Knoxville Medicine Fall 2018

Vol u m e L X X V, N o. 3 • Fal l 2 01 8

Ser v in g t h e G rea t er Met ropolit a n Kno x vi l l e A r e a

KAM’S NEW ONLINE SHOW DOC TALK WITH HOST ELISE DENNENY, MD -PAGE 7

KAM KNOXVILLE ACADEMY OF MEDICINE

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Robin Turley Senior Vice President Medical Private Banking ph: 865-971-2128 email: rlturley@ftb.com

KNOXVILLE ACADEMY OF MEDICINE

KNOXVILLEMEDICINE.ORG

Academy Officers

PRESIDENT’S MESSAGE

KNOXVILLE ACADEMY OF MEDICINE

Neil Coleman, MD

By: Neil Coleman, MD

Tim Wilson, MD

For this issue, I would like to profusely thank all those physicians who participate in the Knoxville Area Project Access (KAPA) program.

The KAPA program provides such a tremendous benefit to our community, and I don’t know if it can be emphasized enough what a remarkable program we have in the Knoxville Academy of Medicine.

Our KAM members and participating physicians are doing a great service to all those people who are underserved, who may work very hard, but yet fall through the gaps and still cannot afford adequate care.

While there are other Project Access programs in the country, KAPA is one of the largest and most successful. Our physicians and KAPA case managers have coordinated hundreds of millions of dollars in donated healthcare since the program began in 2006, helping tens of thousands of patients. On an annual basis, that is over 50,000 medical encounters per year. This is all thanks primarily to the generosity and enthusiasm of our physician community.

Regardless of whether we participate in KAPA, we all care for patients that are underserved or cannot afford the care they receive.

This is where KAPA case managers and the KAPA program can be a service to your practice. By referring patient’s for enrollment in KAPA and agreeing to participate, KAPA staff will help coordinate referrals to other KAPA physician volunteers. They also help patients who may actually qualify for insurance, Medicare, or Medicaid to get enrolled in programs that they may not be aware that they qualify for. This eases the burden on you and your staff to find appropriate care for patient’s you know might need a referral, but are having a hard time finding a specialist that is willing see a patient who may not be able to afford to pay.

I wish to extend an invitation to any physician who has not yet participated, but who has

PRESIDENT

PRESIDENT ELECT

Daniel Bustamante, MD SECRETARY

Jeff Ollis, MD TREASURER

Thomas Pollard, MD

IMMEDIATE PAST PRESIDENT

Kimberly Weaver, PhD CEO

Board of Trustees Michael Brunson, MD Brian Daley, MD David Harris, MD Zac Jumper, MD Ceeccy Yang, MD

Ex- Officio Board Members Richard Briggs, MD Debbie Christiansen, MD Randal Dabbs, MD Elise Denneny, MD Richard DePersio, MD Jerry Epps, MD Tina Callicutt -KAMA Mike Maggart, MD Patrick McFarland, MD Robert Page, MD Max Keeling -LMU

Publisher Kim Weaver, PhD

Editor Jonathan Weaver

Production Coordinator Margaret Maddox

Advertising David Caudill ADVERTISING: For advertising information, call the Academy offices at (865) 531-2766. The magazine is published four times per year by the Knoxville Academy of Medicine (KAM). All rights reserved. This publication or any part thereof may not be reproduced without the expressed written consent of the KAM. The appearance of advertising in KAM publications is not a KAM guarantee/endorsement of the product or the claims made for the product by the manufacturer.

The fact that an advertisement for a product, service, or company has appeared in a KAM publication shall not be referred to in collateral advertising. The KAM

KAM

the desire to help. It is easy to participate in KAPA, and you can determine the level of participation or how many patients you would be willing to see. KAPA staff work hard to ensure that care is spread equitably among participating physicians. Visit the KAPA page at http://www.knoxvilleareaprojectaccess. org for more information about the program. Please call the Academy 865531-2766 and ask to speak to Danielle Sims about enrolling in KAPA. Also feel free to give me a call or send an email if you have any questions about the program.

Thank you again to all who support the Knoxville Academy of Medicine and KAPA. Best wishes, Neil Coleman, M.D. 865-474-8866 ncoleman@dermpathpartners.com

Calendar of Events NOVEMBER 8

Pizza & Politics at LMU Angelo’s in the Gap

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Legislative Dinner Gettysvue Country Club, 6:30 pm

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Pizza & Politics UT Residents & Students Barley’s Tap Rm & Pizzeria-Knox, 6:00 pm

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Emeritus Holiday Luncheon Naples Italian Restaurant, 11:30 am

DECEMBER 6

Blount County Holiday Party

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Roane/Anderson Counties Holiday Party Calhoun’s at Oak Ridge, 6:30 pm

reserves the right to accept or reject any advertising in

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the publication.

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ACADEMY NEWS New Members A big welcome to our newest members! We are excited that you have decided to join the Knoxville Academy of Medicine.

DARRELL BENTON, MD

CYNTHIA W. NIENDORFF, MD

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THOMAS CHRISTIANSON, MD

LESLIE PERRY, MD

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RICHARD GLOVER, MD

LORI STAUDENMAIER, DO

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JASON KENNEDY, MD

LAUREN C. THOMA, MD

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MICHAEL D. MCDONALD, DO

NIKKI ZITE, MD

Left Column Top to Bottom: Darrell Benton, MD; Thomas Christianson, MD; Richard Glover, MD; Jason Kennedy, MD.

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Center Column Top to Bottom: Michael D. McDonald, DO; Muddassir Mehmood, MD; Cynthia W. Niendorff, MD; Leslie Perry, MD.

