April 2014 JMSMA

April

VOL. LV

2014

No. 4

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Hugh Durrence, M.D.

PHC Health

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Loans | Treasury Management | Can-Do Attitude © 2014 Regions Bank. All loans and lines subject to credit approval.

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD Associate Editors Karen A. Evers Managing Editor

Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors The Association James A.Rish, MD President Claude Brunson, MD President-Elect Michael Mansour, MD Secretary-Treasurer R. Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices.

CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com.

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The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

Copyright© 2014 Mississippi State Medical Association.

APRIL 2014

VOLUME 55

NUMBER 4

Scientific Articles Series: Concepts in End-of-Life Care - Advance Directives 108 Derek T. Hansen, MD; Sharon Douglas, MD; Rajesh Bhagat, MD

Patient Perception of Care Received by Students at the Jackson Free Clinic

113

Jeb S. Clark, MS; Adam Bollaert, JD; Stephen O. Sills, MD; Joy H. Clark, PhD; David Norris, MD

President’s Page The Prescription Drug Abuse Epidemic

126

James A. Rish, MD; MSMA President

Editorial Health Disparities, Population Health, and Preventive Medicine

128

Michael Mansour, MD

Departments From the Editor: Auditor’s Outdated Study Disservice to State 106 CME in the Sand 122 MSMA: Nominating Committee Seeks Vacancies for MSMA Offices 130 Letters 132 Physician’s Bookshelf: Five Days at Memorial 135 Poetry in Medicine: “Cough” 136

About The Cover:

River Morning - This photo was taken on the Pearl River near the old Jackson waterworks plant by Will Sorey, MD, a pediatrician at Batson Children’s Hopsital who lives in Brandon.

He writes, “The Pearl River seems ordinary and barely rates a glance from travelers. Morning light dictates otherwise as muddy water reflects blue sky. Wakening sounds build to greet the occasional kayaker. Coffee beckons me to savor the cool of the morning. I willingly oblige.” r

April

VOL. LV

2014

No. 4

Official Publication of the MSMA Since 1959

April 2014 JOURNAL MSMA 105

From the Editor: Auditor’s Outdated Study Disservice to State

I

have long been a fan of State Auditor Stacey Pickering and his entire family. However, his office’s release of a superficial and outdated study on the financial strength of the state’s rural hospitals was a disservice to all rural Mississippians (“The Financial Health of Publicly Owned Rural Mississippi Hospitals,” Report #137, www.osa.state.ms.us). Mr. Pickering, who looked at audited financial reports from 20092012, has studied a corpse and determined the dead patient is healthy because it had a pulse 3 years ago. Hospital officials will tell you that over 60% of all state hospitals are currently operating in the red, with many of those rural hospitals.

The report reveals how out-of-touch the average state or federal public official is with what’s happening on the ground.

The financial environment since 2012 for all hospitals has become toxic. The federal government, our state Medicaid program, and insurance companies are daily engaging in adversarial behaviors to deny appropriate payment for appropriate services provided. These recent stressors include: the reverse fraud of RAC audits (which are extracting payments for appropriate services from hospitals on technicalities); significant ACA Medicare cuts on all hospitals; the trend to

deny “admission status” to hospitalized patients so hospital reimbursement is less than the cost of treating the patients; Medicaid “taxes” on hospitals; Medicaid’s and Medicare’s transition to managed care; and the expensive (and medically unhelpful) transition to electronic medical records.

The most revealing conclusion about Lucius M. Lampton, MD rural medicine in Pickering’s ridiculous report is that the strongest rural hospitals in the state are facing record employee cuts and financial losses. McComb’s hospital CEO recently told its Rotary Club of reductions in hospital revenue of up to 8 million a year, which he projected to equal 400 job losses. If the strongest is suffering so, what’s happening to the less strong?

Worse days are to come for rural hospitals if we, like Mr. Pickering, deny a problem exists. He simply needs to visit the rural hospitals to see the tragic financial environment they face and also the critical patient needs they address.

Contact me at lukelampton@cableone.net.

—Lucius M. “Luke” Lampton, MD, Editor

Journal Editorial Advisory Board Myron W. Lockey, MD Chair, JMSMA Editorial Advisory Board Journal MSMA Editor Emeritus, Madison Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson

Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson

Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

106 JOURNAL MSMA April 2014

Paul “Hal” Moore Jr., MD Radiologist Singing River Radiology Group, Pascagoula

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

Jason G. Murphy, MD Surgeon

Surgical Clinic Associates, Jackson

Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson

Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport

William Lineaweaver, MD Sharon Douglas, MD Editor, Annals of Plastic Surgery Professor of Medicine and Associate Dean for VA Medical Director Education, University of Mississippi School of Medicine, JMS Burn and Reconstruction Center, Jackson Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Michael D. Maples, MD Vice Preisdent, Chief of Medical Operations Baptist Health Systems, Jackson Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson

Darden H. North, MD Obstetrician/Gynecologist Jackson Health Care-Women, Flowood Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

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April 2014 JOURNAL MSMA 107

• Scientific Articles • Series: Concepts in End-of-Life Care Advance Directives Derek T. Hansen, MD; Sharon Douglas, MD; Rajesh Bhagat, MD [This is the fourth article in a 5-part series: Concepts in End-of-Life Care. Previous articles addressed general concepts in end-oflife care, palliative care, and DNR orders. The final article will address grief.]

I

ntroduction

End-of-life care has long been the focus of debate among physicians, policy makers, and the public.

Traditionally, decision-making regarding end-of-life health care was based on professional authority under the assumption that physicians acted in their patient’s best interest. However, as invasive medical technology has progressed, individuals and their loved-ones, in the context of the advancing patient rights movement, have sought to reduce and/or refuse the use of life-sustaining treatments under certain circumstances in favor of an individualized autonomous end-of-life less aggressive or invasive treatment plan.

Individualized health care directed decisions can be formalized into what is known as an “advance directive.”

All 50 states recognize legal forms of advance directives to include an individual instruction, also known as a Living Will by some, and a durable power of attorney or surrogate for health care decisions. By definition, an advance directive, which must be made by a legally competent patient, is either a statement the patient makes about his or her wishes related to invasive life sustaining instrumentation and medical care or a means of appointing a surrogate to make decisions in accordance with the patient’s current values and beliefs regarding end-of-life care.1 A statutory advance directive is a legally binding document and may be completed in the presence of a notary public or two witnesses. The importance of an advance directive in illustrating a patient’s wishes regarding life-sustaining treatment was highlighted

by Nancy Cruzan’s tragic motor vehicle accident in 1983.

Author Affiliations: Internal Medicine Resident (Dr. Hansen), Professor of Medicine (Dr. Douglas), Associate Professor of Medicine (Dr. Bhagat) Department of Medicine, University of Mississippi Medical Center, Jackson.

Corresponding Author: Derek T. Hansen, MD; Department of Medicine, 2500 North State Street, Jackson, MS 39216.

108 JOURNAL MSMA April 2014

The Case of Nancy Cruzan On January 11, 1983, paramedics found 26-year-old Nancy Cruzan without respiratory or cardiac function after her car overturned. It was estimated that she was without oxygen for 12-14 minutes, resulting in irreversible damage to her cerebral cortex. For the next seven years until her death, Nancy Cruzan remained in a persistent vegetative state breathing on her own but fed through a gastrostomy tube. Cruzan’s parents, realizing that she would never regain consciousness, requested termination of artificial hydration and nutrition procedures. The hospital staff refused to honor the family’s request without court approval since that would lead to her demise. The Cruzans then took their case to court. Immediately after a probate court ruled in favor of Cruzan’s parents, the Missouri State Supreme Court repealed the ruling, arguing that the state’s utmost priority is to protect the interests of the patient. Furthermore, they stated that only clear evidence that the patient herself would have refused treatment would be considered grounds for her removal from life support. Nancy Cruzan’s parents lacked such evidence.

In a landmark decision in June 1990, the United States Supreme Court in a split decision confirmed the judgment of the Missouri State Supreme Court and maintained that in the case of incompetent patients, each state has the right to require clear and convincing evidence of that patient’s former wishes to decline such medical treatment.2 Importantly, the right to self-determination outweighs the state’s interests including the right for a competent person to refuse life-saving and sustaining treatment even though risking death. Five months later, Nancy Cruzan’s friends offered new and convincing testimony to a lower court, which finally granted the removal of Cruzan’s feeding tube. Cruzan died shortly thereafter. The landmark decision of the United States Supreme Court in 1990 eventually led to the formation of the Patient Self Determination Act as a means to define legally an advance directive.

The Patient Self-Determination Act (PSDA)

In order to recognize the rights of all patients, the Health Care Financing Administration passed the Patient Self-Determination Act as a part of the Omnibus Budget Reconciliation Act of 1990. This act defines an Advance Directive as a written or oral instruction, such as a living will or durable power of attorney for health care, recognized under state law, relating to the provision of health care when the individual is incapacitated. Furthermore, the act requires all health care facilities receiving Medicare or Medicaid reimbursement such as hospitals, skilled nursing facilities, home health agencies, hospices, and prepaid health care organizations to notify all patients of their right to make decisions concerning medical care, including their right to refuse medical or surgical treatment and to formulate advance directives. Not only must these facilities document whether or not their patients have drawn up advance directives, but they also must inform patients about the purpose of advance directives and any related institutional policies or state laws.3 The Patient SelfDetermination Act further urges these institutions to engage in efforts to educate its staff and the community about advance directives. The Patient Self-Determination Act of 1990 has been evaluated in several studies with regard to its ability to promote advance directive completion. The SUPPORT trial found that the number of patients with an advance directive did not increase soon after passage of the Act.4

Mississippi Law Relative to Advance Directives

In 1998 the Mississippi Legislature enacted the Uniform Health Care Decisions Act as a model for simplifying multiple health care provisions into a single comprehensive act. The Uniform Health Care Decisions Act was originally developed by the National Conference of Commissioners on Uniform State Laws as the primary model for a flexible combined advance directive and default surrogate law.

The purpose of the Uniform Health Care Decisions Act was to provide a comprehensive form with options for instructions, appointment of an agent, organ donation, an option to name a primary physician, and to recognize default surrogates in the absence of an advance directive. Furthermore, the act established very simple rules for recognizing almost any kind of written or oral statement as an advance directive.

The Act stipulates that an advance health care directive is the means by which an individual can make his or her wishes known in the event he or she becomes incapacitated.5 As a result of the Uniform Health Care Decisions Act, two types of advance directives are statutorily recognized in Mississippi: Individual Instruction and Power of Attorney for Health Care.

Mississippi Individual Instruction Directive

Competent individuals have the right to make health care decisions. However, if a patient is unable to make his or her own health care decisions they may employ a previously

known individual instruction. Individual Instruction is a written or verbal form of personalized directives that articulates an individual’s direction concerning end of life health care decisions. Instructions given by the patient may be restricted to take effect only if a previously specified situation develops.

Individual instruction is binding and must be honored by the patient’s agent, surrogate, or primary physician until retracted by the patient. However, a physician, hospital, or nursing home has the right to refuse to implement a patient’s individual instruction, but the provider not honoring the patient’s instructions must transfer the patient to a facility or provider that will honor that patient’s individual instruction.

The state of Mississippi does not advocate for any specific format for a patient’s individual instructions and does not require that they be filed with the Mississippi Department of Health. However, Mississippi does provide a simple format for those instructions that deal with end-oflife decisions related to life support withdrawal, artificial nutrition and hydration, relief from pain, and other wishes.

