February 2013 JOURNAL MSMA by Journal MSMA

February

VOL. LIV

2013

No. 2

BEACON Imagine the possibilities. You’ve heard of the Beacon Grant.

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What can the Grant do for my practice and my patients?

DHA has established the BLUES (Better Living Utilizing Electronic Systems) Beacon Community to work with physicians and other healthcare providers across the Delta region. Your Delta BLUES Beacon is testing innovations with over 35 Delta providers, including Clinical Decision Support, Diabetic Retinopathy Screening, Medication Therapy Management, Care Transitions and Health Information Exchange.

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The Delta BLUES Beacon Program is available to physicians in ten counties across the Mississippi Delta area until March 2013. How can the BLUES Beacon guide you?

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Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD Associate Editors Karen A. Evers Managing Editor Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors

The Association Steven L. Demetropoulos, MD President James A. Rish, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director

FEBRUARY 2013

VOLUME 54

NUMBER 2

Scientific Articles Recommendations after Non-Localizing Sestamibi and Ultrasound 36 Scans in Primary Hyperparathyroid Disease: Order More Scans or Explore Surgically? Nicholas E. Hoda, PhD; Paul Phillips, MD; Naveed Ahmed, MD

Special Article Friends of Medicine Can Make a Difference: Organize a Mini-Internship

Karen A. Evers, Managing Editor

President’s Page Why is your Membership Important?

Steven L. Demetropoulos, MD, MSMA President JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright© 2013 Mississippi State Medical Association.

Related Organizations Mississippi State Department of Health

Departments From the Editor Physician’s Bookshelf Una Voce

About The Cover: “Crossroads of the Confederacy” – Martin M. Pomphrey, Jr., MD, who serves on the MSMA Committee on Publications, photographed the junction of the Memphis & Charleston and the Mobile & Ohio Railroads, located in Corinth, Mississippi. During the Civil War, these two railroads were the longest in the Western Confederacy and gave Corinth its strategic importance. Today, the historic depot is a museum displaying Civil War relics, American Indian outfits, along with railroad memorabilia. Dr. Pomphrey is a semi-retired orthopaedic surgeon sub-specializing in sports medicine who practiced with Oktibbeha County Hospital (OCH) Bone and Joint Clinic in Starkville. r February

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Official Publication

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2013

No. 2

of the MSMA Since 1959

FEBRUARY 2013 JOURNAL MSMA 33

From the Editor

he end of February brought great news for Mississippi’s physicians. A three judge panel of the 5th U. S. Circuit Court of Appeals upheld as constitutional an essential aspect of the state’s tort reform law: the $1 million cap on noneconomic damages in personal injury cases. (Mississippi’s separate $500,000 limit in medical malpractice cases was not at issue but still at risk in the constitutional challenge.) The challenge had been brought by Lisa Learmonth, who had sued Sears, Roebuck and Co. in 2006 after being involved in a traffic accident with one of the company’s vans near Philadelphia. An earlier jury had found Sears liable for her injuries and awarded her $2.2 million for noneconomic damages. Subsequently, a federal judge reduced that to $1 million in line with Mississippi’s tort law. The three judge panel ruled at February’s end that this federal trial judge had acted properly. Writing for the three judge panel, Judge Carolyn D. King stated that state law “can be interpreted not to alter a jury’s factual damages determination, but instead to impose a strictly legal limitation on the judgment that provides the remedy for a noneconomic injury.” Learmonth also argued that by imposing caps, Mississippi’s Legislature had violated the state’s separation of powers. King rejected this assertion, writing: “The statute’s command that a judge ‘shall’ limit a noneconomic damages judgment is tantamount to a command that a judge shall apply substantive law. This legislative

tautology does not represent an impermissible intrusion on any judicial function.” This well-reasoned decision should provide guidance for Mississippi courts not if but when these courts debate the cap’s constitutionality. This federal ruling is critically important. The tort reform passed in 2002 and 2004 not only improved the quality of medical practice for every physician in the state (by changing its litigation climate) but also proved essential in increasing the physician workforce in our underserved state. Simply put, physicians and our patients cannot let trial lawyers destroy the practice of medicine with frivolous and inappropriate lawsuits that burden physicians and healthcare communities both financially and emotionally. Learmonth v. Sears, Roebuck & Co. is the most serious challenge Mississippi’s tort law has so far faced. This outcome is certainly reassuring, but our work is hardly done. There will be other judicial and legislative challenges in the years ahead. We must remain vigilant to preserve the hard-won victory of tort reform. We must be sure that competent and fair-minded judges are being elected and appointed, especially at the state supreme court and

appellate court levels. We must remain active and engaged in local and state elections to ensure the quality of all three branches of state government, all of which play critical roles in preserving tort reform. —Lucius M. Lampton, MD, JMSMA Editor

Journal Editorial Advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD, FAAP, FACS Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH Epidemiologist Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for V A Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP Residency Program Director North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A Kirchner, MD Nephrologist G.V. Montgomery VA Medical Center, Jackson Brett C. Lampton, MD Internist/Hospitalist Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport William Lineaweaver, MD, FACS Editor, Annals of Plastic Surgery Medical Director JMS Burn and Reconstruction Center, Brandon John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital

34 JOURNAL MSMA FEBRUARY 2013

Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD, FACC Clinical Cardiologist, Hattiesburg Clinic Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD, MBA, CPE, MS Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

Medical Assurance Company of Mississippi

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Defense of Claims FEBRUARY 2013 JOURNAL MSMA 35

• Scientific Articles • Recommendations after Non-Localizing Sestamibi and Ultrasound Scans in Primary Hyperparathyroid Disease: Order More Scans or Explore Surgically? Nicholas E. Hoda, PhD; Paul Phillips, MD; Naveed Ahmed, MD

bstract

Background: Treatment for primary hyperparathyroidism (PHPT) is surgical excision. Sestamibi and ultrasound scans, used to locate hyperfunctioning glands, can fail to do so. When both preoperative studies are non-localizing, options include 1) referral to a surgeon for a bilateral neck examination or 2) additional preoperative imaging. Study Design: Retrospective review of patients who underwent a parathyroidectomy from January 2010 to December 2011 at the University of Mississippi Medical Center (UMMC) was conducted. Only patients with negative or inconclusive findings on both sestamibi and ultrasound scans were included. The subsequent courses of action and the operative and postoperative outcomes were retrospectively reviewed. Results: Negative or inconclusive preoperative findings were present in 3 of 26 patients (12%). Additional imaging studies were ordered for 1 patient, which also produced nonlocalizing findings. All three patients underwent bilateral neck examination (BNE) with intraoperative PTH assay. A parathyroid adenoma was found in each case but was found in an ectopic location or in the presence of a multinodular goiter. Surgery yielded appropriate PTH levels for all 3 patients and each patient was eucalcemic at follow-up. Conclusions: Non-localizing preoperative scans may result from ectopic parathyroid adenoma or presence of a multinodular goiter in PHPT. When presented with negative preoperative studies, we propose that the patient be scheduled for bilateral neck examination with intraoperative PTH assay Author Information: Dr. Hoda is a fourth year medical student. Dr. Phillips is a fifth year resident in the Department of Surgery. Dr. Ahmed is a general Surgeon and an Associate Professor in the Department of Surgery. All are at the University of Mississippi Medical Center in Jackson. Corresponding Author: Naveed Ahmed, MD, 2500 North State Street, Department of Surgery, University of Mississippi Medical Center, Jackson, MS 39216. (601)984-5120. (nahmed@umc.edu).

36 JOURNAL MSMA FEBRUARY 2013

rather than for additional preoperative studies. The surgeon’s level of experience with four gland exploration and a thorough understanding of normal and aberrant positioning of parathyroid glands are imperative for patient safety and treatment, especially when localization studies have failed.

Key Words: Sestamibi

scan;

Ultrasound; Negative imaging; Non-localizing findings; Ectopic parathyroid adenoma; Multinodular goiter; Primary hyperparathyroidism; Parathyroidectomy; Bilateral neck examination

Introduction

Epidemiology, Diagnosis, and Presentation Primary hyperparathyroidism (PHPT) is a common disease in the US, affecting 1% of the adult population with an incidence of 100,000 new diagnoses per year.1,2 Since the widespread use of multichannel biochemical screening tests began in the 1970’s, the majority of patients are “asymptomatic” at presentation and are diagnosed based on the combination of an elevated or inappropriately normal parathyroid hormone (PTH) level with an elevated total serum calcium level. Despite being categorized as “asymptomatic,” these patients frequently have nonspecific complaints such as anorexia, nausea, constipation, polydipsia, polyuria, weakness, fatigue, lethargy, memory loss, and depressed mood when more closely evaluated.3,4 Symptomatic presentation does still occur, however, as nephrolithiasis and bone pain of osteitis fibrosis cystica are seen in up to 20% and 2% of patients with PHPT, respectively.5 Treatment Recommendations Parathyroidectomy is recognized as the treatment for symptomatic PHPT. The recommendations for treatment of asymptomatic PHPT have been controversial for the past twenty years. In 2002, the National Institutes of Health (NIH) held a Workshop on Asymptomatic PHPT to revise initial recommendations previously made in 1990. The 2002 recommendations

Table 1. 2002 NIH Recommendations For Parathyroidectomy Serum calcium level 24-hour urine calcium excretion Creatinine clearance

