April-May 2022 Memphis Medical News by Pamela Harris

FOCUS TOPICS WOMEN’S HEALTH • NURSING ISSUES • ONCOLOGY • HEALTHCARE REAL ESTATE

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New Construction, Strategic Expansion Changing Landscape at St. Jude

Report from new SVP of Campus Operations, Jose Fernandez By JAMES DOWD

Testing When Patients are Young Can Inform Better Care as They Age

When he joined St. Jude Children’s Research Hospital in the summer of 2021, Jose Fernandez understood that his foreseeable future would require extraordinary attention to detail and keen juggling skills. Stepping into a newly created role as senior vice president of campus operations, Fernandez was charged with overseeing the design, construction and facilities departments that are in the midst of nearly $2 billion in building and expansion projects. In addition, Fernandez manages the organization’s food service, biomedical engineering and environmental services. And he’s playing an integral role in the major expansion of the campus that’s part of the St. Jude strategic plan for 2022-27. As he nears his first anniversary with St. Jude, Fernandez is excited about the ongoing building projects that are transforming the organization’s campus as well as the face of downtown Memphis. “We’re already tweaking our strategic plans to accommodate further growth and technological advances,” Fernandez said. “There’s a lot going on at St. Jude with projects that we have to focus on day-to-day, but we’re also continually looking forward and preparing for the future.” Among several key projects that are nearing completion, Family Commons is scheduled

Brother/sister physicians at MOGA enjoy being there for patients during some of their most vulnerable times With a father who is a physician and a mother, a former neo-natal ICU nurse, the Williams children understand why people might assume their futures in healthcare were chosen for them the day they were born.

Profile on page 3

ANA Reveals Top Federal Legislative Priorities The American Nurses Association (ANA) recently unveiled its leading federal legislative priorities for Congress covering safe staffing, nursing workforce development, home health, opioid epidemic, workplace violence, and COVID-19.

Article on page 7

See more local news in Grand Rounds on pages 9-12

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Jose Fernandez

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The Murky Waters of Long COVID The impact on women’s health, need for more research, depression issues and new initiatives By LYNNE JETER

The suicide last May of Long COVID sufferer Heidi Ferrer rocked the COVID-19 world, lending a face to the debated diagnosis. A TV writer for “Dawson’s Creek” and “Wasteland,” Ferrer had been battling extended COVID symptoms for nearly a year when she called it quits. She foreshadowed her death when she posted on her social media blog: “In my darkest moments, I told my husband that if I didn’t get better, I did not want to live like this. I wasn’t suicidal, I just couldn’t see any quality of life, long term, and there was no end in sight.” Demographically, Ferrer was smack in the middle of Long COVID sufferers. Female, white, 50, and income of more than $85,000 annually. (CONTI2NUED ON PAGE 6)

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PHYSICIAN SPOTLIGHT

Testing When Patients are Young Can Inform Better Care as They Age Brother/sister physicians at MOGA enjoy being there for patients during some of their most vulnerable times By LAWRENCE BUSER

With a father who is a physician and a mother, a former neo-natal ICU nurse, the Williams children understand why people might assume their futures in healthcare were chosen for them the day they were born. After all: three children, three doctors. “People say ‘Well, have you been telling them since they were babies what they were going to do?’” said Heather Wherry, MD, who is with Memphis Obstetrics and Gynecological Association (MOGA.) “They never pushed medicine, but there’s three of us and we all ended up in medicine, but I feel like it was for very different reasons. They encouraged us to figure out our own paths and to make ourselves happy. “I’ve always enjoyed women’s health care, particularly obstetrics. We take care of them in one of the most vulnerable times of their lives, whether it’s while they’re pregnant, or postpartum, or when they’re going through menopause. We tend to be their healthcare providers during some of their most vulnerable times.” Her older brother, Jason Williams, MD, also with MOGA, was a chemistry major at the University of Tennessee when he decided he did not want to spend his life in a lab. “Kind of late in the game I decided I wanted to do medicine,” he said. “I like the surgery, particularly the types of surgery. They’re not five-hour or 10-hour cases. They’re cases involving patients we see who have a need for surgery. These are our personal clinic patients we operate on so it’s a little different than surgery in some other surgery fields. “We are generalists and we function as quasi-PCPs for younger healthier patients with things like genetics screening and BRCA screening. This is new medicine, so the younger doctors are a lot more aggressive with this because we were trained and tested on these screening algorithms. This is becoming a more pertinent thing. What we’re doing for someone in their 30s who may have an abnormal gene for breast cancer, might change what the rest of their life care is. From residency to this year there have been testing changes, what-we’re-testing changes, and who meets criteria for this. I’ve had a string of young patients recently with breast cancer.” While the two obstetricians are only in MEMPHISMEDICALNEWS

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the same MOGA office twice a week, they do consult with one another on patients. If there are very serious problems, they may call on their middle brother, Dr. David Williams, a critical care pulmonologist who practices with their father, Dr. Glenn Williams. “If we have to call for their help, it’s never a good thing because it means our patient is critically ill and needs ICU-level of care,” said Wherry, “but we actually all love collaborating on patients. Jason and I routinely call or speak in person about patients, just getting each other’s opinion and perspective on how to approach situations. “We also love being in the same practice because our patients feel at ease seeing the other doctor. If I’m out of town or unavailable I might tell one of my pregnant patients ‘Don’t worry, you’re going to see Dr. Williams. He’s my brother.’ They love it and it makes them feel at ease.” The brother and sister physicians each help bring 150 to 200 babies into the world each year, which means they’re on call about one night a week and then every fifth weekend. Whether a delivery goes smoothly or may require some intervention, she adds, each one is a special event. “Deliveries can often be routine until they aren’t,” said Wherry. “In obstetrics things can go south very quickly and you have to be able to remain calm and think on your feet very fast. Also, every delivery is a very special moment in your patient’s life no matter how many times we may do them in our practice. So, in that way, they’re all a little different.” The biggest single change in medicine

in the past two decades, they agree, is the use of electronic medical records which can be viewed as a blessing and a curse.