Mississippi Power of Attorney for Health Care

Power of Attorney for Health Care is a document through which a patient is able to define someone, such as a family member or friend, as a legally appointed agent to make health care decisions for him or her if they are unable to make their own decisions due to permanent or temporary illness. Power of Attorney for Health Care stipulates that an agent’s authority is applicable when the patient’s primary physician determines that the patient is unable to make his or her own health care decisions. Patients may also designate someone to make health care decisions for them immediately despite maintaining the capability and competence to make their own decisions. Power of Attorney for Health Care dictates that the patient’s agent or proxy must make health care decisions in accordance with any individual instructions, verbal or written, given by the patient and any other desires known by the agent. However, if the patient’s wishes are unknown, the agent must consider the patient’s own personal values and beliefs when making health care decisions.

Power of Attorney for Health Care allows patients to name an alternative agent if their first choice is not agreeable or available to make decisions on their behalf. If a court of law requires guardianship, Power of Attorney for Health Care by default nominates the agent selected by the patient. Moreover, if the agent chosen by the patient is not willing or able to act as guardian then subsequent alternate agents will be appointed in the order assigned by the patient.

A provision within the Power of Attorney for Health Care enables the patient to limit the influence of the agent or proxy. The patient must express these limitations in writing in Section 2 of Part 1 of the Mississippi Advance Health Care Directive. If the patient decides not to restrict the authority of his or her agent, the agent will have the legal right to consent or refuse treatment, select or discharge health care

April 2014 JOURNAL MSMA 109

providers and institutions, and withhold or withdrawal artificial nutrition and all other forms of life-sustaining treatment.

The state of Mississippi recognizes that patients have the ability to revoke their agent’s authority by signed writing or by personally informing their primary physician or health care provider. An individual may withdraw all or part of advance health-care directive at any time or manner whether written or verbal. However, Mississippi requires that all additions or changes to an advance directive be completed in the presence of two non-related witnesses or a notary republic. Annulment, divorce, or dissolution of marriage rescinds a previous appointment of a spouse as an agent unless otherwise indicated in the Power of Attorney for Health Care. An advance health care directive that conflicts with an earlier directive will dissolve the earlier directive in favor of the most current health care directive.

Primary Physician and Organ Donation

The Mississippi Advance Health Care Directive provides the patient with the ability to designate a primary physician to take care of them at the end of life. The directive also allows the individual to authorize the donation of organs to a person requiring transplant, a licensed hospital, a medical school or university, or any person operating a bank or storage facility for organ transplantation. The decision to undergo organ donation may not be superseded by a patient’s next of kin upon the death of the patient.5

Utilization of Advance Directives

In spite of widespread legislative efforts to encourage advance care planning, studies suggest that only 18-36% of adults have completed an advance directive.6 Moreover, individuals with acute life threatening medical conditions, a group for which advance directives are especially relevant, have completed advance directives only at a marginally higher rate than the general population. Less than 50% of terminally ill patients have an advance directive in their medical record, and among individuals with chronic diseases, only 33% have completed an advance directive.7 Conversely, factors associated with an increased likelihood of advance care planning and advance directive completion include older age, type of condition, disease burden, higher socioeconomic status, knowledge about end of life treatment options, care setting, and a long standing relationship with a primary care physician.

Certain ethnic groups are less likely to engage in advance care planning or complete advance directives. A systematic review with regards to end of life decision-making found that non-White groups had less knowledge about advance directives and were less likely to support the use of advance directives based on a general distrust of the health care system, overall spiritual concerns, and greater preferences for life-sustaining therapies.8 Furthermore, studies suggest that advance directives may be incompatible with the beliefs and traditions of Hispanic and Native Americans, who appear

110 JOURNAL MSMA April 2014

to prefer a family-centered and collective decision-making rather than individual and autonomous decision-making.9

Advance Directives according to Clinical Setting

The prevalence of advance care planning varies according to the clinical setting. Despite the relatively high concentration of severely ill patients in hospitals, the completion of advance directives appears to be only modest in acute care facilities.

Advance care planning would seem to have the greatest influence in the outpatient setting where a patient is routinely able to discuss in detail the risks and benefits of varied end-of-life treatment approaches in the absence of an acute life threatening illness. However, in the Intensive Care Unit, where the most aggressive care is provided and where the majority of deaths involve withholding or withdrawing treatment, determining patient preferences and values can be confounded by poor communication between patient and family members, influence of the family’s desires on the patient’s wishes, and disagreement among family members regarding the use of life-supporting treatment.10 Advance directives are completed in long-term care populations more often that in other acute care settings. A systematic review of end of life care in nursing homes from 1995 to 2002 found that advance care discussions with nursing home residents increased after implementation of the Patient Self Determination Act.11 While individual studies conflict regarding advance care planning in nursing home populations, it appears that over 65% of nursing home residents have an advance directive. The completion of at least one advance directive was highest among discharged hospice patients at 88%, and lowest among home health care patients at 28%.

Among home health care and nursing home populations, those aged 85 years and over were more than twice as likely as those under age 65 to have an advance directive 41% compared with 17% for home health care patients and 77% compared with 36% for nursing home residents. This finding may reflect the higher rates of disability and chronic conditions among persons greater than 65 and over, which may make people more likely to consider their end of life care preferences.

Age differences existed among discharged hospice care patients, but they were less pronounced than in other settings.12

Barriers for Completion

Knowledge alone regarding advance directives does not increase their use. Numerous barriers inhibit advance care planning and completion. Evidence suggests that as people age and their overall health declines they are more willing to participate in advance care planning. However, the low rate of engagement in the general population suggests that physicians and patients do not fully recognize their opportunities to impact end-of-life care through advance care planning. Barriers to completion of advance directives include lack of communication between patients and their families,

physician’s clinical experience and training, and confusion regarding the legal organization of advance directives.

One of the greatest obstacles to participation in advance care planning is the unwillingness of patients and their family members to discuss the issue of death and the finality of end of life planning. Some patients diagnosed with a debilitating illness fear initiating and managing of end of life decision-making, preferring to defer the responsibility to their families or primary physicians. Some patients worry about burdening their family members or friends with the responsibility and anxiety of making end-of-life decisions even though an advance directive can alleviate ambiguity surrounding future end-of-life care. Most patients expect the physician to bring up the topic of advance care planning.

Physician barriers are often related to lack of time, lack of experience with advance care planning, and reimbursement for prolonged family discussions. Reviewing advance directives in the office setting may require up to an hour if the physician meets with the patient, health care proxy, and other family members.

Furthermore, some physicians are uncomfortable with the subject and lack the experience to discuss properly advance care planning. Some physicians prefer to wait for the patient to raise the issue. These actions or inactions hinder advance care planning and subsequent implementation of advance directives.13

Application of Advance Directives

The most successful advance care planning methods include group-based interventions consisting of the patient, primary physician, and surrogate that are repeated over time.

Group-based conferences are more effective in stimulating discussion and generating questions regarding end-of-life care. The ability of the primary physician to assist in the interactions of the patient, family, and surrogate early and over time may be the key to a successful advance directive.14

A methodology that is suitable to the patient’s life stage in conjunction with group-based interactions may also promote effective and interactive advance care planning.

The first period occurs at any age in the physician’s office possibly at the time of a yearly wellness visit. At this stage, the patient’s primary care physician should initiate rudimentary discussions regarding advance care planning and encourage the patient to discuss their wishes regarding end-of-life treatment with family even in the absence of a completed advance directive. Advance care planning is then readdressed at subsequent health maintenance visits. See Table.

The ensuing phase of advance care planning occurs when the patient develops a chronic progressive illness. At this stage, the patient’s primary care physician will initiate a more indepth discussion including prognosis and patient’s care goals regarding their illness. Further discussions about care goals, which can change as the patient’s disease progresses, may help improve the accurateness and or specificity of their directive.15 This will allow the patient as well as the designated surrogate the opportunity to re-evaluate previous preferences and broad statements and articulate a more specified consistent treatment plan, such as Physician Orders for Life-Sustaining Treatment.

Differences between Advance Directives and POLST

Physician Orders for Life-Sustaining Treatment translates patient’s goals for end-of-life treatment into medical orders.16 POLST requires a discussion between the physician and the patient or patient’s authorized surrogate and is employed when the patient has a terminal condition. This requires the physician to discern the requests of the patient in light of his or her current specific terminal condition and discuss available care options. An advance directive, on the other hand, aims to engage the physician and patient in an end-of-life treatment discussion, but does not require the presence of a physician

Table. Implementation of Advance Directives Life Stage

Discussion Topics

Interventions

Wellness Visit

“If you became ill, who would make your medical decisions?”

Review advance directive forms

Diagnosis of chronic disease

“Your health has changed.

Have you discussed your concerns with your loved ones?”

Meet with the patient, surrogate, and family members

“If time becomes short, what is most important to you?”

Discuss prognosis and personal goals

Worsening Frailty

Diagnosis of terminal illness “Given your current condition, what are your priorities and how best can we support you?”

Discuss prognosis. Advance directives, palliative care, and POLST

Adapted from Spoelhof GD, Elliott B. Implementing advance directives in office practice. Am Fam Physician 2012;85(5):461-466.

April 2014 JOURNAL MSMA 111

for completion. While being able to complete any advance directive in any setting regardless of health status offers the patient maximum flexibility, the absence of a physician may lead to problems interpreting potential usefulness or futility of life-sustaining medical interventions. Furthermore, a physician in a shared decision-making discussion with the patient completes a POLST form as specific medical orders, while only the patient, in the presence of two witnesses or a notary public, may complete a legal advance directive, which may be vague and less disease specific. Of course, assistance from a social worker or other health care professional may be utilized to help the patient fill out advance directives.

Conclusion

Advance directives and advance care planning are important tools that can assist with end-of-life preparation at any time during a patient’s life. The accumulated evidence suggests that end-of-life decision-making in the United States is often poorly implemented with patients receiving care inconsistent with their preferences or prognosis, occasionally leading to undue suffering. The relevance of an advance directive for a patient, at any age and health status, in portraying a patient’s wishes regarding the presence or absence of life-sustaining treatment was underscored by the case of Terri Schiavo.

On February 25, 1990, 26-year-old Terri Schiavo collapsed in her home and never regained consciousness. Her plight prompted a contentious decade-long legal debate that resulted in Ms. Schivo’s percutaneous endoscopic gastrostomy (PEG) tube being removed and reinserted twice.17 Throughout the process, the judiciary found that Michael Schiavo, her 1.

An advance directive consists of a patient’s wishes regarding how his or her health care should be managed when he or she loses decision-making capacity.

2.

All fifty states recognize some form of both an

individual instruction directive and a proxy directive.

3.

Any patient at any stage of life can fill out an advance directive.

4.

The patient in the presence of two witnesses or a

notary republic can complete an advanced directive.

5.

An advance directive can be changed or revoked at any time.

6.

Physicians should encourage their patients to

discuss their wishes with family members even if

they have not completed a statutory advance directive.

7.

In contrast to an advance directive, Physician Orders for Life Sustaining Treatment are actually physician orders and are meant only for terminally ill patients.

112 JOURNAL MSMA April 2014

legal husband, acted appropriately and attentively and that the diagnosis of persistent vegetative state (PVS), though highly debated, was reliable. Furthermore, evidence supported the husband’s conclusion that his wife would not want to live in a persistent vegetative state. These findings remained constant, surviving numerous but unsuccessful motions and intrusions from national advocacy groups and the federal government.

