August 2013 JMSMA

August

James A. Rish, MD VOL. LIV

2013

2013-2014 MSMA President No. 8

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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 Steven L. Demetropoulos, MD President James A.Rish, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer 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© 2013 Mississippi State Medical Association.

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Official Publication

AUGUST 2013

VOLUME 54

NUMBER 8

Scientific Articles

Clinical Problem-Solving Case: Competitive EDge or Over the Cliff ?

224

Christopher D. Boston, MD

Special Articles

Real Men Don’t Need Anesthesia: Dr. Porter and the Pascagoula Connection

227

Chris E. Wiggins, MD

An Interview with James A. Rish, MD 2013-2014 MSMA President

234

Karen A. Evers, Managing Editor

MSMA- Official Address of the 145th President

241

Steven L. Demetropoulos, MD

Related Organizations

Mississippi State Department of Health

226

Departments

From the Editor: The Dog Days of Summer, and a New President Poetry in Medicine Letters Images in Mississippi Medicine

222 229 230 245

Alliance Spotlight

Mrs. James A. (Susan) Rish

246

About The Cover:

James A. Rish, MD - Presidential Portrait—Tupelo native James A. Rish, MD is the 146th president of our MSMA. The inauguration as 2013-14 MSMA President was held at the Jackson Hilton in conjunction with our MSMA’s 145th Annual Session, August 1617, at the Norman C. Nelson Student Union on the campus of the University of Mississippi.

Dr. Rish is board certified in internal medicine, pulmonary diseases, and critical care medicine, and in private practice with Pulmonary Consultants. He has served on staff at North Mississippi Medical Center since 1995. An interview with Dr. Rish and an Alliance feature on his wife Susan are included in this issue of the JMSMA. r August

James A. Rish, MD

VOL. LIV

2013

2013-2014 MSMA President No. 8

of the MSMA Since 1959

August 2013 JOURNAL MSMA 221

From the Editor: The Dog Days of Summer, and a New President

W

ith the bright ascent of Sirius, the South descends into the dog days of summer, that humid, sultry period of punishing heat and merciful afternoon rain. Our children have started school again, their summer break sadly over, and the regular routine of life begins anew. Football has begun again, and soon the Bulldogs, Rebels, Golden Eagles, and our beloved Saints will be the focus of our Saturdays and Sundays. Soon, cool mornings will appear, and leaves will turn red, orange, and gold. But not quite yet, for the Southern summer is slow to release its grip!

This issue of the Journal contains an intimate interview with our new President, Dr. James A. Rish of Tupelo. Dr. Rish is a gifted pulmonary physician with integrity and vision.

He’s known for wearing a bow tie as well as for his humility, competence, and compassion as a physician. He juggles the burden of a busy medical practice and his responsibilities as father and husband with grace and dignity. He’s an example and role model for all of us, and our Association is blessed to have him as President. It is a year of double presidencies for the Rish family; his wife Susan will be inaugurated

as President of the Southern Medical Association Alliance this fall.

As we go to press, the 145th Annual Session of the MSMA House of Delegates has met. Besides the inauguration of Dr. Rish as our new President, the meeting witnessed the historic election on August 17th of our first African-American President-Elect, Dr. Lucius M. Lampton, MD Claude Brunson. This achievement ranks as one of the most important milestones in our Association’s 157 year history. Dr. Brunson has served with distinction at both state medical and at the University of Mississippi Medical Center. He is very deserving of this honor, and one can expect great things from him. The courageous leadership of such members as Dr. Helen Barnes, Dr. Robert Smith, Dr. Gilbert Mason, Dr. Matthew Page, Dr. Oswald Smith, Dr. Freda Bush, and many others paved the way for this momentous achievement.

Contact me lukelampton@cableone.net or slow mail to me at JMSMA, P.O. Box 2548, Ridgeland, MS 39158-2548.

—Lucius M. “Luke” Lampton, MD, Editor

Journal Editorial Advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian 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, FAAP, FACS 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 Thomas E. Dobbs, MD, MPH Health Officer, District VII/VIII Mississippi State Department of Health, Hattiesburg

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, 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 Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A Kirchner, MD Nephrologist G.V. Montgomery VA Medical Center, Jackson Brett C. Lampton, MD Internist/Hospitalist Baptist Memorial Hospital, Oxford

Philip L. Levin, MD President, Gulf Coast Writers Association Sharon Douglas, MD Emergency Medicine Physician, Gulfport Chair, AMA Council on Ethical & Judicial Affairs

Professor of Medicine and Associate Dean for V A William Lineaweaver, MD, FACS Education, University of Mississippi School of Medicine, Editor, Annals of Plastic Surgery Associate Chief of Staff for Education and Ethics, Medical Director G.V. Montgomery VA Medical Center, Jackson JMS Burn and Reconstruction Center, Brandon Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist The Street Clinic, Vicksburg

222 JOURNAL MSMA August 2013

John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital

Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon

Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson 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, FACC Clinical Cardiologist, Hattiesburg Clinic Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD, MBA, CPE, MS Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

Medical Assurance Company of Mississippi Serving Generations of Mississippi Physicians When Paul H. Moore, III, MD, began his practice of medicine in 2013, he had many decisions to make.

But for the decision of medical liability insurance, he only had to look to his father and grandfather and follow in their footsteps. The Moore family of physicians is one of several multi-generational families that Medical Assurance Company of Mississippi has protected through the years by providing their professional liability insurance.

For over 35 years, Mississippi physicians have looked to MACM for their professional liability needs.

Today, MACM is an integral part of Mississippi’s healthcare community through its dedication to risk management and claims services for our insureds.

A dedicated staff and physician involvement at every level guarantee that the interests of our policyholders remain the top priority. This, combined with the many years of loyalty and support from our insureds, is what allows MACM to be the carrier of choice in Mississippi for generations of Mississippi physicians.

Left to Right: Paul H. Moore, III, MD Urogynecology, Jackson P. H. (Hal) Moore, Jr., MD Radiology, Pascagoula Paul H. Moore, Sr., MD Radiology, Pascagoula

For more information on MACM’s professional liability coverage:

1.800.325.4172 • www.macm.net August 2013 JOURNAL MSMA 223

• Clinical Problem-solving Case • Competitive EDge or Over the Cliff?

Christopher D. Boston, MD

I

ntroduction

A 45-year-old healthy Caucasian male presented to family medicine clinic with the chief complaint of excessive fatigue and not feeling like himself for about a year. He admitted being somewhat depressed and having no energy. He worried that he might be diabetic because he was constantly thirsty and had a dry mouth, although he denied blurred vision or excessive hunger. He stated that 18 months ago he could bench press over 400 pounds but currently felt like he could hardly lift anything. On review of systems, he also admitted to intermittent abdominal cramping and diarrhea along with a 24-pound weight loss over the preceding months.

Chronic fatigue is a self-reported, persistent and disabling tiredness, weakness or exhaustion lasting 6 months or longer.1 It is highly prevalent in the general population with estimates ranging between 12% and 25%.2 Although there is a broad differential, medical or psychiatric diagnoses can explain fatigue in approximately two-thirds of cases.3 This patient mentions diabetes and depression as potential causes for his fatigue, but I need a more thorough history and physical exam to help narrow my diagnostic workup.

On physical examination, the patient’s blood pressure was 138/99 mmHg and vital signs were otherwise stable. He had a muscular build and was in no distress. His pulmonary, cardiac and abdominal exams were unremarkable, and he had no lymphadenopathy. His neurologic exam was afocal, and he presented with normal mood and affect. On further questioning about his previous ability to lift large amounts of weight, he admitted to using anabolic steroids. He stated he had used steroids for years and was currently getting his medication shipped from Mexico. He developed a dosing regimen with the assistance of bodybuilding friends, and at times was injecting up to 3000mg intramuscularly a week.

He also took several over-the-counter supplements hoping to increase his energy and stamina.

Author Information: Dr. Boston is an Assistant Professor in the Department of Family Medicine, University of Mississippi Medical Center, Jackson, MS 39216.

Corresponding author: Christopher D. Boston, MD; 2500 N. State Street, Department of Family Medicine, University of Mississippi Medical Center, Jackson, MS 39216, 601-984-5425 (office) 601-8150989 (fax) [cboston2@umc.edu].