“There are many upsides to EMR, including continuity of care, clarity of the records and the ease of access,” said Wherry. “On the downside, sometimes completing everything in the EMR can contribute to burnout and makes it so most providers in direct patient care actually spend more time completing medical records than we do face to face with patients. For anyone who spent the better part of their adult lives learning to be able to take care of patients, that is a very frustrating part of the job.” The single biggest challenge in caring for patients, they agree, is obesity. “We always see articles that our pregnancy outcomes in this country don’t rank where they should when we look at the world stage and I think obesity is the number one reason for that,” said Wil(CONTINUED ON PAGE 5)

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New Construction, Strategic Expansion Changing Landscape, continued from page 1 to open this fall. Following a brief grand opening period during which media and other guests will be allowed to tour the site, the innovative space will be closed to outsiders and available as a recuperative space for patients and their families. Family Commons will offer a place to take a break from medical procedures and staff and provide a creative environment that allows patients to recharge. Family Commons has been made possible in part by a $50 million donation by AbbVie, a research-based global biopharmaceutical company. Highlights at Family Commons include resting nooks where patients and family members can reserve rooms to relax or sleep, along with art, music and maker spaces where young people can express their creative abilities. There will also be a space for parents to gather and share their stories, and a thoughtfully designed playground that is accessible for those undergoing cancer treatments or with mobility restrictions. The area reflects input from current and former patients and parents about the kind of mini-getaway that will provide the best environment possible. “This will be a magical place for our patients and their families, with beautiful colors and oversized ladybugs and a relaxed, fun atmosphere that allows them to get away from the reality of medical staff and treatments for a while,” Fernandez said. “I’m excited about the possibilities

of this vision. Marlo Thomas has been intimately involved in this project and we all want this to be a space of love.” Set to open in the spring of 2023 is Domino’s Village, funded primarily by a 10-year, $100 million pledge by Domino’s. The six-story complex will incorporate nearly 300,000 square feet and feature outdoor green spaces and an underground parking garage. Families will be able to utilize the building’s 140 units for short- or long-term stays while their

children are undergoing treatments. The structure will include one-bedroom hotel suites, as well as apartments that offer two or three bedrooms and provide a homelike environment. “A diagnosis of pediatric cancer or other life-threatening diseases affects the entire family, and treatments can take months or even years,” said James R. Downing, MD, St. Jude president and chief executive officer. “We asked patients and their families to tell us

what would make their experience the best possible while staying at St. Jude. Their thoughts and ideas are reflected in the planning and design of this new residence.” Another component of the St. Jude strategic plan is an outpatient clinical building and a clinical office building that will break ground this summer. Originally designed at 600,000 square feet, the project has increased the footprint by (CONTINUED ON PAGE 5)

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Help Make College Dreams Reality Once upon a time, college was a dream some parents had for their children and a goal youngsters might have for their future. That was then. Today, college isn’t just a dream; it’s practically a requirement. According to 2021 U.S. Bureau of Labor Statistics, workers with a bachelor’s degree had a median annual wage that was twice as much as high school graduates. Those holding a bachelor’s degree have historically experienced a much lower unemployment rate. Unfortunately, this greater earning potential is coming with an ever-increasing price tag. Today, the four-year cost of many Chirag Chauhan, AIF®, CFP® private colleges is well over $100,000, according to the College Board. With tuition and fees rising almost 7% annually, the cost of a four-year education in 2035 could top $417,000 for a private school and $212,000 for a public school.

529 Plans

New Construction, continued from page 4

100,000 square feet to accommodate growth trends. “This is necessary to address the ongoing expansion of our organization. Originally, we anticipated adding 1,400 new staffers and now that’s grown to 2,300,” Fernandez said. “We are also taking a more sophisticated approach to building design and how environment can facilitate healing as we strive to meet the needs of our patients, their families and our employees.” Rather than traditional interior, closed off waiting rooms, the new outpatient building will feature waiting rooms with glass panels that offer outdoor viewing. The state-of-the-art clinic will contain flex exam rooms and allow St.

Jude to see more patients than ever before. And the proximity of patient treatment, healing spaces and research facilities ensures that the organization’s mission is always top of mind. “One of the most innovative things about St. Jude is that the compactness of our campus means you can pretty much get from one point to another fairly quickly,” Fernandez said. “We’re intentional about creating this sense of community where people bump into each other in the hallways and discuss ideas or new research or treatment options. We want them to be as close together as possible to share with one another and come up with great ways to continue to do the amazing things we do.”

Testing When Patients are Young Can Inform Better Care, continued from page 3 liams. “There’s not a quick fix. We’ll see someone for a breast exam or a pap smear or a mammogram, but only have a finite amount of time with patients. We can’t just say ‘You need to have weight-loss counseling as part of your 15 minutes with a patient each year. That’s not going to change someone’s life trajectory. We have to explore other avenues. “Society is going to have to address this all the way around, but part of this is going to have to be ownership. People are going to have to realize that this is not a sustainable way to live.” Adds Wherry: “Obesity is reaching every single area of medicine. It’s the biggest problem that we face. Whether it’s patients getting diabetes early or hypertension early, obesity is just causing a lot of general health problems during pregnancy. We talk to our senior partners all the time and they say they used to have a few gestational diabetics or a few with different severe health problems, but it’s like that’s our average patient now. memphismedicalnews

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“And it’s across the board, male and female. No one is spared the obesity increases we’re seeing. There are so many layers here, like access to food, making healthier choices in schools and homes, exercise – all those things from a young age. Physicians absolutely play an important role in this and in combatting issues where people already are obese, but this is a problem we’re going to have to address on the front end.” Wherry and Williams try to keep a balanced work-home life. Both enjoy traveling and pursuing outdoor activities with their families. Dr. Wherry and her husband, Scott, have a 4-year-old son, Luke. Dr. Williams and wife Lana have a one-year-old daughter, Bobbie Brook. His 17-year-old son, Cooper, is making career plans. “He adamantly has refused any interest in medicine whatsoever,” his dad said with a laugh. “He’s very interested in aviation. He might become a pilot.”