>1.0mg/dL above reference range >400mg Reduced by 30% compared with agematched control subjects Bone mineral density Reduce by >2.5 SD compared with sexand race-matched controls at forearm, lumbar spine, or hip (T score) Patient Age <50 years Other Patients for whom continued follow-up is not desirable or possible Table 1. 2002 NIH Recommendations For Parathyroidectomy attempted to provide research-based criteria as to when surgery thyroidism. Thus far, MIP with positive preoperative localizing was advisable. The 2002 recommendations are listed in Table 1.6 imaging and intraoperative PTH measurement has been shown Despite these NIH recommendations, the American Asto be as effective and have comparable complication rates as sociation of Clinical Endocrinologists and The American Asdoes bilateral neck exploration (BNE) for single parathyroid sociation of Endocrine Surgeons (AACE/AAES) Task Force adenomas.12,13 MIP also offers potential benefits of shorter operon Primary Hyperparathyroidism have recommended that opations, decreased risk of injury to the recurrent laryngeal nerve, erative management be “considered and recommended for all decreased risk of post-operative hypocalcemia, improved cosasymptomatic patients with PHPT who have a reasonable life metic results, and decreased cost.14-17 7 expectancy and suitable operative and anesthesia risk factors.” Despite the advances and advantages offered by MIP, The Task Force recommendation was in response to difficulty BNE continues to be useful in several situations including negdifferentiating between those in whom the disease will and will ative preoperative imaging by both sestamibi and ultrasound not progress and to the difficulties associated with long-term given the incidence of multi-gland disease, general hyperplasia, medical follow-up including costs and increased patient responand ectopic location.18,19 Lack of localizing findings have been sibility to stay well-hydrated and limit calcium intake. Addiattributed to several causes including ectopic gland location, tionally, parathyroidectomy has been shown to result in signifiphysiological variation of the abnormal gland, and enlargement cant improvement of symptoms for patients who did not meet of nearby structures.19-23 Between four percent to seventeen per8 the NIH criteria. Also, subjective health-related quality-of-life cent of patients with hyperparathyroidism have been reported to symptoms such as overall health, muscle strength, energy level, have hyperfunctioning glands located in ectopic positions.24 To endurance, and anxiety level, which are not considered in the understand why nearly up to one-fifth of parathyroid glands are NIH criteria for “symptomatic” PTHP, have been demonstrated located in ectopic locales as well as where the typical and ectoto show significant improvement after parathyroidectomy at pic glands are most frequently located, an understanding of the 1-month, 6-month, and 1- to 2-year follow-up.9 Parathyroidecdevelopment of the glands during embryogenesis is beneficial. tomy for asymptomatic PTHP has also yielded significant benAt the beginning of the fifth week, the third and fourth phaeficial improvements in femoral neck and hip bone density as ryngeal pouches develop into the inferior parathyroid glands well as in social, emotional, and psychological functioning.10 In and superior parathyroid glands, respectively. The third pouch 2008, the Third International Workshop on primary hyperparaalso develops into the thymus. Typically by the seventh week thyroidism convened to review and update the previous recomthe glands have descended to their final location. The inferior mendations in light of the most recent research in regards to parathyroid glands and thymus descend to the inferior dorsal the treatment of asymptomatic patients. Presently, consultation surface of the thyroid gland. The superior parathyroid glands with an experienced parathyroid surgeon is recommended for descend to the medial aspect of the superior dorsal surface of asymptomatic patients in light of the improvements in neurothe thyroid gland.25,26 Ectopy of either of the inferior parathycognitive functioning, bone density, and fracture risk after sucroid glands is most common and is most often found to have cessful parathyroidectomy.11 migrated with the thymus to the anterior mediastinum. An ecBilateral approach under general anesthesia for a fourtopic superior parathyroid gland is most often located in the gland exploration of the neck is the gold standard for sympretroesophageal or retropharyngeal space, tracheoesophageal tomatic PHPT treatment. However, the current trend in surgery groove, thyroid gland, or posterior mediastinum.23,24 In regards has been toward a minimally invasive unilateral approach aided to the increased likelihood of ectopy in the left- or right-sided by preoperative localization studies, most often a Technetium parathyroid glands, research has yielded mixed findings.27,28 Tc 99m sestamibi scan with single-photon emission computed Also of potential concern is that only 80% of humans have been tomography (SPECT) and ultrasonography, and intraoperafound to have four parathyroid glands. Thirteen percent of hutive PTH assay. The rationale for the trend for the minimally mans have been reported to have five or more glands, and 3% invasive parathyroidectomy (MIP) is that single parathyroid have been reported to have three glands.25 Physiological explaadenomas account for 80% to 90% of all primary hyperparanations for negative localizing imaging include hyperplasia and

FEBRUARY 2013 JOURNAL MSMA 37

multiple gland disease, which have been more commonly found in patients with non-localizing abnormal glands. These non-localizing glands have also been found to have significantly less weight, less volume, and be composed of more chief cells than oxyphil cells.21,22 Lastly, enlarged anatomy in proximity to the parathyroid glands has been found to negatively impact the capabilities of imaging modalities to identify parathyroid glands. Specifically, the presence of a multinodular goiter of the thyroid and increased body mass index (BMI) have been found to significantly decrease the sensitivity of the imaging modalities.22,29 The case examples below demonstrate the successful use of bilateral neck examination (BNE) and subsequent parathyroidectomy when imaging studies have failed to localize a hyperfunctioning parathyroid gland in the setting of presumed primary hyperparathyroidism. These cases illustrate the importance for a parathyroid surgeon to have a thorough understanding of various causes of negative localization studies.

Methods In this IRB-approved, retrospective case review, clinical data was gathered on all patients who underwent a parathyroidectomy for presumed primary hyperparathyroidism by the Department of General Surgery at the University of Mississippi Medical Center (UMMC) between January 1, 2010, and December 31, 2011. Of the 26 patients identified, only 3 patients (12%) had a sestamibi scan and an ultrasound, both of which failed to provide localization information. Data reviewed included electronic medical records of all previous appointments at our institution to examine presenting complaints, past medical history, calcium and PTH levels, imaging studies, and operative findings.

Results

Patient 1 – Ectopic Location in Tracheoesophageal Groove A 61-year-old female was referred to the department of surgery for the treatment of primary hyperparathyroidism. Past medical history included hypercalcemia (range 10.6mg/dL 12.4mg/dL), elevated PTH (range 83mcg/mL – 85mcg/mL), renal calculus, constipation, and chronic bilateral foot pain. Previous imaging studies included: 1) thyroid/neck sonogram, 2) radionuclide (technetium 99m sestamibi) parathyroid imaging with SPECT, 3) CT soft tissue neck with IV contrast, and 4) PET scan of skull base to mid-thigh. Findings of the thyroid/neck sonogram included multiple, small bilateral thyroid nodules and a complex right lobe thyroid nodule consistent with multiple adenomas. No sonographic signs indicating an enlarged parathyroid gland were seen. An ultrasound-guided fine needle aspirate (FNA) of the complex nodule identified the tissue as a benign follicular nodule/goiter. The radionuclide parathyroid imaging with SPECT early findings included mild, heterogenous distribution of the technetium 99m sestamibi in the thyroid gland with two areas of increased uptake noted in the left supraclavicular area and left neck. The delayed findings included washout of activity in the thyroid gland with faint, per-

38 JOURNAL MSMA FEBRUARY 2013

sistent activity but persistent foci of increased activity in the left supraclavicular area and left neck. There was no significant focal persistent increased uptake to suggest ectopic parathyroid tissue in the chest. These findings were considered suggestive of multinodular goiter disease of the thyroid. There was no scintographic evidence of hyperfunctioning parathyroid adenoma. A CT of the neck was recommended for further evaluation of the persistent foci of increased activity in the left supraclavicular area and left neck because these areas were considered suspicious for metastatic or reactive lymph nodes. The subsequent CT soft tissue neck with IV contrast findings included multiple, small bilateral thyroid nodules. No other mass or lymphadenopathy was seen within the neck and there was no specific abnormality to correlate with areas of hypermetabolic activity of the radionuclide scan. A PET scan was then conducted in an attempt to determine the location of a hyperfunctioning gland. No evidence of abnormal activity within the thyroid gland or supraclavicular fossa was found, nor was there a correlate for the areas of increased activity of the radionuclide scan. No abnormal activity was identified to suggest primary malignancy or metastatic disease either. The options of surgical treatment and medical management, as well as the risks associated with choosing no treatment, were discussed with the patient. In light of the non-localizing imaging studies, bilateral neck exploration (BNE) with intraoperative PTH measurement was recommended to identify abnormal gland(s) for parathyroidectomy, to which the patient agreed. Intraoperatively, the left inferior parathyroid gland was identified in its normal anatomical position and the left superior gland was located posteriorly in the tracheoesophageal groove. The superior gland appeared grossly enlarged at approximately 4.25cm in its greatest dimension. The inferior left parathyroid gland appeared normal. A baseline PTH level was drawn and found to be 160mcg/mL. The left superior gland was excised and sent for intraoperative pathologic examination as a frozen section. Pathology reported the specimen to be a parathyroid adenoma weighing 0.5402g. An intraoperative PTH level was drawn 10 minutes after excision of the superior left parathyroid gland and found to have decreased to 20.6mcg/mL (87% decrease). The right superior and inferior parathyroid glands were then located at their respective normal anatomical positions and appeared to be of normal size. The operation was then completed without complication, and the patient tolerated the procedure well. On post-operative day 1, the patient’s calcium level was 9.0mg/dL and at the 1-month follow-up appointment her calcium level was 9.5mg/dL. Patient 2 – Ectopic Location in Anterior Mediastinum A 66-year-old male was referred to the department of surgery for the treatment of primary hyperparathyroidism. Past medical history included hypercalcemia (range 10.4mg/ dL - 12.2mg/dL), elevated PTH (range 76mcg/mL – 160mcg/ mL), kidney stones, degenerative osteoarthritis, coronary artery