224 JOURNAL MSMA August 2013

Unfortunately, inappropriate use of anabolic steroids to improve athletic performance is fairly common. It is estimated that there are as many as 3 million anabolic steroid users in the United States, and 2.7%-2.9% of young American adults have used anabolic steroids at least once.4 The beneficial effects of anabolic steroids on the musculoskeletal system have been well documented, yet many potential deleterious side effects need to be considered.5 Pharmacologic doses of androgens may lead to lipid profile disorders, hepatotoxicity, erythrocytosis, testicular atrophy, gynecomastia, and psychological abnormalities.6-8 On initial workup, he had a fasting glucose of 85 mg/dL and Hgb A1c of 3.8%, which essentially ruled out the diagnosis of diabetes. Further studies were ordered to evaluate his fatigue and to investigate potential side effects of his androgenic steroid use. These included a complete metabolic panel, blood counts, thyroid stimulating hormone, vitamin B12, and testosterone concentration. The patient was prescribed escitalopram (Lexapro) daily for depression and counseled on discontinuing his steroid use. After he left clinic, his lab results were found to be largely within normal limits with two notable exceptions. His testosterone concentration was less than 30.5 ng/dL (reference range 280-800ng/dL) and his serum calcium was 11.7 mg/dL (8.410.2 ng/dL).

His low testosterone concentration was not unexpected as a common adverse effect of androgen use is suppression of endogenous testicular function. More pressing is his elevated serum calcium concentration. Many of his symptoms including gastrointestinal complaints, polydipsia, depression, fatigue and muscle weakness can be attributed to hypercalcemia.9 The most common causes of hypercalcemia include hyperparathyroidism, malignancy, and thiazide diuretic use, though the differential is broad.10 This patient is young, with a lower overall risk for malignancy, and is not taking any prescription medications.

I think it is likely that he may be taking an over-the-counter supplement that could contribute to his hypercalcemia.

Additional studies were ordered to determine the cause for his hypercalcemia. His parathyroid hormone concentration of 16.6 pg/mL was normal. His vitamin D, 25-OH concentration was greater than 138.8 ng/mL. At this point, the patient was contacted and strongly encouraged to discontinue any over-the-counter supplements he may be

taking. On follow up in clinic, he admitted to taking “megadoses” of vitamin D along with other over-the-counter supplements to enhance his weight training and fitness.

Within several days of discontinuing his supplements, he started to feel much better. He noted a reduction in his abdominal complaints along with improvement in fatigue and strength.

Vitamin D is a fat-soluble vitamin found in fortified milk, cereal and bread, and more substantially in fatty fish and codliver oil. It is also synthesized in the skin during exposure to UV-rays in sunlight. The Institute of Medicine has defined the “tolerable upper intake level” for vitamin D as 4000 IU daily for healthy adults and children age 9-18 years while the Recommended Dietary Allowance for ages 1-70 years is 600 IU.11 While vitamin D is essential for calcium homeostasis and bone health, toxicity may have profound clinical implications.

Optimum vitamin D concentration of greater than 25ng/mL is sufficient for good bone health.12 Diagnosis of vitamin D intoxication can be made with concentrations over 100ng/mL.13 At follow up, the patient was doing well and had ceased his vitamin D supplementation. He continued to use anabolic steroids and was referred to an endocrinologist to assist with physiologic testosterone administration in effort to decrease the risk of adverse effects with high-dose testosterone. His calcium and vitamin D concentrations returned to normal limits at 10.0mg/dL and 68.5 ng/mL, respectively.

The final diagnosis in this case is hypercalcemia secondary to vitamin D toxicity along with androgenic steroid abuse. Use of supplements, both legally and illicitly, is commonplace in the athletic and sports population. Since the Dietary Supplement Health and Education Act of 1994, supplement sales have risen dramatically, and supplements are largely exempt from FDA regulation.14 Specific to this case, vitamin D deficiency has recently been linked to decreased physical performance in athletic individuals, and, therefore, athletes may be more likely to take extra vitamin D.15 As physicians and healthcare providers, it is important to counsel our patients on the potential detrimental effects of supplement use as this case illustrates.

6.

Sjöqvist F, Garle M, Rane A. Use of doping agents, particularly anabolic steroids, in sports and society. Lancet. 2008;371(9627):1872-1882.

7.

Thompson PD, Cullinane EM, Sady SP, et al. Contrasting effects of testosterone and stanozolol on serum lipoprotein levels. JAMA. 1989; 261(8):1165-1168.

8.

Stergiopoulos K, Brennan JJ, Mathews R, Setaro JF, Kort S. Anabolic steroids, acute myocardial infarction and polycythemia: a case report and review of the literature. Vasc Health Risk Manag. 2008; 4(6):1475-1480.

9.

Greco DS. Endocrine causes of calcium disorders. Top Companion Anim Med. 2012;27(4):150-155.

10. Dent DM, Miller JL, Klaff L, Barron J. The incidence and causes of hypercalcemia. Postgrad Med J. 1987;63(743):745-750.

11. www.iom.edu. Report at a Glance, Dietary Reference Intakes for Calcium and Vitamin D. Available at: http://www.iom.edu/Reports/2010/DietaryReference-Intakes-for-Calcium-and-Vitamin-D/DRI-Values.aspx.

Accessed May 31, 2013.

12. Brighurst HR, Demay MB, Krane SM, Kronenberg HM. Bone and Mineral Metabolism in Health and Diseases. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 17th ed. Vol 2. New York: McGraw Hill; 2008:2365-2377.

13. John TP, Harald J. Disorders of the parathyroid gland and calcium homeostasis. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th ed.

Vol 2. New York: McGraw Hill;2012:2365-77.

14. Mason BC, Lavallee ME. Emerging Supplements in Sports. Sports Health. 2012;4(2):142-146.

15. Watkins CM, Lively MW. A review of vitamin D and its effects on athletes. Phys Sportsmed. 2012;40(3):26-31.

Congratulations, Dr. Grantham.

Key Words: fatigue, vitamin d, hypercalcemia References 1.

Wessely S. The epidemiology of chronic fatigue syndrome. Epidemiol Rev. 1995;17:139-151.

2.

Chou KL. Chronic fatigue and affective disorders in older adults: Evidence from the 2007 British National Psychiatric Morbidity Survey.

Journal of Affective Disorders. 2013;145(3):331-335.

3.

Buchwald D, Umali P, Umali J, Kith P, Pearlman T, Komaroff AL. Chronic Fatigue and the Chronic Fatigue Syndrome: Prevalence in a Pacific Northwest Health Care System. Ann Intern Med. 1995;123(2):81-88.

4.

Parkinson AB, Evans NA. Anabolic androgenic steroids: a survey of 500 users. Med Sci Sports Exerc. 2006;38(4):644-651.

5.

Bhasin S, Storer TW, Berman N, et al. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. N Engl J Med. 1996;335(1):1-7.

Dr. William Grantham,

Medical Director of MEA Clinton, was re-elected for a second term on the

Mississippi State Medical Association Board of Trustees.

Contact us today for information on how you could become part of MEA’s winning team.

Rachel Williamson 601-898-7527

recruiter@meamedicalclinics.com meamedicalclinics.com

August 2013 JOURNAL MSMA 225

• MSDH • Mississippi Reportable Disease Statistics

June 2013 Figures for the current month are provisional

Totals include reports from the Department of Corrections and those not reported from a specific District.

For the most current MMR figures, visit the Mississippi State Department of Health website: www.

HealthyMS.com. † Data not available.

226 JOURNAL MSMA August 2013

• Special Article •

Real Men Don’t Need Anesthesia: Dr. Porter and the Pascagoula Connection Chris E. Wiggins, MD

T

here is an interesting juncture of events that involves Mississippi military history, a forgotten army post, a close-minded doctor, and early Fig 1. attitudes about the use of general anesthetics. The time was Dr. John B. 1848, immediately following the Mexican War, and the place Porter. was Pascagoula. This episode came to light as a result of a At the time project by the Jackson County Historical and Genealogical of the postSociety, led by Roger Hansen, a military historian, to recover Mexican War and reinter the remains of American veterans of that war army post in along with locating the exact site of the military camp and its Pascagoula hospital. he held The story broke in 1979. Hurricane Frederic had the rank of just passed altering the shoreline. A fisherman found “Surgeon,” coffins containing human remains in the shallow water of later retiring Greenwood Island, a swampy peninsula of the Pascagoula as a colonel. beach that residents thought of only as a picturesque and always uninhabited bookend to their view of Mississippi Sound. Research and archeological excavation soon revealed a different picture.1 A military hospital was established on nearby It was 1848, and the war with Mexico had just ended.

