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Physician Spotlight: Change Can Be Good West Tennessee radiation oncologist Paul Koerner, MD, reflects on the changes he has seen over his career Over the past 20 years, there have been a number of changes and improvements in the treatment of cancer and West Tennessee has seen its share of those. One of the leading cancer treatment providers in West Tennessee, Cancer Care Centers has seen its share of changes in the past two years.

Profile on page 3.

Violence in U.S. Emergency Departments on the Rise ACEP Survey Highlights Growing Risk By their very nature, emergency departments are high-stakes settings filled with vulnerable patients and frightened families. Increasingly, they are also high-risk settings for healthcare providers, staff and patients.

The Role of Telemedicine in Rural West Tennessee Is telemedicine having an impact? By SUZANNE BOYD

According to the Census Bureau, there are 60 million people who live in rural communities, but only nine percent of U.S. physicians practice in these areas. According to the National Rural Health Association (NRHA) in the U.S., there are only 30 specialists available for every 100,000 patients in rural areas. This can cause patients in rural or remote areas to endure longer travels just to access specialists and life-saving treatments for specific diseases. Rural health facilities are turning to technology to address these issues by bringing the specialists to the patients via telemedicine. West Tennessee hospitals are finding increasing ways to implement this in their facilities and some are finding grants to help cover the costs of bringing the technology.  Telemedicine is the use of telecommunications technology such as phones and computers to provide clinical services to patients over long-distance communication. Aside from connecting patients and medical providers, telemedicine also offers a way for healthcare professionals to consult with other physicians or specialists in the diagnosis or treatment of a patient without having to leave their own facilities.

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Small Towns, Big Fight for Continued Access to Care Rural Hospitals Face Death by a Thousand Cuts

By CINDY SANDERS

More than 60 million Americans – nearly one in five residents – live in rural communities. While these small towns and wide swaths of farmland are an integral part of the American fabric, the nation has seen the rural population drop from 54.4 percent in 1910 to 19.3 percent a century later, according to the U.S. Census Bureau. As Americans have migrated to urban areas and urban clusters, it has become increasingly difficult to sustain services, particularly access to healthcare, in many of these rural communities. Although a little more than 80 percent of the country lives in urban areas

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Crystal Broyles stands next to one of the telemedicine carts used at Baptist Memorial Hospital – Union City

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PhysicianSpotlight

Change Can Be Good

West Tennessee radiation oncologist Paul Koerner, MD, reflects on the changes he has seen over his career By SUZANNE BOYD

Over the past 20 years, there have been a number of changes and improvements in the treatment of cancer and West Tennessee has seen its share of those. One of the leading cancer treatment providers in West Tennessee, Cancer Care Centers has seen its share of changes in the past two years. Radiation oncologist, Paul Koerner, MD knows about those changes. A native of Knoxville and a graduate of East Tennessee State University medical school, Koerner came to Jackson in the summer of 1999 at the completion of his residency at the University of Louisville in Kentucky. He joined Dr. William Permenter in practice at Cancer Care Centers which had clinics in Jackson, Paris and Dyersburg. It was one of the first practices in West Tennessee to offer both radiation and chemotherapy. “Technology has had a big impact on oncology,” said Koerner. “When I was in training, computers played only a small role in the planning and delivering treatment to a patient. Today, they play a primary role. Improved technology allows us to be more precise with the radiation which allows us to administer the treatment more effectively.” One thing that has remained stable in the practice is the patient load. “There will always be a certain percentage of the population that will need cancer treatment, so your patient numbers are actually more dependent upon population growth in the area,” said Koerner.

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Dr. Paul Koerner jammin’ on stage with his band, Early Roman Kings

