FOCUS TOPICS LEGISLATIVE AGENDA • CARDIOLOGY • GENOMICS
February 2020 >> $5 ON ROUNDS
From India and Up and Down the East Coast, Cardiologist Nirav Patel Finds Jackson Home
THA, TMA Outline Legislative Priorities
Telehealth, CON, Scope of Practice Lead Concerns By CINDy SANDERS
Striving to do his best and be ﬁrst has been the life-long mantra for Nirav Patel, MD. Growing up, it drove him to be the ﬁrst in his class and the ﬁrst in his family to enter the medical ﬁeld. Along the way, Patel has learned that one of the biggest parts of striving to be your best, is constantly looking for ways to improve. A lesson he puts into practice, both in his personal life and as an interventional cardiologist, at the Heart and Vascular Center of West Tennessee.
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The Tennessee General Assembly reconvened in January for the second half of the 111th session. Hundreds of bills have been filed that intersect with the broad topic of healthcare. While many will never make it out of committee, two major provider and facility organizations – Tennessee Hospital Association (THA) and Tennessee Medical Association (TMA) – will keep watch for bills impacting their membership while also pursuing action on their own legislative priorities. From consensus items to ones causing consternation, the leadership of two organizations was surveyed to learn their 2020 priorities and key advocacy issues.
The THA has new leadership, but ongoing priority concerns. Wendy Long, MD, MPH, last fall was named president and CEO of the statewide organization, taking the reins from Craig Becker, who retired after more than 25 years at the (CONTINUED ON PAGE 5)
St. Jude’s Team Empowering Global Research Community Finding Cures Faster by Making Genomic Data Available BY JUDY OTTO Miracles seem to be commonplace at St. Jude Children’s Research Hospital, a belief widely accepted by most Mid-Southerners. The latest example may be St. Jude Cloud, introduced in April 2018 and continuing to dazzle as it evolves under the eye of Alex Gout, PhD, the project’s scientific lead. The Cloud’s nucleus began to coalesce ten years ago, when high-level researchers at St. Jude teamed with Washington University in St. Louis to devise the Pediatric Cancer Genome Sequencing Project. Until that time, Gout explains, most cancer research, in the form of cancer genomic sequencing, was focused on adult cancers—which affected a larger number of individuals.
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From India and Up and Down the East Coast, Cardiologist Nirav Patel Finds Jackson Home Being the best means constantly improving By SUZANNE BOYD
also serves as the CEO of the practice’s vasStriving to do cular lab at the clinic his best and be first location in Dyersburg has been the life-long which opened in the mantra for Nirav Fall of 2018. “We recPatel, MD. Growing ognized a tremendous up, it drove him to be need for this lab due the first in his class and to the vast amount of the first in his family severe peripheral arto enter the medical tery disease we were field. Along the way, seeing. There were Patel has learned that all these patients who one of the biggest were undertreated/unparts of striving to be derdiagnosed with vasyour best, is constantly cular problems which looking for ways to could ultimately lead to Dr. Patel performs a procedure in the Vascular Lab at the Heart and Vascular Center of West Tennessee. improve. A lesson amputations when the he puts into practice, disease advanced,” said training.” both in his personal life and as an interPatel. “We have also had to raise comIn keeping with his desire to improve ventional cardiologist, at the Heart and munity awareness and education on this and be the best, Patel sought further trainVascular Center of West Tennessee. disease because many do not know what it ing with a one-year fellowship in intervenGrowing up in India under a meritis or that it needs to be addressed.” tional cardiology at Maimonides Hospital based educational system, Patel’s success Outside of work, family time is imMedical Center in New York. “Working in the classroom afforded him his choice portant to Patel who is the father to a with MCI and heart attack patients to imof what field he would pursue. “From the nine-year-old son and a four-year-old prove their life and prolong the quality of third grade until the twelfth, I finished at daughter, both of whom he describes as their life,” he said, “gave me tremendous the top of my class so I had my pick of feisty and wild. For about five months out experience in the field of interventional what I would study in college,” said Patel. cardiology because I got to really get my “I was thinking either medicine or comhands and feet wet with lots of procedures. puter science but was drawn to medicine I learned so much since it was a very busy since it is one of the most respected and community hospital in Brooklyn.” reputable fields