February 2014 JMSMA epub

February

VOL. LV

2014

No. 2

Fulfills MSBML requirement for 5 hours of approved continuing medical Fulfills MSBML requirement 5 hourssubstances of approved continuing medical education (CME) on prescribingfor controlled education (CME) on prescribing controlled substances

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Thisactivity activityhas hasbeen beenplanned plannedand andimplemented implemented inin accordance accordance with with the the Essential This Essential Areas Areas and and Policies Policiesofofthe theAccreditation AccreditationCouncil CouncilforforContinuing Continuing Medical Education through the joint sponsorship of the Mississippi State Medical Association and the Mississippi Professionals Medical Education through the joint sponsorship of the Mississippi State Medical Association and the Mississippi ProfessionalsHealth HealthProgram.

Program.TheThe MississippiState StateMedical MedicalAssociation Associationisisaccredited accredited by by the the Accreditation Accreditation Council Mississippi Council for for Continuing Continuing Medical MedicalEducation Educationtotoprovide providecontinuing continuingmedical medical education for physicians.

The Mississippi State Medical Association designates this live activity for a maximum of 5 AMA PRA Category I Credits .ďƒ” education for physicians. The Mississippi State Medical Association designates this live activity for a maximum of 5 AMA PRA Category I Credits .ďƒ” Physicians should only claim credit commensurate with the extent of their participation in the activity.

Physicians should only claim credit commensurate with the extent of their participation in the activity.

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

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

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

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

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

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

Copyright© 2014 Mississippi State Medical Association.

Official Publication of the MSMA Since 1959

FEBRUARY 2014

VOLUME 55

NUMBER 2

Scientific Articles

Relevance of Linguistic and Cultural Training among Non-Clinical Personnel at the University of Mississippi Medical Center: A Qualitative Study 34 Christianne M. Pinell-Jansen, MPH; Chris Anne Rodgers Arthur, PhD, MPH; Susan Hart-Hester, PhD Prognostic Value of Cardiac-Specific Troponins in Chronic Obstructive 40 Pulmonary Disease Exacerbations: A Systematic Review Nauman Chaudary, MD and Stephen A. Geraci, MD

President’s Page

The Season of Change 54 James A. Rish, MD

Related Organizations

MSMA YPS “CME in the Sand” 52 Mississippi State Department of Health 56 MSMA Alliance 62 MSMA Board of Trustees 66

Departments

From the Editor: Buttermilk is Good for What Ails Farmer Jones 30 MedWeb News 32 Physician’s Bookshelf: Mortality –Michael Gillette 45 Public Health Report Card 2014 47 Letters: Positions on Medicaid Expansion and Editor’s Response 58 Personals 60 Poetry in Medicine: “Sedation” –Benjamin A. Morris 64 Uncommon Thread: Vegetarian Hunting in Garlandsville, Mississippi 67

About The Cover: Monuments of the King and Queen of the Romani

(Gypsies) Meridian’s Rose Hill Cemetery, where the oldest marker is dated 1853, is a wellmaintained, historic cemetery, where residents of the area have buried their dead for over 150 years. Buried in the cemetery are Confederate soldiers, well-known politicians, and lesser known respected everyday citizens. One of the grave monuments includes the King and Queen of the Romani (Gypsies), Emil and Kelly Mitchell. When Queen Kelly died at age 47 during childbirth with her 15th or 16th child in Coatopa, Alabama, Meridian became the burial place because it was the closest town that had access to an ice plant which would be needed to preserve her body. Within a few days, thousands of members of the Mitchell Tribe would travel to mourn their queen. An article that appeared in the Meridian Dispatch, on February 7, 1915, describes the scene at the funeral home: “On one side of the parlors, with candelabra at the head and foot stands the magnificent silver-trimmed metallic casket. Hermetically sealed within, in all the barbaric splendor of a medieval Queen lays Mrs. Callie (Kelly) Mitchell, Queen of the Gypsies of America. Her swarthy face with its high cheekbones is typical of Romany tribes and the head, the upper portion of which is covered with bright silken drapery pinned at the back with pins, rests upon a cushion of filmy silk and satin. The hair is braided Gypsy fashion and the dark tresses shine. The body is attired in a Royal robe of Gypsy Green and other bright colors contrasting vividly with the somber hues usual under such circumstances. Two necklaces are around the neck, one of shells, an heirloom that was descended through generations. The lower part of the body is draped with ‘Sacred Linen’ treasured

by Gypsy bands for the use only when death overtakes one of their numbers. When the children arrive, each will put a memento of some kind in the casket and it will devolve upon the youngest child to place her mother’s earrings in the ear.”

On February 12, 1915, a funeral procession, complete with a Gypsy band and carriages carrying immediate family members, women, and children, followed the hearse from the funeral home to St. Paul’s Episcopal Church where Rector H. W. Wells officiated at the traditional Episcopal funeral rite. Ever since, people come to pay their respects, leave gifts, and can ask the queen to provide answers to their problems from beyond grave. Upon close inspection of the monument, one can see various beverage containers, beads, keys, sun glasses and other unusual mementoes. Photograph by Joe R. Bumgardner, MD of Starkville, a retired general surgeon who practiced there for 27 years. r February

VOL. LV

2014

No. 2

February 2014 JOURNAL MSMA 29

From the Editor: Buttermilk is good for what ails Farmer Jones

M

y friend Dr. John Neill, a Jackson neurosurgeon, descends of a long line of physicians. He tells an interesting medical anecdote of his physician grandfather Torrey George McCallum, MD, of Laurel.

McCallum, who graduated in 1894 from Tulane Medical School, eventually left the practice of medicine for law and politics, later becoming mayor of Laurel. His anecdote is one of my favorite doctor stories, revealing truth about the practice of this difficult art.

The story goes that soon after his arrival in Laurel in the late 1890s, young Dr. McCallum was approached on the dusty city streets by a farmer named Jones as he was headed on a house call. “I am sick, Dr. McCallum!!! I have a sore throat, a cough, and have been having fever for a month! I think I am dying!” Farmer Jones complained. So as physicians do, McCallum pulled out his new prescription pad and wrote three prescriptions, telling his patient to take the scripts to the local pharmacist and then carefully to take the medicine as he directed.

Ten days later, the young doctor bumped into Farmer

Jones on the dirt streets of Laurel.

“How did you do with the medicine?” asked Dr. McCallum. Farmer Jones answered: “Well, Doc. I never filled those prescriptions you wrote. Instead, I drank a glass of buttermilk every night for a week, and I got better.” As Farmer Jones walked away, Dr. McCallum pulled out Lucius M. Lampton, MD his notebook and recorded for future use: “Buttermilk is good for what ails Farmer Jones.”

What is the moral of the story? Sometimes, we don’t need to meddle in a patient’s problem. We are too quick to institute therapy, when the natural course of an illness may resolve all on its own, without us complicating it. Also, our patients know often what is best for them! Osler told us to care more for the “individual patient” than for the disease. Farmer Jones believed in his buttermilk, and whether or not it cured his sore throat, he was firmly convinced it did.

Contact me at lukelampton@cableone.net.

Lucius M. “Luke” Lampton, MD, Editor

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

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

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

30 JOURNAL MSMA February 2014

Paul “Hal” Moore Jr., MD Radiologist Singing River Radiology Group, Pascagoula

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

Jason G. Murphy, MD Surgeon

Surgical Clinic Associates, Jackson

Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson

Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport

William Lineaweaver, MD Sharon Douglas, MD Editor, Annals of Plastic Surgery Professor of Medicine and Associate Dean for VA Medical Director Education, University of Mississippi School of Medicine, JMS Burn and Reconstruction Center, Jackson Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Michael D. Maples, MD Vice Preisdent, Chief of Medicial Operations Baptist Health Systems, Jackson Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson

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

Telemedicine

is the practice of delivering health care services such as diagnosis, consultation, or treatment through the use of interactive audio, video, or other electronic media.

Telemedicine must be conducted as a “real-time” consultation, and does not include the use of audio-only telephone, email, or facsimile. Access to quality healthcare in underserved areas is one of the most important promised benefits of telemedicine. However, reimbursement for telemedicine services also known as telehealth services has been slow to develop. Recently, however, there are beginning to be changes. The 2013 Mississippi Legislative Session brought about changes with SB2209, requiring insurance companies to reimburse physicians and other healthcare providers providing telemedicine coverage to the same extent as traditionally administered services.

Currently, a large portion of the financing and reimbursement for telemedicine services originates with Medicare. The expansion of Medicare reimbursement began when Congress passed the Balanced Budget Act of 1997, mandating Medicare reimburse telehealth provided care and fund demonstration projects. The telehealth requirements and services covered by Medicare can be found at on the CMS website.

As of July 1, 2013, all health insurance plans in the state must provide coverage for telemedicine services to the same extent as traditionally delivered care.

The Division of Medicaid has entered into a Memorandum of Understanding with the University of Mississippi Medicaid Center (UMMC) to expand telemedicine services provided through UMMC on a demonstration-project basis. Currently, Medicaid covers telemedicine services for psychiatry and radiology statewide. Telemedical services for ER and stroke are covered when the services rendered were part of the telemedicine demonstration project.

Medicaid policy for coverage of telemedicine services are as follows:

Psychiatry

(Administrative Code Title 23, Part 206, Rule 1.9): Medication Evaluation & Monitoring is the intentional face-to-face interaction (including telehealth transmissions) between a physician, physician assistant, or a nurse practitioner and a beneficiary for the purpose of: o assessing the need for psychotropic medication; o prescribing medications; and o regular periodic monitoring of the medications prescribed for therapeutic effect and medical safety

Billing Instructions: Medicaid will reimburse for telepsychiatry when the appropriate CPT code is billed in accordance with the above policy and the modifier GT is used.

Teleradiology (Administrative Code Title 23, Part 220, Rule 1.4): The electronic transmission of radiological images from one location to another for the purpose of interpretation.

Billing Instructions: Mississippi Medicaid will reimburse one technical and one professional component for teleradiology services. Medically necessary teleradiology is covered only when the originating site documents state that there are no local radiologists to interpret the images. The site provider must bill using the appropriate CPT radiological code with the TC and GT modifier. Example: 70460 – TC – GT. The hub site provider must bill using the appropriate CPT radiological code with the 26 and GT modifier. Example: 70460 – 26 – GT [Disclaimer: This informational content prepared by MSMA staff is provided to JMSMA readers as an update from the 2013 Mississippi Legislative Session. No commercial activity is associated with this nor has any revenue been exchanged with respect towards keeping JMSMA editorial integrity intact.]

• MedWeb News • Five Inadvertent HIPAA Violations by Physicians

P

Tracey Haas, DO, MPH and Co-Founder, DocBookMD

hysicians do not plan ahead to violate HIPAA; but in this digital age you may be doing it because you did not plan ahead. The recent final rule of the HITECH Act outlines that even if the physician is unaware of the violation, he may be fined a civil penalty of $100 - $50,000 per violation. It is time for even the most resistant physician to pay attention to how he handles protected health information (PHI).

To assist MSMA members, the Association offers DocBookMD free to all actively practicing member physicians. Here we will outline five common ways you could be breaking HIPAA/HITECH privacy and security rules – and not even know it.

1. Texting PHI to members of your care team It’s a simple scenario: you’ve left the office and your nurse texts you that Mr. Smith is having a reaction to the medication you’ve just prescribed. She has included his name and phone number in the text. You may know that texting PHI is not legal but feel justified because it is a serious medical issue. Perhaps you even believe that deleting the text right away will protect you – and Mr. Smith. In reality, this text message with PHI has just passed from your nurse’s phone, through her phone carrier, to your phone carrier, and then to you – four vulnerable points where this unprotected message could be intercepted or breached. A secure messaging app like DocBookMD encrypts this type of message as it passes through all four points of contact. Ideally, both sender and recipient should be verified and have signed a business associate agreement (BAA).

