Our laboratory's current transformative research efforts focus on studying immune health in the context of surgery and anesthesia. Our interest stems from previous work elucidating the modulation of inflammatory responses by anesthetic and analgesic drugs.
The aim of studying immunity in patients undergoing surgery is to identify immune phenotypes predictive of aversive postoperative outcomes including protracted recovery and infection. Our major working hypotheses are that 1) specific immune phenotypes will predict the risk for developing postoperative complications, 2) immune phenotyping will lead to the discovery of mechanisms aggravating or alleviating such risk, and 3) gained knowledge will allow devising immune-modulatory strategies mitigating such risk. Mass cytometry (CyTOF), proteomics, and functional ex-vivo immune assays are the major molecular tools for the systems-based numerical and functional exploration of the circulating immune system.
The SPADE tree depicts the immune architecture in blood of a patient undergoing hip surgery. SPADE is an unsupervised clustering algorithm that distills multidimensional single cell data (mass cytometry; CyTOF) down to interconnected clusters on the basis of cell surface markers. The approach conveys the relationship between cell clusters as each node of cells is connected to its phenotypically most similar node and enables identification of known as well as unexpected cell types. A) White frames depict specific immune cell compartments. The tree is colored for expression of the cell surface marker CD4. The color scale indicates the median intensity of the CD4+ T cell signal for each cell node. The size of a node indicates relative cell frequency. B) The tree is colored to reflect signal intensity (phosphorylation) of the transcription factor STAT3 for each cell node before and 1h, 24h, 72h, and 4 wks after surgery. Activation of STAT 3 was highly structured as it followed a specific temporal pattern in distinct cell subsets. Figure courtesy of Dr. Brice Gaudilliere.
As the Director of Psychology Services for the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University Medical Center, I treat the psychological problems of children with complex pain problems. I also conduct clinical research to improve patient care in this area. For example, my team is using the newly developed Health Registry database called Peds-CHOIR (Pediatric Collaborative Health Outcomes Information Registry). Peds-CHOIR is a novel, open-source outcome-tracking learning health system (LHS) that allows us to collect the data we need to make decisions about the best treatments for children who experience chronic pain. Until now, a way to collect and analyze this data has been lacking. Specific clinical research goals under study are: understand variables to help optimize patient and clinician resources, learn how a LHS helps actively engage patient and caregivers in treatment, track longitudinal outcomes, understand the predictors of persistent pain into adulthood, and describe the phenotype of patients that tend to be responders versus non responders to treatment so that early interventions can improve treatment efficacy.
I am also the director of the Pediatric Pain Psychology Fellowship Program and, in collaboration with others around the country, am developing the educational curriculum for pediatric pain psychology fellowship training. Recently published commentary in the Pediatric Pain Letter details efforts to formalize the training process.
I am currently interested in hematological and hemostatic changes in pregnancy which are relevant to obstetric anesthetic practice.There are important hematological changes that occur in the peripartum period,and I am interested in the mechanisms by which anesthetic interventions affect these hematological changes with concomitant effects on maternal outcomes. We are also investigating the use of point-of-care systems (such as thromboelastography) to assess coagulation and hemostatic changes in the peri and postpartum period. Previous research has included: the assessment of hypothermia and shivering in patients undergoing Cesarean delivery; the effect of fluid preloading on coagulation; assessments of anesthetic interventions for patients undergoing vaginal twin delivery.
Dr. Chu’s research focuses on 3 main areas: mechanisms of physiologic adaptations to chronic opioid exposure, innovation in medical education, and a recent new focus on patient-centered innovation in clinical research and quality improvement.
Mechanisms of physiologic adaptations to chronic opioid exposure
Opioids are the cornerstone medication for the treatment of moderate to severe pain. Analgesic tolerance, physical dependence and opioid-induced hyperalgesia are known sequelae of chronic opioid exposure that may complicate the use of opioid analgesic drugs for the treatment of chronic painful conditions.
Dr. Chu’s work in this area spans nearly 10 years and has resulted in numerous publications that have examined changes in pain sensitivity and the central nervous system in humans associated with chronic opioid exposure. Dr. Chu’s work has been supported by RO1 and KO2 research grants from the National Institutes of Health. His most recent publication in this field is:
Lin JC, Chu LF, Stringer EA, Baker KS, Sayyid ZN, Sun J, Campbell KA, Younger JW. One month of oral morphine decreases gray matter volume in the right amygdala of individuals with low back pain: confirmation of previously reported Magnetic Resonance Imaging results. Pain Medicine, 2015 Dec 26; 0: 1-8.