I could enter. I was the Throughout his medical training and first in my family to enter medicine and fellowships, Patel’s work experience inI guess I lit the torch for my siblings. My cluded the Cleveland Clinic Foundation brother went to medical school two years in Ohio and Piedmont Heart Institute in after me, and my sister went into pharAtlanta. He also worked at the Washingmacy ten years later.” ton County Regional Medical Center in Throughout his medical training at Sandersville, Ga., Doctors Hospital of AuM S University of Baroda Medical Colgusta, Trinity Hospital of Augusta and the lege in India, Patel began to pursue trainVA Medical Center in Augusta. ing in cardiac and heart-related fields. As In 2012, as his interventional cardihe graduated medical school in 2002, he ology fellowship was drawing to a close, decided to pursue training in the United Patel began interviewing for a full-time States and began preparing to take the practice location. Having experienced U.S. medical entrance exams. He came Southern hospitality and a warmer clito America in 2003 and matched with mate while in Georgia, Patel looked below his first choice, an internal medicine resithe Mason Dixon line for his permanent dency at the Medical College of Georgia home. The Heart and Vascular Center of in Augusta. West Tennessee and Jackson were where “It was the best place with some of he decided to put down roots. the best patients you could care for. The “I had a friend that I did my resiattendings were also outstanding as were dency and cardiology fellowship with who the other residents. I loved it so much and was also coming here,” he said. “And learned so much that when the opportuwhile a lot has changed, personally and nity came to be the chief resident there, I professionally for me as well as in terms of took it even though it was more of an acathe local medical landscape, if I had to do demic and administrative position,” said it all over again, I would still pick Jackson Patel. “I then completed a fellowship in and this practice.” cardiovascular medicine there from 2009 While he primarily practices in Jackto 2011. It was one of the best times of my son, Patel rotates through the satellite life in terms of education, learning and adclinics in McKenzie and Adamsville. He vancing my medical and cardiology-based westtnmedicalnews
of each year, Patel’s parents from India live with him, which he says is a treat since his mom takes over the cooking. “They also spend some time each year with my brother in Kansas City who is also a cardiologist, as well as with my sister in London,” he said. An avid reader, Patel likes to unwind at night reading. He mostly chooses spiritual and well-being types of books or ones that are business related. He also has a love for football, especially the NFL and the Seattle Seahawks. Travel is another passion of Patel’s and he loves to getaway even if it is just for a couple of days. “I have traveled to European and South American cities,” he said. “Florida is also a great getaway because I love the water, even though I don’t know how to swim. I love to watch the waves.” Looking back, Patel says he couldn’t do anything else. “I always think we can improve in how we take care of our patients, especially those with complex vascular problems,” he said. “I love cardiology and cardiovascular medicine as a whole. Looking back, this is the best thing I could have done.”
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St. Jude’s Team, continued from page 1 The project sequenced about 700 pediatric cancers, which led to countless discoveries detailed in high profile publications and scientific journals. Published papers, Gout points out, require substantiating references, i.e. sequencing data or other data generated with that publication. Central repositories, however, “were cumbersome to access, cumbersome for us to upload our pediatric cancer genome sequencing data to, and cumbersome for users around the world to download this data to their own computing environment—which might take hours or even days,” Gout noted. “It was a big mess.” The solution – St. Jude Cloud: a platform in the cloud, developed at St. Jude to share all of the rich genomic pediatric cancer data generated over the previous ten years. From its launch in the spring of 2018 through August 2019, more than 50,000 users from across the world had accessed the Cloud. Today, less than 6 months later, that figure has more than doubled, and now exceeds 100,000 users, including 61 institutions in 16 countries. St. Jude Cloud, a partnership with Microsoft and DNAnexus, offers three interactive data-sharing platforms where scientists can use an array of exceptional tools to manipulate data in the form of whole genomes, whole exomes, and RNAsequenced data derived from pediatric cancer patients—rare data now available to doctors and researchers anywhere in the world. “The driving force behind any scientific endeavor is