“There are three main ways to treat cancer: surgery, radiation or some form of chemotherapy. Radiation therapy is utilized in about 30-40 percent of all cancers, which has not changed much. One thing I have seen a change in is that there are slightly fewer diseases that we use radiation treatment for. Chemotherapy has

improved so much that it can be administered without adding radiation to the treatment.” Having three locations across West Tennessee Koerner says is a huge benefit to patients, especially those who require radiation treatments. “Radiation treatments are given on a daily basis over a

period of few weeks. That can be burdensome on patients who may have transportation issues or financial barriers,” he said. “Fortunately for our patients, they can choose the clinic that is most convenient for them and it also means most patients do not have to drive more than an hour to receive their treatment.” Collaboration has also improved in oncology as a specialty. There is just a tremendous amount of collaboration among all cancer centers, especially the larger ones. The internet has vastly improved this since we can use that to find the latest studies as well as what larger cancer centers are doing that may be of benefit to our patients. Patients can also receive a treatment protocol from a major cancer center that we can implement here in West Tennessee.” Away from the office, Koerner still enjoys indulging his passion for music. He continues to play guitar as well as several other instruments in both the worship band at West Jackson Baptist Church and in the band Early Roman Kings. “We play in Nashville quite a bit as well as around West Tennessee and have a website with photos and videos. It is definitely a hobby that I love but I am definitely not quitting my day job.” One more big change that is on the horizon for Koerner and his wife, Amy, is that in the fall, they will be empty nesters when they will have two kids in college. “I have no idea what it will be like to not have the kids at home,” he said. “Having our daughter already in college, I feel like we are in somewhat of a transition phase. But with both gone, that is going to be unchartered territory for us.”

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The Role of Telemedicine in Rural West Tennessee, continued from page 1

A 2012 report by the Institute of Medicine for the National Academies, entitled The Role of Telehealth in an Evolving Health Care Environment, found that telehealth drives volume, increases quality of care, and reduces costs by reducing readmissions and unnecessary emergency department visits for rural communities. Through telemedicine, rural hospitals can serve rural patients at better costs and help cut down on the time it takes rural patients to receive care, particularly specialty care. In 2003, Hardin Medical Center implemented telemedicine through working directly with Dr. Jeffrey Woodside who was then in charge of the telemedicine program at UT-Memphis. “Woodside later retired and moved to Hardin County where he serves on the HMC Board of Directors,” said Nick Lewis, CEO of Hardin Medical Center in Savannah. “The telemedicine program offered patients Nick Lewis access to specialties including dermatology, neurology, otolaryngology and psychology. Unfortunately, the program dissolved when UT-Memphis opted out of it.” Over the past two years Baptist Me-

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morial Hospital-Union City has implemented telemedicine in several areas including the emergency room, medicalsurgical and the critical care unit. “We currently utilize it for neurology, psychiatry, nephrology and infectious disease. We hope to add pulmonology soon since we have a large patient population with lung issues,” said Crystal Broyles, CCU Nurse Manager for Baptist Memorial Hospital–Union City. “We also have an Electronic Intensive Care Unit, which is a form of telemedicine that uses state of the art technology to provide an additional layer of critical care service.” While the technology has been well received by both patients and physicians, unfortunately it still does not always prevent a patient from being transferred. “Telemedicine does not overcome the issue of rural area hospitals not having all the available equipment or services needed to provide some of the services that the telemed doctors prescribe,” said Broyles. “This results in the patient being transferred to another hospital that can supply the needed equipment or services.” Behavioral health is another area where telehealth can have a critical impact, giving physicians and their patients access to scarce and often remote resources. The Veterans Administration, for example, recently  launched a telehealth program for rural vets with Post Traumatic Stress Disorder. More than

