VOL. LIX • NO. 2 • 2018 by Journal MSMA

anytime, anywhere:

download issuu to read the Journal MSMA wherever you go.

VOL. LIX • NO. 2 • FEBRUARY 2018

EDITOR Lucius M. Lampton, MD

THE ASSOCIATION President William M. Grantham, MD

ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD

President-Elect Michael Mansour, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer W. Mark Horne, MD

PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD and the Editors

Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Executive Director Charmain Kanosky

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. Jill Gordon, MSMA Director of Marketing. Ph. 601-853-6733, ext. 324, Email: JGordon@MSMAonline.com 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 © 2018 Mississippi State Medical Association.

SCIENCE IN MEDICINE Top 10 Facts You Should Know about Sleep Terrors in Children Luis A. Hernandez, MD; Oscar M. Rodriguez, MD Top 10 Facts You Should Know About Diabetic Eye Disease Corey Breland Parish, MD; Kimberly W. Crowder, MD How Clinicians Can Better Interface with Surgical Pathologists for Better Patient Care Varsha Manucha, MD; Veena Shenoy, MD; Mirna Vargas; Israh Akhtar, MD; Divya Shenoy (M3); Jack Lewin, MD Racial Differences for Accelerated Partial Breast Irradiation (APBI) for the Treatment of Early Stage Breast Cancer Veeresh Michael, PhD; Jessica H. Bailey, PhD; Lei Zhang, PhD; Ellen Jones, PhD DEPARTMENTS From the Editor – Stand There, Don’t Just Do Something Lucius M. Lampton, MD, Editor President’s Page – Thoughts on Leadership William M. Grantham, MD Images in Mississippi Medicine – Foster General Hospital Poetry and Medicine – A Deadly Bug Ron Cannon, MD LEADERSHIP Are You an Introvert? It Might Mean You’re a Good Leader Hannah O. Brown Physician Leadership Skills – Why Doctors Make Poor Leaders and What You Can Do About It Dike Drummond, MD MSMA Physician Leadership Academy – Growing Leaders in Medicine Physician Leadership Academy Profiles The Higher You Go: A Physician Leader Shares Lessons Learned David J. Norris, MD The Leader in my Mirror… Charles Sampson Leading Amidst Generational Change Donna Ritchey, APR The Value of Leadership Training: Leadership Academy Students' Perspectives RELATED ORGANIZATIONS The Physicians Foundation American Medical Association Mississippi State Department of Health (MSDH)

76 78

74 116 123 124

90 92 96 107 108 110

114

117 121 122

ABOUT THE COVER

Official Publication

MSMA • Since 1959

“POINTING THE WAY”– Our cover photo seems to portray perfectly this issue’s focus on “Leadership.” On a recent visit to Chicago, home of the AMA, Dr. Stanley Hartness was captivated by the 25-foot-tall bronze Lincoln sculpture called “Return Visit.” Lincoln stands next to another large-scale figure representing a common man who holds a copy of the Gettysburg Address “as if Lincoln is explaining the tenets of the address and what relevancy those words would have today,” said Paula Stoeke, curator at Seward Johnson Atelier in California. —Ed.

JOURNAL MSMA

F R O M

T H E

E D I T O R

Stand There, Don't Just Do Something

he art and practice of medicine entail examination, diagnosis, therapy, and prevention. Thought plus action seem the essential components of what a physician does. Often our days are a series of patient encounters with resulting medical decisions, which almost always include a plan of action. Modern technology has provided physicians an armamentarium of weapons to examine patients and Lucius M. Lampton, MD battle disease. We docs are sometimes Editor quick to order unnecessary diagnostic tests or prescribe excessive drugs or treatments simply because we can and they are available. However, should a physician always take an action with a patient? Sometimes observation and a follow-up exam are the best routes. Restraint and patience surely need more emphasis in our practices. A maxim of one of my physician mentors was “Stand there, don’t just do something.” This insightful phrase encourages reflection and restraint in our efforts to heal. Especially in our age of over-prescribing, over-testing, and rising health care costs, physicians should remind ourselves that

often the best care for our patient may be no action, no test, and no prescription at all but rather reassurance, rest, and follow-up. One of the more important books in Mississippi medical history is Dr. William H. Holcombe’s “Yellow Fever and its Homeopathic Treatment,” published in 1856. This Natchez physician took over the Mississippi State Hospital in 1854 and ran it under homeopathic management. He wrote: “During that time no bleeding, purgatives, calomel, blisters or other allopathic measures have been used within its walls.” Holcombe’s statistics with the treatment of yellow fever, cholera, pneumonia, and all diseases revealed better outcome with less aggressive treatment. Although the “like cures like” homeopathic approach was not the reason, the restraint of Holcombe with aggressive therapeutics, which he called “coarse allopathic drugging,” did provide superior results. The homeopaths, despite their bizarre medical philosophy, asserted the most relevant critique of nineteenth century medicine’s propensity to overtreat to the point of patient harm. Action seems to be the focus of much of our work. However, in the practice of our very difficult art, physicians need to remember that to "stand there" and take no action is often the best action of all. Q Contact me at lukelampton@cableone.net.

JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD

EMERGENCY MEDICINE Philip Levin, MD

MEDICAL STUDENT John F. G. Bobo, M2

ALLERGY/IMMUNOLOGY Stephen B. LeBlanc, MD Patricia H. Stewart, MD

EPIDEMIOLOGY/PUBLIC HEALTH Mary Margaret Currier, MD, MPH Thomas E. Dobbs, MD, MPH

NEPHROLOGY Jorge Castaneda, MD Harvey A. Gersh, MD

ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD J. Edward Hill, MD Ben Earl Kitchens, MD James J. Withers, MD

OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Darden H. North, MD

CARDIOVASCULAR DISEASE Cameron Guild, MD Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD Nisha S. Withane, MD, Fellow CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

74 VOL. 59 • NO. 2 • 2018

GENERAL SURGERY Andrew C. Mallette, MD HEMATOLOGY Vincent E Herrin, MD INTERNAL MEDICINE Daniel P. Edney, MD W. Mark Horne, MD Daniel W. Jones, MD Brett C. Lampton, MD Jimmy Lee Stewart, Jr., MD

ORTHOPEDIC SURGERY Chris E. Wiggins, MD OTOLARYNGOLOGY Bradford J. Dye, III, MD PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD PEDIATRICS Michael Artigues, MD Owen B. Evans, MD

PLASTIC SURGERY William C. Lineaweaver, MD Chair, Journal Editorial Advisory Board PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RHEUMATOLOGY Shweta Kishore, MD C. Ann Myers, MD UROLOGY W. Lamar Weems, MD

EVEN THE PROS NEED ADVICE AND SUPPORT In golf, a caddy is the person who carries a player's bag and clubs, gives insightful advice, and provides support. A good caddy is aware of the challenges and obstacles of the golf course being played, along with the best strategy in playing it. When selecting a professional liability partner, you want a carrier who has the experience and the fortitude necessary to help guide you. Let MACM walk beside you and carry your bag.

www.macm.net | 800-325-4172

JOURNAL MSMA

S C I E N C E

I N

M E D I C I N E

Top 10 Facts You Should Know About Sleep Terrors in Children LUIS A. HERNANDEZ, MD; OSCAR M. RODRIGUEZ, MD Introduction Parasomnias are characterized by an arousal from sleep to a state between sleep and wakefulness with unwanted abnormal motor, behavioral, or sensory experiences. They can be divided into arousals from non-rem (NREM) sleep, rapid-eye-movement (REM) sleep and other parasomnias.1 Sleep terrors, also known as “night terrors”, are classified in the NREM sleep group. Understanding the features of this parasomnia is useful in practice, as it can be a stressful experience for parents and disruptive to the household. Sleep terrors present at a young age. The reported prevalence is variable and ranges from 1%17% in children down to 2% after 15 years of age. The most common age of presentation is between 4 to 12 years of age but can present as early as 1.5 years.1, 2, 3

Genetic factors play an important role in parasomnias. Family history increases the likelihood of sleep terrors, and there is an increased association between monozygotic twins.3, 4

2 3

A component of sympathetic activation is what characterizes a sleep terror. Screaming is a strong component associated with sitting up, tachycardia, tachypnea, sweating, flushed skin, tremulousness, confusion, vocalizations, mydriasis, and “glassy-eyed look”. 1, 5 A less violent form of parasomnia, known as confusional arousal, can present with vocalization or crying without the sympathetic activation or screaming.1, 6 Sleep terrors do not usually have an impact. They are benign and a sign of a still maturing brain. 7 A single episode of sleep terror can last up to 40 minutes, but it usually doesn’t last longer than a few minutes. After the episode, children can go back quietly to sleep without having any memory of the event the next morning.5, 6

Sleep terrors are not nightmares. Sleep terrors usually occur during the 1st half of the night during deep sleep, while nightmares tend to occur during the 2nd half of the night when REM sleep is more prevalent. Unlike sleep terrors, nightmares can be recalled and can be associated with underlying anxiety or post-traumatic stress disorder.1, 8

76 VOL. 59 • NO. 2 • 2018

Sleep terrors can be caused by different precipitating factors that alter sleep. These factors include insufficient sleep, inadequate sleep hygiene, or disorders causing partial awakenings like fever, obstructive sleep apnea (OSA), periodic limb movement disorder, gastroesophageal reflux disease, forced awakenings, and certain medications.9, 10

A sleep study is not necessary for the diagnosis of sleep terrors. A history with classic symptoms can make the diagnosis. A sleep study for the diagnosis is not necessary, unless the presentation is atypical, if the safety of the patient is in danger, or if there is snoring, which may suggest OSA.9, 11

Sleep terrors and sleepwalking commonly overlap with each other. Different types of parasomnias can be present at the same time in a single individual causing an overlap of sleep disorders. During an episode of sleep terror, a child will mostly remain in bed but can abruptly walk, run, or have violent behavior.3, 12

Treatment of sleep terrors should focus on adequate sleep hygiene. Consistent bedtimes, avoiding sleep deprivation, electronic screen time or caffeine prior to bed, and managing underlying conditions like OSA are the main tools in the treatment of night terrors.8, 13 Children will typically outgrow sleep terrors. 3 A safe environment like avoiding an obstructed pathway in the room is important.

Pharmacological treatment for sleep terrors is reserved for difficult cases. Pharmacotherapy would be considered only if episodes are frequent, prove to be dangerous for the child, or episodes are causing significant household sleep disruption. Low-dose clonazepam, a benzodiazepine, is preferred, but also melatonin can be prescribed for 3 to 6 months.13, 14, 15

Conclusion Sleep terrors are characterized by arousals into a sleep-wake state accompanied by fear, anxiety, screaming, crying, and, sometimes escaping-like movements out of the bed, without recollection of

the event by the child. Children eventually outgrow sleep terrors for which the correct treatment starts with parent reassurance, maintaining a good sleep hygiene, and a safe environment around the house. A sleep study or referral to a sleep specialist should be considered if there is suspicion of sleep apnea, or a concern for the child’s safety. Q

9. 10. 11. 12.

References 1. 2. 3. 4. 5 6. 7. 8.

American Academy of Sleep Medicine. International Classification of Sleep Disorders: Diagnostic and Coding Manual. 3rd ed. Darien, IL: American Acadaemy of Sleep Medicine, 2014; 229-239, 257-263. Laberge L, Tremblay R, Vitaro F, et Al. Development of Parasomnias from Childhood to Early adolescence. Pediatrics. 2000;106(1):67-74. Petit D, Pennestri MH, Paquet J, et al. Childhood Sleepwalking and Sleep Terrors: A Longitudinal Study of Prevalence and Familial Aggregation. JAMA Pediatr. 2015;169(7):653-8. Nguyen Bi, Pérusse D, Paquet J, et al. Sleep terrors in children: A prospective study of twins. Pediatrics. 2008;122:e1164-e1167. Avidan AY, Kaplish N. The parasomnias: Epidemiology, clinical features, and diagnostic approach. Clin Chest Med. 2010;31(2):353-370. Sheldon S, Ferber R, Kryger M, et al. Principles in practice of Pediatric Sleep Medicine. 2nd ed. China; Elsevier Saunders, 2014;313-319. Nevsimalova S, Prihodova I, Kemlink D, et al. Childhood parasomnia-a disorder of sleep maturation? Eur J Paediatr Neurol. 2013;17(6):615-9. Haupt M, Sheldon SH, Loghmanee D. Just a scary dream? A brief review of sleep terrors, nightmares, and rapid eye movement sleep behavior disorder. Pediatr Ann. 2013;42(10):211-6.

13. 14. 15.

Guilleminault C, Palombini L, Pelayo R, et al. Sleepwalking and sleep terrors in prepubertal children: what triggers them? Pediatrics. 2003;111(1):e17-25. Pressman MR. Factors that predispose, prime and precipitate NREM parasomnias in adults: clinical and forensic implications. Sleep Med Rev. 2007;11(1):5-30. Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep. 2005;28(4):499-521. Ohayon MM, Guilleminault C, Priest RG. Night terrors, sleepwalking, and confusional arousals in the general population: their frequency and relationship to other sleep and mental disorders. J Clin Psychiatry. 1999;60(4):268-76. Attarian H, Zhu L. Treatment options for disorders of arousal: a case series. Int J Neurosci. 2013;123(9):623-5. Horváth A, Papp A, Szűcs A. Progress in elucidating the pathophysiological basis of nonrapid eye movement parasomnias: not yet informing therapeutic strategies. Nat Sci Sleep. 2016;8:73-9. Ozcan O, Dönmez YE. Melatonin treatment for childhood sleep terror. J Child Adolesc Psychopharmacol. 2014;24(9):528-9.

Author information Graduated from Universidad de San Carlos in Guatemala City, Guatemala and completed an observership in the Division of Pediatric Pulmonary and Sleep Medicine at the University of Mississippi Medical Center (Hernandez). Assistant Professor in the Department of Pediatrics at the University of Mississippi Medical Center. Board certified in Pediatric Pulmonary and Sleep Medicine (Rodriguez). Corresponding Author: Oscar M. Rodriguez, MD, 2500 North State St., Jackson, MS 39216, Phone: 601984-5205, Email: orodriguezpineda@umc.edu.

JOURNAL MSMA

S C I E N C E

I N

M E D I C I N E

Top 10 Facts You Should Know About Diabetic Eye Disease COREY BRELAND PARISH, MD; KIMBERLY W. CROWDER, MD Introduction Diabetic eye disease, primarily diabetic retinopathy (DR), is a leading cause of visual impairment in the United States. A 2014 CDC survey estimated 29.1 million individuals, 9.3% of the United States population, had diabetes and another 86 million individuals had pre-diabetes.1 Mississippi has one of the highest rates of diabetes in the nation with 13.6% of the population affected, so it is important that we are aware of complications of this disease.2 What is Diabetic Retinopathy? DR occurs when vasculature in the eye becomes diseased with pericyte loss, endothelial cell dysfunction, capillary micro-angiopathy and other small vessel changes.3 Leakage from this unhealthy vasculature leads to diabetic macular edema (DME), which decreases vision. Eventually, ischemia of retinal tissue can occur, resulting in proliferative diabetic retinopathy (PDR).3 In PDR, retinal ischemia stimulates neo-angiogenic factors, resulting in fibro-vascular complexes and vision threatening complications.

Who gets Diabetic Retinopathy? The National Eye Institute reports a slight (51%) female predominance. A US population study showed higher rates of diabetic retinopathy in Hispanics (33.4%) and non-Hispanic blacks (26.5%) compared to non-Hispanic whites (18.2%).4 Other studies have suggested a prevalence of DR up to 45% in those of Native American ancestry.5,6 This is relevant to us since many members of the Mississippi Band of Choctaw Indians are our patients. Prevalence of sight threatening DR also increases after age 65.7

What are risk factors for Diabetic Retinopathy? The Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) showed that after 20+ years, 97.5% of Type 1 diabetics and over 60% of Type 2 diabetics had developed retinopathy.3,8,9 Degree of hyperglycemia is an important risk factor for progression after patients develop baseline retinopathy.10

Figure 2. This photo is from a 41-year-old male with nonproliferative diabetic retinopathy. Note the hypopigmented spots (A) that represent laser scars from prior focal laser treatment for diabetic macular edema (DME). There are also numerous microaneurysms (B).

78 VOL. 59 â&#x20AC;˘ NO. 2 â&#x20AC;˘ 2018

Figure 1. This is an example of a normal eye exam. The optic disc (A) is a normal coloration. The retinal vessels (B) are normal in course and caliber. The central macula (C), which is responsible for central vision, is without pathology.

Figure 3. This photo was obtained from a patient with active, untreated proliferative diabetic retinopathy. The optic nerve (A) is obscured by the overlying ďŹ brovascular membrane. A good example of ďŹ ne branching neo-vascularization (B) is seen as well. The neo-vascular membrane complex (C) completely obscures the macula.