As exemplified by the case of Terri Schiavo, early and routine advance care planning is ideal since a person’s capacity to make decisions may diminish over the progression of a chronic debilitating illness or suddenly as in the case of a cardiac arrest. The goal of advance care planning is to ensure that the goals of care are prospectively mapped-out, whether written or verbal, so that comfort and resource use can be maximized according to the patient’s autonomy and disputes over end-of-life treatment goals can be avoided at a powerful, significant time in the life of the dying patient.

References 1.

American Medical Association, Council on Ethical and Judicial Affairs: Code of medical ethics: current opinions with annotations, 2010-2011 ed, Chicago, 2010, American Medical Association, Opinion 2.225; 125-126.

2.

Cruzan v Director, Missouri Department of Health, 497 US 261 (1990).

3.

Patient Self Determination Act (PSDA). Omnibus Reconciliation Act of 1990.

4.

Connors AF, Jr, Dawson NV, Desbiens NA, et al. A Controlled Trial to Improve Care for Seriously III Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA 1995;274(20):1591-1598.

5.

Mississippi, Miss. Code Ann. §§ 41-41-201 to 41-41-229. Uniform Health Care Decisions Act. Available at: http://www.nccusl.org/Update/ ActSearchResults.aspx. Accessed April 13, 2013.

6.

Emanuel LL, Barry MJ, Stoeckle JD, Ettelson LM, Emanuel EJ. Advance directives for medical care: A case for greater use. N Engl J Med 1991;324(13):889-895.

7.

Bravo G, Dubois MF, Paquet M. Advance directives for health care and research: Prevalence and correlates. Alzheimer Dis Assoc Disord 2003;17(4):215-222.

8.

Kwak J, Haley WE. Current research findings on end-of-life decision making among racially or ethnically diverse groups. Gerontologist 2005;45(5):634-641.

9.

Searight HR, Gafford J. Cultural diversity at the end of life: Issues and guidelines for family physicians. Am Fam Physician 2005;71(3):515-522.

10. Thelen M. End-of-life decision-making in intensive care. Crit Care Nurse 2005;25(6):28-37.

11. Oliver DP, Porock D, Zweig S. End-of-life care in U.S nursing homes: A review of the evidence. J Am Med Dir Assoc 2004;5(3):147-155.

12. Jones AL, Moss AJ, Harris-Kojetin LD. Use of advance directives in longterm care populations. NCHS data brief, no 54. Hyattsville, MD: National Center for Health Statistics. 2011.

13. Ramsaroop SD, Reid MC, Adelman RD. Completing an advance directive in the primary care setting: what do we need for success? J Am Geriatr Soc 2007;55(2):277-283.

14. Spoelhof GD, Elliott B. Implementing advance directives in office practice. Am Fam Physician 2012;85(5):461-466.

15. Aitken PV. Incorporating advance care planning into family practice. Am Fam Physician 1999;59(3):605-614,617-620.

16. Norris LT, Douglas SP. Series: Concepts in end-of-life care, do not resuscitate (DNR). J Miss Med Assoc. 2013,54(6):164-174.

17. Cerminara K, Goodman K. Key events in the case of Theresa Marie Schiavo. Available at: http://www.miami.edu/ethics2/schiavo/timeline. htm. Accessed February 2, 2014.

• Scientific •

Patient Perception of Care Received by Students at the Jackson Free Clinic Jeb S. Clark, MS; Adam Bollaert, JD; Stephen O. Sills, MD; Joy H. Clark, PhD; David Norris, MD

A

bstract

Introduction. Little has been done to examine the role of student-run free clinics in patient care. In this study we examine patient perceptions of care provided by medical students in comparison to that provided by licensed physicians.

Care providers were judged on perceived exam thoroughness, trust, and overall patient satisfaction.

Methods. Patients were asked to complete a 37 question survey after being examined by either medical students or by a physician.

Results. Differences between physicians and students were not observed for perceived thoroughness, trust, or overall satisfaction scores. Patients who reported never being married gave lower satisfaction scores (p = 0.024); however, all patients reported being satisfied with their care.

Conclusions. Patients are satisfied with the care they received at the Jackson Free Clinic regardless of the provider’s level of training. Patients did not report students to be less thorough in their exams than physicians. Furthermore, patients reported equal trust in students and physicians.

Key words: Student Run, Free Clinic, Satisfaction

Introduction

There are 111 student-run clinics in the United States.1 Student-run clinics are somewhat atypical in their accessibility, manner in which patients are treated, populations served, and services provided. The Jackson Free Clinic (JFC) is a student-run clinic in the heart of Jackson, Mississippi, which opened in the fall of 2000, to provide both learning experiences Author Information: Current medical student (M4) at University of Mississippi and Chairman of Research at the Jackson Free Clinic (Mr. Clark). Frequent volunteer at the Jackson Free Clinic (Mr. Bollaert). Former Jackson Free Clinic Student Director and current anesthesiology resident at Virginia Mason Medical Center, WA (Dr. Sills). Clinical psychologist at Methodist Rehabilitation Center who has completed several studies in cross-cultural research (Dr. Clark).

Assistant Professor in the Department of Family Medicine at the University of Mississippi and the Jackson Free Clinic physician board member (Dr. Norris).

Corresponding Author: Jeb Clark, Jackson Free Clinic, Attn: Research Chair, PO Box 4892, Jackson, MS 39296-4892 ph: (601)355-5161 (JSClark@umc.edu).

for medical students of the University of Mississippi Medical Center School of Medicine as well as acute, chronic, and preventive care to the uninsured population of Jackson. The care model employed at JFC makes use of volunteer medical students to provide the base of care to patients. Typically, student volunteers assemble in teams of three to five with at least one senior student (third- or fourth-year medical student) with the remaining team members ranging in their medical training level from undergraduate students to second-year medical students. Typical operations at JFC consist of the patient receiving a full patient interview and physical exam by the student team followed by a period during which the student team deliberates and decides on a plan of treatment. Treatment plans are then discussed with a volunteer attending physician who repeats the examination as necessary. Treatment plan implementation is then carried out by the student team.

Patient satisfaction surveys have become an increasingly important method of evaluating physicians and their practices.2-5 These surveys have shown that satisfaction is not affected by the level of health care provider who provides the treatment.6 With the advent of the student-run free clinic, the role of medical students as health care providers and administrators has largely increased.7 The effect of student participation in patient care has long been debated as to its impact on patient satisfaction.1,8-12 However, these studies focused on the effect of student-patient interaction on patient satisfaction among insured populations. It is well documented that minority populations, which make up a disproportionate number of free clinic customers, are less likely to receive appropriate care and more likely to be dissatisfied.13-15 To date, only a single student-run free clinic has determined that the population they serve is satisfied with the care they receive.16 Therefore, a deficit exists in the knowledge surrounding the populations served by studentrun free clinics. Due to this disparity in data concerning the patient population served by student-run free clinics and the level of patient satisfaction in these clinics, we conducted a six month study to examine patient satisfaction in JFC and specifically to examine the effect of student-patient interaction, in comparison to physician-patient interaction, on patient satisfaction. Furthermore, we attempted to correlate specific patient demographics to identify key factors that are likely indicators of patient satisfaction.

April 2014 JOURNAL MSMA 113

Methods

Study Design. Each week, JFC begins seeing patients at 11:30am, and patients are seen in the order of arrival. The typical procedure for patient care is outlined in Figure 1. Depending on the complexity of the patient’s illness, a single student group may see one patient per hour on average.

For this study, student groups continued to operate as indicated above; however, during the period of deliberation, patients were administered the study questionnaire by a member of the research staff. Patients were asked to complete the questionnaire prior to the return of their student group and prior to having any treatment rendered to them. Upon completion, patients deposited the completed survey in a designated receptacle. To determine if patient satisfaction is influenced by student-patient interaction, physician volunteers were also asked to interview

patients. To minimize differences in patient wait times, physicians were asked to see no more than one patient every hour.

Furthermore, following patient interviews, physicians deliberated for approximately 20 minutes, during which time the physician’s patient was administered the survey (Figure 1). Surveys were administered to every patient at Jackson Free Clinic each week for a period of six months. Each patient was allowed to complete only one survey during the study period. This study was designated as exempt from IRB approval by the University of Mississippi IRB.

Student Groups. Each week, depending on the number of senior student volunteers (third- and fourth-year medical students), 1 to 5 student groups were organized. Underclassmen and pre-medical students were randomly assigned to these groups by a member of the JFC staff who was not a Figure 1. Flow chart and time scale for patient care at Jackson Free member of the research team. For inclusion in this Clinic during this study. Typically, patients are interviewed and examined study, groups consisted of only one upper classman by students. The students then deliberate to determine a treatment plan and no more than three and no less than two underwhich is then presented to an attending physician. Following patient classmen or pre-medical students. Groups of this presentation, treatment is rendered by the students as deemed necessary size and makeup are representative of the typical by the attending physician. For the purpose of this study, physicians were group assignments at the JFC. asked to interview and examine patients, following a similar time scale as students. Surveys were administered to patients in the portion of the time scale shaded in gray.

Physician Volunteers. Physician volunteers are recruited from local hospitals and clinics on a regular basis by a member of the JFC staff who is not associated with this study. Typical physician volunteers are licensed Family Medicine or Internal Medicine physicians. Jackson Free Clinic does designate specific days when dermatology, gynecology, and ophthalmology specialists treat patients. However, for the purposes of this study, patients seen by these specialists and any student groups involved with these patients were not included.

Treatment Assignment. Assignments for patients to be treated by volunteer physicians or student teams were made by a member of the JFC staff who was not part of the study. Staff members were asked to ensure that all student groups had been assigned patients prior to physician assignments being made. However, all assignments were based on patient order of arrival. There was no knowledge of patient complaint or treatment complexity prior to assignment.

Figure 1.

114 JOURNAL MSMA April 2014

Patient Population. Jackson Free Clinic limits its patient population to the uninsured. Many of the patients are unemployed and/or homeless. The majority of patient visits are typical for Mississippi and consist largely of management of hypertension, diabetes, and cholesterol. However, other common patient complaints include depression and back and joint pain.

Administration of Questionnaire. Questionnaires were administered to patients during physician/student group deliberation, following patient interviews and physical exams. Administration of the questionnaire was completed by a member of the research staff at JFC. Research staff were not allowed to be involved with patient care during the course of this study.

Patients were informed that participation was voluntary and that questionnaires were used for research purposes and to improve JFC. They were also informed that their responses were anonymous and seen only by research staff. Furthermore, patients were asked to base their responses to questionnaire questions on their interaction with students/physicians they interacted with that day. Upon completion of the questionnaire, patients were asked to return the questionnaire to a designated recepTable. Jackson Free Clinic Patient Demographics Count/Value/Ratio # of sampled (n) # had insurance at some point since age 25 Time as a Patient at JFC First Visit Less than 6 months Between 6 mo – 1 yr Between 1 yr - 3 yrs Greater than 3 yrs Age Min Max Average Sex Males sampled Females sampled Race African American Caucasian Hispanic Asian Other Family Married Separated Divorced Widowed Never Married Income Below $20,000 Between $20,000 - 39,999 Between $40,000 -59,999 Education < HS Diploma HS Diploma / GED At least some college College Degree Self-Reported Medical Issues Hypertension Diabetes Dyslipidemia Headaches/Migraines Obesity Seasonal Allergies Back Pain Heart Failure Asthma Depression

43 28 12 5 5 13 8 29 65 49 15 28 35 6 1 0 1 17 7 4 3 12

tacle. For those unable or incapable of reading the questionnaire, a member of the research staff verbally administered the questionnaire, or a family member of the patient, if present, was given the option of communicating the questions to the patient.