MUDDASSIR MEHMOOD, MD CARDIOLOGY University Cardiology 1940 Alcoa Hwy #E310 Knoxville, TN 37920

KYLE KLEPPE, MD

RADIOLOGY Abercrombie Radiology 1112 Weisgarber Rd Knoxville, TN 37909

ANESTHESIOLOGY University Anesthesiologists 1924 Alcoa Hwy #U-109 Knoxville, TN 37920

PEDIATRICS Children’s Faith Pediatrics 1341 Branton Blvd #102 Knoxville, TN 37922

INTERNAL MEDICINE UT Hospitalists 1924 Alcoa Hwy Box 56 Knoxville, TN 37920

EMERGENCY MEDICINE Team Health - Ft. Sanders Regional Hospital 1901 West Clinch Avenue Knoxville, TN 37916

Right Column Top to Bottom: Lori Staudenmaier, DO; Lauren C. Thoma, MD; Nikki Zite, MD; Kyle Kleppe, MD.

ANESTHESIOLOGY Encore Pain Specialists 11416 Grigsby Chapel Rd Knoxville, TN 37934

PEDIATRICS Children’s Faith Pediatrics 1341 Branton Blvd #102 Knoxville, TN 37922

FAMILY MEDICINE Summit Medical Group 10215 Kingston Pike, Suite 100 Knoxville, TN 37922

FAMILY MEDICINE Summit Medical Group 7211 Wellington Dr Ste 201 Knoxville, TN 37919

OBSTETRICS AND GYNECOLOGY Women’s Specialty Care 1928 Alcoa Hwy Bldg B Ste 300 Knoxville, TN 37920

GENERAL SURGERY University Surgeons Associates 1934 Alcoa Hwy Ste D285 Knoxville, TN 37920

Additionally, we would like to welcome the following new KAM Student Members: Brianna Avitabile Thomas Ballard Prachi Bansal Becky Barnett Seth Bennett Alexis Bishop Allison Breda Tanner Brondhaver Anna Cerrati Lauren Chadwell Alejandro Chavez Jordan Christopher Timothy Clark Taryn Colbert

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Hunter Calvert Nadera Dabbain Kaleb Darrow Jennifer Eaton Brittany Fehlbaum Ryan Fox Jacob Frankovitz Bret Gallihugh Arielle Garamizzo Bryan Grubbs Kayla Hamden Rance Harden Ryan Huestina Brianne Kelly

Byanca Kerolie John Kim Austin Kirksey Mary Elizabeth Klopp Lexi Kobishop Brianna Larson Bradford Layman Xing Li Veronica Mai Rabia Malik Matthew Mascioli Julia Mead William Neltner Stephanie Nguyen

Shaily Patel Jenny Patel Vipsa Patel Zach Pierson Jon Scarborough Reeda Shakir Kelsey Simmons Anantha K Singarajah Philip Stephens Vincent Vetrano Angelica Walinski Caleb Walker Abbi White

KAM KNOXVILLE ACADEMY OF MEDICINE

KAM/KAMA Annual Picnic

The annual KAM/KAMA picnic was once again held at Gettysvue Lower Pool as it has been for the past several years. KAMA, The Knoxville Academy of Medicine Alliance, is the spousal organization for the Knoxville Academy of Medicine. Capital Financial Group co-sponsored the evening with the Knoxville Academy of Medicine. New this year, food was provided by food truck vendors, The Taco Man and Artistic Pops . For many years this event has brought together KAM and KAMA members, and potential members, along with their families to enjoy an evening of summer fun. KAMA has always done an amazing job of organizing the event and this year’s addition of food truck flair raised the bar yet again. Many thanks to the efforts and hard work from KAMA.

KAM and Capital Financial Welcome LMU DeBusk College of Medicine Students New and returning students of LMU-DCOM were invited to gather together at a favorite hot spot, Angelo’s in the Gap, for KAM’s annual Grillin’ & Chillin’ event. This year’s event was sponsored by Capital Financial, and provided the students with an opportunity to take a break from studies, relax and enjoy fellowship as the new school year begins. Those in attendance enjoyed a few hours with their peers enjoying hot dogs, hamburgers, soft drinks and beer while getting to know each other and gain a better understanding of all the benefits of organized medicine.

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ACADEMY NEWS Update from the Board of Medical Examiners By: Reeves Johnson, MD

At the Tennessee AFP Practice Enhancement Seminar last March, I gave a presentation titled, Update on Supervision of Physician Assistants and Collaboration with Nurse Practitioners. There had been recent changes by the legislature that made this topic appropriate. In order to assess the current understanding of this important subject, I asked the attendees to fill out a questionnaire before I spoke. I have included the questions which a majority did not answer correctly.

And by the way, the new term for a Mid-Level Provider is Advanced Practice Professional (APP). Also, since my presentation, our state legislature changed the law such that for Physician Assistants, the term collaboration is substituted for supervision as it was done previously for Nurse Practitioners.

1. An APP that has taken special training to perform cosmetic procedures even though the supervising/collaborating MD has no experience in this field may do so only if: A: The training is certified and approved by the Board of Medical Examiners (BME) or Board of Nursing B: The APP was doing this under a previous supervising physician C: Both A and B D: The procedure is in the MD’s usual scope of practice and the supervising MD becomes competent at it Just because the APP may be qualified to perform a medical service, unless the supervising/collaborating physician is likewise qualified, the APP is not allowed to perform it. This can happen in a situation where an APP approaches a family physician regarding starting to offer Botox injections as part of the practice. Even though the APP may have been doing this for many years at a plastic surgeon’s office, unless the family physician can demonstrate competence in this area, this service is not allowed.