2. Taking a photo of a patient on your mobile phone To some this sounds silly; to others, it is as common as verifying a rash with a colleague or following the margins of a cellulitis day by day. When these photos are viewed by eyes for which they are not intended you may be in violation of your patient’s privacy. It’s important to be aware of where and how patient information and images are stored. Apps that allow you to take a secure photo are just as important as sending the message securely. DocBookMD allows photos to be taken within the secure messaging app itself – never stored on your phone or within your phone’s photo album. Always use this type of feature when taking any photo of a patient or patient information.

3. Receiving text messages from your answering service Many physicians believe a text message from a third party, like an answering service, shifts the responsibility for a violation of HIPAA – this is simply not true. Many services do send a patient’s name, phone number and chief complaint via SMS text. The answering service may verify that it is encrypted on their end, but if PHI pops onto the physician’s screen, it is certainly not secure on her end – and this is where the physician’s responsibility lies. Talk with your answering service today to see how it protects you at both ends of the communication.

4. Allowing your child to borrow your phone that contains PHI Many folks allow their kids to use their phones to play games on apps while in the car. If your phone has an app that can access PHI, then you may be guilty of a HIPAA breach if the information is viewed by or sent to someone for whom it is not intended. The simple fix is to utilize the pin-lock feature on your messaging app and, for double-protection, always password protect your phone.

5. Not reporting a lost or stolen device that contains PHI Losing your smartphone or tablet is a pain for many reasons. However, if you have patient information on that device, you could be held responsible for a HIPAA breach if you do not report the loss right away. The ability to disable an app remotely that contains or handles PHI is an absolute must for technology that handles communications in the medical space. Be sure to ask for this feature from any company claiming to help you be HIPAA-compliant in the mobile world.

Remember: Being HIPAA-compliant is an active process. A device can claim to be HIPAA secure, but it is a person who must ensure compliance.

DocBookMD partners with MSMA to bring members a free, HIPAA-secure messaging app that uniquely provides extra security to avoid each of these potential pitfalls. DocBookMD is available in Mississippi only to MSMA members actively practicing.

For more information on the mobile app, visit www.DocBookMD.com or call toll-free 888-930-2048. To join MSMA, visit MSMAonline.com or call 601-853-6733. Membership is open to any MD or DO licensed to practice in Mississippi. r

32 JOURNAL MSMA February 2014

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February 2014 JOURNAL MSMA 33

• Scientific Articles • Relevance of Linguistic and Cultural Training among Non-Clinical Personnel at the University of Mississippi Medical Center: A Qualitative Study Christianne M. Pinell-Jansen, MPH; Chris Anne Rodgers Arthur, PhD, MPH, MCHES; Susan Hart-Hester, PhD, RHIA

A

bstract

Background: An academic medical center presents a unique environment where non-clinical staff provide vital services to a cross-section of people. A medical Spanish course was offered to a non-clinical department, campus police, in response to the growing number of Hispanics or Latinos seeking care within the health center. Method: In October 2007, a structured group discussion with six course participants was convened at the end of the Occupational Spanish course, using a topic guide to direct the conversation. Results: Content analysis revealed that participation in the course: (1) increased interest and provided a model for other departments, (2) promoted ability to respond, (3) enhanced cultural and linguistic competence, and (4) increased confidence, effectiveness, and value in their work. Conclusions: Structured cultural and linguistic training within an academic health center can contribute to a safe, secure environment, a more competent, responsive workforce, and enhance services to limited English proficient (LEP) patients.

Key Words: academic health center, Hispanic / Latino, medical Spanish, cultural training, campus police Author Affiliations: Ms. Pinell-Jansen is a biostatistician and instructor, former coordinator of Culturally and Linguistically Appropriate Services (CLAS), Institute for Improvement of Minority Health and Health Disparities in the Delta Region (MIGMH/DRI), and former instructor in the Department of Family Medicine and the Department of Internal Medicine at the University of Mississippi Medical Center (UMMC). Dr. Arthur is Professor in the Department of Family Medicine at UMMC. Dr. Hart-Hester is a retired UMMC-Professor in the Department of Family Medicine, and currently an Associate Professor in Health Information Management at Alabama State University.

Corresponding Author: Christianne Pinell-Jansen, MPH, MIGMH/ DRI – JMM, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505. (601)503-3512. (cpinelljansen@att.net).

Disclosure of Funding/Support: Program (CPIMP061018-01) and study (1CPIMP091054-01-04) supported in part by Department of Health and Human Services’ Office of Minority Health grants. authorship; and have approved the final version of this paper.

34 JOURNAL MSMA February 2014

Introduction The number of Hispanics or Latinos1,2 has increased dramatically with an estimated 106% growth over 2000 Census data,3 suggesting that Hispanics or Latinos are the fastest growing minority group in the United States.4-6 Data from the Centers for Diseases Control and Prevention (CDC) indicate that Hispanics or Latinos are less likely to have a regular healthcare physician than non-Hispanic Whites and African Americans,7,8 and more likely to receive primary care through the hospital emergency room (ER).9-11 Difficulty communicating with healthcare providers is a major barrier to access to health care for many whose first language is Spanish.12 The first point of contact for limited English proficient (LEP) Hispanics or Latinos accessing health care within an academic health center may be non-clinical personnel, i.e., a uniformed medical center officer.13 These officers, who can be sworn and non-sworn officers, provide law enforcement, interact with clinicians, non-clinicians, students, patients, and visitors.14-18 In this article, we explore the value and relevance of occupational Spanish to a non-clinical group within an academic health center (campus police) which participated in a structured group discussion after completing an 11 week face-to-face course19 that focused on linguistic and cultural competence. Although materials related to occupational Spanish courses and resources for law enforcement personnel are available,20-26 only a few studies27 have evaluated the impact of language courses in this particular group. We found no studies documenting the relevance of language or cultural training specifically among campus police at an academic medical center, making our study unique.

Method

In order to provide a social context for research, two members of our research team convened a conversation with six campus police in order to implement a qualitative analysis28 utilizing a semi-structured in-person group discussion29 format to examine the relevance of a face-to-face occupational Spanish course of eleven 3-hour sessions. Two members (CRA, CPJ) of our three-person research team were present during the group discussion session which was video recorded.

One author (CRA), a trained facilitator, and the other (CPJ), the course instructor, conducted the interview. We used a discussion topic guide, with thirteen pre-established prompting questions to engage the six campus police participants (List 1).

The 1-hour group discussion addressed the following questions (List 1): (1) campus police responsibilities, (2) work area, (3) past contact with Spanish speakers, (4) post-course changes, (5) colleagues’ response, (6) motives to take the class, (7) proficiency and progress, (8) complementary learning resource acquisition, (9) learning challenges, (10) goals, (11) feelings, (12) further comments, and (13) course arrangements. Although the guide was used, levels of questions included knowledge, source of information, experience, and opinion.30 Furthermore, the discussion was highly interactive with probes and follow-up questions used to provide greater depth. At several points, the participants began to talk among themselves, as well as with the interviewer, creating a more natural atmosphere.

The group discussion was professionally recorded, and it was transcribed by a contractor. We, the authors, analyzed the narrative data separately, for thematic content, identified patterns, and reached consensus through discussions.31 We submitted a final de-identified summary report to the Campus Police Department.

List 1.

Participants

8. Has anybody purchased anything outside of the class for Spanish? Where do you go and what kind of things you look for? Tell us about your experiences.

From March to May 2007, seven English-speaking law enforcement personnel (6 men and 1 woman; 3 non-Hispanic White and 4 non-Hispanic African American), employed by the Campus Police Department at UMMC, an urban academic medical center, attended an 11 week 33-hour occupational Spanish course. Six of the seven participants (5 men and 1 woman) voluntarily agreed to participate in the one-hour group discussion in October 2007. The group included three officers, two captains, and one investigator. The facilitator explained to the group the reason for the activity and the procedure. Participants could withdraw from the discussion at any point without negative consequences. We obtained a waiver of written consent and Expedited Review approval from the University of Mississippi Medical Center Institutional Review Board (IRB) for this study.

Discussion Topic Guide Used by a Facilitator to Convene a Structured Group with Six Academic Health Center Campus Police Regarding the Value of Medical and Occupational Spanish Training and its Relevance to Their Work at the University of Mississippi Medical Center, 2007

1. Briefly tell us your title and what responsibilities are associated with your title.

2. Where are you as you do your work at the medical center?

3. Have you had any contact with individuals who speak Spanish? Do you have experiences that you can share about your contact with individuals whose primary language is Spanish? Has anyone had any direct contact, experiences, conversations, and attempts to converse?

4. Has taking the class changed in any way the way that you view your work? If so, can you talk about that?

5. Have you had conversations with colleagues or friends about taking Spanish? What are the responses about you taking the class and learning Spanish?

6. Why did you take the class? What was your motivation for taking it?

7.

Let’s talk about your level of proficiency and how you perceive how well you’re doing. How are you progressing?

9. What has been the greatest challenge for you in learning Spanish? What’s been the hardest thing for you? What has been the biggest barrier you perceive to make progress?

Why do you think that is?

10. What are your goals for yourselves in terms of Spanish?

11. How do you feel about the fact that you are learning Spanish? What does it feel like?

12. Is there anything else? Is there any other observation or comment you want to share and maybe I didn’t ask, and it’s a thought that you had? Please feel free to share that thought with us.

13. I have one last question. How did the Spanish classes start with the police? Who initiated the contact?

Occupational Spanish Course

The occupational Spanish course in which the campus police participated was designed specifically for law enforcement and emergency personnel.19 The curricula, which included phonics, vocabulary, verbs, sentence construction, and cultural tips used a textbook,32 a workbook,33 and an audio CD.34

Analysis

The session was video-taped, and an external person was hired to transcribe the DVD verbatim. We (CPJ, CRA, SH) reviewed the participants’ responses and (separately) conducted independent Level 1 (open) coding of groups of words, ideas, phrases, and comments. Although an interview guide was used, inductive coding was utilized to accommodate discussions that

were spontaneous, relevant, and informative. The coding was further informed by the content and structure of the interviews.

Colloquial language was commonly implemented by the participants; therefore, “meaning” was an important consideration when interpreting certain words or phrases. The group discussed this first level of coding and in a subsequent course of analysis, independently developed Level 2 (category) codes.35 The group exchanged the category codes, and through discussions that followed, themes emerged through a combination of inductive and deductive decisions. Through subsequent discussions, the group reached a consensus regarding their interpretation of the data.

February 2014 JOURNAL MSMA 35

Results After the process of coding and reassembling the narrative data, we identified seven specific themes: (1) the value and relevance of medical Spanish to the roles and responsibilities of campus police; (2) changing demographics and increasing diversity within the community; (3) cross-departmental interest in occupational Spanish instruction; (4) buy-in and engagement among participants; (5) cultural tolerance and understanding; (6) personal and professional gain; and (7) perceived barriers.

Theme 1: The value and relevance of medical Spanish to the roles and responsibilities of campus police Job descriptions and duties by the participants were consistent with those identified in other academic medical center campus police around the country. In general, officers patrolled the premises by foot, bike, or car. For instance, an officer described her duties as “I’m a mountain bike patrolman.” Captains and investigators, on the other hand, worked mostly in offices and performed behind-the-scene duties.

