December 13 JMSMA

December

VOL. LIV

2013

No. 12

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

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

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

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

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

Copyright© 2013 Mississippi State Medical Association.

DECEMBER 2013

VOLUME 54

NUMBER 12

Scientific Articles Survey of Beliefs of UMMC First-Year Medical Students about Evolution and its Relevance to Medicine

336

Alan D. Penman, MD, PhD, MPH

Clinical Problem-Solving: The Hidden Culprit

342

Anthony Y. Chen, MD

President’s Page The Horizon

348

James A. Rish, MD

Editorial Physician, Heal Thyself

351

D. Stanley Hartness, MD; Associate Editor

Related Organizations University of Mississippi Medical Center: The Anniversary of TelEmergency

340

Richard L. Summers, MD; Kristi Henderson, DNP; Kristen C. Isom, RN; Robert L. Galli, MD

Departments From the Editor: Punishment of the Gods

334

New Members

350

Letters: MSMA Position on Medicaid Expansion

352

William C. Lineaweaver, MD

Editor’s Response to Medicaid Expansion Letter

352

Lucius M. Lampton, MD

Una Voce: The Interloper

353

Dwalia S. South, MD

Poetry and Medicine: “Some Music in Boston”

355

William C. Lineaweaver, MD

Subject/Author Index

369

About The Cover: Holly in Snow - Martin M. Pomphrey, Jr., MD, who serves on the MSMA Committee on Publications, took this photo in his yard after a snow storm in beautiful, historic downtown Mayhew, Mississippi. Dr. Pomphrey is a semiretired orthopaedic surgeon sub-specializing in sports medicine who practiced with Oktibbeha County Hospital (OCH) Bone and Joint Clinic in Starkville. r

December

VOL. LIV

2013

No. 12

Official Publication of the MSMA Since 1959

December 2013 JOURNAL MSMA 333

From the Editor: Punishment of the Gods

O

ne of the hottest topics of discussion at midNovember’s AMA gathering centered on the elimination of SGR (Medicare’s Sustainable Growth Rate). Enacted by Congress in 1997, SGR is the formula utilized by Congress to control federal spending on physician services. The flawed thinking behind it was to ensure that the yearly increase in Medicare spending did not exceed growth in GDP (gross domestic product). Each year physicians face dramatic cuts in their payments, often double-digit percentage, and each year Congress has blocked, at the last minute, the annual cuts as ordered by SGR in what is usually called a “doc fix.” A repeal of this brainless method has long been on the AMA national agenda, and significant momentum exists to replace SGR with a new payment system. In late November, nearly 260 members of the U. S. House of Representatives signed a letter advocating repeal of SGR by year’s end.

Despite this good news, physicians must be careful what they ask for. Our profession’s attempts to repeal SGR may be a lesson of unintended consequences. The so-called “permanent solution” may create new and worse problems for physicians. Among the

demands of Congress is a ten-year freeze on any increase in physician payments, which any business would perceive as ludicrous.

With costs rising yearly, even monthly, in the operation of a typical medical practice, how does a ten-year freeze make sense? The math for a medical practice doesn’t add up. Lucius M. Lampton, MD The AMA House of Delegates loudly voiced concern that such a freeze will decimate physician practices.

Thus, your AMA is pushing repeal along, but was told by its House in no uncertain terms not to endorse an SGR solution which would contain such poison.

The Irish poet and playwright Oscar Wilde wrote in Act 2 of his witty play An Ideal Husband: “when the gods wish to punish us, they answer our prayers.” He was, in his lyrical voice, capturing an ancient Roman aphorism; “Cave quae cupis”… beware what you wish for. Physicians must also be careful what we wish for: we might get it!

Contact me at lukelampton@cableone.net.

—Lucius M. “Luke” Lampton, MD, Editor

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

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

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

Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson 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 Medicial Operations Baptist Health Systems, Jackson Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

334 JOURNAL MSMA December 2013

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

Medical Assurance Company of Mississippi

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Working with Young Physicians December 2013 JOURNAL MSMA 335

• Scientific Articles • Survey of Beliefs of UMMC First-Year Medical Students about Evolution and its Relevance to Medicine Alan D. Penman, MD, PhD, MPH

I

ntroduction

Human biology is a foundation for medicine, and a central organizing concept in biology is that life changes and develops through evolution. Evolution is as fundamental to medicine as physics or chemistry, and evolutionary knowledge gives a deeper understanding of health and disease.1-7 Researchers in the field of evolutionary medicine have suggested that evolutionary biology should not simply be an optional topic in medical school but instead should be taught as one of the basic medical sciences.8,9According to Nesse in January, 2010: “No medical school in the United States offers evolutionary biology as a medical science, and most have no evolution at all in the curriculum.”10 In a survey of North American medical school deans in 2003, only 32% of the respondents reported that their schools covered at least 8 of 16 core topics in evolutionary biology, and only 16% of the schools reported having any faculty with a PhD in evolutionary biology.11 A possible problem for integration of evolutionary biology into medical education is the attitude of some students. With that in mind, I surveyed the UMMC first-year (M1) medical students about their beliefs about evolution and its relevance to medicine.

Methods

The survey was approved by the Institutional Review Board at UMMC. The anonymous survey was administered electronically to M1 students in two successive years: at the end of the fall semester in 2011 (n=136) and at the beginning of the fall semester in 2012 (n=135), using SurveyMonkey (www. surveymonkey.com).

Author Affiliations: Dr. Penman is a Professor in the Center of Biostatistics and Bioinformatics and the Department of Medicine at the University of Mississippi Medical Center in Jackson. He is the head of data analytics for the Jackson field site of the Atherosclerosis Risk in Communities Study, funded by the NIH/NHLBI, and directs and teaches courses in public health, epidemiology, and biostatistics.

Corresponding Author: Alan D. Penman, MD, Center of Biostatistics and Bioinformatics and Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216 (apenman@umc.edu).

336 JOURNAL MSMA December 2013

Results

Ninety-three (68%) students responded in 2011 and 77 (57%) students in 2012. Detailed results are given in the table.

Prior knowledge of evolution In both 2011 and 2012, 66% of respondents reported having learned “quite a lot” or “a lot” about evolution before studying medicine; 14% in 2011 and 17% in 2012 reported having learned “little” or “very little.” The most frequently cited context of learning about evolution before medical school was a college course (or courses) (75% in 2011, 82% in 2012). Sixty percent in 2011 and 65% in 2012 had had a course or courses on evolution in high school.

Acceptance of evolution Seventy-three percent of respondents in 2011 and 87% in 2012 reported that they accept that some kind of biological evolution, lasting many millions of years, has occurred on earth; the most commonly given reason for accepting evolution was that “the evidence is clear and unambiguous” (72% in 2011, 78% in 2012).

Twenty-seven percent of respondents in 2011 and 13% in 2012 did not accept that some kind of biological evolution has occurred. The most commonly given reason for rejecting evolution was “acceptance of the literal truth of a religious creation account” (95% in 2011, 89% in 2012).

Of the non-acceptors, the vast majority (91% in 2011, 100% in 2012) accepted that microevolution (natural selection operating within a species to adapt to fine scale environmental change) occurs, but not macroevolution (species changing from one kind to another). Consistent with this, the majority of nonacceptors (96% in 2011, 78% in 2012) accepted natural selection as an explanation for increasing microbial drug resistance.

Human evolution in the medical curriculum and implications for practice i. Among respondents who accept evolution In this group 52% in 2011 and 55% in 2012 rate the relevance of evolutionary biology to an understanding of

medicine as “high” or “very high”; 31% in 2011 and 19% in 2012 rate the relevance as “low” or “very low.” Seventy-five percent in 2011 and 86% in 2012 think that evolution should be

included in the medical curriculum as a mandatory subject or as an elective option (with a slight majority favoring an elective option).

Table. Survey of beliefs of UMMC first-year medical students about evolution and its relevance to medicine: response numbers (%) How much have you learned about evolution before studying medicine?

Do you accept that some kind of biological evolution, lasting many millions of years, has occurred on earth?

Do you accept that microevolution (natural selection operating within a species to adapt to fine scale environmental change) occurs?

Rate the relevance of evolutionary biology to an understanding of medicine.

Evolution should be included in the medical curriculum: It has been a common finding that following the introduction of a drug to treat a disease caused by a micro-organism, the micro-organism becomes increasingly resistant to the drug. Widespread use of the drug now may make it useless in treating future patients. a) Do you accept that this is an example of natural selection? b) In treating patients with such drugs, is your duty mostly to present patients or future patients?

Rate the relevance of evolutionary biology to an understanding of medicine.

Evolution should be included in the medical curriculum: It has been a common finding that following the introduction of a drug to treat a disease caused by a micro-organism, the micro-organism becomes increasingly resistant to the drug. Widespread use of the drug now may make it useless in treating future patients. c) Do you accept that this is an example of natural selection? d) In treating patients with such drugs, is your duty mostly to present patients or future patients?

2011 (N=136) 61/93 (66%)

2012 (N=135) 51/77 (66%)

13/93 (14%)

13/77 (17%)

68/93 (73%)

67/77 (87%)

20/22* (91%)

9/9** (100%)

High or very high

30/58 (52%)

34/62 (55%)

Low or very low as a mandatory subject

18/58 (31%)

12/62 (19%)

21/59 (36%)

23/63 (37%)

23/59 (39%)

31/63 (49%)

57/59 (97%)

58/61 (95%)

Present patients: 51/59 (86%)

Present patients: 51/62 (82%)

4/22 (18%)

1/9 (11%)

12/22 (55%)

6/9 (67%)

3/22 (14%)

3/9 (33%)

11/22 (50%)

3/9 (33%)

21/22 (96%)

7/9 (78%)

Present patients: 20/21 (95%)

Present patients: 8/9 (89%)

Quite a lot/a lot Very little/little

as an elective option

High or very high Low or very low as a mandatory subject as an elective option

*out of 25 respondents who did not accept that some kind of biological evolution has occurred. **out of 10 respondents who did not accept that some kind of biological evolution has occurred.