Survey Instrument. The questionnaire developed for this study was modeled after the Primary Care Assessment Survey (PCAS).3 Questions from the PCAS that were not deemed appropriate for the study population or JFC operations were either modified or excluded from this study’s questionnaire. The questionnaire consisted of three sections. The first section contained nine general demographic questions focusing on patient age, sex, race, family income, education level, and patient’s perceived health status. No personally identifiable information (name, social security number, etc.) was collected as part of the questionnaire. The second section of the survey contained 20 questions which per% of population tained to the patient interview, evaluating interviewer thoroughness/communication and trust as 65% well as the patient’s level of satisfaction with his or her care. The third section consisted of eight 27.9% questions which pertained to overall patient satis11.6% faction with JFC operations. All questions, with 11.6% 30.2% the exception of one question from each of sections 18.6% two and three, were measured using a Likert Scale containing six possible answers ranging from very poor to excellent. The third section of the survey also contained an extra question concerning patient thoughts on receiving care from medical students.

35% 65% For this question, possible patient responses were: “I do not like students being part of my health care 81% 13.9% and only want a physician,” “I do not mind stu2.3% dents as long as a physician is also in the room,” “I 0% don’t care as long as I get the care I need,” and “I 2.3% prefer being treated by medical students and seeing 39.5% the physician only when needed.”

16.3% 9.3% 6.9% 27.9%

36 6 1

85.7% 14.2% 2.3%

8 21 12 2

18.6% 48.8% 27.9% 4.6%

32 13 19 15 14 16 17 6 4 15

74.4% 30.2% 44.1% 34.8% 32.5% 37.2% 39.5% 13.9% 9.3% 34.8%

Statistical Analysis. Patient responses to questions were converted to a numerical score ranging from one (Very poor) to six (Excellent).

Question groupings which evaluated thoroughness/communication, trust, and overall satisfaction were analyzed using Item Analysis.17 Questions which resulted in a Cronbach’s alpha < 0.70 were excluded from analysis. Summed scores for each of the question groupings were generated for further analyses. A MANOVA was completed with summed thoroughness, trust, and satisfaction scores as dependent variables to determine if patient demographics and/or care providers (student or physician) were significant descriptors. Significance is reported when p < 0.05. When a significant descriptor was found, either Chi-Square or

April 2014 JOURNAL MSMA 115

LSD Post-Hoc tests were completed as appropriate. All statistical analyses were completed using SPSS 20 (IBM Inc, Armonk, NY, USA).

Results

Patient Demographics. Every patient that visited JFC during the 6 months of the study was asked to complete a survey. A total of 46 surveys were administered of which 43 were completed and returned by patients (93% completion rate).

Of the 43 completed surveys, 16 were completed by patients who were examined strictly by physicians; the remaining 27 were completed by patients who interacted strictly with student groups. Patient demographics are displayed in the Table. The majority of patients sampled (30.2%) have been patients of JFC for a period greater than one year but less than three years, while 27.9% of patients were sampled during their first visit to JFC. Sixty-five percent of patients reported that at some point in their life, since the age of 25, they have had health insurance.

Patient’s ages ranged from 29 to 65 with an mean age of 49. For every female patient sampled, 0.53 males were sampled. The majority of patients (81%) were African-American. Eighty-five point six percent of patients reported a yearly family income of less than $20,000 and 48.8% claimed to have completed high school or obtained a GED. The most common self-reported medical problems were hypertension (74.4%) and high cholesterol (44.1%).

Thoroughness. A total of 8 questions were used to analyze the patient’s perception of how thorough the students/physicians were in their care. Item analysis of the eight questions Figure 2. Mean summed scores for thoroughness (○), trust (□) and satisfaction scores (×) for patients treated by physicians and students. Whiskers represent standard deviations of the mean. No significant differences were observed between patients interviewed and examined by students or physicians for thoroughness, trust or satisfaction.

Thoroughness Trust OverallSatisfaction

60

produced a Cronbach’s Alpha of 0.942. Summed thoroughness scores are shown in Figure 2. There was no significant association of patient demographics with thoroughness ratings. Furthermore, there was no significant difference in thoroughness ratings between patients seen by physicians and those seen by student groups.

Trust. A total of 7 questions were used to analyze the patient’s trust in their care provider. However, Item Analysis of the seven questions produced a Cronbach’s Alpha of 0.65.

Therefore, two questions were removed from the analysis to produce a Cronbach’s Alpha of 0.706. Summed trust scores are shown in Figure 2. Trust scores were not associated with any of the patient demographic factors collected. Also, trust scores were not significantly different between patients examined by physicians and those examined by students. Prior insurance status approached significance as an indicator of trust (p = 0.066).

Overall Satisfaction. A total of 5 questions were used to analyze patient overall satisfaction with JFC. These five questions produced a Cronbach’s Alpha of 0.862. Summed overall satisfaction scores are shown in Figure 2. All patients indicated that the care they received at JFC was as good as or better than other clinics patients had attended. Also, all patients who completed the survey indicated that they would recommend JFC to friends and family members. Of the patient demographic factors collected, marital status, shown in Figure 3, was a significant indicator of patient satisfaction (p = 0.024). Patients who reported never being married were less satisfied with their Figure 3. The effect of patient marriage status on satisfaction scores. Patients who reported having never been married had significantly lower satisfaction scores than patients who were widowed (p = 0.022), patients who were married (p = 0.006) and patients who were reportedly separated (p = 0.037). Divorced patients did not report significantly different satisfaction scores as those who were never married. Circles represent means.

Whiskers represent standard deviations of the mean.

AB

50

40.00

A

Overall Satisfaction

Mean Score

A 40

30

20

A B

35.00

30.00

10

0

Student

Physician

25.00

Care Provider

Figure 2.

116 JOURNAL MSMA April 2014

married

separated

divorced

Marriage Status

Figure 3.

widowed

never married

care. No significant differences in patient satisfaction scores were noted in patients treated by physicians compared to those treated by student groups.

Patient thoughts on care provided by medical students.

None of the patients indicated that they did not like medical students as part of their care. Roughly 31% of patients indicated that they prefer the presence of a physician in the room with the medical student, 48% indicated that they didnâ&#x20AC;&#x2122;t care who provided the medical care as long as the patient got the treatment they needed, and 21% responded that they prefer being treated by medical students and only interacting with the attending physician when necessary.

Discussion

The clinic model employed by JFC is unique among the primary care facilities in Mississippi in that JFC is only open on a single day of the week and provides completely free medical care to the uninsured. The most significant difference, however, is that volunteer medical students provide this free medical care. The clinic model employed at JFC is not unique among the 111 established student-run free clinics.7 In general, patients are satisfied with the care they receive at free clinics.18 The Community Aid, Relief, Education, and Support (C.A.R.E.S.) clinic, run by students at the Medical University of South Carolina, operates under a similar clinic model as JFC, and reports similarly high levels of patient satisfaction, but with a patient population that is largely Caucasian.16 The patient population of JFC consists largely of African-Americans (81%) of low socio-economic status. AfricanAmericans have been shown to be less satisfied with their health care.13,19 Proposed reasons for lower satisfaction scores among African-Americans include perceived discrimination20,21 and higher expectations of care.22 In contrast, the present study demonstrated high satisfaction and trust scores among the predominantly African-American population served by JFC. One specific goal of this study was to examine if patient satisfaction is negatively impacted when students act as the primary interface for medical care. Student involvement in patient care has been the subject of several studies and shown to have little to no effect on patient satisfaction.1,9,11 However, the study conducted by Gress et al randomly assigned patients to be treated by physicians only or by a medical student followed by a physician; while patient satisfaction scores were not significantly affected by medical student treatment, a majority of patients stated they would prefer not to see students in subsequent visits.9 Interestingly, the data collected in the current study does not correlate with the results of Gress et al. Patients of JFC who were treated by physicians expressed equal levels of trust as those treated by students. Patients did not indicate that medical students were significantly less thorough in their interviews and exams than physicians. In addition, 48% of JFC patients indicated no preference in who provided their medical care and

another 21% specifically indicated that they prefer medical students over physicians. Finally, 65% of the patients which took part in this study were established patients. This discrepancy is most likely explained by the fact that patients who are willing to receive care at student-run free clinics make up a specific subset of the population which is not represented by the current literature. It is also possible that medical students spend more time empathizing with and teaching patients. Further research is needed to determine what factors, unique to student-run free clinics, impact patient satisfaction levels.

We acknowledge that this study was limited by a small sample size and as a result, the statistical power was low. The patient population included homeless individuals withouth mail or internet, requiring us to administer the survey during clinic. Although their participation in this study was optional and would not affect their care, we cannot exclude the possibility that this could have influenced patient responses to the questionnaire. We also cannot exclude that responses to the questionnaire were not influenced by previous interactions with JFC volunteers. Despite these limitations, the high satisfaction scores returned by all patients in this study suggest that patients of JFC are satisfied with the care they receive regardless of the level of care provider.

Acknowledgments Thanks to all student volunteers at Jackson Free Clinic as well as to all physician volunteers who participated in this study. Special thanks to Dr. Jerry Clark, associate Dean of Students, for supporting this study and operations at the JFC.

References 1.

Simon SR, Peters AS, Christiansen CL, et al. Effect of medical student teaching on patient satisfaction in a managed care setting.

J Gen Intern Med. 2000;15:457-461.

2.

Evans RG, Edwards A, Evans S, et al. Assessing the practicing physician using patient surveys: a systematic review of instruments and feedback methods. Fam Prac. 2007;24: 117-127.

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Safran DG, Taira DA, Rogers WH, et al. Linking primary care performance to outcomes of care. J Fam Prac. 1998;47:213-220.

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Taira DA, Safran DG, Seto TB, et al. Do patient assessments of primary care differ by patient ethnicity. Health Serv Res. 2001;36:1059-1071.

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White B. Measuring patient satisfaction: How to do it and why to bother. Fam Pract Manag. 1999;6:40-44.

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Hooker RS, Potts R and Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. Permanente J. 1997;1:38-42.

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Simpson SA and Long JA. Medical student-run health clinics: important contributors to patient care and medical education. J Gen Intern Med. 2007;22:352-356.

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Ching SL, Gates EA and Robertson PA. Factors influencing obstetric and gynecological patientsâ&#x20AC;&#x2122; decisions towards medical student involvement in the outpatient setting. Am J Obstet Gynecol.

2000;182:1429-1432.

9.

Gress TW, Flynn JA, Rubin HR, et al. Effect of student involvement on patient perceptions of ambulatory care visits. J Gen Intern Med. 2002;17:420-427.

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10. Moore GT. Health maintenance organizations and medical education: breaking the barriers. Acad Med. 1990;65:427-432.

11. O’Malley PG, Omori DM, Landry FJ, et al. A prospective study to assess the effect of ambulatory teaching on patient satisfaction.

Acad Med. 1997;72:1015-1017.

THE

12. Santen SA, Hemphill RR, Spanier CM, et al. ‘Sorry, its my first time!’ Will patients consent to medical students learning procedures. Med Ed. 2005;39:365-369.

13. Becker G and Newsom E. Socioeconomic status and dissatisfaction with health care among chronically ill African-Americans.

Am J Public Health. 2003;93:742-748.

L.L.C

writing enhancement for all professional documents

Making what you write right!