Dr. Chu was the senior author of this paper, in which decreased gray matter volume was observed in several reward- and pain-related regions in the morphine group, including the bilateral amygdala, left inferior orbitofrontal cortex, and bilateral pre-supplementary motor areas.
Innovation in Medical Education
As founder and Director of the Stanford Anesthesia Informatics and Media lab, Dr. Chu has an international reputation as a leader in medical education innovation. He has conducted seminal work in understanding the unique learning needs of millennial postgraduate anesthesiology learners and used this knowledge to create blended and online learning for anesthesiology residents. Dr. Chu’s educational programs (START, STARTprep, and Learnly) are used by 40% of all anesthesiology residents in the United States and many more around the globe.
Dr. Chu also conducted seminal design work in co-creating the Stanford Emergency Manual, which is a book of emergency aid checklists used by anesthesiologists worldwide. Dr. Chu developed a productive collaboration with Stanford computer scientists to scientifically study the role of design in effective use and implementation of dynamic computer-generated emergency aids. Dr. Chu also founded and directs the world’s most-discussed academic conference on the future of medical education: Medicine X | ED. Dr. Chu’s scholarship in medical education has been published in leading medical journals. One of his many publications in this field is:
Lighthall G, Harrison TK, Chu LF. Laryngeal Mask Airway in Medical Emergencies. New England Journal of Medicine. 2013; 369 (20)
Dr. Chu was the senior author of this paper, which demonstrates the use of mask airways for the ventilation of patients in cardiac arrest using both video and text.
Patient-centered Research in Clinical Research and Quality Improvement
In 2011, Dr. Chu founded Stanford Medicine X, the world’s most-discussed academic medical conference. This conference, now a year-round academic program at Stanford, focuses on innovation in medicine at the intersection of emerging technologies and patient-centered care.
Dr. Chu has an international reputation as a health care innovator and is frequently invited to give talks on the role of emerging technology, precision medicine, and patient-centered care at medical conferences worldwide. The Stanford Medicine X conference reaches over 5,500,000 individuals in 60 countries around the world. This global community closely follows the innovative work and Everyone Included™ co-creation and leadership models for working with patients that Dr. Chu has established through his groundbreaking work at Medicine X. Dr. Chu received an R13 grant from the Agency for Healthcare Research Quality to establish Medicine X at Stanford. Under his leadership, the program has developed scholarship in engaging and bringing patients into academic medicine to help improve clinical research and quality. In recognition of Dr. Chu’s international stature in this new field, he was recently appointed to the editorial board of The BMJ. Furthermore, his most recent article in this field has been accepted at The BMJ:
Everyone Included: moving beyond patients included. Chu LF, Utengen A, Kadry B, Kucharski SE, Campos H, Crockett J, Dawson N, Clauson K. Provisional acceptance, submission in revision. The British Medical Journal; 2016.
Here, Dr. Chu describes the importance of patient involvement in academic medical conferences and how meaningful participation from everyone will be required in order to improve the health care industry. The Everyone Included model, developed by Dr. Chu, is increasingly influencing policy and academic medicine. For example, 3 of President Obama’s Precision Medicine Initiative patient research design principles derived directly from Stanford Medicine X and Dr. Chu’s Everyone Included co-creation principles.
The Clark laboratory has various projects all focused on mechanisms supporting chronic pain. The first project area involves persistent pain after injuries to the extremities, including tissue damage caused by limb fracture and surgery. Models involving laboratory animals are commonly used, although human tissue samples and translational research studies are a part of the overall program. Most of this work involves evaluating the contributions of neural activation of the innate and adaptive systems of immunity. The neurogenic underpinnings of persistent pain in the setting of limb injury, the sources and targets of inflammatory mediators, and the targets of injury-related autoimmunity are all areas of interest for the group. Ultimately, our goal is to inform the design of therapies that can be taken to early-stage clinical trials.