December 2013 JOURNAL MSMA 337

1

Faced with the problem of increasing microbial drug resistance, 86% in 2011 and 82% in 2012 feel that their duty is mostly to current patients, even though continued widespread use of the drug now may make it useless in treating future patients. ii. Among respondents who do not accept evolution In this group 18% percent in 2011 and 11% in 2012 rate the relevance of evolutionary biology to an understanding of medicine as “high” or “very high;” 55% in 2011 and 67% in 2012 rate the relevance as “low” or “very low.” Despite this, the majority of non-acceptors – 64% in 2011, 67% in 2012 – think that evolution should be included in the medical curriculum as a mandatory subject or as an elective option (with a large majority in 2011 favoring an elective option).

As with the group of acceptors, in the situation of increasing microbial drug resistance the vast majority of non-acceptors (95% in 2011, 89% in 2012) feel that their duty is mostly to current patients rather than future patients.

Discussion The findings of this brief survey are clear. The majority of M1 students at UMMC who responded to this survey accept evolution, and even most of the non-acceptors accept that microevolution occurs. Regardless of beliefs about evolution and its relevance to medicine, two-thirds of respondents think that evolution should be included in the medical curriculum either as a mandatory subject or as an elective option.

Very few similar surveys (none from U.S. medical schools) have been published, so it is difficult to make comparisons. At the University of Glasgow, Scotland, 10% of first year medical students in 1999 and 11% in 2002 rejected the occurrence of biological evolution,12,13 similar to the 13% of M1 students at UMMC in 2012. A national survey of 1,472 U.S. physicians in 2007 revealed that the majority of all doctors (78%) accept evolution.14 In this survey, nearly one-third of respondents who accept evolution rate the relevance of evolutionary biology to an understanding of medicine as “low” or “very low”. This likely reflects the fact that the students are at an early stage in their medical education, but it also indicates the importance of explaining the large and increasing number of applications of evolutionary thinking to many areas of medical practice and research.1-7,15,16 Almost all respondents accept natural selection as an explanation for increasing microbial resistance; however, almost all still feel that their duty is mostly to current patients, not the future.

This is a clear example of an area where teaching on evolutionary medicine could make an important impact on medical practice.

As with all surveys, a possible limitation is the less than optimal response rate. Here, 32% of the M1 class in 2011 and 43% in 2012 did not respond. Assuming (in the extreme case) that all non-respondents did not accept evolution in any form, it can be calculated that 65% (88/136) of the class in 2011 would accept evolution in some form and 35% (48/136) would

338 JOURNAL MSMA December 2013

not; in the 2011 class, 56% (76/135) of the 2012 class would accept evolution in some form and 44% (59/135) would not.

Thus, in both classes a majority of students would still accept evolution in some form. Therefore, it is reasonable to assume that the survey results are representative of the whole class.

Interest in the application of evolutionary principles and methods to the teaching and practice of medicine is growing rapidly; there is now an online journal (http://evmedreview. com/), and a textbook specifically aimed at medical students (“Principles of Evolutionary Medicine” by Peter Gluckman, Alan Beedle and Mark Hanson. Oxford University Press, USA; 2009). This would be an opportune moment to consider introducing a course on evolution and its relevance to medicine for medical students at UMMC – at least as an elective option, initially. Furthermore, 14% of M1 students responding to this survey reported having learned “little” or “very little” about evolution before studying medicine. As coursework on evolutionary medicine is integrated into the medical curriculum, consideration will also need to be given to making at least one college course on evolution a prerequisite for medical school entry.

Acknowledgements The author would like to thank Professor J.R. Downie of the Institute of Biodiversity, Animal Health and Comparative Medicine, Glasgow University, Scotland for permission to use his student survey (with modification) and Robyn Herring of the Office of Academic Affairs, UMMC for help with administering the survey electronically.

References 1.

Nesse RM, Dawkins R. Evolution: Medicine’s most basic science, in Oxford Textbook of Medicine, ed 5, Warrell DA, Cox TM, Firth JD, Benz EJJ (eds). Oxford: Oxford University Press; 2010:12-15.

2.

Perlman RL. Evolutionary biology: a basic science for medicine in the 21st century. Perspect Biol Med. 2011;54(1):75-88.

3.

Gluckman PD, Bergstrom CT. Evolutionary biology within medicine: a perspective of growing value. BMJ. 2011;343:d7671.

4.

Stearns SC. Evolutionary medicine: its scope, interest and potential. Proc Biol Sci. 2012;279(1746):4305-21.

5.

Varki A. Nothing in medicine makes sense, except in the light of evolution. J Mol Med (Berl). 2012;90(5):481-94.

6.

Rühli FJ, Henneberg M. New perspectives on evolutionary medicine: the relevance of microevolution for human health and disease. BMC Med. 2013;11:115.

7.

Brüne M, Hochberg Z. Evolutionary medicine--the quest for a better understanding of health, disease and prevention. BMC Med. 2013;11:116.

8.

Nesse RM, Bergstrom CT, Ellison PT, et al. Evolution in health and medicine Sackler colloquium: Making evolutionary biology a basic science for medicine. Proc Natl Acad Sci U S A. 2009;107 (Suppl 1):1800-1807.

9.

Antolin MF, Jenkins KP, Bergstrom CT, et al. Evolution and medicine in undergraduate education: a prescription for all biology students. Evolution. 2012;66:1991-2006.

10. Medical students may soon be tested on evolution. Available at: http://www.eurekalert.org/pub_releases/2010-01/nesc-msm012 510.php.

11. Nesse RM, Schiffman JD. Evolutionary Biology in the Medical School Curriculum. Bioscience. 2003;53:585-587.

12. Downie JR, Barron NJ. Evolution and religion: attitudes of Scottish first year biology and medical students to the teaching of evolutionary biology. Journal of Biological Education.

2000;34:139-146.

13. Downie JR. Evolution in Health and Disease: The Role of Evolutionary Biology in the Medical Curriculum. Bioscience Education E-Journal. 2004;4-3.

14. The Jewish Theological Seminary. Evolution vs. Intelligent Design- National Survey of Physicians. Available at: http:// www.jtsa.edu/Community_Engagement/Louis_Finkelstein_ Institute_for_Religious_and_Social_Studies/Public_Interest_ Surveys/Evolution_vs_Intelligent_Design.xml?ss=print.

15. Nesse RM, Stearns SC. The great opportunity: Evolutionary applications to medicine and public health. Evolutionary Applications. 2008;1:28-48.

16. Alcock J, Schwartz MD. A clinical perspective in Evolutionary Medicine: What we wish we had learned in medical school. Evo Edu Outreach. 2011;4:574-579.

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December 2013 JOURNAL MSMA 339

• UMMC • The Anniversary of TelEmergency Richard L. Summers, MD; Kristi Henderson, DNP; Kristen C. Isom, RN; Robert L. Galli, MD

M

ississippi is a national leader in telemedicine/ telehealth, and this year marks the tenth year of using technology to improve health care in our state. The telehealth program has expanded rapidly over the last two years, but it all started in emergency medicine. The TelEmergency Program at the University of Mississippi Medical Center (UMMC) began as a pilot project with three hospitals in October 2003.1 The program was initially started with the assistance of private funding from the Bower Foundation, acquired by Dr. Richard Summers. Conceptualized and organized by Robert L. Galli, MD, and Kristi Henderson, DNP, NP-BC, the program was born from a consensus within the UMMC Department of Emergency Medicine that there was a serious need to improve emergency care in our state. A strategy which uses a telemedicine connection to provide some emergency medicine expertise to these struggling medical communities is one possible solution.

Our TelEmergency system operates like an ED on a 24/7 basis with a board certified emergency physician in our telemedicine console room ready to answer all calls. Emergency consultations are available for any patient that arrives to one of our distant-sites as determined by the provider at that location. We encourage engagement with the service for all higher acuity patients but welcome any teleconsult.

An example is with acute stroke care and the use of thrombolytics. Most emergency physicians prefer to manage these cases in consultation with a stroke neurologist.

Telestroke can be considered a variation of emergency telemedicine in which a stroke specialist is engaged from a remote location to advise about management decisions during an acute presentation.2 We have used facilitated consultations in our TelEmergency system with a number of specialties inAuthor Information: Professor and Chairman, Department of Emergency Medicine, University of Mississippi Medical Center (Dr. Summers); Director, Center for Telehealth, University of Mississippi Medical Center (Henderson); Stroke & STEMI Coordinator, Telemedicine Liaison, Anderson Regional Hospital (Ms. Isom); Professor and Director of TelEmergency, Department of Emergency Medicine, University of Mississippi Medical Center (Dr. Galli).

Correspondance: UMMC Center for TeleHealth, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. www.umc.edu/telehealth, Telephone: 601-815-2020 (telemed@umc.edu).

340 JOURNAL MSMA December 2013

cluding neurologists, psychiatrists, and obstetricians, to bring the expertise of those specialties to the small community hospital emergency department in a way that was never before possible. Whether you need an emergency infectious disease consultation in remote Rwanda or a stroke neurologist’s advice in the rural Delta of Mississippi, it is now all possible.