As described per a captain, “Primarily it depends on how they [officers] are assigned for that particular day, I mean, when they report today. Depending on the man power, they may be assigned one day to the ER; they can be assigned to patrol the North end of campus or work the stadium or the front hospital. It depends on who is there, and what’s going on, and how they are assigned.”

A captain acknowledged encountering Spanish speaking patients, visitors, or employees as, “[…] when you walk out of campus police escort, somebody [speaking Spanish] is going to flag you down before you can get in the car and ask you how to get somewhere […], but […] primarily, my experience [of interacting with Spanish speakers] is through the hospital [with Spanish speaking employees].”

Throughout the discussion, respondents stated that police who work in office settings, i.e. captains and investigators, have less contact with Spanish speakers than policemen in the field, i.e. patrolling officers. As a chief investigator described, “ […]

I really don’t come into contact with a whole lot of Hispanics or Latinos. When I do, […] I kind of recognize some of the language, since I’ve been in this class. […]. Most of the time, when I come on campus, is [due to] an investigation, and I come into contact, let’s say, [while] walking through the hallways.

Other than that, I don’t get a chance to see them as much as the other officers do.” However, captains regarded occupational Spanish as essential to personal and professional safety, particularly as it relates to their law enforcement responsibilities.

Patrolling officers stated that the emergency room (ER) was among the places where they often have encounters with Spanish speaking patients, “I mainly relieve the ER during the week, I work Monday to Friday. […] That’s when the other officers have to go to break or lunch break. [If the Spanish speaking patients] have to go take the shots, most of them come to the ER, I have contact with them. [I have contact] one-on-one

36 JOURNAL MSMA February 2014

[with] who speaks Spanish. Some of them speak no-English. I realize I know more Spanish than what I thought I did. I recognize some words […], I listen. Then I can kind of tell what they are talking about, also I can be walking by, sometimes, and I hear them talk, and I recognize stuff they are saying.”

Theme 2: Changing demographics and increasing diversity within the community Campus police noted the increasing numbers of Spanish speaking individuals employed by the university and among patients seen in the clinics and hospital. An officer described his awareness of this changing environment by stating, “So, about a couple [of] days ago I was looking on the UMC website and come to find out there is a lot of employees who speak other languages, especially Spanish, and I was amazed!” Some participants expressed that the Spanish speaking population has doubled or maybe tripled in the last years. An officer voiced noticing an increase in the Hispanic or Latino population among patients, faculty and staff healthcare workers, as well as in the stores, “It’s not just at UMC. I mean, it’s everywhere. It’s in your neighborhood. It’s in your grocery store. It’s in Walmart. The population is growing.”

Theme 3: Cross-departmental interest in occupational Spanish instruction The police indicated that their participation in the course created interest among other university staff, faculty, clinicians and non-clinicians, and campus police members who did not participate in the course. A captain articulated, “It’s definitely got more people in our Department that want to do it. I think that if they had the opportunity they would, and if they knew what we went through, I mean, it was a fun class.”

An officer affirmed, “[It happens] as well at children hospital, [and at the] clinic. They were asking. Every department, their director, was trying to find out who had [it]? Who offered the class? They want to see if they can get their people [in].” According to respondents, this excitement became contagious and increased curiosity and desire among those with whom they came into contact. Another officer stated, “It’s not just our department that’s expressing an interest among Spanish cause even down at the ER, they’ve found out that we are taking it, and they are like, ‘we want to sign up for it too, but who do we talk […] to?’ ” Theme 4: Buy-in and Engagement among participants Participants expressed excitement about practicing the new language among themselves and with their colleagues. Many participants claimed they carried around their Spanish-English dictionary or class textbook to improve communication with patients. An officer claimed, “Well the first time I was out there [at ER] I had been taking some Spanish and that’s when I learned to take my dictionary wherever I go because, a lot of times, if you have the dictionary, [it will help with] the key words […].”

Most participants expressed attempting, on their own, to learn more by obtaining CD’s and audiotapes to listen to while

driving, watching T.V., or accessing the internet. One captain remarked, “I went and bought a small translation book. […]

I have a 5 or 6 disc CD set that I put it in my car and listen to for 15 to 20 minutes at a time and I […] can certainly understand a lot more that I can speak which is probably more important anyway […], to understand. […] You have to go to your internet homepage, usually on AT&T, you get Spanish and you read the overhead, what it’s saying here. [I] try to read through it like the news headlines and stuff like that. I make it like half way through it and switch it back over.” Another captain explained what he has done in order to practice more outside the classroom as, “like with Direct T.V., put it on Spanish, and see if I can make out some.”

Theme 5: Cultural tolerance and understanding One officer stated that, “Before I attended class, I kind of was irritated with them [Spanish speakers]. Well, I mean no harm but I was kind of irritated because I couldn’t understand what they were saying, you know. You couldn’t always find an interpreter all the time, and it made it [hard]. Especially when they come to you, and she’s crying or something, or they have a baby crying and you don’t know what the problem is. […]

So after learning in the class, I kind of got a better understanding. […] Now, I kind of got some control of the situation.”

Theme 6: Personal and professional gain Several police personnel expressed an increased selfesteem, accomplishment, and motivation to keep learning. A captain described it as, “I had an instance where I was called about a complaint on a police officer. A patient, he was actually a student at [a neighboring university] from Mexico or [the] state of [New] Mexico. […]. His father was there as well, and […], he was telling his father, and he [was] telling me. […] I could pick up a lot of what he was saying just from having the class […]”. Another captain confided that, “I think it just built up kind of my confidence, knowing that I had to encounter someone that spoke Spanish […].”

Although they would still require the interpreter to assist non-English speaking patients, participants stated that they felt more in control of the situation. An officer explained, “We have had one arrest. […] He said, ‘OK’. I mean, he was OK with it, but he knew what I said. But, before I took that class I would’ve never [been able to do it]. […]

I called [the hospital interpreter]. I said, ‘please would you come up?’ […] Because I could kind of understand a little bit what the wife was saying, and I knew that she’d told me that was her husband, but they were talking so fast…”

Participants expressed they felt better equipped to follow up a conversation, expressing the sentiment of increased reassurance in handling interactions with non-English speaking individuals seeking care at the hospital. Some participants expressed that by learning another language, they have had the opportunity to meet people otherwise unreachable due to lan-

guage barriers, therefore expanding their social network. For others, learning another language has been the stimulus to learn more - fostering a new personal and professional challenge.

Theme 7: Perceived Barriers Time and the mechanics of the language were perceived as the biggest barriers. Participants expressed the desire to invest more time on practicing or learning Spanish, but their job and family duties took priority, limiting the time they could spend learning the new language. A captain described, “When I’m sitting at the desk, I’m working on other things or the projects, and when my mind falls, ‘I need to be studying Spanish’. Then something else comes up, so by that time, it’s time to go home for the day. So, when I get home […] I got family responsibilities; there’s just no time for me to really concentrate on just my Spanish lessons. […] So, then when I finally get a break, [I] try to make sure I do my homework and everything. […] [This] helps us out a lot; [it] pushes you back into your learning mode again. But, you still kind of cram a little bit. When you cram, everybody knows it’s just hard to retain after that. You just can’t keep it […].” An officer confirmed, “Time. Well, I would love to do this more.”

Discussion and Conclusions Through the seven identified themes, we observed that both officers who patrol the premises and behind the scene personnel have encountered patients, visitors, or other Spanish-speaking workers. Patrolling officers seemed to have encountered more Spanish-speaking patients and visitors than their law enforcement colleagues. The point of access where this exposure was more apparent was the emergency room (ER) which is consistent with other studies.9-11 Participants identified language barriers as a source of frustration and feeling not in control of the situation.

Coincidentally, language barriers have been often identified as a major obstacle when addressing public safety issues36-37 and a barrier for LEP Hispanic or Latino populations to access healthcare.37-38 Participants expressed they often provided customer service when encountering patients or visitors in the parking lots and hospital surroundings. Besides learning Spanish, an officer expressed the course made her aware some Hispanics or Latinos may experience difficulties communicating with law enforcement personnel due to a lack of perceived differences between police and military force in their countries of origin.39 Across ranks, participants expressed the course had improved their communicative skills by making them able to better understand not only the language but also the culture of Spanish-speaking individuals, promoting a safer and more secure environment among clients and other health care workers. Some participants linked the linguistic aspect of the course to personal and professional safety. The course increased their cultural awareness and their desire to learn more about other cultures.

Some expressed reading the news in Spanish, talking to Spanishspeaking people, or learning more about the Spanish language

February 2014 JOURNAL MSMA 37

or culture in general. This initiative is key in order to have a better understanding of the patient as a whole and create patient and family-centered care to promote quality care and patient safety.40 Furthermore, the development of interpersonal, attitudinal, and communication skills among staff (i.e., campus police) positively impacts patient satisfaction,41-43 as well as improves interaction between minorities and healthcare personnel,44-45 thereby, positively impacting the community’s perception of the institution, as well as the stability of its work environment.46 One officer shared he asked a visitor, who had parked in a non-parking zone, to move her car. He said the woman reacted in a defensive manner and cursed him back in Spanish. Motivated by the course, he had taken the initiative to expand his vocabulary and picked up some of the words the visitor was saying.

Aware of the situation, he smiled and told her, in Spanish, to be careful because she never knew who could understand what she was saying. Taken by surprise the driver smiled back and moved her car. By taking the time to learn another language and culture, the officer had expressed interest and effort to communicate in this community’s language. This helps build confianza (trust)47 which helps build positive relationships with the community.48 The Civil Rights Act of 1964 (Title VI) requires facilities receiving federal assistance to offer access to services, regardless of race, color, or national origin.49 Consequently, LEP may be recognized as a proxy for national origin, challenging facilities to provide “meaningful access” for LEP persons via appropriate communication strategies.50 Standards 1 and 3 of the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care specifically state that health organizations should ensure culturally and linguistically compatible care, and ensure that staff receive ongoing cultural and linguistically appropriate training.51 The implications of our study address healthcare workforce policies. Some studies have shown that cultural training has proven beneficial among healthcare students52 and that cross-cultural education can contribute to minimize health disparities.53 The inclusion of cultural competency training has been addressed through Healthy People 202054 and the Liaison Committee on Medical Education (LCME), the nationally recognized accrediting authority for medical education programs.55-56 Considering the idiosyncrasy of an academic medical center, cultural and linguistic training among students and staff across campus is a must, and campus police should be listed among the recipients.

Our study has several limitations: (1) some experts suggest individual interviews rather than a group discussion may have served as a better control for participant bias; (2) originally our intention, focus groups were not possible due to the small size of the class (n=6), so more than one group discussion was not possible. Assessment of the need for language and cultural training by other departments within the same academic medical center is an important follow-up to this study.

In conclusion, our study examined the relevance of oc-

38 JOURNAL MSMA February 2014

cupational Spanish language training for academic medical center campus police. As the diversity of our population increases, interactions among first responders, such as the campus police at an urban academic medical center, must address culturally appropriate language and customs. Structured cultural and linguistic training within an academic health center can contribute to a safe, secure environment, a more competent, responsive workforce, and enhanced services to limited English proficient (LEP) patients.

Acknowledgements: The authors want to thank the UMMC Campus Police Department for their support and participation. The findings, opinions and recommendations expressed therein are those of the authors and not necessarily those of the University of Mississippi Medical Center, the Department of Health and Human Services, or the UMMC Campus Police Department.

Funding/Support: Program (CPIMP061018-01) and study (1CPIMP091054-01-04) supported in part by Department of Health and Human Services’ Office of Minority Health grants.