A 529 plan is an investment plan ran by a state, designed to help families save for future college costs. If the plan satisfies a few basic requirements, the federal tax law provides special tax benefits to the plan participant. There also may be state tax deduction benefits depending on your state’s plan. If you choose to invest in a 529 plan, you are not restricted to just the plan offered by your own state. However, there may be state tax implications for selecting another state’s plan. One of the key advantages of a 529 plan is the income tax breaks on the non-deductible contributions. Any earnings grow tax-deferred for as long as the money stays in the plan. And when the plan makes a distribution to pay for the beneficiary’s college costs, the distribution is federal tax-free as well. Another major advantage is that the account holder stays in control of the assets in a 529 account. The named beneficiary has no rights to the funds. In fact, the account holder has the flexibility to change beneficiaries at any time, but only once per year. The account holder decides when withdrawals are taken and for what purpose. Most plans even allow account holders to reclaim the funds for themselves any time they desire. However, earnings will be subject to income tax and an additional 10% penalty on non-qualified withdrawals. In addition to these benefits, 529 plans are one of many ways to save for college. Once you decide on a plan, the assets are professionally managed either by the state treasurer’s office or by an outside investment company. And everyone is eligible to take advantage of these plans—there are generally no income limitations or age restrictions. You may be tempted to give your children or grandchildren trendy toys or electronic devices as gifts but creating or contributing to a 529 plan for them might be a smarter, more-impactful, and longer-lasting present. Instead of buying them something that breaks or goes out of date in a couple of years, you’re investing in their future in a meaningful way that could change the course of their lives. In addition, you don’t need to worry about the potential supply chain issues we face during the holiday season!

529 Tidbits A few tidbits about this powerful savings/investing tool: • While 529 plan assets can be used to pay for tuition and books, they can also pay for computers, internet access and other equipment. • 529 plans are not just for college. They can be used to pay up to $10,000 per year per student for K through 12th grade programs. • 529 assets can also be used to pay for registered apprenticeship programs and repayment of college debt. • There are also other benefits. For example, 529 contributors may qualify for a state income-tax deduction or credit. We would love to talk to you about the benefits and options of 529 plans, and work with you to develop the best plan for your children, grandchildren, or other loved ones. Chirag Chauhan, MBA, AIF®, CFP® is a managing partner of Bluff City Advisory Group in Memphis, Tennessee. For more info, please visit bluffcityadvisory.com.

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The Murky Waters of Long COVID, continued from page 1 Defining Long COVID

An estimated 30 percent of COVID19 patients have Long COVID symptoms, with middle-aged white females representing the lion’s share. But what exactly are those symptoms? Long COVID has been used as an umbrella term to include both physical and mental health consequences, ranging from prolonged illness to hospitalization. Yet controversy has swirled concerning the laundry list of debilitating ongoing symptoms, such as muscle pain, unrelenting fatigue, breathlessness, anxiety, depression and “brain fog.” For example, fatigue and “brain fog” are comprised of more than 200 symptoms. “Brain fog” has recently been added to the Collins Dictionary as a “usually temporary inability to concentrate and think clearly,” but the term also covers neuropsychiatric problems including migraines, high anxiety, fatigue, insomnia and even autism. Other common issues include heart palpitations, loss or smell or taste, and joint pain. “COVID took my hair and after two years, it’s still not back to normal,” said Tami Lairamore of Littleton, Co., 51, who contracted COVID-19 in November 2020 and again in July 2021 and has been sporting hairpieces. “Now I need a hip replacement, which I’m not sure is related to the inflammation issues I’ve had since COVID round two. I didn’t have a problem before. I keep wondering when these symptoms will disappear or at least become more manageable.” The CDC has limited its symptom list of Long COVID to 13 primary indications that Pennsylvania attorney Michael Fumento called “worthless in distinguishing Long COVID from other illnesses.” NIAID (National Institute of Allergy and Infectious Diseases) Director Anthony Fauci declared at a December 2020 symposium that Long COVID is

President Biden Rallies Surge in Long COVID Research On April 5, President Biden continued a national research push on Long COVID, instructing federal agencies to support patients dealing with the enigmatic condition. The White House also acknowledged Long COVID as a disability. “The emphasis on treatment for Long COVID and recognizing that this could be a source of ongoing disability are long overdue,” said Lena Wen, MD, a former Baltimore health commissioner. The Department of Health and Human Services has been tasked with building on the $1.15 billion RECOVER (Researching COVID to Enhance Recovery) Initiative, already ongoing at the National Institutes of Health. The study calls for 40,000 participants with and without Long COVID symptoms. In particular, Biden targeted federal agencies to support patients and physicians by providing science-based best practices for treating Long COVID, preserving access to insurance coverage, and protecting the rights of workers dealing with Long COVID, particularly concerning mental health.

“quite real and quite expensive.” He later called Long COVID symptoms “highly suggestive” of myalgic encephalomyelitis and chronic fatigue syndrome (ME/CFS).