Telemedicine equipment mounted on a mobile cart allows for two-way audio and visual communication between the patient or distant provider and the physician at our console. The technology allows for a thorough exam remotely to include the ability to auscultate the heart and lungs, examine the inner ear, nose, and skin. Technology can be utilized to complete any portion of the exams as if in-person except for those involving smell and touch. There are also mechanisms in place for the electronic downloading and surveillance of images, laboratory data, and electrocardiograms from the distant site. With this system we have assisted in running codes, delivering babies, and many other forms of acute care management in real time. If necessary, we can easily launch the helicopter from the telemedicine room for quick transports, and in the past we have sent a doctor to the distant site in a time of disaster. We also have some telemedicine sites on oil rigs in the Gulf of Mexico. Preventing the unnecessary transport of patients can save thousands of dollars.

The current TelEmergency program now serves nineteen rural hospital emergency departments in Mississippi at multiple geographically distant sites through interactions with nurse practitioners, family medicine physicians, and emergency physicians. Nine more hospitals are slated to join the program over the next six months.3 The vast majority of these small EDs are covered by nurse practitioners who see approximately 2,000 patients per month as a part of the Telemergency Program.

To qualify for our program, these nurse practitioners undergo an initial rigorous course of special training beyond their traditional license and then have required ongoing continuing educational requirements to remain in the program. Our 10 year volume of patients served by our program is estimated at 422,000. TelEmergency consultation is requested for 40.5% of the patients seen, and they are evaluated collaboratively by the nurse practitioner and our TelEmergency physician via an audiovisual connection. Audiovisual teleconsultations between the University ED physician and the nurse practitioner at the rural site occur at the rate of about 50 per month.

One of the goals of the program is to prevent unnecessary transfers. The majority of patients (57.32%) are discharged from the ED at the rural site while 21.82% are transferred to other hospitals for a higher level of care (see dispositions chart).

Satisfaction surveys reveal 93.6% of patients are comfortable or very comfortable with the system, 98.7% had no difficulty seeing or hearing the TelEmergency physician, 91.2% of patients are more likely to come back to this ED because of the TelEmergency Program, and 85.6% rated the overall care as good or excellent. Among hospital administrators, 100% feel that the level of care in their ED has increased or remained the same because of the TelEmergency program, 87.5% feel that it costs less or about the same to cover their ED with the TelEmergency program than with a dedicated emergency physician, 85.7% feel that their overall ED volume has increased since the implementation of the TelEmergency Program, 85.7% feel their number of admissions have increased since implementation of the TelEmergency Program.

There are some unique issues associated with the development of a viable financial and business plan for telemedicine. Coding and reimbursement can be challenging. Variations between states’ reimbursement for telehealth services and regulatory issues related to medical licensure, hospital credentialing, and the Department of Health are just a few of the challenges. As telemedicine services expand so do regulations related to its delivery. Mississippi made great strides when Governor Phil Bryant signed legislation mandating both public and private health insurance companies reimburse for telehealth services at the same rates as in-person services are reimbursemed. Federal legislation (HR 3306) has been submitted by Congressman Gregg Harper that would clear some additional barriers to telehealth services.4

As we reflect on the successes and challenges we have faced with the development of this program, we also want to discuss the evolution of the technology and future directions for telemedicine.

Unlike the conditions of ten years ago at the inception of our TelEmergency program, telecommunication and internet connectivity is almost ubiquitous throughout the United States. However, available bandwidth remains a challenge in some areas of Mississippi. The challenge with sharing medical information in telemedicine is to make this transfer of data secure and HIPPA compliant without dramatically changing the utility of the interaction. Many solutions exist and cost continues to decrease making it a viable option on a larger scale.

So what is the future of telemedicine? The complexity of modern healthcare coupled with the financial crisis has resulted in a situation in which there is an increasing need to improve quality while lowering costs. Sharing medical providers and health care resources can be done through telehealth, resulting in improved resource utilization thereby lowering costs. Communities that had limited medical services can now bring needed health care services to their community virtually. The UMMC Center for TeleHealth serves to coordinate all telehealth consults, remote patient monitoring, distance education, and workforce development initiatives.

The success of these first ten years of telehealth/telemedicine has been largely a result of the TelEmergency Program.

The positive impact of this program led to the development of UMMC’s Center for TeleHealth which is now serving 84 different sites where one of over 20 different telemedicine services is being delivered. The vision for the Center for TeleHealth is to eliminate geographic barriers to accessing healthcare in Mississippi. Outreach staff from UMMC’s Center for Telehealth are providing hands-on education and informational sessions throughout Mississippi. Contact them to set up an informational session to learn more about what telehealth can do for your community.

Additional Resouces National TeleHealth Policy Resource Center, www.telehealthpolicy.us Phone: 877-707-7172 (info@cchpca.org).

South Central Telehealth Resource Center, www.learntelehealth.org Phone: 855-664-3450 (info@learntelehealth.org).

American Telemedicine Association, www.americantelemed.org.

References 1.

Galli R, Keith JC, McKenzie K, Hall GS, Henderson K. TelEmergency: a novel system for delivering emergency care to rural hospitals. Ann Emerg Med. 2008;51(3):275-84.

2.

Albright KC, Schott TC, Boland DF, George L, Boland KP, Wohlford-Wessels MP, Finnerty EP, Jacoby MR. Acute stroke care in a neurologically underserved state: lessons learned from the Iowa Stroke Survey. J Stroke Cerebrovasc Dis. 2009;18(3):203-7.

3.

Center for TeleHealth. (2013). Accessed from http://umc.edu/telehealth.

4.

Bipartisan telehealth bill introduced. (2013). Accessed from http://harper. house.gov/press-release/bipartisan-telehealth-bill-introduced.

December 2013 JOURNAL MSMA 341

• Clinical Problem-Solving • The Hidden Culprit Anthony Y. Chen, MD

A

n 83-year-old Caucasian male with a history of coronary artery disease, dyslipidemia, osteoarthritis, and gastro-esophageal reflux disease presented to the Emergency Department complaining of generalized weakness. He reported having been bitten on the nose by a “buffalo gnat” 10 days earlier. He was evaluated at that time by his primary care physician and prescribed cephalexin (Keflex). Shortly after starting the medication, he experienced tongue swelling. He stopped the medication, and the angioedema spontaneously resolved.

After this episode, however, he reported experiencing progressive generalized weakness.

In an 83-year-old presenting with weakness, the differential is very broad. I would first like to characterize whether he is experiencing fatigue versus primary muscle weakness. Given his history of coronary artery disease, it would be important to determine if his weakness is secondary to unstable angina or heart failure. Furthermore, if his history is more suggestive of fatigue, I would also be concerned about hypothyroidism, anemia, infection, malignancy or depression. If, on the other hand, he has primary muscle weakness, this may point toward neurologic, inflammatory or rheumatologic conditions.

Metabolic imbalances and medication side effects may also be causes of his symptoms.1 Prior to being bitten by the insect, our patient experienced no weakness and had been regularly mowing the lawn without chest pain, shortness of breath or fatigue.

He denied symptoms of orthopnea or edema. Further questioning regarding his weakness revealed difficulty rising from a chair and combing his hair.

His presentation is suggestive of primary proximal muscle weakness. Possible causes would include inflammatory conditions such as polymyositis and dermatomyositis or autoimmune diseases affecting the nervous system or a vasculitis.2,3 Statin and alcohol toxicity can also be associated with proximal muscle weakness.1 Furthermore, given the acute Author Information: Dr. Chen was a resident in the Department of Family Medicine at the University of Mississippi School of Medicine.

Corresponding Author: Anthony Y. Chen, MD, 1807 Slaughter Lane, Suite 490, Austin, TX 78748. Phone: (512) 282-8967 (AnthonyChen@yahoo.com).

342 JOURNAL MSMA December 2013

presentation of his symptoms, I would be concerned for a recent stroke or infection. Obtaining more history and performing a physical examination would help narrow the differential.

Associated symptoms the patient complained of included nausea and non-bloody emesis for 1 day as well as subjective fever with headache. He denied photophobia, nuchal rigidity or cough. His review of systems was positive for dysuria. Otherwise, he denied trauma, rashes, melena, hematochezia or other sources of bleeding. Depression screening questions were unremarkable. The patient’s family history was significant for thyroid cancer and a daughter with multiple sclerosis. He was a prior smoker but quit 40 years ago. He denied alcohol or drug use. His medications included aspirin, celecoxib (Celebrex), simvastatin (Zocor), lansoprazole (Prevacid), and metoprolol (Toprol-XL).

The patient’s subjective fever, gastrointestinal and genitourinary symptoms suggest a possible urinary tract infection. Particularly in the elderly, patients with urinary tract infections can present with symptoms including weakness. Emesis can also be associated with dehydration and hypokalemia that may result in muscle weakness.4 However, with only one episode of emesis this would be less likely. The patient’s history of smoking, age, and family history would place him at a higher risk for malignancy. Regarding his home medications, simvastatin can cause myopathy.5 Furthermore, due to his recent insect bite, insect-borne diseases would also be a consideration. I would be interested in evaluating the patient’s vital signs and physical exam for additional clues.

On physical examination, the patient was alert, oriented and afebrile with a blood pressure of 109/73 mmHg, and a heart rate was 66 beats per minute. His blood pressure and pulse were consistent with prior measurements in his medical record. Mucous membranes were dry, and there was no thyromegaly or lymphadenopathy. Heart sounds were normal with no jugular venous distention, carotid bruits or edema noted. Respiratory and abdominal exams were unremarkable. Cranial nerves II through XII were grossly intact. He had 5/5 symmetrical strength in his lower extremities and 5/5 strength in his hands. Abduction of his upper extremities showed 3/5 strength on the right and 4/5 strength on the left. Sensation and deep tendon reflexes were normal, and his skin exam was unremarkable.