Other disclosures: None.

Ethical approval: This study received expedited review approval (IRB File # 2007-0167) from the Institutional Review Board at the University of Mississippi Medical Center.

Disclaimers: None.

Previous presentations: An abstract was presented at the Xavier University of Louisiana College of Pharmacy’s Fourth Health Disparities Conference in New Orleans, Louisiana, on March 27-29, 2011 and at the SHRP Research Day Proceedings in Jackson, Mississippi, on April 26-27, 2012. A second abstract was presented at the Jackson State University (JSU) 12th Annual Conference, Eliminating Health Disparities, in Jackson, Mississippi, on October 11-12, 2012.

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39. The South Carolina Commission for Minority Affairs. Findings from the Hispanic/Latino Ad Hoc Committee Presented to Governor Jim Hodges, State of South Carolina, 2001. http://www.state.sc.us/cma/Hispanic_Report/htm/ Public_Safety.htm Accessed August 5, 2013.

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45. Brach C, Fraserirector I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. 2000 57: 181, Med Care Res Rev. DOI: 10.1177/107755800773743655.

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Consultants, Inc. August 2012. http://www.partnersintraining.com/schedule. htm. Accessed December 10, 2012.

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26. National Institute of Justice. Office of Justice Programs. Español for Law Enforcement: An Interactive Training Tool. 2012. http://www.nij.gov/pubssum/201801.htm. Accessed December 21, 2012.

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27. Blandino DM, Rivardo MG. The acquisition and retention of job-specific Spanish vocabulary by English-speaking law enforcement officers. Journal of Police and Criminal Psychology, Fall 2006, Volume 21, Issue 2, pp. 68-82.

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• Scientific • Prognostic Value of Cardiac-Specific Troponins in Chronic Obstructive Pulmonary Disease Exacerbations: A Systematic Review Nauman Chaudary, MD and Stephen A. Geraci, MD [Dr. N. Chaudary, a pulmonologist and Director the Adult Cystic Fibrosis Service at UMMC, and Dr. S. Geraci, a cardiologist and Vice Chair of Medicine have combined forces to help answer a puzzle: what do abnormal cardiac troponins mean in patients with chronic obstructive pulmonary disease? The results of their systematic review may come as a surprise.]

—Richard D. deShazo, MD, Associate Editor

A

bstract

Background. Cardiac troponins are specific and sensitive biomarkers used for diagnosis and prognosis in myocardial infarction. Troponin elevations can also occur in other disorders and may be useful to predict mortality. This systematic review is intended to determine whether or not elevated troponins are predictive of mortality (in-hospital, short term, and longer term) among patients admitted with COPD exacerbation.

Methods. PubMed/Medline was searched to identify relevant English language articles that measured troponin T or troponin I in patients hospitalized for COPD exacerbation and assessed mortality, with or without other clinical outcomes. Only studies of significant size that presented original data were included.

Results. Nine research reports (4 prospective, 5 retrospective) qualified for review. Mortality was consistently increased in seven of these studies among COPD patients who had elevated troponin levels during an exacerbation. One retrospective study found no effect on (in-hospital) mortality but reported increased morbidity (greater oxygen requirements and more ventilatory failure) and increased length of hospital stay in patients with elevated troponin whereas discharge troponin T in one prospective study predicted hospitalizations.

Conclusions. The review shows a strong direct association between cardiac troponin and mortality in patients hospitalized for COPD exacerbations. Troponin monitoring could of Author Information: Division of Pulmonary, Critical Care and Sleep Medicine (Dr. Chaudary); Division of Cardiovascular Diseases; Department of Medicine (Dr. Geraci) University of Mississippi School of Medicine, Jackson, MS. (Dr. Chaudary and Dr. Geraci).

Corresponding Author: Nauman Chaudary, MD, Division of Pulmonary and Critical Care Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 Phone: (601)984-5650, Fax: (601)984-5658. (NChaudary@umc.edu).

Funding/Support: None

Conflict of Interest: None

40 JOURNAL MSMA February 2014

fer useful prognostic information in this population and might identify a group of patients to target for more intensive therapeutic interventions.

Key terms: troponin, chronic obstructive pulmonary disease, COPD exacerbation, prognosis, review Introduction Cardiac troponin (Tn) I and T (TnI, TnT) are specific markers for cardiac injury and strong predictors of outcome in patients with acute coronary syndromes. Troponin elevations can also be seen in a variety of non-coronary conditions such as sepsis syndrome,1 amyloidosis,2 intracranial hemorrhage,3 hemodialysis-treated chronic kidney disease,4 fragility hip fracture,5 and diabetic ketoacidosis,6 where they appear to portend a poor prognosis in the absence of evidence of coronary-mediated ischemia. While Tn elevations have also been reported in patients with chronic obstructive pulmonary disease (COPD) exacerbations,7 no review thus far has systematically summarized these findings. The purpose of this review was to determine if Tn elevations, in the absence of clinical evidence of myocardial ischemia or acute coronary syndrome, associate with increased short- and/or long-term mortality in patients hospitalized for COPD exacerbations.

Methods PubMed/MEDLINE (accessed August 21, 2012) searches were performed using key words “COPD” and “troponin”, “COPD exacerbation” and “myocardial injury,” “myocardial injury” alone, and “COPD” alone. Search limits included English Language articles and cardiac markers other than troponin (e.g., creatine kinase, creatine kinase-MB, lactate dehydrogenase). Articles identified by these criteria were screened by title and abstract for relevance to mortality in COPD exacerbation.

Reports of single cases, opinion papers, review articles, and studies employing troponin as end point (rather than a predicting variable) were excluded. Papers were also excluded if the study population’s primary reason of hospitalization was not a COPD exacerbation or where data from subjects with a COPD exacerbation could not be examined separately from those with concurrent conditions (e.g. acute myocardial infarction, “critical illness,” sepsis or heart failure) within a larger study (Figure).

Figure. Flow sheet of literature search results and article selection Original PubMed/MEDLINE Searches

20 initial articles

2 Case Reports

18 Concurrent MI or heart failiure or critical illness 1 Editorial

8

Cardiac catheterization related findings

9 Articles Included in Review

Results The above search strategy yielded 20 initial articles: 1 was editorial commentary, 2 were single case reports, and 8 had study populations where COPD exacerbation was not the primary diagnosis or where data from subpopulations with concurrent critical illnesses, heart failure or myocardial infarction could not be separated from patients with a COPD exacerbation alone and were excluded. Nine published reports, therefore, qualified for review, including 4 prospective and 5 retrospective studies. While TnI was measured in 4 studies, TnT was reported in 4, and 1 study measured both TnI and TnT (Table). In total, 1729 patients were reported in aggregate in these 9 papers.

Hoiseth8 prospectively analyzed 99 patients hospitalized with COPD exacerbations between January 2005 and Decem-

ber 2008. There were 219 blood samples studied for troponin after including 120 of 191 readmissions from the index group.

The lower limit of detection of TnT was 3.0 ng/L and upper limit of normal of 14 ng/L. Patients were categorized into 3 groups based upon TnT levels sampled on admission: <14.0, 14.0-39.9 and >40.0 ng/L. They were followed until death or study termination. During a median follow-up time of 1.9 years, 57 patients (58%) died, 97 patients (98%) had measurable levels of TnT, and 73 (74%) had TnT above the normal range (>14.0 ng/L).

The prevalences of patients having TnT <14.0, 14.0-39.9 and >40 ng/L were 26.3, 37.4 and 36.4% respectively; crude mortality rates (95% CI) were 4.6 (1.5-14.2), 30.2 (20.3-45.1) and 58.3 (40.8-83.4) per 100 patient-years respectively. The study found a more significant association between TnT and mortality (p<0.001) in patients with presenting heart rates >100/minute.

Brekke9 retrospectively examined the ability of elevated TnT (>0.04 mcg/L), sampled within 24 hours of admission for COPD exacerbation, to predict mortality in 396 patients over 4.5 years. This observation reveals a highly significant difference in overall survival (p<.0001) in patients with, versus those without, TnT elevation. The hazard ratio (95% CI) for log [TnT] was 1.24 (1.04-1.47) for the TnT-positive group.

Baillard10 prospectively evaluated the incidence and prognostic value of admission TnI levels in 71 patients admitted to the intensive care unit for severe COPD exacerbations.

Kaplan-Meier survival curves showed that the probability of in-hospital death was higher in patients with an elevated TnI (p=.002). In a logistic regression model, TnI elevation (p=.03) and SAPS II (Simplified acute physiology score II) (p=.02) were identified as independent predictors of in-hospital death.

A retrospective study by Fruchter11 assessed the predictive value of Tn levels on long-term survival in 182 patients following acute exacerbations of COPD. There were 99 patients with TnI levels < 0.03 mcg/L and 83 with TnI levels >0.03 mcg/L on samples drawn within 24 hours of admission. The maximum observation time was 6 years. The probabilities of survival at 1, 3 and 5 years in patients with TnI levels <0.03 mcg/L was 91%, 78% and 70%, while the corresponding probabilities in patients with TnI levels >0.03 mcg/L were 75%, 70% and 58% (p=.005) respectively. Age, ischemic heart disease and total troponin concentrations were also found to be significant independent predictors of mortality, while pCO2 on admission was only marginally predictive.

The retrospective study by Harvey12 determined the frequency of serum Tn elevation in 188 patients admitted to the hospital with a primary diagnosis of COPD exacerbation.

Troponins were considered elevated at levels >0.4 mcg/L for TnI and >0.03 mcg/L for TnT. There were no significant differences in in-hospital mortality between the raised and normal troponin groups. Patients with Tn elevations tended to be older (75.7 vs. 70.0 years, p=.001), had lower pulse oximetry saturations (85.6% vs. 89.6%, p=.003), were more acidotic (pH 7.34 vs. 7.40, p=.002), hypercapnic (pCO2 58.0 vs. 49.1 mm

February 2014 JOURNAL MSMA 41

Marcun15 prospectively followed hospitalizations and Hg, p=.04), and had significantly longer stays (5 vs. 3 days, p=.001). There was a trend toward higher domiciliary oxygen mortality for 6 months in 127 patients with acute exacerbause in the group with elevated Tn (17% vs. 6%, p=.034). tions of COPD who had elevated troponin T and NT-proBNP. 13 Martins retrospectively ascertained the range of TnI Serum concentrations of both NT-proBNP and TnT were elconcentrations among 173 patients with acute exacerbations of evated on admission in 60% and 36% and at discharge in 28% COPD and evaluated the biomarker’s ability to predict mortality and 19% of patients. During follow-up, 53 patients (42%) and need for noninvasive ventilatory support (NIVS). Samples were hospitalized and 17 patients (13%) died. In a multivarifor TnI were drawn within 48 hours of admission and labeled ate model, TroponinT at discharge predicted hospitalizations as baseline (first measurement) and peak (maximum value re(p=0.017) whereas admission NT-proBNP predicted mortality. corded during hospitalization). A positive admission TnI was Kelly16 retrospectively studied 252 emergency departdefined as >0.012 ng/mL. The median initial TnI concentration ment patients with acute exacerbations of COPD who were adwas 0.030 ng/mL, and the Table. Summary of Included Studies. median value of peak TnI was 0.040 ng/mL. Over- Study Type of study N Troponin Clinical Predictive all 18 month survival measured outcome of Mortality (Yes/No) was significantly higher P value (p=.030) among patients with negative baseline Hoiseth8 Prospective 99 TnT Mortality over yes TnI and peak TnI conPeak >40ng/L 3 years f/u <0.001 centrations (p=.021).