14. Clancy CM and Stryer DB. Racial and ethnic disparities and primary care experience. Heath Serv Res. 2001;36:979-986.

15. Fiscella K and Epstein RM. So much to do, so little time: Care for the socially disadvantaged and the 15-minute visit. Arch Intern Med. 2008;168:1843-1852.

Providing writing, editing, and polishing for medical articles and journals THE

16. Ellett JD, Campbell JA and Gonsalves WC. Patient satisfaction in a student-run free medical clinic. Fam Med. 2010;42:16-18.

17. Strube MJ. Reliability and generalizability theory, in Reading and understanding more multivariate statistics, ed 1, Grimm LG and Yarnold PR (ed). Washington DC: American Psychological Association; 2000:23-66.

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18. Gertz AM, Frank S and Blixen CE. A survey of patients and providers at free clinics across the United States. J Commun Health.

2011;36:83-93.

19. Barr DA. Race/ethnicity and patient satisfaction: using the appropriate method to test for perceived differences in care. J Gen Intern Med. 2004;19:937-943.

20. Fowler-Brown A, Ashkin E, Corbie-Smith G, et al. Perception of racial barriers to health care in the rural south. J. Health Care Poor U. 2006;17:86-100.

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21. Sorkin DH, Ngo-Metzger Q and De Alba I. Racial/ethnic discrimination in health care: impact on perceived quality of care. J Gen The Writeologist Medical ad.indd Intern Med. 2010;25:390-396.

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22. Guerra CE, McDonald VJ, Ravenell KL, et al. Effect of race on patient expectations regarding their primary care physicians. Fam Pract. 2008;25:49-55.

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12th Annual CME in the Sand

May 24-27, 2014 Sandestin Golf and Beach Resort

ATTENDEE REGISTRATION: (Please PRINT Clearly) Name: Practice/Clinic Name: Specialty:

E-mail:

Preferred Address: City:

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EVENT REGISTRATION: (All events are included in registration fee. Please check all that you plan to attend) CME Sessions – May 24 - 27

# Adults

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Welcome Reception – Sunday, May 25 Family Dinner – Monday, May 26

Registration is $300. Payment accepted by check or credit card or visit www.MSMAonline.com to register online.

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CANCELLATION POLICY: In the event that you need to cancel your reservation, your full registration fee, less $50 processing fee, will be refunded if notified on or before May 1. No refunds will be made after May 1.

Please send completed registration forms with payment to: Mississippi State Medical Association, Attn: Jenny White, PO Box 2548, Ridgeland, MS 39158 or fax to (601)853-6746

April 2014 JOURNAL MSMA 123

• Clinical Problem-Solving • My Aching Muscles Preston McDonnell, MD and Shannon Pittman-Moore, MD

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37-year-old black female with a past medical history of hypertension, depression and allergic rhinitis presented to clinic for follow up of depression and her annual Pap smear. She complained of seasonal allergies which required a recent visit to the emergency department. She had been taking her antidepressants as prescribed and thought her depression was well controlled. She complained of abdominal pain associated with exercise and sit ups. She also described tightness in her arms associated with over-the-head activities and with cooking and stirring. Her review of systems was otherwise negative. Her vital signs and physical exam were unremarkable with the exception of slight left arm pain when the rotator cuff was tested. The motor and sensory exam of the upper extremities was normal.

The patient’s complaint of pain in her abdomen and arms is nonspecific. It would be helpful to know if the patient has had any recent events that could predispose her to a rotator cuff injury. Pain with over head activities is common with rotator cuff injuries.1 Conservative management at this point would be appropriate given the clinical presentation.

The patient was referred to physical therapy, prescribed meloxicam (Mobic) 15 mg daily and asked to follow up in 1 month. The patient returned to clinic 3 months later complaining of diffuse muscle aches in her shoulders, arms, legs and back. She stated that it had become increasingly difficult to walk and comb her hair. She reported that she never went to physical therapy as recommended and the pain in her muscles had been gradually worsening. She denied recent fevers or night sweats. She denied weight loss or skin rashes. On exam, her vital signs were stable with a blood pressure of 127/82 mmHg and a pulse of 84 beats per minute. She was afebrile with a normal respiratory rate.

Her physical exam showed what appeared to be muscle hypertrophy in her arms and decreased range of motion of her shoulders bilaterally.

Author Information: Dr. McDonnell was a resident in the Department of Family Medicine at the University of Mississippi School of Medicine. Dr. Pittman-Moore is Associate Professor and Residency Director, Medical Director, UP Family Medicine, University of Mississippi Medical Center, Department of Family Medicine, Jackson.

Corresponding Author: Preston McDonnell, MD; Copiah Medical Associates, 123 Bobo Drive, Crystal Springs, MS 39059 (Preston_ mcdonnell@hotmail.com).

124 JOURNAL MSMA April 2014

Some consideration should be given to conditions that cause generalized myalgias, with particular attention to the autoimmune diseases, particularly lupus. About 9 out of 10 people diagnosed with lupus are women ages 15-45, and African American women are three times more likely to be diagnosed with lupus than Caucasian women.2 Infectious causes should also be considered. Metabolic processes can cause generalize myalgias as well. Given her history of depression, fibromyalgia would also be plausible. Depression is present in 30 to 50 percent of patients at the time of diagnosis of fibromyalgia.3 Further history and laboratory investigation is recommended.

The patient was continued on meloxicam, and creatine kinase (CK), antinuclear antibody (ANA) reflex panel, erythrocyte sedimentation rate and rheumatoid factor (RF) studies were ordered. Two weeks later the patient returned to clinic with diffuse muscle swelling and pain.

She had facial edema and pain in her arms, hands, legs and back. She denied rash or fever. Since her most recent clinic visit, she had been admitted to the hospital for chest pain evaluation. Her workup had been negative for an acute myocardial infarction, but she was found to have an elevated CK of 4141 U/L (reference range 3-232 U/L). She denied recent travel foreign or domestic and reported no recent exposures to ticks and no fever. There was no recent change in her medications. She denied a family history of lupus, rheumatoid arthritis or sarcoid. Her physical exam showed normal vital signs. She was not in acute distress. She was able to rise from a seated position without assistance. Her arms and legs were tight and tender due to the edema. No rash or erythema was appreciated. Her face was edematous.

She had 1+ pitting edema in her arms and legs. Review of her lab results from her hospitalization indicated an elevated ANA in addition to the elevated CK already noted.

The ANA titer was 1:320 (normal titer 1:80 or less). The patient was referred to a rheumatologist, and additional studies were ordered. She was prescribed prednisone 60mg daily, tapered over 6 days to 10 mg. She was encouraged to continue aggressive oral hydration with water.

Given the elevated CK, evaluation of her kidney function is warranted. Aggressive hydration is appropriate to protect the kidneys. Further investigation to identify the cause of her elevated CK and ANA is also warranted. Has the patient taken medications commonly associated with an elevated CK

such as a statin or a recreation drug such as cocaine? With the elevated ANA, further ANA testing needs to be done to confirm lupus. An anti-dsDNA antibody and anti-Smith antibody are most appropriate. Given the swelling and tightness of the skin, scleroderma should be considered as well.

A repeat CK 2 weeks later was still elevated at 4874 U/L. Her erythrocyte sedimentation rate, RF and reflexive ANA panel were normal. However, the patient’s creatinine was elevated to 1.42 mg/dL. Her baseline creatinine was 0.8 mg/dL. Given her rise in creatinine and persistently elevated CK, the patient was sent to the hospital for direct admission.

It is necessary to obtain another thorough history and physical exam to identify missing pieces that could give clues to her diagnosis. At the top of our differential is an autoimmune process, but what else could cause this presentation? The patient is taking no medicines that should affect her CK, and she reports no recent strenuous events.

Further history tells us that other than depressive symptoms, the patient also has been having significant constipation, a noted weight gain of 15 pounds, constant fatigue and cold/heat intolerance over the last 4 months.

The patient’s symptoms follow a classic pattern of hypothyroidism, which is seen fairly commonly in middle aged females. Muscle complaints (weakness, cramps, myalgias) have occurred in 79% of patients with hypothyroidism.4 CK elevation occurs in 57-90% of patients with hypothyroidism.5 Accordingly, we will investigate her thyroid function.

On the morning after admission, the patient’s thyroid stimulating hormone (TSH) was elevated at 92.51 (normal 0.27 - 4.20 mcIU/mL). Also, the patient’s urine myoglobin was positive. This finding along with the CK greater that 10 times the upper limit of normal is consistent with the diagnosis of rhabdomyolysis. In addition to intravenous fluids, the patient was prescribed levothyroxine (Synthroid) 100 mcg daily based on her weight.

Now we have a cause for our clinical features and abnormal lab studies: hypothyroid induced rhabdomyolysis.

There have been several case reports of extremely high elevations of serum CK and rhabdomyolysis associated with hypothyroidism.6,7 It is important to make sure that the patient’s kidney function and CK concentration trend down to prevent any permanent damage. CK concentrations fall quickly with treatment, normalizing over a few weeks, generally well before TSH concentrations normalize.8 Clinical symptoms recover more slowly over a median of 5.5 months.4 The patient remained hospitalized for 2 additional days until her kidney function began trending to normal (1.2mg/dL at discharge) as well as her CK (1204 U/L at discharge). At clinic follow up over the next 4 months the patient’s kidney function and CK concentration returned to her baseline. Her TSH normalized along with resolution of her clinical symptoms by this follow up.

Key Words: Hypothyroidism, Renal Insufficiency,

Rhabdomyolysis References 1.

OrthoInfo.aaos.org. Rotator Cuff Tears. Available at: http://orthoinfo. aaos.org/topic.cfm?topic=A00064. Accessed March 16, 2012.

2.

WomensHealth.gov. Lupus Fact Sheet. Available at: http://www. womenshealth.gov/publications/our-publications/fact-sheet/lupus.cfm.

Accessed April 21, 2012.

3.

Weir PT, Harlan GA, Nkoy FL, et al. The incidence of fibromyalgia and its associated comorbidities: a population-based retrospective cohort study based on International Classification of Diseases, 9th Revision codes. J Clin Rheumatol. 2006; 12:124-128.

4.

Duyff RF, Van den Bosch J, Laman DM, et al. Neuromuscular findings in thyroid dysfunction: a prosepective clinical and electrodiagnostic study. J Neurol Neurosurg Psychiatry 2000; 68:750-755.

5.

Hekimsoy Z, Oktem IK. Serum creatine kinase levels in overt and subclinical hypothyroidism. Edocr Res. 2005; 31:171-175.

6.

Halverson PB, Kozin F, Ryan LM, Sulaiman AR. Rhabdomyolysis and renal failure in hypothyroidism. Ann Intern Med. 1979; 91:57-58.

7.

Sekine N, Yamamoto M, Michikawa M, et al. Rhabdomyolysis and acute renal failure in a patient with hypothyroidism. Intern Med 1993; 32:269-271.

8.

Madariaga MG. Polymyositis-like syndrome in hypothyroidism: review of cases reported over the past twenty-five years. Thyroid 2002; 12:331-336.

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• President’s Page • The Prescription Drug Abuse Epidemic

P

rescription drug abuse is the fastest growing drug problem within the United States. We have all witnessed the staggering extent of analgesic prescription drug use within our practices. It is not unusual within the course of my day to see multiple consecutive patients all of whom are on a narcotic analgesic or anxiolytic of some form or another. Indeed the current crisis dwarfs any other drug epidemic in the history of our nation.