These next two questions have to do with chart review.

2. All charts must be reviewed in 10 days and signed in 30 days if: (One or more may be correct.)

A: A controlled substance is prescribed by the APP B: The APP refers a patient to a specialist

C: The APP writes a prescription outside of the protocol D: The patient seen by the APP requests a review E: The APP has a temporary license 3. Every __ days, a physician supervising/collaborating with an APP must visit the location where the APP practices and review at least __% of all charts of patients seen by the APP. A: 60 days/10% B: 30 days/20% C: 90 days/25% D: 60 days/20% One of the more common areas a physician is disciplined is failure to perform proper chart review. This is especially an issue if a controlled substance is prescribed. Even though most of the top 50 prescribers of controlled substances are APPs, they all should have a supervising/collaborating physician. At least 20% of all charts of patients seen by an APP must be reviewed each month along with the required monthly site visit, but 100% of charts in which a controlled substance was issued or a prescription is written outside of protocol must be reviewed in 10 days and signed in 30 days. This also holds true if the patient seen by the APP requests it or the APP has a temporary license.

Finally, regarding collaboration, the law also states, “Any rules that purport to regulate the collaboration of Nurse Practitioners with physicians shall be jointly adopted by the BME and the Board of Nursing”. T.C.A §63-7-123(d). The same likewise is true for Physician Assistants in that any rules are to be jointly adopted by the BME and the Committee on Physician Assistants. This has not been completed, so the current rules remain in force, however, a task force of members of the BME is currently working on this. There will eventually be new rules proposed and a Rulemaking hearing scheduled to allow for public comment, both in writing and in person.

Answers: 1. D 2. A, C, D, E 3. B

The Knoxville Academy of Medicine mourns the recent loss of these physician members

Turan Ozdil, MD 3/25/1925 – 5/25/2018 51 year member

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James (Jim) Chancet Lett, MD 8/3/1931 – 8/18/2018 39 year member

Daniel Stevenson Goudelock, MD 3/16/1932 – 8/20/2018 39 year member

ACADEMY NEWS

KAM KNOXVILLE ACADEMY OF MEDICINE

Knoxville Medicine’s Doc Talk already a Hit! In October, the Knoxville Academy of Medicine released its first episodes of Knoxville Medicine’s Doc Talk, an online production hosted by KAM Past President and TMA President-Elect, Elise Denneny, MD. Each segment of Doc Talk features KAM Members and is designed as community education broadcast. Topics are chosen that are of public interest but also promote KAM member practices. New episodes are released each Wednesday via social media as part of KAM’s Wellness Wednesday program.

All broadcasts can be viewed by visiting KnoxvilleMedicine.org or

can be found on iTunes, YouTube, Facebook, Spotify, and SoundCloud.

An online library of episodes will be available for up to one year and the member’s practice is encouraged to use the videos as part of the practice web and social media presence. Advertising opportunities are also available. If you are a KAM member and would like to volunteer to participate as a Doc Talk special guest, contact Ashley Robeson, KAM Membership Manager at arobeson@knoxvillemedicine.org or by calling (865) 531-2766.

Blount County Medical Society Quarterly Update By: Travis Groth, OD, BCMS President

“We’re blessed with the opportunity to stand for something-for liberty and freedom and fairness. And these are things worth fighting for, worth devoting out lives to.” –Ronald Reagan. As fireworks ring out and the 4th of July passes, I am left ever more thankful for our wonderful country, for those men and women who risk their lives daily to protect our freedoms, and for all those who participate in the wellbeing of our citizens. Blount County has worked effortlessly to improve our health care for the community and will continue to do so largely in part with the support of our local community hospital-Blount Memorial.

With this growth comes the opportunity for change.

I would like to announce that the Blount County Medical Society now has a Facebook page, Instagram account, and Twitter account. I see social media as possibly the greatest opportunity to reach out to not

KNOXVILLEMEDICINE.ORG

only all providers in the region but also to the community so that we can show that we are unified and working together. I must admit, change can sometimes be scary, but we must embrace it. Posted on the sites were the Tailgate party for the Tennessee vs Georgia Football game on September 29th. Yours truly roasted a 200 lb pig! Another upcoming event will be joining KAM for a fun trip to Keeneland in October to enjoy the horse races while gaining CME on the way.

This last quarter has been filled with hard work, much of which has been behind the scenes. I encourage everyone to join our social networks as they get up and running and sign up for upcoming events. This is great opportunities to meet new physicians in the community and get involved in the Blount County Medical Society.

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ACADEMY NEWS Legislative Update

Independent Nurse Practice By: Elise Denneny, MD, FAAO-HNS, FACS KAM Legislative Chair Medicine has always fought scope of practice issues. Nurse practitioners have been campaigning for independent practice in Tennessee for the past decade and in 2019 they will again bring another bill, “full practice authority”, expanding the practice of medicine.

What are their positions?

1. Independent nurse practitioners will solve the problem of rural access to care. Unlikely. The AMA has mapped the distribution of nurse practitioners in states that have already expanded nurse practitioner scope and these “geomaps” show no greater penetration of nurse practitioners in rural areas.

2. Independent nurse practice will help address the projected shortage of primary care providers. As more lives are covered under the ACA there is projected greater demand for primary care service and we are not graduating greater numbers of primary care physicians. Who will fill the gap? Both physician extenders, physician assistants and nurse practitioners have been posited as a solution. Flooding the health care market with physician extenders will address supply BUT this may also expand the health care marketplace and increase overall health care dollars spent by the state. We believe that a team based model will provide value while reigning in costs.