Crude mortality rate Chang14 prospec58.3% per 100 tively examined the aspatient years sociation of TnT with Brekke9 Retrospective 396 TnT Mortality over yes mortality in a cohort of >0.04mcg/L 4.5 years f/u <0.0001 patients with COPD exHazard ratio acerbations. Both TnT for log TnT and NT-proBNP were 1.24 measured on admission. Baillard10 Prospective 71 TnI In hospital yes Median mortality 0.03 The primary end point >1.00ng/mL Adjusted odds was 30-day all-cause ratio 6.52 mortality. Elevated NT11 Fruchter Retrospective 182 TnI Mortality at 1, yes proBNP (>220 pmol/L) >0.03mcg/L 3 and 5 years 0.003 was present in 65 of Probability of 244 patients (27.5%) survival 58% at and significantly pre5 years dicted 30-day mortality Harvey12 Retrospective 188 TnI and TnT In hospital No >0.4mcg/L mortality “p” not (OR 9.0, 95% CI 3.1TnI given 26.2, p<.001). Elevated >0.03mcg/L TnT (>0.03 mcg/L) was TnT found in 40/241 patients Martins13 Retrospective 173 TnI Mortality over yes (16.6%) and also pre>0.012ng/mL 18 months 0.012 dicted 30-day mortality (OR=6.0, 95% CI 2.4- Chang14 Prospective 241 TnT Mortality at 30 yes 16.5, p<.001). The two >0.03mcg/L days <0.001 cardiac biomarkers apOdds ratio 6 peared to have synergis- Marcun15 Prospective 127 TnT Mortality at 6 No months 0.017 tic associations with surHazard ratio vival: 30-day mortality hospitalizations among patients with ele2.89 vations of both NT-proBKelly16 Retrospective 252 TnI In hospital Yes NP and TnT was 15-fold >0.04ng/ml mortality “p” not higher than among paOdds ratio 8.3 given tients with normal values of both (p<.001).

TnI = troponin I. TnT = troponin T.

42 JOURNAL MSMA February 2014

mitted to hospital and in whom TnI (99th percentile >0.04ng/ ml) was assayed at presentation. The primary outcome was inhospital mortality. The study found an in-hospital mortality of 4.4% [n=11; 95% confidence interval (CI) 2.5-7.7%]. Seventy nine patients had elevated troponin of greater than 99th percentile (31%, 95% CI 26-37%). Mortality in patients with elevated troponin was 11.4% (9/79; 95% CI 6.1–20.3%) compared with 1.2% in those without troponin elevation (2/173; 95% CI 0.3–4.1%). Factors independently associated with mortality were troponin elevation [odds ratio (OR) 8.3, 95% CI 1.5843.7], pH below 7.2 (OR 12.7, 95% CI 1.86-86.4), and requirement for noninvasive ventilation (OR 8.09, 95% CI 1.61-40.8).

Discussion In this systematic review, seven observational studies8,9,10,11,13,14,16 identified an increased mortality in patients who had a Tn elevation within 24-48 hours of admission for a COPD exacerbation, and five9,10,11,14,16 suggested elevated Tn independently predicted mortality in this setting. Harvey’s retrospective study12 measured the frequency of troponin positivity in COPD exacerbations; mortality was not predicted (for unclear reasons), but higher morbidity (greater oxygen requirements, more ventilatory failure and increased length of hospitalization) was suggested in the Tn-positive patients. All reviewed reports reasonably excluded acute coronary syndrome cases from their analyses. Depending upon design, these studies showed associations between Tn elevation and both short-term10,14,16 and long-term8,9,11,13 mortality.

Troponin elevations in patients with acute COPD exacerbation have generally been attributed to one of several potential mechanisms, including elevated pulmonary arterial pressure,8 associated heart failure17 and hypoxia with tachycardia.18 Other adverse outcomes were also significantly associated with troponin elevations, including increased oxygen requirements,10 prolonged length of hospital stay,12 and significantly increased need for NIVS.13 These findings appear to add credence to the premise that important clinical outcomes separate from mortality could also be predicted by admission Tn levels.

Patients with elevated troponin early in their hospital courses could serve as a high-risk subpopulation for interventional studies aimed at reducing mortality: differing treatment approaches for their lung disease, cardioprotective measures, or some other (e.g., cytokine inhibition) intervention. Highest risk cohorts, with the most adverse events to potentially reduce by an active treatment, are typically those used in first-line trials. Troponin-positive patients with acute COPD exacerbation may fill this important investigational role.

Limitations of this review include the inherent (selection) bias of retrospective studies, the small sample sizes in the prospective studies, and potential confounding variables (i.e., undiagnosed concurrent illnesses which could separately result in Tn elevation) which were not definitively excluded in most studies. Most of studies are single center, in-

troducing possible recruitment bias. Despite these limitations, 7 of 9 papers found a statistically significant higher mortality among patients with exacerbated COPD who manifested elevated serum Tn concentrations early in their hospital courses.

Conclusion This review supports the observation that, among patients hospitalized for COPD exacerbations, troponin T or I elevation independently associates with in-hospital, short-term and long-term mortality. Large, multicenter prospective observational studies, with more thorough data collection (particularly related to the presence or absence of underlying heart disease) are needed to substantiate these findings. Identifying high-risk patients could set the stage for future interventional trials aimed at reducing mortality in COPD exacerbation.

Acknowledgements Dr. Chaudary served as the guarantor of the paper and takes responsibility for the integrity of the work as a whole from inception to published article. He contributed to the concept and design of study, analysis and interpretation of the included studies, and provision of final approval of the version to be published.

Dr. Geraci contributed to concept and design of the paper, interpretation of the included studies, critical revision of the article, and provision of final approval of the version to be published.

The authors also acknowledge and thank Dr. Richard deShazo for his review and suggestions on the paper.

References 1.

Mehta NJ, Khan IA, Gupta V, Jani K, Gowda RM, Smith PR. Cardiac troponin I predicts myocardial dysfunction and adverse outcome in septic shock. Int J Cardiol. 2004;95:13-17.

2.

Dispenzieri A, Gertz MA, Kyle RA, Lacy MQ, Burnitt MF, Therneau TM, Greipp PR, Witzig TE, Lust JA, Rajkumar SV, Fonseca R, Zeldenrust SR, McGregor CGA, Jaffe AS. Serum cardiac troponins and N-terminal pro-brain natriuretic peptide: A staging system for primary systemic amyloidosis. J Clin Oncol. 2004;22:3751-3757.

3.

Sandhu R, Aronow WS, Rajdev A, Sukhija R, Amin H, D’alquila K, Sangha A. Relation of cardiac troponin I levels with in-hospital mortality in patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Am J Cardiol. 2008;102:632-634.

4.

Khan NA, Hemmelgarn BR, Tonelli M, Thompson CR, Levin A. Prognostic value of troponin T and I among asymptomatic patients with end-stage renal disease: a meta-analysis. Circulation. 2005;112:3088-3096.

5.

Chong CP, Lam QT, Ryan JE, Sinnappu RN, Kwang W. Incidence of post-operative troponin I rises and 1-year mortality after emergency orthopaedic surgery in older patients. Age and Ageing. 2009;38:168-174.

6.

Al-Mallah M, Zuberi O, Arida M, Kim HE. Positive troponin in diabetic ketoacidosis without evident acute coronary syndrome predicts adverse cardiac events. Clin Cardiol. 2008;31(2):67-71.

7.

Fabbri M, Beghe B, Agusti A. Cardiovascular mechanisms of death in severe COPD exacerbation. Time to think and act beyond guidelines.

Thorax. 2011;66:748-754.

8.

Høiseth AD, Neukamm A, Karlsson BD, Omland T, Brekke PH, Søyseth V. Elevated high-sensitivity cardiac troponin T is associated with increased mortality after acute exacerbation of chronic obstructive pulmonary disease. Thorax. 2011;66:775-781.

February 2014 JOURNAL MSMA 43

9.

Brekke PH, Omland T, Holmedal SH, Smith P, Voyseth V. Troponin T elevation and long-term mortality after chronic obstructive pulmonary disease exacerbation. Eur Respir J. 2008;31:563-570.

10. Baillard C, Boussarsar M, Fosse JP, Girou E, Le Toumelin P, Cracco C, Jaber S, Cohen Y, Brochard L: Cardiac troponin I in patients with severe exacerbation of chronic obstructive pulmonary disease. Inten Care Med. 2003;29:584-589.

19. Geraci SA. Canary in the coal mine: Cardiac troponins in non-coronary diseases. Am J Med. ePublished ahead of press in February 2012.

20. Sin DD, Anthonisen NR, Soriano JB, Agusti AG. Mortality in COPD. Role of comorbidities. Eur Resp J. 2006;28:1245-1257.

21. Hansson GK, Inflammation, atherosclerosis and coronary artery disease.

N Engl J Med. 2005;352:1685-1695.

11. Fruchter O, Yigla M. Cardiac troponin-I predicts long-term mortality in chronic obstructive pulmonary disease. COPD. 2009;6:155-161.

12. Harvey MG, Hancox RJ. Elevation of cardiac troponins in exacerbation of chronic obstructive pulmonary disease. Emerg Med Australas.

2004;16:212-215.

The PEN is greater than the SWORD

13. Martins CS, Rodrigues MJ, Miranda VP, et al. Prognostic value of cardiac troponin I in patients with COPD acute exacerbation. Neth J Med. 2009;67:341-349.

14. Chang L, Robinson C, Mills D, Sullivan D, Karalus C, McLachlan D, Hancox J. Biochemical markers of cardiac dysfunction predict mortality in acute exacerbations of COPD. Thorax. 2011;66:764-768.

15. Marcun R, Sustic A, Brguljan PM, Kadivec S, Farkas J, Kosnik M, Coats AJ, Anker SD, Lainscak M. Cardiac biomarkers predict outcome after hospitalisation for an acute exacerbation of chronic obstructive pulmonary disease. Int J Cardiol. 2012 Jun 3. [Epub ahead of print].

16. Kelly AM, Klim S. Is elevated troponin associated with in-hospital mortality in emergency department patients admitted with chronic obstructive pulmonary disease?. Eur J Emerg Med. 2012 Apr 8. [Epub ahead of print].

17. Brekk PH, Omland T, Smith P, Søyseth V. Underdiagnosis of myocardial infarction in COPD. Cardiac Infarction Injury Score (CIIS) in patients hospitalised for COPD exacerbation. Respir Med. 2008;102:1243-1247.

18. Peacoc F, Marco T, Fonarow G, Diercks D, Wynne J, Apple F, and Wu A. Cardiac troponin and outcome in acute heart failure. N Engl J Med 2008;358:2117-2126.

E

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

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

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• Physician’s Bookshelf • Mortality by Christopher Hitchens, Atlantic Books: New York, 2012.

104 pages, $22.99.

Review By Michael Gillette, M4 Tulane University School of Medicine Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.

—Susan Sontag, Illness As Metaphor (1978)

E

ven as Christopher Hitchens lay dying, he continued to wrestle with the great questions of the human condition.

In the last months of his life, Hitchens feverishly penned dozens of far-reaching essays for Vanity Fair, the Atlantic, and Free Inquiry. He wrote on totalitarianism, Gandhi, C.K. Chesterton, explored the courage of Joan Didion, and predicted the Egyptian revolution lacked the resources to truly “break the chains of tyranny.”