disease, hypertension, atrial fibrillation, diabetes, hepatitis C, peptic ulcer disease, benign prostatic hypertrophy, colon cancer, prostate cancer, hypercholesterolemia, and almost twenty emergency department visits over the previous eight years which were primarily for abdominal, flank, and lower back pain. Previous imaging studies included 1) radionuclide (technetium 99m sestamibi) parathyroid imaging with SPECT and 2) ultrasonography limited to the thyroid gland. The sestamibi scan results included no localization of a parathyroid gland but did identify a slight asymmetry of the thyroid with activity extending inferiorly on the left. The results of the ultrasound included a normal size thyroid with a nodule in the left lobe and no identification of a parathyroid gland. Without the benefit of localization, a bilateral neck exploration was recommended with the possibility of a total versus subtotal parathyroidectomy to which the patient agreed. Prior to surgery, a baseline PTH level was drawn and was measured to be 216.9mcg/mL. The operation proceeded with routine identification of the right inferior and superior parathyroid glands and then left superior parathyroid gland, which all appeared normal and were found in their normal anatomic locations. After failing to locate the left inferior parathyroid gland in its typical location, dissection was continued caudally where a parathyroid-like structure was identified posterior to the left subclavian vein entering the anterior mediastinum. This tissue was removed and sent to pathology as a frozen section. Pathology reported the specimen to be a parathyroid adenoma weighing 0.8470g and1.7cm in its greatest dimension. An intraoperative PTH level drawn 10 minutes after excision was measured at 52.2mcg/mL (75.9% decrease). The operation was then completed without complication, and the patient tolerated the procedure well. The following day the patient continued to do well and was discharged with a serum calcium of 9.2mg/dL. After three months, the patient’s calcium level was 10.0mg/dL. Patient 3 ES – Multinodular Goiter A 70-year-old female was referred to the department of surgery for treatment of primary hyperparathyroidism. Past medical history included hypercalcemia (range 11.1mg/dL – 12.3mg/dL), elevated PTH (range 71.2mcg/mL – 124.0mcg/ mL), hypertension, morbid obesity, arthralgia, adrenal incidentaloma, multinodular goiter disease of the thyroid, ascites, and multiple left renal cysts. Previous imaging studies included 1) radionuclide (technetium 99m cardiolite) parathyroid imaging, 2) several ultrasounds limited to the thyroid gland, and 3) radionuclide (technetium 99m sestamibi) parathyroid imaging. The cardiolite parathyroid scan found no evidence of a parathyroid adenoma but did identify a focus of activity for which an ultrasound was recommended for further evaluation. The follow-up ultrasound identified multiple bilateral nodules and a dominant 1.6cm nodule in the left lobe of the thyroid for which FNA was recommended for further characterization. The patient declined the FNA at that time and received two additional follow-up scans over the next three years which demonstrated no change.

The sestamibi scan identified a region of persistent uptake in the upper left lobe of the thyroid gland which was suggestive of a large hyperfunctioning parathyroid adenoma. However, due to the heterogenous uptake throughout the thyroid and multinodular goiter, a follow-up thyroid scan was recommended for further evaluation. The patient was reluctant to undergo additional imaging at that time and was subsequently referred to the department of surgery. The radiologic findings were discussed with the patient, and the recommendation was made for a bilateral neck examination with parathyroidectomy. Intraoperatively, the left superior parathyroid gland was encountered in its normal anatomical location and found to be grossly enlarged at approximately 4.5cm in its greatest dimension (Figure 1). The remaining 3 parathyroid glands were identified in their expected locations and were found to be normal in appearance. A baseline PTH level was drawn and found to be 110.3mcg/mL. The left superior gland was then excised and sent for frozen pathologic examination, which was reported as a parathyroid adenoma weighing 4.274g (Figure 2). After 10 minutes an intraoperative PTH level was drawn and was measured to be 40.7mcg/mL (63% decrease). The operation was then completed without complicaFigure 1. En Vivo Parathyroid tion, and the patient Adenoma did well postoperatively. On postoperative day 1, her serum calcium level was 10.8mg/dL and at 2 months followup had decreased to 10.1mg/dL.

Discussion Ultrasound and sestamibi studies may fail to localize a hyperfunctioning pararthyroid gland

Figure 2. Ex Vivo Adenoma

FEBRUARY 2013 JOURNAL MSMA 39

Table 2. Parathyroid Hormone (PTH) and Calcium (Ca) measurements Pre-excision PTH Patient 1 160mcg/mL

Post-Excision PTH 20.6mcg/mL (87% decrease) Patient 2 216.9mcg/mL 52.2mcg/mL (75.9% decrease) Patient 3 110.3mcg/mL 40.7mcg/mL (63% decrease)

Post-Op Day 1 Follow-up Serum Ca Serum Ca 9.0mg/dL 9.5mg/dL (1 month) 9.2mg/dL 10.0mg/dL (1 month) 10.8mg/dL 10.1mg/dL (2 month)

ilezikian JP, Silverberg SJ. AsympB tomatic primary hyperparathyroidism.

laraj DM, Clark OH. Current sta tus and E treatment of primary hyperparathyroidism. The Permanente Journal. 2008;12(1):3237.

N Engl J Med. 2004;350:1746-1751.

5. M ack LA, Pasieka JL. Asymptomatic primary hyperparathyroidism: A surgical perspective. Surg Clin North Am. 2004;84:803816. 6. Bilezikian JP, Potts JT Jr, Fuleihan GE, et

Table Parathyroidworkup Hormone and CalciumAt(Ca) al. Summary statement from a workshop on during the2.preoperative for (PTH) parathyroidectomy. thatmeasurements asymptomatic primary hyperparathyroidpoint, a physician must decide how to proceed. Options include ism: A perspective for the 21st century. J Clin Endocrinol Metab. 2002;87(12):53531) referral to a surgeon for a bilateral neck examination or 2) 5361. additional preoperative imaging. In our experience, additional 7. AACE/AAES Task Force on Primary Hyperparathyroidism. pre-operative CT scan and PET scan also resulted in negative The American Association of Clinical Endocrinologists and The findings. At an additional expense of $700 and $2200, respecAmerican Association of Endocrine Surgeons position statement on the diagnosis and management of primary hyperparathyroidtively, and additional exposure to radiation, imaging studies ism. Endocrine Practice. 2005;11(1):49-54. are not a benign process and must be considered carefully as 8. Eigelberger M, Cheah WK, Ituarte PHG, et al. The NIH criteria they may not provide additional information. We propose an for parathyroidectomy in asymptomatic primary hyperparathy- algorithm which progresses from sestamibi scan to ultrasound roidism: Are they too limited? Ann Surg. 2004; 239(4):528-535. scan directly to surgery regardless of the presence or absence 9. Edwards ME, Rotramel A, Beyer T, et al. Improvement in the of localizing findings. For patients who have had negative health-related quality-of-life symptoms of hyperparathyroidism is durable on long-term follow-up. Surgery 2006;140(4):655-664. preoperative localization findings, we recommend utilization 10. Rao DS, Phillips ER, Divine GW, et al. Randomized controlled of bilateral neck examination. The necessity of adjunct use of clinical trial of surgery versus no surgery in patients with mild intraoperative PTH measurement remains controversial. As in asymptomatic primary hyperparathyroidism. J Clin Endocrinol our cases where the intraoperative PTH measurement needed Metab. 2004;89(11):5415-5422. to be drawn only once due to the successful decrease of PTH, 11. Udelsman R, Pasieka JL, Sturgeon C, et al. Surgery for asympopponents argue that the assay unnecessarily increases the costs tomatic primary hyperparathyroidism: Proceedings of the third international workshop. J Clin Endocrinol Metab. 2009;94(2): of the operations. However, proponents of intraoperative PTH 366-372. assays maintain that the opportunity to realize the need to con12. Sidhu S, Neill AK, Russell CF. Long-term outcome of unilateral tinue with the exploratory surgery if the PTH levels had not parathyroid exploration for primary hyperparathyroidism due to decreased, as would be the case in multiglandular disease, is presumed solitary adenoma. World J Surg. 2003;27:339-342. incentive for its utilization, especially in the setting of negative 13. Westerdahl J, Berfenfelz A. Unilateral versus bilateral neck expreoperative localization attempts. The 3 case examples above ploration for primary hyperparathyroidism: Five-year follow-up of a randomized controlled trial. Ann Surg. 2007;246(6):976-980. outline why the surgeonâ&#x20AC;&#x2122;s level of experience with 4 gland exploration as well as a thorough understanding of normal and ab14. Norman J, Chheda H, Farrell C. Minimally invasive parathyroidectomy for primary hyperparathyroidism: Decreasing operative errant positioning of parathyroid glands are imperative for patime and potential complications while improving cosmetic retient safety and treatment. In light of negative imaging studies, sults. Am Surg. 1998;64(5):391-395. the surgeon is encouraged to be aware that the imaging studies 15. Kountakis SE, Maillard AJ. Parathyroid adenomas: Is bilateral may be falsely negative in the setting of multinodular goiter neck exploration necessary? Am J Otolarygol. 1999;20(6):396399. disease or ectopic parathyroid gland location. When superior parathyroid glands are not found in their typical location, the 16. Ruda J, Hollenbeak C, Stack B. The cost-effectiveness of sestamibi scanning compared to the bilateral neck exploration for ectopic gland may be located in the tracheoesophageal groove. the treatment of primary hyperparathyroidism. Otolaryngol Clin Inferior parathyroid glands not found in their normal locale may North Am. 2004;37(4):855-870. be found in the mediastinum. In our experience, this knowledge 17. Fraker DL, Harsono H, Lewis R. Minimally invasive parathyroidin the hands of an accomplished parathyroid surgeon can result ectomy: Benefits and requirements of localization, diagnosis, and intraoperative PTH monitoring. Long-term results. World J Surg. in a successful parathyroidectomy despite negative preopera2009;33:2256-2265. tive imaging studies.

References 1. Melton LJ III. Epidemiology of primary hyperparathyroidism. J Bone Mineral Res. 1991; 6(suppl 2):S25-S30. 2. Consensus development conference statement. J Bone Mineral Res. 1991; 6(suppl 2):S9-S13.

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18. Mihai R, Barczynski M, Iacobone M, et al. Surgical strategy for sporadic primary hyperparathyroidism: An evidence-based approach to surgical strategy, patient selection, surgical access, and reoperations. Langenbecks Arch Surg. 2009; 294:785-798. 19. Seebag F, Hubbard JG, Mawaja S, et al. Negative preoperative localization studies are highly predictive of multiglandular disease in sporadic primary hyperparathyroidism. Surgery 2003;134(6):1038-1041.

