where a lot of my clinical research is being conducted,” he says. “Being a member of their research team at St. Jude was a big part of why I wanted to come to Memphis because it’s such a spectacular institution and they have so many resources and so much data. They were looking for a cardiologist who’s interested in these areas so it’s just worked out well in a lot of ways.” Dr. Jefferies and his wife, Shari, a child psychiatrist, have a son, 9, and a daughter, 8. Since he travels frequently, family activities such as golf and tennis are a priority when he is home as well as coaching his son’s flag football team.
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TMA Hopes to Serve as Resource as State Lawmakers Meet Group Focusing on Opioids, Scope of Practice While Building Relationships
Officials of the Tennessee Medical agement. TMA will work with the legislaAssociation (TMA), the state’s largest proture to amend the law to address specific fessional organization for doctors, say it will issues raised by doctors and patients. TMA intentionally limit its list of issues it plans has developed a number of proprietary to support while meeting with members of resources to help educate doctors and other the new-look state legislature while the lawprescribers on Tennessee’s opioid prescribmakers are deliberating in Nashville. ing laws at tnmed.org/opioids. Dr. Matthew L. Mancini, TMA Scope of Practice – TMA is on alert President for 2018-2019, said as the 111th to continue defending against any proposTennessee General Assembly als that would threaten patient convened on Capitol Hill, the safety and quality of care by most important item on the removing physician oversight organization’s to-do list was for nurses, physician assistants perhaps “building relationor any other midlevel providships.” ers. TMA for years has led TMA is considered one of doctors’ opposition to nurse the most influential healthcare independent practice in Tenadvocacy groups on Capitol nessee and in 2016 reached Hill. an agreement with the Ten“With a third of the men nessee Nurses Association that and women in the General included a three-year moraMatthew Mancini Assembly being brand new torium on all independent this session – along with a new practice bills. The moratorium governor – we expect to devote a lot of expires at the end of the 2019 session, but time building relationships and serving as a doctors expect the debate to resurface in resource on important healthcare matters,” 2019, particularly around expanding access said Dr. Mancini, a Knoxville surgeon, to care in rural areas. TMA will continue ‘The General Assembly first created promoting physician-led, team-based care TMA for this purpose,” Dr. Mancini conas the safest, most efficient and effective tinued. “More than 180 years later, we are healthcare delivery model in Tennessee. still the most effective voice representing MAT Parity – TMA will ask the physicians’ interests, promoting public poliGeneral Assembly to consider a resolution cies and stopping or improving laws, rules encouraging health insurance companies and regulations that may threaten patient to include Medication-Assisted Treatment safety or quality of care. That core mistherapies in patients’ health plans and sion has not changed and will not change, reimburse specialists who provide MAT regardless of the specific issues.” services at rates comparable to other treatTMA’s 2019 legislative priorities are ments. TMA has long advocated for more improving opioid prescribing laws, defendaccessible and well-funded treatment ing scope of practice and pursuing a reaoptions for patients struggling with subsonable compromise on payment issues. stance abuse. Using medications in comTaking a closer look at each one: bination with counseling and behavioral Balance Billing – As lawmakers therapies is a necessary strategy in the continue to look for ways to address the ongoing fight against Tennessee’s opioid issue of patients receiving “surprise medical abuse epidemic. bills,” TMA wants to protect physicians’ TMA is a nonprofit advocacy orgarights to get fairly compensated for services nization, serving more than 9,600 memthey provide out of a health plan network bers with legislative, legal/regulatory and while remaining fair to patients who are insurance advocacy, physician leadership caught between their health plan and their training and other programs. physician. TMA has led previous efforts to TMA’s biggest advocacy event of the find a reasonable solution and will continue year, Day on the Hill, is scheduled for to defend physicians’ rights if legislation is Tuesday, March 26. Last March more filed by other stakeholders this session. than 300 physicians descended upon NashOpioid Epidemic – While TMA ville’s Cordell Hull Building for the annual was able to make significant improvements event and TMA expects another large to Gov. Haslam’s “TN Together” legislacrowd this year as doctors from around tion in 2018, some of the unintended conthe state visit Nashville to meet with lawsequences doctors initially feared the new makers, attend committee hearings, and law would create are manifesting across advocate for their profession and patients. the state. New restrictions on prescribThose interested in learning more about ing and dispensing are no doubt reducing more about TMA’s legislative advocacy at overall initial supply, but are also unreatnmed.org/legislative and follow TMA @ sonably obstructing some patients from tnmed and @tnmedonthehill. accessing legitimate, effective pain manAdditional story on Page 13. memphismedicalnews
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The Evolving Role of the CMO, continued from page 1 key is to keep one simple rule in mind: Always put the patient first. The rule surfaced recently when the trio of CMOs had a roundtable discussion conducted by Pamela Haskins, publisher of Memphis Medical News. Participants in the roundtable discussion were: • Martin Croce, MD, CMO, Regional One Health • Susan Nelson, MD, CMO, Church Health • Henry Sullivant, MD, Vice President and CMO, Baptist Memorial Healthcare. The group discussed a range of topics, including the importance of staying connected to patients and the challenges the CMOs face in their positions, such as the patient’s perception of quality care and how important it is to bridge the divide between hospital administration and providers.