The second major project area involves the identification of mechanisms responsible for persistent pain after traumatic brain injury (TBI). In this context, the laboratory is interested in understanding how changes in descending systems of nociceptive modulation as well as changes in nociceptive signal transmission within the spinal cord might contribute to the very high incidence of chronic pain after even mild forms of TBI. Recent projects have focused on damage to the locus coeruleus after TBI and associated deficits in spinal noradrenergic function. Additional work involves spinal epigenetic changes leading to the enhanced expression of pain-related signaling molecules.
My body of scientific work is dedicated to elucidating the primary influence of psychological factors on the experience of pain; specifically targeting psychological factors (pain catastrophizing) as a pathway to reduce pain, improve response to medical treatment (including surgery), and reduce reliance on prescription opioids; and addressing unmet needs for pain psychology services in the U.S. I have a specific interest in integrating pain psychology and pain catastrophizing interventions into the perioperative setting to enhance recovery after surgery. I secured roughly $5.2M in research funding in 2015. (Learn more at www.bethdarnall.com)
Current NIH Grants
- Co-PI on an NIH R01 from NCCIH focusing on mechanisms of catastrophizing, and a comparative effectiveness trial of a targeted single session class that treats pain catastrophizing (see Darnall BD, et al 2014 J Pain Res). Co-PI Dr. Sean Mackey; 2015-2020.
- I am the Stanford Site-PI for a multisite R01 that is investigating the intergenerational transmission of pain in at-risk children of mothers with chronic pain. Overall PI Dr. Anna Wilson, OHSU; 2015-2020.
- I am Co-Investigator for a program project center grant (P01 AT006651; PD is Dr. Sean Mackey), the Stanford Center for Back Pain, which is studying cognition and emotion regulation, and the distinct and shared mechanisms of 3 evidence-based treatments (MBSR, CBT, and acupuncture) in chronic pain.
- I am Co-Investigator for a study of Sex/Gender-Specific Brain Risks for Prescription Opioids in Chronic Low Back Pain (PI: Dr. Sean Mackey).
Current Stanford Grants
- Spectrum-Stanford Health Care Innovation Challenge Grant
- I am Co-I for this project in which we are integrating the Collaborative Health Outcomes Information Registry (CHOIR) into the Perioperative Clinic at Stanford. We are studying my pain psychology video intervention for catastrophizing as a demonstration project of the clinical utility of CHOIR as a platform to improve surgical outcomes. PI: Sean Mackey, MD, PhD; 2016.
- 2. Stanford Faculty Innovation Award (2015 2016)
- I am Co-I for this project in which we are phenotyping patients at-risk for low patient satisfaction prior to their initial visit to the pain clinic and implementing a targeted, coordinated care model to optimize patient satisfaction. PI: Dr. Ming-Chih Kao.
In addition to the Spectrum-Stanford Health Care Innovation Grant (above), we are conducting a pilot RCT study of an internet-based perioperative pain psychology/ catastrophizing treatment I developed. We are examining effects on catastrophizing, post-surgical pain and function in multiple surgical groups at Stanford University, including women undergoing surgery for breast cancer.
My research interest is focused on transfusion practices and perioperative management of coagulation in pediatric cardiac patients. Currently, I have several ongoing clinical research projects, both retrospective studies and randomized clinical trials. Current project include 1) Blood transfusion practices and subsequent outcomes in on-bypass and off-bypass Fontan patients; 2) Blood transfusion practices and subsequent outcomes in TOF-MAPCA patients; 3) Restrospective review of the use of FEIBA in post-cardiopulmoary bypass bleeding in pediatric cardiac patients; 4) Repurposing fibrinogen concentrate for post-cardiopulmonary bypass bleeding in neonates/infants; 5) Development of a transfusion algorithm for pediatric cardiac patients.
My research interest is in clinical research on the pharmacokinetics and pharmacodynamics of drugs. Medications studied are those commonly used for anesthesia and analgesia. Additionally, other drugs are studied if they have unique characteristics that require intensive or specialized monitoring. Particular effort is used to obtain quality real-time data from intensive pharmacokinetic - pharmacodynamic studies to enable mathematical modeling of drug effect on the human body. Mathematical modeling of data is mainly performed with NONMEMâ. Where possible, research projects use the electroencephalogram to quantitate pharmacodynamic effect and develop mathematical models to relate pharmacokinetics to pharmacodynamic response. The main interest of my research projects is to develop novel ways to model and describe clinical pharmacology relationships.