Duration and severity of hyperglycemia are the strongest risk factors for diabetic retinopathy.11 Hypertension as well as elevated triglycerides and lipids are other implicated risk factors.8-10,12-15 When should patients see an ophthalmologist? American Academy of Ophthalmology guidelines recommend Type 1 diabetes have an eye exam 5 years after diagnosis.11 Type 2 diabetics should have an eye exam immediately after diagnosis because 30% will already have existing retinopathy.11 Lifelong annual follow up is recommended for all diabetics, though only 60% of diabetic patients receive annual eye exams.11

What about diabetes in pregnancy? Diabetic retinopathy can worsen during pregnancy. Pregnant diabetic patients should have an eye exam at the time of conception and another later during the first trimester.11 Further follow up is dictated by exam findings. Note that gestational diabetics do not develop retinopathy and do not require an eye exam during pregnancy.11,16-18

Does Glycemic control reduce Diabetic Retinopathy? In the Diabetes Control and Complications Trial (DCCT), intensive glycemic control reduced the risk of developing diabetic retinopathy by 76% and slowed progression by 54% in Type 1 diabetics.19 The United Kingdom Prospective Diabetes Study showed Type 2 diabetics also benefited from tight glycemic control.20 Specifically, a 1% decrease in Hemoglobin A1C equated to nearly a one third reduction in retinopathy.21

What treatments do we have for Diabetic Retinopathy? Lasers were an early treatment method for diabetic retinopathy. In pan retinal photocoagulation (PRP), laser energy is delivered to ischemic retinal tissue to prevent or promote regression of proliferative diabetic retinopathy.3,22 Laser can be delivered in a more focal manner to treat diabetic macular edema.23 More recently, intraocular injections of AntiVascular Endothelial Growth Factor agents have become the standard for treating DME since they offer superior visual outcomes compared to laser.24,25 These medications are also used to promote regression of PDR.3 Lasers and intraocular injections are very common in ophthalmic practice.

Figure 4. A 51- year-old male with a history of proliferative diabetic retinopathy (PDR) that required surgery. There is diabetic macular edema (DME) with exudates (A). There are numerous pan-retinal photocoagulation laser scars (B). The vasculature (C) appears attenuated and unhealthy. After treatment with intraocular anti-VEGF agents for DME, this patient retained 20/25 central vision.

What are other ocular manifestations of diabetes? Diabetics develop cataracts requiring surgical management earlier than non-diabetic patients.26 Diabetics also experience intermittent fluctuations in their vision secondary to osmotic effects on the lens from fluctuating blood glucose levels.27,28 Patients are at risk for micro-vascular events such as

JOURNAL MSMA

ischemic third nerve palsies and retinal arterial or venous occlusions. They can develop intraocular hemorrhage, retinal detachments and neo-vascular glaucoma, all secondary to PDR and all often requiring surgical management.

11. 12.

What about fenoﬁbrate? Recent studies have shown beneficial effects of this medication on DR.29,30 In the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study, fenofibrate, 160mg daily, in combination with simvastatin reduced progression of diabetic retinopathy by 40% compared with simvastatin alone.29,31 The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study showed a 40% reduction in laser treatments with fenofibrate 200mg daily versus placebo .30,31 These results appear independent of effects on lipid profile. We recommend that patients with diabetic retinopathy be strongly considered for this medication regardless of serum lipid levels.

What do we tell our patients about diabetic retinopathy? We encourage patients to follow closely with their primary care providers for their overall diabetic care. We generally recommended a goal HgbA1c of 7% or less with our patients.11 We counsel them that although we can treat eye disease once it occurs, the best thing they can do is manage their blood sugar diligently to minimize complications. We try to ensure our patients have a PCP to help them work toward these goals.

Conclusion

13. 14. 15.

16.

17. 18. 19.

20. 21. 22. 23.

Diabetes is a devastating disease and diabetic retinopathy can significantly affect a patient’s life and potentially lead to blindness. The take home message is that the best ways you can help a diabetic patient’s vision are tight glycemic management and ensuring that they receive regular ophthalmic exams. Q References Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014. 2. Centers for Disease Control and Prevention. Division of Diabetes Translation. US Diabetes Surveillance System. Available at http://www.cdc.gov/diabetes/data. 3. Retinal Vascular Disease: Diabetic Retinopathy. Basic and Clinical Science Course (BCSC) Section 12: Retina and Vitreous. San Francisco: American Academy of Ophthalmology; 2014-2015. 4. Harris MI, Klein R, Cowie CC, et al. Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A U.S. population study. Diabetes Care 1998;21(8):1230-5. 5. Berinstein DM, Stahn RM, Welty TK, et al. The prevalence of diabetic retinopathy and associated risk factors among Sioux Indians. Diabetes Care 1997;20(5):757-9. 6. Gao X, Gauderman WJ, Marjoram P, et al. Native American Ancestry Is Associated With Severe Diabetic Retinopathy in Latinos. Invest Ophthalmic Vis Sci. 2014;55(9):6041-6045. 7. Zhang X, Saaddine JB, Chou C, et al. Prevalence of Diabetic Retinopathy in the United States, 2005-2008. JAMA 2010;304(6):649-656. 8. Klein R, Klein BEK, Moss SE, et al. The Wisconsin Epidemiologic Study of Diabetic Retinopathy II. Prevalence and Risk of Diabetic Retinopathy When Age at Diagnosis Is Less Than 30 Years. Arch Ophthal. 1984;102(4):520-526. 9. Klein R, Klein BEK, Moss SE, et al. The Wisconsin Epidemiologic Study of Diabetic Retinopathy III. Prevalence and Risk of Diabetic Retinopathy When Age at Diagnosis Is 30 or More Years. Arch Ophthal. 1984;102(4):527-532. 10. Davis MD, Fisher MR, Gangnon RE, et al. Risk factors for high-risk proliferative

24. 25. 26.

80 VOL. 59 • NO. 2 • 2018

27. 28. 29. 30. 31.

diabetic retinopathy and severe visual loss: Early Treatment Diabetic Retinopathy Study Report #18.. Invest Ophthalmic Vis Sci. 1998;39(2):233-252. AAO PPP Retina/Vitreous Panel, Hoskins Center for Quality Eye Care. Diabetic Retinopathy Preferred Practice Patterns – Updated 2016. https://www.aao.org/ preferred-practice-pattern/diabetic-retinopathy-ppp-updated-2016. Klein R, Klein BEK. Blood pressure control and diabetic retinopathy. Br J Ophthalmic. 2002;86(4):365-367. Dodson PM, Galton DJ, Winder AF. Retinal vascular abnormalities in the hyperlipidemias. Trans Ophthalmic Soc UK. 1981;101:17–21. Miljanovic B, Glynn RJ, Nathan DM, et al. A prospective study of serum lipids and risk of diabetic macular edema in type 1 diabetes. Diabetes 2004;53:2883–2892. Chew EY, Klein ML, Ferris FL, et al. Association of Elevated Serum Lipid Levels With Retinal Hard Exudates in Diabetic Retinopathy Early Treatment Diabetic Retinopathy Study (ETDRS) Report 22. Arch Ophthalmic. 1996;114(9):10791084. Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study. National Institute of Child Health and Human Development Diabetes in Early Pregnancy Study. Diabetes Care 1995;18:631-7. Chapman C, Blaydon S, Clement S, et al. Utility of Routine Ophthalmologic Examination in Patients with Gestational Diabetes Mellitus. Diabetes Care 1993;16:1413–1414. Macfarlane DP, O’Sullivan EP, Dorman S, et al. The Utility of Retinal Screening in Gestational Diabetes. Diabetic Med. 2013;30(8):1009-10. The Diabetes Control and Complications Trial Research Group. The Effect of Intensive Treatment of Diabetes on the Development and Progression of LongTerm Complications in Insulin-Dependent Diabetes Mellitus. N Engl J Med. 1993;329:977-986. The UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998;317:703. Kohner, EM. Microvascular disease: what does the UKPDS tell us about diabetic retinopathy? Diabetic Medicine. 2008;25:20–24. The Diabetic Retinopathy Study Research Group. Preliminary report on effects of photocoagulation therapy. Am J Ophthalmic. 1976;81(4):383-96. Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation for diabetic macular edema. ETDRS Report Number I. Arch Ophthalmic. 1985;103:1796-1806. Nguyen QD, Brown DM, et al; RISE and RIDE Research Group. Ranibizumab for diabetic macular edema: results from 2 phase III randomized trials: RISE and RIDE. Ophthalmology 2012;119(4):789-801. Mitchell P, Bandello F, Schmidt-Erfurth U, et al. The RESTORE study: ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema. Ophthalmology. 2011;118(4):615-25. Klein BE, Klein R, Moss SE. Incidence of cataract surgery in the Wisconsin Epidemiologic Study of Diabetic Retinopathy. Am J Ophthalmic. 1995;119:295– 300. Duke-Elders. Changes in refraction in diabetes mellitus. Br J Ophthalmic. 1925;9:167-87. Saito Y, Ohm G, Kinoshita S, et al. Transient hyperopia with lens swelling at initial therapy in diabetes. Br J Ophthalmic. 1993;77(3):145-148. ACCORD Study Group and ACCORD Eye Study Group. Effects of medical therapies on retinopathy progression in type 2 diabetes. New Engle J Med 2010;363:233–244. Keechi AC, Mitchell P, Summanen PA, et al. Effect of fenofibrate on the need for laser treatment for diabetic retinopathy (FIELD study): a randomised controlled trial. Lancet 2007;370:1687–1697. Wright AD and Dodson PM. Medical management of diabetic retinopathy: fenofibrate and ACCORD Eye studies. Eye 2011;25:843–849.

Acknowledgements: Matthew Olson, CRA, Director of Ophthalmic Imaging Services, University of Mississippi Medical Center, Department of Ophthalmology.

Author Information: PGY4 UMMC (Parish). Chair and Professor (Crowder). Both in the Department of Ophthalmology, University of Mississippi Medical Center, Jackson. Corresponding Author: Kimberly W. Crowder, MD, UMMC Dept. of Ophthalmology, 2500 North State Street, Jackson, MS 39216. Email: kcrowder@umc.edu.

Employee Management Made Simple RELATIONSHIPS Through the development of personal and professional relationships, we create a customized approach for each employer. We assess your unique situation and design strategies utilizing products, services, and technology to make employee management simple and efﬁcient. By providing effective training and implementation of these strategies, we bring human resources, payroll, and beneﬁts together to meet your organizational goals.

H.R. • • • • • • •

HR Assessments Onboarding Processes Policies, Procedures, & Employee Handbooks Fair Labor Standards Act Assessments Other Federal & State Employment Laws Job Analysis & Job Descriptions Employee Relations, Performance & Discipline Support • Supervisor & Employee Training • Investigations

BENEFITS PAYROLL • • • • • • • •

Payroll Systems Human Resources Information System (HRIS) Time & Attendance Affordable Care Act (ACA) Tracking & Reporting Leave Management (FMLA) Performance Management Recruitment W-2’s

• • • • • • • • •

COBRA Administration Online Benefit Administration Group Health, Cancer, Dental, Vision Group Life & Disability Cafeteria Plans Benefit & Cost Analysis Benefit Communication & Enrollment ACA Training & Support 401(K) Profit Sharing & other retirement plans • Plan Design & Compliance Consulting • IRS & DOL audit support

Jackson, MS • Oxford, MS • Madisonville, LA • 877-759-5765 • www.MWGEmployerServices.com JOURNAL MSMA

S C I E N C E

I N

M E D I C I N E

How Clinicians Can Better Interface with Surgical Pathologists for Better Patient Care VARSHA MANUCHA, MD; VEENA SHENOY, MD; MIRNA VARGAS; ISRAH AKHTAR, MD; DIVYA SHENOY (M3); JACK LEWIN, MD

Summary Surgical pathology is the most significant and time-consuming area for most pathologists. It involves examination of biopsies and resected specimens. To arrive at an accurate diagnosis it is very important for the clinician to communicate with the pathologist. This article discusses the importance of interface between pathologist and clinicians and multiple ways a clinician can get involved in helping the pathologists make a diagnosis. Introduction Pathologists are consultant physicians involved in tissue and laboratory analyses, assisting in the diagnoses and treatment of patients. Communication between the pathologist and clinician is important to deliver optimal patient care. It must occur in both directions and should include a free exchange of clinical information and explanation of the thought processes used by both physicians. 1 We briefly discuss three main areas where clinicians can interface with a surgical pathologist. Clinical history Gone are the days when pathologists practiced pathology in a “vacuum”. Advent of personalized medicine makes it imperative for pathologists to have complete access to clinical information and imaging findings. Access to electronic medical records helps the pathologist to put the missing pieces of the puzzle together and thereby render a holistic diagnosis. Personal communication with the clinician and platforms such as tumor boards helps the pathologist to communicate the abnormalities of histology as well as uncertainties. 2 The importance of communication is not limited to diagnosis of cancer but extends to all other body systems and disease spectrums. For example, in the setting of gastrointestinal diseases, the endoscopist must provide the pathologist with information about the patient, including results of the gross examination, biopsy location, relevant clinical history, bowel preparation, and current medications.3 The pathologist in turn must provide a reproducible and useful report that answers the clinical questions posed by the endoscopist. 3 In addition to the clinical history, the source of specimen, previous history of malignancy and any outside pathology reports, if available, are very useful in diagnosis. Use of nonspecific terms such as “rule out”, often used on requisition forms must be avoided as it may result in diagnostic delays and the unnecessary application of pathology stains and sections. 4 82 VOL. 59 • NO. 2 • 2018

Specimen Fixation and Transport It is pertinent that the submitting physician follows the specimen collection and submission protocols in order to avoid a compromise in the diagnosis. The type of fixative, volume of fixative and the type specimen containers influence the preservation of tissue. Frozen sections, lymph nodes, muscle biopsies and tissue for flow cytometry should be submitted fresh. Skin and kidney biopsies for immunofluorescence need special fixative like Zues fixative. Routine processing of specimens takes anywhere from 20 – 48 hours depending on when the specimen is received in the laboratory. Larger specimens need additional fixation time and bones need to be decalcified before processing which eventually affects the turnaround time. When in doubt it is better to call the pathology laboratory instead of second guessing the pathologist. Intraoperative Consultations/Frozen Sections Implicit in the term "intraoperative consultation" is that the pathologist is a consultant and has an obligation to be familiar with the clinical aspects of the case before rendering an opinion. 5 There is only one purpose in the frozen section and that is to make a therapeutic decision.6 Requests for frozen section are inappropriate when there are no immediate management issues at stake and there is a risk of compromising the specimen. Inappropriate frozen sections are sometimes requested by surgeons who do not fully understand the limitations of intraoperative evaluation.6 Ancillary Studies Although immunohistochemistry and molecular diagnostics have revolutionized diagnostic pathology, morphology remains the gold standard against which any claim based on new technology needs to be measured. A clear-cut correlation exists between some cytogenetic/ molecular alterations and the tumor morphology/phenotypes. 7 The correlation of biomarker data with traditional histomorphology lies exclusively in the realm of the anatomic surgical pathologist. Only the pathologist can comment on the presence, absence, and differential expression of biomarkers in tumor cells versus normal cells, in in situ tumors versus invasive tumors, and in different grades and patterns.8 Communication with the pathologist can help the clinician in selection of appropriate tests, in ordering of panels with assessment of individual or fewer genes, thereby reducing significant unwarranted cost expenditure.

Table. Example of Surgical Pathology Quality Management Plan

! !& " , ( " ( ! ! - " ! ! " ! & $ , " ( / "! - % ! )

) ! & " !& / ! " !& ! " ! " ! ! & !

# %! ! ! " ! & + & ' ! * ! & .

: 59

&) ! &

" ! &

: 59

! &

&) ! &

" ) ! &

: 39

&) ! &

: 39

&) ! &

: 39

! $ ) ! & &) ! &

: 29

" "

: 29 : 39

&) ! & ! & ! &

: 59

! &

619,$ ! 46 " -

! &

! & ! &

*TAT is calculated from the time of specimen receipt to electronic release of ďŹ nal report

Conclusion: There is a broad range of different fields where pathologists and clinicians should work together, ranging from intraoperative consultation, evaluation of biopsy samples, and ordering of molecular tests etc. Clinicopathological conference is a great interactive tool to discuss cases for personalizing treatment and continuing medical education. Without maintaining traditionally good cooperation, neither clinicians nor pathologists can give proper answers to the challenges and professional questions of the new era. Q

7. 8.

References 1. 2. 3.

