August 2014 JMSMA

August

Claude D. Brunson, MD VOL. LV

2014

2014-2015 MSMA President No. 8

GET READY FOR

ICD-10

STAY ON THE ROAD TO 10 STEPS TO HELP YOU TRANSITION The ICD-10 transition will affect every part of your practice, from software upgrades, to patient registration and referrals, to clinical documentation and billing.

CMS can help you prepare. Visit the CMS website at www.cms.gov/ICD10 and find out how to: •

Make a Plan—Look at the codes you use, develop a budget, and prepare your staff

•

Train Your Staff—Find options and resources to help your staff get ready for the transition

•

Update Your Processe—Review your policies, procedures, forms, and templates

•

Talk to Your Vendors and Payers—Talk to your software vendors, clearinghouses, and billing services

•

Test Your Systems and Processes—Test within your practice and with your vendors and payers

Now is the time to get ready. www.cms.gov/ICD10

Official CMS Industry Resources for the ICD-10 Transition

www.cms.gov/ICD10

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.

SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available.

ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548.

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.

AUGUST 2014

VOLUME 55

NUMBER 8

Scientific Articles How Early Elective Deliveries Impact Infant Health in Mississippi

252

Amy Radican-Wald, DrPH(c), MPH; Charlene Collier, MD, MPH; Dick Johnson, MS

Progress in the Early Identification of Hearing Impaired Infants in Mississippi

256

Ojus Malphurs Jr., PhD and William D. Mustain, PhD

Clinical Problem-Solving Case: “I keep falling all the time...”

259

Jessica Jones, MD

Special Article An Interview with Claude D. Brunson, MD; MSMA President 2014-2015

262

Karen A. Evers, Managing Editor

President’s Page Farewell Address

269

James A. Rish, MD; MSMA President

Related Organizations

Mississippi Professionals Health Program: Physicians’ Health Corner Mississippi State Department of Health

276 278

Departments From the Editor: Reaching the Finish Line with Dignity Letters: Jackson Free Clinic Seeks Good Samaritan Doctors Legal Ease: Harper Grace’s Law

250 272 273

Adam Woods, MSMA Law Clerk

Poetry and Medicine

280

About The Cover: 147th MSMA President— Claude Brunson, MD, of Jackson was inaugurated MSMA President after serving as PresidentElect for one year and on the Board of Trustees since 2008. Dr. Brunson is Senior Advisor to the Vice Chancellor for External Affairs and Professor of Anesthesiology at the University of Mississippi Medical Center.

The inaugural gala took place Friday. August 16 at the Jackson Hilton in conjunction with the Annual Session of the MSMA House of Delegates held at the UMC Norman C. Nelson Student Union. r August

Claude D. Brunson, MD

VOL. LV

2014

2014-2015 MSMA President No. 8

Official Publication of the MSMA Since 1959

August 2014 JOURNAL MSMA 249

From the Editor: Reaching the Finish Line with Dignity

“S

tart the conversation,” begins an awardwinning MSMA Alliance brochure on advanced health care directives, designed by 2013-14 President Mollie Pontius of Ocean Springs. For too many patients, that conversation about advanced directives and DNR status begins too late, and often not even with the patient, but with their charged family outside their hospital room, with the patient in bed dying, unable to make their own decision.

What I ask family members when faced with such situations is “What would your mother (or father) want to be done?” Too often, family members want much more than the patient would have desired for whatever reasons of guilt or emotion.

This brilliant and attractive brochure encourages patients and physicians to begin that important conversation well before the desperate last minute, with hopes that all patients in Mississippi can reach “the finish line with dignity.” Pontius sought input from many of the leading hospice physicians in the state in creating the brochure. A glossary of terms, from “Life Support” to “POLST,” provides patients a resource in making an informed end-of-life decision. It encourages patients to talk IN ADVANCE to their physicians and families and to make the

plan they want for their end-of-life.

This helpful brochure was honored nationally by the AMA Alliance, with Pontius receiving a HAP (Health Awareness Promotion) Award for it this summer in Chicago. This brochure also complements successful legislative efforts by our MSMA with POLST (Physicians Orders for LifeLucius M. Lampton, MD Sustaining Treatment) this year, which provided for a legal planning tool for patients to define their medical preferences through actionable physician orders.

Brava to Mollie Pontius and our MSMA Alliance for creating this exceptional tool for the practicing physician to “start the conversation” of end-of-life planning with our patients. It will help educate them and encourage them to discuss with us what care they desire for themselves. This brochure needs to be in every physician office lobby in the state.

Contact our MSMA to get some at no cost for your office.

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 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

250 JOURNAL MSMA August 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 and Author Jackson Health Care for 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

Medical Assurance Company of Mississippi At MACM, our insureds are more than just a policy number.

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Knowing Our Insureds August 2014 JOURNAL MSMA 251

• Scientific Articles • How Early Elective Deliveries Impact Infant Health in Mississippi Amy Radican-Wald, DrPH(c), MPH; Charlene Collier, MD, MPH, MHS; Dick Johnson, MS

A

bstract

Background: Infants delivered early for non-medical reasons are at increased risk of poor birth outcomes.

Trends and associated health outcomes were unexamined in Mississippi.

Objective: Determine elective delivery trends and impacts on infant mortality.

Methods: Identify cesarean deliveries and inductions without medical indications from birth certificate records linked with death certificate records. Assess differences in death rates between those born electively during 37 and 38 weeks compared to 39 weeks gestation.

Results: Early elective delivery rates increased significantly (p<.01) from 8.5% in 2001 to a peak of 17.8% in 2008.

The rate began to decline in 2008 and was 16.5% in 2011.

Neonates born electively before 39 weeks gestation had threefold higher death rates [2.1 per 1,000] than neonates born at 39 weeks gestation [0.6 per 1,000], a statistically significant difference.

Conclusion: Early elective deliveries in Mississippi are associated with increased infant mortality. Reducing this common practice could improve birth outcomes in the state.

Key Words: Infant Mortality, Perinatal Service Delivery,

Health Policy, Public Health Author Affiliations: Senior Policy Analyst at the Center for Mississippi Health Policy and a Doctoral Candidate in the Department of Health Sciences at Jackson State University (Dr. Radican-Wald). Perinatal Health Research and Policy Consultant at the Mississippi State Department of Health (MSDH) and Assistant Professor, Obstetrics and Gynecology, University of Mississippi Medical Center (Dr. Collier). Vital Statistics Systems Manager at the MSDH (Mr. Johnson).

Corresponding Author: Amy Radican-Wald, 120 N. Congress Street, Suite 700, Jackson, MS 39201 (aradican-wald@mshealthpolicy. com) or Charlene Collier, 570 E Woodrow Wilson Drive, Jackson, MS 39215 (Charlene.Collier@msdh.ms.gov).

252 JOURNAL MSMA August 2014

Introduction

Early elective deliveries are those performed through an induction of labor or a scheduled cesarean section from 37 weeks to less than 39 weeks gestation, without a medical or obstetric indication. While classic teaching defined pregnancies after 37 weeks as ‘term’, this definition has changed based upon the recognition that neonatal morbidity varies during this time.1 Research has shown that elective deliveries performed during the ‘early term’ period of 37 to 38 weeks, 6 days are associated with higher risks than those at ‘full term’ from 39 weeks through 41 weeks. These risks include a higher rate of neonatal intensive care unit admissions from transient tachypnea and respiratory distress syndrome, increased mechanical ventilation, feeding problems, sepsis, and prolonged hospitalization.2-6 Inductions during this ‘early term’ period are also at greater risk of resulting in cesarean delivery.2 As there have been no proven health benefits for this practice and many documented harms, the American College of Obstetricians and Gynecologists recommends against performing elective deliveries before 39 weeks gestation.7,8 Examples of medical indications for an induction of labor or planned cesarean section before 39 weeks include conditions such as premature rupture of membranes, intrauterine infection, placental abruption, fetal compromise, preeclampsia, poorly controlled diabetes and other maternal medical conditions.7 Common reasons for delivery that are considered elective include convenience for the patient or physician, a history of fast labors, suspected fetal macrosomia, prodromal labor, and maternal discomfort or exhaustion with pregnancy. A mature fetal lung maturity test result before 39 weeks without an appropriate clinical situation is also not an indication for delivery.8 In the United States, the rate of elective inductions and cesarean deliveries increased significantly from 1990 through 2006.9 Induction rates rose from 9.5% in 1990 to 22.5% in 2006 as cesarean rates reached 32%.10 Much of this increase is attributed to non-medically indicated deliveries.9 Due to recent

national efforts to reduce this practice, the rate of early elective Methods deliveries fell from 17% in 2010 to 11.2% in 2012. Great All singleton live births occurring in Mississippi were asvariation remains in the rate of early elective deliveries among sessed by completed weeks of gestation using 2001 to 2011 birth the states, ranging from under 5% to over 25%.11 According to certificate data. Non-medically indicated cesarean deliveries the consensus reached through partnerships among experts and and inductions were identified using an algorithm that removed the March of Dimes, acceptable early elective delivery rates indicated deliveries such as preeclampsia and fetal distress, are considered to be less than 5%, rather than 0%, as there will among others. The early elective delivery rate was calculated continue to be acceptable reasons for delivery that do not fit into as the number of deliveries between 37 weeks and 38 weeks, 6 measured indications and errors in measurement can persist.2 days with no documented labor or medical indication for early There is limited published data about early elective delivdelivery. Trends in all deliveries were also assessed. Tests for eries in Mississippi. Of the five Mississippi hospitals reporting statistical significance at an alpha level of .05 were calculated. to Leapfrog in 2012, rates of elective deliveries ranged from a Death certificate records from 2007 to 2011 were linked low of 2.2% to a high of 50%â&#x20AC;&#x201D;well above the national target with birth certificate records during the same time frame for inrate of 5% or less.11 As early elective deliveries are a source fants up to 28 days old in order to discern mortality rates shortly of preventable morbidity and mortality and since Mississippi after birth. Death rates for early, non-medically indicated delivcontinues to have the highest infant mortality rate in the United eries were then compared to the death rates for infants delivered States, understanding this practice is important for improving at 39 weeks of gestation. Confidence intervals were calculated at birth outcomes in the state.12 In this study, we describe the statethe 95% level to determine statistically significant differences. wide trends in early elective deliveries in Mississippi and explore the Trends impact of practice infant mortality.

Results Figure_1: forthis Livehealth Birthscare

by Week of on Gestation in Mississippi, 2001-2011 Delivery Rate Trends Fig 1. Trends for Live Births by Week of Gestation in Mississippi, 2001-2011 In Mississippi, all deliveries between 39-41 weeks gestation declined <39 Weeks 39-41 Weeks significantly between 2001 to 2011 from 65% 60.6% to 49.6% (p<.01) (Figure 1). Dur60.6% ing the same time frame, deliveries be57.9% fore 39 weeks of gestation rose signifi55.4% 55% 54.1% cantly (p<.01). Half of all infants born 52.0% 50.4% 50.8% 49.6% 50.2% during this time frame were delivered 50.1% 50.1% 49.5% before 39 weeks of completed gestation.