Given the patient’s proximal muscle weakness of his upper extremities, I would like to obtain a creatine kinase as this marker can be elevated in inflammatory myopathies.6 Furthermore, with signs of dehydration and the patient’s recent emesis, I would obtain a complete metabolic panel to evaluate for electrolyte abnormalities. A complete blood count with differential would assist in determining if infection is a contributing factor, and the hematocrit would be useful in evaluating for anemia. Given the patient’s dysuria, a urinalysis (UA) could reveal a source of infection. I would also check a thyroid stimulating hormone concentration as hypothyroid myopathy may present with proximal muscle weakness.7 Obtaining an erythrocyte sedimentation rate (ESR) and an antinuclear antibody assay (ANA) may be useful as elevations in these would suggest a rheumatologic myopathy which may also present with muscle weakness.8-10 The creatine kinase, complete metabolic panel, and thyroid stimulating hormone were unremarkable. The complete blood count was notable for a leukocytosis of 14.1 x 103/uL and a left shift with 86% segmented neutrophils and 5% lymphocytes. The patient’s hemoglobin was only slightly below normal at 12.7 g/dL. This concentration was stable compared to his prior evaluations. UA was significant for 1+ leukocyte esterase, 3+ blood, white blood cell count of 20-29 cells per high power field (HPF), 30-49 red blood cells (RBC) per HPF, and a mildly elevated specific gravity of 1.030. The patient’s ESR was increased at 88 mm/hr, and the ANA and autoimmune panel results were pending.

These initial results are consistent with a urinary tract infection and mild dehydration both of which may be associated with weakness particularly in the elderly. I would obtain blood and urine cultures and initiate intravenous fluid hydration. Also, considering the patient’s medication allergies, I would start empiric treatment with nitrofurantoin (Macrobid).

The following day the patient was febrile to 101.9°F, and his leukocytosis increased to 16.3 x 103/uL. His upper extremity weakness was unchanged. He also began complaining of a non-productive cough. Auscultation of the chest did not reveal wheezing, crackles or rhonchi. Blood cultures showed no growth while the urine culture was positive for Proteus mirabilis, sensitive to trimethoprimsulfamethoxazole (Bactrim) and doripenem (Doribax). The ANA and autoimmune panel results were still pending.

Given the patient’s cough with the background of fever and worsening leukocytosis, I would be concerned for pneumonia.

Although intravenous fluids can sometimes result in iatrogenic pulmonary edema that may present with cough, this is unlikely in our patient as he had been receiving normal saline with 20mEq potassium chloride per liter at 75 mL per hour. This rate was a little greater than half of his maintenance fluid requirement based on his weight. I would, however, like to obtain a chest radiograph to evaluate for pulmonary infection. I would also like to change his antibiotics to doripenem (Doribax) and trimethoprim-sulfamethoxazole (Bactrim) to better treat the

Proteus mirabilis infection.

The chest radiograph did not show infiltrates. However, numerous calcified granulomas were identified in both lungs which were stable when compared to an image taken one year earlier. The patient’s fever persisted to 101.7°F, and the leukocytosis increased to 17.2 x 103/uL. The weakness in his upper extremities was unchanged. Furthermore, the autoimmune panel results showed the ANA, rheumatoid factor, anti-centromere antibody, anti-Ro antibodies, anti-La antibodies, anti-topoisomerase I 70 antibodies, anti-histone antibodies, anti-Smith antibodies, anti-ribonucleoprotein antibody, and anti-double-stranded deoxyribonucleic acid antibodies all within normal limits.

The patient’s differential diagnosis at this juncture includes other infectious causes including viral illnesses. Diseases involving the central nervous system would be a consideration given the persistence of his upper extremity proximal muscle weakness. Furthermore, the numerous calcified granulomas on the chest radiograph may also suggest a vasculitis or prior fungal infection. I would consult infectious disease and neurology to assist with our patient’s care.

Infectious disease recommended repeating a UA, blood and urine cultures as well as evaluating for West Nile virus, human immunodeficiency virus (HIV), and Epstein-Barr virus (EBV). Cerebral spinal fluid evaluation with testing for syphilis and fungal infections was also recommended.

Neurology advised obtaining a magnetic resonance image (MRI) of the brain and cervical spine as well as performing electromyography (EMG) to assist in isolating the lesion responsible for our patient’s weakness.

West Nile immunoglobulin G and immunoglobulin M results returned within normal limits, and the HIV result was non-reactive. Monospot test for EBV was negative.

Repeat UA showed RBCs too numerous to count and trace protein as well as granular and hyaline casts. Repeat blood and urine cultures revealed no growth. Cerebral spinal fluid evaluation including a test for syphilis was also unremarkable.

The MRI brain was significant for diffuse atrophy and patchy increased signal in the periventricular white matter compatible with sequel of small vessel disease and aging changes. The MRI of the cervical spine demonstrated multi-level degenerative disc disease without evidence of central canal stenosis or peripheral nerve compression. The EMG findings, however, were consistent with peripheral polyneuropathy. During this time it was also noted that the patient’s creatinine increased from 0.9 mg/dL to 1.8 mg/ dL while the patient had still been receiving intravenous fluids and tolerating a regular diet. Urine electrolytes were obtained and the fractional excretion of sodium was calculated to be 2.2%.

Based on these studies, there is no clear evidence of an infectious cause for our patient’s symptoms, and I would discontinue antibiotics. The neurologic evaluation and imaging

December 2013 JOURNAL MSMA 343

have not revealed pathology in the central nervous system to explain his persistent weakness. The patient’s fractional excretion of sodium is consistent with intrinsic renal disease.

His UA is also suggestive of possible glomerulonephritis.

Given these findings and the patient’s persistent fever, elevated ESR, proximal muscle weakness with an EMG consistent with a peripheral polyneuropathy, and a chest radiograph with calcified granulomas, this would point more firmly toward a vasculitis. In evaluating a vasculitis, I would obtain antimyeloperoxidase antibodies (pANCA) and anti-proteinase 3 antibodies (cANCA) to test for conditions such as ChurgStrauss syndrome, microscopic polyangiitis, and Wegener’s granulomatosis. I would also check complement C3 and C4 deficiency, which may suggest immune complex formation.11 Evaluating cryoglobulins would also be helpful to diagnose mixed essential cryoglobulinemia, which may be seen in a primary or secondary vasculitis.11 I would also test for hepatitis B and C as these infections may be associated with an immune complex mediated vasculitis.11 Given the acute renal insufficiency and glomerulonephritis, a nephrology consultation would be of assistance.

Nephrology recommended the above mentioned tests and a renal biopsy. Empiric treatment with methylprednisolone 500mg IV was also started. Additionally, neurology recommended a muscle biopsy. The patient’s fever and weakness improved with the initiation of steroid therapy. The cryoglobulin screen, hepatitis panel, and C3 and C4 complement concentrations were unremarkable.

The pANCA result was negative at less than 6 U/mL. However, cANCA was markedly elevated at 23 U/mL, which was consistent with a positive result. The left renal biopsy revealed necrotizing and crescentic glomerulonephritis suspicious for ANCA-mediated glomerulonephritis, and the right deltoid muscle biopsy pathology was also consistent with necrotizing vasculitis involving small arteries.

These test results and the patient’s clinical presentation confirmed the diagnosis of Wegener’s granulomatosis. In addition to treatment with steroids, he may also benefit from treatment with cyclophosphamide (Cytoxan). Given the potential side effects of these medications, he would need to be closely monitored.

Our patient was subsequently prescribed cyclophosphamide. Prednisone therapy was continued. His fever resolved and strength improved. His glomerular filtration rate decreased from 38 mL/min/1.73m2 and remained at 16 mL/min/1.73m2. He was subsequently discharged home with close follow up. Several months later, his glomerular filtration rate had improved and stabilized at 36mL/ min/1.73m2. His strength had returned to baseline. He had not experienced any side effects from the cyclophosphamide and prednisone therapy. There was no evidence of other organ involvement, and he had not developed recurrent flares.

344 JOURNAL MSMA December 2013

Wegener’s granulomatosis is an autoimmune disease that causes inflammatory reactions and a necrotizing vasculitis of small and medium sized vessels.3 The classic pathologic triad is inflammation of the small and medium vessels along with necrotizing granulomas of the upper respiratory tract and crescentic glomerulonephritis.3 The cause of Wegener’s granulomatosis is unclear although Staphylococcus aureus infections have been implicated as a possible triggering event in susceptible individuals.12 Given that this patient had presented with symptoms of Wegener’s granulomatosis after being bitten by a buffalo gnat and developing a cellulitis, it is possible that a staphylococcus infection may have triggered the development of Wegener’s granulomatosis. If untreated, the prognosis of patients with Wegener’s granulomatosis is poor with an average lifespan of 1 to 2 years. However, with treatment as many as 90% respond, and long-term remission is achieved by up to 75% of patients.3 In summary, our patient’s presentation initially pointed toward an infectious cause. However, the persistence of his symptoms, despite adequate treatment and the development of new symptoms, suggested a hidden culprit that was ultimately apprehended.

References 1. Saguil A. Evaluation of the patient with muscle weakness. Am Fam Physician. 2005 Apr; 71(7):1327-1334.

2. Albashir S, Olansky L, Sasidhar M. Progressive muscle weakness: more there than meets the eye. Cleve Clin J Med.2011;78:6:385-391.

3. Ramsey M, Owens D. Wegener’s Granulomatosis: A review of the clinical implications, diagnosis and treatment. Laboratory Medicine.

2006;37:2:114-116. Available at: http://labmed.ascpjournals.org/content/ 37/2/114.abstract.

4. Aminoff MJ, Riggs JE. Neurologic manifestations of electrolyte disturbances. Neurology and General Medicine: Expert Consult, 4th ed.

2008;19:347-355.

5. Sathasivam S, Lecky B. Statin induced myopathy. BMJ. 2008;337:a2286.

6. Targoff IN. Laboratory testing in the diagnosis and management of idiopathic inflammatory myopathies. Rheum Dis Clin North Am. 2002;28:859-890.