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500 vets signed up for the study, indicating how telehealth technology may be the only option for many rural residents. West Tennessee Healthcare’s Pathways Behavioral Health Services has utilized telemedicine for nearly five years, especially in its satellite locations. “It can be very beneficial in providing diagnostic support and in determining whether a patient in outlying areas needs to be transferred to a facility that can provide a higher level of care. Often times it is the only way to see a patient and provide the necessary medical management,” said Wes Crawford, Behavioral Health Service Line Administrator for Pathways Behavioral Health Services a division of West Tennessee Healthcare. “It has also allowed our physicians to better utilize their time treating patients as opposed to traveling from satellite clinic to satellite clinic. Each of our satellite locations, Dyersburg, Union City and Lexington, are set up to access telemedicine services when necessary.” Pathways utilized a grant two years ago to purchase the equipment needed to allow the program to really grow. “Some of the stations we utilize cost between $12-15,000 when we implemented the program,” said Crawford. “It has greatly improved our access to clients. They do have to be in one of our facilities to utilize it because it has to be a secure connection that is HIPPA compliant. We also have a nurse present to be sure we know who will be on the line when the call is made and that things are working correctly.” A primary concern among rural physicians is whether telehealth is a realistic solution for their practice—financially and technically. The good news is that federal programs and advancements in technology are helping to rectify disparities in care. The Centers for Medicare and Medicaid Services has unveiled a new Rural Health strategy designed to make it easier for clinicians in rural areas to use telehealth technologies by reducing some of the barriers to telehealth such as reimbursement, cross-state licensure issues, and the administrative and financial burden to implement telemedicine. Thanks to a grant from the Delta Region Community Health Systems Development – Technical Assistance Program Hardin Medical Center hopes to utilize telemedicine again. “The purpose of this program is to enhance healthcare delivery in the Delta Region through intensive technical assistance to providers in select rural communities, including critical access hospitals, small rural hospitals, rural health clinics and other healthcare organizations,” said Lewis. “It is our hope that some of the grant funding will be earmarked for a new telemedicine software program.” The grant, which was awarded in late 2018, is through the Delta Regional Authority (DRA), in collaboration with the Health Resources & Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) is launching the Delta Region Community Health Systems Development – Techni-

cal Assistance Program. “The terms of the grant stipulate the funding will be used for improving the hospital or clinic financial operations,” said Lewis. “It is designed to increase the efficiency of the local healthcare delivery system practices by focusing on care coordination, social services integration, emergency medical services access, and workforce recruitment and retention. One of the goals of the program is to increase the use of telemedicine to fill service gaps and access to care.” Lewis sees the implementation of a new telemedicine program at Hardin Medical Center having an immediate influence on one of the most challenging issues for a rural community; access to care, especially specialty care. “The access will immediately improve health outcomes for those who might not otherwise receive the specialized care they need. Patients who participate will receive care faster and as a result, most will recover quicker,” said Lewis. “In addition to providing patients with access to care, telemedicine programs can also support healthcare professionals through consults and educational programs.” Medicare reimbursement is a major challenge for telemedicine, with states each having their own standards by which their Medicaid programs will reimburse for telemedicine expenses. There is no single standard telemedicine reimbursement system for private payers, either. In February 2018, the House and Senate passed a budget deal that included the Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017 that allowed Medicare to cover more services for treating chronically ill patients. This was the largest boost to federal telehealth coverage in 17 years. The act has instigated legislators to funnel more Medicare money into telemedicine by allowing Medicare to cover more services for treating chronically ill patients. With tools such as telehealth, rural physicians can better coordinate care for medically complex patients and address the root causes of diseases. Telehealth becomes the equalizer between urban and rural areas, giving everyone access to high-quality care, regardless of where they reside.

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Violence in U.S. Emergency Departments on the Rise ACEP Survey Highlights Growing Risk By CINDY SANDERS

By their very nature, emergency departments are high-stakes settings filled with vulnerable patients and frightened families. Increasingly, they are also highrisk settings for healthcare providers, staff and patients. Last fall, the American College of Emergency Physicians released data and insights into the rising violence in U.S. Emergency Departments. In a poll of more than 3,500 emergency physicians nationwide, nearly seven in 10 said ED violence is increasing, and nearly eight in 10 said the violence harms patient care. “More needs to be done,” said ACEP President Vidor Friedman, MD, FACEP, in presenting the survey results during the organization’s annual meeting. “Violence in emergency departments is not only affecting medical staff, it is affecting patients,” he continued. Findings from the poll, included: • 47 percent of emergency physicians reported having been physically assaulted at work, with 60 percent of those assaults occurring in the past year. • 71 percent personally witnessed others being assaulted during their shifts. • 77 percent said patient care was being affected with 51 percent of those saying that patients also have been physically harmed. • 50 percent believe the majority of attacks are from people seeking drugs or under the influence of drugs or alcohol. While 70 percent of those surveyed said hospital administration or hospital security did respond to the incident, only 21 percent said hospital security arrested the assailant or enlisted law enforcement to do so; 6 percent said hospital administration advised them to press charges; and 3 percent said hospital security pressed charges. The other 70 percent said response to the assault resulted in a behavioral flag being added to a patient’s chart or ‘other’ measure. The vast majority of physicians said patients were responsible for the attack, but 28 percent reported being assaulted by a patient’s family member or friend (results totaled more than 100 percent because some respondents had been attacked more than once). 83 percent of emergency physician respondents said a patient has threatened to return to harm them or their emergency staff. The most common types of assault are being hit, slapped, spit upon, punched, kicked or scratched. In addition, to physical attacks, 80 percent of male and 96 percent of female emergency physicians report having a patient or visitor make inappropriate comments or unwanted advances. 34 percent believe a lack of punitive westtnmedicalnews