perception of care is just as important. CMOs must be considerate to the community’s needs and then offer up a strategy. “Perception these days is reality,” Dr. Sullivant said. “It’s not enough to provide quality care; the patient must perceive the quality of care is the best. It’s become a key factor, and leadership must be responsive. At Baptist, I meet jointly with each hospital CEO monthly to discuss each community’s perception of the care it receives from our system.” Dr. Nelson agrees and said a patient’s perceived access to care makes a big difference as well. “It doesn’t matter how smart you are or how good of a physician you are, if the patient isn’t happy with the care or how to access it, that’s what matters,” Dr. Nelson said. “That’s where we are now in healthcare.”
Another challenge CMOs are faced with is merging their organization’s goals and each provider’s goals, which can sometimes be different. “We must develop a relationship with our provider community and foster them, so we can align strategic goals, “Dr. Sullivant said. “The center of the conversation is what’s right for patient care.” Dr. Croce makes the effort to do this at Regional Medical Center. “CMOs need to be seen walking the hallways in hospitals and visiting different departments,” Dr. Croce said. “I visit the newborn center purposefully because it’s a department that isn’t my specialty. I didn’t live in their world. I’m the voice for all physicians, and in order to be effective in what I’m doing, I must understand how someone else handles patient care.”
All three CMOs said they became physicians to show compassionate care to patients. Even though they’ve transitioned to a top administrative role, they affirm it’s more important than ever to stay connected to the patient in order to make toplevel decisions on patient care. “Hospitals are obscured by so many layers that administration can forget the patients,” said Dr. Croce, who transitioned from chief of trauma at Regional One Health to CMO last August. “You need physicians and nurses there to take care of them.” Dr. Nelson said she stays connected to patients by still practicing family medicine. Three-and-a-half days a week she treats patients at Church Health, a local faith-based nonprofit organization that provides primary and specialty healthcare to low-income and uninsured Shelby County residents. “It’s important for me to still see patients because it helps me remember why I’m sitting in a meeting,” Dr. Nelson said. “I experience what it’s like each day in patient care at Church Health. I have the best of both worlds, which directly impacts the patient. It helps keep me grounded. I continue to energize my passion in order to make the system work better.” As a result of her clinical efforts and experience, she said that she and her team have been able to cut down on wait times for low-income and uninsured patients to see a physician from four months to two weeks. Additionally, she saw the need for Church Health to offer urgent care for walk-in patients during certain hours. Church Health relies on a volunteer network of physicians and nurses to assist in primary care evening clinics and specialty clinics. Similarly, Dr. Croce and Dr. Nelson both battled cancer as physicians. They said they bring a unique perspective to the executive table because they have experienced healthcare from both sides. “I’ve had to maneuver through the system,” Dr. Croce said. “I’ve seen what the process looks like from the provider 8
Bridge the Silos
Martin Croce, MD
and patient side, and I think that helps me see the advantages and disadvantages in my role.” Dr. Nelson said her experience as a patient helped her implement culture change. “You realize small things matter,” she said. “It can be as simple as telling providers and medical staff to wear a name tag and introduce themselves. I can’t tell you how scary it is as a patient who is receiving treatment for cancer when the provider or staff doesn’t tell me their name. Something as simple as that makes a big impact on the patient.” Dr. Sullivant, an OB/ GYN who transitioned to CMO of a 22-hospital system at Baptist, said he still makes decisions with patients in mind every day, but instead of impacting 34 patients per day as he did in his medical practice, he can make a difference in the lives of thousands of patients. “There’s nothing like being at a patient’s bedside and it’s easy to become disconnected, but we can connect back to that purpose in a different way and affect more patients on a larger scale,” Dr. Sullivant said.