Adding to the Confusion

Long COVID symptoms sometimes mimic autoimmune diseases, which are more prevalent in women ages 40-60. For instance, conditions such as rheumatoid arthritis, Hashimoto’s (thyroid) disease and lupus are two to three times more common in middle-aged women than men. “It’s possible, that for such women, the body’s immune system turns on to fight COVID, but then can’t turn back off and so remains on the attack, creating other problems in different organs and parts of the body, similar to an autoimmune response,” said Sharon Stills, NMD, a naturopathic medical doctor specializing in menopausal women. Another possible connection with autoimmune issues “means that lurking behind the scenes in all this could be inflammation,” said Stills.

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Limited Research So Far

With the pandemic occurring barely more than two years ago, it’s little wonder research is lacking. In two British studies last year, there’s debate whether Long COVID sufferers actually had COVID. The largest study as of September 2021 was published last July by researchers at University College London, which acknowledged that 27 percent of Long COVID sufferers had evidence of exposure to the SARS-COV-2 virus, whether antigen or antibody. A smaller British study, conducted in August, determined only 17.2 percent were test-confirmed positive. The greatest complaint: sufferers felt terrible, with symptoms mimicking COVID. Former NIH Director Francis Collins recognized Long COVID by having his agency assign the name “Post-acute Sequelae of COVID-19 (PASC).” Soon after, Congress approved $1.15 billion in funding over four years to support research on PASC. Parenthetically, the average NIH grant is $500,000, with an application success rate of roughly 20 percent.

The Depressive Component

“You’ll get no (NIH) funds hypothesizing that Long COVID is essentially depression and that therefore, it needs to be treated like depression,” wrote Fumento. “Instead, you’ll propound on how it’s a mystery disease with as yet no successful therapies.” The New England Journal of Medicine perhaps got ahead of the controversy by saying “some commentators have characterized it as a mental illness,” and this “augurs poorly for many people with Long COVID.” Regardless, Ferrer’s demise took away the “just snap out of it!” formula that some misinformed practitioners have used with depressives. The federal government estimates that nearly twothirds of Americans who commit suicide were primarily depressed. Now, depression among Long COVID patients who suffer from persistent fatigue, mental and physical slowing down, and difficulty concentrating is a pathology that has been described “as real as cancer and heart disease.”

Vanderbilt Team Helps Long COVID Sufferers Battle Cognitive Issues The Adult Post-Acute COVID Clinic at Vanderbilt University Medical Center (VUMC) recently unveiled new studies determining the cause of symptoms and the value of treatments such as physical therapy and cognitive training for Long COVID patients. VUMC is also seeking answers outside mainstream medicine. For example, the Nashville-based center is participating in a study to determine whether a video game development for children with attention deficit disorder by Bostonbased Akili Interactive may also improve cognitive functioning in post-acute COVID patients. In March, nearly 30 new patients entered the video game study from support groups, “with some patients literally crying when they learn that they’re eligible to participate,” said James Jackson, PsyD, research professor of medicine and James Jackson lead psychologist for the Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center at VUMC. “We’re clear about it not being a panacea,” he said. “We don’t know if it works. That’s why we’re studying it. But the emotionality the patients have shown has been a reminder for us of how debilitated they really are.” Concurrently, several colleagues from the CIBS Center are leading online peer support groups for Long COVID sufferers and their families. “Increasingly, we’re getting referrals from physicians around the country who know about the work we’re doing and send their patients to us,” said Jackson. A CIBS Center patient, Jane Storie of Hermitage, Tenn., 38, contracted COVID-19 in October 2020 and continues to be plagued by debilitating symptoms. “It’s a sobering reality,” said Storie. “As a society, we expect doctors to know everything, but realize that nobody knows much, and everybody’s doing the best they can to figure it out.”

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ANA Reveals Top Federal Legislative Priorities Health System Transformation Eclipses Other Issues The American Nurses Association (ANA) recently unveiled its leading federal legislative priorities for Congress covering safe staffing, nursing workforce development, home health, opioid epidemic, workplace violence, and COVID-19.

Health System Transformation

Renovating America’s health system tops the list and calls for following four major principles: safeguarding universal access to a standard package of essential healthcare services for all U.S. residents; optimizing primary, community-based and preventive care, while also supporting the cost-effective use of innovative, technologydriven, acute, hospital-based services; boosting mechanisms to stimulate the costeffective use of healthcare services while also minimizing burdens on those without the means to cost-share; and delivering a sufficient supply of a skilled workforce dedicated to providing high quality healthcare services. “Universal access includes an essential benefits package to provide access to comprehensive services, prohibition of the denial of coverage due to pre-existing conditions, inclusion of children on parents’ health coverage until the age of 26, and expansion of Medicaid as a safety net for economically disadvantaged people,” said Willa Fuller, BSN, RN, executive director of the Florida Willa Fuller Nurses Association, and a national ANA spokesperson. Optimizing care calls for a primary healthcare focused on developing an engaged partnership with patients, and includes preventive, curative, and rehabilitative services delivered in coordinated manner. It also means removing barriers and restrictions that hinder RNs and APRNs from fully contributing to community patient care; and care coordination that lowers costs and improves outcomes via consistent and sustaining payment models. “Encouraging mechanisms to stimulate the cost-effective use of healthcare services starts with a partnership between the government and private sector to address healthcare affordability,” explained Fuller. “Payment systems must reward quality and the appropriate, effective use of resources. Also, beneficiaries paying a portion of their healthcare should be provided an incentive for the efficient use of services while being assured that deductibles and co-payments do not negatively impact care.” Elimination of lifetime caps or annul limits on coverage should be part of the plan, and federal subsidies based on an income-based sliding scale should assure insurance coverage.