49.3% 49.6% 49.5% 50.1% 48.6% 47.2% The increase in deliveries before 45% 45.1% 39 weeks is primarily attributable to a 43.6% 41.0% rise in early term births during 37 and 38.3% 38 weeks gestation (Figure 2). While 35% preterm deliveries at 36 weeks gesta2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 tion or less remained relatively stable, deliveries during the early term period Figure 2: Trends for Live Births by Week of Gestation in Mississippi, 2001-2011 Fig 2. Trends for Live Births by Week of Gestation in Mississippi, 2001-2011 of 37 and 38 weeks increased significantly (p<.01) from 26.7% to 36.5%. <37 Weeks 37-38 Weeks 39-41 Weeks Early elective delivery trends in 65% 60.6% Mississippi from 2001 to 2011 are shown 57.9% 55.4% in Figure 3.

The rate rose significantly 54.1% 55% 52.0% 50.8% 50.1% 49.3% 49.6% 50.2% 50.1% (p<.01) from 8.5% in 2001 to a peak of 17.8% in 2008. The rates began to de45% cline from 2009 through 2011. Yet, 1 36.4% 36.0% 36.5% 36.9% 35.5% 33.3% 34.3% 35% 32.0% out of every 6 infants born in 2011 were 30.5% 28.3% 26.7% delivered before 39 weeks of completed 25% gestation without any medical indication.

15% 5%

11.6%

2001

12.7%

2002

13.1% 13.1%

2003

2004

13.9%

2005

14.3%

2006

14.0%

2007

13.5%

2008

13.8%

2009

13.5%

2010

13.1%

2011

Death Rate Analyses Infant mortality is far less common for those delivered during the early term period than those delivered before

August 2014 JOURNAL MSMA 253

deliveries with notable successes. In 2011, 5 states collaborated in a rapidcycle improvement program and reduced Early Elective Delivery Rates 24.0% the rates of early elective delivery from 27.8% in the first month to 4.8% by the 12th month.13 South Carolina announced 19.0% 17.8% 17.0% 16.3% 16.5% 15.9% a 45% reduction in early elective deliver15.0% 14.1% ies through its Birth Outcomes Initiative 13.3% 14.0% 11.7% and estimated a cost savings of $6 mil9.8% lion dollars for the state within the first 8.5% 9.0% quarter of 2013.17 Successful strategies to reduce non-medically indicated de4.0% liveries have included implementing de2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 livery scheduling policies that require a medical indication for planned deliveries Fig 4. Neonatal Death Rates for Early Elective and 39 Week Deliveries before 39 weeks gestation and payment Figure 4: Neonatal Death Rates for Early Elective and 39 Week Deliveries in Mississippi, 20072011 in Mississippi, 2007-2011 reforms to discourage the practice.17,18 In light of the developing evidence, the Mississippi State Department of 3.0 Neonatal Death Rate per 1,000 Deliveries Health recently partnered with the Mis2.5 sissippi Hospital Association and the 2.1 state chapters of the March of Dimes and 2.0 the American College of Obstetricians and Gynecologists to request hospitals 1.5 performing obstetric services implement 1.0 1.0 firm policies to reduce early elective de0.6 liveries. Facilities officially pledging to 0.5 do so in 2014 will be recognized publicly for their efforts to curtail this practice.

0.0 37 Weeks (Elective) 38 Weeks (Elective) 39 Weeks It is encouraging to note that Mississippi is showing declines in early elective delivery rates that, with ongoing sup37 weeks.12 Over the 5 year period examined (Figure 4), neoport, will translate to improved birth outcomes. Vital statistics nates delivered electively at 37 weeks gestation had three-fold show the majority of infant deaths in Mississippi are among higher death rates [2.1 per 1,000; 95%CI: 1.20,3.41] compared those born with anomalies or prematurely.12 Consistent with to those delivered at 39 weeks gestation [0.6 per 1,000; 95%CI: other study findings, this research demonstrates a significantly 0.43,0.82]. Thus, electively delivered, early term infants in higher rate of death among neonates delivered electively durMississippi had significantly higher death rates within their first ing the ‘early term’ of gestation in Mississippi. While not all 28 days of life than those delivered at 39 weeks of gestation. poor birth outcomes can be prevented and elective deliveries during the early term period may at times be justified, reducDiscussion ing this practice can lead to improved birth outcomes in MisNationally, there has been a growing concern about early sissippi, where infant death remains a significant challenge. elective deliveries and numerous quality improvement efforts extended to decrease this practice.13-15 No studies have demonReferences strated an increased rate of stillbirth or poor outcomes by eliminat1. The American College of Obstetricians and Gynecologists Coming non-medically indicated deliveries before 39 weeks.14 Given mittee on Obstetric Practice The Society for Maternal–Fetal Medthe extent of data showing the potential harm of early elective icine. Definition of term pregnancy, committee opinion No. 579. deliveries and proven capacity for hospitals to modify this pracObstet Gynecol 2013;122:1139–1140. tice, the Joint Commission now includes early elective deliveries 2. Clark SL, Miller DD, Belfort MA, Dildy GA, Frye DK, Meybefore 39 weeks as a quality indicator for obstetric hospitals.16 ers JA. Neonatal and maternal outcomes associated with elective The March of Dimes began focusing on reducing early term delivery. Am J Obstet Gynecol 2009; 200(2):156.e1-156.e4. elective deliveries through a campaign called ‘Healthy Babies 3. Morrison J, Rennie J, Milton P. Neonatal respiratory morbidity are Worth the Wait’ in 2007.14 Since then, states across the and mode of delivery at term: influence of timing of elective caesarean section. BJOG 1995;102:101-106. country have partnered on initiatives to reduce early elective

Figure 3: Trends of Early Elective Delivery Rates in Mississippi, 2001-2011

Fig 3. Trends of Early Elective Delivery Rates in Mississippi, 2001-2011

254 JOURNAL MSMA August 2014

4.

Madar J, Richmond S, Hey E. Surfactant-deficient respiratory distress after elective delivery at term. Act Peadiatr.

1999;88:1244-1248.

13. Oshiro B, Kowaleski L, Sappenfield W, et al. A multistate quality improvement program to decrease elective deliveries before 39 weeks of gestation. Obstet Gynecol. 2013; 121(5):1025-1031.

5.

Sutton L, Sayer G, Bajuk B, Richardson V, Berry G, HendersonSmart D. Do very sick neonates born at term have antenatal risk?

Infants ventilated primarily for lung disease. Acta Obstet Gynecol Scand. 2001;80:917-925.

6.

Hook B, Kiwi R, Amini SB, Fanaroff A, Hack M. Neonatal morbidity after elective repeat cesarean section and trial of labor. Pediatrics 1997;100(3):348-353.

14. Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, Kowalewski L. Elimination of non-medically indicated (elective) deliveries before 39 weeks gestational age: California maternal quality care collaborative toolkit to transform maternity care. 1st ed. White Plains, NY: March of Dimes; 2010.

7.

The American College of Obstetricians and Gynecologists Committee on Obstetric Practice The Society for Maternal–Fetal Medicine. Non-medically indicated early term deliveries, committee opinion No. 561. Obstet Gynecol. 2013;121:911–915.

8.

The American College of Obstetricians and Gynecologists. Induction of labor, ACOG Practice Bulletin No. 107. Obstet Gynecol 2009;114:386–397.

9.

Zhang J, Yancey MK, Henderson CE. U.S. national trends in labor induction, 1989-1998. J Reprod Med. 2002;47:120–124.

10. Martin J, Hamilton B, Sutton P, et al. Births: final data for 2006.

National Vital Statistics Reports. Atlanta, GA: National Center for Health Statistics; 2009. Available at: http://www.cdc.gov/ nchs/data/nvsr/nvsr57/nvsr57_07.pdf. Accessed March 12, 2014.

11. The LeapFrog Group. Hospital rates of early scheduled deliveries. 2012. Available at: http://www.leapfroggroup.org/tooearlydeliveries. Accessed March 9, 2014.

15. Ohio Perinatal Quality Collaborative Writing Committee. A statewide initiative to reduce inappropriate scheduled births at 36 0/38 6/7 weeks’ gestation. Am J Obstet Gynecol. 2010;202(3):243.e1243.e6.

16. The Joint Commission. Improving performance on perinatal care measures. The Source 2013;11(7):16-19.

17. Perelman N, Delbanco S, Vargas-Johnson, A. Using education, collaboration, and payment reform to reduce early elective deliveries: A case study of South Carolina’s birth outcomes initiative.

New York, NY: Catalyst for Payment Reform in collaboration with Milbank Memorial Fund; November 2013.

18. Clark SL, Frye DR, Meyers JA, et al. Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth. Am J Obstet Gynecol 2010; 203(5):449. e1-449.e6.

12. Mississippi State Department of Health. Vital Statistics Report. 2012. Available at: http://msdh.ms.gov/phs/2012/Bulletin/ vr2012.pdf. Accessed March 10, 2014.

Advocacy, Leadership, Quality and Professional Identity

AnnuAl Scientific ASSembly October 30-November 1, 2014

SAndeStin Golf And beAch ReSoRt, deStin, fl bAytowne confeRence centeR

Assembly Highlights and Events

How to Register Online: sma.org/assembly Telephone: 800.423.4992, ext. 620 Mail or Fax -Download Form: sma.org/assembly

Education!

Alliance Activities!

w Pulmonary Diseases w Cardiovascular Diseases w New Drugs Update w Risk Management w Health Reform Update w “Watson” in Healthcare w Quality of Care/Medical Necessity w Abstract Presentations w Poster Presentations

w Raffle w General Sessions w State and County Project Exhibits w Celebrating its 90th Anniversary

Collegiality and Networking! w Welcome Reception w Hospitality Area w SMA/SMAA Presidents’ Installation Luncheon

Halloween Family Fun! w Trick or Treat in Sandestin’s Village Streets w DJ Music – Events Plaza Stage w Spooky Fireworks

August 2014 JOURNAL MSMA 255

• Scientific •

Progress in the Early Identification of Hearing Impaired Infants in Mississippi Ojus Malphurs Jr., PhD and William D. Mustain, PhD

A

bstract

The prevalence of permanent congenital hearing loss is three to four infants per thousand live births. Because early intervention is effective in preventing speech and language delay, the NIH has recommended universal newborn hearing screening. Prior to this recommendation, several states, including Mississippi which had one of the first hospital based screening programs, had statewide programs,.