James A. Rish, MD 2013-14 MSMA President

The number of prescriptions filled for opioid pain relievers has dramatically increased over the past decade and a half. Distribution through the pharmaceutical supply chain was the equivalent of 96 milligrams of morphine per person in 1997 and a whopping 700 milligrams per person in 2007, representing an increase of greater than 600%. This represents enough morphine per person for everyone in the United States to take 5 mg of Vicodin every 4 hours for three weeks.

According to data from the National Survey on Drug Use and Health (NSDUH), nearly one-third of people aged 12 and over who used drugs for the first time in 2009 began so by using a prescription drug non-medically. Because these medications are prescribed by a medical professional and dispensed by a pharmacist, some naively believe that these substances are safer than illicit drugs.

Opiate overdoses, once almost exclusively related to heroin use, are now increasingly due to abuse of prescription painkillers. The use of opioid analgesics has driven the increase in unintentional drug overdose death rates. Since 2003 opioid analgesics have been involved in more overdose deaths than heroin and cocaine combined. In 2007 there were approximately 27,000 unintentional drug overdose deaths in the United States which equates to 1 death every 19 minutes! If that does not get your attention, for every unintentional opioid analgesic overdose death nine persons are admitted for substance abuse treatment, 35 visit our emergency rooms, 161 report drug abuse or dependence, and 461 report using opioid analgesics for nonmedical purposes.

How we reached this point is a question that has been the subject of much discussion. Care for patients with complex chronic pain problems is challenging, and education on the appropriate use of these very addictive medications is lacking to a significant degree in our training. We have also born witness to creation of a culture in which no one should ever have to endure pain. Certainly the Joint Commission’s campaign promoting pain as the fifth vital sign has heightened our awareness of chronic pain among our patients, and in doing so, may have contributed to overzealous prescribing of these medications. While temperature, heart rate, respiratory rate, and blood pressure are objective measures; the perception of pain is not. One’s pain threshold can vary quite substantially from individual to individual. In addition, we are all familiar with the seemingly growing number of patients who spend a great deal of time and effort doctor shopping for these types of medications. These persons are not only at high risk for overdose themselves but also for diverting drugs to others for nonmedical use often at substantial profit.

Therefore, there could be growing economic motivation for this behavior.

The real question is how do we go about addressing this enormous societal burden. The stakes are obviously high. If we are unsuccessful in solving this problem, we will invite additional regulation and legislative intervention that I suspect will not be welcomed by our profession. Take, for example, Kentucky where one is are required by law to query the Prescription Drug Monitoring System data bank each and every time a prescription of this type is written.

126 JOURNAL MSMA April 2014

I doubt anyone would argue that education is one of our most powerful weapons in this war. We must wage public educational campaigns on the dangers and risks of these types of drugs. We must also educate healthcare professionals on responsible prescribing practices. Doctor shopping is a crime in Mississippi. We must be vigilant in identifying patients that doctor shop, and, when identified, refer them to drug rehabilitation programs and/ or notify the authorities. We must have a robust prescription drug monitoring program to identify doctor shoppers and problem prescribers.

I am proud to mention that your medical association has been very proactive in dealing with this challenging issue. MSMA has developed educational resources for physicians treating chronic pain. There are also educational handouts available for patients who struggle with prescription drug abuse. In addition, there are posters available to place in your waiting rooms and exam rooms to raise awareness of prescription drug abuse and diversion. If you would like copies of these valuable resources for your practice, please contact Hannah Duchesne at HDuchesne@MSMAonline.com.

MSMA, along with the pharmacy board, has also been actively involved in working with the Prescription Monitoring Program to become more user-friendly and easily accessible. Physicians holding a Mississippi license are required to be enrolled in the program. I would encourage you to consult this powerful tool when prescribing these medications.

The Mississippi State Board of Medical Licensure now requires each Mississippi physician holding a DEA certificate to get at least five CME hours related to prescribing. I have to confess that at first I was a little outdone with this requirement as were many of you. However, I must say that it was an eye-opening experience and the motivation behind my writing this article.

MSMA has twelve CME hours available at a nominal cost that meet the requirements of the licensure board. It is accessible 24/7 at MSMAonline.com so as to have a minimal impact on time away from the office. The five required hours are also included in the CME available at CME in the Sand scheduled for the Memorial Day weekend in Destin. I would love to see you there.

PHYSICIANS NEEDED Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, Neurologists, Psychiatrists, etc. interested in performing consultative evaluations according to Social Security guidelines.

OR Physicians to review Social Security disability claims at the

Mississippi Department of Rehabilitation Services (MDRS) in Madison MS.

Contact us at: Mary Jane Williams 601-853-5556 or Gwendolyn Williams 601- 853-5449

DISABILITY DETERMINATION SERVICES 1-800-962-2230

April 2014 JOURNAL MSMA 127

â&#x20AC;˘ Editorial â&#x20AC;˘ Health Disparities, Population Health, and Preventive Medicine

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Michael Mansour, MD

ardiovascular disease, including heart disease and stroke, is the leading cause of death in the United States regardless of self-determined race/ ethnicity.1 Cardiologists play a major role in the secondary prevention of cardiovascular disease. An even greater impact can be seen by combining efforts with primary care providers, thus multiplying the provider to patient ratio nearly twenty fold.

It is unlikely that a healthy adult less than 50 or 60 years old will see a cardiologist.

Yet, this is the group that has the most to gain from prevention. When a patient enters the healthcare system for hypertension or diabetes, it is important to address all issues related to cardiovascular health such as smoking cessation, lipid management, and weight control.

Nearly as great an impact can be achieved in reducing cardiovascular death with effective lifestyle changes as has been attributed to improved cardiovascular care from 1980 to 2000.2 For all persons with hypertension, the potential benefits of a healthy diet, weight control, and regular exercise cannot be overemphasized. Hypertension leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately.3 For cholesterol management, the goal of therapy is no longer the achievement of a target LDL. Rather, the primary aim of drug therapy is the use of a statin drug among those most likely to benefit.4 There is compelling evidence also that control of blood pressure and blood cholesterol significantly reduces the risks of cardiovascular disease in patients with type II diabetes.5 Controlling lipids and hypertension is appropriate for prevention by any measure of cost effectiveness since both of these have been proven to decrease morbidity and mortality.

Continuity of care is fundamentally important in carrying out primary and secondary prevention. The spectrum of preventive care is especially suited to the collaborative practice of healthcare delivery by physician extenders working with physicians. Both in terms of individual patient prevention and in terms of population health, primary and secondary prevention will be fundamentally important to controlling healthcare costs compared to the costs of paying for acute and chronic illness.6 For more than a century, cardiovascular disease has been the number one killer in the United States and accounts for more than 36% of all deaths in the United States. The total cost of cardiovascular disease and stroke in the United States for 2007 was estimated at $448.5 billion.7 Healthy lifestyle, proper diet, physical activity, avoidance of smoking, and maintaining appropriate weight are all essential in the primary and secondary prevention of cardiovascular events.8,9,10 The importance of preventive healthcare and population health is particularly apparent in the Mississippi Delta where the life expectancy of 72.2 years ranks 98th compared to countries around the world. Given the sophistication of healthcare in the United States, it is also surprising that the United States ranks 33rd in world life expectancy with a life expectancy of 79 years. Japanese rank first with a life expectancy of 82.3 year. Social determinants of health play a major role in preventive health and long term outcomes. This is clearly seen in the Mississippi Delta where data from the United States Department of Health and Centers for Disease Control show that the health and well-being of African-Americans in this region are comparable to Americans living in 1974. Caucasians also lag far behind the average well-being of other citizens in the United States with a human development health index comparable to those in the United States in 1997. This index, based on data from the Mississippi Department of Health and the Centers for Disease Control, incorporates life expectancy at birth, access to knowledge using school enrollment age three and older, educational attainment of those 25 years of age and older, and standard of living using median earnings.

Preventive medicine and population health will be major determinants of the future of the Mississippi Delta and the United States as a whole.11

128 JOURNAL MSMA April 2014

The need for primary and secondary prevention is even more apparent when considering the efforts over the past 50 years to increase access to care in the Mississippi Delta through federal programs such as the federally funded healthcare clinics. It appears that there will never be enough money or healthcare providers to improve poor health and life expectancy to the levels seen in the United States as a whole unless an effective campaign for preventive healthcare is undertaken.

As the World Health Organization has proposed, the greatest impact to be made in advancing healthcare is through preventive medicine. The American College of Cardiology and the American Heart Association, working in cooperation with the National Heart, Lung, and Blood Institute, have published multiple guidelines in recent months. The implementation of the guidelines facilitates the goals of preventing cardiovascular disease and improving the healthcare of people living with these diseases.12 They highlight the need for primary prevention, especially with regard to use of statin therapy. These guidelines go beyond total mortality prevention to prevention of major non-fatal atherosclerotic cardiovascular events. This is a major step in facing the challenge to reduce the burden of morbidity from non-fatal cardiovascular and cerebrovascular events. This effort at primary prevention is critical to reducing the projected tripling of atherosclerotic disease related healthcare costs over the next twenty years.13,14 The global epidemic of non-communicable diseases poses challenges to the healthcare system of all countries. High-income countries face the challenge of increasing costs of technology and intensive healthcare for aging populations while low and middle income countries continue to be faced with scarce resources and lack of access to advanced healthcare technology.

Non-communicable diseases will be the predominate global public health challenge of the 21st Century. The United Nations and the World Health Organization have called for a 25% reduction in mortality for non-communicable diseases among persons between the ages of 30 and 70 by the year 2025. This goal will require preventive measures aimed at increased physical activity, reduced sodium intake, reduction in tobacco use, improved hypertension control and halting the rising incidence of obesity and diabetes. These preventive measures along with improved access to healthcare will enable us to achieve the 25% reduction in cardiovascular related death by 2025.15,16 The U.S. ranking of 33rd in life expectancy and the rising costs of healthcare demonstrate that population health with primary and secondary prevention of cardiovascular disease is not just an issue for poor countries and poor regions of this country, such as the Mississippi Delta, and around the world, but is clearly a challenge that must be undertaken by healthcare providers and society as a whole. The impact of these measures may one day be seen as the most important contribution to world health in the 21st century.

References 1.

Ferdinand, KC, Rodriguez F, Nasser SA, et al. Cardiorenal metabolic syndrome and cardiometabolic risks in minority populations. Cardiorenal Med. 2014; 4:1-11.

2.

Ford ES, Ajami UA, Croft JB et al. Explaining the decrease in US deaths from coronary disease, 1980-2000. N Engl J Med. 2007;356:2388-2398.

3.

James PA; Opaul S, Carter BL, et al. 2014 Evidence-based guidelines for the management of high blood pressure in adults. Report from the panel members appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2014;311(5):507-520. Published online December 18, 2013.

4.

Psaty BM, Weiss NS; 2013 ACC/AHA Guidelines on the treatment of blood cholesterol: a fresh interpretation of old evidence. JAMA. 2014;311(5):461-462.

5.

Redherg RF, Benjamin EJ, Bittner V, et al. ACCF/AHA 2009 Performance measures for primary prevention of cardiovascular disease in adults. J Am Coll Cardiology. 2009;54(14):1364-1405.

6.

Bone AA; Presidents Page: Longevity, prevention, and health care reform. JACC 2009;54(10):956-957.

7.

Rosammond W, Flegal K, Furie K. Heart Disease and Stroke Statistics â&#x20AC;&#x201C; 2008 update. A report from the American Heart Association Statistics Committee and Strokes Statistics Subcommittee. Circulation. 2008;117:e25-e146.

8.