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Safe Staffing

A sufficient supply of skilled workers dedicated to providing high quality healthcare services should include an adequate number of highly trained RNs, and increased funding via grants or loan repayments for programs and services intent on increasing the primary care workforce. This funding should elevate support for expanding nursing faculty and workforce diversity. “The ANA continues to lobby for safe staffing ratios critical to achieving the correct staffing levels,” said Fuller, noting that Congressmen Peter Welch (D-Vermont) and Morgan Griffith (R-Virginia) recently coauthored a letter to the White House COVID-19 Task Force calling for an investigation into staffing agencies’ price gouging during the pandemic. Collaborative efforts have resulted in state-level safe staffing laws in seven states: Oregon, Texas, Illinois, Connecticut, Ohio, Washington and Nevada.

Nursing Workforce Development

Because nurses continue to represent the largest group of healthcare providers whose services are linked to quality and cost-effectiveness, fully trained nurses are critical. “Increased demand for RNs in the coming years will be driven in part by an aging population,” said Fuller. According to the Pew Research Center, an estimated 10,000 people are turning 65 on a daily basis, a trend that will continue until 2030. “As such, the healthcare workforce will need to grow to keep up with demand for nursing care in traditional acute care settings and the expansion of non-hospital settings such as home and long-term care,” said Fuller. In 2020, Congress signed into

law the Title VIII Nursing Workforce Reauthorization Act that was included in the CARES Act. It reauthorizes nursing workforce development programs through fiscal year 2024. “Not only is it the largest source of federal funding for nursing education, but the programs are invaluable to institutions that educate RNs to practice, particularly in rural and underserved communities,” said Fuller, noting the ANA will continue to lobby Congress and the Administration to appropriate more annual funds to the Title VIII programs. Major grant programs within Title VIII cover advanced education nursing; workforce diversity grants; grants for nurse education, practice, and retention; national nurse service corps’ Nurse Education Loan Repayment Program; nurse faculty loan programs; and comprehensive geriatric education grants.

permanent authority to prescribe Medication Assisted Treatment (MAT), which also grants clinical nurse specialists, certified RN anesthetists, and registered nurse-midwives this authorization through 2023. Last year, the Mainstreaming Addiction Treatment Act of 2021 aimed to eliminate the separate registration requirement for dispensing certain narcotic drugs for maintenance or detoxification treatment. “Current law requires prescribers to apply for a waiver to prescribe buprenorphine to treat addiction after completing a multi-hour educational course,” said Fuller.

Workplace Violence

The ANA promotes the authorization of APRNs to provide appropriate, timely care for their home health patients, instead of allowing patients needing the service to languish while waiting for physician approval, particularly in rural and underserved areas. For now, the CARES Act allows NPs and CNs to order home health services for Medicare beneficiaries without physician approval.

Because one in four nurses has been abused in the workplace, the ANA has led the charge to end nurse abuse at the federal and state levels. Last February, the House of Representatives introduced the Workplace Violence Prevention for Health Care and Social Service Workers Act (HR 1195) to require Occupational Safety and Health Administration (OSHA) to develop enforceable standards to protect employees. This legislation passed the House last April 16 with wide bipartisan support on a 254-166 vote. The ANA is working with bill sponsors to facilitate its passage and be signed into law by President Biden this Congress.

Opioid Epidemic

COVID-19

Home Health

Because nurses remain at the forefront of the national health crisis, the opioid epidemic must be addressed with a comprehensive approach from communitybased programs to government action at every level, said Fuller. During the past two Congresses, dozens of bills have addressed this issue. In 2018, the SUPPORT for patients and the Communities Act gave NPs and PAs

“As response to the pandemic evolves, so too has the nature of ANA’s work— addressing priority issues from availability of Personal Protective Equipment (PPE) and decontamination to vaccine rollout and distribution guidance,” said Fuller, adding that ANA also promotes improved public health infrastructure funding, mental health and hazard pay, and controversial vaccination requirements.

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To Measure and Reduce Diagnostic Error, Start with the Data You Have By DAVID L. FELDMAN, MD

As a patient safety problem, diagnostic error differs from wrong-site surgery or medication errors. While we have not yet eliminated these errors, we know that systems-safety interventions like checklists and time-outs make an impact. But in considering diagnostic errors—when we are often trying to get inside someone’s head to determine why they did or didn’t think a certain thing—it is a totally different proposition. Moreover, at times, we lack clear distinctions between true diagnostic error and the natural progression of a disease. We know that diagnostic errors occur across specialties and patient populations, but surprisingly, we see that common conditions are often missed. Progress has been made over the past decade, as shown by Hardeep Singh, MD, MPH, during his recent presentation for the Healthcare Risk Advisors (HRA) Virtual Conference Series. Dr. Singh, an expert in diagnostic safety for the VA Medical Center in Houston and a Professor of Medicine for Baylor College, says that healthcare is striding through the 2020s with its best tools yet to continue improving. To improve diagnostic safety, he recommends focusing not just on individual performance, but also on the performance of the system where clinicians practice. For example, an organization must first measure its current rate of diagnostic error—which is easier said than done.

Use Accessible Data to Measure Diagnostic Error

For those planning to improve diagnostic safety in their own institutions, Dr. Singh suggests four potential sources of data: Use the data that are already available. Adverse event reports, medical malpractice data, and patient complaints present learning opportunities. Solicit reports from clinicians about diagnostic errors and near misses. Most reports come from nurses, pharmacists, and other allied health professionals. Many clinicians are reluctant to report. Find a way to invite their information that makes sense for your organization.