Perception of Care
One of the challenges CMOs face nationwide is providing quality of care at a lower cost, but Dr. Sullivant said that CMOs must take that concept one step further. He said understanding a patient’s
(CONTINUED ON PAGE 9)
Susan Nelson, MD memphismedicalnews
The Evolving Role continued from page 8
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Henry Sullivant, MD
Dr. Sullivant compares his job to a three-dimensional chess game where he has to lessen the gap between each department at the hospital, which he said can sometimes want to operate independently. “I handle many issues at once, like financing, quality and nursing,” Dr. Sullivant said. “All of these departments can live in silos, so it’s my job to merge them and bridge the divide.”
Seek Admin Roles
All three CMOs stress the need for physicians to seek more administrative roles in a hospital or clinical setting. They say the physician’s goal to do what’s best for the patient doesn’t change even though he or she may no longer treat a patient directly. “We need more physicians in administration roles,” Dr. Croce said. “There aren’t enough of us pursuing leadership roles in hospitals. Your No. 1 job is to make sure that patients have access to care
no matter what. It’s our job to take care of patients who can’t take care of themselves.” Dr. Sullivant stresses that it’s a good idea for physicians who are interested in becoming CMOs to enroll in a masters of healthcare management program or a similar training program that covers business administration, public health and hospital administration. “This is the hardest job I’ve ever had, but it’s also the most stimulating and fun,” Dr. Sullivant said. “I feel like I’m still meeting the same call to affect patient’s lives, but instead of a few at a time, it’s thousands.”
Keep It Simple
Despite the complexity of the CMO position, experts agree that in the final analysis it’s the patient who matters most. “I’ve learned that it’s important to keep it simple,” Dr. Croce said. “You must always put the patient first and if you do that, you can’t go wrong.”
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As the founding physician of Memphis Cardiovascular Center. Dr. Shala has been practicing Cardiovascular Medicine in Memphis since 2000, and has received numerous awards and honors, including multiple Physician Recognition awards from the American Medical Association and the James Givens’ Award for Excellence from the University of Tennessee. He was recognized in 2007 by the National Committee for Quality Assurance for his excellence in cardiac care. He was also the recipient of Diversity Memphis ‘Humanitarian of the Year’ award in 2011. Outside of Memphis Cardiovascular Center, his contributions include participation in multiple professional organizations including fellowships in the American College of Cardiology (FACC), the American Society for Cardiovascular Angiography and Interventions (FSCAI), the American Society of Echocardiography (FASE), and the American Society of Nuclear Cardiology (FASNC). He is also a member of the American Society of Cardiovascular Computed Tomography.
For more information visit our website: MedicalOfMemphis.com or call 901.261.0700 FEBRUARY 2019
Updated Cholesterol Guidelines Take a Personalized Approach By CINDY SANDERS
The American Heart Association (AHA) and American College of Cardiology (ACC) last November released an update to the 2013 cholesterol guidelines, calling for more personalized risk assessments to guide primary and secondary cardiovascular disease prevention throughout a patient’s lifetime. “Both guidelines were heavily based on evidence that has developed in terms of what can benefit patients,” said Neil Stone, MD, MACP, FAHA, FACC, who worked on the 2018 guideline update and served as vice chair of the writing committee. Stone, a Chicago-based cardiologist and AHA national spokesperson added, “Both begin with emphasizing that lifestyle change is most important.” In fact, he continued, the new guidelines focus on adopting a heart-healthy lifestyle from a young age and build upon the 2013 emphasis on identifying and addressing lifetime risks to prevent cardiovascular disease (CVD). The update also provides additional guidance for physicians to help them drill down for a more robust and personalized risk assessment that considers multiple factors and treatment paths.
tion should be prescribed in a stepped approach, first with a maximum intensity statin treatment, adding ezetimibe if desired LDL cholesterol levels aren’t met and then adding a PCSK9 inhibitor if further cholesterol reduction is needed. Stone, who is a professor of medicine at Northwestern University’s Feinberg School of Medicine and the medical director of the Vascular Center of the Bluhm Cardiovascular Institute of Northwestern Memorial Hospital, noted the personalized risk stratification results in a score to help inform next steps for primary prevention and additional treatment options for secondary prevention.