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20. Ruda JM, Hollenbeak CS, Stack BC Jr. A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003. Otolaryngol Head Neck Surg. 2005;132(3):359692. 21. Chiu B, Sturgeon C, Angelos P. What is the link between nonlocalizing sestamibi scans, multigland disease, and persistent hypercalcemia? A study of 401 consecutive patients undergoing parathyroidectomy. Surgery. 2006;140(3):418-422. 22. Berber E, Parikh RT, Ballem N, et al. Factors contributing to negative parathyroid localization: An analysis of 1000 patients. Surgery. 2008;144:74-79. 23. Erbil Y, Barbaros U, Tukenmez M, et al. Impact of adenoma weight and ectopic location of parathyroid adenoma on localization study results. World J Surg. 2008;32:566-571. 24. Phitayakorn R, McHenry CR. Incidence and location of ectopic abnormal parathyroid glands. Am J Surg. 2006;191:418-423.

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25. Akerström G, Malmaeus J, Bergstrom R. Surgical anatomy of human parathyroid glands. Surgery 1984;95(1):14-21. 26. Augustine MM, Bravo PE, Zeiger MA. Surgical treatment of primary hyperparathyroidism. Endocrine Practice. 2011;17(suppl 1):75-82. 27. Marzouki HZ, Chavannes M, Tamilia M, et al. Location of parathyroid adenomas: 7-year experience. J Otolaryngol Head Neck Surg. 2010;39:551-554. 28. Amin AL, Wang TS, Wade TH, et al. Nonlocalizing imaging studies for hyperparathyroidism: Where to explore first? J Am Coll Surg 2011;213(6):793-799. 29. Kamaya A, Quon A, Jeffrey RB. Sonography of the abnormal parathyroid gland. Ultrasound Q. 2006;22:253-262.

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FEBRUARY 2013 JOURNAL MSMA 41

• Special Article •

Friends of Medicine Can Make a Difference:

Organize a Mini-Internship Program Karen A. Evers, Managing Editor

n October 14-16, 2012, MSMA Chief of Staff, General Counsel Neely Carlton and I served as Singing River Medical Society mini-interns, along with Senators Michael Watson and Brice Wiggins; Representative Charles Busby; Ed Hagar, Director of Compensation Benefits and HRIS at Ingalls Shipbuilding, and Morris Strickland, Board of Trustees Member Singing River Health System (SRHS), the host and co-sponsor of the mini-internship program. For two days, we shadowed MSMA President Steve Demetropoulos and his colleagues who made themselves available to provide insight and answer questions. As interns, we spent half a day in each one-on-one placement with physicians, rotating through four assignments during an intensive two-day program covering emergency medical care, primary care, surgery, and an additional specialty. We observed firsthand how the changing rules and regulations in the “business” of medicine affect patient-care. Personally, working with our MSMA members and growing up as “a doctor’s daughter” familiar with the sacrifices made, I’ve always been protective of the profession’s reputation. Naysayers berating the profession, thinking doctors get rich at others’ expense, caused me to opine the side I knew. Over the last decade, I’ve found myself increasingly more defensive. The conversation has changed from explaining medical student loan repayment debt, managed care, and exorbitant malpractice insurance rates shifting to SGR, EMRs, big pharma, and the insurance industry. Going through the mini-internship program opened a valuable window of visibility into the physical and fiscal conditions affecting today’s medical business. It provided a more convincing argument for protecting medicine’s most personal level: the doctor-patient relationship. Television medical dramas (with their glitz, glam, and sex like rabbits) and internet sites (rating doctors based on ease of appointments, wait time, and parking accessibility) give no creed to physicians’ true clinical expertise or patient-satisfaction, distorting the public’s views of medicine and doctors instead. Allowing an intern to experience the doctor/patient relationship from the physician’s point of view helps humanize physicians, building support and better understanding between physicians and the public. For this intern, it was a “feel good” experience providing insight to dispel others’ views of doctors being cold and greedy — or the romantic view of the TV doctor. The internship provided a completely new perspective of what goes on behind-the-scenes. After observing SRHS doctors show their sincere concern, care, and interest in improving the quality of life for each patient, I, too, sensed an uneasiness and frustration about the external factors influencing medicine. Such intrusions like EMR reconciliation, restrictions imposed by third party payors, second opinions, pre-certification, retrospective reviews, downcoding, prescriber rating reports, and insurance approved clinical practice guidelines make it easy to become cynical, if not careful. As an intern, I saw the red tape barrier dividing the physician from the patient, often holding hostage the core of doctoring. While intended for “meaningful use,” the word “Epic” became a temporary tattoo on my brain. Ultimately, however, it was refreshing to observe doctors as leaders of the medical team. Through the mini-internship program, one gains insight to some of the numerous issues faced by those trying to meet the healthcare needs of the many. At Singing River, their enthusiasm and compassion for what they do are contagious, trickling down comradely throughout the healthcare team. Interestingly, what I observed as an intern at Singing River was much different from my perception as a patient of an academic medical center. The mini-internship was an amazing opportunity and an invaluable experience for which I’ll always be grateful. If you have questions about getting started with your own mini-internship program, you may call Dr. Richard Whitlock, MiniInternship Co-Director, at (228)990-6252 or Dr. John Weldon, Co-Director, at (228)324-7015. They will be happy to discuss program details with you or you may contact me: KEvers@MSMAonline.com or (601)853-6733.

ntroduction

In his inaugural address, MSMA President Dr. Steve Demetropoulos advocated the mini-internship program as a great opportunity for component medical societies to work in coalition with their local hospital to enhance the image of physicians. A mini-internship program is a grassroots effort to improve understanding of realities and challenges facing medicine by elected officials, other leaders in the community, and the media who make or influence health care policy. The program involves inviting public officials, business

42 JOURNAL MSMA FEBRUARY 2013

leaders, their staff, media, and others to visit hospital departments, medical practices, and spend clinical time with the physicians. Like traditional medical training, the “intern” is allowed to directly observe and learn from interactions among doctors’ specialties, the emergency medical services system, patients, family members, and other health care providers. The goal is to build relationships that could prove helpful for medicine in the future. Dr. Demetropoulos says, “It is a great way to allow others to see a side of medicine that they would not see any other way.”

HOW TO GET STARTED 1. Meet with component medical society leaders for approval of the program. 2. Begin by organizing a planning committee and assigning duties to each member. Appoint different chairs to coordinate physician recruitment, participant recruitment, scheduling, publicity, etc.

Senator Brice Wiggins (R-Pascagoula), MSMA President Dr. Steve Demetropoulos, and Senator Michael Watson (R-Pascagoula) –– It is hoped that as a result of the educational experience of seeing the process of medical practice from the inside, those who decide how the state’s health care delivery will be structured are better prepared to make those decisions.

3. Alert the medical community about your plans and ask for volunteers, such as members of the medical society, who will escort participants. 4. Create an information packet for physicians that includes several copies of a letter explaining the purpose of the program to be distributed to patients along with a consent form allowing participants to be present during patient appointments, surgery, etc. 5. Contact all hospitals where miniinternships will take place to gain the necessary clearance. A contract may be necessary. Consult legal counsel to follow protocol.

MSMA President and emergency medicine physician Dr. Steve Demetropoulos with Singing River Health System CEO Chris Anderson and SRHS Board Trustee Morris Strickland, who also participated as in intern

6. Decide how many participants are preferred and begin extending invitations. Create a packet of information that includes a schedule, program guidelines, and a list of medical terminology. 7. Send news releases to local media to notify them of the dates and purpose of the program. 8. Schedule an orientation session for physicians and participants to meet prior to the internship. This brief session gives the medical society and the Alliance the opportunity to explain how the program works and for physicians and participants to get acquainted.

Hospitalist Dr. John Weldon, Inpatient Physician Services, calls a patient’s relative to question who will take care of a stroke patient ready for discharge, only to find out his patient is the caregiver for another relative. Dr. Weldon is co-director of the mini-internship program (with Dr. Richard Whitlock). He is board certified in hospice and palliative medicine from the American Board of Internal Medicine, making him a part of the new Supportive Care and Palliative Medicine Program.

9. Schedule a debriefing session for participants to share their thoughts and observations. You may want to develop an evaluation form for physicians and for the “interns.” Consider creating a diploma or certificate to commemorate the internship experience. 10. Send thank-you letters to all physicians and participants. FEBRUARY 2013 JOURNAL MSMA 43

THE ADVANTAGES TO MINI-INTERNSHIP • for Doctors

• for Interns

1. Promotes better understanding between doctors and the community. 2. Renews doctors’ enthusiasm for medicine.

1. Gives a behind-the-scenes look at the medical profession and lets interns personally experience a doctor’s world.

3. Gets doctors more involved with the community.

2. Allows doctors and interns to learn from each other.

4. Gives doctors community resources they didn’t have before.

3. Shows interns the human side of doctors.

• for Medical Society

• for Community

1. Gives business decision makers and media personnel exposure to the various aspects of organized medicine. 2. Affords members the opportunity to be involved in society activities. 3. Allows the community to be involved in society activities. 4. Costs less than most community relations projects and consistently receives excellent results.

South Coast Family Physician Dr. Richard Whitlock, co-director of the mini-internship program– Interns note he dictates in front of his patients, then asks if he omitted anything, allowing patients to elaborate on things they may not have mentioned and ask questions. Another observation was his knack for making analogies to the patient’s lifestyle (e.g., explaining to a motor dealer, like putting the wrong pressure in tires or sugar in the gas tank).

4. Gives leaders and opinion makers resources to rely on when making critical decisions on health care.

1. Makes the community aware of the difficulties involved in the day to day lives of physicians. 2. Spotlights the excellent care available in our community. 3. Expands the knowledge and opinions of the physician’s life in the community. 4. Allows the community to get involved with the medical society.

While rotating through emergency services, some interns found it challenging to keep pace with MSMA President Dr. Steve Demetropoulos. Here, he cares for a patient brought in following a motorcycle accident. Observing Dr. Demetropoulos, one is reminded medicine is much more than EKGs, IVs, and x-rays. First and foremost, it’s people. The mini-internship creates understanding through personal experience.