Learn from patients. At many institutions, patient complaints are being gathered but not being harvested for signals for improvement. Meanwhile, researchers hear patients say things like, “I kept telling them about this specific concern, but they didn’t listen to me.” Whether it is a case of misaligned expectations or actual diagnostic error, every patient complaint is an opportunity to learn. Open notes could also be leveraged for improvement opportunities. Make your EHR work for you. Your EHR can help you identify patients with diagnostic concerns by flagging records selectively with e-triggers. For instance, you might view only records that fit a certain clinical profile versus all records. Two examples include: (a) a low-risk patient who is transferred to ICU or initiates a rapid response team within 15 days of admission, or (b) a patient who visits primary care, followed by an unplanned hospital admission within 14 days. These scenarios invite us to ask if there was a missed red flag.

Address Ambiguous Responsibility with Clear Policies

In healthcare, and especially in any fragmented healthcare systems, the responsibility of who is doing what may not always be clear. Here is an example of ambiguous responsibility that Dr. Singh discussed: A primary care physician refers a patient to a pulmonologist. The pulmonologist orders a test that returns an abnormal finding. An EHR will alert both clinicians of that result, so who is responsible for follow-up? What Dr. Singh’s team found is that each might think it’s the other. To address ambiguous responsibility, all organizations should create, formalize, and promote a crystal-clear policy regarding who is responsible for follow-up of abnormal test results and in what time frame.

Close the Calibration Gap with Feedback

Calibration is the alignment between diagnostic accuracy and a physician’s confidence in that accuracy. For a vignette

We have more tools than ever before to help us improve diagnostic safety. To begin implementing them, start with any of the valuable, open-source resources below. • Agency for Healthcare Research and Quality (AHRQ): Operational Measurement of Diagnostic Safety: State of the Science • Institute for Healthcare Improvement (IHI): Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era • World Health Organization (WHO): Diagnostic Errors: Technical Series on Safer Primary Care • WHO: Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care

study,1 physicians were presented with sample cases, both relatively easy and hard to diagnose. Physicians were asked for their differential diagnoses and their confidence in their differential diagnoses. Before they rendered their final diagnosis for each case, physicians were asked if they had resource requests, such as wishing to consult a colleague, desk reference, or web-based tool. Dr. Singh and fellow researchers had hypothesized that when cases were more difficult, clinicians would seek more assistance, because they would be very uncertain—but that turned out not to be the case. For the easier-to-diagnose cases, physicians were right about 56 percent of the time, and fairly confident. But accuracy for the difficult cases was below 6 percent—with confidence almost unchanged. That’s the calibration gap—and it can be closed with feedback. Finding ways to close it will be crucial to our long-term efforts to improve diagnosis. At HRA, among other things, we are working with our emergency department (ED) collaborative on missed strokes. From a small review of 43 HRA cardiovascular diagnostic cases, we saw that 20 of those patients returned to an ED after their first presentation. Of those, 10 presented at a different ED, so the clinicians they first saw probably did not know those outcomes. Physicians, like all other professionals, need accurate and timely feedback to gauge performance. When patients simply go elsewhere, we lose valuable information.

Make a System-Wide Effort

Dr. Singh’s findings align with our claims experience at HRA and The Doctors

Company. Roughly 20 percent of claims involve diagnostic error, and what we learn from such claims has implications for patient safety in all areas of ambulatory, inpatient, and ED care. Examining our medical malpractice claims through the lens of the diagnostic process of care framework created by CRICO, the risk management arm of the Harvard medical institutions, we see that care most often diverges from an optimal outcome early on, with an incomplete history or with a cognitive bias like anchoring or premature closure. To address these ongoing concerns, which affect clinicians and patients across the spectrum of care, we are engaging in a variety of efforts—from a new project looking at primary care, to partnering with national societies to improve diagnosis and prevent errors. In envisioning healthcare’s next decade, Dr. Singh sees many promising developments in diagnostic safety, but says we still have miles to go. As we implement new tools and best practices to foster learning and improvement, it’s time to make diagnostic safety not just an individual priority, but also an organizational priority. David L. Feldman, MD, MBA, FACS, is Chief Medical Officer of The Doctors Company and TDC Group; Senior Vice President, Healthcare Risk Advisors.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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GrandRounds Tennessee Hospital Association Appoints Saint Francis Healthcare CEO to its Board of Directors Tennessee Hospital Association recently named Chris Cosby, Market CEO of Saint Francis Healthcare and CEO of Saint Francis HospitalMemphis, to its board of directors. In this role with the THA, Cosby and other Chris Cosby board members will discuss issues and policies that affect Tennessee hospitals, including deciding THA’s positions on major issues, setting THA’s goals each year and providing direction on advocacy, quality initiatives and other THA activities. Cosby assumed his role with Saint Francis in Nov. 2021. Before coming to Saint Francis, he served as the CEO of Poinciana Medical Center in Orlando, Florida for five years. Cosby holds a Master of Science in Healthcare Administration and an MBA from the University of Alabama at Birmingham as well as a Bachelor of Science in Health Administration from Auburn University.

ReCharging the Midsouth Medical Group Management Association The Board of Directors for MSMGMA is committed to recharging our local chapter with more high-quality speakers, more networking opportunities, and evolving to meet the needs of today’s practice management leader. In order to do that, we need membership! We hope you will join at https:// www.tmgma.com/MidSouth-MGMA as an individual or call Cara Azhar at (901) 496-3227 to discuss your entire group joining. Our goals are simple: 1. Continue to advocate for patients and the medical practice 2. Create a stronger social and professional bond for the medical community in partnership with Memphis Medical Society and other organizations 3. Educate our members to improve their practice and support their pursuit of CMPE/ACMPE certification You can learn more at our website: https://www.midsouthmgma.org/ Several meetings set for the year already are: • May 19: Kim Jenkins, OrthoSouth (Innovations in Healthcare series) • June 16: Dr. Scott Morris, Church Health (Innovations in Healthcare series) • September TBD: Member Social at Wiseacre • November 17: Advocacy Panel with local healthcare experts …and more to be confirmed. We hope to see you on our rolls and at a member luncheon soon.