discovery and advancement of knowledge,” Gout reminds us. “Anyone in the pediatric cancer space is trying to discover or make advances toward better understanding of the disease and developing treatment. Therefore we want as many people looking at this data as possible, because the more brains we have on the case, the quicker we’re going to come up with discoveries and solutions to treating childhood cancers.” The more that’s shared, the more that’s learned; increased genome sequencing and analysis are revealing more and more about the long-term negative health effects of cancer treatment. Over time, less-toxic interventions are replacing treatments like radiation, which is being eliminated over time, as less toxic treatments are developed. Gout’s fascination with pediatric cancer genomics was home-grown in Australia, where he studied genetics as an undergraduate, followed by a graduate degree in computer science, a PhD in medical biology/infectious disease, and additional post-doctorate studies in pediatric oncology genomics before spending time at the Broad Institute at HarvardMIT in Boston as part of his post-doctoral focus. He returned to the U.S. in 2017 as editor for Nature Communications’ Cancer Genomics, a prestigious scientific journal—until Jinghui Zhang, PhD and chair of the St. Jude Dept. of Computational Biology, invited him to join the fledgling St. Jude Cloud project, late in 2018, as the
project’s Scientific Lead. “It’s been a fantastic experience; St. Jude is an absolutely amazing place,” he adds. “The St. Jude Cloud project is really paving the way for how we share genomic data with the world, and how we analyze genomic data, as well. I’m so happy that I came!” His efforts shepherded the project into its next phase in May 2019—making real-time clinical genomics available in the Cloud. Instead of waiting for the publication of related research (the traditional path, which can sometimes take years) before sharing the data, St. Jude now uploads unmined, de-identified patient data on a monthly basis. “We don’t want to delay other people’s access to this data—and potentially finding their own discoveries,” says Gout. “Instead, as soon as we sequence the data and generate it, we want to put it out into the world. Because pediatric cancer is such a rare disease, we need a lot of data to find associations and commonalities and correlations in order to make discoveries. The faster we share, the faster we allow this discovery process to happen.” The Survivorship Portal, a new feature of St. Jude Cloud, was introduced last fall, as part of a National Cancer Institute (NCI)-funded project. “This is a fascinating study,” Gout marvels. “They’ve accumulated between 3,000 and 5,000 patients who have, once upon a time, been treated at St. Jude for cancer. Many of these survivors return to St. Jude voluntarily every year, to have more than 100 different phenotypes measured: their blood pressure, heart characteristics, eye strength, mental agility, weight, height, BMI, etc. We study their DNA, if they agree; we look at these clinical phenotypes, the cancer they had in the past, the treatment used, and consider whether or not those things have affected their lives moving forward, in 5, 10, or 15 years. “Proper analysis of these data sets may enable us to serve preventative measures when we’re treating another child with cancer,” he suggests, “by comparing the results shown for patients with a similar genomic profile, who received different therapies, as recorded in the Survivorship Portal. “The Survivorship Project is a really beautiful retrospective study whereby we can leverage the accumulated knowledge that we can get from previously treated patients, and how we develop that treatment strategy for future patients.” The newest evolution -- Today, St. Jude Cloud anticipates its newest evolution: Federated data analysis of collaborating but currently incompatible genomic clouds. “Those who hold major pediatric databases use different clouds, and don’t allow simultaneous access between them,” says Gout. “We have over 10,000 whole genomes sequenced within St. Jude Cloud,” he reminds us. “With such a large number of samples, we need to think about new ways to house and analyze this data—new ways to develop processing (CONTINUED ON PAGE 6)
THA, TMA Outline Legislative Priorities, continued from page 1 helm. Among continuing concerns are maintenance of the state’s certificate of need program, the voluntary hospital assessment and support for rural hospitals. Additionally, THA is focused on measures to improve telehealth laws as usage continues to increase. CON: THA is a strong supporter of Tennessee’s certificate of need program, believing the regulations help level the playing field and dissuade “cherry picking” the commercially insured patients that keep hospitals financially viable. “We do definitely believe the CON program is absolutely essential,” Dr Long said. “We think it helps in managing Wendy Long healthcare cost, workforce demands and making sure access to quality healthcare services is available throughout Tennessee.” She added the CON program was a hot topic last year and expects legislation to be introduced again this session. “We agree there are some improvements that could be made in the CON process or operation of the program, and we hope that is the focus.” She noted THA is happy to work with the Legislature to improve the efficiency and transparency of the program in a way that isn’t detrimental to the un-