The need for personalized risk stratification and intervention is great in the United States. Stone pointed out we live in a country where one of every three people dies of heart disease or stroke annually and nearly six in 10 people develop heart disease during their lifetime. Additionally, he said, one-third of American adults have high levels of low-density lipoprotein cholesterol (LDL-C), known as the ‘bad’ cho-
The MidSouth MGMA Invites MEDICAL PRACTICE MANAGERS To Join Our Organization in 2019. We invite you to attend one of our upcoming executive-level educational luncheons:
FEBRUARY 28 Mitch Graves & George Wortham, MD, Metrocare Success within Value Based Healthcare Trilogy Update
lesterol that contributes to plaque buildup and narrowed arteries. Key highlights from the updated cholesterol clinical practice guidelines statement, which was released this past November during the AHA’s 2018 Scientific Sessions conference in Chicago, include: • High cholesterol, at any age, can increase a person’s lifetime risk for heart disease and stroke. A healthy lifestyle is the first step in prevention and treatment to lower that risk. • The 2018 guidelines recommend more detailed risk assessments to help healthcare providers better determine a person’s individualized risk and treatment options. • In some cases, a coronary artery calcium score can help determine a person’s need for cholesterol-lowering treatment, if their risk status is uncertain or if the treatment decision isn’t clear. • While statins are still the first choice of medication for lowering cholesterol, new drug options are available for people who have already had a heart attack or stroke and are at highest risk of having another. For those people, medica-
For those who have not yet had a heart attack or stroke, Stone said the updated guidelines call for patients with a very high LDL – 190 or more – to be on a high intensity statin. For those with diabetes between the ages of 40 and 75, no matter what the LDL number, the updated guidelines continue the 2013 recommendation for them to be on a statin, as well. He added, “Those who have longstanding diabetes or are older than 50 may do better on a higher intensity of statin.” The new guidelines call for a more nuanced approach to statin use in the largest group – those 40 to 75 without diabetes or the highest LDL-C. Stone said by virtue of four different clinical trials assessing 10-year risk, individuals with a score of 7.5-19.9 percent should at least be considered for statin therapy. He added, those with a score of 5 percent or less typically don’t need statins, and those with a score of 20 percent or higher on the risk calculator should automatically be on statin therapy. “The previous guidelines recommended a clinician-patient risk discussion before a statin was given,” he said of the borderline group. “The new guidelines also recommend a clinician-patient discussion, but they give more details of what
(CONTINUED ON PAGE 11)
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Updated Cholesterol Guidelines, continued from page 10
that should be. The idea is to provide a way for doctors to give patients, who aren’t sure whether to take a statin, factors to show a patient what their personal risks are.” In addition to traditional risk factors like smoking and high blood pressure, the new guidelines outline a number of other risk-enhancing factors to consider, including: family history and ethnicity, LDL≥160, triglycerides persistently above 175, premature menopause or pre-eclampsia, chronic inflammatory conditions such as rheumatoid arthritis, metabolic syndrome, and chronic kidney disease.
tion of ezetimibe would get a significant portion of high-risk patients under the 70 LDL benchmark. Available as a generic, ezetimibe is typically affordable and well tolerated by patients. For those who cannot achieve the desired goals with a combination of statin and ezetimibe, a PCSK9 inhibitor could be added. The new guidelines also note a PCSK9 inhibitor might be added as a primary prevention tool for individuals who have a genetic condition that causes high LDL-C. However, Stone noted, the shot is considerably more expensive. Some insurers have been slow to cover the treatment,
We point out even if you’re on a statin, you need to focus on lifestyle because the lower you can get your number on a statin, the lower your risk.
- Dr. Neil Stone
A coronary artery calcium (CAC) score can also help tip the scale on whether or not to start statin treatment immediately. A CAC of zero has typically indicated a low risk of CVD, which has been borne out by two large-scale studies. “We are not recommending calcium scores as a screening test,” Stone stressed. “We’re using it as a tie-breaker … it can be the decider,” he added. “Someone with a (risk assessment) score of 9 percent, few other risk factors, and a coronary calcium score of zero may wish to postpone statin use for five to 10 years because their risk is relatively low,” Stone continued of using the personalized approach at the heart of the new guidelines. For everyone, no matter where their risk assessment percentage falls, he stressed the importance of lifestyle modification to either delay or prevent the need for statins or to enhance the work of statins in maintaining heart health. “We point out even if you’re on a statin, you need to focus on lifestyle because the lower you can get your number on a statin, the lower your risk,” stated Stone.
For individuals who have already suffered a heart attack or stroke, the new guidelines call for additional intervention when LDL-C is not well controlled. “We have three trials showing if the LDL is above 70 in people who are very high risk, they might benefit from not just a maximally tolerated statin but also the non-statin ezetimibe or PCSK9 shot,” explained Stone. He added the recommendation is for a stepwise approach. Stone said the addimemphismedicalnews
although there has been movement in recent months to lower the cost. The AHA and ACC are bringing together stakeholders to further discuss financial barriers to achieving optimal primary and secondary prevention of heart disease and stroke.