7. Duyff RF, Van den Bosch J, Laman DM, van Loon BJ, Linssen WH. Neuromuscular findings in thyroid dysfunction: a prospective clinical and electrodiagnostic study. J Neurol Neurosurg Psychiatry.

2000;68(6):750-755.

8. BrasingtonRD Jr, Kahl LE, Ranganathan P, Latinis KM, Velazquez C, Atkinson JP. Immunologic rheumatic disorders. J Allergy ClinImmunol.

2003:111(2 suppl):S593-601.

9. Nadeau SE. Neurologic manifestations of connective tissue disease. Neurol Clin. 2002;20:151-178.

10. Lim KL, Abdul-Wahab R, Lowe J, Powell RJ. Muscle biopsy abnormalities in systemic lupus erythematosus: correlation with clinical and laboratory parameters. Ann Rheum Dis. 1994:53:178-182.

11. Roane DW, GrigerDR, Grant D. An approach to diagnosis and initial management of systemic vasculitis. Am Fam Physician. 1999 Oct 1:60(5):1421-1430.

12. Popa ER, Tervaert JW. The relation between Staphylococcus aureus and Wegener’s granulomatosis: current knowledge and future direction. Intern Med. 2003;42:771-780.

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Are medical journals headed for the endangered species list? Not on your life. Scientific medical publications continue to be a primary source for up-to-date data. Your Journal of the Mississippi State Medical Association is alive and kicking. Immerse yourself. Read the Journal online or in print.

Contact us today for information on cost-efficient advertising opportunities to reach an upscale audience of physicians statewide with our monthly medical magazine.

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346 JOURNAL MSMA December 2013

Save the Date!

May 24-27, 2014 12th Annual CME in the Sand Sandestin Golf and Beach Resort Tentative Agenda Saturday, May 24 9:00 - 4:00 MSMA BOT Meeting 11:00 - 2:00 CME Sessions

Sunday, May 25 9:00 - 1:00 6:30 PM

CME Sessions Welcome Reception with Children’s Activities

Monday, May 26 7:15 8:00 9:00 6:30

- 8:00 -12:30 AM PM

Breakfast with Exhibitors CME Sessions Spouse/Children’s BINGO Family Dinner with Children’s Activities

Tuesday, May 27 7:15 - 8:00 Breakfast with Exhibitors 8:00 -12:30 CME Sessions

For more information visit www.MSMAonline.com December 2013 JOURNAL MSMA 347

• President’s Page • The Horizon

T

here is a lot happening at your MSMA these days. I would like to highlight a few events to remind everyone about the exceptional value you get for your dues dollars. Speaking of dollars, the Council on Budget and Finance meets each year in November to propose a budget for the upcoming year. They examine financial statements and find a way to finance projects identified by the House of Delegates (HOD). Fortunately, we are on sound financial footing. This is largely James A. Rish, MD due to membership, and 2013 set record highs in all member categories.

2013-14 MSMA President Under the leadership of Dr. Helen Turner, the MSMA Foundation Advisory Board is designing a long-term fundraising strategy with assistance from a professional development director, Stacey Ferreri. The second annual Cadaver Course 5K run featured UMMC medical students dressed as zombies who entertained the athletes along the route. Not only does this event help the Foundation’s bottom line, it also emphasizes the importance of healthy living, which is what we as doctors advocate. The Foundation is a 501(C)3 organization through which educational, charitable, and scientific endeavors can be supported. The advisory board is developing additional activities and planned giving opportunities. So, as we enter the holiday season please consider a tax-deductible gift to the MSMA Foundation. No gift is too small.

Work on the upcoming legislative agenda is underway; the Council on Legislation met with representatives of specialty societies and state health agencies in October to identify legislation of interest to all. We will continue to push for smoke-free air, although this continues to be an uphill battle against the powerful casino lobby. We have had much success getting clean air laws passed at the municipal level, and, along with the Clean Air Coalition, we will continue seeking local ordinances to protect against secondhand smoke. You can help by getting your local medical society to sponsor Physicians for SmokeFree Cities and pursue local city and county ordinances that prohibit smoking in all indoor public places. Contact MSMA’s Director of Government Affairs Blake Bell for assistance from the state headquarters: 601-853-6733 or BBell@MSMAonline.com.

MSMA will promote evidenced-based youth concussion or “Return to Play” legislation to protect our young athletes. We will advocate for creation of a POLST (Physician Orders for Life Sustaining Treatment) paradigm program for our state in which the wishes of our patients can be respected consistently at the end of their lives.

As directed by the House of Delegates (HOD), MSMA will initiate an effort to reform the State Board of Mental Health, seeking greater physician involvement and oversight. We will be ready for scope of practice battles as well as any legislation that could compromise the sacred physician-patient relationship. We will need all hands on deck for our legislative efforts. Please take every opportunity possible to discuss these issues with your local legislators. Your influence can have a huge impact in their decision-making process.

At the national level, MSMA itook three resolutions that resulted from our Annual Session to the interim meeting of the American Medical Association. One asked the Joint Commission to reevaluate “Pain as the Fifth Vital Sign” in the setting of our current prescription drug abuse epidemic. There was a resolution to examine reimbursement to Critical Access Hospitals and the impact of that reimbursement policy on other small rural hospitals. The third MSMA resolution promoted changes to the current Rural and Off-Site Rural Training Track Requirements to preserve and encourage more interest in rural residency programs.

These programs have been shown to place a high percentage of graduates in a rural primary care setting.

Other topics discussed at the AMA included the inadequacies of the Two-Midnight Rule and efforts to petition Centers for Medicare and Medicaid Services (CMS) to repeal the August 19 rules regarding Hospital Inpatient Admission Order and Certification as well as reaffirmation of efforts to make the Medicare and Medicaid Recovery Audit Contractor program more

348 JOURNAL MSMA December 2013

fair and balanced. There will be discussions relating to the Sunshine Act and the interpretation of the educational materials exemption. This could inadvertently prevent timely distribution of scientifically reviewed relevant medical information to physicians and their patients, potentially undermining efforts to improve the quality of care provided to our patients.

This is but a small sampling of the work being done on behalf of the physicians of our state and nation. I highly encourage our Mississippi physicians to maintain membership in AMA or join if not already a member. We must continue to put pressure on our policy makers to address our concerns on these and so many other important issues in an effort to continually improve the access and quality of care that our patients deserve. And the AMA’s is the voice that is heard on Capitol Hill.

As access to affordable quality health care and Medicaid expansion loom in the minds of physicians, hospital administrators, and legislators, MSMA sponsored a forum entitled “Solutions for Covering the Uninsured in Mississippi” December 6, 2013, in Ridgeland. This brought a full complement of interested parties to the table and include presentations from the Center for Mississippi Health Policy, the Mississippi Economic Policy Center, and the Heritage Foundation. Legislative leaders are also invited. This event encouraged open and honest discussion in direct response to the HOD resolution calling for the Board of Trustees with assistance from the Council on Medical Service to seek consultation from a diverse array of stakeholders to ascertain the historical and economic truths regarding Medicaid expansion.

The Ad Hoc Committee Studying Governance of the Journal has been appointed and meets in January to review the governance structure of JAMA and propose an oversight policy for the Journal MSMA. The Council on Public Information will soon begin its work creating the annual Mississippi Public Health Report Card. The Report Card highlights our state’s health indices which are always an interesting and sobering reminder of our health standing relative to national norms. This will be presented to legislators January 16, 2014, during the Capitol Screening Initiative (CSI) organized by the Alliance, which will give you an opportunity to speak directly to your legislators and support our legislative agenda. And while we’re talking about the The National Auction Group Capitol, I encourage you to join MMPAC – the Mississippi Medical Political Action Committee. It’s one of the most important #680 — Florence, ALcan support. initiatives we physicians

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• New Members •

BAINS, KARANPREET, Marks; Specialty: Infectious Disease.

ROBINSON, ERIC, Tupelo; Specialty: Internal Medicine.

BALDWIN, BARBRETT A., West Point; Specialty: Obstetrics & Gynecology.

STERLING, KEVIN, Tupelo; Specialty: Internal Medicine.

BLANCHARD, SUSAN A., Long Beach; Specialty: Family Medicine.

SUTHERLAND, JAMES WILLIAM, Jackson; Specialty: Diagnostic Radiology.

BURKETT, BENJAMIN R., Petal; Specialty: Pediatrics.

SWITZER, ERIN, Jackson; Specialty: General Surgery

DAVIS, WILLIAM LEE, Starkville; Specialty: Emergency Medicine.

TAN, JIAHUAI, Tupelo; Specialty: Hematology/Oncology.

MAJID, TANWEER, Laurel; Specialty: General Surgery.

WALTERS, JACKSON L., Starkville; Specialty: Anesthesiology.

MALOZZI, CHRISTOPHER M., Ocean Springs; Specialty: Cardiovascular Disease.

WETZEL, RAUN, Gulfport; Specialty: Diagnostic Radiology.

OLIVER, JOSEPH AUTHUR, Jackson; Specialty: Radiology.

WILLINGHAM, CYNTHIA ANDREA, Greenwood; Specialty: Physical Medicine & Rehabilitation.

RAMIREZ, DANIEL, Jackson; Specialty: Vascular Surgery.

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• Editorial • Physician, Heal Thyself D. Stanley Hartness, MD, Associate Editor

“A physician who treats himself has a fool for a patient.”

S

ir William Osler, revered Canadian physician called one of the icons of modern medicine, said a mouthful when he uttered these insightful words. Yet, despite his timeless admonition, doctors seem to persist in launching their fleets of “ships of fools” all too often.

Mine began taking on water about three weeks ago following a routine annual physical examination. I was gratified and thankful to have received a good report… no glaring abnormalities… “aging like a bottle of fine wine”…decent labs… “could stand to lose a little weight”…uneventful flu vaccine… “see you in a year.”