Nakhleh RE. What is quality in surgical pathology? J Clin Pathol. 2006;59:669672. Nakhleh R E, Zarbo R J. Surgical pathology specimen identification and accessioning: a College of American Pathologists Qâ&#x20AC;?Probes study of 1,004,115 cases from 417 institutions. Arch Pathol Lab Med. 1996;120:227â&#x20AC;&#x201C;233. Nakhleh Re, Zarbo RJ. Amended reports in surgical pathology and implications for diagnostic error detection and avoidance: a College of American Pathologistsâ&#x20AC;&#x2122; Qâ&#x20AC;?probes study of 1,667,547 accessioned cases in 359 laboratories. Arch Pathol Lab Med. 1998; 122(4):303-309. LeClaire J. Histology shortage opens doors. http://allhealthcare.monster. com/training/articles/201-histology-shortage-opens-doors. Accessed on

January 27, 2017. Tufel G. Histotechnology faces new challenges and ongoing challenges. Published on August 15, 2014. http://www.clpmag.com/2014/08/ histotechnology-faces-new-ongoing-challenges/?ref=cl-title. Accessed on January 27, 2017. Fitzgibbons PL. Postanalytic variables: report adequacy and integrity. In: Nakhleh RE, Fitzgibbons PL (ed). Quality management in anatomic pathology: promoting patient safety through systems improvement and error reduction. Northfield: The College of American Pathologists. 2005:61-65. Volmar KR, Idowu MO, Souers RJ, Karcher DS, Nakhleh RE. TAT for large or complex specimens in surgical pathology. A CAP Q-probes study of 56 institutions. Arch Pathol Lab Med. 2015;139:171-177. Richard J. Zarbo, Raouf E. Nakhleh, and Molly Walsh. Customer Satisfaction in Anatomic Pathology. Arch Pathol Lab Med. 2003;127(1):23-29.

Author Information: Associate Professor, Director of Surgical Pathology (Manucha); Associate Professor (Shenoy); BSCT (ASCP), AP Laboratory Manager (Vargas); Associate Professor (Akhtar); Medical Student (M3) (Shenoy); Professor, Director of Anatomic Pathology (Lewin). All authors are affiliated with the University of Mississippi Medical Center, Jackson. Correspondence: Varsha Manucha, Associate Professor, Department of Pathology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. Office: 601-984-1570 Fax: 601-984-1531 E-mail:vmanucha@umc.edu.

JOURNAL MSMA

S C I E N C E

I N

M E D I C I N E

Racial Differences for Accelerated Partial Breast Irradiation (APBI) for the Treatment of Early Stage Breast Cancer VEERESH MICHAEL, PHD; JESSICA H. BAILEY, PHD; LEI ZHANG, PHD; ELLEN JONES, PHD Introduction: Breast cancer incidence in Mississippi is among the lowest in the country, but, mortality is among the highest. Accelerated Partial Breast Irradiation (APBI) is a valid option for lowering the risk of recurrence when compared to no radiation therapy after breast conservation surgery. Methods: Mississippi Cancer Registry (MCR) data were used to identify early stage breast cancer patients and statistical analysis was performed to determine if racial differences exist for patients who received radiation treatment after breast conservation surgery. Results: Data analysis revealed significant differences for radiation treatment modality selected based on race as well as other demographics. Results showed that white women were significantly more likely to have external beam radiation or APBI brachytherapy treatment. Conclusion: Understanding racial differences in breast cancer treatment modality can inform early screening, treatment and follow up for disparate populations in Mississippi. Key words: early stage breast cancer, brachytherapy, radiation therapy, racial disparities INTRODUCTION Breast cancer is the second leading cause of cancer death among women, accounting for nearly 33% cancers diagnosed in U.S. women. In 2010, the Centers for Disease Control and Prevention (CDC) reported Mississippi’s breast cancer incidence in Mississippi as the lowest among other states, but, deaths were the highest.1 Mississippi had the lowest categorical incidence in the U.S. of invasive and in-situ cases for all races from 2006-2010, with African Americans having higher invasive and death rate incidence than Caucasians. The related death rate, however, is in the highest interval for all races when compared to other states.2 Traditionally, radical mastectomy with an average of 6 weeks of radiation therapy and/or chemotherapy was a woman’s only treatment option. However, since the 1990s, the combination of surgery plus radiation known as Breast Conservation Therapy (BCT) has been studied to be equivalent to mastectomy regarding long-term early stage survival (stages 0-II). The National Institutes

84 VOL. 59 • NO. 2 • 2018

of Health recommend that Breast Conservation Surgery (BCS) is the preferred early-stage treatment. BCS is underutilized in Mississippi and has the lowest use among southern states.1 Development of Accelerated Partial Breast Irradiation (APBI) radiation therapy has offered qualified patients a viable and effective alternative. The High Dose Rate (HDR) brachytherapy method allows shorter, less cumbersome treatment time than conventional External Beam Radiation Therapy. The two-step process involves surgical lumpectomy with insertion of a balloon or strut type catheter. Next, radioactive Iridium-192 is temporarily placed via the catheter on a daily basis, typically for five days. APBI treatment eligibility is based on primary tumor size/volume and staging as well as patient age. Mississippi has one of the lowest utilization rates of this method. High rates of mastectomy, higher than typical rates of late stage breast cancer (stage III and IV) incidence, and low use of HDR brachytherapy APBI create a unique disparity for Mississippi early-stage breast cancer patients. Recently, Breast Conservation Surgery (BCS) has gained favorability and is called Breast Conservation Therapy (BCT) when followed by Radiation Therapy to reduce recurrence risk.4, 5, 6 Unfortunately, many women who undergo BCT choose to eliminate radiation after lumpectomy. Without any form of radiation therapy, the risk of local recurrence is more than doubled necessitating the need to investigate reasons for excluding radiation treatment.6 METHODS The data set utilized for analysis in this study contained patient data for early-stage breast cancer patients obtained from the Mississippi Cancer Registry (MCR) for retrospective chart review of cases from 2004-2013. The latest data available was for 2013 and catheter-based APBI treatments were scarce in Mississippi before 2003. Catheter-based APBI accounts for almost all APBI within the state with only one facility offering non-catheter-based APBI treatments. An analysis of APBI eligible women was performed to determine if patient race can be predictor of type of radiation treatment chosen, including only analytic cases and excluding recurrences. The data set contains only patients diagnosed and treated in the state of Mississippi and includes categories for patient demographics as well as clinical information including disease staging, type of surgical intervention, and radiation therapy

technique if any radiation treatment was utilized. APBI patient selection is based on patient age, diagnosis, tumor size, and lymph node status among other criteria. The surgical intervention code formatting in MCR data as well as other variables were used to classify patients as eligible for APBI treatment using Summary Staging and Collaborative Staging methods. APBI treatment eligibility was categorized from MCR data with the use of site specific surgical codes for breast cancer among other factors to identify women that underwent BCS. Radiation treatment was the outcome variable. The independent variable was race and for regression analysis included other covariates of patient demographics including insurance, county of diagnosis, and availability of physicians and treatment facilities. The final data received from the MCR contained 23,315 records for female early stage breast cancer patients. A special consideration was made to limit the data to the first breast cancer to avoid an issue that might skew the treatment decision. Patient selection for APBI eligibility was based on evaluating seven variables: age greater than or equal to 45 years, surgery code to include only BCS patients, a tumor size of less than or equal to 3 cm, collaborative stage extension coding to include T-1 with no extension of disease, no lymph node involvement, no metastases, and a summary stage coding of in-situ or localized. After eliminating missing data, 16,490 records were considered for suitability criteria. Of these, 74.9% were not considered suitable for APBI. The remaining 25.1% or 4,132 records were considered APBI eligible and were used for statistical analysis. Examination of the data for analysis of early-stage breast cancer patients and their treatment categorized by radiation outcome (No Radiation, External Beam, or Brachytherapy) was carried out through the relation to patient race. For regression analysis, predictors included measures of location of radiation treatment facilities in Mississippi (linear accelerator based facilities, catheter-based HDR brachytherapy, or both), and surgeon and radiation oncologist availability per Mississippi county. County and individual demographic characteristics were also included as potential confounders for interest on their own. The Pearsonâ&#x20AC;&#x2122;s Chi-square analysis was used to determine if the outcome variable of radiation treatment modality differed by race alone. Further modeling was done by regression analysis. Binary and multinomial regression analysis were used to further determine the interaction of the independent variables as well as investigating factors or predictors associated with the major outcome variable of radiation modality. The regression analysis was used to quantify the relationship between outcome variable and the independent variables acting as predictors when controlling for other confounders or covariates. The results generated odds ratio and their 95% confidence intervals (CIs) which quantified the likelihood that an independent variable as a predictor has increased or decreased odds of a particular outcome when

controlling for other covariates. Statistical analysis was performed at a significance level of 0.05, and the results with p-value < 0.05 were deemed significant. RESULTS The resulting 25.1% or 4,132 records were considered APBI eligible and used for statistical analysis to determine if race is associated with the outcome measured by type of radiation treatment. The outcome variable was sectioned into three categories: no radiation treatment, external beam radiation, or brachytherapy radiation received after BCS. The overwhelming majority were non-Hispanic and either black or white. The ethnicity breakdown was divided into only two categories, non-Hispanic whites with 2,857 or 71% patients and non-Hispanic black patients at 1,169 or 29.0%. The outcome or dependent variable is the radiation treatment. It is calculated that 31.6% of these APBI eligible women received no radiation, 60.4% received external beam treatment, and only 7.8% received brachytherapy radiation. The outcome variable can be stated in another way to reflect those patients who received no radiation versus those who received some forms of radiation whether it is external beam treatment or brachytherapy. The number of patients who received no radiation was 31.7% in those who received some forms of radiation therapy was 68.3%. Categorizing the data in this matter allows for binomial regression analysis. Furthermore, of particular interest is the number of patients who received brachytherapy as their treatment versus no radiation for further binomial regression analysis. It is assumed that those who received brachytherapy treatment received an HDR catheter-based APBI treatment for their early stage breast cancer treatment following BCS. It should be noted that relatively few, only 313 patients or 7.8%, received brachytherapy treatment over the 10 year period. The radiation treatment modality was treated as the outcome variable with three possible outcomes: No Radiation, External Beam, or Brachytherapy. For race, there is a significant relationship between race and the radiation treatment delivered (p < 0.0001) as shown in Table 1. The outcome or dependent variable was coded to reflect those who received no radiation and those that received some type of radiation regardless whether it was external beam or brachytherapy as shown in Table 2. The odds ratio indicates the likelihood of radiation Table 1. Chi-Square Analysis by Radiation Treatment Modality Characteristic

No Radiation N

External Beam N %

Brachytherapy N

Total (4020) 1274 31.7 Race Non-Hispanic Whites 812 65.4

2433

60.5

313

7.8

1734

73.2

246

78.8

Non-Hispanic Blacks 429

636

26.8

21.2

34.6

p-value <0.0001

JOURNAL MSMA

treatment. The first binary regression analysis had an outcome of No Radiation vs. Radiation. For race, it is a significant predictor (p<0.0001) to determine if the patient received radiation treatment or not. The non-Hispanic whites are 1.43 (95% CI: 1.231, 1.664) times more likely to receive some type of radiation treatment than non-Hispanic blacks even when controlling for other covariates. Another binary regression analysis was performed which had an outcome variable of No Radiation vs. Brachytherapy. This analysis compares women that received no radiation treatment with those who received brachytherapy treatment. For race, the analysis shows a highly significant (p<0.0001) association with race as a predictor variable. The white patients are 1.80 (95% CI: 1.319, 2.455) times more likely to receive brachytherapy than no radiation treatment at all. Multinomial logistic regression allows regression analysis for all three radiation treatment levels: No Radiation, External beam, and Brachytherapy. The results are shown in Table 3 where no radiation treatment is the reference for the outcome variable. The first part of the analysis compares levels: External Beam treatment with No Radiation as the reference. Race has a highly significant association (p<0.0001) where white patients are 1.40 times more likely to receive external beam treatment than no radiation. The second part of the analysis compares levels: Brachytherapy treatment with No Radiation as the reference. Again, there is strong evidence that race is a strong predictor of treatment where white patients are 1.80 times more likely to receive brachytherapy than no radiation treatment with a statistically significant result (p<0.0001). For the category of race, Chi-square analysis showed a statistically significant relationship with the treatment type while acting as an independent variable. In the binary logistic regression analysis for outcome of radiation versus no radiation, race was again a statistically significant predictor as was true for the binary regression comparing no radiation versus brachytherapy. In the multinomial logistic regression race was statistically significant when comparing external beam to no radiation as well as brachytherapy to no radiation. In the binary and multinomial logistic regression analysis, there is strong evidence that race is a highly significant predictor of radiation treatment modality. Statistical analysis indicates that white patients are more likely to receive some type of radiation and specifically brachytherapy radiation than black patients. DISCUSSION AND CONCLUSION Studies have established that BCS outcomes are similar to mastectomy in reduction of recurrence and overall survival of early stage breast cancer when BCS is followed by radiation whether external beam radiation or APBI. Although APBI patients must meet strict eligibility criteria, it is shown to be a valid treatment option equivalent to traditional radiation therapy. Often patients do not receive traditional radiation therapy for a variety of reasons such as

86 VOL. 59 • NO. 2 • 2018

Table 2. Binary Logistic Regression for No Radiation vs. Radiationa Binary Logistic Regression for No Radiation vs. Brachytherapyb Odds Characteristic Non-Hispanic Whites

95% C.I.

Ratio

Lower

Upper

p-value

1.43

1.23

1.66

<0.0001

1.80

1.32

2.46

<0.0001

Non-Hispanic Blacks (referent) Non-Hispanic Whites b Non-Hispanic Blacks (referent) a b

Regression for No Radiation vs. Radiation (External Beam and Brachytherapy) Regression Analysis for No Radiation vs. Brachytherapy Other covariates: Insurance & Urban vs. Rural county, Availability within county for Rad Onc, Surgeon, External beam facility, and Catheter APBI facility

Table 3. Multinomial Logistic Regression Analysis for Radiation Treatment 95% C.I. p-value

Odds Lower Upper Ratio Bound Bound

External Beam -Non Hisp. Whites External Beam -Non Hisp. Blacks (referent)

<0.0001

1.40

1.20

1.63

Brachytherapy -Non Hisp. Whites

<0.0001

1.80

1.32

2.44

Characteristic

Brachytherapy -Non Hisp. Blacks (referent)

Other covariates: Insurance & Urban vs. Rural county, Availability within county for Rad Onc, Surgeon, External beam facility, and Catheter APBI facility

access to physicians, proximity to treatment facilities, unable to take time off from work, and financial burdens among a variety of other reasons. It is these patients that APBI treatment is directed towards since they would not otherwise receive any radiation therapy. In Mississippi, MCR data analysis has shown that a patient’s race, other demographics, and availability of physicians and treatment facilities serve as a statistically significant predicting factor in radiation treatment outcome and ultimately the utilization of APBI brachytherapy for APBI eligible patients. While results were similar to studies from different parts of the country, variations in use of adjuvant radiotherapy have not been examined in Mississippi and provide insight into APBI utilization and other radiation treatment or lack of radiotherapy within Mississippi. Racial disparity can influence breast cancer diagnosis and treatment as is shown in the literature indicating race as a predictor for the disparity in breast cancer mortality with lower decline in mortality among African-American and Hispanic women. From 1995-2005, a Texas study showed late-stage diagnosis, low SES, and geographic factors were all predictors showing racial disparities in breast cancer mortality.7 Studies have shown that African-American women die at an increased rate.8 The analysis of APBI eligible women in Mississippi indicates agreement with race being a significant predictor in radiation treatment outcome. In Mississippi, for early stage APBI eligible breast cancer patients, non-Hispanic white women are 1.43 times more likely to receive some form of radiation treatment whether it is external beam radiation or brachytherapy.

Furthermore, non-Hispanic white women are 1.8 times more likely to receive brachytherapy APBI treatment than non-Hispanic black women when compared to receiving no radiation at all. Hence, for eligible early stage breast cancer women who undergo BCS in Mississippi, APBI brachytherapy treatment is a significant predictor in favor of non-Hispanic white women to reduce the risk of recurrence. Other confounders in the analysis included other demographics, and availability of physicians and treatment facilities. Controlling for all other covariates still yielded a statistically significant racial difference among patients who received APBI therapy. For all statistical tests, non-Hispanic whites were statistically more likely to receive external beam as well as HDR brachytherapy treatment. Q

Smith, GL, Xu, Y, Shih, YC, et al. Breast-conserving surgery in older patients with invasive breast cancer: current patterns of treatment across the United States. J Am Coll Surg. 2009; 209(4), 425-433 e422. doi: 10.1016/j. jamcollsurg.2009.06.363.

Vicini, FA., Arthur, DW. Breast brachytherapy: North American experience. Semin Radiat Oncol. 2005; 15(2), 108-115.

Njeh, CF, Saunders, MW, Langton, CM. Accelerated Partial Breast Irradiation (APBI): A review of available techniques. Radiat Oncol. 2010; 5, 90. doi: 10.1186/1748-717X-5-90.