derlying reasons certificates of need were originally implemented. “We certainly worry about rural hospitals if there are changes to the CON program,” she said. Hospital Assessment: Dr. Long said THA will again voluntarily bring the annual hospital assessment legislation to Tennessee lawmakers. The assessment at the state level draws down matching federal dollars for the TennCare program. She noted the idea of hospitals’ picking up what had traditionally been funded by the state first occurred in 2010 at the height of the recession. “We were looking at substantial changes to services and benefits in TennCare. As a result of that set of dire circumstances, hospitals came forward and voluntarily offered to put up the necessary funding. That assessment today generates $602 million in state funding, which draws down a federal grant for a total of $1.7 billion.” The rate of assessment will remain at the current rate of 4.87 percent of a hospital’s net patient revenue. The funding, Long explained, averts limits on certain benefits, including physical, speech and occupational therapy, for TennCare enrollees. It also avoids a 7 percent reduction in TennCare provider rates. Although hospitals have agreed to the assessment annually for the last decade, Dr. Long said it shouldn’t be considered an automatic conclusion. “It’s something we discuss each and every year. I would
not characterize it as an easy decision,” she noted. “Hospitals continue to hope at some point the state might begin to replace this money with other revenue sources, but that has not happened so each and every year, hospitals have to reassess the issue.” Rural Hospital Support: In 2018, the General Assembly created the Rural Hospital Transformation Program to support work between at-risk rural hospitals and consultants who would assess the facilities and formulate strategies to improve hospital viability and access to care. As a result of this program, Dr. Long said several hospitals have completed the work with consultants and now have a list of recommendations in hand. “Some good suggestions were made . . . but in many, if not all, cases, there was a need for funding resources,” she said. “This was a great first step to do the analysis to come up with these plans. Now we’d like to see funding be directed to help the hospitals be in a position to implement those plans.” Telehealth: THA is working in concert with a number of provider organizations to tweak Tennessee telehealth laws. Long, who previously served as director of TennCare, noted she has been involved in telehealth for many years. Originally, technology was the big obstacle. As tech improved, the next question was whether or not patients would use it. “People really do like it,” she noted. “Now, I think
our focus is on reimbursement.” Long continued, “We’re working the Tennessee Medical Association on legislation to try to make sure payment is there. The vast majority of insurers do pay on the originating end – but not all – so that’s one of the areas we’d like to clean up.” In addition to codifying facilities that host the patient encounter receive a site origination fee, other desired modifications include establishing infrastructure and payment parity for provider-based telehealth services to enable patients to receive ongoing care from their existing physicians via a telehealth encounter and ensuring coverage for remote patient monitoring in a manner consistent with current Centers for Medicare and Medicaid Services policy. TennCare: While not a legislative agenda item, Dr. Long said keeping hospitals in mind as TennCare begins the bid process for managed care contracts is definitely an advocacy issue for THA. “This is a ‘once-in-a-not-very-often’ bid,” said Long, adding the hope is appropriate language is included in the RFP and awarded contracts to ensure hospitals are fairly considered and compensated. Improving access to care is another key advocacy issue. “We would still love to see expansion of the number of people with access to insurance in the state, but we don’t see any kind of appetite for traditional Medicaid expansion,” Long ex(CONTINUED ON PAGE 6)
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THA, TMA Outline Legislative Priorities, continued from page 5 plained. “But, we do perceive the block grant the state proposed as a step in the right direction and will continue to be very engaged as the proposal moves forward.”