AMA Asks Congress to Fix Medicare Physician Payment System and Reject Arbitrary Payment Freeze that Jeopardizes Patient Access The American Medical Association (AMA) warned congressional leaders that the Medicare Payment Advisory Commission (MedPAC) report sent to Congress contains flawed analyses that would imperil patient access to highquality care. The MedPAC report recommended a continuation of the freeze in Medicare physician fee payments but ignores a host of trailing indicators, none more obvious than the impact of the COVID-19 pandemic on physician practices. In 2020, there was a $13.9 billion decrease in Medicare physician fee schedule spending as patients delayed treatments. Burnout, stress, workload, and fear of COVID Infection are leading one in five physicians to consider leaving their current practice within two years. The letter to Congress includes a chart -- based on an analysis of data from the Medicare Trustees – that shows Medicare physician payment has been reduced 20 percent, adjusted for inflation, from 2001–2021. That analysis does not include the recent inflationary spike. Also, the Medicare physician payment system lacks an adequate annual physician payment update similar to other Medicare providers In its letter, the AMA emphasized the urgency for Congress to “work with the physician community to develop solutions to the systematic problems with the Medicare physician payment system and preserve patient access to care. At a minimum, Congress must establish a stable, annual Medicare physician payment update that keeps pace with inflation and practice costs and allows for innovation to ensure Medicare patients continue to have access to physician practice-based care.”

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GrandRounds John Schorge, MD, Joins UTHSC College of Medicine as Chair of OB/GYN John Schorge, MD, joined the College of Medicine at the University of Tennessee Health Science Center as the chair of obstetrics and gynecology (OB/GYN). Coming from Tufts Medical Center in Boston, he brings nearly three decades of experience. John Schorge As OB/GYN chair and as a gynecologic oncologist, Dr. Schorge will be working with Regional One Health (ROH) to help with the development of its cancer program. Dr. Schorge will also oversee the obstetrics side of the department, a unit caring for some of the most-complex pregnancy cases in the region. Dr. Schorge received his Bachelor of Science degree from the University of Michigan in 1989 and his MD from Vanderbilt University School of Medicine in 1993. He completed his internship, residency, and fellowship at Brigham and Women’s Hospital/Harvard Medical School in Boston. He served as assistant professor at UT Southwestern Medical School in Dallas, associate professor at Massachusetts General Hospital/ Harvard Medical School, and professor at Tufts University School of Medicine. His most recent leadership positions

include division chief of Gynecologic Oncology in the Department of Obstetrics and Gynecology at Tufts Medical Center and associate director for Cancer Operations at Tufts Cancer Center. Dr. Schorge is the recipient of many awards and honors, including Best Doctors in Dallas, D Magazine (20062008); Top Doctors, Boston Magazine (2010-2021); and Top Doctors, U.S. News and World Report (2011-2019). Having received more than $1.7 million in research funding, he has published nearly 130 peer-reviewed papers, 30 book chapters, numerous editorials, case reports, abstracts, and authored/edited nine books.

National Pediatric Cancer Foundation Issues Call for Research Proposals National Pediatric Cancer Foundation (NPCF) announced today it is seeking research proposals as part of its 43 Challenge program, a national awareness and funding initiative aimed at making radical progress in pediatric cancer research. In recognition of the 43 children diagnosed with cancer each day, NPCF is offering the $4.3 million research grant program – set to open on April 3 (4/3) – to medical, science, technology and corporate innovators and thought leaders with novel ideas to make progress in the fight against cancer

among children. The best ideas will be selected and funded, ranging from $1 million to $4.3 million grants, in the name of improving the lives of children diagnosed with cancer. NPCF is advocating for new solutions that promote significant advances in addressing pediatric cancer and therapies. The goal of the grant research program is to explore the possibility that an innovative proposal could possibly be found within another aspect of the medical, science or technology fields. Casting a wider net for this research opportunity offers a chance to explore fields which may have been previously overlooked with regard to cancer research. NPCF’s main mission is funding research to eliminate childhood cancer, and the grant program is just one way it works to accomplish this. The organization desires science that is novel, can significantly improve the lives of children with cancer and/or makes radical progress against pediatric cancers within the next few years. Applications may come from one or more of the following fields and be submitted by individuals, multidisciplinary teams, research institutions, healthcare providers or corporate partnerships: · Oncology · Biochemistry · Biology / Ecology

· Medical Physics · Bio-Medical Engineering · Artificial Intelligence · Therapeutics · Genomics · Molecular Biology Interested applicants may submit an LOI/ ABSTRACT from April 3-May 31, 2022. This abstract will be used to check eligibility and to initially interpret proposals to determine which projects will be asked to submit a full proposal. To submit an LOI/ ABSTRACT and for more details, visit nationalpcf.org/43challenge. The projects selected will then be invited to submit a single-page application and be interviewed by the NPCF / Selection Committee. Grant winner(s) will be announced Sept. 1, 2022.