Once treatment has started, whether lifestyle modification only or modification with medication, physicians should schedule a follow-up appointment within four to 12 weeks to assess adherence and effectiveness with a fasting lipid test. The guidelines then call for retesting every three to 12 months, depending on determined needs. Stone said the new guidelines recognize and address the cumulative effects of high cholesterol over a lifetime. In most children, an initial test could be administered between the ages of 9 and 11. For some children with a strong family history of heart disease and high cholesterol, selective cholesterol testing might be appropriate as young as age two. While most children won’t need medication, physicians should use the test to discuss the positive impact healthy behaviors have on lifetime CVD risk. The updated guidelines offer a more individualized method to controlling cholesterol. “Before, it wasn’t a one-size-fitsall approach, but everybody thought if you had a score of 7.5 percent or more, you automatically go on statin therapy. The new guidelines really make it clear how to use enhancers to personalize the risk discussion,” Stone concluded. For a link to the new guidelines, please go online to MemphisMedicalNews.com.
IS YOUR LICENSE IN JEOPARDY? Medical/Nursing Board Inquiries Investigations • Disciplinary Actions Attorney Ashley Cleek has been representing individual providers and hospitals in medical malpractice cases throughout Tennessee for the past 15 years. He also assists physicians, nurses, and midlevel providers who are under investigation or facing disciplinary action by the medical/nursing board. Mr. Cleek has significant appellate experience, handling numerous cases before the Tennessee Court of Appeals, Tennessee Supreme Court, and the United States Court of Appeals for the Sixth Circuit. He is an AVPreeminent® rated lawyer, which is the highest rating available in the Martindale-Hubbell® evaluation system.
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UTHSC, VA Memphis Key Participants In National Blood Pressure Study Researchers at Johnson, who also the University of Tenserved as the vice nessee Health Science chair of the National Center (UTHSC) and Steering Committhe Memphis Veterans tee for the SPRINT Affairs (VA) Medical study. “This is a Center were part of the very important findSPRINT MIND (Systolic ing, as it may reduce Blood Pressure Intervenconcerns that many tion Trial Memory and clinicians had that Cognition IN Decreased lower systolic blood Hypertension) multipressure in older persite clinical trial, which sons might be harmlate last month released ful to their brain.” study findings showing The Alzheimthat intensive lowering of er’s Association has blood pressure reduced agreed to fund addithe risk of mild cognitional follow-up of tive impairment (MCI), SPRINT MIND a known risk factor for participants in the dementia. hope that sufficient Mild cognitive dementia cases will impairment causes difaccrue, allowing for a ficulty with cognition, more definitive statethinking, remembering, ment on these study and reasoning that is outcomes. Dr. Nichgreater than expected ols is encouraged with normal aging. by the association’s Dementia is a more Leaders of the Memphis sites for the national SPRINT MIND clinical trial are, from left, Karen C. Johnson, MD, MPH; commitment to help severe form of loss in William Cushman, MD; Barry Wall, MD; Catherine Womack, MD; Linda Nichols, PhD; and Jennifer Martindale-Adams, EdD. provide more concognitive functions that clusive study results. reduces a person’s ability “We are thrilled Memphis hosts two SPRINT study ter Network (CCN). William Cushman, to perform everyday tasks. Hypertension, that the Alzheimer’s Association will sites, one at UTHSC and one at the MemMD, chief of Preventive Medicine at the or high blood pressure, is very common be working with us to continue to folphis VA Medical Center. UTHSC’s site, Memphis VA, and professor of Prevenin adults age 50 and older and is a leadlow SPRINT MIND participants,” Dr. which followed 175 participants, was led tive Medicine, Medicine, and Physiology ing risk factor for heart disease, stroke, Nichols said. “We may be able to deterby Karen C. Johnson, MD, MPH, prinat UTHSC, serves as the principal invesand kidney failure. A growing body of mine if intensive blood pressure control cipal investigator, College of Medicine tigator for the VA Network. Dr. Barry research suggests that hypertension has will reduce dementia in addition to mild Endowed Professor in Women’s Health, Wall, also from the Memphis VA, is the been identified as a potentially modificognitive impairment.” and professor of Preventive Medicine at co-principal investigator for the SPRINT able risk factor for MCI and dementia. In August 2015, the SPRINT trial UTHSC, and Catherine Womack, MD, VA Clinical Center Network (CCN) and Launched in 2010 by the National was stopped earlier than planned when associate professor in the Department of principal investigator for the VA MemHeart, Lung, and Blood Institute the beneficial effects of intensive blood Preventive Medicine and co-chief of the phis SPRINT clinical site that recruited (NHLBI) of the National Institutes of pressure management on mortality and Division of Internal Medicine in the Col80 veterans for SPRINT. Linda Nichols Health (NIH), SPRINT enrolled more cardiovascular disease were discovered. lege of Medicine at UTHSC. PhD, professor, and Jennifer Martindalethan 9,300 adults age 50 and older with The SPRINT MIND findings provide The Memphis VA Medical Center, Adams, EdD, associate professor in the hypertension who were at a high risk promise that individuals can take steps to which served as a VA Network hub and Department of Preventive Medicine at for cardiovascular disease. They were lower their risk of mild cognitive impairclinical site, followed 1,660 participants UTHSC, were VA CCN consultants recruited from approximately 102 mediment