In 1981 the Lions Clubs of Mississippi and the University of Mississippi Medical Center began an infant hearing screening program, which was described in Volume XXX of The Journal of the Mississippi State Medical Association. This program was recognized in 1986 with an award from the U.S. Secretary of Health and Human Services, and by 1989, the Lions Club had persuaded twenty-two hospitals that this was a needed service.1 Twelve years after the start of the program in Mississippi, the National Institutes of Health (NIH) recommended universal newborn hearing screening.2 This article reviews Mississippi’s efforts toward early identification of hearing loss and provides an update on the current screening program.

1964-65 Rubella Epidemic

Interest in early identification actually began almost fifty years ago after the rubella epidemic of 1964-65, which produced thousands of infants with congenital hearing loss.3 Because an unusually large number of children with delayed speech and language entered school in the 1970’s, the Mississippi Legislature recommended a “method of early detection and registration” and in 1974 passed Section 37-23-151 authorizing a registry. No registry was ever established, and the Legislature Author Affiliations: Ojus Malphurs Jr., PhD, CCC-SLP/A, is retired from the University of Mississippi Medical Center and has a private practice, Infant Hearing Services, located at Select Specialty Hospital in Jackson. William D. Mustain, PhD CCC-A, is a Professor in the Department of Otolaryngology and Communicative Sciences at the University of Mississippi Medical Center in Jackson.

Corresponding Author: William D. Mustain, PhD, Dept. of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216

256 JOURNAL MSMA August 2014

never funded one. Several other states established registries of “at risk” children but had limited success because at least half of the children with hearing loss had no risk factors and at that time there were problems testing very young children. The University Medical Center (UMC) attempted to use a registry; however, in spite of considerable time and effort, the rate of identification at less than a year of age was only 5% and at less than two years was only 10%. In 1998, the Legislature repealed Mississippi’s registry law.

Lions Club

In 1978, the President of Lions International issued a call for Lions Clubs to fulfill Helen Keller’s original challenge to include the service needs of the hearing impaired as well as the visually impaired. In response, the Lions Clubs of Mississippi met with professionals in the state with an interest in hearing impaired children. In spite of philosophical differences concerning the best educational management approach, early identification was the most frequently mentioned need.

Initially, the Lions Club and UMC made television public service announcements showing the responses of normal hearing children and encouraging parents to contact the Health Department if they were concerned about their child. In 1981, the Lions purchased a new screening device, the Crib-O-Gram, developed at Stanford University. By 1991, 50,385 infants had been screened at UMC and other hospitals throughout the state with 69 hearing impaired children identified. A review in 1994 indicated that 32% of these hearing impaired children had been identified by six months of age and 48% by one year. Obviously, newborn hearing screening was a considerable improvement over the use of a registry.

Problems

As expected, there were problems in starting a new program: (1) Diagnostic techniques at that time were limited to behavioral tests, which were subjective and required the cooperation of the child, (2) Resources were not always available for the purchase of hearing aids and (3) Existing educational programs were focused on classroom instruction of older children and were generally not appropriate for infants.

In 1986, the Lions Club bought auditory brainstem response (ABR) equipment for use by audiologists at UMC, and valid assessment of hearing became possible in very young children, reducing the time between screening failure and confirmation of hearing status. Funding for hearing aids became available after a pediatrician at the State Department of Health determined that if regulations required screening for hearing loss in children, then Medicaid should purchase hearing aids when a loss was identified. Also, hearing aids became more affordable after UMC began dispensing hearing aids at slightly more than wholesale cost. In order to provide educational services, UMC sent a teacher to Utah State University in 1981 to learn the SKI*HI home intervention program where parents were instructed in techniques to help their hearing impaired child learn language through speech and/or signing and to obtain maximum benefit from hearing aids. It was well suited to a rural state such as Mississippi and could be implemented shortly after the diagnosis of hearing loss.

Recent Developments

By the late 1980’s and early 1990’s advances in technology produced two new techniques for screening hearing in newborn infants: otoacoustic emissions (OAE), which measures sounds generated by the hair cells of the cochlea, and automated auditory brainstem response (AABR), which measures evoked auditory potentials from the brain stem. These advances have now become the major techniques used for screening hearing and led to the 1993 NIH recommendation for universal newborn hearing screening. In 1997, Mississippi became the third state to pass legislation (Section 41-90-1 through 9) requiring hospitals to screen infants for hearing loss and physicians to inform parents of the results and to refer for diagnostic testing.

It also provided fiscal support to the State Department of Health and authorized the collection of “information necessary to effectively plan and establish a comprehensive system of developmentally appropriate services for infants and toddlers.”

The State Department of Health was very successful in obtaining Federal funding for the purchase of new screening equipment for hospitals, and it was relatively easy to train the nursing staff because of their previous experience with the Crib-O-Gram. The newborn hearing screening program is now administered by the Early Hearing Detection and Intervention (EHDI) Program in the State Department of Health.

Prevalence and Referral Rates

As with any screening program, it is useful to know the prevalence of the disorder and the expected referral rate. With an infant hearing screening program this would be helpful in predicting the number of infants needing follow-up evaluations and the number of hearing impaired infants expected to be identified. In the past, the information provided by the Mississippi EHDI program has been inconsistent and often of

limited value. The two best authorities on data for infant hearing screening programs in the United States are the National Center for Hearing Assessment and Management (NCHAM) and the Centers for Disease Control and Prevention (CDC). In 2007, NCHAM reviewed successful programs and found “prevalence rates of three to four per thousand.”4 The CDC reported that 98% of infants born in the United States in 2010 were screened for hearing loss with a referral rate of 1.7 % and a prevalence of 1.4 per thousand infants screened. This prevalence rate was lower than expected because 39.4% of infants who failed screening did not receive a diagnostic evaluation and were considered lost to follow-up (LTF). For Mississippi, the CDC reported that the referral rate was 1.4%, prevalence 2 infants per thousand and LTF was 5.7%.5 Mississippi was obviously doing better than the United States in 2010; however, neither was meeting the prevalence rate predicted by NCHAM.

Lost-to-Follow-up

Lost-to-Follow-up has been recognized as a major problem in early identification and has generated considerable interest and additional funding for screening programs in the United States. In 2008, a working group of the American Speech, Language Hearing Association concluded “ that the available evidence provides neither meaningful direction in identifying the patients/families at highest risk for LTF nor in decreasing that risk.” Other published articles attempted to explain LTF based on factors such as economic status, race and distance from diagnostic services. An article from California recommended that parents be given a standardized message after a screening failure and that an appointment be scheduled immediately after the screening.6 A similar article from one facility in Mississippi involving more than a thousand appointments over a period of seven years showed an improvement in LTF from 39% to 4.9% if an audiologist gave the standardized message and the appointment was scheduled promptly.7 Recent data from the CDC indicates that for 2011 LTF for the United States decreased from 39.4% to 35.3% and for California from 18.1% to 8.4%; however, in Mississippi, LTF increased from 5.7% to 9.2% during the same period.

Conclusions

During the past forty years there have been many advances affecting hearing impaired children, including the rubella vaccine which has eliminated one of the major causes of congenital hearing loss. Improvements have also included better screening and diagnostic testing of infants, the development of digital hearing aids, cochlear implants and more effective educational intervention. The goal has always been a more normal life for hearing impaired children for which early identification is an essential first step. Another benefit is a potential savings in educational expense with fewer children needing special education services or repeating a grade

August 2014 JOURNAL MSMA 257

in school. As stated in the 1989 article on infant hearing screening, â&#x20AC;?In this area of healthcare, the challenge is not whether Mississippi can avoid being last, but can we be first.â&#x20AC;?

References 1.

Malphurs O. Infant Hearing Screening in Mississippi. J. Miss Med Assoc.1989; 30:245-248.

2.

Early Identification of Hearing Impairment in Infants and Young Children. NIH Consens. Statement, 1993; 11(1), March, 1993.

3.

Doctor PV, Davis FE. Educational impact of the 1964-65 rubella epidemic in the United States. Amer Ann Deaf. 1972; 117:11-13.

4.

National Center for Hearing Assessment and Management at Utah State University. Retrieved from www.infanthearing.org.

5.

CDC. Annual Data 2010, Early Hearing Detection and Intervention (EDHI) Program. Retrieved from www.cdc.gov/ ncbddd/hearingloss/edhi-data.html

6.

Russ SA, et al. Improving Follow-up to Newborn Hearing Screening: A Learning-Collaborative Experience. Pediatrics, 126 Supplement 1, August 2010, S59-S69.

7.

Malphurs O, Mustain WD. Improving loss to follow-up for newborn hearing screening. ASHA Lead. November, 2010;5-6.

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

DISABILITY DETERMINATION SERVICES 1-800-962-2230 258 JOURNAL MSMA August 2014

• Clinical Problem-Solving •

“I keep falling all the time…”

Jessica Jones, MD

A

19-year-old female presented to clinic with a complaint of falls and muscle weakness of her legs for about 3 months. Her most recent fall was 3 days ago. She stated that she was walking up the stairs when her legs became weak. She fell backwards and hit her head, causing broken teeth and a laceration on chin. After her legs became weak, she was unable to walk. She had associated dizziness and headache that was sharp in nature.

She also complained of 30 pounds of weight loss during the previous 3 months due to decreased appetite.

She denied tingling and numbness. She denied blurry vision, double vision, hearing loss or eye pain upon movement. She denied muscle pain or cramps. She had regular bowel movements and denied urinary incontinence. She reported swelling of her feet and being unable to wear shoes. She denied recent viral or bacterial illness. She had no known drug allergies. She denied smoking, alcohol, illicit drug use and recent travel. Her family had to help her with daily activities of life. She had been given tramadol (Ultram), which did not help, and erythromycin (E-mycin) for her laceration by an emergency physician at another hospital. She took no other medicines. Her menstrual periods were regular. She had had an elective abortion one year prior to presentation. She worked at a restaurant but had to stop due to her falls and weakness of her legs. She had no other significant past medical history. She denied a family history of seizures, cerebrovascular accidents, autoimmune diseases and inflammatory myopathies.

Author Affiliations: Dr. Jones was a resident in the Department of Family Medicine at the University of Mississippi Medical Center in Jackson.

Corresponding Author: Jessica Jones, MD, Baptist Health Systems, 1225 North State Street, Jackson, MS 39202. Ph: 601-968-1000 (jdjones2000@gmail.com).

Her vital signs were normal. Her cardiac, pulmonary and abdominal examinations were normal. She did have a laceration on her left chin that had sutures with no erythema, bleeding or warmth but no other rashes, abrasions or lesions. She was alert and oriented to time, person and place. Her speech and language were normal. Her cranial nerves II to XII were grossly intact. She had normal sensation and reflexes of her upper and lower extremities. The strength of her bilateral upper extremities was 3/5 in her biceps, triceps and trapezius muscles, and she had proximal muscle weakness of her upper extremities. In her lower extremities, hip flexors and leg extensors were 2/5 with intact dorsiflexion and plantar flexion. She was not able to rise from a sitting position to a standing position without assistance; however, once standing, she was able to walk by dragging her feet with each step.