When I awoke the next morning with significant hoarseness, my mind briefly considered that pesky flu shot as the culprit (like many of my own patients naturally would’ve). Nah…not a chance…killed virus, etc., etc. So, mere coincidence was as good as any other explanation.

Over the next week, my voice took on a definite “Louis Armstrong” quality to the point that attending choir practice and singing with the choir on Sunday morning (two of my favorite activities) were no longer options. Then the cough set in…and I’m talking COUGH to the brink of bronchospasm, vomiting, and near-syncope. Even my wife got a little concerned! But strangely enough I didn’t feel bad, my appetite remained ravenous, there was never any fever, and my sleep was never interrupted by so much as a clearing of the throat. But the second my feet hit the floor every morning, the cough returned with a vengeance. I sucked on so many Ricola natural herb drops that all I could hear were alphorns echoing in my head!

By week three with no evidence of resolution, out of desperation and frustration I prescribed for myself one of those magical Medrol Dosepaks™. Unable to pick it up until late afternoon, I decided to wait until the following morning to begin so I wouldn’t be wired and flushed all night from taking all the first day’s tablets as one dose.

It was at that point that I had an epiphany. Not only had I received my flu shot at the time of my physical, I had also mentioned to my doctor a problem with increasing nocturia (I suppose the fine wine had begun to leak) and was given a prescription for Flomax (tamsulosin), the first dose of which I had taken that same evening. Could it be? I’ve prescribed that same medication to countless patients with symptomatic BPH through the years and don’t recall any similar complaints.

I’d already taken my dose for that evening when I “googled” the side effects. There they were…hoarseness…cough.

It was indeed a bittersweet discovery since I slept that night through with no bathroom visits for the first time in forever! My symptoms improved dramatically within a couple of days of stopping the medication so the decision was a no-brainer…and the facility IS handy.

It’s always been my contention that being a doctor is sort of like being a detective. And when those roles of doctor, detective, and fool intersect, you usually wind up with, as they say, a hot mess! Maybe Sir William was on to something afterall. r

December 2013 JOURNAL MSMA 351

• Letters • Dear Dr. Lampton, I congratulate you and Dr. deShazo on the two excellent articles in the July 2013 JMSMA describing the integration of the medical profession in Mississippi.

The articles were dramatic. Stylistically, they achieved a remarkable effect. The pioneers and proponents of integration were depicted as individuals. Their opponents were relegated to an anonymous, bigoted crowd now bypassed by history, as they deserve to be.

Sadly, one quote that I remembered while reading the articles is William Faulkner’s observation, “The past is not dead; it is not even past.” A great part of the political dynamic in this state is descended from the bitter opposition to integration. Now, the same irrational collateral issues, specious constitutional arguments, and evasion of critical issues are being applied to the opportunity to expand Medicaid coverage under the provision of the Patient Protection and Affordable Care Act. Medicaid expansion in Mississippi would occur under established federal law ruled constitutional by the United States Supreme Court. Federal tax money would underwrite this expansion which would bring some measure of health insurance to over 100,000 citizens. The effects of this expansion would extend to hospitals and providers by reimbursing some measure of services.

This expansion would undoubtedly critically improve the lives of Mississippians who live with the worst health statistics in this country, a level of illness and misery that includes heartbreaking rates of maternal and infant morbidity.

Analogous to civil rights legislation, this federal expansion addresses an enormous problem not soluble on a state level.

Does the Journal or the MSMA have a position on Medicaid expansion? Thirty or forty years from now, this journal may publish articles describing the efforts to extend health care coverage to the poorest citizens of the poorest state of this country. Will the Journal and the MSMA have a role in those articles?

Sincerely, William C. Lineaweaver, MD, Jackson Dear Dr. Lineaweaver, Thank you for your kind and thoughtful comments. The Journal historically has not taken editorial positions as a publication which differ from our MSMA, although its editors and our members frequently express in this open forum opinions counter to established MSMA policy.

You are not alone among our membership in seeing our leadership as AWOL on this important, yet divisive, issue, as was evident at our recent Annual Session. Resolutions and reference committee discussions there made clear that our House of Delegates seeks more clarity from the board regarding this issue, as well as more board leadership on the issue, based on the feelings of our membership. However, this is an evolving and divisive issue not only for our membership but also for our state and nation.

Our own MSMA’s current position on Medicaid expansion is subtle and complicated, at present, largely due to the complicated political dynamic within the state. Fear of undercutting MSMA’s significant political influence at the legislature, which is needed on other critical medical issues, has kept our leadership from stepping out in the forefront of this controversial fray. When asked to provide MSMA’s position, staff provided the following talking points for our board leadership: “Medicaid is a complex issue. The Mississippi State Medical Association has long supported the Medicaid program – it is the safety net for thousands of Mississippians who have no other means. In fact, some 90% of MSMA physicians accept Medicaid, and we agree that access should not be a barrier. Physicians do not envy the lawmakers who would have to cut important programs or raise taxes to find $300 million of new money to meet the federal match. We certainly support expanded access to medical care for those in need; however, we just as certainly want to protect important programs and keep taxes affordable. MSMA will work with the legislature and the Division of Medicaid to provide the best possible care to all they deem eligible.” This apparently is as close to a “position” our MSMA has taken of late on the issue.

I do agree, strongly so, that our JMSMA should be playing a role in this debate. It is our moral responsibility as physicians to be leaders for our state and our patients on medical issues. The attempts to survey Mississippi physicians reveal us to be very conflicted over this issue. Your Editors strongly encourage our readers and membership to utilize our JMSMA as an open forum for discussion of the issue of Medicaid expansion. Our MSMA has been asked by our membership to assume its proper role as the leaders of medicine in the state. What is best for medicine and our patients? Tell us! Our association’s position is critical, and your letters to the editor or contributed editorials can help shape MSMA’s evolving leadership on this issue. Please send your opinions to me at lukelampton@cableone.net cc. to kevers@msmaonline.com or mail to me at JMSMA EDITOR, P. O. Box 2548, Ridgeland, MS 39158-2548.

Lucius “Luke” Lampton, MD, Magnolia JMSMA Editor

352 JOURNAL MSMA December 2013

• Una Voce •

A

The Interloper

t 2:35 PM last Thursday, without any hint of warning, our clinic’s entire Electronic Health Record (EHR) system crashed. In the middle of writing prescriptions to send electro-magically to my patient’s mail order pharmacy, the screen faded to a sickly gray with that whirling blue tornado in the center which always signals impending trouble. Front office and nursing staff as well were all paralyzed mid-stride and sat helplessly watching the icon sit and spin. We shut our computers down, then with crossed fingers tried to reboot. This time, absolutely nothing happened. There were fresh patients in three rooms, triaged and waiting for me to see them. All their vital signs and complaints had been logged in and existed nowhere else except cyberspace. There was no hard copy appointment list or sign-in sheet of patient names to refer to for clues. The nurses, one of whom had only been working in this practice for two Dwalia S. South, MD weeks, could not recall the names of the patients behind the exam room doors, or which of them had the next appointment. I felt like a contestant on Monty Hall’s “Let’s Make A Deal” show… do I choose door number one, two, or three?

Nevertheless, computer or no, the show must go on as they say, for there are other people in the waiting room to see. These folks were totally unaware of our computer meltdown; the clinic lights had not even flickered.

I went to my desk drawer and retrieved a fossilized prescription pad, a Viagra ball point that required some priming, and some note paper so old that it actually had the name of a pharmaceutical company emblazoned on each page. With tools now in hand, I swallowed hard then charged into exam room #1.

After a year of going through the agony of withdrawal from my dependency on paper charts, I entered the patient’s room without balancing the unwieldy laptop computer in hand. Suddenly, I felt almost naked. No, a perhaps better word is ‘released’… freed from the weight of the techno-albatross around my neck. Instead of fumbling self-consciously on the computer with my attentions focused on getting the right chart up onscreen, my first action was to greet, shake hands, and actually make eye contact with the patient. I explained our situation and apologized for not having all her information at hand. She was a familiar patient that I have seen for many years but usually only at annual intervals. When someone only goes to their doctor once a year, the office visit is a pretty big deal for them. You want and need to get it right.

As the visit progressed it was even more evident to me that without the omnipresent computer between us, there was a renewed sense of the sacred intimacy between doctor and patient. There was no Interloper, no third party in the room, who commanded more of my attention than did the ailing person during our limited time together. My hands were busy performing an actual physical examination on her, not pointing and clicking, and ‘sloppy and pasting’ mindlessly in the name of meaningless use. Oops, I meant to say ‘meaningful use.’

Then we came to the close of the visit, the prescription writing. Bless this patient’s heart; she actually brought a list of the meds she needed refilled. There was something so sweetly nostalgic about writing them out longhand while talking about each medication with the patient, something I had been missing as the information traversed the pathways from my brain, down my arm, into my hand, my pen, onto paper, then from my hand back to the patient. I quickly realized that putting the black ink on the white paper had a calming and satisfying effect on me somehow. I reveled in the joy of my nostalgia.

Just as I was about to wrap things up with her, I realized with the embarrassment one feels when having a senior moment, that I could not complete her prescriptions. For the life of me, I couldn’t remember Evelyn’s last name. I made some excuse and walked back to the nurse’s station to ask them for help.

“Y’all, what is the last name of that patient in room one? I can’t finish these prescriptions without knowing, and I’m too embarrassed to ask her. I’ve treated this woman on and off for years, and I just went totally blank!” But, they were clueless.

Then, I did the old memory jogging trick I have relied on since post-menopausal senility began to take its toll…by going through the alphabet for clues….Evelyn A___, Evelyn B___, Evelyn C___ and so on. I then found her in my mind’s ‘J’ file…

Evelyn Johnson. Whew.