44 JOURNAL MSMA FEBRUARY 2013

ER Dr. Jason Black uses Epic EHR software’s voice recognition system to dictate EMRs after sutering an ice pick laceration. Time spent in front of an Epic screen is time most physicians would rather spend with their patients. Dr. Black is relatively new to Singng River, having received his MD from the University of Mississippi School of Medicine.

“We (Singing River Medical Society) have conducted about thirteen mini-internships. It was so well received we had every one of our legislators go through it. We invited judges, CEOs, members of the board of trustees of the hospital, and healthcare decision-makers for all the local industries. The two things that everyone walked away with from the events were these: 1) ‘We didn’t know that you guys worked so hard. Our feet are so tired, and we are exhausted.’ 2) ‘You have an incredible job that touches the lives of people in such a unique way.’ The program helps you to develop more relationships and more influence within your community,” Dr. Demetropoulos says. Over 75 leaders have completed the Singing River program. A cross-section includes: Steve Bowden, International Paper; Norm Szydlowski, then CEO - Chevron; Jerry St. Pe’, then with Ingalls Shipbuilding; Rep. Carmel Wells Smith; Rep. John Read; Attorney William Reed; Justice Chuck McRae, Supreme Court Judge; J.J. Fletcher, The First (formerly SouthTrust Bank); Mr. Tommy Chelette, Mississippi Press Register; and Ginger Lay, Premier Health.

Background Singing River Medical Society organized their miniinternship program in 1995. To knowledge it is the first in Mississippi. Dr. Richard Whitlock who directs the program said, “Nothing beats firsthand experience. The program puts others in physicians’ shoes. When they see things as we do they receive their viewpoints more readily.”

“Since the program has expanded we’ve added a codirector, Dr. John Weldon,” he added. “Together we help organize the logistics of the program.” Designed to focus more on the “art” of the practice of medicine, the mini-internship allows the intern to experience the doctor/patient relationship from the physician’s point of view. “It has proved to be a very effective method of building support for medicine’s goals among legislators and other influential members of the community. It also provides a great opportunity for medical societies to work in coalition to enhance the image of physicians,” Dr. Whitlock acknowledged Originally, the mini-internship concept is the brainchild of Portland, Oregon, psychiatrist Ralph Crawshaw, MD. In 1976, while Dr. Crawshaw was president of the Multnomah County Medical Society in Portland, William Zieverink, MD and Collette Wright, who was then associate director for the society, helped pioneer the program. According to AMA literature, The Upjohn Company provided an educational grant to produce the campaign. The AMA held focus groups to develop the program. The story1 unfolds like this: In the early 1970’s, Dr. Crawshaw was a columnist for a prominent medical journal. He assumed the editor had a strong clinical background, but was surprised to find his experience was solely in consumer publications. Dr. Crawshaw exclaimed to the editor, “Why don’t you go out and see what’s going on in offices and hospitals?”

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“I’d like to,” the editor replied, “but no one’s ever asked me to.” Dr. Crawshaw offered to arrange for the editor to spend several days observing doctors in hospital and office settings. The editor eagerly accepted — and became the first “intern.” Ms. Wright2 recalled, “Dr. Crawshaw realized the medical profession is surrounded by very influential people who are continually making decisions about the direction of the profession without appreciation of the doctor/patient relationship, except as a patient. He had the idea to gather some of the decision-makers in the community, get them to put on a white coat, and start moving through the whole (medical) system. Others in medically related fields soon heard about the editor’s experience and asked Dr. Crawshaw to set up mini-internships for them. As the word spread about the mini-internships, other medical societies across the country started their own programs.”

Mini-Internship.Front.AP.pdf

SAMPLE FORMS 6/5/12

2:43 PM

The Mini-Internship Program An old adage says you can’t know a man’s troubles until you’ve walked a hundred miles in his shoes. That premise is the basis of the mini-internship program. Individuals from outside the field of medicine – such as legislators, business and community leaders, journalists, and attorneys – observe a physician in action for a one or two-day period.

For details contact MISSISSIPPI STATE MEDICAL ASSOCIATION 601-853-6733

MSMAonline.com

Follow in a Physician’s Footsteps … the mini-internship for friends of medicine

Advantages This type of program offers advantages to both the physicians and the interns who are involved. It promotes better understanding between physicians and community leaders by revealing the realistic, human aspects of health care delivery problems. It can be a cost-effective community relations tool and has the added advantage of increasing involvement in political activities. Perhaps the best result from the physician’s standpoint is the establishment of positive relationships with legislators and key leaders, which can be of great value in achieving the Association’s long-term goals. The interns also benefit by exposure to a perspective on the delivery of medical care not often available to the layperson. It also affords an opportunity for opinion makers and political leaders to develop contacts and resources within the medical profession, which they can rely on for advice when making decisions that will affect the future delivery of health care in their communities. “Done properly, it can be a ‘win-win’ situation for all involved,” said Dr. Demetropoulos.

Organization Your medical society should coordinate the mini-intern program. Give careful thought to which legislators and community leaders should be invited to participate. Consider inviting state and federal elected officials, members of key legislative committees, industry and business leaders from the community, members of the media, clergy, and leaders of service groups. It is usually best to have no more than one or two interns observing in a department at any given time. Obtain permission for the visit in advance from the hospital administrators involved. Be prepared to discuss with the administrators the advantages this type of program provides for the hospital as well as for physicians and the community. Plan dates to host interns. After the list of potential interns has been determined, send invitations to these individuals. (Sample letters are available on the MSMA

46 JOURNAL MSMA FEBRUARY 2013

Look for the brochure icon (above) to download sample invitations, letters, and forms. Examples are available on our website: @MSMAonline.com.

PROGRAM RULES • Patient confidentiality – Interns agree not to discuss any patients by name and to limit discussion of cases to the internship forums; interns also agree to respect each patient’s right to refuse their presence during office visits, consultations or treatments. Patients are advised of the program prior to the interns’ arrival and are given the opportunity to decline. • Adherence to schedules – Interns agree to strict adherence to pre-arranged schedules so no delays are caused in surgeries, other procedures, hospital rounds or office visits. Use of the mini-internship for self-promotion is forbidden. Interns are prohibited from printing or making any statements which could be construed as promoting themselves or their businesses upon participating in this program. • Orientation – The program begins with an orientation dinner at which time the interns and their preceptor-physicians meet each other, the schedules and rules for the mini-internships are reviewed, and questions about what to expect are answered. • Debriefing – The internships conclude with a debriefing dinner, and participants are given an opportunity to evaluate the program. The debriefing dinner is a vital part of the program.

authority, that is responsible for public health matters as part of its official mandate.” A state legislator or representative of a state health regulatory body could reasonably be considered a public health authority. However, other potential interns who do not have an official governmental function related to health care oversight would not fall under this exception and would require diligence in ensuring that written consent is obtained from all patients who will interact with the intern. Consent or refusal should be noted in the patient’s chart. Even if the intern falls within the definition of a public health authority, medical societies should strictly follow the consent and documentation steps to ensure compliance with HIPAA and respect the wishes of all patients.

Orientation Consider hosting a casual arrival dinner (the night before their rotation) for interns to meet members of your medical society and meet their preceptors. Go over the program rules, provide each intern a schedule, and have them report directly to the preceptor/department at the agreed-upon time. Obtain a signed confidentiality agreement.

The Intern Visit

MSMA President Dr. Steve Demetropoulos and Morris Strickland, Board of Trustees Member, Singing River Health System - Dr. Demetropoulos has practiced emergency medicine in Pascagoula for over 25 years. website.) An excellent time for elected officials to visit is during legislative recess periods, when they have fewer commitments at the Capitol and tend to be in the area to meet with constituents. Once the intern has accepted, send an acknowledgement letter with specifics regarding date, time, location, etc. Choose the physicians involved carefully, also. They should be knowledgeable and conversant with the issues important in both the local and national medical arenas. They should be ready to discuss their concerns, without preaching in an innate way, and should use patient interactions to demonstrate important points to the intern.

HIPAA Compliance It is critical that all mini-internship visits fully comply with the Health Insurance Portability and Accountability Act. HIPAA provides an exception to this prohibition when information is given to a public health authority, which is defined as “an agency or authority of the United States, a state, a territory, a political subdivision of a state or territory, or an Indian tribe, or a person or entity acting under a grant of authority from or contract with such public agency, including the employees or agents of such public agency or its contractors or persons or entities to whom it has granted

Provide a white lab coat for the intern to wear. A name tag or badge identifying the intern by name or as a “visitor” can be used, depending on hospital policy. If the intern is an elected official, it may be appropriate to have a photographer present to document the visit for the media. If this is considered, discuss the idea with and secure an approval from hospital administration public affairs and (if an elected official) the intern’s media relation’s aide (press secretary) prior to the visit. Most programs have the intern follow a physician who is actively caring for patients. If the shift is busy, there may be little time for discussion between the intern and the physician. It is important to remember that the intern should be supervised at all times so an assistant should be prepared to fulfill this role if needed. Ask the patient’s permission for the intern to observe the evaluation and treatment. The physician should introduce the intern to each patient who is to be evaluated. Document consent or refusal to consent in the patient’s chart. The intern will need to leave the exam room if the patient does not consent to the intern’s presence. Obviously, interns should not be present during any part of the physical examination that may be embarrassing to the patient, during questioning or counseling of a sensitive or private nature, or if the intern is acquainted with the patient. Use common sense and respect patient confidentiality and feelings. Be particularly careful when dealing with situations concerning death and dying. This is something that emergency personnel deal with frequently, but these situations can be extremely difficult emotionally for laypersons. Be especially cognizant of and sensitive to the intern’s level of comfort in these matters.