Greenwood Island. This location, separate from the garrison, Some 10,000 Regular Army soldiers had to recuperate and be chosen to isolate any disease and so that “noxious odors reassigned.1 Those brought by ship through New At was Fig. 1:the Dr.port Johnof B. Porter. the time of the post-Mexican War army post in Pascagoula he held the rank could blow out to sea.” It was named Camp Lawson after Orleans and stationed on its swampy outskirts found the place of “Surgeon,” later retiring as a colonel. the Army Surgeon General of the time. Enter Mexican War hot, unsanitary, and rife with Yellow Fever. To deal with this surgeon John B. Porter.

General David Twiggs, in a case of out of the frying pan and Porter was the camp surgeon whom history remembers into another one, established a garrison in Pascagoula, which at as a staunch opponent of general anesthesia. When he came the time was a resort village used by coastal big-city residents to the camp with the soldiers in 1848 he already had plenty to escape those same oppressive features. As it would turn out, of experience during the Mexican campaign where he had Pascagoula’s climate and geography were not any different opportunity to observe the use of ether while working under from that of New Orleans, and the wings of mosquitoes soon Surgeon Edward H. Barton, the man credited with the first brought the last ingredient they were seeking to avoid. wartime use of anesthetic (amputation, 1847, Vera Cruz).

The army post on the beachfront was named Camp Porter found the camp hospital consisting of four wooden Jefferson Davis. Davis, who some thirteen years later would barracks, he described as “mere shells, leaking in rainy become president of the Confederacy, was already a famous weather” along with several storehouses and a wharf. It could man. A West Point graduate, prior Congressman, and colonel, accommodate 300 infirm soldiers. Porter went on to say, he had acquitted himself well in the recent war. The 1500 man “The troops arrived at the installation are in pitiful condition, brigade, which was more than the entire city of Pascagoula suffering mainly from chronic dysentery…”2 From July at the time, remained in existence for about eight months as to November 1848, 100 of the 449 hospitalized dysentery soldiers were transferred in, reassigned, released, or, as in the patients died, a mortality rate of 22%. Another 37 died of case of the coffins—died.

August 2013 JOURNAL MSMA 227

Fig 2. Map of Camp Lawson U.S. Military Hospital. No photographs of the facility exist. The four hospital barracks can be clearly seen along with warehouses and a pier for steamships. The main army post, Camp Fig. 2.Davis, Map is of indicated Camp Lawson Military NoIt photographs the facility exist.

Thethe four hospital Jefferson at theU.S. position of Hospital. the arrow. was located of approximately where Pascagoula Beachbarracks Park iscan now. be clearly seen along with warehouses and a pier for steamships. The main army post, Camp Jefferson Davis, is indicated at the position of the arrow. It was located approximately where the Pascagoula Park iswere now.near the hospital. These other causes.

Some Beach of the burials recovered and in 2011 reinterred with full military honors in the 1 were the coffins exposed in 1979.

Biloxi National Cemetery.

With soldiers reassigned, the entire Army post and hospital closed by the end of 1848. Porter went on to continue three decades of service, retiring from the US Army during the References Civil War in August 1862. Throughout his career, he remained 1. Hansen R. Military historian, Pascagoula, Mississippi. In email steadfastly against general anesthesia. Initially there had been correspondence February 27, 2012. basis for concern about ether because of its explosiveness 2. Gillett MC The Army Medical Department, 1818-1865. Washington, , and the fragility of the equipment necessary to generate it.

DC: U. S. Government Printing Office; 1987:123-4.

This led Surgeon General Lawson, himself, to conclude that 3. Barger L. Historian, US Army Medical Command. In email correspondence May 29, 2012. it was impractical in Mexico. However, impracticality was 4.

“Army Surgeon John B. Porter.” Available at http://www.generalnot Porter’s beef. He blamed ether for slow healing as well anaesthesia.com/people/john-b-porter.html Accessed July 1, 2012. as for excessive bleeding in a thigh amputation he witnessed.

He concluded it damaged the blood and speculated about the Author Information relationship between ether and an increase in hospital gangrene.

Dr. Wiggins is an orthopaedic surgeon from Pascagoula.

He also inaccurately stated that hospital gangrene had never 3 He originally, started his orthopaedic practice in 1977, and existed before the use of anesthesia. Porter’s opposition to it has steadily grown with expansion to Lucedale in 1985. In painless surgery went beyond his medical opinions to reflect 2001, the merger with Bienville Orthopaedic Specialists made a prevailing military ethos of the time: fit soldiers did not need their organization the largest orthopaedic group in Mississippi. such escapism; in fact, they might even be made less masculine Dr. Wiggins continues to maintain an active general by the process of pain avoidance.4 orthopaedic practice. Knee, ankle, and shoulder conditions Notwithstanding Dr. Porter’s views, military medicine are the majority of problems dealt with using methods ranging did move forward. By the onset of the American Civil War, from office treatments, outpatient arthroscopy, to the latest 1861, general anesthesia was widely accepted and employed open surgical procedures. In recent years Dr. Wiggins has where available. With regard to the coffins and the remains of developed some side pursuits, writing and developing products American veterans of the Mexican War found in Pascagoula, for the medical market. He is a member of the Journal MSMA after several expeditions, a total of six soldiers have been Editorial Advisory Board.

228 JOURNAL MSMA August 2013

• Poetry in Medicine • [This month, we print a poem by Robert Ray “Bob” McGee, MD, a Clarksdale internist. McGee writes under the pseudonym of Thomas Browne, MD. He recently published a lovely and brilliant volume of poetry entitled “Case Reports and Other Epiphanies,” printed by the Old Man’s Press of Clarksdale. He’s an accomplished and talented poet, publishing poems as early as 1980 in such publications as the “Annals of Internal Medicine” and “The Pharos.” A selection of his writing was also included in Dr. Trey Emerson’s “Avocation of Compassion,” published in 1989. To obtain a copy of his poetry collection, go to lulu.com or write to Dr. McGee directly at 303 Cypress Avenue, Clarksdale, MS 38614. This poem offers up a reflection on a physician’s desk which connects with every doctor’s practice and the seeing of our patients.(and how we worry about them!) Look for more of his poems in coming journals. Any physician is invited to submit poems for publication in the JMSMA, attention: Dr. Lampton or email me at lukelampton@cableone.net.]—Ed.

Doctor’s Desk The cluttered residue Of the day’s doings Litters my desk.

The records of disease Are fixed in lines, Long litanies of unhealth, The accounts Of those who came and went Seeking solace.

Did they find it?

Charts lie in disarray, Life’s blood in ink, Dry dead sheets Smelling Of pain, anxiety and dubious hopes.

I wrote it all down After I listened.

The records stand.

How are the sick tonight?

I worry.

—Thomas Browne, MD; Clarksdale August 2013 JOURNAL MSMA 229

• Letters • Obamacare and Bedside Ultrasound

D

ear Editor,

In this day of Obamacare and alleged attempts to save money while attempting to produce quality medical care, I find the article entitled “Bedside Ultrasound Detection of Long Bone Fractures” to be counterproductive. [Patel R, Tollefson B. Bedside ultrasound detection of long bone fractures, J Miss Med Assoc. 2013;54(6):59-162] It encourages the waste of money and promotes what I call “Proceduralists” in the field of medicine, i.e. doctors more interested in performing and charging for a procedure than in providing quality patient care.

Let me be more specific. Case 1 has already had an x-ray diagnosis of a fracture and presents with tenderness of the distal femur and knee. Did anyone think to call the other hospital and get his or her x-ray results? Apparently not.

No, let’s get an ultrasound and find a “possible tibial plateau fracture,” and then get a CT scan, which showed a “minimally displaced fracture of the tibial intercondylar eminence.”