After a thorough physical examination, it was apparent that she had some musculoskeletal or neurological process. After an emotional visit in clinic, she was asked to return to clinic the following day for follow up. With her muscle weakness, I immediately thought about neuromuscular diseases, connective tissue diseases, or an inflammatory myopathy, including fibrillations. I also worry about a neurological or a musculoskeletal cause of her muscle weakness. Given her age and onset of symptoms, I would investigate for a neurological cause such as multiple sclerosis and Guillain-Barre Syndrome. I would obtain a complete blood count, electrolytes, liver function panel, sedimentation rate, rheumatoid factor, noncontrast computed tomography (CT) head scan and a creatinine phosphokinase. I am unsure of a cause and want more history.

Upon my arrival in clinic the following day, I was greeted by the patient’s blood work. The patient’s white cell count, hematocrit, electrolytes and renal function were normal. Her liver function panel was abnormal, with an aspartate aminotransferase (AST) of 389 U/L (reference range 0-37 U/L) and an alanine transaminase (ALT) of 169 U/L (0-40 U/L). Creatinine

August 2014 JOURNAL MSMA 259

phosphokinase (CPK) was abnormal at 17,235 U/L (24-195 U/L). Sedimentation concentration (ESR) was slightly abnormal at 23 mm/hr (<20 mm/hr). Lactate dehydrogenase (LDH) was significantly elevated at 1631 U/L (135-214 U/L). A noncontrast CT head was normal.

Given patient’s proximal muscle weakness of her shoulder and legs and elevated CPK, she was immediately hospitalized and given intravenous fluids and sodium bicarbonate to protect her kidneys from the muscle damage.

Due to her elevated ALT and AST, we obtained a hepatitis panel to investigate for liver pathology such as obstruction or hepatocellular disease. Her hepatitis panel was negative.

Abdominal sonography to evaluate liver and gallbladder function showed no cause for biliary obstruction or hepatocellular disease. CT of abdomen and pelvis was negative.

She was negative for HIV; therefore, this did not indicate an immunological pathology. To investigate for any rheumatological pathology, anti-neutrophil cytoplasmic antibody (ANCA) and anti-smooth muscle antibody was obtained and found to be negative. Ceruloplasmin, rheumatoid factor and CRP were all within normal limits.

Her negative initial laboratory studies did not indicate any rheumatological pathology such as systemic lupus erythematous, rheumatoid arthritis, Sjögren’s or mixed connective tissue diseases.

Due to her elevated creatinine kinase, a neurology consultant suggested an electromyogram (EMG) that showed some of the evidence associated with an inflammatory myopathy, including fibrillations. Inflammatory myopathies, which include dermatomyositis and polymyositis, are infrequently associated with specific autoantibodies that facilitate diagnosis. 2,3 A general surgeon performed a muscle biopsy of right thigh.

Although we failed to find evidence of rheumatological diseases that could be associated with specific autoantibodies, there are some rheumatological processes that are diagnosed by clinical presentation. Inflammatory myopathies, which include dermatomyositis and polymyositis, are pathologies that do not correlate with any specific autoantibody.

Dermatomyositis is an autoimmune disease that causes skeletal muscle inflammation and weakness by immune complex deposition in blood vessels with complement activations.

It is also associated with skin manifestations such as erythematous rash, heliotrope rash (purplish discoloration over upper eyelids) and Gottron’s papules. Gottron’s papules are pathognomonic for this disease with scaly areas over dorsum of proximal interphalangeal joints and metacarpophalangeal joints.1 Polymyositis (PM) is a T cell mediated muscle pathology that can cause skeletal muscle inflammation and weakness. It occurs in childhood (7 to 15 years) and in midlife (30 to 50 years).1

260 JOURNAL MSMA August 2014

There is an approximately 3:1 female predominance. Persons of African and Hispanic descent are at increased risk for development of PM and also have poorer outcomes than Caucasians.

Inflammatory myopathies are distinguished by the muscle biopsy. In adults with dermatomyositis, a muscle biopsy will show abnormal muscle fibers that are scattered through the fascicle with no signs of vasculopathy or immune complex deposition.4 In polymyositis, inflammatory cells such as lymphocytes and macrophages infiltrate within the fascicle invading individual muscle fibers.5 The patient’s muscle biopsy demonstrated evidence of myopathy including necrotic fibers and a non-specific inflammatory cell infiltrate within the muscle fascicles. Magnetic resonance imaging of brain with and without contrast was normal. She was given high dose methylprednisolone (Solu-Medrol) per rheumatology consultant recommendations. Her creatinine phosphokinase concentrations immediately responded to the treatment and decreased to 5335 U/L. She was then transitioned to prednisone and azathioprine (Imuran) with improvement in her muscle strength of her shoulder and hip girdle.

The muscle biopsy certainly clarified the cause of the patient’s muscle weakness. From a histological view, focal collections of mononuclear cells can be seen surrounding and invading the myofibers in polymyositis.6 Lymphocytes, macrophages, plasma cells, basophils and neutrophils can be seen with lymphocytes being the predominate inflammatory cell.

The muscle cells (myocytes) demonstrate evidence of necrosis with degeneration and regeneration. Diffuse muscle fiber injury can be seen throughout the fascicle as evidenced by varying muscle fiber size.7 Increased connective tissue or fibrosis in the interstitial areas can be seen around the myocytes. With lymphocytes being the predominate mononuclear cell, the cause of polymyositis suggests a cytotoxic T lymphocyte-mediated process that surrounds and invades normal-appearing myocytes in endomysial areas.

As with my patient, symmetric, proximal muscle weakness is present in most cases of polymyositis. This causes difficulty arising from chairs, getting out of cars, reaching overhead or combing hair. Some patients have generalized fatigue, muscle pain or weight loss.

A complete history and physical, including past medical and family history, should be our first priority. After obtaining a history and physical, general lab studies should be ordered that include complete blood count, electrolytes and muscle enzymes. Creatine kinase (CK), creatine phosphokinase (CPK), lactate dehydrogenase (LDH) and aldolase are the muscle enzymes routinely measured in the evaluation of myopathy.8 Electromyography and muscle biopsy will reveal the cause of muscle weakness in many cases. After careful diagnosis, patients with polymyositis should be assessed for malignancies.

The treatment of PM is aimed at decreasing inflammation in target tissues, relieving symptoms and rebuilding endurance and muscle strength.1 Corticosteroids are the initial and primary treatment for PM. An adequate initial dose of 1mg/kg/day of prednisone or equivalent will suffice. Evidence suggests that one should continue prednisone until or possibly even after the serum creatine kinase normalizes. High-dose intravenous corticosteroids (1g/day for 3 days) and additional immunosuppressive therapy may be useful as initial treatments in severe cases.9

opathies. A Clinical Features. Primer on the Rheumatic Diseases, 13th edition. Springer Science and Business Media. New York, New York 2008;363-367.

3.

Rider LG and Miller FW. Pathology and pathogenesis of idiopathic inflammatory myopathies. Primer on the Rheumatic Diseases. Ed. Klippel JH, Stone JH, Crofford LJ, White PH. Springer. 2008. Pg 368 - 388.

4.

Goebels N, Michaelis D, Engelhardt M, et al. Differential expression of perforin in muscle-infiltrating T cells in polymyositis and dermatomyositis. J Clin Invest. 1996;97:2905-2910.

5. Hohlfeld R, Engel AG. The immunobiology of muscle. Immunol Today. 1994;15:269-275.

In summary, this patient’s signs and symptoms pointed 6. Saguil A. Evaluation of the patient with muscle weakness. Am toward several different pathologies. was interesting going for iPhone, iPad, It Android, and all web-enabled mobile devices Fam Physician. 2005;71(7):1327-1336. through the differential diagnoses, trying to rule out various 7. Engel AG, Arahata K. Monoclonal antibody analysis of monodisease processes. Her falls improved drastically with cornuclear cells in myopathies. II: Phenotypes of autoinvasive Put the Journal MSMA in the palm of your hand. ticosteroids and intravenous fluids after finding a definitive cells in polymyositis and inclusion body myositis. Ann Neurol.

Full Flip-page.

Every month. 1984;16:209-220. diagnosis. After rehabilitation withcolor. physical and occupational therapy, she was able to ambulate with no assistance and to 8. Emslie-Smith AM, Arahata K, Engel AG. Major histocompatresume her normal activities. ibility complex class I antigen expression, immunolocalization

Keywords:

of interferon subtypes, and T cell-mediated cytotoxicity in myopathies. Hum Pathol. 1989;20:224-230.

polymyositis, myopathy, creatinine kinase

9.

References 1.

Goldman L, Ausiello D. Cecil Textbook of Medicine.

Philadephia, PA: Elsevier; 2004.

2.

Wortmann RL. Klippel JH (Ed). Idiopathic Inflammatory My-

Dalakas MC, Hohlfeld R. Polymyositis and dermatomyositis.

Lancet. 2003;362:971-976.

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August 2014 JOURNAL MSMA 261

• Special Article • An Interview with Claude D. Brunson, MD MSMA President 2014-2015 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.] —Ed.

F

amily

I grew up in Auburn, Alabama, in the shadows of Auburn University where my mother worked and retired. I was the third of four children: two older brothers and a younger sister. I grew up in a single parent home. My father died when I was a young boy so my mother and grandmother, who lived with us, reared me.

My mother worked full-time and most often held two jobs. My grandmother stayed home and raised the children.

We probably were a bit sheltered. Education was considered “a must” and something in which you had to excel. Personal responsibility was another value emphasized to us as an essential attribute.

Children: I am a father of three beautiful daughters. My oldest, Christin, just finished Ole Miss Law School in 2013 and completed an LL.M. program in May 2014 in Health Care Law at the University of Houston Law School. My middle daughter Chelsea and youngest Claudia are still in college.

Education (Auburn vs. Alabama)

I grew up living just a few miles away from the Auburn University campus. In fact, my brothers and I used to walk to the campus to visit my mother at work some days during the summer when school was out. I was the first one in my family to attend a university, and it was a given that I would go to college. So, I enrolled in the Summer Quarter at Auburn University just two weeks after graduating high school.

In retrospect, I think that I was just trying to get college done as quickly as I could since I had to attend. The problem was I didn’t have a true desire to be there.

Dr. Brunson compliments his mother and grandmother for overcoming extraordinary challenges to make sure he and his siblings had the best opportunities to succeed.

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While there, a recruiter came to campus and spoke on being in the Navy– how you could just sail the seas and see the world. It sounded enchanting to me so I signed up (took me another two weeks to break this unforgivable news to my mother and family).

I never thought of myself as being a military person. However, if I was going to enlist, it had to be the Navy or Air Force (I didn’t like sleeping in the woods). Anyway, I enlisted as a Hospital Corpsman and immediately was assigned to the Fleet Marine Force following specialist training as a field medicine technician (Spent the next three and half years sleeping in the woods).