FEBRUARY 2013 JOURNAL MSMA 47

Interns are not allowed to inspect patient records; however, record reconciliation and related paperwork can be demonstrated. It can be advantageous allowing the intern to listen in on the call to the insurance company for authorization to evaluate and treat the patient. This experience can provide the intern with valuable insight on the difficulties and delays in receiving such authorization. Additionally, the intern will have the opportunity to learn about the formality burdens of practice. Allow interns to listen to your interactions with the medical staff, other physicians, and family members, and explain the significance of these conversations with the intern. Take every opportunity to discuss the issues important to your medical society/association and encourage any questions that the intern may have on various aspects and problems of medical care. Always remember that the intern is not likely to be fluent in medical terminology, acronyms, or abbreviations, so speak in layperson terms, and avoid jargon. The program’s goals are more likely accomplished through open, frank, and honest discussions of real problems and issues.

Debriefing “During the debriefing dinners we’ve hosted, it’s always been rewarding to see all of the program participants - interns and preceptors alike - enthusiastic about its effectiveness in establishing two-way communications between the world of medicine and the community at large,” Dr. Whitlock said. “Participants see it as a positive and productive time of sharing their common experience which provides a ‘psychological closure’ to the program,” he explained.

For additional information about SRHS’s mini-internship program contact: Cindy Seymour, Singing River Medical Society, Telephone (602)246-8901 or Karen Evers, Managing Editor (601)853-6733. Sample invitations, letters, and forms can be found on our website: @MSMAonline.com.

Acknowledgments:

Special thanks to Singing River Medical Society, especially mini-internship co-directors Dr. Richard Whitlock and Dr. John Weldon who coordinated the mini-internship program, MSMA President Dr. Steve Demetropoulos, and Singing River Health System for hosting the program. In addition to Drs. Whitlock, Weldon, and Demetropoulos, the author recognizes all of the doctors who served as preceptors: Dr. Ben Gatewood (Singing River Health Regional Cancer Center); Dr. Dionne Jackson and Dr. Jeremy Wiggington (Singing River Health System Clinics); Dr. Jason Black (Singing River Health System Emergency Services); Dr. Randy Roth (Singing River Inpatient Services); Dr. Ara Travers (South Coast Family Physicians); Dr. Richard Eubanks; Dr. David Jenkins; Dr. Mark Lyell; Dr. David Spencer, Jr.; Dr. David Spencer, Sr.; and Dr. Eric Washington (Surgery). The author would also like to thank Cindy Seymour and Janet Williams for their assistance organizing the Singing River Medical Society mini-internship program.

References 1. 2.

How it all began. Clark County Medical Society. www. clarkcountymedical.org. Accessed February 2, 2013. Doctors (cont.). Spartanburg Herald-Journal. February 6, 1992. http://news. google.com/newspapers?nid=1876&dat=19920206&id=uzEfAAAAIBAJ& sjid=9c4EAAAAIBAJ&pg=4752,1731683. Accessed February 2, 2013.

After the visit Consider hosting a dinner at the end of the program, especially if several interns have visited different departments. Allow each intern and physician to express impressions of the visit and provide time for an open forum to discuss questions, observations, concerns, etc. The cost of this function should be covered by the medical society or sponsoring organization. A group photo is another publicity opportunity. Provide an evaluation form for all interns and physicians who participated in the program. The evaluation form should ask for the impressions of the participants and solicit suggestions on how to improve the program. Consider sending a “certificate of completion” of the mini-internship program to the individuals involved.

Summary The mini-internship program cultivates relationships and influence with government officials and other important leaders. Because of the educational experience of seeing the process of medical practice from the inside, hopefully, those who decide how Mississippi health care delivery will be structured are better prepared to make those policy decisions. Sample letters are available to help get your component society started (@MSMAonline.com).

48 JOURNAL MSMA FEBRUARY 2013

Save The Date! 2013 MSMA “CME In thE SAnd”

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Friday, May 24, 2013 — 1:30 p.M. The Raven Golf Course Sandestin Golf and Beach Resort

CME Prior to Tournament — 8:15 A.M. For more information and to sign up, call Wendy Powell at Medical Assurance Company of Mississippi 1.800.325.4172

• President’s Page • Why is your Membership Important?

hy is your membership in the State Medical Association important? First of all, the numbers are important. An organization that has 5,000 members has much more influence with the legislature on both political issues and with public opinion than an organization which has 500 members. Your dues are important to our organization. The money that you contribute to be a member goes to fund all the various programs that we are involved with as an organization. I will describe some of these later but they range from the legislative agenda to the professionals health program to addressing public health issues. We value your membership and your dues money, and I think it is good for us to review our accomplishments on behalf of the physicians in our Steven L. Demetropoulos, MD 2012-13 MSMA President organization. First of all we have some ongoing initiatives that we fund every year that benefit every single doctor in the state whether an MSMA member or not. These include: 1. The Mississippi Professionals Health Program. 2. The CME programs held across the state that we officially accredit. 3. We endorse and offer a number of financial and business services including insurance products, credit cards, collection companies, and internet advertising. 4. We work to keep you informed through updates and publications like our weekly e-mail newsletters “MSMA Physicians’ Position” and “Lifeline,” as well as our monthly Journal of the Mississippi State Medical Association. 5. Now let me tell you about some of the things we have done on the legislative front. We have advocated for smoke free legislation, worked towards getting junk food out of school vending machines, increasing the cigarette tax, putting doctors back in charge of the Board of Health, creating the Rural Physician Scholarship Program and the Office of Physician Workforce, and increasing the medical school class size. We worked with the AMA to ensure that Mississippi physicians receive the geographic practice cost index payment differential from Medicare and assure that doctors were receiving retroactive claim adjustments for the SGR (Sustainable Growth Rate) update authorized by Congress. We passed “Truth in Advertising” legislation, which requires all healthcare providers to identify properly who they are by posting their credentials. We also fought to maintain the collaborative practice between physicians and nurse practitioners across the state. We work hard to defend scope of practice issues between physicians and all the other healthcare providers who want to practice medicine. 6. MSMA’S Claims Advocacy for Physicians (CAP) Committee works hard to resolve any type of claims issues and disputes with insurance companies and deals with HMOs, Medicare, and Medicaid on behalf of any MSMA member. 7. We work to promote doctors’ practices. One area called MississippiDoctors.com is an expanded version of a doctor finder feature that sets up basic internet footprints for every MSMA physician with optional advertising for those who are interested. We publish an annual Directory of Mississippi. 8. We offer Primary Prescription which is generic dispensing in physicians’ offices. It is a proven system to dispense generic medications to increase patient compliance and practice profits. 9. We have internet advertising with MSMAOnlineJobs.com in which we try to keep Mississippi residents in Mississippi and encourage those trained out-of-state to come back home. It is a job bank and is always current and fully searchable by location and specialty. 10. And of course our tort reform victories in 2002 and 2004 continue to pay dividends for us today with some of the lowest malpractice coverage rates that we have had in the last 10 years and a much better tort claims environment in our state which encourages new physicians to come into the state as well.

FEBRUARY 2013 JOURNAL MSMA 49

11. MSMA fought to get physician reimbursement of Medicaid to be at 90% of Medicare. 12. We insisted that the legislature put doctors in charge of the Board of Health. 13. We act as a resource for HIPAA regulations and RAC (Recovery Audit Contractor) audits. As you can see, your organization has been very busy on your behalf advocating for you, protecting your practice, and ultimately protecting the patients that you serve. I think you can also see from this long list that not only members, but also every doctor in the state, benefit from the activities of MSMA. That’s why we think it is important for every doctor in the state to be a part of our Mississippi State Medical Association because we all benefit from the actions of our Association. We know that you all make a sacrifice to join the organization, both in terms of your dues and your time, so we want to make sure that we earn your membership dollars and your commitment by the hard work that we do on behalf of each of you, our valued members, each day.

ust what the doctor ordered

CARIBBEAN ROAST PORK

The next recipe is for an entrée. I haven’t featured an entrée yet, and entrées are usually a bit more difficult to do. Everybody has his or her favorite, but I will just give you one to start with. This is a Caribbean Roast Pork. I take a small pork loin (more if you have company). Drizzle it with olive oil, then pepper it heavily and add salt. Put it on the grill and char it on each side. When there are good grill marks in the meat, pull it off the grill. I apply garlic heavily across the top of it and sprinkle ground cumin generously. I drizzle it again with olive oil, and I also add it in a Pyrex dish. Bake in a 350˚ oven for about 45 minutes. You can lemon juice. Wrap the roast in aluminum foil and place continue to add a little lemon juice and olive oil to it as it When your medical office is short-staffed, cooks if you like. The lemon juice and olive oil make a you get frustrated. great sauce to put on top of it. After it’s finished cooking, remove it from the pan and slice it. Then you have the lemon juice, olive oil, garlic, and peppery mixture to drizzle over the top of it. This roast really makes a great entrée. It is very nicely done with rosemary potatoes, black beans, and a good salad. I hope you enjoy this entrée. Until next month, Good eating!

When you get frustrated, you dread going to work and you start playing hooky. When you start playing hooky, the bills pile up. When the bills pile up, Mama ain’t happy. When Mama ain’t happy, ain’t nobody happy.

Caribbean Roast Pork

KEEP MAMA HAPPY. When your office is short-staffed, use the MSMA Online Job Bank! Learn more: www.MSMAonlinejobs.com 50 JOURNAL MSMA FEBRUARY 2013

MSMA ’s th

11 Annual

In the Sand!

Live CME

8:15 am - 11:45 am Friday 24 8:15 am - 12:45 am Saturday 25th & Sunday 26th 8:15 am - 12:45 am Monday 27th 8:20 am - 10:30 am Tuesday 28th

Social Events

Thursday 23rd: Welcome Reception Friday 24th: MACM Golf Tournament Sunday 26th: UMMC Alumni Family Cruise Monday 27th: Fireworks & Dinner on the Beach

FREE TIME Lots of it to spend with your family! provide continuing 2013 medical education for physicians. The MSMA The Mississippi State Medical Association is accredited by the Accreditation Council for Continuing Medical Education toFEBRUARY JOURNAL MSMA 51 Foundation, Inc. designates this live activity for a maximum of 9.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Application for CME credit has been filed with the American Academy of Family Physicians. Determination of credit is pending.