The latter would most likely be seen on a routine x-ray and saved the expense of the ultrasound and CT scan. The presence of the aforementioned fracture would have caused a hemarthrosis, which would present as a knee effusion on clinical exam. The latter was not mentioned in the clinical exam. The history and physical may be old fashioned but are the most cost effective diagnostic tools a doctor can use on a patient.

Then it gets worse. The radiologist dials for dollars and recommends an MRI to check the ACL. Granted, I have not seen the x-rays, but judging from the description of the x-ray, the ACL is attached to the “minimally displaced fracture” and one should not need an expensive MRI to tell it is intact.

There is no documentation in the article to justify a 6-day hospitalization for bruises, abrasions, and minimally displaced fractures. The latter were most likely treated nonoperatively with a knee immobilizer and crutches (which she already had), but the article does not provide that information.

Case 2 presents another patient who presents to the UMC ER from another hospital. He too had an x-ray diagnosis of fracture and presents with a deformed ankle on physical. The history notes an inversion injury. Given that information, does anyone not suspect that this patient probably has a fracture? Come on! We do not need an ultrasound. We need a bedside portable x-ray followed by an Ortho consult. The ultrasound represents wasted time and money.

The article goes on to advocate the use of ultrasound for a hematoma block. Call me old fashioned, but if one knows

skeletal anatomy and can both see and feel the hematoma, how can we justify the expense of an ultrasound? Getting an ultrasound and an x-ray on an obvious fracture reminds me of the guy who wears a belt and suspenders to keep his pants up.

In the conclusion of the article, the authors propose the use of ultrasound when x-ray capabilities are not readily available to provide “early stabilization in severely injured patients.” They claim ultrasound is “more sensitive than physical exam” and “can be performed by people with minimal training in ultrasound.”

That reminds me of the kid who just got a new hammer.

Everything looks like a nail. How many facilities in this country provide emergency care for severely injured patients without the availability of x-ray? Forty-three years ago, I worked at a USPHS hospital in tiny Bethel, Alaska, an Eskimo community 400 miles west of Anchorage, serving 50 native villages with no roads. Transportation was by plane, boat, or snow machine. You don’t get more isolated than that, and yet we had x-ray. I’m willing to bet there are no facilities in this country today that provide emergency care to trauma patients that have no x-ray capability.

In my 30 plus years’ experience, I have never examined a conscious patient who did not experience tenderness at a fracture site, no matter what the x-ray showed or didn’t show.

As I said before, the H&P is the one tool in the doctor’s armamentarium that provides the most bang for the diagnostic buck. Additionally, if there is any doubt, a splint, sling, and/ or crutches can be applied. Talking to patients takes time but is cheap. Using one’s hands, as in physical exam, is likewise cheap but effective. Let me give an example. Not long ago, sitting in Mayhew, Mississippi, I received a call from my daughter in Chicago. My 5-year-old granddaughter was complaining of elbow pain. The history was that she had fallen off her bed and landed on her arm. I told my daughter, who has NO medical training, how to examine her. She followed my instructions, and based on the information, I diagnosed a possible growth plate fracture of the proximal radius. I recommended a visit to the local orthopedist. The exam and x-ray documented the suspected fracture, and a cast was applied. It’s not rocket science.

If we are going to save money and yet maintain quality of medical care, we need to emphasize the basic H&P instead of depending on the latest procedures. We definitely don’t need the belt and suspender approach to diagnosing a fracture, as in case 1, i.e. x-ray, ultrasound, CT, and MRI. —Martin M. Pomphrey, MD; Mayhew

Editorials, letters, and commentary represent the opinions of the author(s) and not necessarily those of the Journal MSMA or the Mississippi State Medical Association.

230 JOURNAL MSMA August 2013

• Letters •

W

“Bedside Ultrasound ...” Author Response

e want to thank the writer for his thoughtful letter and the opportunity it presents to address an important role of ultrasound in extremity trauma. I’m not suggesting that ultrasound be used to evaluate a known fracture. On the contrary, I am advocating that ultrasound be used to assist the provider in deciding whether an x-ray or other specialized imaging is needed. Showing the ultrasound image of a fracture next to the corresponding x-ray illustrates the capability and accuracy of ultrasound in the evaluation of potential fractures.

I agree the physical exam is extremely important and can often reduce the need to order unnecessary expensive diagnostic studies. However, many negative x-rays result despite a thorough physical exam. Modern emergency medicine trained physicians are proficiently adept in the use of bedside ultrasound as an extension of the physical exam. In this perspective, ultrasound is no more a “procedure” than use of the stethoscope to auscultate the heart. In experienced hands, bedside ultrasound can greatly improve patient through time and decrease unnecessary, costly testing.

Consider the following scenarios: a 22-year-old female presents to the emergency department after twisting her ankle. She has significant tenderness to palpation and refuses

to bear weight. According to the Ottawa ankle rules, the exam findings suggest that an x-ray series is needed to rule out a fracture. The x-ray is obtained after the requisite pregnancy test and ultimately shows no evidence of a fracture.

Alternatively, consider the same patient seen by an emergency medicine physician who uses bedside ultrasound as an extension of the physical exam. After seeing no evidence of fracture via ultrasound, the physician decides not to order the costly x-ray series.

In both scenarios, the patient is correctly diagnosed with an ankle sprain and treated appropriately. In the first scenario, however, the patient requires a much longer length of stay in the emergency room and receives a significantly larger bill.

In short, I feel that an ultrasound exam is not a procedure, as you suggest, but a cost effective extension of the physical exam. One should not discount the utility of ultrasound simply because of familiarity with existing technology. The medical community would be amiss not to investigate modalities that could expand its armamentarium in providing high-quality and cost-effective care.

—Brian J. Tollefson, MD, CAQSM, RMSK

University of Mississippi Medical Center, Jackson

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• Special Article •

An Interview with James A. Rish, MD 2013-2014 MSMA President Karen A. Evers, Managing Editor [Each year the JMSMA interviews the incoming president. Here we go behind the scenes. Due to space limitations, the answered questions do the speaking for this interview. See more on Dr. Rish’s wife, Susan, in the Alliance Spotlight this issue, p. 246.] —Ed.

F

amily

I grew up in Pontotoc, Mississippi as the youngest of five children. My mother taught school, and my father had a radio, television, and communications business. My father worked long hours, and we saw him only briefly at night during dinner. We had a happy home life. Church was a very prominent part of my childhood. I enjoyed reading and playing tennis. In high school, I played the drums in the band which to a large extent was the center of my social activities. Upon graduation, it was expected that I would attend Ole Miss, as everyone else in my family had done. I became part of the third generation to attend Ole Miss. My great aunt and uncle were even professors at Ole Miss.

Milestones

I became interested in medicine because of my father. He wanted to become a doctor, but due to limited financial resources, was unable to go to medical school. After college, he worked with a local physician named Dr. John Dyer in his surgical practice in Houston, Mississippi. He often observed and sometimes assisted during surgery.

In high school, my favorite courses were science related. Despite my father, oldest brother, and sister pursing engineering, I realized I wanted to go to medical school because I had a deep love for the biological sciences and an insatiable curiosity about how the body worked.

My most memorable moment from medical school was when I returned home during my first year for a friend’s wedding. Everyone commented on how much weight I had lost and how pale I appeared. As I reflect, all I remember doing was studying and smelling like formaldehyde. I was fortunate to have been married, or I probably would have been in much worse shape.

I did have some fun through the years. I played the drums for our medical school class band. Performing provided many fond memories of my friends and the ASB parties.

My proudest accomplishment came during my fellowship year. I was very fortunate to be able to research and publish several articles on tuberculosis in the American Journal of Respiratory and Critical Care Medicine. This was meaningful because my mother was diagnosed with tuberculosis just after she was married and spent several years in the sanatorium in Magee, Mississippi.

Dr. and Mrs. James A. (Susan) Rish, 2009 MSMA Annual Session in Oxford— Dr. Rish was the recipient of the James C. Waites Leadership Award given annually to a physician under 50 who is an outstanding leader in organized medicine and community affairs.

234 JOURNAL MSMA August 2013

Organized Medicine

Dr. and Mrs. Rish — 2010 “Give Back” gala fundraiser for the MSMA Foundation

Dr. Rish’s family with grandparents, James and Evelyn Walters, December 2012

My first experience with organized medicine came during my residency. My wife, Susan, had taken a job administrated by the Arkansas Medical Society. As a perk of her job, she was invited to their annual session held in Hot Springs, Arkansas. This was the first time I had even thought about physician issues other than those related to diagnosis and treatment of various disease states. When we relocated to Tupelo in 1995 to begin private practice Susan immediately joined the MSMA Alliance and I joined the Mississippi State Medical Association.