Stampfer MJ, Hn FB, Manson JE. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med.2000;343:16-22.

9.

Knoops KT, de Groot LC, Kromhout D. Mediterranean diet, lifestyle factors, and 10 year mortality in elderly European men and women: the HALE Project.

JAMA. 2004;292:1433-1439.

10. Akesson A, Weismayer C., Newby PK. Combined Effect of low-risk dietary and lifestyle behaviors in primary prevention of myocardial infarction in women.

Arch Intern Med. 2007;167:2122-2127.

11. de Shazo, RD. Food stamps, public health, politics, a new Mississippi social determinant of health, and the MMPAC budget. J Miss State Med Assoc.

2013;54(10):296-299.

12. Hunter DJ, Reddy KS. Noncommunicable diseases. N Engl J Med. 2013;369:1336-1343.

13. Marten SS, Blumenthal RS. The wait is over: the cholesterol treatment guidelines are here. Cardiology Today. December 2013.

14. Harold & Jessup; JACC 2013;62(22):2145-2146.

15. Smith et al. Reducing the global burden of cardiovascular diseases. JACC 2013;62(22):2151-2153.

16. Harold JG. Presidentâ&#x20AC;&#x2122;s Page: Heart month and the American College of Cardiology: A lesson in partnerships, member values, and patient education. J Am Coll Cardiol. 2014;63(4):373-374.

April 2014 JOURNAL MSMA 129

• MSMA • Committee Seeks Candidates for Vacancies in MSMA Offices

D

elegates attending the 146th MSMA Annual Session August 15-16, 2014, in Jackson will cast ballots to fill new terms of office for a number of association posts. The Nominating Committee is seeking input from the membership as the committee prepares a slate of nominees. The list of nominees developed by the Nominating Committee will be published to the entire membership before June 15, 2014. Eligibility: All nominees must be active members of the association.

No physician may be put forth on the ballot unless that physician has expressed a willingness to serve if elected.

Nominations for Vacancies: A chart follows listing the vacancies that will be filled by election at the 146th Annual Session in 2014. The names of incumbents, the length of each term of office and the incumbent’s eligibility to be re-elected are indicated. Nominating Committee: The Nominating Committee is composed of the nine most recent Past Presidents of the association residing in Mississippi. The Immediate Past President is the chair.

MSMA VACANCIES 2014

EMAIL NOMINATIONS to CKanosky@ MSMAonline.com or contact any member of the Nominating Committee: Steve Demetropoulos, MD; Tom Joiner, MD; Tim Alford, MD; Randy Easterling, MD; Pat Barrett, MD; Dwalia South, MD; Eric Lindstrom, MD; Helen Turner, MD and Steve Parvin, MD.

OFFICERS & TRUSTEES

INCUMBENT

COUNCILS

INCUMBENT

President-Elect

CLAUDE D. BRUNSON

Budget & Finance at large

JENNIFER GHOLSON

Trustee District 4

CLAY HAYS, JR.

Constitution & Bylaws at large

PHILIP MERIDETH

Trustee District 6

JEFFREY MORRIS

Legislation District 6

CHRIS MAULDIN

Trustee District 7`

DANIEL P. EDNEY

Legislation District 7

J. ANN REA

Trustee District 8

LEE VOULTERS

Legislation District 8

LEE VOULTERS

Trustee, Resident/Fellow

JANE BEEBE JONES

Legislation Resident

JULIA THOMPSON

Trustee, Medical Student HOUSE OF DELEGATES

SAVANNAH DUCKWORTH INCUMBENT

Legislation Student

LUKE CONNER AINSWORTH

Medical Education District 1

KATHERINE PATTERSON

Speaker of the House

R. LEE GIFFIN

Medical Education District 3

J. MURRAY ESTESS, JR.

Vice Speaker of the House JOURNAL MSMA

GERI WEILAND INCUMBENT

Medical Service District 1

ALFIO RAUSA

Medical Service District 2

BILL MAYO

Editor Associate Editor

LUCIUS LAMPTON

Medical Service District 3

LAURA GRAY

STANLEY HARTNESS

Medical Service Resident

TAL HENDRIX

Terms of Office: President-elect: 1 year 2014-2015; Officers, Trustees & Medical Service Student Councils (physicians): 3 years 2014-2017; Trustees & Councils (students & Public Information District 4 residents): 1 year 2014-2015. Speaker and Vice Speaker: 3 years 2014-2017; Journal Editor: 3 years 2014-2017; Journal Associate Editor: 2 years 2014- Public Information District 5 2016.Incumbents NOT eligible for re-election are noted as strikethrough.

Public Information District 6

130 JOURNAL MSMA April 2014

EMILY BRANDON JENNIFER BRYAN DEWITT CRAWFORD CHRISTIE THORNTON

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April 2014 JOURNAL MSMA 131

• Letters • Buttermilk is Good for What Ails Farmer Jones Dear JMSMA Editor: The buttermilk article you wrote in the February [ Lampton, L. Buttermilk is good for what ails farmer Jones. J Miss State Med Assoc. 2014;55(2):30] brought to mind another patient who did not follow through on his doctor’s advice. I am a retired, board-certified otorhinolaryngologist, and I seldom had to work below the collar bone.

At Rotary Club I sat by a friend and patient who had a slight cough and a drippy nose. He said he had treated the cold with a lot of things, but he could not get rid of it. I told him, at this stage, the best treatment would be for him to get his wife to rub his chest with Vicks salve.

About a week later I ran into him and noticed that his nasal and cough symptoms had not subsided. I asked if he had done what I told him. He replied that he had tried to, but his wife told him to “do it yourself.”

Good medical advice is sometimes hard to follow.

William Darrell Austin, MD; Greenville Dear JMSMA Editor: Your buttermilk story reminded me of a friend who grew up in a small west Texas town where her Dad was the only physician for miles. Two of his favorite past times were fishing and occasionally “taking a little nip of spirits.” On one of his afternoons off he loaded up his pickup truck with all his fishing gear and a thermos that he had filled with local blackberry wine. As he was excited about wetting a hook for a lazy summer Texas afternoon, he sped through the little town only to be stopped by the local Fuzz (who knew him well). The town cop sticks his head in the pickup window and inquires “Doc, what you in such a big hurry about?” Her father replied that he guessed he was just excited about an afternoon to enjoy his favorite past time. The policeman then inquired about just what was in the thermos only to open it and discover Doc’s blackberry wine. “Doc, this ain’t water, this is wine.” To which Doc exclaimed, “Lord Jesus has done it again!”

My friend’s other story about her father was the fact that her parents had always slept in separate single beds in the same bedroom. One Christmas while home from college she boldly asked her father about the sleeping arrangements despite having a house full of kids. Doc, with a broad smile on his face, replied, “I always wear a hat to bed.” My friend puzzled by his explanation, inquired as to how that was a reasonable explanation. Doc replied again with a sheepish grin, “I throw the hat on her bed. Sometimes your mother throws it back but quite a few times she brings it back.”

Perhaps when you need a light touch these stories will be entertaining.

J. George Smith, MD; Jackson

Case Report on Enteric Myiasis in Mississippi Dear JMSMA Editor: Myiasis is the word used to describe invasion of fly larvae into the tissue or organs of a living animal. Enteric myiasis is one form of myiasis occurring when fly larvae are reported from the stomach or intestines and, if it happens, is usually accidental caused by consuming food products containing fly eggs or larvae. Reported symptoms may include cramps, vomiting, and diarrhea.1 Several fly species have been reported to cause enteric myiasis, including Sarcophaga haemorrhoidalis (Family Sarcophagidae), Musca stabulans (Family Muscidae), and Eristalis tenax (Family Syrphidae).2-4 Although rare, several cases of enteric myiasis due to the soldier fly, Hermetia illucens (Family Stratiomyidae), have been reported in temperate and tropical locations.2-5 The larvae of H. illucens can be found in decaying organic matter such as decaying fruits, vegetables, beehives, and feces6 and may be accidentally ingested. The problem with these reports in the medical literature is the fact that soldier fly larvae are often found in toilets because toilets frequently leak a little around the connection to the sewer, allowing water and organic debris to accumulate — perfect conditions for soldier fly larvae. Therefore, many reports of enteric myiasis are simply contamination of the stool or toilet bowl. However, we recently encountered a confirmed case of enteric myiasis due to the soldier fly in Mississippi.

132 JOURNAL MSMA April 2014

A 7-year-old female Caucasian from north Mississippi experienced coughing, nasal congestion, nausea, and vomiting for about two days. En route to the clinic, the girl vomited and the mother observed a live worm-like creature in the vomit.

She collected the specimen and presented it to her healthcare provider upon arrival at the clinic. The patient was treated symptomatically for the wheezing with albuterol sulfate 0.083% and Pulmicort 0.5 mg/ml. The larva was sent to Mississippi State University where it was identified as Hermetia illucens by the senior author. The origin of this accidental myiasis case is unknown, but the mom reported that her daughter had eaten plums or muscadines 48 hours prior to vomiting. Hermetia illucens eggs or larvae may have been present on the fruit when the patient ate them. It is reasonable to assume that enteric myiasis may have caused the nausea and upset stomach in this patient; however, her wheezing and nasal congestion were most likely unrelated.

This event provides additional evidence that fly larvae occasionally may be found in the human GI tract.

Jerome Goddard , PhD; Kyle Hoppens; Starkville and Keicia Lynn, FNP; West Point Department of Biochemistry, Molecular Biology, Entomology, and Plant Pathology, 100 Twelve Lane, Clay Lyle Entomology, Mississippi State University, Mississippi State, MS 39762 ( jgoddard@entomology.msstate.edu.) Keicia Lynn, FNP; West Point Children’s Clinic, 720 Medical Center Drive, West Point, MS 39773 (ktilley@live.com) References 1. James MT. The flies that cause myiasis in man, US Dept. of Agriculture; 1947.

2. Lee HL, Chandrawathani P, Wong WY, Tharam S, Lim WY. A case of human enteric myiasis due to larvae of Hermetia illucens (Family: Stratiomyiadae): first Malaysian J. Pathol. 1995;17(2):109.

3. Meleney HE, Harwood PD. Human intestinal myiasis due to the larvae of the soldier fly, Hermetia illucens Linne (Diptera, Stratiomyidae). Am. J. Trop. Med. Hyg. 1935;1(1):45-49.

4. Nagakura K, Kawauichi-Kato Y, Thchibana H, Kaneda Y, Shinonaga S, Kano R. Three cases of intestinal myiasis in Japan. J. Infect. Dis. 1991;163(5):1170-1171.

5. Causey OR. Experimental intestinal myiasis. Am. J. Epidemiol. 1938;28(3):481-486.

6. Tomberlin JK, Adler PH, Myers HM. Development of the black soldier fly (Diptera: Stratiomyidae) in relation to temperature. Environ. Entomol. 2009;38(3):930-934.

American Doctors Eagerly Practice Evidence-Based Medicine but Refuse to Learn from Failed Social Engineering Dear JMSMA Editor: Dr. Rish told us in his message in the January issue that we should all support the AMA because “the AMA is the voice that is heard on Capitol Hill.” In the current issue he encourages us to support the ACA because it is the law of the land. “We must get our voices heard to craft this legislation that works for the sake of our patients- we must dismiss politics and focus.”

News flash. Obviously the voice of the AMA has not been heard. It has fallen on deaf ears. The same deaf ears that brought us other “laws of the land:” the SGR, DRG, RVU, HMO, PPO, HIPAA, HITECH, EHR, HLE, ICD9, ICD10, etc., none of which have proven to work for the sake of our patients. They have not cut costs or improved morbidity. Yet the AMA supported an unproven ACA, just like all the other acronyms.