Biagioli, MC, Harris, EE. Accelerated partial breast irradiation: potential roles following breast-conserving surgery. Cancer Control. 2010; 17(3), 191-204.

Tian, N, Goovaerts, P, Zhan, FB, et al. Identifying risk factors for disparities in breast cancer mortality among African-American and Hispanic women. Womens Health Issues. 2012; 22(3), e267-276. doi: 10.1016/j.whi.2011.11.007.

Whitman, S, Orsi, J, Hurlbert, M. The racial disparity in breast cancer mortality in the 25 largest cities in the United States. Cancer Epidemiol. 2012; 36(2), e147-151. doi: 10.1016/j.canep.2011.10.012.

References 1.

Centers for Disease Control and Prevention. Female Breast Cancer Incidence Rates* by State, 2013. https://www.cdc.gov/cancer/breast/statistics/state. htm. Accessed April 10, 2017.

Cancer.gov. Incidence Rates for Mississippi Breast, 2009-2013. h t t p s : / / s t a te c a n c e r p ro f i l e s . c a n c e r. g o v / m a p / m a p. w i t h i m a g e . php?28&001&055&00&2&01&0&1&5&0#results. Accessed April 10, 2017.

Author Information: Medial Physicist, St. Dominic Cancer Center, Jackson, MS (Michael). Professor Health Administration and Dean, School of Health Related Professions, University of Mississippi Medical Center (Bailey). Professor, School of Nursing, at the University of Mississippi Medical Center (Zhang). Doctor of Health Administration Program, School of Health Related Professions, University of Mississippi Medical Center (Jones).

JOURNAL MSMA

L E A D E R S H I P

Are You an Introvert? It Might Mean You're a Good Leader HANNAH O. BROWN Natural skills such as listening and thoughtfulness can be an advantage when working toward leadership positions.

intelligence, which can be really beneficial in leadership positions.”

Being comfortable in her role as a leader took time and dedication to mastering skills that didn’t necessarily come naturally to her, but Riddle has powered through by giving herself permission to be herself instead of scolding herself internally for the things she’s not doing.

egan Riddle, MD, PhD, MS, considers herself a lifelong introvert, and for a long time she didn’t think of herself as a leader. It wasn’t until she found herself in a leadership position by chance that she realized that she was suited for the job. “I think when you are typically kind of the quiet one in the room, you don’t necessarily naturally think, ‘Oh, yeah, I want to sign up for that leadership role,’ or ‘I want to run for office in medical school,’ ” Riddle says. “And if you don’t think of yourself that way, then you don’t have to step into those opportunities.” Now Riddle is the chief resident of psychiatry inpatient and emergency services at the University of Washington — a leadership role she has held for several months.

“There is a widespread misconception that to be a successful leader, introverts are disadvantaged,” says Patricia Williams, MD, a certified master practitioner of the Myers-Briggs Type Indicator and adjunct professor at American University. “In fact, there have been some studies that suggest that in medicine, the higher you go as a leader the more likely you are to be an introvert.” One 2011 study, “Reversing the Extraverted Leadership Advantage,” published by the Academy of Management Journal, suggested that extroverted leaders actually can be detrimental to group performance when employees are inclined to demonstrate proactive behavior, such as voicing constructive ideas and taking personal initiative to improve work methods. Conversely, though, when employees aren’t proactive, extroverted leaders can help increase performance. “[Introverts] can often give people a sense of calm because they seem outwardly unraveled,” Williams says. “The problem with extroverted leaders is they are not always comfortable with silence, so they don’t always listen as well as introverted leaders do.” Over the years, Riddle has realized that she does things differently than many of her colleagues, especially when it comes to interacting with others and participating in meetings. “I think as introverts we tend to think more, talk less, which sometimes has its advantages and allows for a little more diplomacy,” Riddle said. “I think that we are good at reading other people and, you know, having that sort of emotional

88 VOL. 59 • NO. 2 • 2018

Introverts can learn to use natural skills such as listening and thoughtfulness to their advantage when working towards leadership positions, Riddle says. She also recommends cultivating mentorships and, importantly, taking the time needed to recharge. As Riddle transitioned into her role as chief resident, she noticed that her colleagues have begun to change the way the treat her. “I have realized that I am capable of doing this, and other people also think of me that way and think of me as a leader, so it just becomes more comfortable,” she says. “When I push myself to say something at a meeting, people will listen because they respect what I have to say.” After years of working with doctors on both sides of the spectrum, Williams believes leadership has less to do with whether a person is introverted or extroverted and more to do with self-awareness. “I find that there are not advantages or disadvantages,” she says, “it’s just that the issues are different.” Williams says introversion and extroversion describe an individual’s preference, not a permanent state of being. The question is really about which style of relating is more personally invigorating. She compares it right- or left-handedness. While everyone has a preference, it is possible to learn to use the other hand if circumstances demand it. Q Reprinted with permission from the American Association for Physician Leadership – https://www.physicianleaders.org/

Addiction is a chronic, progressive, potentially fatal, treatable disease. Thatâ&#x20AC;&#x2122;s why we offer a full continuum of care designed to support long-term recovery. Medical Detox â&#x20AC;˘ Residential â&#x20AC;˘ IOP â&#x20AC;˘ PHP â&#x20AC;˘ Sober Living â&#x20AC;˘ Aftercare â&#x20AC;˘ Alumni 3 Ä?-Ä? iĂ&#x20AC;Ă&#x152;Â&#x2C6;wi` Medical Director 3 24/7 Nursing 3 CARF Accredited 3 iĂ&#x20AC;Ă&#x152;Â&#x2C6;wi`

3 Equine Therapy 3 Wilderness Therapy 3 Art Therapy 3 Fitness Center 3 Challenge Course

3 Semi-private Rooms 3 Dual Diagnosis 3 12-Step Based 3 24/7 Admission 3 BCBS-MS Accepted

Quality, research-based treatment for drug and alcohol addiction 110-acre residential campus in Lafayette County â&#x20AC;˘ 1WVRCVKGPV QHĆ&#x201A;EGU KP 1ZHQTF 6WRGNQ CPF 1NKXG $TCPEJ Young Adult Program

Experiential Therapies

Family Programs

Call for Referrals Mary L. Smith Director of Admissions 662.281.9992 ext. 1 mlsmith@contactaac.com Not Medicaid eligible

Oxford Treatment Center â&#x20AC;˘ 297 CR 244 â&#x20AC;˘ Etta, MS 38627 â&#x20AC;˘ oxfordtreatment.com An American Addiction Centers Facility JOURNAL MSMA

L E A D E R S H I P

Why Doctors Make Poor Leaders and What You Can Do About It DIKE DRUMMOND, MD

ne of the big practice challenges most of us face is a frustrating gap in our physician leadership skills. We step out of residency and are instantly installed as the leader of a multidisciplinary team charged with delivering the highest quality care to our patients. This new physician leadership role can be daunting. We are prepared to diagnose and treat … but what about all the other questions about patient flow and personnel issues that come our way? At times It can feel like you don’t “have what it takes” when, in fact, this physician leadership vacuum is a natural consequence of our medical training and medicine’s unique business model. And if you take on a leadership role in your organization - say, a medical director or CMO - your inability to navigate a complex bureaucracy and intricate matrix of relationships will become immediately apparent. How can you be an effective physician leader, when all you were taught to do is see patients?

Here are three challenges to acquiring physician leadership skills that are hard wired into our training process – with suggestions on how to bypass them for a better day at the office for you, your staff and your patients. Without these skills you are doing all the heavy lifting for your team and working WAY too hard. 1) A Dysfunctional Default Physician Leadership Style Our medical training is almost exclusively focused on our clinical skill set. We take a minimum of 7 years in medical school and residency to learn and practice the ability to diagnose and treat. That knowledge base is nearly overwhelming all by itself and it is unfortunately not sufficient once we are out in practice. Once we graduate we quickly recognize that the act of seeing patients and delivering our treatment plan is dependent on a whole team of people. We are meant to be an effective team leader right out of the gate, but were never taught the basic physician leadership skills to play this role. We automatically adopt a dysfunctional physician leadership style based on “giving orders.” The clinical actions of diagnosis and treatment are simply adopted as our default physician leadership style. When faced with any practice challenge, we assume we must be the one who comes up with the answers (diagnose) and then tell everyone on the team what to do (treat).

90 VOL. 59 • NO. 2 • 2018

We learn a “top-down” physician leadership style naturally and automatically. This default “command and control” physician leadership style – the same one used in the military – has its consequences. It turns your team into sheep. Here’s what I mean … It will seem to you like they have lost the ability to make independent decisions. Dike Drummond, MD Everything they perceive as a problem — from the front desk to the billing office — is brought to you for a solution. Have you ever felt overwhelmed by people asking you non-clinical questions about scheduling, billing and such? The top-down physician leadership paradigm produces that naturally. They all look to you for answers because you are the apex of the top-down pyramid. It does not have to be that way. A simple change to a more collaborative and team centered physician leadership style can make a huge and immediate difference. What you can do diﬀerently? Physician Leadership begins when you understand there are multiple areas of your practice where YOU ARE NOT THE EXPERT — and start to use the whole team’s expertise to address the problems you are facing. After all, you are in the room with the patient, doing your best to solve the clinical issues while the rest of your staff spends their day actually working in your scheduling and billing systems. They are the experts in what is going on in those areas … not you. The key to leveraged physician leadership is not you figuring out the answers … it is easier than that. The key is to ask more questions … and give fewer orders Try becoming more of a facilitator … not “the boss” and source of all the answers. A more effective physician leadership style is to ask your people what THEY suggest as the solutions to the problems they discover. You might even tell them to only bring you a problem if they bring their thoughts on a solution at the same time.

Have regular meetings where you work “on” the practice and deal with these issues as a collaborative team … rather than spending all your time working “in” your practice. This is the key to a much more effective physician leadership style. You begin leveraging the skills and experience of your entire team. When you work together to systemize and delegate you won’t feel like you are doing all the work and your team will feel honored and more involved. A better practice experience for you, your staff and your patients will result. 2) No Physician Leadership Training and a Nonsensical Business Model When did you ever receive training on physician leadership skills? Didn’t happen in my residency. It is foreign territory for most of us. Physicians as a group tend to see physician leadership, facilitation and the meetings required to coordinate the actions of a team as necessary evils we would like someone else to address. I have heard this over and over. “I just want to be left alone and see patients.” That is because you were only trained to perform that activity. The subjects of physician leadership and organizational development are absent in our medical training and yet become crucial to our success out in practice. Then there is our business model … which often makes no sense at all. Imagine the CEO of an automobile manufacturer who is simultaneously the only person who can put the doors on the cars in the assembly line. The boss is the biggest bottleneck in the system. Who would design a business like that? Welcome to the world of medicine. You are the leader and the piece worker on the line at the same time. You have the complete skill set to do your work on the line … seeing patients behind a closed door in the office. Unfortunately, your physician leadership skill set is ignored at the same time that it is required to fill the other major role you play in the practice. The key is to respect, understand and begin acquiring physician leadership skills. Understand how to lead effectively will make your life easier and your team and patients happier and healthier. A great place to start is to beef up your physician leadership skills with some of best books on the general subject of business leadership. Books like these classics. “First Break All the Rules” “The E-Myth” “The Five Dysfunctions of a Team” “7 Habits of Highly Effective People” “The Leadership Challenge” “What Got You Here, Won’t Get You There” Any of these books will give you multiple instantly effective tools you can use with your teams.

3) We Demonize Managers and Become Part of the Problem If I say – “Medical Director” to you … what are the first words that come into your head? I will wager they were not positive ones. This common knee jerk reaction has important negative consequences for everyone. Physicians as a group tend to see anyone in a management role as “the enemy”. If these people would just do their jobs, we could finally be left alone to “just see patients”. These are the “bean counters” and “pencil pushers”. It gets even worse if that same manager, medical director or administrator is also a physician. For those of our brothers and sisters who have stepped into administrative roles … we tend to see them as failures, traitors … “they’ve gone over to the dark side” or worse. We demonize managers/administrators at our own risk These organizational leaders are charged with managing and improving the function of the larger systems that play such a big role in your practice. We can fight them and become part of the problem. We have all seen and done this … bringing them only problems and complaints. Our interactions can become hostile venting sessions and nothing gets accomplished. Or we can take responsibility to become part of the solution As a team leader in the front lines of patient care, you can make a difference by working to influence and support these managers and administrators. You and your team have valuable experience to share with those who are charged with running and improving these larger systems. This physician leadership role at this larger system level is even more important now as hospital based physician networks are rapidly forming across the nation from what used to be independent practices. • What are your suggestions for improvement in these larger systems? • W ho needs to know and how can you help them implement the changes you recommend? We can each play a role in helping these larger systems become more functional, but not if we retreat to our exam rooms and simply complain. In my experience, any efforts doctors put into their own physician leadership development pays immediate dividends. Putting some effort into • Studying Physician Leadership • Leveraging your team with your new physician leadership skills • Playing a role in improving the larger systems is a way to quickly improve the practice experience for you and your staff and the quality of care you and your team provide to your patients. Q Reprinted with the permission of Dike Drummond, MD, CEO of www.TheHappyMD.com. Burnout Prevention & Leadership Development for Physicians

JOURNAL MSMA

L E A D E R S H I P

Are You a Physician Leader?

PLA Group 2017-2018: Front Row (L to R) Drs. Tamara Glenn, Dedri Ivory, Michelle Owens, LaToya Mason. Second Row (L to R) Drs. Renia Dotson, John Vanderloo, Roderick Givens, Corey Jackson, Christy Vowell

Refine your skills through MSMA’s Physician Leadership Academy “I wish they taught this in medical school…” That’s the number one comment we hear from physicians at the MSMA Physician Leadership Academy. And, it’s why your state medical association has stepped up to offer physicians of all ages the specific leadership training they need to thrive in the new world of medicine. Physicians need to know a few things that aren’t taught in medical school: the skills to influence the medical environment, how to collaboratively lead multi-disciplinary teams, when to use media/communications to advance ideas, how regulators affect your practice and ways to convincingly voice the physician’s position with lawmakers. Physicians are seeking ways to prepare for and lead organizations like practice groups, medical staffs, management teams, MSMA; and, the Physician Leadership Academy is the answer. Participants gain valuable experience in core aptitudes so they can excel in leadership positions within their own practice, in organized medicine, and the public policy arena. Here’s what scholars say: “This is something every doctor needs.” “I have already used my new skills with my patients, staff and

92 VOL. 59 • NO. 2 • 2018

colleagues.’ “I’m ready for more; when does the advanced class start?” MSMA is expanding our efforts to include leadership sessions for residents as part of their didactic training. In addition, on-line CME has been developed by MSMA for members to access via In-Reach. We appreciate the support of The Physicians Foundation grant which allows MSMA to provide these leadership opportunities to our members. For more information, please visit our website at MSMAonline.com.

L E A D E R S H I P

Growing Leaders in Medicine

PLA Group 2016-2017 Front Row (L to R) Drs. Scott Hambleton, Meredith Travelstead, Son Lam Second Row (L to R) Drs. Chaz Richardson, LaFarra Young, Shawn McKinney, Ann Chancellor Roberson, Peggy Ladner Boles, Justin Turner

PLA Group 2015-2016 Front Row (L to R) Drs. Jonatham Adkins, Angela Shannon, Gerald McKinney, Chasity Torrence, Jonathan Jones Second Row (L to R) Drs. Ervin Fox, Daniel Venarske, Hossein Behniaye, Angela WingďŹ eld, Angela Pennington, Tondre Buck

JOURNAL MSMA

L E A D E R S H I P

Growing Leaders in Medicine

PLA Group 2014-2015 Front Row (L to R) Drs. Barbara Saunders, Violet Yeager, Robin Schwartz, Carlos Latorre, Page Branam, Mark Horne Second Row (L to R) Drs. William Waller, Chris Schwartz, Joe Austin, Timothy Beacham, John Cross, Kenneth Thomas

The Heart of Hospice Difference At Heart of Hospice our mission is to serve all hospice eligible patients the way they desire to be served. We work with each patient to develop a plan of care that is unique to their specific situation. Physical therapy, IV therapies, radiation and other comforting treatments approved by the physician may be included in the patient’s plan of care. As always, the Heart of Hospice team will be working 24/7 to admit eligible patients who need our care. HEARTOFHOSPICE.NET * Counties shaded blue represent Heart of Hospice’s service area

Transforming end-of-life care in the communities we serve

94 VOL. 59 • NO. 2 • 2018

HEART OF HOSPICE

MISSISSIPPI Northwest Delta Jackson Southern Referral Line: 1.844.HOH.0411

M S M A

Jill Gordon Joins Staﬀ as Marketing Director

he Mississippi State Medical Association welcomes Jill Gordon as Director of Marketing. “I’m excited,” Gordon said. “This role will offer many unique opportunities that will allow me to bring ideas to the table and utilize the experience I gained in the Banking and Financial services industry. Get ready to see lots of exciting things happening at MSMA.” After 18 years in banking and finance, Gordon is now turning her talents to expanding membership and increasing participation at MSMA. She will be seeking qualified partners for the organization as its membership grows that will further increase membership value. “My core talent is helping people,” Gordon said. “By engaging our members and finding the right business connections, I know we will take the MSMA’s mission to the next level.” Contact Jill: JGordon@msmaonline.com | 601.853.6733 ex. 324 Follow Jill for exciting news and announcements: LinkedIn @jwgordon2

Pain.