and dementia, and it could be as at 25 VA medical centers within the and also co-principal investigators for the cal centers and clinical practices througheasy as lowering their blood pressure. SPRINT Veterans Affairs Clinical CenSPRINT MIND study. out the United States and Puerto Rico. “The fact that cognition and demenThe SPRINT MIND study, an tia were not worsened and there were essential component of the umbrella even some improvements is very encourSPRINT study, aimed to address aging in light of the impressive improvewhether aggressive blood pressure ment in cardiovascular outcomes with control would also reduce the risk of intensive blood pressure lowering in developing dementia and cognitive SPRINT,” Dr. Cushman said. impairment. The study results show that “These findings provide hope to treating blood pressure to a goal of less anyone who is concerned about developthan 120 mm Hg does not statistically ing memory problems,” Dr. Martindalereduce the risk of dementia, but does Adams said. significantly reduce the risk of develSPRINT study findings have already • Former systems admin for UTHSC oping MCI. Authors of the SPRINT had a world-wide impact on how people • Over 17 years experience MIND study conclude that this result define hypertension and how doctors • US Navy Network Security may have been due to fewer cases of treat hypertension. The American Col• Microsoft Certified dementia occurring during the study. lege of Cardiology and the American • Networking services “The SPRINT MIND study has Heart Association published new blood • Security Specialist shown for the first time that intensive pressure guidelines in 2017 based on control of blood pressure in older people SPRINT data. The SPRINT MIND Let us help you keep significantly reduced the risk of develstudy results were reported in the Jan. John Pantall, Microsoft Certified oping mild cognitive impairment, a 28, 2019 edition of the Journal of the your information safe! 901.466.6358 || email@example.com precursor of early dementia,” said Dr. American Medical Association.
Is the missing
MEMPHIS MEDICAL NEW PHOTO BY HUGO REYNOLDS
THA Eyes Three Issues During Current Session Of General Assembly The Tennessee Hospital Association (THA) is working to bring three pieces of legislation to the Tennessee General Assembly in addition to focused advocacy on a number of other issues during the current session. The 111th Tennessee General Assembly convened its initial session last month. With more than 30 new legislators, a new governor and new members of leadership in each chamber, the session is attracting considerable attention from the healthcare community as well as the media. The session promises to be a busy time with several major priorities for hospitals on THA’s legislative agenda. According to the THA, this year the organization will bring three pieces of legislation in addition to focused advocacy on a number of other issues. An item on the THA website reports that the three priorities are:
mentation and ensure patients receive relevant and useful information about healthcare services as it relates to insurance benefits and cost-sharing
Certificate of Need
• THA will bring legislation to continue to fund a shortfall in the TennCare budget through the voluntary hospital assessment • This maintains coverage for physical, speech and occupational therapies, physician office visits and other services, as well as avoidance of a significant provider rate reduction
• Americans for Prosperity (AFP) Tennessee, the state level arm of the national conservative political organization of the same name, has identified elimination of certificate of need (CON) as one of its 2019 priorities • Arguments that introducing free market principles to the healthcare system in Tennessee by eliminating CON would help reduce cost and improve access to care fail to understand the unique financial model of hospitals and other providers or the precarious financial situation experienced my many rural hospitals in the state • Hospitals support continuation of the CON program and worked closely with legislators in 2016 to significantly overhaul and modernize the law, with an agreement to no additional changes for three years • Given this action and 2018’s extension of the Health Services and Development Agency (HSDA) for three years, THA believes it is premature to reexamine the CON law and elimination would run counter to last year’s action by the General Assembly
Modify Nurse Practice Act
• An update to the Nurse Practice Act is needed to address issues identified by the Centers for Medicare & Medicaid Services (CMS) related to EMTALA requirements for OB and psychiatric patients • THA will bring legislation to clarify in statute that patient assessments performed by a registered nurse to determine if an emergency medical condition exists do not constitute a diagnosis • Such clarification is consistent with longstanding practice in hospitals between nurses and physicians
• THA members have identified the need to clarify several elements of 2018’s out-of-network notice legislation, which often has been referred to as Public Chapter 840 • This year’s legislation does not seek to change the intent of the law, but rather clarify elements of the law to ease implememphismedicalnews
• Legislation is expected in 2019 to remove sheriffs from state law that requires law enforcement to transport mental health patients • THA is working with the Tennessee Department of Mental Health and Substance Abuse Services and other stakeholders to identify alternative means and processes for transporting affected patients, as well as funding for such a solution, to present to the legislature for consideration
Dr. James Eason Honored Methodist Le Bonheur Healthcare has named its Transplant Institute, currently under construction in Shorb Tower at Methodist University Hospital, in honor of James D. Eason, MD, a long-time Memphis transplant surgeon who serves as program director of the institute.