As for dismissing politics, is that not what the AMA has already done? Politics is just not political parties– Dems vs.

Republicians. Politics is the art of being sagacious and prudent. Politics is the engine used by hyper-liberals to get big government to control our lives.

And control it they did. The ACA was passed in the middle of the night literally, by parliamentary chicanery, without any Republican support and was not vetted or even read (ask Nancy Pelosi). We lost by dismissing politics and so did our patients.

The legislation has already been crafted. We lost to hyper-liberals whose government health care is not about health or care but the crown jewel of bureaucrats: government. It’s all about the liberal mantra: more government spending equals better outcomes equals more social justice.

This should not be a season of change. Or a season of hope and change which sounds like the slogan I have heard from the President for many years. This should be a season of repeal and replacement. There are many options. We still have time to replace this ACA including its 30 plus revisions whichever is the law of the land.

Social justice means medical care for all. It is the most noble of goals. It can be done by central bureaucrats or by market forces. I tried the one by bureaucrats in Canada. Doctors in Canada were also naïve. We thought our voices were heard, and we refused to play politics. In the end the Canadian health system is a skeleton of its former self with greatly increased costs and no reduction in mordibitity. Canada and Europe should serve as the canary in the mine. It is difficult for me to believe why so many American doctors eagerly practice evidence-based medicine but refuse to learn from failed social engineering. They refused to practice evidence-based social engineering, to get political or be politic.

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•

Letters •

So Dr. Rish, I encourage you to let our voices be heard but you should also hear voices of those who practiced in an ACAlike system and fled to come to America. I also encourage you not to dismiss politics. If you do not engage the hyper-liberals will destroy the medical system.

Plato warned us that those who refuse to engage in politics will be governed by their inferiors. Plato let his voice be heard.

But he also heard the voice of people like Homer who told him about the story of the Trojan horse- a story that unfortunately many doctors should hear again and again.

To those who are enamored by the ACA and the AMA lets follow the advice of Dr. Rish and make this a season of changea change to repeal and replace, not capitule. Let us also focus, as he advises, so the best medical system on the planet does not disappear like Troy.

Calvin S. Ennis, MD; Pascagoula

Response to Letters on Medicaid Expansion Dear JMSMA Editor: In response to [Letters: Positions on Medicaid. J Miss State Med Assoc. 2014;55(2):58], MSMA will forever need to advocate for the better health of Mississippians. In fact, we are now moving toward healthy practices for the survival of our planet. It behooves us as physicians to think forwardly on a wider scale, not just of the future of one generation, but centuries of them, those that exist now and are to come. We are not just talking about caring for people who are born and bred Mississippians, but those who will encompass worlds, in both location and vocation. We all deserve the best health care that Mississippi can offer but particularly, our children do. They are our torch for the future, to be seen by countless billions. They all need to be healthy enough to survive infancy, make it past adolescence, and into the adult world with all the potential, tools, knowledge, great health, and choices available to them as global citizens. They all must be healthy to have the freedom to choose and find their paths in life whether it be a passion, service, or any other type of positive societal contribution! They cannot be held back by the bondage of poor health or health outcomes! They all must be healthy to endure life’s challenges and to sustain the future generations. This is no time to be small minded, shortsighted, cheap, divided, and petty–constraining “their” potential, possibilities, and power!

As such, I am not interested in who is “friends” with this governor or any other or “vice versa” in our organization. We are to be about the business of health and wellness- not relational politics! We must push our governor in whatever direction we feel is best for the overall improved health and wellbeing of all of our citizens. Holding Mississippians back while we await the governor to decide whether he deems it appropriate to overhaul the Medicaid system, or when, is doing them a great disservice!

Our governor does not appear to be in any great hurry to revamp that bureaucratic system. However, we should be in a hurry to raise our state’s health status! We have been given a grade of “F”! What would you do if your child brought an “F” home in any subject? I would expect an analysis to get to the ROOT cause and a proactive move to modify that outcome in the future, in a timely manner. That’s how an ongoing and flexible process, impact, and outcome evaluation works. These offices should already be re-evaluating Medicaid continuously with a diverse team of ideas which lead to an improvement in its process, impact, and outcome. Maybe we should ask the Medicaid division to be removed from under the governor and instead placed under the insurance commissioner or the like!

Mississippi has always had a chance to create a fair, diverse, all-inclusive plan for any of its past years of history and has failed to do so until now forced to by this federal administration. Of course, Mississippi stakeholders were allowed at the table when the ACA was first being developed from the grassroots up. What if your insurance plan was being hijacked because politics were at play? Do not punish the citizens who live here for the perceived ills of Medicaid, et al. They did not create the ills. Advocate on the side of improved health for all. For as physicians, that is, and will always be, our responsibility! Then, reimbursements might work out better because our patients might actually become the driving force behind or in front of us, speaking up with us on our behalf. We reap what we sow and, as physicians, we are connected to all of our citizens. We would have no work if not for the public. We do not and cannot survive in a vacuum. Connections to others of all diversities of levels in this life as an all-inclusive team are key. Collaboration across all boundaries and not just the ones we deem to “fit” our mold or whom we consider “our friends” should be a way to help us achieve a better grade in state health more so than 365 degrees of separation. FEAR to create a more diverse team of ideas can kill an organization. WE aren’t politicians running for office needing to play favorites to any one view.

Valerie Short, MD, MPH; Jackson

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• Physician’s Bookshelf • Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital by Sheri Fink Crown Publishers; New York, NY 2013, 558 pp.

Report from the UMMC Internal Medicine Book Club Review by Jacob Graham, MD, PGY-3, University of Mississippi Medical Center (accepted to University of Alabama at Birmingham’s hospice and palliative medicine fellowship) and Sharon Douglas, MD, Professor of Medicine, UMMC

F

ive Days at Memorial was written by Pulitzer Prize-winning journalist Sheri Fink, MD, PhD. A former relief worker in disaster and conflict zones, Fink wrote her first book, War Hospital: A True Story of Surgery and Survival, about medical professionals under siege during the genocide in Srebrenica, Bosnia-Herzegovina.1 Five Days at Memorial is the result of more than five hundred interviews with eye witnesses and others close to the events at Memorial Medical Center during and after Hurricane Katrina. Interviewees included doctors, nurses, and other medical personnel, hospital executives and government officials, attorneys and ethicists, patients and families.

Part 1: Deadly Choices is a thorough recounting of the five horrific days in 2005, starting with the hurricane’s landfall and ending with the hospital’s complete evacuation. The prologue gives a glimpse of the major issues faced on the final day, when there is a frantic race to get all who are still alive out of the hospital before nightfall. In the face of potential violence afer dark and definite post-storm hardships, doctors and nurses struggle to decide how to prioritize patients for rescue and what to do with those who are unlikely to survive. In the sweltering heat, as the body count continues to rise, life and death choices are made on a seemingly ad hoc basis, causing medical personnel to ask, “Can we do this? Do we really have to do this?”

After ramping up every reader’s sympathetic nervous system in the prologue, the author takes a step back in Chapter 1 and discusses New Orleans disaster preparedness in historical perspective. The tension builds again in Chapter 2 as we’re back in the present, the day before the storm, along with the approximately two thousand medical personnel, patients, and family members (and their pets) who intend to weather another storm in the New Orleans stronghold. In the following chapters, we meet major players and observe wide swings of emotion as the hurricane hits and passes, leaving Memorial largely unharmed. Panic creeps in as the floodwaters inexplicably continue to rise and as reports about “zombie hordes” of looters and a possible declaration of martial law filter through the hospital, more exaggerated with each telling.

Memorial goes into “survival mode” when canals are breached and fifteen feet of water rushes toward the hospital from Lake Pontchartrain. There is a sinking feeling among the leadership that some patients will not make it out alive. Hospital personnel exhibit extraordinary heroism in the evacuation efforts, straining to move patients to rescue points and improvising to make up for the lack of electricity-dependent technologies. Equally on display is the lack of coordination among the rescuers and those being rescued. When all are finally being moved in earnest on Day 5, it is too late for many of the patients.

Part 2: Reckoning delves into a historical review of medico-ethical issues such as triage, disaster medicine, prioritization for organ transplants, and physician-assisted death. Does physician intent distinguish palliative care from euthanasia, or is this just a euphemism, since both make use of powerful medicines that have potential to shorten life? When three healthcare personnel are charged with hastening patients’ deaths in the final hours at Memorial, this important question is somewhat overshadowed by concerns regarding local and national fall-out should these heroes be convicted.

Five Days at Memorial is an important book for Mississippi doctors to read because of the many ethical issues discussed related to disaster medicine. Thought should be given and education provided in order to understand triage in time of disaster, when changes in the normal approach to patient care may occur and when medical standards of care may be hard to maintain. We give the book 10 out of 10 and enthusiastically recommend it.

Reference: Sheri Fink. http://www.sherifink.net/. Accessed February 22, 2014.

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• Poetry and Medicine • [This month, we print another poem from “Coronary” by Benjamin A. Morris, a Mississippi born poet who lives in New Orleans. Morris is the son of Hattiesburg urologist and MSMA member Dr. Toxey M. Morris. “Sedation” provides a family view of the alien world of medicine when a loved one is hanging on for dear life. Published in 2011, “Coronary” includes 24 sonnets all centered on a similar theme: his personal experience of his father Toxey’s illness and hospitalization. (Toxey is in good health today!) The lovely volume includes original artwork by Dr. Morris on its cover. Now in its third edition, copies are available at independent bookstores in the New Orleans area and at Main Street Books in Hattiesburg. Benjamin is the author of numerous works of poetry, fiction, nonfiction, and drama. He has received many honors for his writing, including a fellowship for poetry from the Mississippi Arts Commission. More information, including how to purchase “Coronary,” is available at benjaminalanmorris.com. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net]—Ed.

Cough We like that cough, the doctor said, the mucus gargling its way into your throat. Hard to call the sound beautiful―earlier he’d looked us in the eye and said edema―but it’s all we’ve got of your voice. So give us more: give us a symphony of phlegm, a chorus of sputum and of blood, grant an hour’s concert of the fluids you produce and bore us with how long the encore labors on.

We’re long past due to hear a music other than from your vent and from your wires; this silence has been killing us, and one of us has got to go. I’ll call our brothers― you play those flooded lungs like a lyre.

—Benjamin A. Morris, New Orleans

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Have You Considered a Life Settlement For Your Old Life Insurance Policy?

What is a Life Settlement?

A life settlement is the sale of an existing life insurance policy on the secondary market to a third party investor.

Who or What May Qualify?  If the person insured by the policy is age 70 or older  If the person insured has any major medical conditions  If the policy has a death benefit of $250,000 or more  Policies including, but not limited to, universal life, term insurance, variable life insurance or whole life insurance  If any cash value exists in the policy, the amount is relatively small

For More Information on Life Settlements, contact: H. Larry Fortenberry, CPA, CLU, ChFC Executive Planning Group, PA 1640 Lelia Drive, Suite 220 PO Box 16566 Jackson, MS 39216 (601) 982-3000

Why Use a Life Settlement?  Term life insurance policy will expire  Old policy that is no longer needed or premiums cannot be paid  A policy that was purchased for a business buy/sell and is no longer needed  A policy was purchased for a business that has been sold or is not needed  There may be a better policy available at a lower cost

 Estate value has changed and the policy is no longer needed

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