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(L-R) Drs. Terry Kowalenko, Vidor Friedman and Leigh Vinocur present survey findings at an ACEP meeting.

consequence is the biggest contributing factor to the issue, and another 32 percent said behavioral health patients are driving the increases in violence (and 41 percent think the majority of attacks are from psychiatric patients). “Just in hospitals and healthcare in general, people are at their most vulnerable, and family members are at their most worried. The ER is the worst-case scenario for most, so it is this extremely volatile experience,” said Leigh Vinocur, MD, FACEP, past chair of ACEP’s Emergency Department Violence Committee and a national spokesperson for Leigh Vinocur the organization. She added that when most people think about doctors and nurses being harmed or killed, they think of those practicing in war-torn counties. “Yet, here in the United States, it’s possible for your ER physician to become a victim of violence.” The reasons for increasing violence are multifactorial. “I always say the emergency department is a microcosm of society – gun violence, domestic violence, homelessness, psychiatric issues. As there is an increase in violence in society, it’s going to spill over into the emergency department,” noted Vinocur, a board-certified emergency physician with more than 25 years of experience.

Add overcrowding and boarding into the mix of heightened emotions, and Vinocur said it isn’t surprising to see tempers flare. While nearly half the physicians surveyed have been physically assaulted and more than 70 percent have witnessed someone else be assaulted, Vinocur said the numbers climb even higher when verbal abuse is added to equation. And while this poll was conducted among emergency physicians, she said nurses are often on the front lines of the potential danger. “The person who is more hands-on with the patient is susceptible to even more abuse,” she pointed out. “If you look at the Bureau of Labor Statistics, being a healthcare professional is one of the most dangerous professions … and it’s very underreported,” Vinocur said, noting those in healthcare chose the profession to help people and often don’t report incidences because they recognize patients are under stress and don’t want to stigmatize them. Even while being mindful the situation might cause patients and family members to act in ways they normally wouldn’t, Vinocur said she believes hospitals are trying to get in front of bad behaviors that could quickly escalate. “Hospitals and health systems realize it’s the safety of their employees and also the safety of their patients,” she said. Of increasing concern, however, are freestanding EDs and urgent care centers. While most hospitals have guards, Vinocur pointed out, “In these ambulatory settings where you are siloed and there’s no security, you are even more vulnerable … and a lot of healthcare is moving to ambu-

latory settings.” To offset the disturbing trend in violence, Vinocur said there are a number of concrete steps facilities and health systems could take to improve safety. Additional security is one key step whether that is in the form of more guards or more cameras on site. When adding security cameras, it’s beneficial to have the devices visible so that individuals are aware their actions are being recorded. Improved visitor screening is another crucial step. In some areas, particularly large urban areas, metal detectors help screen for weapons. In addition, Vinocur said staff should be trained to ask patients if there is anyone who shouldn’t be allowed in to see them to help curb potential domestic violence interactions. “Training people to deescalate situations, too, is important … teaching hospital staff to recognize the signs of someone who is escalating as they are starting to get more and more agitated,” she said. Vinocur noted clinicians could also play a vital role in easing agitation through clear communication with patients and family members to keep them up to speed. While it’s easy for physicians to get distracted because they are so busy, she said it’s crucial to be aware of how stressful the situation is for patients and their families and why it’s so important to foster engagement. “Tensions run high,” Vinocur concluded. “Open communication can help allay fears and help mitigate out-of-control feelings. It can help ameliorate the very emotional experience of healthcare.” And a calmer emergency department is ultimately a safer one. MARCH 2019