3. “Supervised” nurse practitioners are not really supervised. Nurse practitioner supervision/collaboration is a relationship that requires time and responsible applied attention. The state has established parameters for supervising physicians. Geography appears to impact timing and quality of supervision. Close proximity collaborative models as in multi practice and hospital based teams may have closer communication than collaborative relationships across state counties.

What is the data?

1. Less antibiotic stewardship was found with nurse practitioners and physician assistants. The Infectious Disease Society compares prescribing habits for URI from 1998-2011 and found NP and PAs more frequently prescribed antibiotics. If we extrapolate this to Tennessee’s problem of poly pharmacy, will independent practice further the proliferation of multiple drugs taken by Tennesseans? We already know that poly pharmacy is a driver of increased health care costs. https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3864987/ 2. Independent practice increases unnecessary referrals. Many physicians saw this pattern firsthand years ago and in 2013 the data from Mayo Clinic confirmed that the quality of referrals from physicians was more clinically relevant and appropriate than independent nurse practitioners whose referrals were evaluated as having little clinical value.

3. Independent nurse practice increases use of unnecessary imaging.

JAMA Internal medicine recently studied nurse practitioner patterns and found nurse practitioners ordered diagnostic tests more frequently in both the emergency and outpatient setting. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374

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https://www.kevinmd.com/blog/2015/01/physician-assistants-nurse-practitioners-really-save-money.html What are possible urban legends?

1. All nurse practitioners want independent practice. The majority I know prefer to work with a team where relationships support each other. Hidden past negative experiences with deep emotional scars often drive passionate policies.

2. Nurse practitioners have the ability to practice independently after graduation. The physician educational model requires critical hours of real-time clinical experience AND a residency before independent practice. There exist still DNP programs that are accredited by the ACEN (Accreditation Commission for Education in Nursing) where nurse practitioners graduate with no clinical experience. If nurses want to practice “medicine” should not this be a uniform standard? Is there equivalency between the board exams for medical students and nurse practitioners? There is not one standard group that administers tests to examinees wishing nurse practitioner certification. (Both the American Nurses Credentialing Center ANCC and the American Association of Nurse Practitioners AANP offer different exams) 3. The nursing board can adequately license and supervise independent nurse practitioners. If independent nurse practitioners practice medicine should this not be under the Board of Medicine?

4. The quality of care will change with expansion of nurse practitioners.

If you survey the public some will say. “even if quality of care changes with expansion of nurse practitioners, “good enough” standard is good enough …especially in areas of low access” Hmmm. The standard of care is not tiered by geography or socioeconomic status.

What can you do?

1. TMA is leading a summit on aligning the interests of all physicians across the state in November. Specialty societies will meet separately and jointly to understand positions, concerns and interests. Shared goals will be developed after conversation debating specialty society assumptions and evidence. Shared negotiations/strategies (i.e. utility unmatched medical student graduates pathway) will be aligned so the house of medicine will speak with one voice. You can share additional data you may have with us. elise.denneny@greaterknoxent. com. The outcome of shared core values and goals will be transparent and it is important for us give full support to our colleagues.

2. You can be a member of organized medicine! Dues go towards advocacy! Your dues supported the study which produced data supporting increased utilization of imaging. Future dues will continue to produce evidence based decisions 3. Use your relationships with your senator and representative and their staff to educate them. Roughly 1/3 of the state legislature is new and learning about issues that have been before the legislature for the past decade. You have that historical perspective and intelligence.

I would be remiss in my duties if I did not reiterate that despite this important issue we still have prior authorization, burnout, Pharma, EOC, and balanced billing/ narrow networks on our radar. THANK YOU for caring about your patients and the practice of medicine.

Elise Denneny

KAM KNOXVILLE ACADEMY OF MEDICINE

Is there a doctor in this voting booth?

By: Terry Nowell, MD PGY1 UTMCK, Department of Anesthesiology

In 2016, 61.4% of the general population cast ballots in the presidential election. In the 2014 midterms, that percentage was only 36.4% of Americans [1]. Who are the Americans voting in elections? Aggregate data from the most recent elections shows that voters tend to be older (71% of >60yo vs.

43% ≤29yo), wealthier (78% earning >$150,000/yr vs.

41% earning <$15,000/yr) and more educated (85% post-graduate vs. 31% no high school degree) when compared to non-voting citizens [2].

However, there is at least one exception to this data - physicians. In the largest study investigating physician turnout, doctors had a turnout rate of 41.5%. To compare, that is 9% lower than the general population and 22% lower than lawyers [3]. How is it possible that physicians are less likely to be in the voting booth than their patients? It could be due to practical reasons, such as onerous workloads, opportunity cost of taking two hours away from a private practice, or simply schedules incongruous with getting to the polls.

More concerning is the argument that physicians are placing less value on civic engagement. If this is true, this disengagement is coming at a time in which healthcare reform has become a central issue in

the political discourse. Over the past decade, both political parties have brought healthcare to the forefront of their platforms. Moreover, a June 2018 poll from the Pew Research Center found that healthcare remains a top issue for voters in the upcoming midterm elections [4]. There is little doubt that the results of this election will impact decisions on physician compensation, drug pricing, graduate medical education funding, and the future of the ACA insurance marketplace. On a state-level, the next governor and body of legislators will make policy decisions on Medicaid expansion, scope of practice of midlevel providers, and the opioid crisis. All of these decisions will have a direct and noticeable impact on how we practice medicine.

Thus, it is vital that KAM members, community physicians, and residents go to the polls this November. Many strategies have been implemented to help mobilize physicians to participate in elections, but it appears that the simplest strategies continue to be the most effective. First, every physician should be registered to vote in their community. Second, early voting and by-mail voting can be utilized in the weeks preceding the election; hospitals, employers, and residencies should share this information with their physicians. Finally, simply sharing with colleagues that you voted will have a dramatic impact on their likelihood to vote.