I quickly realized how much I enjoyed the politics of medicine.

Dr. James Waites was instrumental in helping me become a member of the Board of Trustees for the Mississippi Physician Care Network. As I have progressed in leadership roles with the MSMA, I had many excellent mentors. I think one of the most important things I have learned is to remain calm, be a good listener, analyze the circumstances, and weigh the pros and cons to make the best decision.

Needless to say, I am still perfecting this technique.

Gumtree Race, May 2009

Parker and Peyton Rish, new Eagle Scouts 2007

August 2013 JOURNAL MSMA 235

Cross Country Meet 2010 – Preston, Dr. Rish, and Parker

Thanksgiving 2008, delighted with his smoked turkey

Sonoma Valley travel with high school friends, 2011

Birthday 2008 — Dr. Rish and his twin sister, Julie McCord, RN, MPH

Susan, Kenny Mask, and Dr. Rish at their 30th High School Reunion

236 JOURNAL MSMA August 2013

Easter Sunday at First Methodist Church 2013

James A. Rish, MD, Tupelo Pulmonologist MSMA President 2013-14

At a Glance •

Graduated magna cum laude with a bachelor’s degree from the University of Mississippi, 1983.

•

Received his medical degree from the University of Mississippi School of Medicine in 1989, Residency training in internal medicine at the University of Arkansas for Medical Sciences, 1992.

•

Fellowship training in the division of Pulmonary and Critical Care Medicine at the University of Arkansas for Medical Sciences, 1995.

•

Board certified in Internal Medicine, Pulmonary Diseases, and Critical Care Medicine; in private practice with Pulmonary Consultants, and on staff at North Mississippi Medical Center (NMMC) in Tupelo, Mississippi, since 1995.

•

NMMC roles served: Pulmonary Section Head, Chairman of Medicine, and Chief of Staff; member of the Cancer Committee, Physician Recruitment Committee, and chair of the Quality Standards Committee for North Mississippi Medical Clinics. Currently: Chair of the Medical Staff Credentials Committee and Medical Director of the Respiratory Therapy Department.

•

Member and Past President of the Northeast Mississippi Medical Society, member of the MSMA Board of Trustees where he has served as chairman for two years. Recipient of the the MSMA James C. Waites Leadership Award in 2009. Member of the Board of Trustees and Executive Committee of the Mississippi Physician Care Network. Member of the Southern Medical Association and currently serves on the Leadership Committee. Member of the Board of Directors of the Medical Chapter of the University of Mississippi Medical Center Alumni Association where he served as President in 2009.

Member of the American Medical Association, serving as both a past Delegate and current Alternate Delegate of the Mississippi Delegation.

•

Member of the First United Methodist Church of Tupelo. Served in fund-raising efforts for HealthWorks!, Yocona Area Boy Scouts Council, and Itawamba Community College Health Sciences Center.

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Married to Susan W. Rish and has three sons: Parker, Peyton, and Preston.

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Avid runner and enjoys working in his yard.

August 2013 JOURNAL MSMA 237

Community Service

I enjoy attending First United Methodist Church in Tupelo, where I serve as an usher during the early traditional service.

In addition, I served as an assistant scout leader for our church Troop 12. Susan and I are proud parents of three Eagle Scouts.

I have assisted in various fundraising activities in our community, including the Yocona Area Council Friends of Scouting Campaign, HealthWorks!, and Itawamba Community College Health Sciences Center. I have also testified before the City Council in our successful effort in eliminating smoking in restaurants and public places in Tupelo.

Platform

I became intrigued with an end-of-life article published in 2012 in the Wall Street Journal by Dr. Ken Murray [Entire essay published: Murray K. How doctors die, J Miss Med Assoc. 2013;54(3):67-69] which pointed out that when physicians are faced with life threatening devastating illness they often do not opt for complicated treatment and life sustaining therapies. Therefore, if advanced directives and comfort-oriented care are good enough for physicians, should they not be good enough for our patients as well? I feel that we as physicians need to do a better job in taking the time to explain to our patients and their families the likelihood of success or delay in the inevitable that various life sustaining therapies provide. I would like our association to pursue legislation relating to Physician Orders for Life Sustaining Treatment or POLST. Aside from the ongoing debate regarding Medicaid expansion, I hope to be able to continue to address the problems with our Medicaid managed care programs including burdensome prior authorization requirements, drug formulary issues, and specialty participation in the programs. I would also like to continue our efforts in developing a Patient Centered Medical Home Model for delivery of care as an alternative for our existing managed care programs.

Balance

As a Pulmonary/Critical Care physician, I work very long hours. It can be very difficult to have a personal life. For this reason, when I do have time off, I try to spend as much quality time with my family as possible. I am fortunate to have an understanding family that continues to make sacrifices for my busy schedule. continued p. 240...

238 JOURNAL MSMA August 2013

James A. Rish, MD; MSMA President 2013-14

What they say about him...

I have watched Jim “grow up” in MSMA. He has always been logical and level headed. He will do a great job as our President. —J. Patrick Barrett, MD; MSMA Past President, Madison To have a physician from Northeast Mississippi from our clinic as the incoming President is a great privilege. As Dr Rish’s clinic manager, I cannot tell you how proud I am of him. His leadership comes straight from his heart. I know when I get his Press Ganey score each month it is not below 99%. This is due to the compassion and quality that he shows his patients every day. —DeeDee Bates, Office Manager, Pulmonary Consultants, Tupelo Clear thinking, articulate, and a straight shooter, this is the kind of leadership we need and appreciate. —Richard D. deShazo, MD; Billy S. Guyton Distinguished Professor, Professor of Medicine and Pediatrics, The University of Mississippi Medical Center, Jackson I have had the pleasure of working side-by-side with Dr. Rish for almost two years. As his nurse, I can say without a doubt that he will do a superior job as president. He has a true passion for the issues that affect the physicians and healthcare providers of the state of Mississippi. With that said, he also has the welfare of the patients he cares for in mind as well. He is caring, compassionate, and extremely thorough with every patient he meets. —Blair Guin, RN; Pulmonary Consultants, North Mississippi Health Services, Tupelo With his sartorial collection of dapper bow ties, he’s a president after my own heart! —Stanley Hartness, MD; MSMA Past President, Jackson

He will be fine as long as you don’t bring attention to the aluminum foil hat or cardboard wings. He remains cautious about asking for my written recommendations. He will be fine.—Lyndon H. Perkins, MD; Pulmonary Consultants, Tupelo I have known Jim Rish since he arrived in Tupelo back in the 20th century. Don’t let his bow tie fool you, Jim really is a nerd. No, I am just kidding. Jim is a great father, husband, and doctor. He has dedicated much of his time and energy to MSMA, and the state of Mississippi is better off because of him. —Wayne A Slocum, MD; Obstetrics-Gynecology Associates, Tupelo When I think of Jim I see his smiling countenance always framed with his signature specs and bow tie; this image of him is always in my mind when I pause to refer a complicated patient to see him. I tell my patient, “You will really like Dr. Rish, he will not only listen to your lungs, he will actually listen to YOU.” And when I hand my patient their appointment card, I breathe a little easier knowing that Jim is on our healthcare team.

And, I can’t think of Jim Rish without thinking of grand times we’ve spent with sweet Susan, his wife. What a wonderful pair! Each Christmas we unfailingly receive a card with the latest picture of their three boys, the trio always in a hilarious pose that stays on my refrigerator door for months.

It’s easy to see a young Jim and Susan in their mischievous faces.