The Tennessee Medical Association has a number of priorities on the table for 2020: Balance billing, telehealth and the state professional privilege tax are all on the organization’s radar. And, after a three-year moratorium, the contentious issue of scope-of-practice regulations has returned. TMA CEO Russ Miller, CAE, shared insights on his organization’s stance on all four topics. Balance Billing: Although no related bills gained Russ Miller traction in the Tennessee General Assembly last year, Miller said the U.S. Congress is looking at the issue of “surprise medical bills.” He believes solutions ultimately will occur at both a federal and state level. “Whatever happens at the federal level, we’ll try to improve upon at the state level to best serve our physicians and their patients,” said Miller. “Nobody should be caught by a surprise bill and be stuck with tens of thousands of dollars. We’ve got to help the patients who get caught in that situation.” While everyone has an example of a patient caught in a situation usually out of their control, Miller said such surprises are still fairly rare in comparison to the normal delivery of care. However, he added, out-of-network surprise billings seem to be increasing in frequency and becoming more expensive for the patient responsible for payment. He cited a narrowing of insurance networks as a key contributing factor to the problem. “This is not about doctors or hospitals gouging patients, it’s about this insurance network wrinkle,” said Miller, adding that TMA is advocating for a so-
lution that exonerates patients from the financial burden of these surprise out-ofnetwork charges while ensuring physicians are paid appropriately for services provided. Miller thinks one solution is to create an average cost for services, but doesn’t believe insurers should be in charge of the benchmarking. “There needs to be a non-biased, third party benchmark set,” he explained. “There must also be some type of independent dispute resolution,” he continued. Citing New York as an example, Miller said disputes happen in less than 2 percent of cases. When a third party arbitrator has been called in to adjudicate, the decisions have been split almost deadeven in favor of payers or providers, he said. Telehealth: A bill supported by TMA in 2019 to ensure telehealth services be reimbursed at the same rates as in-office visits did not pass. However, Miller said it did advance the conversation about rules and reimbursement governing the technology that has become increasingly critical for access to care, particularly in rural and underserved areas or for specialties with a shortage of providers. “There are times you need emergent care, but we’re trying to afford convenience to established patients,” Miller said of using the technology to support medically appropriate encounters, including follow-up appointments. Telehealth interactions are typically defined as synchronous or asynchronous. The former utilizes audio and video technology, along with encryption, to facilitate real-time consults. The latter, also known as “store and forward” applications, have delayed communication and are used to transport images or in a messaging type of format. “Right now, you have a lot of services provided in one of those formats without a lot of regulation around it,” Miller said, adding the goal is to facilitate access to the technology while putting up some guardrails to ensure appropriate use. Tennessee Professional Privi-
St. Jude’s Team, continued from page 4 and analysis software protocols that allow us to work with other large data repositories. “This is a big paradigm shift in doing genomics research in computational biology and other medical research,” he points out. “St. Jude Cloud is the largest genetic sequencing repository in the world, but there are other very large sequencing repositories being born Alex Gout around the world as well. Rather than finding one place where we could combine all of this data, we’re striving towards a federated data analysis approach, whereby we leave all the data in these other large pediatric 6
cancer repositories and develop software analysis programs to analyze the data in multiple locations at the same time.” Other potential participants in the collaborative cloud project include Kids First, at the Children’s Hospital of Philadelphia; and NCI’s Target Study, housed inside NCI Data Commons. “Collaborating with these other repositories and performing federated data analysis would allow us to leverage all of the data that each collectively has,” he notes. This would allow researchers to view scattered and rare cases, comparing commonalities—or lack thereof—without knocking on multiple virtual doors in order to gather and analyze valuable research data. “The federated data analysis project is something very cool that we’ll embark on very soon,” Gout believes.
lege Tax: “It is a privilege to be a doctor, but we shouldn’t be taxed on that,” Miller stated. Prior to adjourning the 2019 session last May, the General Assembly exempted several professions from paying the state’s professional privilege tax, but physicians weren’t included in that group. TMA has advocated for a reduction or removal of the tax for years, and Miller said they would continue working with state lawmakers on the issue. Scope of Practice: After previous talks led nowhere, a three-year moratorium was instituted from 2017-2019 on any scope-of-practice legislation redefining supervisory parameters for advanced practice nurses. With the end of the moratorium, the issue is again at the forefront of discussions between TMA and TNA. “We were at great odds, and the debate was pretty raw,” Miller said of where things left off in the fall of 2016. Since last summer, the two groups have been working toward finding some resolution to the debate. Miller said he perceives some small progress has been made. “There are some things we agree on; some things we’re far apart on; and some things we need to get back to them on,” he said of the current status. While the statutory relationship between physicians and advanced practice nurses changed from being called ‘supervision’ rules to ‘collaborative’ rules in 2016, Miller said there was no real substantive change other than nomenclature. Now the goal of both organizations is to meaningfully modernize and enhance that collaborative arrangement, but there is still significant disagreement on how updated regulations ultimately look. Independent practice for nurses remains the sticking point. “There are situations when care can be delivered efficiently by advanced practice nurses, but we don’t think those instances mean that you can do everything, all the time independently,” Miller said of the physician viewpoint. However, he continued, physicians recognize some of the current rules need updating. Particularly in areas of shortage, it can be difficult for nurses to secure a collaborative agreement with a physician prepared to come onsite for chart reviews monthly. While TMA isn’t willing to abandon collaborative arrangements completely, Miller said there might be ways to build in some flexibility. “We’re trying to modify the relationship. For those APRNs with a lot of experience, reduce the amount of interaction and oversight for them, but those new to practice still need some hours of behind-the-wheel mentoring,” he said. Although the level of oversight could be less for experienced nurses, the TMA stance is that it would never reduce to zero. “Having a physician in the arrangement serves as a vital backstop when there are conditions they (APRNs) are not able to take care of. It’s not good enough to say you’ll refer it,” Miller stated. “We have a hard time understanding why practicing alone will improve the environ-
ment when the entire industry is moving to team-based care.” While completely independent practice is a non-starter for physicians at this point, Miller said there are a number of areas TMA agrees should be addressed. “We need to do a better job of monitoring and regulating those who serve as collaborating physicians,” Miller noted of one frustration nurses have voiced. He added the bureaucracy governing collaborative agreements certainly could be improved, and the willingness to lower the level of oversight for demonstrably experienced APRNs is a shift from even a few years ago. “They (TNA) want to know if whatever we are working on now will lead to an independent pathway, but TMA physicians won’t accept that as a solution.”