Now, more than ever, it is time for doctors to go to the polls.

Access GoVoteTN.com for polling and registration information.

1. Montanaro, D. (2014, November 10). 2014 midterm election turnout lowest in 70 years.

2. McDonald, M. P.. Voter Turnout Data. www.electproject.org.

3. Grande, D., et al. (2007). Do Doctors Vote? Journal of General Internal Medicine,22(5), 585-589. doi:10.1007/s11606-007-0105-8 4. Pew Research Center. (2018, June 20). Voters More Focused on Control of Congress – and the President – Than in Past Midterms

Additionally, we would like to welcome the following new KAM Resident and Fellows: Gabriel Collins, DO Matthew Curry, MD Jacob DePolo, MD Michael Donovan, MD Liliane Ernst, MD David Garcia, MD Tyler C. Hall, DO Brandon Hays, MD Kasey Helmlinger, MD Kerry Hennessy, MD

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Erika Herrera, DO Phillip Hinojosa, MD Joseph Hilopak, DO Luke Iannuzzi, MD Nikhil Jain, MD Eric Johnson, MD Justin Jong, MD Jordan Lakin, DO Nicholas Link, MD Justin Lohmann, DO

Kathryn A. Majdick, MD Callie McAdams, MD Charlotte McCarley, MD William Nunemaker, DO Emeka Nwaneri, MD Kristin O’Connor, MD Clinton Phillips, MD William Riley, MD Phillip P. Rideout, MD Susan Roaten, MD

Scott Shubeck, DO Samuel Walker, DO James D. Webb, MD Shannon Wentworth, MD Alina Wertz, MD Emory Wilson, MD Heidi Worth, MD Katherine Yared, MD Keith Zoeller, MD

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ACADEMY NEWS KAM Day at the Races A Big Win for Members On October 21, 2018, the KAM hosted the annual KAM Day at the Races at Keeneland. The event was sponsored by our friends at Capital Financial Group and Lincoln Financial. KAM members and their guests traveled via motorcoach from Knoxville to Lexington, KY where they enjoyed a delicious buffet lunch overlooking the track. Private betting windows, a fantastic view of the track, and beautiful day to watch the ponies made the excursion a win for everyone! A big thank you to Dale Amburn and Ian Hennessey of London and Amburn Attorneys at Law for providing a CME session on the trip up to Keeneland!

The 2018 Outstanding Resident Scholar Award was presented to Patrick McFarland, MD, Anesthesiology Resident The Outstanding Resident Scholar Award was first presented in 2014. To determine awardees, AOS faculty members, chaired by James Lewis, MD, created a point system used to score research efforts including grants, publications, presentations, and IRB-approved ongoing projects; teaching achievements including teaching awards, presentations at educational conferences, invited lectures and teaching or administrative chief residents; patient care feedback including annual resident exams and The University of Tennessee Medical Center Guardian Angel program; and service through professionalism, service to charities and appointments on committees.

Dr. McFarland has served in several leadership roles at a local, regional and national level which include serving as the Resident Liaison to the Knoxville Academy or Medicine Board, Governing Council Chair and Resident Representative to Independent Medicineâ&#x20AC;&#x2122;s Political Action Committee of Tennessee, Resident Representative for the American Society of Anesthesiologists Political Action Committee, Resident Representative for the Deanâ&#x20AC;&#x2122;s Board of Visitors for the UT Graduate School of Medicine, and Resident Delegate for the state of Tennessee. He has also served as Chief Resident for two years and scored in the top 10th percentile on the Resident In-Training Exams and the top 10th percentile on the American Board of Anesthesiology Basic Science Examination and Anesthesia Knowledge Tests.

LMU Osteoblast Brings New KAM Members In August the students of LMU participated in Osteoblast which is an event designed to allow new and current students the opportunity to learn more about the many clubs and organizations that operate on campus. This year KAM was well represented by Scott Lallier and his board as they recruited members for organized medicine for the KAM, TMA, and AMA. 10

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LEGAL NEWS

KAM KNOXVILLE ACADEMY OF MEDICINE

Supervision of CRNAs: The Law and Liability in Tennessee By: Kelly S. Street, esq.

London & Amburn, P.C.

Certified Registered Nurse Anesthetists (CRNAs) serve an indispensable role in the provision of anesthesia in the United States. They provide anesthesia in nearly every setting, and their importance continually grows. The issue of how CRNAs are supervised, however, remains contentious. Seventeen states, not including Tennessee, allow them to practice independently. Advocates for independent practice argue that the standard of care for a CRNA is the same for an anesthesiologist, but anesthesiologists contend that while CRNAs are competent, supervision is the safest practice. So, what exactly is required by the law in Tennessee? What are the legal ramifications for a physician in a “supervisory” role?

The regulations for the Centers for Medicare and Medicaid Services (CMS) provide that anesthesia must be administered by a CRNA under supervision. “Anesthesia must be administered only by . . . a [CRNA] who . . . is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed.” 42 C.F.R. Section 482.52. The federal government amended this section in 2001 to allow states to “opt out”; though the law in Tennessee does not require supervision, Tennessee has not opted out.