MSMA is so fortunate to have a steady man, a listening healer, to lead us through the perilous waters of change in medicine. My love and prayers go to you and your family always. —Dwalia S. South, MD; MSMA Past President, Ripley

Dr Rish is an absolute favorite with our interns and residents and often their most valuable specialty rotation. This praise for his willingness to take extra time with them and teach is shared by both present and past graduates over many years here at North Mississippi Medical Center. He is an invaluable asset for our teaching program. —Edward Hill, MD; AMA and MSMA Past President, Tupelo

I have known Dr Rish in many roles. He treated my daddy for many years, so I have known him as the family member of a patient, and he treated my dad with kindness and compassion. He always treated him with the utmost care, took the time to talk to my sister and me, and answer any questions we might have. I have also known him as a patient. He always listens to me, discusses things with me, and takes his time to really try to understand what I am Jim, with you as our President, MSMA is in for an telling him. I have also had the privilege of working with outstanding year. We have had many successes, and I know and watching him care for his patients; he truly does care. under your leadership our association will continue to excel. He has a true compassion for medicine, patients, and their The challenges we face in medicine are many, but the families. —Ginger Towery, Pulmonary Consultants, North rewards are great for those who stay the course. Best wishes Mississippi Health Services, Tupelo for a busy, productive, and fun-filled year. —Eric Lindstrom, MD; MSMA Past President, Laurel Dr. Jim Rish is not only a well-respected and devoted clinician but he exhibits the finest characteristics of physician A couple of decades ago, Jim joined what would become leadership. He is humble and fair, a great listener, brings a Pulmonary Consultants in Tupelo as our third man, unbiased perspective to discussions, and is a most effective and second bow tie wearer. We have grown to nine advocate in promoting great patient care. The North pulmonary physicians and three nurse practitioners. He Mississippi Health System is indeed fortunate to have such has been a trusted friend and colleague to whom I’ve even a fine individual in a leadership role - and so are our citizens. referred friends and family members. We’ve deliberated Thank you, Jim. —Mark S. Williams, MD, MBA, JD; Chief together over difficult radiographs, scans, and patients for Medical Officer, North Mississippi Health Services, years. He once asked me to write a recommendation letter Tupelo for a consulting position and I handed him a faux copy.

August 2013 JOURNAL MSMA 239

continued from p. 238...

O

ne of my favorite things about being a physician is the life long learning that is required to manage effectively our patient’s care. Each day brings unique challenges, and no two days are ever the same. I enjoy interacting with people from a wide variety of backgrounds. However, we continue to see attempts at erosion of the physician-patient relationship all in the name of someone’s political agenda. We are being overregulated and subjected to tactics that can only be described as bullying on the part of our government auditors. We are being forced to adopt electronic health records, markedly decreasing our efficiency and increasing our time away from family when there is an inadequate technological infrastructure in place to really make it a useful tool. We have transitioned from evidence-based medicine to reimbursement-based medicine.

It is for these reasons that I have embraced organized medicine. We simply have to work hard to fix these problems for the next generation of physicians. r

For the fun of it— You’re most likely to see me around: Running in local area races.

On the weekends, I love to: Get in long runs with my running club, working in my yard and grilling out with my family and friends.

The high school, college, or pro-sports team I root for are: The Ole Miss Rebels of course!

If I’m listening to music it is probably: Easy listening or female vocal artists like Enya.

My favorite books are: The Dragons of Eden by Carl Sagan and Into Thin Air by Jon Krakauer. I also enjoyed Decision Points by former President George W. Bush.

Favorite movies, old and new: Some of my favorite movies include “Dead Poets Society” and “Beaches” with Bette Midler. I love the older Christmas movies. One of my personal favorites is the 1938 version of “The Christmas Carol,” but I also like the new animated version with Jim Carey as well. I also love “White Christmas and Holiday Inn” starring Bing Crosby. In addition, it is a Rish tradition to watch “Christmas Vacation” with Chevy Chase.

Latest Splurge: Buying a Green Egg. I am passionate about: Everything dealing with politics.

Something about me not everyone knows: I have a twin sister who shares my passion for the medical sciences. She has an RN and MPH degree. We both happen to work at North Mississippi Medical Center where she oversees the Infection Control Department.

Do you like to go-out or stay in? Definitely stay in.

Perfect Meal: Spaghetti, salad, and garlic bread.

Perfect Day: Sharing a light and breezy fall day in the Grove at Ole Miss with family and friends.

Favorite Color: Green.

Cologne: Curve for Men. Text, Email or Cell phone: Prefer to talk to someone in person.

Pets: Not at this time since we lost our little Chihuahua of 12 years, Lolita Maria, this past November.

MSMA member since: 1995.

240 JOURNAL MSMA August 2013

• MSMA • Official Address of the 145th President Steven L. Demetropoulos, MD MSMA Annual Session - August 16, 2013 - Jackson University of Mississippi Medical Center Norman C. Nelson Student Union

T

his is my last opportunity to speak to you as your president so I wanted to address some of the issues and challenges that we face as an organization and make some recommendations and suggestions.

Lack of Involvement: The single biggest challenge that we face is not whether to have Medicaid expansion or cuts to reimbursement rates by insurance companies or increased regulations related to the Affordable Care Act. The biggest challenge that we face in the organization is lack of involvement. As I have gone across the state speaking at different component society meetings I have been disappointed at the turnout at our meetings. If you have two or three hundred doctors in a component society, you would expect that you could probably get 25% (fifty to sixty members) there, but that was not the case. We are lucky to get 10%. Some smaller component societies had better attendance than the larger ones.

If we do not find a way to engage our membership, our association will die a slow and painful death for lack of involvement. In order for us to face all the great challenges of tomorrow, we have to have physicians willing to give of their time and energy to the association so we can all work together for the physicians in the state and more importantly, for our patients. As I have said at many of the component society meetings, engaging our membership is not about a campaign or advertising effort. It is about one doctor asking another doctor if they would be willing to go to a meeting. It is about one doctor asking another doctor if they would be willing to run for office, and it’s about one doctor asking another doctor if they would be willing to attend the annual session. It literally takes one doctor asking another doctor, not any type of campaigns or slogans or group approach, but one person asking another person to be involved and that is not going to happen at the state level. It needs to happen at the level of the local medical society. Let me make some practical suggestions: The best way to communicate with doctors to get them to a meeting is to call them personally. Instead of depending on email or fax, arrange a calling tree through your local component society officers. They can call several people to make sure they are coming to the meeting and those people call a few more people and those people call a few more people until each doctor in the society has actually heard from another doctor that it is important for them to attend a meeting. The only way we can get people involved is by one doctor hearing the voice of another doctor asking them to be involved.

When the presidential visit is on the schedule for the local society meeting, try to make a special effort to get members out. This is when you get to hear the report of what is going on around the state and it is a chance to energize your local membership.

Consider the mini-internship program as the project that you can get behind in your local society and use it to energize your membership.

Doctors do better when they have a project or an issue that they can work on. This is the single best one to develop influence with your local legislators and business leaders. We have all the information to set up that program at the State Medical office. It is a turnkey operation. All you have to do is call and they can get the information to you.

Smoking: As you know, we have tried to move forward with a smoking ban for indoor work places, restaurants, and bars in the state. We tried to make a persuasive argument from the medical side by pointing out the 25 to 30% increase in cardiovascular disease as well as all the associated pulmonary disease related to secondhand smoke. We have tried to demonstrate that local polling data shows that 75% of the people in the state are for a smoking ban. We looked at the effect on business as well as the responses from owners of restaurants and bars. The majority of them were in favor of a smoking ban and there appeared to be no decreased revenues when businesses went smoke free. We made a strong argument why going city by city would not be effective in covering all the state.

We have tried to address some of the barriers encountered in the past such as the casino industry so we carved them out of the bill so we could try to get 98% of the state covered. I think this year’s barrier involved more of a libertarian argument. It basically said that we don’t want to tell somebody what they can do with their business. I fully understand that argument and sympathize with it but we have shown them how we already regulate restaurants and bars. We made an analogy with the seatbelt law and how they were able to come to terms with the personal determination that is involved with wearing seatbelts and how this is very similar to the smoking ban. The smoke free bill is even more important since we are dealing with second hand smoke and the fact that an individual’s rights should end when their smoking negatively impacts the health of others. We

August 2013 JOURNAL MSMA 241

have talked to our legislators about the general health of Mississippians and how we are number one in cardiovascular disease, in the top five for cancer and diabetes, and number one in obesity. Even though these are all serious problems, many of them are so multifactorial it is difficult to do anything about them, but with one bill that bans second hand smoke, we can immediately start decreasing heart attacks, peripheral vascular disease, stroke and lung disease, and it doesn’t cost us anything. They could flip the switch tomorrow on this bill and do more to improve the health of our fellow Mississippians than any other thing that they could do. That is why we need to continue to aggressively pursue this goal as an association.