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Small Towns, Big Fight for Continued Access to Care, continued from page 1 and the clusters surrounding them, the actual land urbanites use is only 3 percent of the country’s total. The remaining 19.3 percent of the population is spread across 97 percent of the nation’s landscape. In a service industry where ‘minutes matter,’ closure of a rural hospital facility likely means adding significant time to get to the next closest medical facility. By the beginning of this year, the National Rural Health Association (NRHA) counted 95 rural hospital closures since 2010 and identified nearly 700 other facilities as being vulnerable for closing. “Everything that NHRA works on can be boiled down to one thing … and that’s Diane R. Calmus access,” stated Diane R. Calmus, regulatory counsel for the NRHA. The reasons for the closures are multifactorial. “It would be really easy if there was a silver bullet to solve the issues, but this has been the result of a whole lot of small cuts,” said Calmus. “A lot of cuts that have happened in D.C. have impacted rural hospitals in a way that haven’t impacted urban counterparts with a different payer mix,” she continued. In its #SaveRuralHospitals action center, the NRHA noted, “The rate of closure has steadily increased since sequestration began and bad debt cuts began to hit rural hospitals, resulting in a rate six times higher in 2015 compared to 2010.” Rural hospitals often lack the specialty services that bring in higher reimbursement to offset losses on general inpatient care and surgeries. Add to that,

Calmus continued, “Rural Americans tend to be older, sicker, poorer than their urban counterparts.” She continued, “We know from MedPAC that at least since 2016, Medicare margins have been, on average, negative. By definition, rural hospitals are providing that frontline care, and that’s where negative margins are even worse.” Calmus said the bad debt cuts have been particularly hard for rural hospitals for a couple of key reasons. Prior to the Affordable Care Act, hospitals could write off a significant portion of their bad debt. However, since ACA was supposed to expand health insurance to everyone, the theory was bad debt would drop dramatically. Therefore, a bad debt cut was put in place. When Medicaid expansion was overruled by the Supreme Court, it left a coverage gap for a lot of Americans, which has been disproportionately felt by rural hospitals with a smaller patient census to offset uninsured care. Even when serving patients with insurance, rural hospitals often have been left with bad debt since paying a $5,000 deductible is nearly impossible for many people. The very nature of frontline care means that rural hospitals often stabilize a patient before sending that individual to an urban counterpart for more specialized treatment. Rural hospitals have found their services fall into the ‘deductible’ part of patient care, whereas insurance has kicked in by the time the patient is transferred to the larger urban center for continued services. “We’ve seen a 50 percent increase in bad debt at rural hospitals that we haven’t seen at urban hospitals,” noted Calmus. Sequestration is another area where federal cuts have made it increasingly difficult for some rural hospitals to keep their

doors open. “Critical Access Hospitals were paid 101 percent the cost of providing care. That was cut by 2 percent by the sequester. If you do the not-so-difficult math, they are not being paid the cost of care,” Calmus said of the cost deficit faced by CAH-designated facilities. The ‘death by a thousand cuts’ reality has taken a steep toll on rural hospitals across the country. “From 2018, 46 percent of rural hospitals were operating at a loss. That’s up from 44 percent in 2017 and 40 percent the year before that,” outlined Calmus. Yet another threat to access is a lack of providers. “Recruitment and retention of physicians is always an issue for rural hospitals,” said Calmus. This is particularly true for a number of specialties. “Between 2004 and 2014, we’ve seen more than 200 rural communities lose their hospital-based obstetrics. Now, the majority of rural counties don’t actually have a place to deliver a baby,” she continued. Coinciding with the decrease in obstetric services has been an increase in precipitous deliveries with more rural babies delivered at home, in ERs, or in the back of an ambulance or in a car en route to a larger facility. On a more positive note, Calmus said, “340B is one of the bright spots in rural healthcare.” In addition to keeping the doors open, she said a number of hospitals are using the 340B money in innovative ways to improve care delivery … and, she stressed, the 340B money isn’t paid for by taxpayers. “The threats to 340B are frequent. We ‘re working constantly to educate legislators and the administration on how well hospitals are using this money,” she admitted. Happily, there are plenty of success stories to share. “Rural hospitals are uniquely positioned to know their patients

in a way doctors in urban communities can’t,” she pointed out. Calmus noted one hospital in Kansas kept seeing a family in the emergency room because they had an infestation of bed bugs. Using just a few 340B dollars took care of the problem at a fraction of the cost of an ER visit. Similarly, another patient was having a hard time controlling his diabetes. Tapping into resources to pay his electric bill meant his insulin could be properly refrigerated and therefore more effective. Calmus said rural hospitals have become incubators for innovative practice. “In so many ways, it’s the rural hospitals who are figuring out how to do more with less,” she pointed out, adding that work mirrors the national call to deliver highvalue care in the most cost-effective manner possible. Despite the many ongoing threats to the nation’s rural healthcare facilities, Calmus said there is much to be excited about, as well. “Rural America is a great place to practice medicine in the cradleto-grave model so many providers say they want to practice.”