My research focuses on the pharmacokinetic and pharmacodynamic (PKPD) evaluation of commonly used sedatives and anesthetics, as well as in the PKPD and mathematical foundations of closed-loop control of anesthesia using EEG-derivative indices as the controlled variables. In particular, I am interested in identifying disease-related or other patient phenotypes, which are associated with alterations in the clinical pharmacology of anesthetics and could affect perioperative outcomes. Currently, I study the effect of sleep-disordered (SDB) breathing on pain processing before and after the administration of opioids in patients suffering from SDB and in healthy volunteers. Also, in the same area of research we investigate the effect of obstructive sleep apnea on postoperative neurobehavioral and medical outcomes in patients undergoing bariatric surgery. In particular, we are interested in identifying metabolic and genetic markers for suboptimum neurobehavioral outcomes and correlate those with the severity of nocturnal hypoxia in this patient population. In collaboration with the Department of Computer Science in Texas Tech University we develop a new system to control anesthesia using the bispectrum of the EEG (BIS) as the controlled variable. This control strategy is based on a method of unsupervised learning called reinforcement learning (RL) and has already demonstrated an excellent performance in simulation studies. The application of RL-based anesthetic control in human subjects is upcoming.
The Patient Safety Center of Inquiry (PSCI) at VA Palo Alto incorporates the research conducted by Drs. Gaba, Howard, K. Fish, and Bushell, and Dr. Sowb (Ph.D.). It is a major research unit associated with the Department of Anesthesia (although we cover many aspects of health care, not just anesthesia).
My current clinical studies are: Determination of remifentanil pharmacokinetics and pharmacodynamics in infants and a comparison of remifentanil with or without spinal anesthesia for children undergoing open heart surgery.
Dr. Honkanen is interested in health policy and the health care system. She has published work looking at how surgery location correlates with complications of T&A surgery in pediatric patients, as an approach to begin to inform policy for the pediatric surgical health care system. Currently she is collaborating on research regarding the distribution of pediatric anesthesiologists in comparison to the pediatric population. In the future, Dr. Honkanen would like to do studies on pediatric surgical outcomes under varying conditions using administrative data sets.
Dr. Macario is interested in the economics of health care, in particular the tradeoffs between costs and outcomes for patients having surgery and anesthesia. He has completed internationally recognized studies on the management of the operating room suite, as well as pioneering work on the cost-effectiveness of drugs and devices. He is Founder and Director of a Postgraduate Fellowship for physicians interested in applying quantitative tools to solve health services research questions. More recently, as Program Director for the anesthesia residency he is interested in education, core competencies of physicians in training, and innovations for clinical training.
Pain is the primary complaint resulting in physician visits and health care resource utilization. The importance of pain as a major worldwide health care problem has been recognized by the World Health Organization, and the need for further research into its mechanisms and control was recognized by the U.S. Congress in its declaration of the years 2001-2010 as the Decade of Pain Control and Research.
The presence of pain and its inadequate treatment in a variety of clinical settings has significant societal impact. Pain contributes to the overall economic burden of disease through increased direct medical costs caused by additional health care resource utilization. It has been estimated that in the United States the cost of health care, compensation, and litigation resulting from pain is more than $200 billion annually.
Historically, pain has been considered in relation to its etiologic or disease factors, such as the relationship between surgery and postoperative pain, herpes zoster and postherpetic neuralgia, and arthritis and painful joints. This has had the effect of addressing pain as a symptom of disease, and although much progress has been made in understanding the molecular and cellular mechanisms of disease, the resulting pain has not necessarily been alleviated. What is required, and has been missing from the evaluation, is an understanding of the underlying mechanisms responsible for the pain itself.
Dr. Mackey has focused his efforts on elucidating and characterizing these underlying mechanisms of pain. In particular, he has focused his efforts on characterizing the mechanisms of pain from the level of the network to behavior. He uses a systems neuroscience approach, which includes the integration of advanced neurobehavioral, psychophysical and neuroimaging techniques.