Recommendations: I am recommending that we pursue a referendum through our legislature which allows this issue to be put before the people for a vote. In this way the legislators won’t have to take sides. It doesn’t matter whether a legislator is for smoke free air or against smoke free air. We are asking them to allow the people to decide. This is an issue that has been before the legislature for the past five or six years. They have not been able to bring it up for consideration and so the most democratic thing to do would be to allow the people to vote on it. I will need your help this coming year talking to our local legislators and helping them understand how important this is to Mississippi doctors but more significantly, how vital it is for the health of our fellow Mississippians. We are asking them to let the people vote on it. A second recommendation is for a bill to be submitted to the legislature calling for a referendum on smoke free air.

Medicaid: The third thing I would like to talk about is Medicaid. I have spent a great deal of time working on a lot of different aspects of Medicaid in an effort to reduce the hassle factor for our doctors as well as our patients. One of the major themes that we have talked about is accountability to physician providers. We need physicians to do more than just complain about issues with Medicaid. We need them to send their complaints to the State Medical Office for data collection. The complaints can be trended both for type of complaint and also for the volume of complaints. These then can be individually handled by the CAP Committee and the trended bigger issues will be presented to the Medicaid director. This will enable us to present real data to Medicaid and talk about things that need to be fixed. Let’s face it. Medicaid is going to be with us regardless of whether there is expansion or not and we need to try to work to improve the system for everyone involved.

Two things that would help to improve the whole process would be for Medicaid to hire a medical director to interact with physicians and to have an advisory board of physicians who meet regularly with the director to give him feedback on issues related to Medicaid recipients.

In regards to the medical home model, we realize that 20% of the Medicaid recipients use 80% of the resources. These are generally chronically ill adults. This is the group for which the medical home model would have the greatest benefit. We really need to continue to challenge our Medicaid director as well as help him to have some pilot sites in the state to use the medical home model. This would be the obvious way for Medicaid to save the most money and improve the quality of life for these chronically ill patients.

Recommendations: 1) State Medical Office to act as a clearing house for Medicaid issues and complaints. 2) Encourage Medicaid to hire a medical director. Develop a physician advisory committee to meet with the Medicaid director on a regular basis. 3) Continue to pursue the medical home model for Medicaid.

Insurance for the Uninsured: As I have struggled with the issue of Medicaid expansion this year, the problem has become less about the disproportionate share funding to hospitals and more about insurance coverage for the uninsured. There are about 250,000 Mississippians who make below the 138th percentile of the poverty level. That equates to about $31,000 per year for a family of four (one adult and three children).

These people generally make about $15.00 an hour without benefits. They serve us in restaurants. They mow our grass. They work on our homes. They are generally less than 50-years-old and are not over-utilizers of health care. They are currently being taken care of in free clinics or in emergency departments across the state.

I am more convinced than ever after serving these patients for the last twenty-five years that they deserve some type of insurance coverage. Just improving the economy with better jobs is not going to cover all these people. They are generally healthy and if you consider their demographics, the most likely thing that is going to happen to them is an injury from an MVA or an on-the-job accident or some type of infection.

They need some type of backstop coverage so that they have a limit on their exposure. By this I mean a catastrophic health insurance plan designed to provide an emergency safety net with an annual deductible of $2,500 to $5,000 after which the insurer provides complete coverage. This would help prevent people who are in a bad MVA and have an open fracture or other serious injury from going bankrupt and losing their home. They could probably have some additional preventive or wellness coverage thru which they could get a visit each year to have their blood pressure, blood sugar and lipids checked as well as getting a general wellness exam. But their insurance coverage at that level cannot cost them $6,000 to $7,000 per year like it would on the current open market.

We have to find some other way to be able to have coverage that is affordable for them. So my next recommendation is that we work with the governor and the legislature to identify a way to cover the uninsured in Mississippi. We need to consider all the possible options and pick the one that provides the best coverage for the least amount of cost to the individuals in the state. I think that everything should be on the table including having an insurance exchange with insurance companies competing for these catastrophic policies. I think Medicaid expansion should be considered. I think a hybrid plan in which people could get a stipend from Medicaid to buy private insurance could be a possibility. We need to commit to doing this over the next year.

Recommendation: We need to work with our Governor and Legislators to provide a plan to cover the uninsured in Mississippi. These are all my recommendations.

242 JOURNAL MSMA August 2013

I would like to leave you with one last recipe. It has been my habit over the course of this year to give you different recipes that I have enjoyed and here is one of my favorites. I really like to think of this as a recipe for life. It comes from 1 Peter, 4:8. It says, “Above all, love each other deeply because love covers a multitude of sins.” This is a recipe you can apply to any aspect of your life, whether dealing with your family or your friends or even in our convention hall during our annual session. We may have differences of opinion. We may feel passionate about a particular issue but when you have compassion towards another person, you can act with respect and courtesy and in a way that is not critical but constructive.

Now this is my chance to thank all those people that have made sacrifices on my behalf this year. First, I would like to thank my wife and children for their support and understanding during this past year. They have been great. I would like to thank my partners and the members of my group for their support over this past year in coverage at work.

I would like to thank the people at the State Medical Association office. Blake Bell and Anna Morris have done a superb job as our lobbyists this year. They worked so well with the legislators. They have excellent reputations and they are seen as reasonable people who provide good information on our behalf to the legislators. I would also like to thank Neely Carlton who supervises their legislative activity and strategy as well as providing great legal direction for our association. I would like to thank Virginia Jackson for coordinating and handling all the scheduling that was done this year on my visits. She has done a superb job and is an excellent asset to our association. I would like to thank Phyllis Williams, who has worked so hard on all the Medicaid issues. As many of you know, she was at Medicaid for greater than twenty years. She knows all the personnel there. She knows the organization and the culture and she has been such an asset to have on our State Medical team. I would like to thank Karen Evers who has worked on the journal articles with me. I want to thank Claude Brunson who has been an excellent chairman of the board, and Tommy Joiner, our past president, both of whom covered for me with events when I wasn’t able to attend. I would like to thank Charmain Kanosky who has really created a culture of excellence at our State Medical Association office. Everyone does their job with enthusiasm, excellence, and commitment, and she has worked very hard to put together this team. I feel like all of them have contributed to my personal success as president this year.

Finally, I would like to thank you, the membership. I have thoroughly enjoyed being your president and visiting you across the state and making new friends. The level of commitment and sacrifice on your part in taking care of our patients makes me so proud of our Association. A little over a year ago, I ended my first presidential speech with a verse from the Bible. It was from the book of Micah 6:8. It talked about what God asks of man--to do justice, to love mercy, and to walk with humility. I would like to end my term with another verse. It is from Paul’s letter to the Galatians 6:9. It says, “Let us not grow weary of doing good, for at the proper time we will reap the harvest if we do not give up.” Sometimes it is easy when you are doing good (like fighting for our patient’s insurance coverage, smoke free air or better access to care) to get frustrated and overwhelmed and feel defeated when many of the problems that we face are not solved in short periods of time but we will be successful in our efforts. The caveat is that we don’t give up. That is why it is important for us, as the physicians in Mississippi, to continue to fight on our patients’ behalf. Let us not grow weary of doing good. At the proper time we will reap the harvest if we don’t give up. Thank you. It has been a privilege to be your president.

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xpress your opinion in the Journal MSMA through a letter to the editor or guest editorial. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information.

While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers. You may submit your letter via email to KEvers@MSMA online.com or mail to: P.O. Box 2548, Ridgeland, MS 39158-2548.