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GrandRounds The Jackson Clinic Announces Addition of New Hospitalist
JACKSON - The Jackson Clinic recently added Dr. Robert T. Giddings to their Hospitalist Department. Dr. Giddings joins Dr. Chelsea Cooper, Dr. William Lofton, Dr. Natasha Mahajan, Dr. Osayawe N. Odeh, Dr. Aleruchi Oleru, Dr. Heather Perry, Dr. Evanna Proctor, Dr. Alan C. Rothrock, Dr. Bryan P. Tygart, Dr. Bradley M. Webb and Dr. Hafsa Zia. Robert T. Giddings The Hospitalist Department is located at Jackson-Madison County General Hospital. Dr. Giddings received his Doctor of Medicine degree from the University of Medicine and Health Sciences, Basseterre, Saint Kits Island. He completed his residency in Family Medicine from the University of Arkansas Medical School, Jonesboro, Ark. and received his undergraduate degree at the University of Texas at Austin, Austin, Tex. Dr. Giddings is Board Certified, American Board of Family Medicine.
ventative approach to health. The program focuses on the latest research and scientific evidence in endocrinology, cardiology, neurology, nutrition and cancer therapies. Murrmann is a founder, chief medical officer and medical director of the McDonald Murrmann Center for Wellness and Health and their Center for Aesthetics and Laser.
West Tennessee Bone & Joint Opens New Location in Dyersburg
DYERSBURG - West Tennessee
Bone & Joint Clinic has a new facility in Dyersburg at 2035 St. John Ave., Ste. 1. Practicing in the clinic are Jason T. Hutchison, MD, and J. Douglas Haltom, MD, both board-certified orthopedic surgeons; and Nurse Practitioner Leigh Ann Brandeberry, AGACNP-BC. The providers had been practicing at the clinic’s old location on Woodlawn Avenue. The new facility, remodeled by Fisher Construction of Milan, expands
patient services and convenience. The Dyersburg clinic is open from 8 a.m. to 5 p.m. Monday to Friday. For an appointment, call 888-661-9825.
The Jackson Clinic Welcomes Our Newest Physician
French Leads Full-Time Clinic in Union City
UNION CITY - Matthew French, a Certified Physician Assistant, treats patients five days a week at West Tennessee Bone & Joint’s clinic in Union City. He practices with physicians G. Blake Chandler, MD, and David A. Pearce, Matthew French MD, who also treat patients in Union City. The clinic, at 1003 E. Reelfoot Ave., is open 8 a.m. to 5 p.m. Monday through Friday. French received his master’s degree in physician assistant studies from Bethel University in 2017 and is a member of the American Academy of Physician Assistants and Tennessee Academy of Physician Assistants. He also holds a master’s degree in business administration and a bachelor’s degree in biology from Murray State University.
Murrmann Achieves New Fellowship
Susan Murrmann, MD, FACOG, recently graduated from a two-year program at the American Academy of Anti-Aging Medicine (a partner with George Washington University School of Medicine and the Metabolic Medical Institute.) She is now a Fellow in Anti-Ag- Susan Murrmann ing, Metabolic and Functional Medicine (FAAMFM) that will allow her to specialize in personalized, anti-aging, and functional medicine that emphasizes a holistic and prewesttnmedicalnews
Caroline Kiser, D.P.M.
PODIATRIST NORTH CAMPUS Board Certified: American Board of Foot and Ankle Surgery
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