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GrandRounds Le Bonheur Children’s Hospital to Expand Heart Institute

Le Bonheur Children’s Hospital unveiled plans this month for a $37.6 million expansion of its Heart Institute that when completed will give it a dedicated 31-bed cardiovascular unit. The two-story expansion will attach 70,500-square-feet on the west side of its hospital at the corner of Poplar Avenue and Dunlap. There will be 10 additional beds in its Cardiovascular Intensive Care Unit for a total of 20 beds. The increased space also will create room for an 11-bed stepdown cardiac unit. A new MRI-guided hybrid catheterization lab also is being added, for a total of three. Construction is scheduled to begin this year. Since 2015 the Heart Institute has added 19 new cardiologists to handle patient growth. Last year it evaluated and treated 387 inpatients.

are manifesting across the state. New restrictions on prescribing and dispensing are no doubt reducing overall initial supply, but are also unreasonably obstructing some patients from accessing legitimate, effective pain management. TMA and the Tennessee Pharmacists Association are working with the legislature to amend the law to address specific issues raised by doctors and patients. TMA has also developed a number of proprietary resources to help educate doctors and other prescribers on Tennessee’s opioid prescribing laws at tnmed.org/opioids.

SCOPE OF PRACTICE – TMA continues defending against proposals that would threaten patient safety and quality of care by removing physician oversight for nurses, physician assistants or any other midlevel providers. TMA for years has led doctors’ opposition to nurse independent practice in Tennessee and is part of a coalition of healthcare organizations promoting physician-led, team-based care as the safest, most efficient and effective healthcare delivery model in Tennessee. MAT PARITY – TMA is asking the General Assembly to consider a resolu-

tion encouraging health insurance companies to include medication assisted treatment in patients’ health plans and reimburse specialists who provide MAT services at rates comparable to other treatments. TMA has long advocated for more accessible and well-funded treatment options for patients struggling with substance abuse. Using medications in combination with counseling and behavioral therapies is a necessary strategy in the ongoing fight against Tennessee’s opioid abuse epidemic. Read more about TMA’s legislative priorities at tnmed.org/legislative

Kosten Kick-It Event Scheduled April 7 at Shelby Farms

The ninth annual Kick-It 5K Run will be held at 1 pm Sunday, April 7 at Shelby Farms Park. The day’s program include a one-mile family walk, food, live entertainment, team photos, a survivor ceremony, and an awards ceremony. The event is the major fundraiser for the Herb Kosten Pancreatic Cancer Charitable Fund, established by his family in order to pay tribute to a man who battled cancer with dignity and courage. The organization’s programs include a yearly symposium headlined by nationally recognized leaders in the field of pancreatic cancer, as well as fellowship training for future pancreatic cancer surgeons. It also hosts a monthly support group meeting, providing hope and help for patients and their families. Those wanting more information should visit www.kostenfoundation.com. 

Doctors’ Day on The Hill Set For Tuesday, March 26

The Tennessee Medical Association (TMA) expects at least 300 physicians from across the state to attend its annual Day on the Hill in Nashville on Tuesday, March 26. Physicians from all regions of Tennessee representing all medical specialties come to Nashville during each legislative session to meet with lawmakers, attend committee meetings and share their expertise on issues affecting healthcare in Tennessee. TMA, recently named the most influential advocacy organization in Tennessee, has an intentionally limited list of topics it is pushing this year in the new-look General Assembly but is a visible and respected voice for any healthcare-related bills that affect doctors and patients. This year’s main issues are: OPIOIDS (SB 0810 / HB 0843) – While TMA was able to make significant improvements to Gov. Haslam’s “TN Together” legislation in 2018, some of the unintended consequences doctors initially feared the new law would create

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