In rural areas, CRNAs often practice independent of an anesthesiologist; at last count, there were forty-three counties in Tennessee that have no anesthesiologist. In such locations, CRNAs provide 100% of the anesthesia, and the supervision requirement is fulfilled by the “operating practitioner” (surgeon). Although, the surgeon does not participate in, direct, or control the anesthesia. In larger hospitals, supervision is usually provided by an anesthesiologist located in the same facility as the CRNA. However, the role of the anesthesiologist is perhaps no less attenuated than that of the surgeon. The anesthesiologist has specific training in the work the CRNA is doing, but he or she is generally not

in the same room. Moreover, an anesthesiologist is usually supervising multiple CRNAs. The supervisory legal duties in these contexts are not clearly defined as the CMS Interpretive Guidelines state a supervising anesthesiologist should be “immediately available.” Whereas, surgeon supervision should “conform to generally accepted standards of anesthesia care.”

This lack of clarity is problematic and creates a potential source of liability for any physician who supervises a CRNA. Regardless of the supervisor’s position, the CRNA is nevertheless monitoring and keeping the patient alive with nearly complete discretion, and this often includes the management of airway emergencies and respiratory issues. Yet, in that rare circumstance when there is a bad patient outcome due to anesthesia provided by a CRNA, the fact that a physician was “supervising” generally results in a lawsuit for not only the CRNA, but also the physician. To a layperson, supervision, as a term, suggests a chain of command or level of control. The actual threshold is lower but the lack of clarity in the law requires that the definition of supervision be painstakingly established in each lawsuit, usually through oral depositions and the testimony of expert witnesses. This fact pattern has played out in many cases we have defended.

The good news, if any, is that sometimes the physician can be extricated from the case so long as it can be proven that the “supervisor” was not directing or controlling the acts of the CRNA. See Parker v. Vanderbilt University, 767 S.W.2d 412 (Tenn. Ct. App. 1988); Goodman v. Pythyon, 803 S.W.2d 697 (Tenn. Ct. App. 1990).

Mr. Street is a partner at London & Amburn in Knoxville, Tennessee and is a graduate of the University of Tennessee College of Law. He focuses his practice on representing the interests of healthcare providers, hospitals, and healthcare-related businesses in civil matters of all types. He has successfully defended numerous cases involving both CRNAs and anesthesiologists.

London Amburn Hosts Annual Healthcare Law Seminar London Amburn is a full service law firm that has provided legal services to the physician community for over a quarter of a century and donates numerous hours of legal services to the Knoxville Academy of Medicine each year. Every year as a service to clients London and Amburn offer a free healthcare law seminar to address some of the top legal issues that are currently impacting physicians in the area. This year’s event was held at the Foundry on September 11th. Speakers included Patti Cotten, Diana Guston, Ian Hennessey, Luke Ihnen, Dan Swanson, Jennifer Pearson Taylor, and Erin Williams from the area’s leading firm in healthcare law. Topics included information on the year’s most frequent issues, an overview of healthcare transactions, Tennessee legislative update, provider audits and appeals, and an employment law update.

KNOXVILLEMEDICINE.ORG

KAM is pleased to announce the new exclusive membership benefit with London Amburn. KAM members will now enjoy discount on legal services, a complimentary subscription to periodic email updates on significant developments in health law, participation in London Amburn’s General Counsel Services Program, and access to free health law education programs produced by the firm. The availability of legal services and acceptance of clients are subject to the firm’s policies. Details on each of these new benefits are available from London Amburn. The benefits provider under this program are free with your KAM membership, but to receive these benefits, KAM members must be enrolled in the program. For more information and to enroll, contact Dale Amburn or Ian Hennessey at (865) 637-0203, or via email at kam@londonamburn.com.

KNOXVILLE MED CINE | 11

TECHNOLOGY NEWS etHIN Establishes Connections to Out of State HIEs for Interstate Medical Records Exchange

Plans were made and work quickly began at both HIEs to create and test the connection. In less than 48 hours from the initial phone call, the connection was established, allowing providers in East Tennessee to retrieve by: Leigh Sterling, Executive Director medical records for North Carolina residents who were seeking care here East Tennessee Health Information Network after evacuating to escape Hurricane Florence.

“Hurricane Florence created a very dire situation for the residents of 496 Breathtaking Views,and other neighboring states, and the hotels and campetHIN provides growing connections to Acres, out of state patient informa-Mountain North Carolina tion through its membership in two national networks…the eHealth Lake, Exgrounds in our area quickly filled up with evacuees,” said Leigh Sterling, Spring Stocked Fruit Trees, 496Fed Acres, Breathtaking Mountain Views, change (eHEX) and the HIE-to-HIE network, Patient Centered Data Home Executive Director of etHIN. “This is the fastest we have ever been able Lodge, and Guest Cabin Spring Fed Stocked Lake, Fruit Trees, with another HIE, and I want to give credit to (PCDH). Connections to North Carolina and Georgia are currently availto establish a connection Offered at $3,250,000 Lodge, and Guest Cabin able under the eHealth Exchange tab in etHIN’s Health Information Portal the etHIN and Health Connex staffs who worked through the late evening (eHIP). Coming soon is a connection to The Health Collaborative, whichat $3,250,000 hours for two days to get the connection working. It was a herculean efOffered covers southern Ohio and parts of northern Kentucky, with numerous adfort on the part of both entities, and all of us at etHIN, including our Board ditional connections in the planning stages. of Directors, are very happy to be part of supporting our North Carolina The volume of available patient information from these connections is neighbors in their time of need.” dependent upon the progress each Health Information Exchange is making “Our neighboring HIEs have been incredibly responsive to our unwith on-boarding health system and providers in their area. This means planned need,” said Christie Burris, Executive Director for NC HIEA. “It’s that the information available to you through etHIN may vary by state or estimated that over one million residents in North Carolina and Virginia region. were evacuated from our coastlines. This is a testament to the collaboration On September 13, etHIN and North Carolina’s statewide health inforof both of our teams and vendor partners and strengthens the importance mation exchange Health Connex, run by the North Carolina HIE Authorof HIEs across the country in supporting the patients and providers that we ity (NC HIEA), finalized an emergency connection to support the medical serve.” records needs of North Carolina residents who evacuated to Tennessee to etHIN and NC HIEA are also both members of the Strategic Health escape Hurricane Florence.