Of the day he became ill, Hitchens wrote: “I have more than once in my time woken up feeling like death. But nothing prepared me for the early-morning in June when I came to consciousness feeling as if I were actually shackled to my own corpse.” In the emergency room, a “shadow casting itself across the negatives” hinted at the diagnosis to come. “The physicians at this sad border post told me my immediate next stop would have to be with an oncologist.” Finding himself at the “stark frontier that marks off the land of malady” with a now revoked good passport, Hitchens began an 18-month voyage through the Kingdom of the Sick.

With the fortitude of a war correspondent, Hitchens reported from his exile. Assailed by metastatic esophageal cancer and the “deadly threat of surrender,” he filed regular dispatches from a place he called Tumortown. The seven collected essays, published as Mortality, are both an honest account of the author’s own struggle and a graduate course in the philosophy of death.

Quoting Voltaire, Francis Collins, Plato, and John Updike, Hitchens writes about everything from friendship to prayer and cancer etiquette. Like Susan Sontag, he rejected the war on cancer, and he movingly argues against Nietzsche’s idea, “What doesn’t kill us makes us stronger.”

In Western Attitudes Toward Death, Phillipe Ariès laments that an unintended consequence of modern medicine is that the act of dying, once a communal event shared at home, is now a “technical phenomenon obtained by a cessation of care.” In an increasing effort to master death, we have “untamed” it, replacing the traditional deathbed with what Elizabeth Kübler-Ross called a “more gruesome…more lonely, mechanical, and dehumanized” death. In these essays, Hitchens reclaims the humanity and dignity of his own demise. His sparkling prose, undiminished by stupefying doses of chemo and narcotics, tells a powerful tale of life on the wrong side of the stethoscope.

Hitchens’s wife, Carol Blue, writes in her evocative afterword, “He made a party of it, transforming the sterile, chilly, neonlighted, humming and beeping and blinking room into a study and salon.” The cruel tyranny of modern medicine that punctuates hospital life—“the poking and prodding, the sample taking, the breathing treatments, the IV bags being changed—nothing kept him from holding court…”

Through Mortality, Hitchens lets us attend his deathbed and engage in the great conversation in essays that feel as if they were written to you and you alone. As physicians we can, at least in these essays, ignore the clinical clutter obscuring death and debate with the man William Buckley once called “the greatest living essayist in the English language.” r

February 2014 JOURNAL MSMA 45

Medley & Brown

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We present and to you Mississippi’s Annual Public HealthExperienced Report Card, sponsored by the Team of Serves Adults, Adolescents Children** PRESIDENT-ELECT Mississippi State Medical Association (MSMA) and the Mississippi State Department Investment Professionals “An Alternative to Inpatient Hospitalization” Claude Brunson, MD Treats:

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of Health (MSDH).

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Documented Record of PAST PRESIDENT * Depression * Psychiatric Evaluations For many years, MSMA and MSDH have reported Mississippi health statistics, and Steven L. Demetropoulos, MD Long-Term Investment Performance * Bipolar Disorder * Medication Monitoring Mississippi has barely moved from the bottom. The cycle begins at birth (first in the Pascagoula * Anxiety/Panic * Group Therapy number of low SECRETARY-TREASURER * PTSD * Individual Therapy birth weight babies, second in teen pregnancy) and continues on into adulthood where we see extremely high rates of obesity How can we Michael *Mansour, MD Anger * Family/Couples Therapy Call usand at diabetes.

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Integrating health education into the Mississippi school system is the first step to -4-U CALL solving 1-877-PSYCH our health problems in future generations. Children and adults alike cannot be

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F I N A N C I A L

A D V I S O R S

M&B MSMA Jun19'13.indd 1

To Mississippi physicians: as authorities on health and wellness, Mississippi communities look to you for guidance in health decisions, and not those just related to disease or sickness. The Healthy Students Act establishes a Wellness Council for each school. This is a place where physicians can volunteer and truly make a difference creating the groundwork to educate future generations about nutrition and exercise to combat obesity, cancer, and diabetes. Physicians can lead this charge.

Jeffrey A. Morris, MD

To Mississippi patients: support your local schools’ efforts to provide healthy, safe environments for your children and future generations. By supporting, volunteering, and spreading the word about health in schools, you are contributing to the wellbeing of your community for years to come.

Jane Beebe Jones, MD

Yours Always in Making Mississippi Healthier,

Dwight S. Keady, Jr., MD Meridian

Secretary, Hattiesburg

Resident/Fellow, Jackson

Savannah Duckworth

Medical Student, Jackson

EXECUTIVE DIRECTOR Charmain Kanosky

James A. Rish, MD MSMA President

Mary Currier, MD, MPH Mississippi State Health Officer

The Physicians Who Care for Mississippi.

46 JOURNAL MSMA February 2014

eport Card 2014.indd 1

6/20/13 3:38 PM

PUBLIC HEALTH IN MISSISSIPPI

12/19/13 3:26 PM

most VERY LOW BIRTH WEIGHT BABIES

Mississippi, we have homework.

Health is academic.

DIABETES CANCER DEATHS OBESITY

2nd most

The 2014 Mississippi Public Health Report Card is brought to you by the Mississippi State Medical Association and the Mississippi State Department of Health. Printing courtesy of Mississippi Physicians Care Network (MPCN).

2nd worst in

7th most

Accident deaths AUTO VEHICLE ACCIDENT DEATHS

6th most

HEART DISEASE

LOW BIRTH WEIGHT BABIES

TEEN BIRTHS ADULT SMOKERS

worst in

worst in

2nd worst in

2nd most

2nd worst in

P.O. Box 2548 • Ridgeland, Mississippi 39158-2548 • 408 West Parkway Place 39157 • 601-853-6733 • Fax 601-853-6746 • www.MSMAonline.com

PRESIDENT James A. Rish, MD Tupelo

PRESIDENT-ELECT Claude Brunson, MD Jackson

PAST PRESIDENT Steven L. Demetropoulos, MD Pascagoula

SECRETARY-TREASURER Michael Mansour, MD

Greenville

SPEAKER R. Lee Giffin, MD Vicksburg

BOARD OF TRUSTEES Lee Voulters, MD

Chair, Pass Christian

Daniel P. Edney, MD Vice Chair, Vicksburg

William M. Grantham, MD

Clinton

J. Clay Hays, Jr., MD

Jackson

S. Carlton Gorton, II, MD Belzoni

Brett C. Lampton, MD Oxford

Steven C. Brandon, MD Starkville

Fellow Mississippians, We present to you Mississippi’s Annual Public Health Report Card, sponsored by the Mississippi State Medical Association (MSMA) and the Mississippi State Department of Health (MSDH).

For many years, MSMA and MSDH have reported Mississippi health statistics, and Mississippi has barely moved from the bottom. The cycle begins at birth (first in the number of low birth weight babies, second in teen pregnancy) and continues on into adulthood where we see extremely high rates of obesity and diabetes. How can we interrupt this cycle? Clearly, medicine needs to move the message from the exam room to a new venue—the classroom. Integral to the idea of preventative health is the teaching and promotion of health in schools.

Integrating health education into the Mississippi school system is the first step to solving our health problems in future generations. Children and adults alike cannot be expected to make responsible, informed decisions regarding the maintenance of their most important possession – their health—without the proper information and tools.

The Centers for Disease Control and Prevention (CDC) established eight highly effective Components of Coordinated School Health. We applaud the Mississippi Legislature’s Healthy Students Act which recognizes that the most effective health education programs begin in the classroom.

To Mississippi physicians: as authorities on health and wellness, Mississippi communities look to you for guidance in health decisions, and not those just related to disease or sickness. The Healthy Students Act establishes a Wellness Council for each school. This is a place where physicians can volunteer and truly make a difference creating the groundwork to educate future generations about nutrition and exercise to combat obesity, cancer, and diabetes. Physicians can lead this charge.

Jeffrey A. Morris, MD

To Mississippi patients: support your local schools’ efforts to provide healthy, safe environments for your children and future generations. By supporting, volunteering, and spreading the word about health in schools, you are contributing to the wellbeing of your community for years to come.

Jane Beebe Jones, MD

Yours Always in Making Mississippi Healthier,

Dwight S. Keady, Jr., MD Meridian

Secretary, Hattiesburg

Resident/Fellow, Jackson

Savannah Duckworth

Medical Student, Jackson

EXECUTIVE DIRECTOR Charmain Kanosky

James A. Rish, MD MSMA President

Mary Currier, MD, MPH Mississippi State Health Officer

The Physicians Who Care for Mississippi.

PUBLIC HEALTH IN MISSISSIPPI

updated your business associate agreements lately?

Have you noticed that your office is receiving lots of new or updated HIPAA Business Associate Agreements (BAAs) and wondered “Why?” Well, that’s because the HITECH (Health Information Technology for Economic and Clinical Health) Act and recent Omnibus Rule changed the rules! Now, you must have an executed Business Associate Agreement (BAA) with any business with which you share Protected Health Information (PHI) or from whom you receive PHI. For example:      

Insurance companies, networks, and claims administrators Entities involved in patient safety activities Health information organizations like e-prescribing gateways Health information exchanges that transmit and maintain PHI Personal health record vendors physicians sponsor for their patients and which require access to the data on a routine basis Any entity that creates, receives, stores, maintains, or transmits PHI on their behalf

Thus, physicians must review their business relationships and determine if they need a BAA with their vendors.

Generally speaking, physicians have until September 23, 2014, to bring all their BA agreements into conformance with the new rules. BA agreements that have not been renewed or modified between March 26, 2013, and September 23, 2013, will be deemed compliant until the date the BA agreement is renewed or modified or until September 22, 2014, whichever is earlier.

Responsibility flows downstream; liability for compliance flows upstream. In other words, physicians are obligated to ensure that their subcontractors comply with the new HIPAA Privacy and Security Rules. Otherwise, the physician could be directly liable for a subcontractor’s breach. For this reason physicians should ensure that indemnity clauses protect them from responsibility for “downstream” breaches.

MSMA resources are available to assist you in your review of business relationships and BAAs. Contact Neely Carlton at NCarlton@MSMAonline.com for more information.

Information is provided as a commentary on legal issues and is not intended to provide advice on any specific legal matter.

?