Jill Gordon Director of Marketing

Why not start relief hiropractic? with chiropractic?

Harvard Medical School has stated that “chiropractic actic spinal raine, neck pain, manipulation may be helpful for back pain, migraine, and whiplash.” on (JAMA) The Journal of the American Medical Association ack pain, spinal recently found that in “patients with acute low back st improvements in pain and function.” manipulative therapy was associated with modest Every day, more voices join in the call to addresss pain with a conservative, non-invasive, non-addicting approach. i id crisis i i that h iis affecting ff i millions illi i We stand ready to contribute in overcoming the opioid off A Americans. Let’s do this. Together.

NewSouth NeuroSpine Campus 2470 Flowood Drive, Suite #125 | Flowood, MS 39232 | (601) 932-9201 | DrFoxworth.com JOURNAL MSMA

P H Y S I C I A N

L E A D E R S H I P

MSMA

A C A D E M Y

Spotlight

Renia Dotson, MD, MPH

r. Renia Dotson decided to go into medicine at an early age after a life-changing event.

“At the age of 13, my mother underwent cardiac arrest in front of me,” Dr. Dotson said. “Needless to say, she didn’t make it. I simply didn’t know what to do; I didn’t know CPR or anything. And I vowed that I would never again not know what to do in a situation like that.” A specialist in colon and rectal surgery, Dr. Dotson chose her specialty for the precision and the decisiveness required in its practice. She found the ability to make clear, focused decisions a perfect fit for how her mind works. As she worked her way through medical school and residency, Dr. Dotson found inspiration and career guidance from many of the physicians she studied under and worked with. There was no single mentor but many who ushered her toward her goal.

96 VOL. 59 • NO. 2 • 2018

“I was more of an observer and I tried to observe all of them and take lessons from them,” she said. “There was no one person but it was more like a village, a whole team of people I drew inspiration from.” By participating in the MSMA Physician Leadership Academy, Dr. Dotson is affirming her belief in the purpose of organized medicine, both as a way to protect physicians and as a way to get patients the care they need. “Organized medicine is important because it is the wave of the future, and if we don’t address it and take the lead in developing organized medicine, something else is going to be handed down to us that we have to live with,” Dr. Dotson said. “We need to come to the table and bring our expertise to the table to develop something that works for everyone. We as physicians are uniquely qualified to do that.”

P H Y S I C I A N

L E A D E R S H I P

MSMA

A C A D E M Y

Spotlight

Roderick Givens, MD r. Roderick C. Givens believes this is an exciting time to be practicing medicine and a challenging time as well. Physicians today are called on more than ever to be patient advocates and exemplars of a vital part of American society. A radiation oncologist, Dr. Givens sees how technology and health care are increasingly interwoven.

Dr. Givens throughout medical school and residency training. “They challenged me as a person to develop into a compassionate individual who combined technology with medicine and offered a human side that is critical to being a good being a physician,” he said. “Those lessons impacted me immeasurably both professionally and personally.”

“In med school, I saw the extraordinary advances that were on the horizon with respect to cancer research and treatment,” he said. “As computer programming, performance and operation have exponentially developed, I have seen breakthroughs that would have been unimaginable in years past but would show an explosion as far as advances in the future.”

Dr. Givens sees organized medicine and the MSMA Physician Leadership Academy as necessary in today’s complex, multilayered world of health care. The competing interests of government, insurance companies and those who actually work with the patients make it more important than ever for physicians to advocate for themselves and their patients.

This focus on technology in no way is a substitute for the human side of practicing medicine, and Dr. Givens was inspired in high school by the compassion of his family’s primary care physician. Seeing this doctor in action led him to choose medicine while in high school. Other mentors inspired

“I hope that through organized medicine, we can develop the ability to truly practice medicine in a reasonable and cost effective way,” Dr. Givens said. “But most importantly, to practice medicine in the appropriate manner that works best for the patients.”

JOURNAL MSMA

P H Y S I C I A N

L E A D E R S H I P

MSMA

A C A D E M Y

Spotlight

Tamara Glenn, MD or Dr. Tamara Glenn, pursuing a career in medicine came after a loved one was diagnosed with a chronic disease. Having recently completed her undergraduate degree at the time, Dr. Glenn was in the field of research, but helping her close relative navigate the illness brought her a new awareness.

them balance educational pursuits, service to others, and raising a family all while serving an at times thankless community. They have taught me a great deal about life that has helped me to grow as a person and many of these lessons are applicable to my growth as a physician as well.”

“The journey opened my eyes to the limited access many have to health care,” Dr. Glenn said. “As a result, I decided to pursue a career in medicine to become an advocate for others in a similar quandary.”

As a participant in organized medicine and in the Physician Leadership Academy, Dr. Glenn sees many opportunities for personal growth and professional development. Still in the early stages of her career, she wants to make a difference in any way she can.

A native of Carthage, Dr. Glenn went to the Mississippi University for Women for undergraduate school and currently is in her residency at the University of Mississippi Medical Center, where she also attended medical school. Along the way, a couple of key mentors influenced her world view. “Rolanda Johnson, Ph.D. and Pastor Carl Johnson are close family friends and long term mentors,” Dr. Glenn said. “I have watched

98 VOL. 59 • NO. 2 • 2018

“Organized medicine is a way for doctors to collaborate with and engage non-treating stake holders involved in healthcare to discuss the most efficient means of providing medical care to patients,” she said. “Organized medicine is vital in today’s complex health care environment. If physicians are going to do what’s best for their patients and their profession, they have to band together and speak up for what’s right for medicine and for their fellow citizens.”

P H Y S I C I A N

L E A D E R S H I P

MSMA

A C A D E M Y

Spotlight

Dedri Ivory, MD

n innate curiosity and a driving need to know the “why” of illness and disease led Dr. Dedri Ivory to the practice of medicine. As early as high school she shadowed physicians in her hometown and knew that medicine was a calling for her. As a rheumatologist and immunologist, Dr. Ivory delves deeply into medical mysteries as part of her work. This helps her focus on the science of the problems before her while attending to the patients’ needs. “My specialty is the ‘C.S.I.’ of medicine because so much of what we do is solving medical mysteries,” Dr. Ivory said. “I use that investigative mindset every day, and I try to engage my patients in the mechanisms of their condition and get them to be as curious about their health as I am.” Through med school and residency, Dr. Ivory learned from her mentors not just the science of medicine but also the caring part as well.

“These mentors showed me that medicine was so much more than just writing prescriptions,” she said. “They believed in a patient-centered approach to healthcare, and challenged me to keep my patients accountable to their outcomes while still being their advocate. One of the greatest lessons I learned from them was the ability to walk the tightrope between advocacy and clinical care.” As a participant in the Physician Leadership Academy and a believer in organized medicine, Dr. Ivory hopes to increase her ability to advocate for physicians and patients alike. She also believes that when physicians organize, they share information with each other and help the profession grow as a whole. “By being part of the Leadership Academy I hope to gain the ability to better use my voice,” Dr. Ivory said. “Physicians are on the front lines every day, yet too often it seems as if policies overlook the role we play. The Leadership Academy will help me become a better advocate for my patients and for my medical practice.”

JOURNAL MSMA

P H Y S I C I A N

L E A D E R S H I P

MSMA

A C A D E M Y

Spotlight

Corey Jackson, MD

or Dr. Jon Corey Jackson, the practice of medicine is a reflection of the values he holds. A psychiatrist with University Physicians, Dr. Jackson knew he wanted to be a doctor before most people know where they want to go to college. His inspiration came from another physician. “One of many heroes during early life was Dr. Henry Lewis, my family physician,” Jackson said. “He was brilliant when it came to his craft, and his down-home, matter-of-fact bedside manner was always clear and concise yet friendly at the same time. He formed relationships with his patients and always came across as both genuine and sincere.” With Dr. Lewis as his inspiration, Dr. Jackson told his parents when he was a preteen that he wanted to go into medicine. Choosing a path in healthcare was less clear—until he attended his first lecture in psychiatry. “I was immediately enthralled!” he said. “I was thrilled to find something so interesting hiding in those first two years of

100 VOL. 59 • NO. 2 • 2018

classroom instruction.” In medical school, Drs. Bo Holloman, John Norton and Maxie Gordon were especially inspirational. And Dr. Grayson Norquist gave Dr. Jackson his current position at the University of Mississippi Medical School. As a practicing psychiatrist, Dr. Jackson finds reward and fulfillment in championing his patients’ positions and advocating for advancements in treatment. Dr. Jackson believes in organized medicine as a way to bring physicians from disparate specialties together to advocate for the well-being of patients. This gives physicians a collective voice that resonates louder than any one voice could. By participating in the MSMA Physician Leadership Academy, Dr. Jackson hopes to be a stronger participant in the collective voice. By honing his skills, he hopes to be a stronger, more meaningful advocate for medicine and for patients. And, perhaps, be the type of doctor his younger self would look up to.

P H Y S I C I A N

L E A D E R S H I P

MSMA

A C A D E M Y

Spotlight

Lori Marshall, MD

r. Lori Marshall approaches the practice of medicine with the mind of a scientist and the heart of a person who cares.

An anesthesiologist at Premier Pain Care in Jackson, Dr. Marshall regularly sees patients when they are at their most desperate. Developing an approach to each patient’s treatment involves rigorous thought and genuine empathy. “The work is rewarding and very challenging,” Dr. Marshall said. “My patients look to me for guidance and care. I work hard to treat the person while I’m treating the symptoms.” She earned her M.D. from the University of Mississippi School of Medicine, where she received the Don Q. Mitchell Barksdale Scholarship for academic excellence. At UMMC, Dr. Marshall also was Director of the Anesthesiology Internship Program and Program Coordinator and Recruiter for the Medcorp Direct Program through the Division of Multicultural Affairs.

While immersed in medical school, she drew inspiration for the shape of her career from her professors and mentors. “When you’re studying and working to become a physician, mentors are vital to your growth,” Dr. Marshall said. “I modeled behavior and goals based on the guidance they gave me.” As a participant in organized medicine, Dr. Marshall is committed to advocating for her profession and for patients. She believes in representing health care professionals and those they care for. “When you see how fast medicine is changing and how many different pressures are brought to bear on providers, it makes sense to be an advocate,” Dr. Marshall said. “Physicians who want the best for their patients and their profession have to speak up. That’s why I’m a part of organized medicine and why I joined the 2017-2018 class of the MSMA Physician Leadership Academy.”

JOURNAL MSMA

101

P H Y S I C I A N

L E A D E R S H I P

MSMA

A C A D E M Y

Spotlight

LaToya Mason, MD

r. LaToya Mason believes in embracing the everexpanding role of the physician, not retreating from it. She sees it as the legacy given to her by her mother, who worked for 36 years as a teacher and mentor. “It has always been an inherent desire of mine to pursue a career that affords me opportunities to share knowledge with while positively impacting the lives of others,” Dr. Mason said. “Etymologically speaking, the word 'doctor' means 'to teach' but the role of a doctor does not terminate there.” An Associate Professor of Anesthesiology at the University of Mississippi Medical Center, Dr. Mason has opportunities to influence students and residents while practicing her profession and conducting research. It’s a busy life, but she wouldn’t have it any other way. “I regularly help educate physicians-in-training, thereby directly impacting the perpetuation of quality anesthetic care in the state of Mississippi,” she said. “I have edited a major textbook of obstetric anesthesia and written several articles in peer-reviewed

102 VOL. 59 • NO. 2 • 2018

journals. I have played various minor roles on a myriad of clinical investigations.” While owning her role as a physician-teacher-educatormentor, Dr. Mason is also fully aware of how the physician’s role is ever expanding. Rather than shy away from this trend, she is dedicated to keeping current. “In this era of modern day medicine, the role of the physician must also encompass business concepts, given that healthcare reform and improved access to healthcare are forefront in the minds of many,” Dr. Mason said. “More than ever, the physician must be cognizant of both best medical practices as well as wise business and practice management decisions as our nation struggles to navigate the economics of health care. For these reasons, I embrace the opportunity to be a participant in the 2017-2018 MSMA Physician Leadership Academy.” By placing no limits on herself, Dr. Mason hopes to continue to grow as a physician and a leader.

P H Y S I C I A N

L E A D E R S H I P

MSMA

A C A D E M Y

Spotlight

Shawn McKinney, MD

or Dr. Shawn McKinney, the practice of medicine is a combination of curiosity, compassion and working with her hands. A general surgeon specializing in breast surgery, Dr. McKinney uses her skills and avid interests to make a difference in her patients’ lives.

helped lead her to medicine as a career.

“I think what I find most rewarding is really connecting with patients and explaining their disease to them in a way they can understand,” she said.

During her studies at Morehouse School of Medicine, Dr. McKinney found great support among the African-American faculty and students, helping her to envision her own career as she moved forward. As a member of the MSMA Physician Leadership Academy and a believer in organized medicine, Dr. McKinney believes that strengthening the voice of medicine is better for doctors, patients and the greater good.

“Patients tell me things they don’t tell anyone else, and there is an immense amount of vulnerability that comes with allowing someone to operate on you. It is my job to make my patients comfortable, educate them, and then fight with them as they battle the disease.”

“Organized medicine is important to me because I am seeing the big picture with regards to policy and how it impacts not just one person at a time, but a whole community, state, and nation,” she said. “Changes can make a major impact and push the needle in a more positive direction.

As a child growing up in New Orleans, Dr. McKinney’s mom worked in a non-medical position at the VA Emergency Room. An established physician at the VA showed Dr. McKinney around from time to time, making a lasting impression that

“I hope to learn how to be a more effective leader, both in my immediate organization and more national organizations. I want to become more involved in improving the health status of this state.”

JOURNAL MSMA

103

P H Y S I C I A N

L E A D E R S H I P

MSMA

A C A D E M Y

Spotlight

Michelle Owens, MD

eadership seems to come naturally to Dr. Michelle Owens, but she stills sees value in continuing to develop her skills. An obstetrician and gynecologist, Dr. Owens practices in Jackson. She joined this year’s class of the Physician Leadership Academy to help hone the skills she already possesses. “I’ve been blessed with many opportunities outside my practice,” she said. “And I know if I continue to work on my leadership skills, I can continue to grow.” Joining the 2018 PLA class puts Dr. Owens in a good spot for adding to her leadership bona fides. Practicing at the University of Mississippi Medical Center, she has been on the faculty at the School of Medicine since 2007. She also was appointed to the State Board of Medical Licensure in 2016 by Gov. Phil Bryant. Dr. Owens attended medical school at the Virginia

104 VOL. 59 • NO. 2 • 2018

Commonwealth School of Medicine, where she was helped by a number of mentors who set examples for how she was to practice medicine. “Many wonderful professors guided me through the process of becoming a physician,” she said. “As a young student, I modeled myself after those physician leaders who demonstrated kindness and knowledge and expertise.” This is a tumultuous time for health care in Mississippi and across the country, and for Dr. Ow-ens, organized medicine is needed more than ever. Which is why she stays involved with MSMA and enjoys the lessons of the PLA. “Physicians need to realize what is at stake,” Dr. Owens said. “Only through organized medicine will we, as health care professionals, make our voices known. As we fight for the best health care for our patients, we have to employ a strong, unified voice. It’s great to be a part of that voice.”

P H Y S I C I A N

L E A D E R S H I P

MSMA

A C A D E M Y

Spotlight

John Vanderloo, MD

o Dr. John Vanderloo, being a physician is the best job in the world and he wouldn’t do anything else if he could. In an era when the pressures on doctors are mounting, his optimism can be surprising. But for him the work is vividly rewarding. “We rejoice, and we cry, we conquer some diseases and are waylaid by others,” Dr. Vanderloo said of being a physician. “The whole time we try to be beacons of light to guide our patients, particularly those marginalized by society. The most meaningful interactions have been when I was able to hold the hand of a dying patient and then comfort their loved ones afterwards.” The son of a doctor, he veered toward law school right after college before realizing his true calling was medicine. Dr. Vanderloo was deeply influenced by Dr. Shannon Pittman while in medical school. “She sets lofty expectations yet gives tools to achieve those expectations,” he said of his mentor. “She has a remarkable

way of being genuine with everyone she meets, as well as amazingly funny. She taught me professionalism, leadership, and compassion.” A family medicine physician, Dr. Vanderloo finds the variety of the daily practice refreshing and challenging. But what he finds truly significant is connecting with his patients in a meaningful way. “The most rewarding aspect is the relationship I build with my patients,” he said. “I love seeing multi-generational families. Of course, with this variety comes an enormous number of differentials, so I love the challenge of constantly thinking and honing my practice.” By participating in the MSMA Physician Leadership Academy, Dr. Vanderloo hopes to increase his participation in organized medicine. He also wants to be better at all aspects of his life and his profession. “I hope to become a better physician, spouse, friend, and advocate, both for patients and for physicians,” he said.