After completing four years in the Navy, I came back to finish college at the University of Alabama because they operated the medical school in Birmingham.

While it seemed to make sense to me, it was the second unforgivable sin I had committed from my family’s perspective. After about a decade, they forgave me of that mortal sin and fully embraced me again, except on the occasions when Auburn plays Alabama in any sport.

Milestones

Personal philosophy: Anything can be achieved through education and personal determination. If you properly prepare yourself and have confidence and determination, then you can overcome most hurdles and achieve your goals.

I think the events that have helped shape my life involve the manner in which I was nurtured: in a single parent home by a loving mother and doting grandmother.

Claude was the third of four children with two older brothers and a younger sister: (l. to r.) Bobby, Delbrow, Patsy, and Claude.

Beneath Dr. Brunson’s astute academic medical persona as senior advisor to the vice chancellor you will find he is a devoted father with three lovely grown daughters whom he is very proud of and who share his affection for education and family values.

Only weeks after graduating from high school Claude Brunson found himself enlisting in the Navy after a recruiter visiting Auburn University, where he had enrolled in the Summer Quarter, made an appeal to him.

The opportunity to sail the seas sounded more enchanting to young Claude than it did to his mother.

Dr. Brunson’s three daughters circa 1996: (l. to r.) Chelsea, the middle child; his youngest Claudia, and his oldest Christin.

August 2014 JOURNAL MSMA 263

Role models: My grandmother was sort of the healer in our closely-knit community. I saw her take care of people who did not have access to medical care. I am certain, had the opportunity existed for her to go to medical school in those days, she would have been a physician and a very fine one at that. Watching her take care of people put the first seed in my mind that I wanted to be a physician. I guess my heroes would be my mother and grandmother for the extraordinary challenges they overcame to make sure my siblings and I had the best opportunity to succeed, in spite of some difficult circumstances they had to endure.

Another hero is the mother of my children. Recently diagnosed with cancer, she has shown the most remarkable strength during her process of treatment, actually letting those close to her lean on her for strength, as they seemed to struggle with the diagnosis in a more difficult way than she did. To see the beauty in her strength has been sustaining for many around her and a gift to her fellow cancer survivors who have found a model in how to deal with a difficult circumstance. This has been awe inspiring to me.

The final hero I want to mention is Dr. Robert Smith, a genteel man who is of enormous stature in what he has done for equality and access in medicine and health care. He has always been someone who quietly advised me and encouraged me to continue along my path in organized medicine and to take advantage of my opportunities to make a difference. I never knew until a few years ago of his impact on health care in so many ways because he has always been an unassuming prince of a gentleman.

Reflections on Medical School

As I alluded to earlier, I became interested in medicine from watching my grandmother care for our neighbors and also from watching the TV-doctors like Marcus Welby, MD. Medicine was something I always thought I wanted to do; my military career confirmed that desire.

My best memories of life as a medical student were the close bonds I made with fellow students as we all struggled to get through the impossible-seeming task of medical school.

Another vivid memory was meeting and spending time with an elderly woman who had lived a full and good life but was in her final stages of life. She gave me the gift of sharing that experience with me, allowing me to understand more completely the full cycle of life and to appreciate the dignified manner in which life can and should end.

Some of the tough times I suppose were the frequent tests, most of which were on Saturdays. It was also tough to lose patients especially with the second-guessing we all do (concerning whether there was something else we could have done).

My medical school years were trying but enjoyable. I wouldnâ&#x20AC;&#x2122;t trade them for anything but probably wouldnâ&#x20AC;&#x2122;t volunteer to do them again either.

University of Mississippi Medical Center (UMMC) Career

I completed my residency in anesthesiology at UMMC and joined the faculty following graduation. I think my proudest accomplishment was as a new chairman, working with our faculty and taking our Anesthesiology residency-training program in from a probationary accreditation to full accreditation. The training program continues to excel to date.

Chelsea

Claudia

264 JOURNAL MSMA August 2014

Christin

Dedication of the Myrlie Evers-Williams Institute for the Elimination of Health Disparities — (l. to r.) Dr. James Keeton, UMMC vice chancellor for health affairs and dean of the School of Medicine; Dr. Bettina Beech, executive director of the institute and UMMC associate vice chancellor for population; Dr. Myrlie Evers-Williams; Dr. Dan Jones, University of Mississippi chancellor; Dr. Claude Brunson, UMMC senior advisor to the vice chancellor for external affairs; and Jamie Christian, associate general counsel.

Challenges transitioning from practicing anesthesiology and chairing that department to becoming Senior Advisor to the Vice Chancellor for External Affairs: The first challenge was to get used to the idea that I didn’t have to be at work at 6:00 every morning anymore.

I didn’t completely give up clinical medicine. I still practice in the O.R., providing care and teaching one day a week. That keeps me balanced in that I continue to do something that I absolutely love. And it keeps me connected to the actual practice of medicine and my physician colleagues.

It was an honor and a privilege to chair the Department of Anesthesiology, and I think we made significant strides in the department while I was chair.

As Senior Advisor for External Affairs, I have found a role that suits me extraordinarily well. I get to represent the UMMC with important entities which we have or need to have a relationship with, for the good of the UMMC: improving access to health care and the health of Mississippians.

Organized Medicine

The seed of organized medicine was planted when the Chief of Staff at UMMC appointed me to chair the Pharmacy and Therapeutics Committee. That gave me my first inkling of how medical practice was, to a degree, managed or regulated. Then I joined Central Medical Society and later became a delegate. I moved up the ranks in Central and found that I actually enjoyed being involved in the organized management of medicine.

From there I began getting involved in all aspects of organized medicine that influenced how we practice, whether in my local, state, national specialty society or in the AMA.

• Mississippi Medical and Surgical Association: As President of Anesthesiology Department Employee Anniversary Celebration

MMSA, I focused more keenly on health care issues that more specifically affected the African-American population: looking into problems that had a disproportionate impact on a minority population of patients than it did in the majority community and looking for possible solutions to those problems.

• American Society of Anesthesiologists: My role on the Board of

Directors for the ASA allowed me to gain insight on how a medical specialty works to establish sound and safe policy for the practice in the specialty across the nation and for the most part across the world.

• Central Medical Society: As President of Central Medical Society, UMC Department of Anesthesiology Christmas Party at Old Capitol Inn — (l. to r.) Dr. Thomas Allingham, Chef Bruce Cain, and Dr. Claude Brunson.

we worked of course on issues that we work on similar to what our statewide concerns were. Additionally, I had the opportunity to work on what was then a cool relationship between the physicians at UMMC and the physicians in private practice. We were able to start bridging the gulf in that relationship.

• Mississippi State Board of Medical Licensure: As a member of the MSBML, I have had the opportunity to help draft rules and regulations governing the practice of medicine in the state with the goal to make sure we are protecting the public’s safety and health through regulation and adherence to the Medical Practice Act.

The challenges faced in these roles are trying to achieve a balance between good policies that advance the practice of medicine without overburdening physicians but that also ensures that we are maintaining a safe and accessible health care system.

Oftentimes, our colleagues feel we have gone too far with policies and regulations while lawmakers think we did not go far enough.

August 2014 JOURNAL MSMA 265

Community Service

• Volunteer organizations: Operation

Shoe String, Mississippi Sickle Cell Foundation

• Church: New Hope Missionary Baptist Platform

No platform per se but I would like to see us work to improve the mental health system in the state and to address health disparities.

Joy of Medicine

The thing I enjoy most about being a doctor is the trust your patients and their families put in you to take care of them. The thing I like least is the overwhelming bureaucracy that has become a part of providing care. While some is necessary, now it seems like physicians spend much of their time filling out paperwork or typing into their computer leaving the patient feeling neglected.

In closing…

I am truly humbled and honored by members’ trust in me to lead MSMA, and I will do my best to represent them, their patients, and practices to the best of my abilities. r

For the fun of it...

You’re most likely to see me around…I like to take walks, go to the movies or a place to have dinner and maybe hear some music.

On the weekends, I love to: Go to the movies to watch a Sci-Fi feature.

The high school, college or pro sports teams I root for are: Auburn High, University of Alabama, New Orleans Saints.

If I’m watching a movie or listening to music, it’s probably: A Sci-Fi movie, R&B music.

I am passionate about: Music Something about me not everyone knows: I was an aspiring poet, and it remains a love of mine.

Go out or stay in? Stay in.

Perfect meal: Filet mignon, baked potato, roll.

Perfect day: Lounging around listening to music.

Favorite book: Beowulf Favorite color: Blue.

Cologne: Terre D’Herme.

Text, email, or cell phone: Text.

Pets: Chocolate lab.

MSMA Member since: 1992

Dr. Brunson, his daughter Claudia, and her mother Pat at the Jack and Jill Foundation Sweetheart Ball

266 JOURNAL MSMA August 2014

Dr. Brunson and his daughter Chelsea at Homecoming

Felicia Anderson and Dr. Brunson, Deptartment of Anesthesiology Christmas Party

Claude D. Brunson, MD: What they say about him...

C

laude is a role model for how to stay calm under pressure. He always looks for ways to collaborate and build consensus, but has great confidence when there is a need to make a decision. No matter what, he always keeps a positive attitude and a sense of humor. —Diane Beebe, MD

C I

laude is a man of few words; but, listen carefully when he speaks because his perspective always provides thoughtful and meaningful insight that is often unique. —Steven T. Case, PhD

’ve worked with Claude on the Board of Trustees for the past 5 years and I’m honored to call him my friend. He is an excellent leader. He is thoughtful, has good insight, and thinks strategically. He leads by example and is a man of character. He will make a superb President. —Steve Demetropoulos, MD, MSMA President 2012-13

O

ne thing is certain about Claude: regardless of the complexity of the situation, he will accurately assess it and diplomatically cut to the heart of the issue… usually before most folks know that there is a situation!

—Scott Hambleton, MD, MPHP Medical Director

D

r. Claude Brunson’s inauguration as President ranks as one of the most significant historical milestones in the Association’s 158-year history. Claude has served with distinction at both state medical and UMMC. He is very deserving of this honor. Such courageous physician leaders 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. I expect great things from his presidency and from him in the future. —Lucius M. “Luke” Lampton, Editor JMSMA

I I

frequently call him “Dr. GQ” because he’s so dapper, and he always completes his outfit with a smile.