February 2014 JOURNAL MSMA 51

12th Annual CME in the Sand May 24 - 27, 2014 Sandestin Golf and Beach Resort Tenta�ve Schedule of Events: FRIDAY, MAY 23, 2014 1:00 ‐ 5:00

MSMA Board of Trustees Mee�ng

SATURDAY, MAY 24, 2014 8:00 – 11:00

MSMA Board of Trustees Mee�ng

11:00 – 12:00 Management of Congenital Heart Disease

Jorge Salazar, MD 12:00

Lunch Provided During CME Session

12:15– 1:15

Orthopaedic Oncology Case Review: Missed Diagnoses and Oops Excisions Jennifer Barr, MD

1:15 ‐ 2:15

MSBML Rules and Regula�ons on Prescribing Opioids and DEA Controlled Substances Scheduling – Prescribing CME John Mutziger, DO

2:15 – 3:15

25 Tips for Maximizing Effec�veness of Controlled Substances and Minimizing Abuse – Prescribing CME Sco� Hambleton, MD

4:00 ‐ 6:00

UMC Alumni Cruise

MONDAY, MAY 26, 2014

SUNDAY, MAY 25, 2014

Breakfast Provided During CME Session

7:30 ‐ 8:30

7:30

New Statewide Stroke System of Care Ruth Fredericks, MD

8:30 ‐ 9:30

Breast Reduc�on in the Obese Popula�on Peter Arnold, MD

9:30 – 11:00

Addic�on as a Brain Disease ‐ Prescribing CME Lloyd Gordon, MD

11:00

Lunch Provided During CME Session

11:15– 12:15

Strategies for the Effec�ve Management Chronic Pain and

Recommenda�ons on the use of Controlled Substances ‐ Prescribing CME Michael Cosgrove, MD

12:15 – 1:15

Mississippi Rising; The Importance of Preven�on in the Epidemic of Cardiovascular Disease Michael Mansour, MD, FACC, FACP

6:00 PM

Welcome Recep�on and MSMA Alliance Silent Auc�on Bene�ng the Scholarship Fund for Medical Students

Breakfast with Exhibitors

7:15 am

Breakfast with Exhibitors

8:00 – 9:00

Transcatheter Valve Replacement (TAVR) ‐ Two Years In William Crowder, MD

8:00 – 9:00

Risk Management Concerns and Strategies in a Changing Healthcare Environment Medical Assurance Company of Mississippi

9:00 – 10:00

Amphetamines ‐ Prescribing CME Mark Williams, MD

10:30 – 11:30 Treatment of Depression: Updates in Current Care Op�ons

Greg Gordon, MD 11:30 ‐ 12:30 ICD‐10 Coding

NaTunya Johnson, Ed.S 6:30

9:00 – 10:00 A Primer on Bariatrics

Anne�e Low, MD

10:00 – 10:30 Break

10:00 – 10:30 Break

Family Dinner and Southern Medical Ice Cream Social

Accommoda�ons: Sandes�n Golf and Beach Resort 9300 Emerald Coast Parkway Miramar Beach, Florida Reserve your room today by calling 800‐320‐8115 or visit: h�p://www.sandes�n.com/22Y0OV.aspx Group Code: 22Y0OV Cut off Date: April 24, 2014

52 JOURNAL MSMA February 2014

TUESDAY, MAY 27, 2014

7:15 am

9:30 – 11:30 am Spouse and Children Ac�vity – BINGO

10:30 – 11:30 Diabetes Update

Marshall Bouldin, MD 11:30 ‐ 12:00

Medicine in Mississippi ‐ Legisla�ve Update Blake Bell, JD

Accommoda�on Beachside Studio* Beachside 1 Bdrm* Westwinds 1 Bdrm* Westwinds 2 Bdrm* Luau Studio

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*A minimum stay of 5 nights is required on Beachfront accommoda�ons.

Please note that room rates quoted do not include 12% fees and 12% taxes.

12th Annual CME in the Sand

May 24-27, 2014 Sandestin Golf and Beach Resort

ATTENDEE REGISTRATION: (Please PRINT Clearly) Name: Practice/Clinic Name: Specialty:

E-mail:

Preferred Address: City:

State:

Zip:

Phone:

Cell Phone:

Invited by:

Spouse/Guest:

Children’s Name and Age:

EVENT REGISTRATION: (All events are included in registration fee. Please check all that you plan to attend) CME Sessions – May 24 - 27

# Adults

# Kids

Welcome Reception – Sunday, May 25 Family Dinner – Monday, May 26

Registration is $300. Payment accepted by check or credit card or visit www.MSMAonline.com to register online.

Credit Card:

Visa

Card Number: Amount to be billed to card: $300

MasterCard

American Express CVV:

Expiration:

Billing Address: Print Name on Card: Signature:

CANCELLATION POLICY: In the event that you need to cancel your reservation, your full registration fee, less $50 processing fee, will be refunded if notified on or before May 1. No refunds will be made after May 1.

Please send completed registration forms with payment to: Mississippi State Medical Association, Attn: Jenny White, PO Box 2548, Ridgeland, MS 39158

February 2014 JOURNAL MSMA 53

• President’s Page • The Season of Change

I

t is my sincere hope that you and your family enjoyed a happy and safe holiday season. At this time of the year, we pause and reflect on the hope that comes with the dawn of a new year. Aside from a harsh influenza season, January has ushered in a new year which will be historically significant to the delivery of health care in the United States. I want to mention two such pivotal events.

First and foremost, we will see the full implementation of the Patient Protection and Affordable Care Act. Whether you agree with the legislation or not, it is the law of the land. Now, more than ever, we need to be engaged James A. Rish, MD and pay attention to the unfolding debate. We must take the time to educate 2013-14 MSMA President ourselves on the important issues that arise as the reality of the “healthcare overhaul” becomes evident in our day-to-day practices. We must get our voices heard and work through our medical association and specialty societies to craft this legislation into something that works for all involved in health care delivery. Most importantly we must get this right for the sake of our patients. We must dismiss the politics and focus on what we need the end product to be.

Another important date in this New Year is October 1, 2014. On this date, the ICD-10-CM code set will go into effect replacing the ICD-9-CM Volumes 1 and 2 set, which has been in place for over 30 years. The transition to the ICD-10 system will be one of the most significant changes to hit physicians and could have a dramatic effect on revenue streams and operations.

There will be a striking increase in the number of codes from 17,000 under the ICD-9 system to 140,000 under the ICD-10 system including codes for such things as macaw bites and injuries related to falling space debris!

This transition was initially set to occur on October 1, 2013. However, the MSMA Delegation working through the AMA successfully delayed implementation. This pushed the compliance date back a year, avoiding conflict with other competing deadlines physicians were tasked with meeting in 2013. On October 1, 2014, transactions submitted with the old ICD-9 codes will be rejected.

The administrative and financial burden this places on the doorstep of physician practices is astonishing. The AMA estimates $23,000.00 per physician. If you have a group of twenty physicians, you are looking at almost half a million dollars. These costs include multiple systems upgrades and testing, increased human capital needs, significant staff training along with inherent increased claim denials, delayed payments, lost or reduced reimbursement, cash flow impacts, and more complex financial reporting. This is yet another unfunded mandate with no added reimbursement available to cover these costs.

In many situations, timing is everything. This conversion could not come at a worse time. Physicians have spent an enormous amount of time implementing electronic health records. Physicians will also now face financial penalties for not participating in various Medicare programs such as e-prescribing, achieving Stage 1 of meaningful use for their electronic health record system, and the Physician Quality Reporting System or PQRS. The full impact of the ICD-10 system is unknown. Comparisons with other countries that have made the transition are made difficult by unique payer environments and different levels of implementation. Canada experienced a large learning curve and loss of productivity. They likened becoming familiar with the ICD-10 coding concepts to learning to read Greek. Their average coding time per record went from12-15 minutes to 33 minutes and turnaround time increased from 69 to 139 days.

54 JOURNAL MSMA February 2014

Advocates of conversion to ICD-10 cite a lack of detail and limited space to accommodate new procedures and disease processes. The ICD-9 code set can no longer expand for additional classification specificity, newly identified disease entities, and other medical advances. Proposed benefits outlined by CMS include improved payment systems and reimbursement accuracy; improved measurement of quality, safety, and efficacy of care; improvements in conducting research, epidemiological studies, and clinical trials; setting of health care policy; monitoring resource utilization;: and prevention and detection of healthcare fraud and abuse.

When sweeping policy discussions are conducted, the litmus test for physicians should be how this change will enhance the care of our patients. It is difficult for most physicians who are just attempting to tread water in the vast sea of increasing governmental health care regulation to see any immediate benefits to our patientâ&#x20AC;&#x2122;s care with this transition. Most of us can certainly appreciate the potential for some long-term benefit in increasing the amount of specific mineable data available to study in innumerable different applications.

There is concern about the readiness of vendors to move to this new code set and that many physicians have systems that may not deliver an upgrade to accommodate ICD-10 conversion until well into 2014. This, along with the huge financial and administrative burdens this transition places on our physician workforce on the heels of the time and effort to meet the regulatory requirements of electronic health record adoption, begs for further delay, repeal or incremental implementation.

We physicians are the lone voice against ICD-10 implementation. We have been informed by Marilyn Tavenner of CMS that ICD-10 would be implemented on October 1, 2014, making further administrative delay highly unlikely. The only other way to repeal or further delay implementation will be through the legislative process. There is proposed legislation in both chambers of Congress to prohibit replacement of ICD-9 with ICD-10. It will be an uphill battle. The insurance and hospital industries have spent a lot of money preparing for the 2014 implementation. Physician practices that have not already begun preparing for this transition will likely experience significant disruption in revenue streams and cash flow after the October 1 date. We must continue to make our congressional leaders aware of these issues and urge them to support legislative changes.

Thank you and God Bless.

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OR Physicians to review Social Security disability claims at the

Mississippi Department of Rehabilitation Services (MDRS) in Madison MS.

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

DISABILITY DETERMINATION SERVICES 1-800-962-2230 February 2014 JOURNAL MSMA 55

• Mississippi State Department of Health •

56 JOURNAL MSMA February 2014

Health Department Recognizes Mississippi Accomplishments

F

ifty years after the release of the first Surgeon General’s report on smoking and health, remarkable progress has been made throughout the United States, much in Mississippi. Yet even with years of progress, tobacco use remains the leading preventable cause of disease, disability, and death in the U.S.

In 1994, Mississippi filed litigation against the tobacco industry that resulted in a $4 billion settlement for the state. As directed by the court, then Attorney General Mike Moore began assembling public and private organizations to develop a tobacco prevention program that resulted in the formation of the Partnership for a Healthy Mississippi (PHM). At the conclusion of the pilot program, approximately $20 million was court-ordered to go directly to PHM from the state’s tobacco settlement. In addition to these funds, the Mississippi State Department of Health (MSDH) received funds from the Centers for Disease Control and Prevention (CDC) for tobacco prevention and cessation efforts.

“Mississippi has experienced a substantial decrease in the prevalence of cigarette smoking in the years following the implementation of a statewide comprehensive tobacco control program,” said Mississippi State Health Officer Dr. Mary Currier.

From 1998 to 2012, the prevalence of current smokers decreased by 40 percent among public high school students and decreased by 72 percent among public middle school students.

In 2010, MSDH received a $2.9 million grant from the CDC to help educate Mississippians on the benefits of smokefree air. Studies from the Social Science Research Center at Mississippi State University in Starkville found that almost 75 percent of Mississippi adults favor a law prohibiting smoking in most public places, including workplaces, offices, restaurants and bars.

The state also received first or second place awards for the most smokefree ordinances passed by cities in 2010 (first place), 2011 (second place), and 2012 (first place). Since 2009, the total state population covered by smokefree ordinances has increased from 10 percent to 26 percent. As of today, Mississippi has 75 cities that have passed 100 percent comprehensive smokefree air ordinances.

“The smokefree air ordinances implemented by these 75 cities will protect all employees and customers in businesses and other public places from the harmful effects of breathing secondhand smoke. There is no safe level of secondhand smoke,” said Currier. “The adoption of these smokefree air ordinances is an important step in improving our state’s overall health status.

However, even if every incorporated community adopted a smokefree air policy, fewer than 50% of Mississippians would be covered, making a statewide law necessary for the most improved health in this state.”

The Surgeon General released the 50th anniversary Surgeon General’s Report (SGR) on smoking and health. The report will highlight 50 years of progress in tobacco control and prevention, present new data on the health consequences of tobacco use, and detail initiatives that can end the tobacco use epidemic in the U.S. Additionally, the MSDH’s Office of Health Data and Research was recently awarded a $14,750 grant from the March of Dimes to reduce smoking during pregnancy, a leading cause of infant mortality.

Among women who smoked at least some during their pregnancies in 2010, the infant mortality rate was 11.9 per 1,000 births compared to 8.3 for women who did not smoke. The rate of infant mortality among black women who smoke is 20.1 and for white women who smoke it s 9.3 per 1,000 births.