A Man of Many Talents Autry Parker, MD, outgoing president of the Memphis Medical Society, performs with the band Copacetic 901 during the organization’s annual Gala at the FedEx Event Center at Shelby Farms. During the event last month, Dr. Jimmie Mancell was installed as the new president. Other board members are Dr. Danielle H. Hassel , President-Elect; Dr. Justin Monroe, Vice-President; Dr. Chris Pokabla, Secretary; Dr. David Cannon, Treasurer; Dr. Parker, Past President. Returning to the Board are Dr. Raymond Walker; Dr. Lindi Vanderwalde; Dr. Christopher Pokabla, Dr. Lisa Usdan, Dr. Joann Wood, Dr. Walter Rayford, Dr. Andrew Watson, Dr. Clay Jackson. New Board Members are Dr. Paul Tackett and Dr. Catherine Womack.
Granite Mountain Hotshot to Speak at February 26 Breakfast After surviving the 2013 Yarnell Hill Wildfire in Arizona and the loss of 19 of his fellow firefighters, Brendan McDonough began suffering from bouts of deep depression and intractable Post-Traumatic Stress. McDonough said he was on the verge of becoming a hopeless, inveterate heroin addict when he decided to turn his life around for the sake of his young daughter. McDonough will share his story of struggle and redemption at 7:30 a.m. on February 26 at the annual Dennis H. Jones Living Well Network Mental Health Breakfast at the Hilton Memphis, 939 Ridge Lake Blvd. McDonough is the subject of the 2017 film Only The Brave, starring Josh Brolin, Jeff Bridges, Taylor Kitsch and Jennifer Connelly. The Yarnell Hill Wildfire, the largest loss of firefighter lives since the 9/11 attacks, In 2011 McDonough enlisted in the Granite Mountain Hotshots, a team of elite firefighters based in Prescott, Arizona. On Granite Mountain Hotshot and subject of the 2017 film Only The Brave, Brendan McDonough will speak in Memphis on February 26. June 30, 2013, while McDonough served as lookout, the Hotshots confronted a freak 3,000 degree inferno in nearby Yarnell, Arizona. The relentless firestorm ultimately trapped his hotshot brothers, killing all 19 within minutes. For ticket or more information, visit methodisthealth.org/livingwellbreakfast or call 901-516-0500. Following the breakfast, attendees are invited to participate in one of three breakout sessions.
GrandRounds Charnell Cain Joins Methodist Medical Group
Dr. Phillip Zeni Plans Vein and Vascular Clinic
Charnel Cain, DO, has joined Methodist Medical Group and will see patients at 1325 Westmoreland. She earned her Bachelor of Science degree in Biology from Jackson State University in Jackson, Mississippi, and continued her edu- Charnell Cain cation by earning her Doctor of Osteopathic Medicine from Lincoln Memorial University-DeBusk College of Osteopathic Medicine in Harrogate, Tennessee. She is board certified in Advanced Life Support in Obstetrics, Advanced Cardiac Life Support/ Basic Life Support, Pediatric Advanced Life Support, Fundamentals of Critical Care Support, Neonatal Resuscitation Protocol, and is a Nexplanon-trained physician.
Phillip T. Zeni, Jr., MD, FSIR, who has been in practice at Baptist East Hospital for the past 19 years, announced plans to open his own practice dealing with varicose veins and other vascular diseases. Dr. Zeni will be owner and medical director of Zenith Medical and Aesthetics. The clinic, which will be 3,000 square feet, is currently under construction at the Regalia Shopping Center in East Memphis and is scheduled to open in April. Dr. Zeni, double-boarded vascular and interventional radiologist, said his facility will be offering procedures designed to alleviate varicose veins and a broad spectrum of vascular diseases.
from Johns Hopkins Department of Orthopaedics managing a post-surgical unit as well as a working as a surgical first assistant. • Susannah Cash is a licensed and certified Physician Assistant who graduated magna cum laude with a Bachelor of Science in biomedical sciences from Auburn University. She earned A Master of Medical Science in phy- Susannah Cash sician assistant studies from the University of Tennessee Health Science Center, graduating first in her class. She was elected and served as President of her graduating class. Levy Dermatology has offices in East Memphis and Collierville.