—Ann Rea, MD

am excited about Claude assuming the reigns as President of MSMA. He is very thoughtful and articulate leader, who has worked hard on behalf of the association. He has dealt with some very tough issues as Board Chair and President-Elect. I have given him some tough assignments this past year, and he has always performed brilliantly. MSMA will be in good hands under his leadership. —James A. Rish, MD, MSMA Immediate Past President

D

r. Brunson has been a trailblazer in Mississippi medicine and beyond. He has held leadership positions in anesthesiology, serving as President of the Mississippi Society of Anesthesiology and a member of the Board of Directors for the American Society of Anesthesiology. He served as President of Central Medical Society and received the Exemplary Physician Award in 2012. He has also served as President of the Mississippi Medical and Surgical Association and was selected as Physician of the Year in 2007. He has served on the Mississippi Board of Medical Licensure, Chair of the Council on Legislation, and Chair of the MSMA Board of Trustees. Congratulations, Claude! I am certain you will be an outstanding president for MSMA. Best wishes. —Helen R. Turner, MD, MSMA President 2005-06

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hen I returned to UMMC as Acting Director of Urology, after a hiatus of 15 years, with the assigned task of replacing the current Director with new recruits, Claude Brunson was in charge of Anesthesia. He was supportive of all my efforts, which included maintaining discipline and morale among a group of residents in a program which had fallen into disarray. It was great consolation to me to find a friend and a highly competent colleague in that critical arena. He has been “first” in many ways, and deservedly so. —W. Lamar Weems, MD, MSMA President 1987-88

August 2014 JOURNAL MSMA 267

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• President’s Page • Farewell Address [This address of the president was delivered at the opening session of the MSMA House of Delegates held Friday, August 15, 2014, at the University of Mississippi Medical Center Norman C. Nelson Student Union in Jackson. It is printed here for our association’s official transactions.] —Ed.

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r. Speaker, Officers, Members of the House of Delegates, Students, Residents, Alliance, Guests, Staff and Friends: Thank you for the awesome honor and privilege to serve as your President over the past year. It has been one of the most challenging though one of the most fulfilling James A. Rish, MD experiences of my career.

2013-14 MSMA President I would like to thank some very special people without whom I don’t know how I could have functioned in this role.

First and foremost, I would like to thank my wife, Susan. She has been there with me every step of the way. She has been my advisor, my speech critic, my sounding board, my chauffeur, and most of all, my best friend and the love of my life. As President Reagan previously said, I married up.

Secondly, I would like to thank Charmain Kanosky and all of the staff for the hard work, dedication, and commitment in making our Association what it is. As I went through the year, I never ceased to be amazed at the number of projects, councils, committees that our Association manages on a day-to-day basis. Over the past year, I have had the opportunity to travel to other states’ annual sessions, and I can safely say that you can be proud about the way it is done in Mississippi.

Third, I want to thank the Board of Trustees whose wisdom and advice I value immeasurably. They are a smart, dedicated, and respectful group of individuals who keep our mission statement and the interests of our membership at the forefront of all issues and negotiations.

I would like to thank my partners for allowing me to serve in this role while keeping the home front running smoothly, particularly during the winter as we dealt with one of the worse flu epidemics in my recent memory. I suspect they are looking forward to getting me back on the weekday call schedule.

I also want to thank Molly Pontius and members of the Alliance for the wonderful work they do on behalf of the Association.

They strengthen and extend the effectiveness of many of our organizational initiatives. This year our Alliance was the proud recipient of a HAP award at the AMA Alliance meeting this past June in Chicago for a brochure entitled Reaching the Finish Line with Dignity that emphasized the importance of end-of-life planning. This complemented our legislative efforts on POLST. Thanks for a job well done.

Lastly, I want to thank Dr. Jimmy Keeton, Vice Chancellor for Health Affairs and Dean of the School of Medicine at the University of Mississippi Medical Center who has allowed us access to this wonderful venue. Dr. Keeton truly understands the value of membership and participation of organized medicine and has been very instrumental in insuring that our academic physicians are strongly represented among our membership. Dr. Keeton will be stepping down from his role at the medical center at June’s end of next year. We appreciate his dedicated service to Mississippi Medicine and wish him well in his retirement.

Understanding the importance of membership and participation in the Association is the most fundamental ingredient of our success and effectiveness as an organization. Unfortunately, it has become our biggest threat. There are far too many of our colleagues content to set idly by while a few work diligently to insure that the practice of medicine and health care delivery in our state and nation do not fall into the wrong hands. We simply cannot afford to allow the practice of our profession to be controlled by any entity that does not have the best interests of our patients and the sustainable welfare of society as a whole as its main focus. John F. Kennedy once said, “Let us resolve to be masters, not the victims, of our history, controlling our own destiny without giving way to blind suspicions and emotions.” We must stress the importance not only of membership but also of active participation in organized medicine to all physicians. This starts at the component and state professional society levels and extends

August 2014 JOURNAL MSMA 269

to the AMA and our national professional societies. We must not weary in our efforts at engagement. Together we are stronger.

It has been an interesting and exciting year. We have had many successes as well as a few disappointments, and I would just like to take a moment to cover some of the highlights.

On the legislative front we were able to finally pass a youth sports concussion law to protect our student athletes who are suspected of suffering a concussive injury. We were the last state in the union to pass this legislation, but, as they say, better late than never. This law took effect July 1, 2014.

Also on the legislative front we were able to clean up the language in Assignment of Benefits legislation. We successfully defeated a number of scope of practice bills. We thwarted efforts on the part of Mississippi’s largest private insurance company to deny coverage for prescription drugs written by an out of network provider, and we successfully assisted with efforts on passage of the Simplification of the School Asthma Plan As we anticipated ,Any Willing Provider legislation drew a lot of controversy. We felt strongly that this legislation would help preserve access to care, particularly in the more rural settings. In doing so, we felt this legislation would protect established patient-physician relationships, therefore maintaining continuity of care with the physicians the patients have come to know and trust. Unfortunately, this was derailed mainly by the insurance industry with misinformation on potential effects this legislation would have on quality initiatives. As a result, it was quite interesting to see a number of physicians align themselves with the insurance industry on this issue. We have been in discussion with the Governor’s Office to create a legislative study group to educate the legislators on this complex issue going forward in the next legislative session. It is my recommendation that we work to further support creation of a legislative study group and continue our efforts at passage of Any Willing Provider legislation.

One of the highlights of the legislative session was passage of POST legislation or Physicians Orders for Sustaining Treatment. This legislation provides for a planning tool that empowers patients and their families to work closely with their physician to define clearly their medical preferences via actionable physician orders when facing a terminal illness. These orders can follow the patient through various care transitions to ensure that the patient’s wishes are respected at the end of their life. This program will require a monumental effort on the part of the Association to successfully educate all of the relevant stakeholders and to implement this important initiative on a statewide level. Therefore, it is my recommendation that the Board of Trustees create a task force to oversee the successful implementation of POST over the entire state and its engagement in the National POLST Paradigm Program.

One of the disappointments in this year’s legislative sessions was expansion of the Medicaid managed care population to 70% of eligible Medicaid beneficiaries. We stood strong in our opposition of this legislation, but the Senate had other plans.

Unknown to us were discussions between the Division of Medicaid and the pediatricians for development of a Pediatric Patient Centered Medical Home through the managed care program or Mississippi CAN. This one issue illustrates the importance of our speaking together as one voice.

Also on the Medicaid front we believe that the program could be greatly improved with input from physicians on the front lines of the delivery of care. We have been working to increase physician input in the Division’s policies and program implementation with provision for a full-time medical director in the appropriations bill. Unfortunately, despite our continued efforts to urge the Medicaid director to move forward in hiring a medical director, the position remains unfilled.

If this is not concerning enough, since June of 2012, the Division of Medicaid has been out of compliance with state and federal laws calling for establishment and maintenance of a Medical Care Advisory Committee. This committee is directed to meet quarterly and allow practicing physicians to (1) advise the division on medical care services and (2) review all State Plan Amendments prior to implementation. We need to continue our efforts and pressure on the Division of Medicaid to insure physicians have input into the program.

As was the charge of the House of Delegates during the proceedings of the 145th Annual Session, a six member ad hoc committee was established to make recommendations to the House of Delegates regarding an MSMA Editorial Governance Plan. This plan was to define clearly the oversight structure related to our publication of Journal MSMA to ensure editorial independence and integrity while respecting and preserving MSMA’s legal responsibilities as a publisher. These members have worked very hard, and I feel have made some excellent recommendations for consideration by the Board of Trustees.

Likewise, an ad hoc committee on Diversity was convened to explore ways to increase diversity among our membership. I think this was a timely endeavor as we reflect back on events occurring at the height of the civil rights movement 50 years ago.

This committee generated very interesting discussions in preparation of forthcoming recommendations. Their work will continue into 2015.

So where do we go from here?

The landscape is changing. The government continues to impose an increasing amount of regulatory burdens and unfunded mandates. The ranks of employed physicians are growing. These are politically tumultuous times with deep partisan divide. It would seem to me that we are in the midst of a renaissance in health care delivery. The only certainty at this point is that health

270 JOURNAL MSMA August 2014

care delivery will be different going forward. We must embrace the political reality that the Patient Protection and Affordable Care Act is not likely to be repealed. This leaves but one option. That is to fix it.

Make no mistake. One of our biggest threats going forward is not to have a seat at the table as we tweak this legislation into a sustainable system of delivery. This comes down to everyone in this room becoming involved and participating in the process.

We cannot allow for the practice of medicine to fall into the hands of governmental or corporate entities whose agenda is not patient centered and fails to meet the needs of physicians in their honorable service to their patients. We must grow our ranks and speak as one loud voice to our legislators and policy makers.

First, we must continue to confront and defeat any policy or legislation on the part of the government or large insurance companies that stands to undermine the sacred doctor-patient relationship.

We must ensure sustainability of the system. We simply have to be able to recruit the best and brightest to our profession.

We must solve the crisis in graduate medical education funding to ensure a robust pipeline of well-trained physicians. We need to continue our efforts in providing the necessary leadership development resources to our members and to be poised to embrace team-based care and population health. We need to maintain a solid physician infrastructure equipped to lead multidisciplinary teams of health care providers.

We must ensure that physician reimbursement is fair and adequate to sustain provision of our services. I call upon MSMA to consider all available options including legislative action at both the state and national levels to modify the legislative / regulatory language of the ACA which makes physicians financially responsible for provision of care in the 60-90 day grace period in the health care exchange when the patient fails to pay their insurance premium.

With the likely inherent trend towards regionalization of health care, we must balance our responsibility to develop policies that protect access to care for our patients in rural areas with the need to be good stewards of all health care resources and technology in a financially sustainable manner. We must not allow any law or policy to stifle the development of exciting new emerging technology. However, we do need to embrace new technology in a rational, evidence-based, and responsible manner.

We must continue efforts to minimize the regulatory burdens in the course of practicing good evidence-based medicine.

We must insist that drug formularies are transparent and can be readily referenced with fair policy to protect a patient’s access to a medication regimen that is controlling their condition despite the financial expediency on the part of the insurance company to switch to a cheaper alternative at the expense of controlling our patient’s condition. We must also ensure that reimbursement and the processing of claims are fair and transparent.

We must police the post-payment audit processes as we now have auditors stumbling over each other. We must demand that auditors not be incentivized to exploit the compliance of often vague policies for their own financial gain.