JOURNAL MSMA

105

P H Y S I C I A N

L E A D E R S H I P

MSMA

A C A D E M Y

Spotlight

Christy Vowell, DO

ong before she became a physician, Dr. Christy Vowell got a chance to help someone in physical distress. When she was 12, she found an elderly next door neighbor injured after falling out of a swing. Dr. Vowell called 911 for help, and a passion for medicine was begun. As an Osteopath, Dr. Vowell practices family medicine in Eupora. She finds greatest reward in sharing important life moments with her patients. “As I experience the joy, the hope of healing and even the peace and comfort of death at times, it is shared with a soul,” Dr. Vowell said. “I have the ability to treasure that part of one’s health and sickness with individuals as I grow close to them in caring for all their needs.”

Being on the front lines of medicine as a family practitioner, Dr. Vowell sees almost daily challenges that go well beyond the actual treatment of patients. These include more rigorous control of health care by insurance companies and government agencies, decreased time with patients, greater administrative control,

106 VOL. 59 • NO. 2 • 2018

electronic medical records and overall physician fatigue and burnout. It’s because of these challenges that she sees how vitally important organized medicine and the Physician Leadership Academy are. “Organized medicine is the only way for physicians to truly keep our voices heard,” Dr. Vowell said. “Unfortunately, physicians are behind the curve on keeping up with these changes and this is in part due to our focus on caring for all of our patients. We have allowed changes to occur that have directly affected the way we practice medicine while others have pushed agendas not in physicians’ best interest.” But Dr. Vowell believes physicians can play an active part in influencing the future of medicine, for doctors and patients alike. “Physicians together can create change if we work together, and I am optimistic that through strong organized medicine groups this will allow for change in the right direction,” she said.

L E A D E R S H I P

The Higher You Go: A Physician Leader Shares Lessons Learned DAVID J. NORRIS, MD, MBA, CPE

to please everyone will simply ensure you will fail as a leader. Your job as a leader is to provide vision and guidance to your people as the organization marches toward its goals. This is why it is critical to have a solid mission and purpose in mind.

The higher you go, the harder it gets.

The higher you go, the more important your actions and behaviors become.

One principle seems to be constant: As you advance in an organization, your job gets more complicated and what is required of you grows. ’ve learned many key lessons working with other physician leaders during my career. One universal principle seems to be constant in every leader’s life: As you advance in an organization as a leader, your job gets more complicated and what is required of you grows.

As you grow as a leader, expect things to get harder, more challenging, more complex and more ambiguous. Whether you’re dealing with patient care, personnel, finances or process improvement issues, the gray areas grow. It becomes more challenging to know what the right decision is. You will realize there might not be one perfectly correct solution or answer. Your duty as a leader is to find the best answer that moves the organization closer toward fulfilling its purpose. You will learn that ambiguity is sometimes the best you can get. The higher you go, the more you will need to know. Your journey merely begins as you transition into leadership. New areas of knowledge, such as finance, leadership and process improvement will be needed if you are to be as effective as possible. Emotional intelligence and communication skills will help you tremendously as you lead others into the future. As more is required of you, the more you will need to grow and expand yourself. Join a leadership organization and network with other leaders. Learn from others when you can. Work each day at improving yourself and growing as a leader. Leaders are made daily, not in a day. The higher you go, the more you’ll give up.

Everyone typically looks to a leader for guidance. They watch and observe the leader’s behavior. Do they cut corners? Do they say one thing and do another? I think this is one of the hardest areas for leaders. People will follow the example we set, so be a model of the behavior you want to see in your organization. If you want a culture of patience, compassion and excellence, then work on yourself every day to display those attributes in your life. It takes time for it to catch on in the organization but it will. As one of my mentors once told me, you cannot lead others if you cannot lead yourself. The higher you go, the more important your “why” becomes. Sometimes it isn’t much fun being a leader. Stress can easily creep into your life. People will bring their problems to you, looking for you to solve those problems for them. You will be pulled in different directions by the differing motives and agendas of others. If you don’t have mission and purpose to guide you, you can easily get sidetracked and set off course. To remain grounded, you must know who you are and why you are doing what you are doing. The best way to stay focused on your why is to join an organization whose why is aligned with yours. If you do that, staying on track will be much easier.

As you grow into your leadership position, more time will be requested of you. You might be appointed to various committees, and your obligations to others will grow. Your schedule will begin to fill and you might begin to feel that you’re not in control of your calendar. Others in your organization will request more of your time and energy as they look to you for answers, help and guidance. You will need to learn to prioritize and protect your time and energy.

The higher you go in leadership, the more rewarding it gets.

The higher you go, the more unsure you may be in your decisions.

David Norris, MD, MBA, CPE, an anesthesiologist in Wichita, Kansas, is also a partner with the Center for Professional Business Development and author of The Financially Intelligent Physician (Author Academy Elite, 2017).

Leading others isn’t easy. It can be challenging to know what the best decision is. You will have many who want to “help” you make a decision. Your job as a leader isn’t to please everyone. Trying

As with most things in life, the most rewarding activities are those that are challenging and difficult. Leading others is no different. It can be very challenging some days. Yet, at the same time it is one of the most rewarding activities you can engage in. If you’re a true leader, you not only help your people and organization get better and stronger, but also you grow and improve yourself. Q

Reprinted with permission from the American Association for Physician Leadership – https://www.physicianleaders.org/

JOURNAL MSMA

107

L E A D E R S H I P

The Leader in my Mirror CHARLES (CHUCK) SAMPSON

few years ago, I was conducting a leadership development program for a group of emerging leaders in a large scientific organization. These were highly educated professionals who had been promoted into leadership positions by virtue of having done well in their technical disciplines and/or having hung around long enough to be offered a promotion. I could tell some people in the room were skeptical about the topics we would be covering in our week together: The Myers-Briggs Type Indicator. Communication. Conflict Management. Team Development. It was Monday morning and participants were introducing themselves, offering their distinctions between managing and leading, and sharing their observations about what effective leaders do (and don’t do) in their attempt to influence others. One participant – we’ll call her Kate – appeared to grow increasingly impatient with the exercise. Her facial expression and posture all said she wasn’t buying any of what she was hearing from her fellow participants. Finally, she spoke, “I’ve been sitting here listening to you all talk about how to lead and manage people and I’ve got one piece of advice for you: Before you manage me, manage YOU.” To describe the moment that followed as “tense” would be an understatement. How to respond? The truth was, she’s right. I now refer to her insight as “Kate’s Admonition”. And it has important implications for physician leadership development. Kate had first-hand experience with people in positions of formal authority (not the same as “a leader”) influencing others poorly. They access the wrong tool, or access the RIGHT tool but don’t use it well, because they haven’t taken responsibility for the condition of their own emotional state first. Sound familiar? Leaders who lack self-awareness have little hope of being able to manage themselves in the face of stress and, when they attempt to influence others, will do so poorly. The order is important. All of the introductory discussion had been about leaders behaving in ways that influenced others favorably. Participants held up examples as if to say “That’s what an effective leader does and that’s what I want to do.” Their aspirations were genuine. It was Kate, however, who zeroed in on the hidden work that precedes the actions we admire. She knew that

108 VOL. 59 • NO. 2 • 2018

’ve been sitting here listening to you all talk

about how to lead and manage people and I’ve got one piece of advice for you: Before you manage me, manage YOU. leadership is about “knowing thyself ” before it is about “technique”. It turns out that Kate’s Admonition lines up with a growing body of empirical evidence that supports both formal physician leadership development and development of self-awareness in particular. • An August 2017 New England Journal of Medicine article confirms what many healthcare providers have known all along: simply appointing a doctor to a leadership post in a healthcare organization isn’t enough.1 • Support for physician leadership development is lacking in most healthcare organizations. 67% of the respondents to a 2015 survey by the American Association of Physician Leadership said that their organizations valued physician leadership “highly” or “very highly”; however, less than half had a formal leadership development program in place.2 These are two sources among many making the case for physician leadership development. Add to these a 2009 study by Green Peak Partners and Cornell University that invites a closer look behind a leader’s actions. Green Peak Partners recruits senior executives for public, venture backed and private equity companies. The stakes are

high in this arena and the egos can be large. Every candidate for executive leadership has a platinum resume. What distinguishes the best candidate for placement? What is the best predictor of executive success? According to the Green Peak-Cornell study, it’s high self-awareness. This is not altogether surprising as executives who are aware of their weaknesses are often better able to hire subordinates who perform well in categories in which the leader lacks acumen. These leaders are also more able to entertain the idea that someone on their team may have an idea that is even better than their own.” 3 Physician leadership development must include building technical skill4 in disciplines like financial analysis, operations management, and strategic planning. The bigger challenge always lies in moving from knowledge to practice – an adaptive skill: it’s one thing to understand the financial basis for quality metrics used by non-clinical administrators in decision-making; it’s another thing entirely to hash out implementation with those same administrators, fellow physicians and clinicians in an effort to move strategy forward. That effort has a better chance of success over the long run in the hands of a self-aware, well-grounded physician leader – one who has taken a good look in the mirror and knows how to manage herself before she manages the rest of us. That is the leader we yearn for in this anxious time of healthcare policy deliberation. Q

References 1. New England Journal of Medicine, August 7, 2017, Mary Jane Kornacki 2. Healthcare Business Insights, January 20, 2017, Elizabeth Elving 3. What Predicts Executive Success, Green Peak Partners http:// greenpeakpartners.com/what-we-think/what-predicts-executivesuccess-green-peak-and-cornell-university-study. 4. The Practice of Adaptive Leadership, Ronald Heifetz, Alexander Grashow, and Marty Linsky Author’s note: There are many sources for cultivating self-awareness and most leadership development programs will include a series of instruments for this purpose. Whether or not you are in such a program, consider these sources for further discovery. They are especially appropriate for use in small groups. • Leadership and Self-Deception, The Arbinger Institute. Explores the path of rigorous honesty as a source of authentic influence and right action. • Thinking Fast and Slow, Daniel Kahneman. Provides a comprehensive look into how we think along with practical insights into how we can make better choices in our personal and professional lives. • The Road Back to You: An Enneagram Journey to Self-Discovery, Ian Morgan Cron and Suzanne Stabile. Reintroduces an ancient system for gaining self-understanding and maturing beyond the limits of personality. Charles (Chuck) Sampson is President of Charles E. Sampson & Associates, a Jackson, Mississippi (USA)-based organizational development practice, and instructs in the MSMA Physician Leadership Academy. Since 1987, he has consulted in the areas of leadership development, organizational effectiveness, and strategic management for clients in healthcare, science, and technology worldwide. Contact him at chuck.sampson@me.com.

Alliance Health Center offers hope for healing and recovery from addiction.

Complete Medical Detoxiﬁcation For opioids, alcohol and other subsances.

Treatment for Addiction Assessments/Admissions available 24 hours a day/ 7 days a week

New Leaf Recovery Flexible 30-day intensive therapy program in home-like setting with partial hospitalization and lodging available. 5000 Hwy. 39 North • Meridian, MS 39301 601.483.6211 • 1.877.853.3094 • AllianceHealthCenter.com JOURNAL MSMA

109

L E A D E R S H I P

Leading Amidst Generation Change DONNA RITCHEY, APR Generational Changes Bring Leadership Challenges Population change and cultural dynamics impact efficiency, operation and the ability to care for patients. Physicians interface with cross-generational audiences, bringing increased challenges to patient care and clinic operations. Individual physicians are not immune to the impact of generational dynamics as practitioners build and advance their practice. Think of your patient profiles. Your employee profiles. These generations respond to different leadership and communication styles. Making time to understand experiences and attitudes across generations will better prepare you to engage, motivate and lead. Too Many Leadership Books, Not Enough Time Bookstores, libraries, magazines and podcasts are full of leadership theories and biographies of great leaders. Academic experts provide insight into theoretical models of organizational leadership. Fascinating when you have extra time… Clinic environments are not immune to generational change. Each generation’s expectation and response to authority and leadership differs and are important to consider from a provider and employer standpoint.

responsibility for final decision resides with the participative leader (willing to listen without repercussion). This model often surfaces efficiencies and ideas from within organization, increasing employee morale, engagement and performance. Boomers, Gen X, Millennials and Gen Z respond well to this style. Transactional –defines specific tasks to perform, accompanied by specific reward of feedback (positive or negative) based on performance results. Managers and employees together agree on set goals and manager is actively engaged in daily or weekly monitoring and review of progress or compliance metrics, free to determine performance and to intervene with employees for additional training or correction. Boomers and Gen X may respond well to this style, while Millennials and Gen Z may churn through. Transformational – marked by high levels of communication, this collaborative style assures that leaders and employees are well informed on organizational priorities and goals. Leaders lead by example, are visible and accessible to employees. Leaders focus on the big picture and delegate smaller tasks and responsibilities to staff members. Boomer, Gen X and older Millennials embrace this model. Younger Millennials may not yet have the discipline to perform well under this management style. It is too early to know about Gen Z.

Primary Leadership Styles Laissez-Faire –this ‘hands-off ’ approach does not provide regular communication, direction or encouragement to employees. This emerges as an avoidance default when leaders are uncomfortable with Human Resources, facilities, inventory, regulatory or operational matters. This model is best for only highly-experienced and trained employees who work as a close unit. Boomers and Gen X may find themselves in this model. The problem is succession as this approach hinders productivity of new employees; and those needing supervision and also poses risk as it cedes control of operations to the vagaries of others.

Different leadership styles may exist within one work environment, depending on size, roles, functions and organizational staffing and structure. When it comes to managing your team, staff and office operations, multiple leadership styles may be appropriate. Timeless Classics Provide Leadership Guidance From Sun Tzu and the Art of War to the Tao De Ching, the masters focus on enduring principles for leadership:

Autocratic –managers possess total authority and impose directives on employees who are not provided rationale or allowed to ask question or offer suggestions. Result is low morale and high turnover. Gen X may be forced to settle for this environment. Millennials and Gen Z will flee.

Q Know Yourself – Be candid and assess your strengths, weaknesses and interests. Make decisions about the best use of your time as it relates to the business of healthcare, your patients and staff and then recruit or assign additional resources to assist you to help advance your vision of patient, business and operational achievement.

Participative –managers value input from team members, but

Q Hold on Loosely (Practice Non-Attachment) – As a physician,

110 VOL. 59 • NO. 2 • 2018

people inherently defer to your expertise. With that reflected authority and leadership it is critically important to realize that you are only one and one person cannot do everything. Lead by example, assemble a team, set expectations and encourage everyone to do their best and work together.

history. These Post-War Babies rejected the hierarchy embraced by their parents, becoming the radicals of the 1970s and the Yuppies of the 1980s. Their world view is “anything is possible” but many now find themselves facing retirement and regretting a life of spend now, worry later. For many, budgets are tight.

Q Gain Contextual Awareness – Accustomed to focusing on clinical data, it is important to evaluate and consider the cultural and life dynamics that impact patient compliance, staff interaction, and situations impacting your colleagues and overall community.

Insights: They value youthfulness and continue to crusade for causes. They question authority but value relationships and teamwork. Boomers want to believe their ideas matter – they were valued as youth, teens and young adults and expect their opinion to be valued or at least acknowledged. Most like clear and concise information and are motivated by their responsibility to others. Increasingly Boomers are having to care for young children of their offspring.

Q Share Your Vision – Own, control and communicate what drives you, your beliefs and expectations so your team has a “foundational compass” in place for guidance as they go about their duties.