Some current research projects and themes:
1. Real-Time Brain Control for Pain
Attaining control over specific neural processes is the primary goal of neuropharmacology and neurostimulation; it is also a critical objective of biological psychiatry and psychology. Training people to be able to modulate specific neural processes has the potential to enable them to have greater control over the resulting behavior, cognition, or associated disease. Recently Dr. Mackey's lab has demonstrated that patients with chronic pain can learn to control a specific region of their brain – the rostral anterior cingulate cortex (rACC) – that is associated with pain processing and perception (PNAS, December 2005, 102:51; 18626-31). Importantly, they found in that study that the increased control in localized brain activity was associated with improvement in pain control. They are expanding this work to: (1) investigate learned control of specific brain networks, (2) determine the optimal brain regions for learned control, (3) characterize the long term effects of this unique methodology and (4) apply it to other neuroscience fields such as depression, addiction and cognitive development. This exciting and unique multidisciplinary collaboration brings together expertise from the fields of Pain, Radiology, Psychology, and Electrical Engineering. Stanford is currently the only institution in the world where this work is occurring.
2. Neuroimaging of the human spinal cord, brainstem and brain and characterization of reward systems, affective dimensions of pain and neural plasticity of pain. 3. Personalized Pain Medicine
The last decade has seen a significant increase in the number and type of pharmacologic therapies for the treatment of chronic pain. Frustratingly, each medication produces pain relief for only a minority (typically 30%) of patients. Not surprisingly, few physicians have the patience required to persist in a strategy involving months of frustrating side-effect laden medication trials until the correct one is found. A method to identify which individual patient with a particular chronic pain problem will respond to a specific drug is needed. Dr. Mackey's team has put together a multidisciplinary team of researchers and clinicians to achieve this goal. They have been developing and using techniques such as: (1) pharmacologic fMRI to elucidate central neural correlates of drug response and side effects, (2) sophisticated pharmacokinetic/pharmacodynamic drug models to characterize individual drug concentrations and effects, (4) novel neurobehavioral and psychophysical measurements to precisely characterize the perceptual aspects of the pain experience, (5) genomics to characterize candidate gene polymorphisms responsible for individual differences in pain perception and analgesic efficacy and (6) novel epidemiologic and statistical methods to develop multivariate models which ultimately predict individual drug responsiveness.
The focus of my clinical trials unit includes Phase II-III pharmaceutical and device trials in therapeutic areas such as high-risk cardiac surgery, septic shock, ARDS, anticoagulation, complicated infections, and a variety of infectious diseases. Currently, we have 5 clinical trials recruiting:
- Toramycin hemoperfusion in adults treated for endotoxemia & severe septic shock.
- Efficacy, immunogenicity and safety of a Clostridium Difficile vaccine for high-risk C.Diff naive adults.
- Levosimendan versus placebo in patients with left ventricular dysfunction at risk for low cardiac output following CABG, mitral valve repair/replacement or a combination of CABG and valve surgeries.
- Safety, efficacy and tolerability of Human Recombinant Alkaline Phosphatase in the treatment of patients with sepsis-associated Acute Kidney Injury.
- The pharmacokinetics, safety and antiviral activity of JNJ-63623872 in combination with Oseltamivir in adults hospitalized with Influenza A Infection.
I have just completed recruitment for a Multicenter Morphine Pharmacogenetic study. Prior to that, I completed a project on anesthesia machine preparation using activated charcoal filters for patients susceptible for malignant hyperthermia.
- An Innovation Testing Strategy for Early Lung disease Surveillance in Cystic Fibrosis (CF) Infants – co-investigator
- A Phase 3, Randomized, Double-blind, Sham-Procedure Controlled Study to Assess the Clinical Efficacy and Safety of ISIS 396443 Administered Intrathecally in Patients with Later-onset Spinal Muscular Atrophy – unblinded study coordinator
- Simulation study evaluating team performance on technical and nontechnical aspects - coordinating with Vanderbilt University.
My interests include medical humanities, literature and medicine, communication in the operating room, ethics and anesthesia, and creative writing.
Lawrence C. Siegel, MD
My research interests are in obstructive sleep apnea. I am also interested in new medical devices (e.g., sleep apnea, cardiovascular surgery, minimally invasive surgery, physiologic measurement) and the pre-clinical and clinical pharmacology of novel anesthetic and analgesic agents.
My research examines questions of health economics and health policy, with a focus on economics and policy in the perioperative setting. One area of interest is the economics of chronic pain, where I am examining several topics. The first is the epidemiology and economics of opioid use in the perioperative setting, where my research examines risk factors for chronic opioid use following surgery as well as the effectiveness of interventions aimed at reducing this risk. In addition, my work is also focusing on the economics and cost-effectiveness of treatments for chronic back pain.