Information Exchange Coalition (SHIEC), which sponsors the nationwide etHIN and NC HIEA began discussions two days prior to the connecPatient Centered Data Home initiative. etHIN is part of the PCDH Hearttion go-live date regarding establishing the connection through the nationland Project, which allows etHIN to connect directly to other health inforwide eHealth Exchange, of which both etHIN and NC HIEA are members. mation exchanges in Indiana, Michigan, and Ohio.

AN EAST TENNESSEE TREASURE AN EAST TENNESSEE TREASURE

URE URE AN AN AN EAST EAST EAST TENNESSEE TENNESSEE TENNESSEE TREASURE TREASURE TREASURE AST TENNESSEE TREASURE 496 496Acres, Acres, Breathtaking Breathtaking Breathtaking Mountain Mountain Mountain Views, Views, Views, 496 Acres, Breathtaking Mountain Views, 496 Acres, Spring Spring Spring Fed Stocked Fed Fed Stocked Stocked Lake, Lake, Lake, Fruit Fruit Trees, Fruit Trees, Trees, Spring Stocked Lake, Fruit Trees, AN Fed EAST TENNESSEE Also included is a detached carport with smokehouse, A true Tennessee Treasure now TREASURE being offered for 496 Acres, Breathtaking Mountain Views, Lodge, and Guest Cabin Lodge, Lodge, Lodge, and Guest and andGuest Guest CabinCabin Cabin Spring Fed Stocked Lake, Fruit Trees, from west Knoxville guest cabin, barn, utility shelter. Please note all private sale.

Located just 35 minutes Offered at $3,250,000 Also included is a detached carport with smokehouse, Lodge, and Guest Cabin A true Tennessee Treasure now being offered for Offered Offered Offered at $3,250,000 at at$3,250,000 $3,250,000

at $3,250,000 structures are being sold in an “as is” condition. and 15 minutes fromOffered the charming community of guest cabin, barn,Treasure utility shelter.

Please note all sale. Located just private sale. Located just 35 minutes from west Knoxville A true Tennessee now being offered for private Maryville, Tennessee. There are approximately 496 acres 35 minutesare from west Knoxville and“as 15 minutes from the charming community being sold of in an is” condition. and 15 minutes from the charming community of Further structures subdivide/development this property of Maryville, Tennessee. There are approximately 496 acres of unspoiled of unspoiled mountain woodlands. Here you will find an Maryville, Tennessee. There are approximately 496 acres is possiblemountain with thewoodlands. approvalHere of the youBlount will find an abundance of apple trees, Further subdivide/development of this property abundance of apple trees, blueberries, and wildlife in blueberries, and wildlife in their natural habitat. of unspoiled mountain woodlands. Here you will find an County Planning Department. is possible with the approval of the Blount their natural habitat. The main lodge encompasses an abundance of apple trees, blueberries, and wildlife in The main lodge encompasses an approximate 2,400 square feet and is County Planning Department. approximate 2,400 square feet and is constructed in the Elementary, Carpenter’s Middle, constructed in the cantilever architectural style. The main lodge is being sold their natural habitat. The main lodge encompasses an Schools: Lanier furnished and includes 2 bedrooms, 2 baths, loft, great room, eat in kitchen and cantilever architectural style. The main lodge is being William Blount High School approximate 2,400 square feet and is constructed in the Schools: Lanier timbers Elementary, Carpenter’s massive exposed throughout.

Adjacent to Middle, the main lodge is a springsold furnished and includes 2 bedrooms, 2 baths, loft, fed and stocked lake.

Plenty of room to canoe, fish, or take an after dinner dip. cantilever architectural style. The main lodge is being Due to theWilliam nature of this property, we respectfully request Blount High School Also included is a detached carport with smokehouse, A true Tennessee Treasure now being offered for great room, eat in kitchen and massive exposed timbers agent be present at all property previews. The guest cabin, barn, utility shelter. Please note all private sale. Located just 35 minutes from west Knoxville sold furnished and includes 2 bedrooms, 2 baths, loft, that the list Also structures are being sold in an “as is” condition. and 15 minutes from the charming community of is aof detached carportcode. with smokehouse,request guest cabin, barn, utility Due to included thebenature this we respectfully property can only accessed via property, private throughout.

Adjacent to the main lodge is a spring-fed Maryville, Tennessee. There are approximately 496 acres Further subdivide/development of this property great room, eat in kitchen and massive exposed timbers shelter.

Please note all structures areproperty being soldpreviews. in an “as is” that the list agent be present at all Thecondition. of unspoiled mountain woodlands.

Here you will find an possible with the approval of the Blount abundance of apple trees, blueberries, wildlife in and stocked lake.andPlenty of isCounty room to canoe, fish, or take an MLS #’scan 1040246 and 1040247. only be accessed via private code. throughout.

Adjacent toPlanning theDepartment. main lodge is a spring-fed Refer to property their natural habitat.

The main lodge encompasses an Further subdivide/development of this property is possible with the approximate 2,400 square feet and is constructed in the Schools: Lanier Elementary, Carpenter’s Middle, after dinnerstyle.dip. cantilever architectural The main lodge islake. being William Blount School and stocked Plenty ofHighroom to canoe, fish, or take an approval of the#’s Blount County Planning Department.