Earn

at MSMA’s

CME in the Sand

CME Speakers

CME Topics

Medicaid · Risk Management · Hypertension · Prescription Drug Abuse · Medication Management · Obesity · Medical Records and the IT Cloud · Dermatology · Oncology · Headaches · Pharmacology · Plastic Surgery and more!

Julie Wyatt MD · Ken Cleveland MD · Steve Demetropoulos MD · Mark Valverde MD · Scott Hambleton MD · Nikki Cleveland MD · Sheila Bouldin MD · Rob Jones JD · David Dzielak PhD and more!

STEP 2: Register with MSMA.

STEP 3: Pack your (beach) bags!

Book online by April 15 at http://bit.ly/VmRjAB OR call 800-320-8115. Group code: 22P8VC

Scan code for MSMAonline.com form OR register by mail/fax with form below. Registration Fee: $300

Don’t forget shades and flip-flops!

Registration Form

Fax to 601-707-3790 or mail to MSMA Attn: Jenny White, PO Box 2548 Ridgeland, MS 39158-2548 Name Specialty Address, City, Zip Phone Spouse / Guest (if applicable) Children’s Name(s) and Age (s) MSMA Social Events

Clinic / Practice Name Email Invited By Payment (comple te credit card information be low or

(check if a ttending a nd indica te number of adults and children per event):

Thur. 5/23 Welcome Reception Mon. 5/27 Family Dinner on Beach

# A du l t s / # Ki ds

52 JOURNAL MSMA FEBRUARY 2013

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ma ke check payable to MSMA): Credit Card Visa Mastercard American Express Card Number_______________________________________ Expira tion_____________ Amount Bille d: $300 Billing Address_____________________________________ Signa ture__________________________________________

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Put the Journal MSMA in the palm of your hand. Full color. Flip-page. Every month.

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FEBRUARY 2013 JOURNAL MSMA 53

• MSDH • Mississippi Reportable Disease Statistics

December 2012 Figures for the current month are provisional

Totals include reports from the Department of Corrections and those not reported from a specific District. For the most current MMR ﬁgures, visit the Mississippi State Department of Health website: www.HealthyMS.com.

54 JOURNAL MSMA FEBRUARY 2013

• Physician’s Bookshelf • How the unsolved murder of a doctor, a secret laboratory in New Orleans, and cancer-causing monkey viruses are linked to Lee Harvey Oswald, the JFK assassination, and emerging global epidemics: A book review of Dr. Mary’s Monkey

Adam Kressel, M3, Tulane University School of Medicine

dward Haslam’s Dr. Mary’s Monkey is an interesting, well-researched exploration into the people and medical mysteries surrounding New Orleans in the 1960s and 1970s. This is Haslam’s second book on this topic and is self-described as being more reflective, better researched, and with the added benefit of “a witness.” Haslam writes in the prologue that his father warned him of the dangers in publishing such a book, since there are powerful forces that would not want this information released. However, it has yet to cause the uproar his father imagined and is more of a six-degrees-of-separation tale rather than a who-done-it mystery. Haslam attempts to relate Lee Harvey Oswald, John F. Kennedy’s assassin, with Dr. Alton Ochsner, an acclaimed physician in New Orleans. Ochsner, along with Dr. Mary Sherman, Haslem argues, were trying to figure out how to solve an emerging problem of monkey viruses contaminating the polio vaccine supply, only discovered after millions of children were inoculated. However, there was another covert operation underway: a plan to use this information to create a biological weapon against Fidel Castro and communist Cuba. With hidden particle accelerators, unsolved murders, and secret corridors in unmarked buildings, this book is filled with what seems to be fast action thrillers that all come together to reinforce the author’s conclusions. The first thing that makes the reader suspicious is the accuracy with which the author portrays his memories and personal encounters. From the time he was 10, Haslam can recount stories and conversations as though they just took place. Documents seen, places visited, all throughout grade school, college, and early career are recounted with seemingly amazing accuracy. Additionally, it is startling how many coincidental encounters the author had with people and locations central to his story. A college girlfriend happens to live in the same apartment as David Ferrie’s secret laboratory, a not-so-detailed assignment as a reporter has him in an unmarked building (now part of the Ritz Carlton Hotel on Canal Street) meeting with people in possession of cabinets of classified documents, an unassuming older English teacher whispering to him at the end of class one day about his responsibility to find out what was going on as a member of the future generation; it all seems too convenient. Now I’m not saying that this book is not well-researched and convincing. Haslam has done an excellent job of putting

Doctor Mary’s Monkey. Edward T. Haslam. Soft cover, 374 pages, Indexed, Illustrated, $19.95. countless pictures, article clippings, documents, and the like throughout the book and in an appendix, but his cum hoc ergo propter hoc argument still reigns true. The fact that these characters were all intertwined in some fashion is no surprise, for the major players in any city will inevitably have heard and perhaps interacted with one another at some point in time. Haslam’s stretch is that he assumes what happened within these relationships to be in line with conspiracy theory. Only at the very end of the book does Haslam state that he cannot draw any conclusions about the secret underground medical laboratory and the current AIDS epidemic. However, there’s a whole chapter devoted to the polio vaccine’s initial problems and how that’s connected with the current statistics regarding cancers in the baby boomer population. He writes, “Today, however, there is abundant evidence of a variety of simian viruses found in the human blood supply. Of particular concern is the DNA from SV-40 repeatedly extracted from several types of tumors, including brain, bone, and previouslyrare chest cancers.” Haslam certainly gets his point across. The problem is that it just doesn’t align with current medical knowledge regarding cancer and HIV/AIDS. Simian viruses, which are believed to be the source of the current HIV strands, quite possibly entered the population with the polio vaccine, but more must be at play since the emergence of HIV in the 1980s was primarily in the homosexual population in a localized area of the country. If millions of school children were given this “monkey virus,” certainly a more widespread outbreak would have occurred. And in terms of the current cancers we see, simply because we can isolate SV-40 DNA from them does not mean that is the cause of the cancer. In my own conversations around New Orleans, I have recently discovered that the FBI files from the Dr. Mary Sherman murder mystery were housed in the Brent House Hotel at the Ochsner Medical Center main campus until Hurricane Katrina in 2005. Where they are now I don’t know. Does this point to a lasting connection between the government and Dr. Ochsner? Probably not.

FEBRUARY 2013 JOURNAL MSMA 55

I also traveled to where David Ferrie was believed to have his secret laboratory, a few houses down from his apartment. The address has changed but the building still looks the way it does in the book. Needless to say, the people living there probably don’t know the history of those buildings, save when a stranger with a camera pauses for a few seconds on the side of the road. I wonder if the smell from all the caged animals is still present inside. Dr. Mary Sherman’s apartment building, which I have passed almost every day without knowing who once lived there, still stands with the same awning and design as Haslam describes. The U.S. Public Health Service Hospital looks uninhabited, although I could not tell for sure. It still sits behind high brick walls with locked guard gates (no guards were seen). The best image I have is the Google Earth© rendition. So, is Haslam’s book a good read? Short answer: yes. It was interesting to read about how the great city of New Orleans was functioning, how history will mold and reshape itself as more information is discovered, new twists are put on people’s words, and government files are declassified. However, I think it falls short of proving the cause and effect relationships between the main characters, namely Dr. Ochsner, Dr. Mary Sherman, Lee Harvey Oswald, David Ferrie, and the Castro overthrow attempts. Is it possible this is all true? Sure. Is it likely? Perhaps. There are certainly things going on behind the scenes of which we laypeople are unaware. Maybe one day we’ll find out the truth, or maybe speculating is more interesting. Thankfully, authors like Haslam are around to entertain us. r

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56 JOURNAL MSMA FEBRUARY 2013

• Una Voce •

Going The Back Way …a Southernism

“F

Dwalia S. South, MD Ripley

ive-Fifteen. I’m going west toward home the back way. In the January dead of winter when daylight steals away from us too soon, there is only blackness along the route homeward from the clinic… so black in fact that there are times when the only thing of interest is the twilight glow from within the homes along the route. I’ve become familiar with illuminated scenes of families kicked back watching TV or eating supper. Over the years I have come to know all these families who live along my path, even those whose names I have never heard.

“A few strings of Christmas twinkle lights are still up and blinking, still doing their appointed job of spreading electric joy in this world of the repressive unsettling darkness. If I head home just at the right time, I am treated to some of the most memorable scenes this side of paradise. Every clear January nightfall seems an epiphany. On various days there are flaming crimson or golden backdrops painted by the haunting radiance of sunset. Skeletal outlines of giant oaks in silhouette form a canvas of ebony lace against our western horizon. Seeing this I am reminded why people long for a heaven so much.”

[ B ] I scribbled down those words a year ago when it dawned on me that the familiar sights and sounds I was experiencing on my daily ‘short-cut’ to and from work would soon be changing dramatically. The new clinic was on track to be completed, up and running by late spring. I must admit that I am a mule-headed old fogey, and I will strain against the reins of change as long as I possibly can. I began to realize how much I would truly miss buzzing through County Road 813, then passing through the city limits briefly on the Shady Grove, Palmer, and Blue Mountain Roads, and finally onto County Road 815 on my workday route. It isn’t even a short-cut really. It is comprised of a zigzagging and curving excursion of just over four miles of pavement and potholes between MS HWY 4 and 15. The time element is exactly the same if I drive the main road to the Ripley ‘metropolis’ and back track toward Blue Mountain. My internal GPS simply guided me to go the most direct way, and I have done so 250 times a year for nearly 25 years. Going the back way to the clinic has become ingrained in my muscle memory, so much so that my right foot moves to hit the brake when I see the Mt. View Baptist Church sign, my daily signal to head south. For the first month after the move I had to consciously restrain myself from making the turn. Then, one morning while on automatic pilot and singing loudly and mindlessly along to an old country song on KUDZU Radio, I actually did turn off and was about halfway to the old office before reality set in. I began meeting some of the usual ‘morning walkers’ along the route. First was Mr. Roger Davis with his hound dog leading him by the leash for their daily stroll. Then there was Mr. William Smith* walking for his heart health by my prescription. He did a double-take and waved me by quizzically as I flew down Blue Mountain Road. I laughed at myself for the error, slowed the truck down, and began looking a little more closely at my old trail.