December 2013 JOURNAL MSMA 353

The rest of the afternoon was much the same. Moments of satisfaction coupled with the terror of not having the report of a chest x-ray that both the patient and I were worried about. Moments of vexation when a patient asked for a new prescription for “some more of that cream you gave me about three years ago, and my blue blood pressure pills, and my white sugar pills. You should know what they are, Doc, you’re the one who gave ‘em to me.” Fulfilling these requests required a phone call to my local pharmacist friend, Bobby Mays, who is just a couple of years older than I am. Bobby loves the computer’s intrusive influence on modern medicine almost as much as I do. Medication lists were quickly faxed over to us, and we then proceeded.

One of the nurses was able to locate a blank patient encounter form that we copied and then used to document carefully by hand the office visits for the remainder of the afternoon. They provided a template for personalized and vital information of the day’s interaction between physician and patient.

Needless to say we survived the rest of the day on a wing and a prayer. It seemed that Big Brother was truly no longer watching over my interactions with patients. I relished that afternoon of freedom from the stinking gray Albatross which I now must bear daily. When I left the clinic that day I felt a bit smug that I had not been outdone by “the system.”

The next morning we were back on-line. I had simple-mindedly and mistakenly hoped that my epistles about the prior day’s office visits could be scanned into the EHR as had been the thousands of my paper charts last year. I still painfully recall the heartsick pang that day in May when a big hulking truck came and hauled off giant boxes of all our patient records to some nether land be scanned and then later incinerated.

However, this was not to be. No, on the following day in addition to the regularly scheduled patient load, we were told that we must reconfigure all of the prior afternoon’s handwritten chart pages into the digital format. This process took longer than actually seeing the patient had the day before. A few concise lines of information had to be transformed into four typewritten pages of useless confabulated jargon and mind-bending double-talk.

When I ruminate about that day in May, I can still feel the gut wrench as if watching my beloved pet be carried away to be euthanized and cremated. The physical library of my experiences with my patients for the past 25 years was about to be summarily destroyed. I grieved for this loss the day my medical music died. Still do.

—Dwalia S. South, MD, Ripley [Names were changed to prevent any possible penalties for HIPAA Privacy Rule Violations] —Ed.

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• Poetry and Medicine • [This month, we print a poem by Dr. William C. Lineaweaver, MD, Medical Director of the JMS Burn and Reconstruction Center, located at Central Mississsippi Medical Center in Jackson. In the spring of 1975, all in one trip, he was interviewing for residency, delivering his first national paper, taking National Boards, and breaking up painfully with a lover. Dr. Lineaweaver writes, “Looking back at that time, the memory of the old musician playing his saxophone on the crowded, jostling subway is a dominant image, like a church window glowing over a dark interior. Are memories like this one a kind of healing, a sign of some sort of interior consolation? Did the pressure of that time work through some alchemy of displacement to make this memory so vivid?”

Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@ cableone.net.] —Ed.

Some Music in Boston (Scene from an internship interview trip, 1975) Old black jazzman Got on the subway At Park Street dada da, And dropped his case Onto two white laps Took out a golden saxophone And began to play.

Watch out, don’t push, He’s high, old man: And stop and start, Open and close, The old man jammed With the subway.

—William C. Lineaweaver, MD Jackson

December 2013 JOURNAL MSMA 355

• Index • Volume LIV

January - December 2013

Subject Index

The letters used to explain in which department the matter indexed appears are as follows: “CPS” for Clinical Problem Solving”; “E,” Editorial; “L,” Letters to the Editor; “PB,” Physician’s Bookshelf; “PM,” Poetry and Medicine; “PP,” President’s Page; “S,” Special Article; “UV” Una Voce; the author’s name follows the entry in brackets. Matters pertaining to related organizations are indexed under the medical organization.

164 Years Later, A Case Report: U. S. Grant, Eye Pain and Swelling in Mexico 1848 [R Collins, J Marszalek], 11

-A-

A Medical Giant Remembered: Dr. Verner Holmes’s Example Continues to Inspire New IHL Physician Member [B Dye III], 108-S Adult Non-Cardiac ECMO for the Treatment of ARDS – The Mississippi Experience [L Frei], 185 Alliance Spotlight Susan W. Rish, 246 AMA The AMA Rolling up its Sleeves [J Lazarus], 143 The Physician Payment Sunshine Act is Here – Are you Ready?

[J Lazarus], 177 An Interview with James A. Rish, MD, 2013-2014 MSMA President [K Evers], 234-S Asclepiad Paul Harold Moore, MD, 220 Thomas Steve Parvin, MD [M Pomphrey], 92

-B-

Bedside Ultrasound Detection of Long Bone Fractures [R Patel, B Tollefson], 159 369 JOURNAL MSMA December 2013

-C-

Caution in Interpretation of the Tumor Marker CA 19.9 in Patients with Obstructive Jaundice: Illustrative Case Reports [T Helling], 96 Clinical Problem-Solving

[presented and edited by the Dept. of Family Medicine, UMMC] Aloha, I’m Back [J Vanderloo], 314-CPS Competitive EDge or Over the Cliff? [C Boston], 224-CPS I Feel like I Had a Stroke in My Throat! [B Smith], 284-CPS Mystery Disease or Wrong Diagnosis? [B Fernando], 124-CPS Snake, Rattle, and Roll [ J Wigginton], 64-CPS Coagulase Positive Staphylococcal Infection: A Major Cause of Eczema Exacerbations [J Chapman, SE Bauman, R Daniel III], 101 Cover Around the Bend [W Sorey], June “Cathedral Ceiling” [R Brahan], March “China Grove Graveyard” [S Anderson], May “Crossroads of the Confederacy” [M Pomphrey, Jr.], February “Cypress Spring” [S Hartness], April

Historical Fuel Prices in Mississippi [J Bumgardner], October Holly in Snow [M Pomphrey], December James A. Rish, M.D. - Presidential Portrait, August “MSMA Photomontage” [W Pontius], July Patient Pipe Progress [T Cobb], November Sunflower by Dr. Ron Cannon of Jackson [R Cannon], September Winterscape [S Chiarito], January

-E-

Editorials “Bottomline-Itis”: Race for the Cure...Please! [S Hartness], 203-E Food Stamps, Public Health, Politics, a New Mississippi Social Determinant of Health, and the MMPAC Budget [R deShazo], 296-E How Doctors Die [K Murray], 67-E Out With the Old...In With the Old, [S Hartness], 24-E In Support of POLST: Better Endof-Life Care for Mississippi [A Barthelemy], 71-E Maples’ Musings (or Musings of a Madman) We Need More Doctors. Really? [M Maples], 204-E Physician, Heal Thyself [S Hartness], 351-E “The Second Rule” [B Temple, S Conteh], 25-E

Emergency Department Triage of Low Acuity Patients to a Federally Qualified Health Center [N Nguyen, J Moore, N McIntosh, M Jones, J Zimmerman, R Summers], 280

-F-

Friends of Medicine Can Make a Difference: Organize a MiniInternship Program [K Evers], 42-S From the Editor [L Lampton], 2, 34, A Rocky Rollout, 278 Functional HIV Cure Achieved in Mississippi, 94 Inviting the Uninvited, 182 Our Democratic MSMA, 154 Punishment of the Gods, 334 Remember, You too are Mortal, 62 The Dog Days of Summer, and a New President, 222 The Katrina Cocktail, 122 The Making of Sausages and Laws, 250 To Live as Men and Women of Good Will, 306

-I-

Images in Mississippi Medicine Dr. Pink Conn of Jayess, Mississippi (1870-1941) [L Lampton], 245 Dr. William Lattimore’s HandWoven Frock Coat [L Lampton], 31 Oswald Garrison Smith, MD (1915-2002), the first AfricanAmerican member of MSMA [L Lampton], 214 Immediate Nerve Grafts to a Median Nerve Injury in a 7-Year-Old Boy: 5-Year Follow-Up [W Lineaweaver], 252 IQH IQH Board Officers Elected, 174 In Memoriam, 327

-J-

Just Off the Press - Info You Want

to Know About Group A Streptococcal Pharyngitis Guidelines [R Ogletree, Jr.], 27 Digoxin Use in Atrial Fibrillation [R Ogletree Jr.], 258 Omega-3 Fatty Acids and Cardiovascular Risk [L Kruse, R Ogletree Jr.], 156 Just what the doctor ordered [S Demetropoulos] Caribbean Roast Pork, 50 Easy Pasta Dish, 168 Grilled Lamb Chops, 202 Minted Orzo with Cucumber and Feta Cheese, 138 Peach Salsa, 106 Rosemary Sweet Potatoes, 20 Spaghetti Squash, 78

-L-

Legal Ease New Laws Expedite Physician Practices, Save Money [C Reeves], 142 Letters “Bedside Ultrasound...” Author Response [B Tollefson], 231-L Obamacare and Bedside Ultrasound [M Pomphrey], 230-L Position on Medicaid Expansion [W Lineaweaver] Editor’s Response [L Lampton], 352-L Terminal Care [R Brock], 174-L -MMississippi Rural Physicians Scholarship Program Mississippi’s Rural Physicians Scholarship Program: Growing our Own Physicians [J Guice], 22 MSDH Health Department Announces New District Health Officer for Public Health District VII, 30

Increases in Prescription Drug Abuse: What Can Mississippi Providers Do? [J Fleming, T Dobbs, P Byers], 132 Mississippi Reportable Disease Statistics April 2013, 158 Mississippi Reportable Disease Statistics August 2013, 300 Mississippi Reportable Disease Statistics December 2012, 54 Mississippi Reportable Disease Statistics February 2013, 104 Mississippi Reportable Disease Statistics January 2013, 70 Mississippi Reportable Disease Statistics June 2013, 226 Mississippi Reportable Disease Statistics March 2013, 131 Mississippi Reportable Disease Statistics May 2013, 188 Mississippi Reportable Disease