A second area of interest examines the economics of the structure of physician practice organizations. In the past, most physicians tended to practice in the context of solo/small group practices. However, this practice model has grown less common over time and today, physicians are more likely to practice in the setting of large group practices. Whether this new model is of benefit—or harm—to patients remains unknown. Currently, I am examining the extent to which this new model has affected outcomes and prices for perioperative care.
At Stanford, I have been involved with Resident Education not only in terms of direct supervision, but by initiating and working on several educational projects (spinal anesthesia teaching module, keyword of the day, using iPads as a teaching tool in the orthopedic rotation, clinical base year rotation, libero lecture program and a feedback tool). My areas of interest in Medical Education are: Developing, leading and evaluating programs; Designing curricula and assessing learners; and Designing, implementing and studying innovations.
Jumbo Williams, MB, ChB
My research has been entirely clinical and focused primarily on (1) anesthesia and pediatric congenital heart disease, (2) perioperative management of coagulation in children and (3) aspects of general pediatric anesthesia. I hope to establish coagulation and open-heart surgery in children as an area of research interest at Stanford. The challenges of pediatric open-heart surgery for congenital heart disease are unique and offer good research opportunities. Stanford's pediatric cardiac anesthesiologists plan to collaborate in research in order to efficiently utilize the relatively small numbers of patients potentially available for clinical study.
Obstetric Anesthesia Research Group
The obstetric anesthesia research group addresses a wide variety of questions related to the field. Two areas are currently our major focus:
- The use of spinal opioids for epidural and spinal anesthesia and analgesia.
- Spinal anesthesia for cesarean delivery.
In addition, we have done research on the economics of obstetric anesthesia, patient perception of risk, experimental pain, and the use of nitroglycerin for preterm labor and external cephalic version.
We have a large number of faculty involved in research and generally have 1 or 2 post-doctoral fellows conducting clinical studies. We have successfully helped undergraduate students, medical students, and residents complete research projects. Our fellows come from our own residency program as well as other academic institutions, and we have provided research opportunities for several foreign scholars. Our past fellows have gone on to academic careers or been very successful in private practice.
One of the strengths of our group is our ability to collaborate with a variety of people in the institution. We have conducted projects in the past with Drs. Alex Macario (economics), Yasser El Sayed (Fetal-Maternal Medicine), David Drover (pharmacokinetics and statistics), and Martin Angst (experiment pain). In the future we hope to collaborate with Dr. David Yeoman's experimental pain laboratory. Regular interaction among the members of the group is the key to the success of our active group. This is facilitated by monthly research meetings and journal clubs. We have also developed a formalized mentoring program. Dr. Riley, the Section Chief, directs the research program and, along with Dr. Sheila Cohen, (previous section chief and an experienced clinical researcher) meets regularly with the junior members of the team to discuss research and other issues.
Regional Anesthesiology and Acute Pain Medicine Research Group
Faculty in the Division of Regional Anesthesia at Stanford have research interests encompassing a variety of topics related to regional anesthesiology and acute pain medicine, including:
- Point-of-Care Ultrasound (POCUS)
- Development of new techniques
- Advances in catheter technology
- Applications of regional anesthesia beyond the perioperative period
- Personalization of acute pain medicine
- Development and implementation of patient care pathways
- Multimodal, opioid-sparing pain relief
- Enhanced Recovery After Surgery (ERAS)
- Outcomes and comparative-effectiveness research
- Simulation and education in regional anesthesia
We have a number of ongoing projects involving faculty, fellows, residents, and medical students. Our group has a full-time research assistant dedicated to the execution of high-quality studies. We collaborate with other institutional departments, including the surgical subspecialties, as well as with other anesthesiology departments across the country. The diversity of interests in our core research team ensures that every trainee has the opportunity to pursue a project that aligns with his or her individual goals.
Meet Our Team
- Jean-Louis Horn, MD
- Edward R. Mariano, MD, MAS
- Ban Tsui, MD
- Sarah J. Madison, MD
- Jan Boublik, MD, PhD
- T. Edward Kim, MD
- Ryan Derby, MD
- Toni Ganaway, BA
- Steven K. Howard, MD
- T. Kyle Harrison, MD
- Cynthia Shum, DNP, MEd, RN, CHSE-A