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Grand Opening of New CareMax Memphis Locations with Community Partners CareMax, Inc., a leading provider of value-based care to seniors, announced the opening of two new CareMax-affiliated facilities in Memphis. These two are the first CareMax locations to open in Tennessee as a part of the company’s strategy to expand its footprint and enter new markets nationwide. The new facilities will be located at 3175 Lenox Park Dr, Ste 100, Memphis, TN and 1407 Union Ave, Suite 305, Memphis, TN, with medical care provided by CareMax-affiliated provider Medical Care of Tennessee, PLLC. Since 2011, CareMax has employed a “Whole Person Health” approach that takes into consideration all facets of a patient’s health, by providing comprehensive, community-based care in one convenient location. From in-house specialists to wellness activities to transportation and social services, this care is designed to treat the entirety of the patient, not just their individual medical conditions. When operating at full capacity, both the Lenox and Union locations will provide primary, specialty and virtual care, transportation to and from appointments, optometry, acupuncture/massage therapy, social services, healthy meals, and wellness activities. CareMax is partnering with several local organizations to address the need for senior-focused value-based care in urban settings. Our goal is to help support existing efforts by community leaders and organizations while introducing our model of care that we have found to be successful in other markets. CareMax is a member of The Professional Network on Aging and is working with the Tennessee Aging Commission to expand its reach in serving seniors by networking with others who serve todays and tomorrow’s seniors. Lastly, CareMax is developing close relationships with faith-based organizations, inclusive of several Tennessee Jurisdictions within the Church of God In Christ, Inc. The CareMax model has proven to be highly successful in Florida, where it currently operates 48 centers serving 83,000 patients. When compared with fee-for-service (FFS) models, per 1,000 patients, CareMax has seen a 52 percent improvement in hospital admissions and a 66 percent improvement in emergency room visits. In addition, the team of physicians affiliated with CareMax will have a patient roster of just 600, compared to the normal primary care provider roster of more than 1,500 patients. This will allow physicians to spend much more time with their patients. Moreover, the CareMax model inherently makes CareMax centers part of the communities they serve. Initiatives are designed to provide additional resources to patients, families and communities, such as outdoor food drives and celebrations, work alongside larger, company-wide pursuits. Team members are mostly hired from the local community, as studies have shown that culturally sensitive, hyper-localized care produces better health outcomes.

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GrandRounds Methodist Le Bonheur Healthcare Names Sarah Colley SVP/Chief Human Resources Officer Colley returns to Memphis after four years in Pensacola, Fla., where she was vice president and chief human resources officer of Baptist Health Care. She previously served as senior vice president of Human Resources of Regional One Health in Sarah Colley Memphis. Before Regional One, Colley held leadership roles with St. Vincent Health System and Southwest Regional Medical Center in Little Rock, Arkansas. Colley holds a bachelor’s degree in political science and sociology from Guilford College in Greensboro, N.C.; a master’s degree in healthcare administration from Webster University and a law degree from University of Arkansas School of Law. She is a Leadership Memphis graduate and was recognized as Memphis Business Journal’s Top 40 Under 40. Colley was named HR Executive of the Year by the Memphis chapter of SHRM, the Society for Human Resource Management. She is past president and board member of the Arkansas Hospital Association Human Resource Association.

UTHSC Team Receives $2 Million For Breast Cancer Genetics Research A University of Tennessee Health Science Center team has received $2.05 million from the National Cancer Institute for an advanced genetics project that could contribute to targeted therapies and personalized treatment for breast cancer. Liza Makowski, PhD, professor Liza Makowski of Hematology and Oncology in the UTHSC College of Medicine, is the lead investigator on the award. Developing new therapies for breast cancer depends on a deeper understanding of individual genetics. Preclinical research is often hampered by the lack of genetic diversity in most animal models, which does not represent the wide variation in humans. Dr. Makowski’s team has created a pre-clinical model using one of the largest and best genetic reference populations, the BXD family of mice. The team crossed the BXD with a model that develops triple negative breast cancer, creating unique hybrids with robust, reliable, and reproducible phenotypic and genomic variation. The genetic variation will be analyzed to determine which regions of DNA contribute to certain characteristics of the

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breast cancer. Dr. Makowski’s preliminary data show large differences in triple-negative-breastcancer characteristics, including early onset tumors, which suggests genetic modifiers impact disease. The team will also test therapies to pinpoint underlying genetics, which will help identify genetic strains that respond well to therapy. The goal is to identify and validate underlying genetic modifiers of breast cancer, enabling advances to improve predictive and personalized treatments. Dr. Makowski’s interdisciplinary team has extensive expertise in chemo- and immune therapy in pre-clinical breast cancer models, immunology, pathology, systems genetics, and advanced computational methods. From UTHSC’s department of Genetics, Genomics and Informatics are Rob Williams, PhD, department chair and professor, Lu Lu, MD, professor, and David Ashbrook, PhD, assistant professor. Neil Hayes, MD, MPH, director of the UTHSC Center for Cancer Research, is also on the team.

Children’s Foundation of Memphis Awards $500,000 to Le Bonheur Children’s for Study The Children’s Foundation of Memphis (CFOM) has awarded a $500,000 grant to Le Bonheur Children’s Hospital to study the role that exercise

has in preventing the development and progression of prediabetes to type 2 diabetes. The study will be led by Webb Smith, PhD, clinical exercise physiologist in the Healthy Lifestyle Clinic at Le Bonheur and assistant professor in the Department of Pediatrics at the University of Tennessee Health Science Center (UTHSC), Ahlee Kim, MD, assistant professor in the Division of Pediatric Endocrinology at UTHSC and Amit Lahoti, MBBS, MD, pediatric endocrinologist at Le Bonheur and associate professor in the Department of Pediatrics, Division of Pediatric Endocrinology at UTHSC. This grant from CFOM will help address this issue as study leaders will screen children in Le Bonheur’s general pediatric clinics for physical inactivity. They will develop and test the effectiveness of preventative interventions for prediabetes that combine health and wellness programs with traditional medical treatment. This grant will provide direct support to incorporate physical activity screening into medical screening for 400 children and identify patients who are at risk of developing type 2 diabetes. One hundred at-risk patients will be recruited to the research project using an innovative personalized “exercise prescription” as a key part of the medical treatment plans.

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