August 2013 JOURNAL MSMA 243

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DISABILITY DETERMINATION SERVICES 1-800-962-2230 244 JOURNAL MSMA August 2013

• Images in Mississippi Medicine • DR. PINK CONN OF JAYESS, MISSISSIPPI (1870-1941)— This photograph is of Dr. John Pinkney “Pink”

Conn, who was born in 1870 in Lincoln County, Mississippi, to John Thomas Conn and Samantha Ann Conn. He was reared there, becoming a teacher at a very young age. He continued to teach until he saved enough money to send himself to medical school. His mother told friends that he “saved every penny he made”— determined one day to pay his way through medical school. He attended and graduated from Tulane University Medical School. After beginning his practice, he sent his brother Tom to medical school, and he too became a physician. Dr. Pink married Nancy Felder, and they had nine children. He bought his first piece of land in 1905 in Lawrence County. It was 40 acres, and he paid $600 cash for it. Eventually he bought a large tract of land joining it from the Denkmann Lumber Company. He built his doctor’s office and home there (see other photo) in the Topeka Community. (Topeka, named for Topeka, Kansas, was formed in 1900 when a lumber railroad was built from Norfield to Jayess.) People called him “Dr. Pink,” and many remember him today with affection and respect. He loved his practice and was a gifted physician. He was known for his diagnostic abilities. He and his brother were the only two physicians in the Topeka area of Lawrence County. As a country doctor, he made his house calls in his horse pulled buggy. Although his practice extended through the Great Depression, his family never went hungry. Many of his patients could not pay him in money, but rather with whatever they could: eggs, a ham, milk, or chickens. He was known and loved throughout his community as a compassionate physician who always went above and beyond to help people. He never retired. He eventually built an office in the town of Monticello, Lawrence County’s seat. Later, he became a state representative, serving several terms in the Legislature. He died while in Jackson in “session” in 1941. He went to his motel room and died there of a heart attack. His wife Nancy received the news of his death by hearing it over the radio while she was attending a camp meeting at Felder’s Campground. His family still resides on the family farm, which now has seen six generations. Thanks to Tab and Brenda Conn, who live on the old farm at Jayess, as well as Margaret Nancy Conn Guy of Pike County, Dr. Pink’s granddaughter, who contributed biographical information for this article.

If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please contact the Journal or me at lukelampton@ cableone.net.

— Lucius Lampton, MD Editor

August 2013 JOURNAL MSMA 245

• Alliance Spotlight • Susan W. Rish

G

rowing Up

Mrs. James (Susan) Rish MSMA Alliance Past President 2003-04 Right: Official Alliance president’s portrait

I tell everyone that I am a “Delta Girl” because that is where I spent the majority of my childhood. I was born in Bangor, Maine and was lucky to grow up in a military family. When my father was sent overseas, my mother, brother, and I lived next door to my maternal grandparents just outside of Charleston, Mississippi. Upon my father’s return to the states, our family moved to Columbus, Mississippi, where we lived close to the air force base. Plattsburg, New York was the next stop, and what a culture shock for us all. My family lived in New York for four years. In 1973, when my father retired from the Air Force, we moved to Webb, Mississippi. My parents bought a piece of property next to my grandmother’s house. This, by the way, was literally on the corner of a cotton field. Can’t get more “Delta Girl” than that!

Meeting Dr. Rish

I was a freshman at Mississippi University for Women, and I mentioned to my new friend, Penny Gafford, that I was looking for someone to date. She happily handed me her photo album and told me to pick someone out and she would arrange a meeting. When I picked out Jim Rish, she told me that he was one of her closest friends from high school. She made the initial call and introduced us through the phone. We made an arrangement to meet. Jim traveled from Oxford, where he was a freshman at the University of Mississippi, to Columbus, for our blind date in November 1979.

After about 10 dates over the next three years, we were engaged the summer before our senior year of college and married immediately after. This year we celebrated our 30th wedding anniversary.

Children

Jim and I were married for nine years before we had our first child. Today, we are lucky to have three wonderful boys. Our first-born is Parker Staten Rish, and he is 21-years-old. Our middle child is Robert Peyton Rish, age 20. The youngest Rish son is James Preston who is 17-years-old.

Free time

I am very fortunate to be a stay at home mother, which has afforded me a great deal of time to spend with my children. As a family, we love to watch movies at home and in the theater. (I think it has a lot to do with the popcorn.) I love to cook, bake, and entertain friends and family. I enjoy traveling, and recently I have

246 JOURNAL MSMA August 2013

Preston, Peyton, and Parker Rish - December 2012

fallen back in love with reading books. I love doing volunteer work. I just can’t say no, and that is purely selfish. I receive such a blessing from helping others. I currently serve as the Lee County Medical Alliance Publicity Chairman, and I am an active member of the MSMAA serving in several roles including the Nominating Committee. I am honored to be the presidentelect for the Southern Medical Association Alliance, and I look forward to traveling the Southern states as the SMAA President beginning in November. I serve as the secretary for my homeowners association, and I volunteer my time with the Altar Guild at First United Methodist Church. I am a member of the Tupelo High School PTO and love spending time with my family at football games in the Grove at Ole Miss. Since I don’t have a house cleaner, the rest of my time is spent cleaning the house.

How did you come to join the Alliance?

Mrs. James A. (Susan) Rish and Mrs. John M. (Dottie) Estess

I began my journey with the medical alliance when Jim was in medical school. I received an invitation in the mail to come to a welcome meeting for new medical student spouses. I still stay in touch with some of those spouses to this day. I have been involved with every level of the Alliance for the past 28 years.

Favorite Alliance Memories

I have so many it is hard to choose just one. Some of the highlights include: • coordinating Mississippi’s Favorite Artists Show for the AMA Foundation Fundraiser during the MSMA convention

• Meeting celebrity Lori Smith from the television show, “Trading Spaces”

• Seeing Helen Turner in a royal blue wig and sunglasses during

the campaign party for Dr. Edward Hill at the AMA Convention in Chicago

• Getting goose bumps every time I hear Karen Morris sing the Susan, with “Trading Spaces” designer Laurie Smith at a 2003 Central Medical Society meeting

National Anthem

• Watching Mary Sue and Don Mitchell swing dance at the MSMA Convention

• Having my mother travel with me to the country alliances during my presidential year

• My children asking if they could stand up with me when AMA

President Jean Howard swore me in as the president of the “United States” instead of the MSMA Alliance

• And celebrating my anniversary in Chicago at the AMAA convention for the past 10 years.

Highlights of your Presidential Year

Susan with Ericka Harold, Miss America 2003

The most notable highlight of my presidential year was the moment I realized I was going to have to give my presidential acceptance speech after Miss America. MSMAA President Eileene McRae invited Miss America to speak to our alliance members as a kick-off for our health project, which was a two-year project to produce a bullying workshop for teachers on the Gulf Coast.

Thanks to Eileene the MSMAA installation luncheon was the bestattended luncheon in history. I had resigned myself to speaking in front of about 40 people, but was shocked to find out the luncheon

August 2013 JOURNAL MSMA 247

had increased to almost 100 attendees. The morning of the luncheon, I was unable to sleep. Of course, the kids and Jim were sleeping soundly; I didn’t want to wake them up. Therefore, I sought solace in the bathroom. I think I jogged about 15 miles trying to shake off my nerves, and at the same time watching myself in the mirror rehearsing my speech over and over again.

After borrowing an inhaler from Karen Morris for my newly acquired stress induced asthma, I gave my speech without a hitch. Now, I was nowhere near as polished as Miss America, but in my defense, it was my first time to give my speech.

Miss America’s speech was part of her platform on bullying so she had given it a few times. My wonderful spouse gave me a beautiful three stone diamond ring to celebrate our 20th anniversary and my installation as the MSMAA President. Overall, it was a great day – I got a new diamond ring, had my picture taken with Miss America while wearing her crown, and was so sore from my impromptu run I could barely move - Good Times!

Advice for fellow physician spouses?

Dr. Rish and children in Kiawah Island, South Carolina 2010

When I was a medical student spouse, our alliance would meet in the homes of the Jackson physician spouses. I remember being in one of the most beautiful homes, and this particular spouse was very wise when she told me to start practicing patience every day. She added, being the spouse of a physician was not always going to be easy; plans get cancelled, dinners will often be served cold, and call nights are lonely. She suggested finding a hobby to fill the time. Her hobby to fill the time was cross-stitching and needle work. As a result, she had filled her home with beautiful pictures and pillows. I took this advice to heart, and I began practicing patience. My hobbies have changed over the years from cross-stitching and making scrapbooks for the children to working Sudoku puzzles, reading, and surfing the internet. Practicing patience is great advice for every situation; it’s almost as good as the Boy Scouts’ motto of “Be prepared.” r

[un]confusing. [un]frustrating. [un]terrible.

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248 JOURNAL MSMA August 2013

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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

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

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