Refer to MLS 1040246 and 1040247. sold furnished and includes 2 bedrooms, 2 baths, loft, Schools: Lanier Elementary, Carpenter’s Middle, William Blount High School great room, eat in kitchen and massive exposed timbers after dinner dip. throughout. Adjacent to the main lodge is a spring-fed Due to the nature of this property, we respectfully request that the list agent be present at all property previews. The property can only be accessed via private code.

and stocked lake. Plenty of room to canoe, fish, or take an after dinner dip.

Due to the nature of this property, we respectfully request that the list agent be present at all property previews. The property can only be accessed via private code.

Refer to MLS #’s 1040246 and 1040247.

Refer to MLS #’s 1040246 and 1040247.

Also included is a detached carport with smokehouse, ure now being offered for guest cabin, barn, utility shelter. Please note all 35 minutes fromFORwest Knoxville Alec Blaine MORE AlecBlaine Blaine - Broker Broker INFORMATION FOR MORE Alec PLEASEofMobile 865.548.5799 structures are being sold in an “as is” condition. charming community 150 Major Reynolds Place, Knoxville, TN 37919 CONTACT Broker alecblaine@gmail.com INFORMATION here are approximately 496 acres Alec Blaine Office: 865-769-4644 FOR MORE PLEASE Further subdivide/development Mobile 865.548.5799 of this property Mobile: 865-548-5799 12 | oodlands.

Here you will find an KNOXVILLE MED CINE Broker INFORMATION smokehouse, mokehouse, Also included Also Alsoincluded included is a detached isisaadetached detached carportcarport carport with smokehouse, with withsmokehouse, smokehouse, A true ATennessee Atrue trueisTennessee Tennessee Treasure Treasure Treasure being now now being being offered offered for for for CONTACT possible with thenow approval of offered the Blount alecblaine@gmail.com Email: alecblaine@gmail.com blueberries, and wildlife in PLEASE Mobile 865.548.5799 ote te all all guest cabin, guest guestcabin, barn, cabin,utility barn, barn,utility shelter. utilityshelter. shelter.

Please Please note Please allLA4060 note noteall all privateprivate private sale. Located sale. sale.Located Located just 35just minutes just35 35minutes minutes from west from from Knoxville west westKnoxville Knoxville County Planning Department. main lodge encompasses an CONTACT alecblaine@gmail.com LA4060

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KAMA CORNER By: Kirstin Kropilak, KAMA President Summer is generally a time of rest & relaxation, without a typical schedule. However, for many KAMA members, we’ve been busy preparing for a great year ahead. It takes a village, as they say. For me, it’s all about teamwork. That’s part of my theme this year. “Create a year of TEAM work! Tactful * Exemplary * Affable * Munificent” Each of those words capture my thoughts and ideas of how to work well together. Ask your favorite KAMA member to explain that. I explained it in the KAMA bulletin. Here are the highlights of what we have done and are working on: • Three of us attended the new Resident Orientation dinner at UT in May. We had our table set up to invite the spouses to join KAMA. See the picture below.

• Robyn Doiron, Cynthia Gash & I met often, taking on the task of creating an updated yearbook design. I want to thank Michele Maves who has been managing the yearbook for as long as I can recall. It’s a huge job and we owe her a huge debt of gratitude.

Presentation of Corporate Sponsor donation from Premier Surgical Associates to KAMA. L to R: Judy Akers, President-Elect; Susan Brown, Doc Rock co-chair; Tina Callicutt, Past President; Kirstin Kropilak, President; Nancy Dudrick; Steve Cruze, COO of Premier Surgical Associates; Kimberly O’Neal Wilson, Premier Surgical Marketing Director.

• Our Medication Task Force has been busy. 15 KAMA members were trained by the MDC in April to teach the elementary school level of the Generation Rx Safe Medication Practices curriculum. Also, the next Knoxville medication collection event will be Oct. 27. We already have 6 permanent drop boxes in the area.

• We just recently made the decision to use Mail Chimp for our emails and formal communication to our members.

• Our first meeting was Sept. 6. Along with a fabulous guest speaker, Hallerin Hilton Hill, we had a special presentation to a corporate sponsor who donated $10K this year: Premier Surgical Associates.

• The KAM/KAMA new member picnic, which was sponsored by KAM and Capital Financial Group, was Sept.7 at Gettysvue lower pool.

• Our first fundraiser, Fashiondrama, was held on Oct. 4th at Gettysvue Country Club. Our theme is this year was “Be Your Own Kind of Beautiful”.

UT Resident Orientation dinner.

L to R: Kirstin Kropilak, KAMA President; Lili Vincent, membership co-chair; Emily Munderloh, Resident Spouse Liaison.

Knoxville Area Project Access Know someone or have a patient who is uninsured?

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1. Send a physician referral form to KAPA 2. KAPA will contact the patient to screen them for the program 3. If eligible, you will be notified of the patient’s enrollment in KAPA 4. KAPA will ensure the patient has a PCP and coordinate any specialty care It’s that easy!

Specialties in need: 1. Gynecology 2. Gastroenterology 3. Dermatology 4. Neurology 5. Neurosurgery

For more information, please contact Danielle Sims at 865-531-2766 or dsims@knoxvillemedicine.org.

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The evening will be packed with great country music, line dancing, a western-themed dinner, a variety of beers in your own bottomless souvenir glass, and a large silent auction.

All proceeds to benefit Knoxville Area Project Access (KAPA).

FOR MORE INFO & TICKETS VISIT KAPABOOTSCOOTIN.COM OR CALL (865) 531-2766