Generational Breakdown (topical review) G.I. & Silent Generation – age 72 and older; experienced hard times from Great Depression to WWII and Korea, these traditionalists adhere to rules, don’t question authority, are patriotic and value family and community. Insights: They don’t deal well with ambiguity or change, are comfortable with top-down “chain of command” authority meaning they want to hear from a physician, not a staffer. They respond well to respect (address as Mr., Sir, Mrs., or honorary “Judge”, etc.). Treat them with formality. This generation may take more staff and physician time and attention as they may be lonely due to isolation. Baby Boomers – ages 53-71; experienced times of unrest from Vietnam War to the fight for Civil Rights, the Sexual Revolution and the Cold War. Known as the “Me” generation, they experienced the highest divorce rate and 2nd marriages in

Generation X – ages 37-52; experienced Watergate, energy crisis, AIDS, were the first generation of latchkey kids; stock market crash; most mothers worked and divorce rates remained high. Their perceptions were shaped by having to take care of themselves (and younger siblings), they watched politicians and evangelists lie and saw their parents get laid off. Gen Xers were pampered by absentee parents and have a sense of entitlement. As they aged, Gen X realized they will be the first generation that will not do as well financially as their parents and are more willing to take on responsibility and put in the extra hours to get a job done to pay the bills. With that background, and given layoffs they saw happen to their parents, they still do not expect to stay at the same job for many years. Insights: This group is skeptical of institutions but loyal to individuals they can count on. Generally unimpressed with authority, they value time and are project and outcome oriented. Many want to get in, get the needed information, get work done and then move on to the next thing. Under pressure, with many single-parent households, Gen Xers struggle to care for both children and aging parents.

Living Generations by Population Living U.S Generations

Born

Population (Estimated)

G.I.

(1901-1926)

32 million

Silent

(1927-1945)

28.3 million

Boomer

(1946-1964)

75.5 million

Gen X

(1965-1980)

65.1 million

Millennial

(1981-2000)

79.4 million

Gen Z

(2001+)

73.6 million

Notice that Millennials now outnumber Boomers, with Gen Z close on their heels. Gen X is the "sandwich" generation – caring for children and aging adults, a diﬃcult challenge even for those living in two-income households. Organizations are struggling to connect to Millennials and Gen Z as employees. Leadership and communication style matters more than ever.

JOURNAL MSMA

111

Millennials – ages 17-36; digital technology reigns supreme; school shootings and terrorist attacks (including 9/11) led their news. Mostly children of divorce, they are the most sheltered generation with “helicopter” parents protecting them from the evils of the world. The first generation of children to have schedules and repeatedly validated with participation trophies. Tech savvy, they embrace cultural diversity and are highly social. Older generations are vexed by their impatience as it relates to advancing their careers. They are competitive workers but gone at 5 p.m. on the dot. Work is a “gig” that fills time between weekends. They expect to influence the terms and conditions of the job and have high expectations for bosses to acknowledge their contributions and fast-track advancement. Millennials invented the term “humble brag.” Insights: They are self-confident but crave affirmative mentoring and feedback. Work is supposed to be “fun.” They value individuality while glued to social media and sharing (often

oversharing personal information). They work better from lists than verbal instruction and chafe under highly structured work environments. Gen Z – ages 0-16; have always lived with the specter of 9/11 and terrorism. Technology is ubiquitous and access to information immediate. Seconds count and this group is admittedly addicted to smartphones. Multiculturalism is embraced. Growth in biracial and minority populations; same-sex marriage and a black president are givens. Gen Z is pragmatic and drawn to safety with lower underage drinking, and smoking, higher seatbelt use and an increase in savings (more pragmatic than Millennials). Anecdotal evidence shows job path interests are being forged less by passion and more by practical realities. Q Donna Ritchey, APR, is Partner and Chief Strategy Officer for Godwin Group, one of the South’s oldest marketing firms focused on building brands and business for a digital world. She provides consultation and message management for organizational change, strategic planning for public policy initiatives and clients in healthcare, banking and finance, energy and education.

Cross-Generational Leadership Competency Checklist U Communication I’m mindful of my non-verbal communication I’m mindful of my vocal tone I speak formally to patients & staﬀ

U Fairness Yes _____ No ____ Yes _____ No ____ Yes _____ No ____

U Organization (Scale of 1-10)

I provide praise but do not play favorites. Yes _____ No ____ I’m ﬂexible allowing staﬀers to change schedules Yes _____ No ____

U Integrity I act and do as I say and as I’d want others to treat me.

My daily routine is structured _______ My oﬃce days are chaotic _______ My clinic days are chaotic _______

Yes _____ No ____

U Delegator I don’t have to control everything but won’t delegate a task that I would not do. Yes _____ No ____

U Consistency

U Facilitator I change procedures often Yes _____ No ____ I hold people accountable (privately or publicly) Yes _____ No ____

U Conﬁdence I’m open to input from others. My ego is big enough to celebrate the success of others.

U Negotiator Yes _____ No ____ Yes _____ No ____

112 VOL. 59 • NO. 2 • 2018

I advocate for my patients and staﬀ in a professional and temperate manner. Yes _____ No____

U Mentor

U Respect I am courteous to people/staﬀ from all walks of life.

I focus on what CAN be accomplished while remaining pragmatic about what we can do. Yes _____ No ____

Yes _____ No ____

I encourage continued education for my staﬀ I am active in professional organizations I am active in my community

Yes _____ No ____ Yes _____ No ____ Yes _____ No ____

Helping you build a more secure future. We invest our own money alongside yours, so we are invested in your success.

Region 8 offers support, compassion and effective treatment for individuals and families seeking to overcome the destructive nature of alcohol and drug use. Services are provided in Copiah, Lincoln, Madison, Rankin and Simpson Counties.

MEDLEY & BROWN F I N A N C I A L

601-982-4123

Ì Male and Female Residential Treatment

A D V I S O R S

(Located in Simpson and Copiah County )

Ì Intensive Outpatient Treatment Program Ì Family Treatment

medleybrown.com

Ì Substance Use Prevention Services Ì Recovery Support Services Ì Employee Assistance Program

For information, contact 601.824.0342 or www.region8mhs.org

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

OR Physicians to review Social Security disability claims at the Mississippi Department of Rehabilitation Services (MDRS) in Madison MS.

DISABILITY DETERMINATION SERVICES 1-800-962-2230

JOURNAL MSMA

113

L E A D E R S H I P

The Value of Leadership Training: Leadership Academy Student Perspectives

n medical school, we learned about the Krebs cycle. The plasticity of blood vessels. The amazing ability of renal tubules to absorb and release electrolytes and nutrients as the body needs. What we did not learn was how to effectively lead a team or deal with difficult personalities or be a voice for those who had none. Some of us could do this naturally and took on leadership roles at school and in our careers. Others were not comfortable in these situations and opted to avoid instead of engage. I was one of the others. I hated confrontation and avoided it at all costs. The thought of dealing with difficult people gave me anxiety, and the act of negotiating was foreign to me. I learned over time as a pediatric oncologist how to deliver bad news and handle patients’ grief. But in my own life, I found it incredibly difficult to speak or fight for myself or hold my own in a verbal disagreement. Even bartering for pricing on my first new car brought significant anxiety and nail-biting, and I leaned on my father for help. This may sound overstated, but the Leadership Academy changed my life. It’s the truth. The class we had on negotiating helped me in getting the job I wanted with the benefits I needed. I am much more comfortable in situations that require compromise and finding common ground between two groups. In my new job as a clinical informatics liaison, I deal with two very different groups of people: non-clinical computer analysts and clinical providers. Sometimes I have to have difficult conversations or deliver bad news, and the Leadership Academy classes helped me approach these in a systematic manner with a goal in mind and to separate emotions from the deal. I learned how to control my own stress level and anxiety and to focus on the goal and end result of the conversation. One of the classes that was particularly eye-opening involved the Myers-Briggs personality assessment. This helped me identify my strengths and weaknesses, and how to use those strengths to my advantage. I could also use that system to identify generally the personalities of those I worked with, especially difficult colleagues and aided in how I could more effectively communicate with them. Knowing a person’s motivation and how he or she views the world can help immensely in negotiation and compromise for different situations. The opportunity to be a Doctor of the Day at the Capitol was an amazing experience. Prior to the Leadership Academy, I was

114 VOL. 59 • NO. 2 • 2018

unaware that this opportunity was available to any physician in the State, and getting the chance to see the legislative process in action helped me appreciate all that the Mississippi Political Action Committee (MPAC) does in support of our profession. My increased confidence and improved communication skills have been positively noted at work. I have been noticed across the University, which has led to more involvement, speaking engagements, and professional advancement opportunities. Prior to the Leadership Academy, these opportunities would have caused anxiety and self-doubt; now I look forward to these and am excited to be more involved in leadership roles. – Sharon Pennington, MD Physician Leadership Academy Class of 2015-2016

According to other alums…

ompared with other leadership courses that I’ve attended over the years, I feel that the MSMA Physician Leadership Academy provided the most comprehensive and rewarding experience of them all. The program is well organized and focused on high yield topics that have benefited me both personally and professionally. – William Waller, MD Dermatology, Hattiesburg

am grateful for the PLA for many reasons. We learned skills that weren’t taught to us in medical school or in residency. Conflict Resolution was an important skill we learned and one that I have used since graduation. One of our assignments was to serve as the Doctor of the Day at the State Capitol. I dreaded this assignment. I was anxious. I didn’t feel I would be welcomed at the Capitol. To my surprise, I had the opposite experience. Both the House and Senate took time out to give me a warm welcome at the beginning of session. Throughout the day, I had several legislators come up to me to thank me for being there. I loved my experience at the Capitol! In fact, I’ve been back many times since then. I’ve served several times as Doctor of the Day. I have joined fellow MSMA members in White Coat Rallies and Calls to Action to advocate on important pressing issues. My colleagues and I have created "Capitol Day" where we advocate during the annual Anesthesiologists Week.

One of my favorite benefits from the PLA was getting to know my classmates. I learned of the challenges physicians from other specialties were facing that I would not otherwise have known about. Our class was indeed a special one. I felt grateful to be in a class with so much talent, warmth, and respect for one another. Many of us have stayed in touch after graduation. One of my highlights at the annual MSMA meeting and CME in the sand is getting to visit with my classmates from the PLA. I spoke with members of the Mississippi Society of Anesthesiologists to share my positive experiences and described the tremendous benefits from attending the PLA. The board was so impressed with the curriculum that they voted to sponsor an anesthesiologist every year from then on. We have had five anesthesiologists graduate from the PLA since its inception. – K. Page Branam, MD Anesthesiology, Jackson

he Leadership Academy gave me a greater awareness of how others perceive me and how I can be a more effective leader in my clinic but also in my community. It was a valuable experience, and I highly recommend it.

At LITHIC, we are Human I.T. Why do we call it that? Because we understand that, even when it comes to technology, it all boils down to a personal relationship. Our goal is to take care of your IT issues, so that you can spend your time doing what you do best. After all, time is money. From HIPPA technology compliance to everyday support, there is no system too complex or network too small. We specialize in:

– Angela Wingﬁeld, MD Dermatology, Gulfport

• Proactive Technology Management • Network Administration • Technology Consulting • Reactive Support Services

Exclusive MSMA Member Beneﬁt Offer: • 10% off monthly service contracts • FREE NETWORK AUDIT

rigo@lithicIT.com

Rigo Cedeno

Senior Engineer

OFFICE

601.487.4444

www.LithicIT.com

MOBILE

601.573.9343

JOURNAL MSMA

115

P R E S I D E N T ’ S

P A G E

Thoughts on Leadership WILLIAM GRANTHAM, MD

n this issue of Journal MSMA, you will read about how the responsibility of being a physician also means taking on a leadership role. This leadership role is important in the successful delivery of care to our patients whether in the clinic or hospital setting. Increasingly with new payment models which will require team based care to reach defined outcome measures, physicians will need to be effective leaders of the team. Through our efforts with MSMA we need to have strong physician leaders to help support and influence regulations and legislation that affect the practice of medicine. We need to be advocates and leaders for our patients and our physician partners. Since so many of us have not had to function as leaders throughout our education and training, it is nice to have resources to help us become good leaders. When you google leadership, you will see many definitions of what good leadership is. To me, leadership is using the resources of people and the organization to steer the ship toward the intended destination. Some people suggest that leadership is corralling or shepherding. It is easy to see in the House of Medicine this analogy is very difficult and complex. Yes, it’s just like herding cats. There are many influential people throughout history who have had something to say about leadership. Ronald Reagan said, “The greatest leader is not necessarily the one who does the greatest things. He is the one that gets the people to do the greatest things." The Scottish novelist John Buchan said, “"The task of leadership is not to put greatness into people, but to elicit it, for the greatness is there already." Admiral Chester W. Nimitz said it better with fewer words: "Leadership consists of picking good men and helping them do their best." After selling more than 19 million books on the subject of leadership Pastor John Maxwell said a leader is “one who knows the way, goes the way, and shows the way." That’s pretty succinct. Our own MSMA CEO says something like that to our association staff. “Do the right thing for the right reason. Every time.” It’s hard to define a higher goal. To be effective leaders, we need to help create a vision, actively promote cohesion around a mission, motivate others to get excited about the mission, and work together to implement it. Great leaders are made, not born, and that fact is why MSMA has invested in developing physician leaders – physicians who are strategic in thought and action. While the thought of becoming a leader can be daunting, leadership is a skill that can be taught and it could be one of the most worthwhile investments you will ever make. I invite you to take advantage of

116 VOL. 59 • NO. 2 • 2018

William M. Grantham, MD MSMA President 2017-2018 MSMA’s many leadership development opportunities, from online CME to the Physician Leadership Academy. Become a leader to help your practice deliver better care to your patients, to help your practice be successful in the face of changing reimbursement models, and to help MSMA and organized medicine in our efforts to ensure that appropriate regulations and legislation are passed that affect medical practice. Let me know what you think about leadership and what it means to you. Q

William M. Grantham, MD MSMA President 2017-2018

Great Leaders are Made, not Born Vince Lombardi said that great leaders are made, not born. “That fact is why MSMA has invested in developing physician leaders,” MSMA President Dr. William M. Grantham said, “We must teach physicians to be strategic in thought and action.” That’s also why The Physicians Foundation has focused millions on leadership development through state medical societies across the country. The Physicians Foundation invested $225,000 in the Mississippi State Medical Association Foundation to establish the MSMA Physician Leadership Academy. This ongoing support has created resources and educational programming to identify, train and cultivate physicians to be leaders in their own practices and in the public policy arena through organized medicine.

systems will require more physician leadership than ever. Dr. Grantham also said that being a physician leader means having the ability to make consistently good strategic choices and the ability to implement effective efficient strategies. “It is about taking health care concerns to a new level of performance, and creating an agile organization that can sustain performance against the emerging challenges to health care delivery,” he said.

Leadership is a skill that can be taught and the investment a physician makes in him- or herself could be one of the most worthwhile a physician will ever eaders are made, they are make. Dr. Grantham said, “I invite not born. They are made you to take advantage of MSMA’s many leadership development by hard eﬀort, which is opportunities, from online CME to the Physician Leadership the price which all of us must Academy.”

pay to achieve any goal that is worthwhile."

“We continually seek ways to support physicians and the Physician Leadership Academy has given many the skills they needed to effectively speak out for medicine and for their patients,” Dr. Grantham said. “In six one-day sessions, the leadership academy focuses on longlasting results that each scholar can put to work from day one.” Inspiring Physician Leaders

This issue of Journal MSMA suggests that the responsibility of being a physician also means being a leader. “To me, leadership is not about a title or position but rather the way in which we create a vision, actively promote cohesion around a mission, motivate others to get excited about the mission, and work together to implement it,” Dr. Grantham said. “Physician leaders stand up for the integrity of our profession and the value we bring to the health care system.” The move to accountable care and metrics driven health care

The MSMA Leadership Academy has been made possible through a generous grant from The Physicians Foundation, a VINCE LOMBARDI nonprofit 501(c)(3) organization that seeks to advance the work of practicing physicians and help facilitate the delivery of healthcare to all patients. It pursues its mission through, a variety of activities including grant making, research, white papers, and policy studies. Since 2005, The Foundation has awarded numerous multiyear grants totaling more than $28 million. In addition, The Foundation focuses on the following core areas: physician leadership, physician practice trends, physician shortage issues, and the impact of healthcare reform on physicians and patients. As the healthcare system in America continues to evolve, The Physicians Foundation is steadfast in its determination to strengthen the physician-patient relationship and assist physicians in sustaining their medical practices in a difficult practice environment. For more information, visit www.PhysiciansFoundation.org.

JOURNAL MSMA

117

L E A D E R S H I P

Outreach Program Gets Mental Health Help to Underserved Dr. Chassity Torrence s specialists in a complex field, psychiatrists understand many populations are underserved by their profession. For Dr. Chasity Torrence, this situation was an opportunity to make a difference. As her Physician Leadership Academy project, Dr. Torrence teamed up with other members of the University of Mississippi Department of Psychiatry to form the Psychiatry Outreach Program and reach out to the underserved community with mental health needs.

Outreach Program were warmly welcomed.

The inspiration for the program came from a colleague, Dr. Sheryl Fleisch from the University of Vanderbilt School of Medicine. Fleisch and her colleagues at Vanderbilt established a program in Nashville to reach underserved patients there. At a grand round that Dr. Torrence attended, Dr. Fleisch told UMMC physicians about the success of the program, which led Dr. Torrence to wonder: Can we do this in Jackson?