FEBRUARY 2013 JOURNAL MSMA 57

The first dwelling on my detour once belonged to that cantankerous Terrell ‘Pappy’ Muller. Pappy knew my schedule and about once a week would flag me down on the roadside, sometimes to ask for a refill on a prescription (because he “didn’t want to bother me at work”) but often to give me a whole smoked pork shoulder (because he “knew I didn’t have much time to cook”). The cadence of his signature greeting phrase “You better GIT SOMEWHERE!” has become part of my own vocabulary. I miss his colorful and often off-color observations on local people and politics. Even Pappy’s take on the weather was entertaining… “Hot damn, it’s one hellacious hot Jessie of a day today, ain’t it, Dwayler?” Congestive heart failure finally waylaid Pappy a few years back. I miss that rascal’s manic waving at me every day from his porch. I’m going to miss viewing the daily progression of Mr. William Spight’s watermelon acreage this season changing from a plowed field, to hills of tiny melon plants, to ten foot long blooming runners. I love watching as almost overnight they bear hundreds of big green and yellow striped fruit, the hopeful fruit, the Dixie Queens, the Black Diamonds, and the Moon and Stars, a wondrous green black melon with a map of the night sky on each one. A little later on, in high summer, these sugary orbs will be for sale piled high like Shiloh cannonballs beneath his front yard shade tree. Mr. William always sees to it that we have a good supply of his melons on our break room table at the clinic. Yes, I am missing seeing all the folks who punctuated my back road journey over the years. Walking distance from the clinic on County Road 815 once lived sweet MabelTruman Ellis. On so many weekday occasions when she would be a patient at my office, she would ask me to “please come take dinner with us” at noon. The invitation always seemed off the cuff, but how could it have been? She never failed to put on a spread of victuals that looked like Sunday dinner with the preacher coming. She always decried every dish she had prepared and served… “Oh, I put too much salt in these peas,” or “Honey, you won’t be able to eat that minute steak, it’s as tough as shoe leather!” Of course, there was always an elegant sufficiency of deliciousness at her groaning buffet. Mabel has been gone probably twenty years now, but I’ll not ever forget her hospitality. She and so many others still live on for me in my recipe album. I can see her elfish grin whenever I come across the yellowed recipe card with a trembling scrawl that says “CAKE by MABEL…easy and good.” I’ll miss watching neighbor Jimmy Hill as he and Glenda would skin the buck they had just taken or clean the fish from their day’s expedition. Animals both wild and tame were part of each day’s journey. Along the path care must be exerted to dodge the Jackson’s chickens or one of the Lence’s calves, which might have slipped through the fence and darted into the road. I’m acquainted with most of the family dogs, particularly the ones who like to sleep in the middle of the road. Many of them are now grey muzzled, bowed-back coon hounds with ears dragging the ground and bench-legged feist dogs who take a minute to get up and out of your way like the little old arthritic men they are. I’ll miss admiring the shepherding white Great Pyrenees guarding her pasture full of two-tone saddle oxford goats and vigilant Border Collies and Blue Heelers nosing jacks and jennies to the trough. Frolicking newborn calves and colts, hopeful for the comfort of their mama’s nursing breast, always gifted me with me a smile on sunny spring mornings. Sometimes surprises lay in store. Coming home the back way one dusky fall evening I rounded one of the many hairpin turns along the route. I slammed on my brakes at what seemed an apparition in my headlights. I watched in awe at what first appeared to be a fat naked woman jogging down the center of the road ahead of me. Was it the ghost of a pudgy Lady Godiva with her flowing blonde locks? When my eyes focused I realized that I was actually viewing the rapid rhythmic agitations of the hind end of white saddle horse in a training session. One of the locals had her tied to the tailgate of his pick-up, and they were going up the county road at a fairly fast clip. Dangerous stuff for all concerned, but in retrospect it was a riotously funny scene that will remain forever in my mind’s eye. I will miss observing the constant metamorphosis of the homes on my daily path… Mr. and Mrs. Euclid Carter have both passed away, and their modest white homestead at the crossroads stands cold and dark. A few of the old deserted houses whose original owners died decades ago have now sadly been completely demolished. One area that used to be a fertile sericea lespedeza hay field has evolved into small cloister of upscale brick dwellings, the homes of hopeful young families whose whole lives are ahead of them. My rambling mind wonders how these homes will come to appear a century or so from now. Will they still stand? Or will their children move off and build homes in other hay fields, or even on other planets? I have watched these dwellings as over the span of years pink or blue balloons appeared on mailboxes to herald a newborn, starched white ribbons were pressed on a door to mark a death, and bold yellow ribbons adorned oak trees for soldiers serving in the eternal Middle-East wars.

58 JOURNAL MSMA FEBRUARY 2013

My daily destination of course was the clinic, Family Medical Center. One of my original nurses there, Maude Wilson, just died this New Year’s Day. Maudie had been in the dementia unit of a nursing home out of town for some years, and I felt the pang of guilt for not having visited my old friend in so long. I wanted to see her sweet smile and pretty silver hair just once more. Thinking of the old days and in her honor, I made it a point this morning to travel to work the back way. I needed to salute the comfortable rough cypresssided office building that had served as my daily home away from home for a quarter century. As I creeped slowly by the now quiet old clinic, I felt I was going through a visitation line at a wake. My office sign is lying on the ground, and the once bustling parking lot is empty and still. Several of the decrepit sycamore maples have finally succumbed in the past few months since we moved…their stark decaying limbs and trunks now bear no signs of life. Then something else caught my eye. Because the site of the clinic was on an ancient farmstead, daffodils planted perhaps a century ago still volunteer there every year. This morning I noticed their green fingers already pushing through the frosty ground. Because the yard man always kept them cut down in summer they haven’t produced their creamy gold blossoms in ages. But the buttercups have endured through all the change the passing years have wrought and remain hopeful for some future spring when they can once again flutter and dance in the breeze. They are at once a resurrection and an epiphany. Much to my chagrin, ‘going the back way’ to work each day is no longer a viable option for me. There is a new route for a new daily journey. We have been in our huge modern clinic building for just over 6 months now. The physical move to unfamiliar surroundings was only part of my angst. The sudden life-altering switch to the electronic medical record system that was inherent in the move wreaked havoc on my middle-aged nervous system. That heart sinking sensation of nausea I felt on awakening to the thought of facing another day wrestling with the laptop computer treating my virtual patients is beginning to subside a bit. No more ‘morning sickness’ because this old dog has almost mastered the new tricks. Everyone practicing medicine these days is a little bit queasy I expect. We are all facing the fears of our everevolving journey as physicians. No one is sure exactly where our healthcare system is headed. If they pretend they do, they are nothing less than liars. We can only extrapolate from our own anxiety how worried and confused our poor patients are. We must find new methods of ‘going the back way’ to our clinics each day…new ways to continue to touch and in turn be touched by our patients.

MSMA Helps Members Fulfill NEW Rx CME Requirements Prescribing Webinar Available NOW!

To register or learn more, click the “New CME Requirement” banner in MSMA’s Online catalog: http://MSMAonline.InReachCE.com

...Continued next page...

FEBRUARY 2013 JOURNAL MSMA 59

• Una Voce •

Journal of the Mississippi State Medical Association 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

A Southernism - continued from p. 59...

Staff Physician Student Health Center Mississippi State University

Robert Cadenhead, Director We must weep because Nothing remains unchanged… Longest Student Health Center we must rejoice that Everything endures… and we must Mississippi State University remain hopeful for the promise of a future spring for us all. 662.325.5895 phone 662.325.8888 fax rcadenhead@saffairs.msstate.edu

The MSU Student Health Center is looking for a BC/BE primary care physician to join the clinical staff. This is a robust clinical setting with focus on the healthcare of a university community. This is modern facility with adequate support staff and a fully integrated EHR environment. Compensation includes a base plus production incentive and full university benefits. Compensation is very competitive with primary care market. No hospital obligation. Malpractice insurance is paid by university. To apply go to www.jobs.msstate.edu search for “Staff Physician.” Inquires may be sent to rwc77@msstate.edu

(Some names were changed to comply with the HIPAA Dearand Dr.Security Cadenhead: Privacy Rules.

Thank you for your interest in the MSMA Past- President Dwalia S. South, MD, JOURNAL MSMA. Your ad ispractice. typesetA pastRipley, is board-certified in family president of the Mississippi Academy Family for a 23 line b/w ad at the rate ofof$5.00 Physicians, she is onplus the medical staff of the per line ($115.00) an additional Family Medical Center Division of North Benton typesetting charge of $25 for a rate of County Health Care, Inc. $140.00 for(Latin the first insertion; $115.00 “Una Voce” for “with one voice”) is Dr. South’s regular Journal column. Her collection thereafter. has been published in a book, by the same name, which may be found on Amazon.com or call This adMorris will run in the February Nancy at (601)783-2441. This 2013 collection of stories, poems, and letters is gleaned issue. Please proof, sign off, fax from backwritings throughout her career.

(FAX 601-853-6746) or call if you have questions, 601-853-6733, extension 323. You will also need to include your full billing information to mail an invoice with a copy of the magazine featuring your ad. All cancellations must be received in writing by the first of the month for PHYSICIANS NEEDED the following month’s issue.

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

OR Physicians to review Social Security disability claims at the

Karen A. in Evers Mississippi Department of Rehabilitation Services (MDRS) Madison MS. Contact us at:

Managing Editor

Leola Meyer 601-853-5487 Toll Free 1-800-962-2230 (Ext. 5487) or Jo Ann Summers 601- 853-5599

DISABILITY DETERMINATION SERVICES 1-800-962-2230 60 JOURNAL MSMA FEBRUARY 2013

What’s Your Specialty? Our specialty is NETWORKING... TPAs Physicians

Hospitals

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

Have You Considered a Life Settlement For Your Old Life Insurance Policy? What is a Life Settlement? A life settlement is the sale of an existing life insurance policy on the secondary market to a third party investor.

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

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

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

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

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