Statistics November 2012, 29 Mississippi Reportable Disease Statistics September 2013, 320 MSMA 145th Annual Session Recap, 269 Mississippi Delegation Seeks Comments on AMA Resolutions, 295 Official Address of the 145th President, Steven L. Demetropoulos, MD, 241

-N-

New Members, 321, 350

-O-

Office of Physician Workforce OMPW Adds Hope for Mississippi’s Healthcare Future [J Mitchell], 175 Opening the Doors of the Great Republic: Sex, Race, and Organized Medicine in Mississippi [L Lampton], 205-S Opioids for Chronic Noncancer Pain: Are They Safe and Effective? [S Hambleton], 4 December 2013 JOURNAL MSMA 370

-P-

Pelvic Synovial Sarcoma of Unknown Primary Origin: Case Report and Literature Review [C Theriot, K Hughes, J Mitchell, B Patterson], 308 Physician’s Bookshelf How the unsolved murder of a doctor, a secret laboratory in New Orleans, and cancercausing monkey viruses are linked to Lee Harvey Oswald, the JFK assassination, and emerging global epidemics: A book review of Dr. Mary’s Monkey (by Edward T. Haslam) [A Kressel], 55-PB Report from the UMMC Internal Medicine Book Club – Death Foretold: Prophecy and Prognosis in Medical Care (by Nicholas A. Christakis) [J Graham], 301-PB The Gift of Pain: Why We Hurt & What We Can Do About It (By Dr. Paul Brand and Philip Yancey) [J Graham], 21-PB Wiggle Room (by Darden North, MD) [W Jones Jr.], 325-PB Poetry and Medicine Call [B Morris], 323-PM Doctor’s Desk [T Browne], 229-PM On Reading to Children [J McEachin], 80-PM Some Music in Boston [W Lineaweaver], 355-PM President’s Page A Balanced Life [S Demetropoulos], 77-PP Inaugural Address of the 146th President, James A. Rish, MD [J Rish], 262-PP POLST [J Rish], 293-PP The Annual Session [S Demetropoulos], 167-PP The Great Epidemic [S Demetropoulos], 137-PP The Horizon [J Rish], 348-PP The Medicaid Conundrum [S Demetropoulos], 105-PP 371 JOURNAL MSMA December 2013

The Power of Saying Thank You [S Demetropoulos], 201-PP When Do Your Rights End and My Rights Begin? [S Demetropoulos], 19-PP Why is your Membership Important? [S Demetropoulos], 49-PP Public Health in Mississippi Report Card 2013, 15

-R-

Real Men Don’t Need Anesthesia: Dr. Porter and the Pascagoula Connection [C Wiggins], 227-S Recommendations after NonLocalizing Sestamibi and Ultrasound Scans in Primary Hyperparathyroid Disease: Order More Scans or Explore Surgically? [N Hoda, P Phillips, N Ahmed], 36

-S-

Screening for Prostatic Disease [S Gupta, C Pound], 255 Series: Concepts in End-of-Life Care - Do Not Resuscitate (DNR) [L Norris, S Douglas], 169 Series: Concepts in End-of-Life Care - Palliative Care Medicine [V Pilkington, M Meeks, S Douglas, G Windham], 81 Significance of Elevated Cardiac Troponin I in Patients with Diabetic Ketoacidosis [A Abdo, S Geraci], 127 Survey of Beliefs of UMMC FirstYear Medical Students about Evolution and its Relevance to Medicine [A Penman], 336 Subject/Author Index Vol. 54, 369

-T-

The Educational Struggles of African-American Physicians in Mississippi: Finding a Path Toward Reconciliation [R deShazo, L Lampton], 189-S Top 10 Facts You Should Know

About Adult Tuberculosis [D Pepper, R Webb, M Holcombe], 318 About Seratonin Syndrome [R Reeves, M Ladner, P Smith], 286 About Severe Sepsis and Septic Shock [D Pepper, R Bhagat, F Bhaijee, J Spurzem], 163 Prescription Drug Abuse: When the Treatment Becomes the Problem [A Kemp, M Clark, J Sherman, J Dahl-Smith], 134 Traumatic Vulvar Hematoma Masquerading as a Bartholin Duct Cyst in a Postmenopausal Woman [J Perkins, P Morris], 8

-U-

UMC SOM Admissions Committee Chair Summarizes UMMC Medical School Class of 2016: Diversity and Excellence Predominate [S Case], 116 Match Day 2013 [G Pettus], 113 UMMC Breaks Ground on New Teaching Building - $63M building to provide space for larger medical class sizes, 118 UMMC Former Asylum Patients’ Resting Place Unearthed on Medical Center Campus, State Institutions to Document, Rebury Decades-Old Remains [G Pettus], 144 Researchers Describe First ‘Functional HIV Cure’ in an Infant, 111 The Anniversary of TelEmergency [R Summers, K Henderson, K Isom, R Galli], 340 Una Voce Disease State? [D South], 216-UV Going the Back Way...a Southernism [D South], 57-UV The Interloper [D South], 353-UV

Uncommon Thread American Bacchus [RS Anderson], 32

Volume LIV

January - December 2013

Author Index

The letters used to explain in which department the author’s matter indexed appears are as follows:“CPS,” Clinical Problem Solving”; “E,” Editorial; “H,” Hardy Abstract; “I,” Images in Mississippi Medicine; “L,” Letters to the Editor; “PB,” Physician’s Bookshelf; “PM,” Poetry and Medicine; “PP,” President’s Page; “S,” Special Article; “UV,” Una Voce.

A

Abdo, Ashraf S., 127 Ahmed, Naveed, 36 Anderson, Russell Scott, 32, May cover

B

Barthelemy, Andre, 71-E Bauman, S.E., 101 Bhagat, Rajesh, 163 Bhaijee, Feriyl, 163 Boston, Christopher D., 224-CPS Brahan, Robert B., March cover Brock, Ralph L., 174-L Browne, Thomas, 229-PM Bumgardner, Joe R., October cover Byers, Paul, 132

C

Cannon, Ron, September cover Case, Steven T., 116 Chapman, John C., 101 Chen, Anthony Y., 342 Chiarito, Susan A., January cover Clark, Molly, 134 Cobb, Tommy J., November cover Collins, Robert K., 11 Conteh, Sulaimin, 25-E

D

Dahl-Smith, Julie, 134 Daniel, C. Ralph, III, 101 Demetropoulos, Steven L., 19-PP, 20, 49-PP, 50, 77-PP, 78, 105PP, 106, 137-PP, 138, 167-PP, 168, 201-PP, 202, 241 deShazo, Richard, 134, 189-S, 296-E Dobbs, Thomas, 132

Douglas, Sharon P., 81, 169 Dye, Bradford J., III, 108-S

E

Evers, Karen A., 42-S, 234-S, 246A

F

Fernando, Benjamin A., 124-CPS Fleming, Joshua W., 132 Frei, Lonnie W., 185

J

Jones, Michael L., 280 Jones, Walter R., Jr., 325-PB

K

Kemp, Ann, 134 Kressel, Adam, 55-PB Kruse, Leslie G., 156

L

Galli, Robert L., 340 Geraci, Stephen A., 127 Graham, Jacob, 21-PB, 301-PB Guice, Janie, 22 Gupta, Shubham, 255

Ladner, Mark E., 286 Lampton, Lucius M. “Luke,” 2, 31, 34, 62, 94, 122, 154, 182, 189-S, 205-S, 214, 222, 245, 250, 278, 306, 334, 352-L Lazarus, Jeremy A., 143, 177 Lineaweaver, William, 252, 352-L, 355-PM

H

M

G

Hambleton, Scott, 4 Hartness, D. Stanley, 24-E, April cover, 203-E, 351-E Helling, Thomas S., 96 Henderson, Kristi, 340 Hoda, Nicholas E., 36 Holcombe, Michael, 318 Hughes, Karen, 308

I

Isom, Kristen C., 340

McEachin, John D., 80-PM McIntosh, Nathan P., 280 Maples, Michael D., 204-E Marszalek, John F., 11 Meeks, W. Mark, 81 Mitchell, John, 175, 308 Moore, Justin B., 280 Morris, Benjamin A., 323-PM Morris, Paula F., 8 Murray, Ken, 67-E Myers, C. Ann, 148-E

N

Nguyen, Nghia D., 280 Norris, Lindsey T., 169 December 2013 JOURNAL MSMA 372

O

R

Reeves, J. Conner, 142 Reeves, Roy R., 286 Rish, James A., 262-PP, 293-PP, 348-PP

Ogletree, Richard L., Jr., 27, 156, 258

P

Temple, Brian, 25-E Theriot, Christie, 308 Tollefson, Brian J., 159, 231-L

V

S

Patel, Rachana M., 159 Patterson, Brandy, 308 Penman, Alan D., 336 Pepper, Dominique J., 163, 318, Perkins, James D., 8 Pettus, Gary, 113, 144 Phillips, Paul, 36 Pilkington, Vicky D., 81 Pomphrey, Martin M., Jr., February cover, 92, 230-L, December cover Pontius, William Frederic “Bill,” July cover Pound, Charles R., 255

T

Sherman, Justin, 134 Smith, P. Brent, 284-CPS Smith, Percy, 286 Sorey, William “Will” H., June cover South, Dwalia S, 57-UV, 216-UV, 253-UV Spurzem, John, 163 Summers, Richard L., 280, 340

Vanderloo, John P.F.H., 314-CPS

W

Webb, Risa M., 318 Wiggins, Chris E., 227-S Wigginton, Jeremy B., 64-CPS Windham, B. Gwen, 81

Z

Zimmerman, Jason, 280

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