The physician must be afforded timely due process and a level playing field in which to appeal the auditor’s decision.

While continuing to meet the needs of our self-employed private practice physician members, we must also focus on providing services that will address the needs of the employed physician. We must recognize and be vigilant as to the potentially awkward nature that employed physicians may find themselves with respect to the conflicts between what is best for our individual patient and what the hospital administration employing that physician feels is best for their bottom line. We must equip our employed physician members with the legal resources and avenues for advice in negotiation of employment contracts that safeguard the physician’s Hippocratic Oath and the ability to put the needs of the patient first and foremost.

As you can see, where we go from here is the next chapter in our unending journey. I have been committed to leaving the Association a little better than I found it. I think that was the commitment of all who have come before me and I dare say all those who will follow me. Though we have a ponderous agenda, I have seen first hand the depth and breath of intellectual talent and treasure that we possess to solve these difficult challenges and ensure our success for years to come.

In my inaugural address, I likened our Association’s efforts to that of training for a marathon. I would like to modify slightly that analogy if I may. It is more that of a relay marathon that never ends. As I pass the torch to a new chapter of leadership, I cannot think of anyone more suited for the task than Dr. Claude Brunson. Claude will become the first Afro-American president of our Association. As we are reminded of the shameful, oppressive, racial divide that existed in this state 50 summers ago, we must always focus on inclusiveness and diversity going forward. I have no doubt that Claude will continue to steer us in the right direction with his broad wisdom and insight.

As I transition to the long list of distinguished men and women who have honorably served our Association in this role before me, the guiding principle has always been and will continue to be the welfare of our patients and our commitment to insuring the sustainable provision of leading-edge quality health care.

God bless you for all you do on the behalf of your patients and the practice of Medicine. Thank you.

August 2014 JOURNAL MSMA 271

• Letters • JFC Seeks Good Samaritan Doctors

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[Congratulations to the physicians and UMMC medical students involved in the important work of the Jackson Free Clinic on being selected recipient of the MSMA Award for Excellence in Wellness Promotion.] —Ed. ear Editor:

A wide variety of reasons can drive people toward a career in medicine, but if you talk to physicians and medical students, a common theme arises: helping others. We all want to make a difference in the lives of others, and every Saturday, University of Mississippi Medical Center students from several disciplines come together to do just that.

The Jackson Free Clinic is a student-run clinic that provides free care every Saturday for patients in need. Originally, the clinic saw only medical patients, but now Clinic patients have access to dental care as well as physical and occupational therapy.

In addition to providing these services, the Clinic is also used as a teaching tool. Third and fourth year students teach first and second year students how to perform a physical exam, take a history, and draw blood, as well as a range of other skills that will be important during clinical rotations and during their medical careers.

All of the care provided at the Clinic is overseen by a physician. Students make a plan for each patient and present that plan to the doctor staffing the clinic, and the doctor makes suggestions and corrections where needed and gives feedback on ways to improve and become more efficient. So, the Clinic depends on doctors to help us help our patients.

Lately, it has become increasingly difficult to schedule physicians to staff the Clinic on Saturdays. Many are working or use days off on the weekends to spend time with families. However, some have relayed concerns over liability and malpractice concerns. Fortunately, Mississippi state law addresses these concerns and offers a resolution. Mississippi Code Section 73-25-38, known as the “Good Samaritan Law,” specifically states that: “Any licensed physician, physician assistant or certified nurse practitioner who voluntarily provides needed medical or health services to any person without the expectation of payment due to the inability of such person to pay for said services shall be immune from liability for any civil action arising out of the provision of such medical or health services provided in good faith on a charitable basis.”

Since all of the care provided at the Jackson Free Clinic is free, and thus charitable, our volunteer physicians are covered by this law and would have immunity from litigation.

I hope this information will alleviate some of the fears and concerns about the legal repercussions that volunteering at the Clinic might bring about. I also hope that having this issue made clear will encourage more physicians to donate a Saturday here and there to help patients who sincerely need it. Were it not for the Clinic, the only care many of our patients would receive would be from the emergency room. The Jackson Free Clinic provides an important service to people in Jackson and the surrounding areas, and it would be impossible to do without the compassion and commitment shown by the physicians who help us each week. For those who would like to be one of those physicians or would like more information about the Clinic, feel free to e-mail me at jscarter@umc.edu or visit our website at www.JacksonFreeClinic.org.

Thank you, Steven Carter, M2, University of Mississippi School of Medicine, Board of Directors, Jackson Free Clinic

272 JOURNAL MSMA August 2014

• Legal Ease • Harper Grace’s Law: Providing Hope to Suffering Children and Opportunity to the State

S

Adam Woods

eizures. Developmental disabilities. Chronic Infections.

Constant fear of injury or death. These are just a few of the tribulations that hundreds of thousands of families face every year, including thousands in Mississippi alone, when their child suffers from epilepsy, a disorder in which a person has two or more seizures that are not brought on by an immediate underlying cause.1 Fortunately, many patients treated for epilepsy are able to attain adequate seizure control through conventional pharmaceutical medications, such as anticonvulsants.

However, 30-40% of patients suffer from refractory, or intractable, seizures, meaning two or more conventional drugs provided them with no relief from their epileptic seizures.1,2 Unfortunately for these refractory patients, there is less than a 10% chance that they will respond to other conventional pharmaceutical treatments, leaving them with an uphill battle in a desperate search to find anything that could stop, or at least lessen, the seizures that often affect most, if not all, aspects of their lives.3

Fighting against such odds has caused many families across the nation to turn to a more non-conventional approach in their search for relief. In August 2013, CNN’s Dr. Sanjay Gupta featured a story about a little girl from Colorado named Charlotte Figi who achieved astounding results using cannabidiol oil (CBD oil) made from a strain of medical marijuana that is low in the psychoactive ingredient tetrahydrocannabinol (THC) and high in the non-psychoactive ingredient cannabidiol (CBD) to treat her Dravet Syndrome.4 Dravet Syndrome is a rare form of refractory epilepsy which begins in infancy and can cause a child to have hundreds of tonic-clonic or grand mal seizures a week. These seizures may cause children to lose consciousness, have convulsions, and, in the case of children like Charlotte, be so severe that they cause their heart to stop. If the child continues to have these uncontrolled seizures, they can leave the child unable to walk, talk, or sleep.5 Charlotte was having up to 300 seizures a week and was prescribed seven seizure medications, all of which failed to provide her with any relief.4 With all other treatment options exhausted, and with the consent of two physicians, Charlotte’s desperate parents decided to try CBD oil. Amazingly, Charlotte responded favorably beginning with the very first dose. She is now having seizures only two to three times a month and is able to walk and interact with her family.4 Charlotte’s incredible experience has caused CBD oil to receive national attention, resulting in a surge of anecdotal evidence supporting its positive effects in the treatment of epilepsy as well as a push from parents of other children that suffer from refractory epilepsy to be able to obtain the treatment for their own children. But, due to marijuana’s federal status as a Schedule I drug, determined by the federal government to have no potential medical use and a high potential for abuse,6 scientific research on CBD oil has been extremely limited, leaving many families across the nation unable to gain access to the treatment.7 However, the social outcry from these parents whose children have not been helped by conventional pharmaceutical medications has resulted in several states pursuing new state legislation that would remove CBD oil from the state’s Schedule I list. Advocates argue that CBD oil contains such trace amounts of THC that it cannot be used recreationally and, therefore, should not be held to the same illegal standard as marijuana.8 Further, researchers are making it clear that CBD oil is unlike medical marijuana because it is orally administered, rather than smoked.9 Recently, 11 states have decided to allow the use of a low THC, high CBD oil, Mississippi being one of them.

August 2014 JOURNAL MSMA 273

On April 17, 2014, Governor Phil Bryant signed into law a bill that gives renewed hope to those that seemed to have so little of it. Passed by an overwhelming majority, House Bill 1231, or “Harper Grace’s Law,” exempted from control “processed cannabis plant extract, oil, or resin that contains more than 15% CBD or a dilution of the resin that contains at least 50 milligrams of CBD per milliliter, but not more than .5% of THC.”10 Senator Josh Harkins of Flowood played a key role in crafting the bill. He began pushing for the new law after seeing the CNN story featuring Charlotte Figi and meeting Harper Grace Durval, a two-year-old Mississippi girl who also suffers from Dravet Syndrome and for whom the bill was named. Harkins commented in an interview that after seeing the video and hearing of Harper Grace and her family’s daily struggles with Dravet Syndrome, he knew “it was a no brainer. If this treatment can help relieve even one person that suffers the way Harper Grace does, then it is worth the fight.”

As it is written, Harper Grace’s Law takes CBD oil off of the Schedule I list, but it can only be used under the tightest controls. The bill offers protection against unlawful possession only to those individuals, as well as their parents or guardians, who suffer from a debilitating epileptic condition or related illness and who received CBD oil pursuant to the order of a physician from the University of Mississippi Medical Center (UMMC). This protection is also provided to the National Center for Natural Products Research at the University of Mississippi (NCNPR) and the Mississippi Agricultural and Forestry Experiment Station at Mississippi State University (MAFES), the only institutions where the oil can be produced. Further, CBD oil can only be obtained from and tested by the NCNPR and dispensed by the Department of Pharmacy Services at UMMC.10 What does this mean for Mississippians wanting to obtain CBD oil? Unfortunately, it means that it will be quite some time before it will be able to be prescribed and administered. Although CBD oil has been exempted from control, there are still many regulatory requirements that must be met and studies that must be conducted before it can be dispensed. Dr. Mahmoud ElSohly, NCNPR research professor and director of the University’s Marijuana Project, and his team have been growing a crop of the low THC, high CBD marijuana strain, which is anticipated to reach maturity this winter. However, even then the plants will still need to be processed and developed into CBD oil, and the Food and Drug Administration’s approval of the final product will be needed before the oil can undergo clinical testing.11 Additionally, once the CBD oil has been processed and the FDA has approved the product and clinical plan, an extensive academic medical study will be required before the oil can be dispensed to patients. For now, there are no current plans to study the effectiveness of CBD oil on seizure activity in adults, even though the law, as passed, does not limit usage to children alone.

However, only children with refractory epilepsy will qualify for the upcoming multi-tiered study.11 Dr. Brad Ingram, a pediatric neurologist at UMMC, explained in an interview that the study will be conducted by the Pediatric Research Center at UMMC. Patient enrollment is anticipated to begin in March or April of 2015, and the study is expected to last at least one to two years, although it could be stopped earlier if it shows no signs of promise.

Though many parents are eager to enroll their children in the study so that they can begin treatment as soon as possible, some children may not be ideal candidates because they do not meet the specifications proposed for each phase of the study.

According to Ingram, the CBD oil will not be administered to those outside of the study until adequate testing has been performed. “Before we can begin administering CBD oil, we have to do everything possible to find out whether it will work and whether it is safe for our children. This entire area is new to everyone; at every stage of the study there is a new question. We have to be smart with how we approach introducing it. We have to exercise the utmost care and responsibility.”