Exam rooms were made available to the Psychiatric Outreach Program, allowing psychiatrists, residents and medical students in the group to see patients on the third Saturday of every month. In addition to providing direct service to patients in need, the members of the program work to ease the burden on emergency rooms in the Jackson area, which all too often have to bear the brunt of care, even for mental health patients.

“The need was there for sure,” she said. “The underserved, under-insured and homeless of the Capital City are not hard to find. The question was, what is the best approach to reach these patients and make a difference.”

Leadership can manifest itself in a variety of ways, but fundamentally it’s about engagement and setting an example. The Psychiatric Outreach Program offers a look into leadership not just as a form of edification for doctors but as a way to reach directly to underserved patients in need. Dr. Torrence said the program has impacted her as well.

Rather than start from scratch, Dr. Torrence and her colleagues—Dr. Matthew Walker, Dr. Charles Richardson, student Yulonda Ross, Dr. Jon Jackson and student Jonathan Baker—decided to reach out to an established clinic where the underserved have been treated for years. After reaching out to the Jackson Free Clinic, the members of the Psychiatric

“With a patient base and a proven record of success already in place, the Jackson Free Clinic was the perfect place to start,” Dr. Torrence said. “We knew we wanted to start building strong connections in the community we would serve, and hopefully have a positive impact on the lives of the underserved patients.”

“I’ve learned a lot throughout this process,” she said. “Not just about leadership and teamwork but about how much power physicians have to go beyond the norm and make an even bigger difference than we normally do. It’s been a thrill.”

Just like the river, you are strong and unstoppable. Find your strength at the river. If you or someone you know is struggling with addiction, call today. (877) 654-9761 118 VOL. 59 • NO. 2 • 2018

At The River www.JourneyPureRiver.com

L E A D E R S H I P

Drug Drop Boxes Underused Tool in Opioid Fight Dr. Timothy Beacham

he opioid/heroin crisis is perhaps the number one public health concern in Mississippi and across the nation. Physicians and other health care providers are working together with law enforcement, addiction specialists, elected officials and others to find the best solution for fighting the problem in Mississippi. Which makes it especially intriguing that MSMA member and former board member Dr. Timothy Beacham launched an effort to help stem the crisis three years ago. Like many great ideas to make a difference, Dr. Beacham turned to a tool already in place but with low awareness. Across the state at some law enforcement headquarters and driver’s license testing stations are drug disposal boxes. The boxes are there to collect unused medication, primarily opioids and other potentially dangerous drugs. The drug disposal boxes are secure and safe. Periodically, law enforcement empties them and burns the drugs inside. It’s the safest way of keeping unused medication off the streets and out of the possession of those struggling with addiction. As part of his Physician Leadership Academy project,

Dr. Beacham wanted to promote the use of the drug drop boxes so more Mississippians would know about this underused resource. “I knew about the program, and I knew the boxes were under-used,” he said. “It just made sense to me that we would promote the boxes to the public and to physicians. Increasing the use of the boxes could only help.” Today, Dr. Beacham’s idea lives on. MSMA is in the process of producing a printed poster to place in physicians’ offices and other medical settings promoting the use of the drug disposal boxes. The poster is one of many efforts the Association is involved with to confront the opioid crisis. For Dr. Beacham, it’s an indication of how leadership manifests itself in creative thinking. “One of the things I learned in the Physician Leadership Academy is to explore creatively the possible solutions,” he said. “To question everything and to remain open minded often brings you the best ideas. Leadership begins with caring, but it is given meaning by following through. It’s great to see MSMA follow through on promoting this idea.”

JOURNAL MSMA

119

120 VOL. 59 • NO. 2 • 2018

A M A

AMA Presents Medal of Valor to Civil Rights Physician Activist Dr. Robert Smith

AMA President Dr. David O. Barbe, left, presents the AMA Medal of Valor to MAFP member Dr. Robert Smith of Jackson.

ONOLULU – The American Medical Association (AMA) honored Robert Smith, MD, with the Medal of Valor Award for fighting social injustice and providing health care to all Mississippi citizens during the civil rights era. Granted by the AMA Board of Trustees, the Medal of Valor Award honors AMA members who demonstrate courage under extraordinary circumstances in nonwartime situations. Dr. Smith was an instrumental figure during the civil rights movement in Mississippi, providing consistent health care to those with little or no access. A founder of the Medical Committee for Civil Rights and the Committee for Human Rights in the mid-1960s, Dr. Smith and other health care professionals aided and treated civil rights workers and many other Mississippians during the Freedom Summer of 1964. “In dangerous, volatile times in our country, Dr. Smith placed himself repeatedly in harm’s way and made it his mission to stand up for the health care rights of African Americans,” said AMA President David O. Barbe, MD. “He is a man of compassion, courage and bravery, who routinely put the health and wellbeing of others ahead of his own by

providing medical care to the poor, uninsured and underserved citizens of Mississippi.” Dr. Smith co-authored, founded and implemented the concept of Federally Qualified Health Centers. He co-founded the nation’s first rural community health center, Delta Health Center, in Mound Bayou, Miss., as well as the Mississippi Primary Health Care Association (MPHCA), which provides accessible and affordable primary medical care and dental care services to individuals and families. There are now more than 10,000 centers serving 30 million Americans, including several hundred thousand Mississippians. A native of Terry, Miss., and graduate of Tougaloo College, Dr. Smith received his medical degree from Howard Medical School and serves as president and chief executive officer of the Central Mississippi Health Services, Inc. He and his wife, Otrie Hickerson Smith, MD, have three children. The AMA presented Dr. Smith the Medal of Valor Award during the opening session of the 2017 AMA Interim Meeting. Q JOURNAL MSMA

121

M I S S I S S I P P I

S T A T E

D E P A R T M E N T

O F

H E A L T H

Mississippi WƌŽǀŝƐŝŽŶĂů ZĞƉŽƌƚĂďůĞ ŝƐĞĂƐĞ ^ƚĂƟƐƟĐƐ December 2017

Public Health District

State Totals*

III

VII

VIII

Dec 2017

Dec YTD 2017 YTD 2016 2016

ϯ ϭ Ϭ Ϭ Ϭ Ϭ Ϭ ϭ ϱ ϯϱ ϮϴϮ Ϭ ϭ Ϭ Ϭ Ϭ Ϭ Ϭ ϭ ϯ ϰϳ ϰϲϵ Early Latent Syphilis ϭϬϰ ϴϲ ϲϳ ϮϬϱ ϲϵ ϯϲ ϭϬϲ ϭϬϲ ϴϳϱ ϴϵϴ ϵ͕ϭϲϵ Gonorrhea ϭϳϵ Ϯϭϭ ϭϱϭ ϰϭϭ ϭϰϬ ϵϯ ϭϵϭ ϮϬϮ ϭ͕ϴϮϱ Ϯ͕ϱϲϮ ϮϬ͕ϵϮϮ Chlamydia Ϯ ϯ ϭ ϭϬ Ϯ ϭ ϭ Ϭ Ϯϰ Ϯϯ ϰϲϬ HIV Disease Ϭ Ϭ ϭ ϯ ϭ Ϭ ϭ Ϯ ϴ ϴ ϰϯ Pulmonary Tuberculosis (TB) Ϭ Ϭ Ϭ Ϭ ϭ Ϭ Ϭ Ϭ ϭ ϯ ϴ Extrapulmonary TB ϲ ϰ ϯ ϭϯ Ϭ ϭ ϯ ϭ ϯϮ ϰϬ ϰϰϭ Mycobacteria Other Than TB Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Diphtheria Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ ϱ ϯϰ Pertussis Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Tetanus Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Poliomyelitis Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Measles Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϯϲ Mumps ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ ϭ ϭ ϰϯ Hepatitis B (acute) ϭ ϭ ϭ ϭ Ϯ ϭ ϭ ϭ ϵ ϵ ϲϴ Invasive ,͘ ŝŶĨůƵĞŶǌĂĞ disease Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϯ Invasive Meningococcal disease Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ ϭ ϭ Ϭ ϯ Hepatitis A (acute) ϭϭ ϰ ϱ ϭϯ ϱ ϯ ϯ ϱ ϱϮ ϱϴ ϭ͕ϭϭϱ Salmonellosis Ϯ Ϯ Ϭ ϲ Ϭ Ϭ Ϭ ϯ ϭϯ ϭϰ ϭϴϭ Shigellosis ϲ ϱ ϭ ϳ Ϭ Ϯ ϯ ϭϬ ϯϲ Ϯϵ ϰϴϳ Campylobacteriosis Ϯ Ϭ Ϭ Ϭ Ϭ Ϭ ϭ Ϭ ϯ Ϯ Ϯϰ ͘ ĐŽůŝ O157:H7/STEC/HUS Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ ϭ Animal Rabies Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ ϭ Lyme disease Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ ϭ ϭϲϭ Rocky Mountain spotted fever Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ ϭ ϲϯ West Nile virus Ύ dŽƚĂůƐ ŝŶĐůƵĚĞ ƌĞƉŽƌƚƐ ĨƌŽŵ ĞƉĂƌƚŵĞŶƚ ŽĨ ŽƌƌĞĐƚŝŽŶƐ ĂŶĚ ƚŚŽƐĞ ŶŽƚ ƌĞƉŽƌƚĞĚ ĨƌŽŵ Ă ƐƉĞĐŝĨŝĐ ŝƐƚƌŝĐƚ͘ ŽŽŶŽƚŝĐ ŝƐĞĂƐĞƐ

ŶƚĞƌŝĐ ŝƐĞĂƐĞƐ

sĂĐĐŝŶĞ WƌĞǀĞŶƚĂďůĞ ŝƐĞĂƐĞƐ

DǇĐŽͲ ďĂĐƚĞƌŝĂů ŝƐĞĂƐĞƐ

^ĞǆƵĂůůǇ dƌĂŶƐŵŝƚƚĞĚ ŝƐĞĂƐĞƐ

Primary & Secondary Syphilis

122 VOL. 59 • NO. 2 • 2018

Ϭ ϭ ϵϲ Ϯϰϳ ϰ Ϭ Ϭ ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ Ϭ ϯ Ϭ Ϯ Ϭ Ϭ Ϭ Ϭ Ϭ

ϯϮϴ ϰϵϰ ϳ͕ϭϱϳ ϮϬ͕ϭϭϱ ϰϮϵ ϰϲ ϭϰ ϰϰϴ Ϭ ϳ ϭ Ϭ Ϭ ϭ ϯϬ ϲϳ Ϭ ϯ ϭ͕ϭϵϭ ϴϭ Ϯϲϴ Ϯϰ ϯ ϭ ϭϬϲ ϰϯ

I M A G E S

I N

M I S S I S S I P P I

M E D I C I N E

OSTER GENERAL HOSPITAL, JACKSON, 1943 – This image is an aerial view of Foster General Hospital, the U. S. Army hospital which opened in Jackson on June 15, 1943. This medical facility was built for the treatment of wounded servicemen during the Second World War. It was renamed as the Jackson V.A. Hospital after World War II and physically moved in the late 1950s eventually to become the G. V. (Sonny) Montgomery V.A. Medical Center located east of UMMC. This original V. A. Hospital was a “gigantic” facility located off Clinton Blvd. in west Jackson. The military hospital was so large that the doctors rode 3-wheel bicycles while making their rounds. In 1957, Governor J. P. Coleman led the effort to move the racially integrated facility and create the current VA east of the University Medical Center. The Legislature resisted his efforts due to the requirement that it be an integrated facility. Coleman, to his credit, stated at that divisive time: “If we’re going to be realistic, we should acknowledge that the federal government is not going to change its policy. The question is whether we want to do it, knowing it will be integrated….I’m in favor of going ahead and giving the federal government permission to construct this facility.” Without Coleman’s brave leadership, the new VA facility would not have been constructed. Currently, the G. V. (Sonny) Montgomery VA Medical Center has 163 operating beds, provides primary, secondary and tertiary medical, surgical, neurological, and psychiatric inpatient care. Services include radiation therapy, magnetic resonance imaging, hemodialysis, cardiac catheterization, sleep studies, substance abuse treatment, post-traumatic stress disorder (PTSD), hematology/oncology, and rehabilitation programs. Both primary and specialized outpatient services are available, including such specialized programs as: ambulatory surgery, spinal cord injury, neurology, infectious disease, substance abuse, PTSD, readjustment counseling, and mental health diagnostic and treatment programs. If you have an old or even somewhat recent photograph or image which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. Q

— Lucius M. “Luke” Lampton, MD; JMSMA Editor JOURNAL MSMA

123

P O E T R Y

A N D

M E D I C I N E

A Deadly Bug ... [This month, we print an insightful poem by the brilliant ENT Dr. Ron Cannon of Jackson (well, Flowood). Ron is one RI P\ PRVW FKHULVKHG PHQWRUV DQG WHDFKHUV 0\ ÂżUVW VFLHQWLÂżF SXEOLFDWLRQ ZDV ZULWWHQ ZLWK 5RQ ZLWK KLV JXLGDQFH in this publication back 25 years ago (on Peritonsillar Abscess). Heâ&#x20AC;&#x2122;s everything I aspire to be as a physician, and I treasured his interest as a teacher in my development as a physician. He writes, â&#x20AC;&#x153;Perhaps this poem is a form of gallows humor. Being politically correct obfuscates the truth and is seen not only in medicine but society as a whole. ,W FORXGV UHDOLW\ DQG VHWV XS DUWLÂżFLDO EDUULHUV 7KH (+5 LV PDGGHQLQJ EHFDXVH LW WDNHV XV DZD\ IURP WKH SK\VLFLDQ SDWLHQW UHODWLRQVKLS ZKLFK LV WKH EHGURFN RI PHGLFLQH 7KLV SRHP LV P\ DWWHPSW WR SRNH IXQ DW VRPH RI WKH PRGHUQ day problems we face on a daily basis.â&#x20AC;? Any physician is invited to submit poems by slow mail for publication in the Journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.] â&#x20AC;&#x201D; ED.

My bright tie makes me look like a pro, Always on the go. Inside the white coat my tie safely hibernates, The patient it touches not, but let me elaborate. A stately journal points out a not so flagrant foul That my tie is a septic source, Iâ&#x20AC;&#x2122;m throwing in the towel. In a fit of scientific quest, my tie immersed in a nutrient brew To see if a pathogen it grew. Iâ&#x20AC;&#x2122;m surprised, but the lab is quite firm, They found a strange new germ. It is all around, this bug is red and itâ&#x20AC;&#x2122;s blue This bug is here to stay, yes itâ&#x20AC;&#x2122;s true. Politicus correcticus, PC, for short, is its name And itâ&#x20AC;&#x2122;s bound for the microbial Hall of Fame. With this PC disease Iâ&#x20AC;&#x2122;m dreadfully ill with fever and chills, Should I take some pills? Since my illness, I am seeing things in a strange new light, It has given me an awful fright

No longer old, but chronologically gifted, Not tall, but vertically inclined There are PC terms in abundance NSQUIP, MACRA, PQRS, HCAPS, to name a few, itâ&#x20AC;&#x2122;s medical alphabet soup knowing them all is a requirement of the PC troop.

Triaged by Betty, no Ebola or Zika virus here, more useless information from Sue At its core this EHR makes me blue. No eye contact or rapport with my patients do I make, Just check the boxes, this EHR gives me a headache I had to hire a scribe This gibberish to transcribe A medical record that is a mile wide and one-half inch deep is the new motto, The EHR software companies selling this stuff have won the lotto. If I think the EHR is great, with a psychiatrist , should I make a date?

I am no longer a doctor, merely a healthcare provider, itâ&#x20AC;&#x2122;s a real shocker

So Iâ&#x20AC;&#x2122;ve burned my tie, my neck now adorned with a government issued chain with this PC infection, my sanity never to regain.

Patients are no longer bald, but follicularly challenged, with this terminology Iâ&#x20AC;&#x2122;m enthralled

There is no cure, for it's folie Ă deux I like being PC â&#x20AC;&#x201C; do you?

Not fat, but a person of substance,

124 VOL. 59 â&#x20AC;˘ NO. 2 â&#x20AC;˘ 2018

â&#x20AC;&#x201C; C. Ron Cannon, MD, Flowood

What’s Your Specialty? Our specialty

is NETWORKING... TPAs Physicians

Hospitals

M I S S I S S I P P I

Physicians Care N ETWO R K

Employer Groups

Insurance Companies

Ancillary Providers

MPCN - THE OBVIOUS CHOICE Change Networks. Not Doctors. 601-605-4756 • www.mpcn-ms.com Sponsored by the Mississippi State Medical Association JOURNAL MSMA

125

August 17-18, 2018 The Westin Jackson

Defining Events in the Evolution of Mississippi Medicine