Four New Staffers Join Levy Dermatology
Acadian Ambulance Begins Operations in Memphis
Joelle Goan Named Program Manager at SOMAVAC Memphis-based a medical device company SOMAVAC Medical Solutions, Inc., has named Joelle Goan program manager to aide in product development and commercial launch of its flagship device SOMAVAC. Goan will oversee all aspects of this and Joelle Goan subsequent devices and their deliverables through commercial lifecycles while working with external partners such as regulatory specialists and vendors. Prior to joining SOMAVAC, Goan was Senior Product Manager at Olympus Surgical Technologies America. The SOMAVAC Sustained Vacuum System is a low-profile, user friendly, wearable medical device that applies sustained vacuum to a surgical site following large-flap forming surgeries to remove fluid effectively and may reduce the risk of seroma.
Methodist Le Bonheur Gains National Recognition Forbes magazine and Statista, an online statistics, market research and business intelligence portal, has ranked Methodist Le Bonheur Healthcare on its 2019 list of Best Employers for Diversity. MLH made the list at 175 out of 500 employers. The top 500 best employers in the country for diversity were chosen based on an independent survey from a representative sample of 50,000 employees working for companies employing at least 1,000 people in their U.S. operations. For the majority of the company’s score, respondents were asked openended questions on a series of statement surrounding the topics of age, gender, equality, ethnicity, disability, LGBTTQ+ and general diversity concerning their employer.
Levy Dermatology which offers medical, surgical, cosmetic and aesthetic skin care, has added four members to its staff. They are: • Meredith Wagner, MD, is a native Memphian who specializes in medical and surgical dermatology. She graduated summa cum laude with honors and was valedictorian of her class at Florida State University. She then Meredith Wagner completed her medical degree at the University of Hawaii John A. Burns School of Medicine where she was inducted into the Alpha Omega Alpha Medical Honor Society. She completed her internship in internal medicine and residency in dermatology at the University of Tennessee Health Science Center. A member of the Society for Pediatric Dermatology Pediatric Dermatology, she worked in private practice in Southern California, specializing in all aspects of medical and surgical dermatology including adult and pediatric care before returning home to Memphis. • Megan Phillips is a licensed and certified physician assistant who graduated with a Bachelor of Science from the University of Tennessee at Martin and received a Master of Science in physician assistant studies from Bethel University Physician Assistant Megan Phillips Program in 2014. • Misty Ivy-Moore is a nurse practitioner who received her associate degree in nursing at Northwest Community College in Senatobia and her Master of Science in nursing at Delta State University. She has worked as a travel nurse in Ewa Beach, Hawaii, Misty Ivy-Moore and Baltimore. While in Baltimore, she held a full-time position
Louisiana-based Acadian Ambulance Service and Memphis-based Emergency Mobile Health Care (EMHC) have completed a merger that will allow EMHC’s management and medical teams to join Acadian Ambulance to continue to provide medical transportation to the Memphis area. Services include critical care transport for the most critically sick or injured patients provided by Acadian’s specially trained personnel. Acadian Ambulance acquired EMHC in September, 2018 Acadian Ambulance is the largest employee-owned ambulance service in the nation and serves more than 20 million residents across 75 counties and parishes in Louisiana, Texas, Mississippi and Tennessee. Acadian is actively recruiting EMTs, advanced EMTs and paramedics for full- and part-time positions. Its Memphis headquarters are at 6972 Appling Farms Parkway.
Three Physicians Join Methodist Medical Group Methodist Medical Group’s practice announced the addition of three new physicians to its staff. They are: Charles Brown, MD, earned both his undergraduate and graduate degrees in chemistry from Jackson State University. He received his medical degree from the University of Iowa Medical School. He is board certified in internal medicine by the American Board of Inter- Charles Brown nal Medicine. Arvind Reddy Ankireddypalli, MD, earned his Doctor of Medicine from Vinayaka Mission’s Kirupananda Variyar Medical College, Salem, Tamilnadu, India. He completed a Fellowship in Geriatrics at St. Luke’s University Health Networks in Bethlehem, Arvind Reddy Pennsylvania, and his Ankireddypalli
Residency at The Brooklyn Hospital Center, a clinical and academic affiliate of Ichan School of Medicine at Mt. Sinai, New York. Elizabeth Maldonado, MD, completed her Bachelor of Science from the University of Memphis and her Doctor of Medicine from the University of Tennessee Elizabeth Health Science Center. Maldonado She is a member of the American Academy of Family Physicians.
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