Ingram further explained that, so far, the Pediatric Research Center’s plan consists of a preliminary testing on healthy adults to determine palatability, adverse effects, and pharmacokinetics of the product. Following this preliminary testing, the study of children suffering from refractory epilepsy will begin. The first phase will consist of 20-25 children, preferably 10 years old or younger, who suffer from severe impairments, such as those requiring gastrostomy tubes to receive nutrition and who are unable to walk and talk. After one to two months, a second group of children with less severe impairments will join the study, such as those that are unable to walk but can still interact with their surroundings. In the last phase, children with no impairments other than refractory epilepsy will join the two previous groups. After the one to two year mark, this last group of children will undergo neuropsychological testing to gauge any negative or positive cognitive responses from the treatment, such as their ability to reason, concentrate, solve problems, and remember.

Although there is much to be done before CBD oil will be available to all those who may benefit, Harper Grace’s Law has opened the door to many new opportunities for Mississippi. “This is a big step toward eventually providing relief for Mississippi children suffering from epilepsy,” Senator Harkins said during the interview. As of now, there is only anecdotal evidence of the benefits that CBD oil offers to children suffering from refractory epilepsy, but Mississippi is in a position to change that by conducting the first scientific study of what CBD oil can actually offer.

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“The difference between what we are doing in Mississippi and what other states are doing is that we are blessed to have access to the resources required to accomplish a legitimate scientific study,” explained Dr. Ingram. “No one else has access to Oxford and the quality control that we do. These children and their parents fight desperately every day, just to get a little bit better, and I am very appreciative of Senator Harkins, Ole Miss, and the entire project for putting them on the radar.”

References 1.

What is Epilepsy? University of Mississippi Medical Center Children’s Neurosciences Web site. Available at: http://www.ummchealth.com/Health_Care_ Services/Neurosciences/Children/Epilepsy/Epilepsy_-_What_is_It/Epilepsy_-_What_is_It_.aspx. Accessed July 22, 2014.

2.

Kelly, Sarah Aminoff. Anticonvuslant Treatment of Epilepsy and Refractory Status Epilepticus: Recent Clinical Trials. The Neurology Report Web site.

2013. Available at: neurologyreport.com/AES2012/kelly.php. Accessed July 27, 2014.

3.

Mohanraj R, Brodie MJ. Diagnosing refractory epilepsy: response to sequential treatment schedules [abstract]. Eur J Neurol. 2006;13:277-282.

4.

Young, Saundra. Marijuana stops child’s severe seizures. CNN Health Web site. August 7, 2013. Available at: http://www.cnn.com/2013/08/07/health/ charlotte-child-medical-marijuana/. Accessed July 21, 2014.

5.

What is Dravet Syndrome? Dravet Syndrome Foundation Web site. Available at: www.dravetfoundation.org/dravet-syndrome/what-is-dravet-syndrome.

Accessed July 22, 2014.

6.

Drug Scheduling. United States Drug Enforcement Administration Web site. Available at: www.justice.gov/dea/druginfo/ds.shtml. Accessed July 27, 2014.

7.

CBD & Epilepsy. CURE Epilepsy Web site. Available at: www.cureepilepsy.org/research/cbd-and-epilepsy.asp. Accessed July 22, 2014.

8.

Schaaf, Mark. Governor signs bill allowing use of marijuana component for health. The Journal Times of Wisconsin Web site. April 16, 2014. Available at: http://journaltimes.com/news/local/governor-signs-bill-allowing-use-of-marijuana-component-for-health/article_1a2931b2-c5c4-11e3-928e-001a4bcf887a. html. Accessed July 22, 2014.

9.

UM Researchers, Physicians Cite Benefits of Harper Grace’s Law. Ole Miss News Web site. March 28, 2014. Available at: http://news.olemiss.edu/umresearchers-physicians-cite-benefits-of-harper-graces-law/#.U9_8q1YzJuZ. Accessed July 21, 2014.

10. Harper Grace’s Law, H.R. 1231, 129th Leg. (Ms. 2014).

11. Statement on the availability of cannabidiol oil. University of Mississippi Medical Center Web site. June 9, 2014. Available at: http://www.umc.edu/News_ and_Publications/Press_Release/2014-06-09-00_Cannabidiol_Oil.aspx. Accessed July 22, 2014.

Adam Woods is a law clerk for the Mississippi State Medical Association and a 3L student at the Mississippi College School of Law.

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August 2014 JOURNAL MSMA 275

• Physicians’ Health Corner • Dr. Scott Hambleton Answers Your Questions Scott Hambleton, MD, Medical Director, Mississippi Professionals Health Program

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am frequently asked the question, “What is a disruptive physician?”

First, I try to avoid using the term disruptive when referring to a physician because it has a pejorative connotation. In my estimation, the term “distressed physician” is more appropriate because distress is a very common cause of the problematic behavior.

Behavior that is disruptive is defined by the AMA as, “Personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care… This includes but is not limited to conduct that interferes with one’s ability to work with other members of the health care team.”

There are many causes of disruptive behavior, including substance abuse, cognitive decline from aging, physical or psychiatric illness, burnout, or underlying personality disorders. Examples of disruptive behavior include use of profane, disrespectful or demeaning language (e.g., referring to hospital staff as stupid); inappropriate chart notes (criticizing treatment provided by other caregivers); unethical or dishonest behavior; inappropriate expressions of anger (throwing charts or instruments); repeated failure to complete medically related duties in a timely fashion; absenteeism; use of sexual comments or innuendo; or professional sexual misconduct (sex with patients or staff).

Ultimately, these behaviors represent a violation of professional boundaries. Boundaries are a line in the sand that represents the edge of appropriate, professional conduct. Obviously, professional boundaries exist as a protective barrier for society. However, they also protect the physician.

The process of becoming a physician and practicing medicine is constantly evolving, always challenging, and at times, unbelievably rewarding. Although practicing medicine is a tremendous privilege, for some it is a frustrating ordeal. Burnout and suicide are experienced at a much higher rate in physicians than in the general population. Alcohol and prescription medication abuse is also more frequent in physicians. We are viewed as the experts when it comes to treating others, however, when it comes to caring for ourselves we are often negligent. When physicians are unable or unwilling to care for themselves, the likelihood of subsequent distress and disruptive behavior is greatly increased, as is the risk of patient harm.

Setting appropriate professional boundaries is the antidote for disruptive behavior, and good self-care is perhaps one of the most effective boundaries to promote professionalism! Effective self-care requires planning and commitment.

Appropriate diet, exercise, and sleep as well as scheduling time for fun and family activities are the essential elements of self-care. Acceptance and utilization of appropriate treatment for underlying medical, psychiatric or personality issues are necessities.

The Mississippi Professionals Health Program offers assistance to distressed physicians with behavioral issues. We can help! Just call 601-420-0240.

If you have questions for Dr. Hambleton about MPHP, you may contact him at the number above or email shambleton@msprofessionalshealth.org. Anonymous questions for this column are also permissable. Send your inquiry to the attention of “Physicians’ Health Corner” at the Journal address.

276 JOURNAL MSMA August 2014

McGowan Workforce Training Center Holmes Community College |412 West Ridgeland Avenue Ridgeland, MS 39157

Name of Registrant(s): ____________________________________________________________________________________________ Name of Clinic: _______________________________________________________________________________ Clinic Address: _______________________________________________________________________________ Email: _________________________________________________ Do you wish to receive 4.5 hours of AAPC CEU? YES NO Telephone:_____________________________

MSMA Member Physician: _____________________________

Payment accepted by check or credit card or visit MSMAonline.com for ONLINE registration. Circle all that apply.

Price includes ICD-10 CM Manual and lunch. o $250 MSMA Member Staff o $300 Non-MSMA Member Staff o Check Payable to MSMA

Mailed to MSMA, Attn: ICD-10 PO 2548 Ridgeland, MS 39157

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August 29, 2014

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September 26, 2014 o Charge Credit Card Credit Card Type: VISA MASTERCARD AMERICAN EXPRESS Name as it appears on card: ______________________________________ *MSMA will add other dates as necessary.

CC Number____________________________ Expiration Date: _________ Amount to be charged: $250 $300 Signature of Cardholder: ________________________________________

Hyatt Jackson/Ridgeland 1016 Highland Colony Parkway Ridgeland 39157 601.898.8815

Contact: Phyllis Williams Director of Practice Strategies Mississippi State Medical Assoc.

601-853-6733 Ex. 322 PWilliams@MSMAonline.com FAX: 601.853.6746

A minimum of 5 people are required in order to host a class on a particular date. Additionally, the class is limited to 24 people on each class date. Should a class be cancelled because 5 people have not registered, you will be offered alternative class dates from which to choose.

August 2014 JOURNAL MSMA 277

• Mississippi State Department of Health •

278 JOURNAL MSMA August 2014

August 2014 JOURNAL MSMA 279

• Poetry and Medicine • [This month, we print another 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 telephone, our “essential” instrument in modern practice, yet still our torturer. Perhaps we sometimes agree, when our telephones ring at the wrong times, that “A. G. Bell should’ve been hanged!” Look for more of his poems in coming journals. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.] —Ed.

Doctor’s Telephone It sits there somnolent In malignant silence, Waiting to spring, A black, alien instrument My master, My torturer.

Its presence hangs a sword In ominous air.

I await the strident ring.

A. G. Bell should’ve been hanged!

— Thomas Browne, MD; Clarksdale

280 JOURNAL MSMA August 2014

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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

Securities Offered Through ValMark Securities, Inc. Member FINRA, SIPC Investment Advisory Services Offered Through ValMark Advisers, Inc. a SEC Registered Investment Advisor 130 Springside Drive, Suite 300 Akron, Ohio 44333-2431* 1-800-765-5201 Executive Planning Group is a separate entity from ValMark Securities, Inc. and ValMark Advisers, Inc. In a life settlement agreement, the current life insurance policy owner transfers the ownership and beneficiary designations to a third party, who receives the death proceeds at the passing of the insured. As a result, this buyer has a financial interest in the seller’s death. When an individual decides to sell their policy, he or she must provide complete access to his or her medical history, and other personal information, that may affect his or her life expectancy. This information is requested during the initial application for a life settlement. After the completion of the sale, there may be an ongoing obligation to disclose similar and additional information at a later date. A life settlement may affect the seller’s eligibility for certain public assistance programs, such as Medicaid, and there may be tax consequences. Individuals should discuss the taxation of the proceeds received with their tax advisor. ValMark Securities considers a life settlement a security transaction. ValMark and its registered representatives act as brokers on the transaction and may receive a fee from the purchaser. A life settlement transaction may require an extended period of time to complete. Due to complexity of the transaction, fees and costs incurred with the life settlement transaction may be substantially higher than other securities.