Smoking during pregnancy is also linked with prematurity and birth defects, major factors in infant death. Mississippi historically leads the nation in the rates of premature births, low infant birthweight, and infant deaths.

“The NEXT (Nurse Educator eXpert Training) project will support the Mississippi State Department of Health’s efforts to reduce infant mortality,” said Dr. Juanita Graham, Grants and Special Projects Coordinator for the Office of Health Data and Research. “Smoking in pregnancy and exposure to secondhand smoke during pregnancy contribute to low infant birthweight, a leading cause of infant death in Mississippi.”

Forty-three percent of Mississippi mothers who smoke quit smoking during pregnancy. However, over half of them resume smoking after pregnancy. Additional intervention, through programs like NEXT, is needed to further reduce smoking among women of child-bearing age before, during and after pregnancy.

The NEXT Program is a train-the-trainer event that will reach 64 nursing faculty throughout Mississippi’s 32 schools of nursing with the potential to reach thousands of new Mississippi nurses and women across the state. The program will use the evidence-based Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) that has previously been effective in helping pregnant women quit smoking.

For more information on smoking and pregnancy, visit HealthyMS.com/pregnancy. r

February 2014 JOURNAL MSMA 57

• Letters • Positions on Medicaid Expansion and Response

D

ear JMSMA Editor,

In the December issue of the Journal MSMA you published a letter from Dr. Lineaweaver who supports Medicaid expansion. [Lineaweaver W. Position on Medicaid expansion. J Miss Med Assoc. 2013;54(12):352.] Then, you added a response from yourself in which you suggest the Board of Trustees was “AWOL” on this issue and failed to “lead.” I believe our readers deserve to know the rest of the story. That is, that the Board took the position it did due to your advice, and that in the Board meetings, you advised the Board not to take a position against Governor Phil Bryant.

The elected trustees and officers of MSMA deserve our sincere thanks for the time and effort they give representing physicians in the battle for the future of health care in our state and country. To effectively defend physicians’ ability to care for our patients, MSMA has to be present every day at the state Capitol in the offices of the senate, house, Governor, and Lt. Governor, as well as in Washington.

To overcome these obstacles your MSMA has developed a most effective army of soldiers comprised of not only physicians but also respected staff. This team of physicians and professionals stands vigil at the capitol every day with each senator and representative, as well as the Governor and Lt. Governor. Our Council on Legislation meets weekly to address legislation concerning medicine, the lawmakers behind such legislation, and how to best approach each one.

Our MMPAC committee is kept involved in all such discussions. We know that we have the most effective legislative team of any at the state Capitol. You must also know this when you request the support of the MSMA to assist in getting the Department of Health’s agenda passed.

As editor you are invited to every Board meeting to hear, question, and discuss the ongoing activities. It is because of this close working relationship between the Board and Editor that I am appalled by your characterization of our board as AWOL on Medicaid or any issue.

In fact, our Board has worked to position MSMA to be effective in these deliberations as well as deliberations yet to come!

And, again, our readers deserve to know that the MSMA Board listened to you and did not oppose Governor Phil Bryant on this issue.

As we all know, in the world of politics you have to pick your “battles” so as not to lose the war!

Sincerely,

—Thomas E. Joiner, MD; MSMA President 2011-2012, Jackson

Editor’s Response to Positions on Medicaid Expansion

D

ear Dr. Joiner,

I appreciate that you read the Journal and listen to my input at Board meetings. You are right that I advised the Board strongly to support and work with Governor Phil Bryant on this issue. He is a personal friend, and one of the strongest friends of medicine that has ever occupied the Governor’s Mansion. He understands clearly the workforce crisis in the state and has partnered with physicians in creating solutions. I continue to advise our state’s physicians to support this governor and work “with him” and not “against him” on all issues which involve medicine and public health. That said, we physicians owe him honest counsel, not silence, and we must push his politics to be the best position for our patients and the physicians of our state.

I am sure that you remember that my request for our Association to support and work with our Governor on this issue contained the caveat that our MSMA leverage its political influence to reform the Division of Medicaid into a more patient

58 JOURNAL MSMA February 2014

and physician friendly agency. Expansion of a flawed “managed care” division with no internal medical oversight would create even more problems for patients and physicians. My comments in late 2012 and early 2013 stressed the need to reform Medicaid promptly into a patient centered medical home model, to secure the Deferred Compensation Plan for our state’s physicians, and to achieve, post-haste, a medical director to advise Medicaid during this critical time period. This caveat, discussed by the Board almost a year ago, has clearly not been accomplished. Others besides me shared these views, and I particularly appreciated the leadership and comments of such Board members as Steve Demetropolous (then President), Tim Alford, Claude Brunson, Lee Giffin, Carlton Gorton, and Steve Brandon.

Also, I expressed then, as did others, the need for our Association to lead in finding a solution for the uninsured patients in our state. Mississippi is not the only state whose political leadership has decided against expansion. Dozens of others have also chosen not to expand Medicaid (the so-called 26 “refusenik” states). What are Tennessee, Oklahoma, South Carolina, Louisiana, and Florida going to do for their uninsured? The Arkansas model is getting a lot of attention, could it work here? Should we not be studying what positive things other states are doing to improve the health status of their uninsured citizens and advise the Governor and the Legislature accordingly? Silence is a surrender of our moral responsibility as physicians, and our leadership must express better answers to AP reporters than “we have no position” due to Medicaid expansion being a “political” issue. [McComb EnterpriseJournal, January 17, 2014] Those familiar with our state Legislature assert the reality that Medicaid expansion was politically dead last year, and it will be politically dead again this year. It is apparent that Mississippi will be taking an alternate path, which will be labeled something other than Medicaid expansion. Physicians and our MSMA must lead in finding the best alternate path for our patients. We must always remember and express to the public that this debate must be focused on the best interests of our patients!

As far as your other observations, your ad hominem attack on me is unwarranted and results from you not reading carefully and fairly my comments. Clearly, you are attacking the editor for comments he did not make. I responded to Dr. Lineaweaver: “You are not alone among our membership in seeing our leadership as AWOL on this important, yet divisive, issue, as was evident at our recent Annual Session,” which reported the reality that many of our members perceived a failure of leadership on the part of our Association and Board. Whatever my own opinion, such is factually indisputable. For anyone who attended the annual session and read resolutions or heard criticism of our Board’s silence on the issue of Medicaid expansion in reference committees, it is obvious that my comments were simply 101 journalism: reporting the facts! My job as Editor is not to be a propagandist for our Board but to attempt to report the facts and to provide an objective forum of debate for our membership and House of Delegates. I am not appointed by the Board but rather elected by the House of Delegates, a constitutional framework carefully crafted by our wise predecessors, who were more interested in vesting aspects of the Association’s power in the membership and the House rather than the Board. It is unfortunate that my reporting of the truth places me at odds with certain Board members.

What our membership expressed at August’s House of Delegates was a desire for us to be leaders on medical and public health issues. Even if our Association concludes that Medicaid expansion is not attainable nor best for our state, the physicians of this state do expect MSMA to lead in finding solutions for our patients, especially the uninsured. Physicians can support our Governor yet forcefully push for such critical things as the transformation of Medicaid. We better support the Governor when we provide knowledgeable and assertive counsel to assist and improve his efforts to care for the uninsured (such as his proposal for additional grant monies for federally qualified community health centers). Our Board should be commended for bringing together the December forum addressing the issue of Medicaid expansion in Mississippi. The event, which was in response to resolution 32, discussed solutions for covering the uninsured population of Mississippi. Moderated by Dr. Al Rausa, the event featured such speakers as Theresa Hanna of the Center for Mississippi Health Policy, Ed Sivak of the Mississippi Economic Policy Center, and Ed Haislmaier of the Heritage Foundation. The forum is the kind of leadership and action our members expect of the Association.

Frankly, Dr. Lineaweaver is right not only on the impropriety of the Board’s silence but also this journal’s, which is directly my responsibility. Hopefully, this journal can rectify its error, by encouraging vigorous debate by our physician readers on the issue, and hopefully the Board can continue to foster discussion, leadership, and action in dealing with the needs of our uninsured patients!

This is a conversation our MSMA needed to have with its members; such seems obvious to me as a member. I appreciate your letter which helps to continue this conversation.

Your Editors strongly encourage our readers and membership to utilize our JMSMA as an open forum for discussion of the issue of Medicaid expansion and any other critical issue impacting health and medicine. Our Association’s position is critical, and your letters to the editor or contributed editorials can help shape MSMA’s evolving leadership on this issue. Please send your opinions to me at LukeLampton@cableone.net and cc to KEvers@MSMAonline.com or mail to me at JMSMA EDITOR, P.O. Box 2548, Ridgeland, MS 39158-2548.

—Lucius “Luke” Lampton, MD; JMSMA Editor, Magnolia The news and comments expressed in the JOURNAL MSMA are those of the indicated author. News content, letters, and opinions are not expressions of the views or official policies of the Mississippi State Medical Association.

February 2014 JOURNAL MSMA 59

• Personals • [The Journal of the Mississippi State Medical Association notes accomplishments of physicians. If you have changed affiliations, received an award, or delivered a notable lecture, we will recognize your achievement in the pages of our JMSMA. We publish personals periodically and invite you to submit success publicity to KEvers@MSMAonline.com. High resolution photos (300dpi) are preferred. Note: Photos cannot be faxed.] —Ed.

MSMA President-Elect Claude Brunson, MD is recipient of the Mississippi Primary Health Care Association’s (MPHCA) 2013 Health Care Leadership Award.

This award is given annually to an outstanding public servant who has shown exceptional leadership and vision with regard to reducing health disparities and improving the health status of Mississippians.

Olivia Berry Hightower, MD, Memorial Medical Oncologist, recently passed board certification in Medical Oncology through the American Board of Internal Medicine (ABIM). Dr. Hightower joined the Memorial Medical Oncology Clinic after completing her residency in Internal Medicine and Oncology Fellowship at Ochsner Clinic in New Orleans. She earned her medical doctorate from the University of Mississippi Medical Center in Jackson, after graduating summa cum laude from the University of Southern Mississippi in Hattiesburg. In addition to being Board Certified in Medical Oncology, she is Board Certified in Internal Medicine. Dr. Hightower practices with five other Medical Oncologists/Hematologists with the Memorial Medical Oncology Clinic, which has offices in the Memorial Cancer Center in Gulfport and the Memorial Physician Clinic on Popp’s Ferry Road in Biloxi.

David McClendon, MD was selected “Program Director of the Year” and recieved the Corporate Award for Excellence presented by Apogee Physicians, the nation’s leading hospitalist group and partner of Biloxi Regional Medical Center in Biloxi. Apogee’s guiding principle is, “What’s best for the patient is best for the practice.”™

60 JOURNAL MSMA February 2014

Dr. McClendon is lead hospitalist of the group and has been recognized for his ideals of safety, quality, service, and value within his leadership.

Dr. McClendon sits on the Board of Trustees of the Mississippi State Medical Association and was recently elected as Chief of Medicine for Biloxi Regional Medical Center. The award ceremony was held in December in Phoenix, Arizona, at the company’s Program Directors Summit, a conference of Apogee’s lead hospitalists from across the country.

Aaron Shirley, MD, who broke a racial barrier at the University of Mississippi Medical Center in 1965 and is one of the state’s civil rights icons, is the recipient of the 2013 Herbert W. Nickens Award from the Association of American Medical Colleges. Honored for his lifetime of service in support of diversity in medical education and the elimination of health disparities, Shirley received the award at a black-tie gala at the AAMC’s annual meeting in Philadelphia, Pa. “For all of his adult life, he has been a courageous champion of civil rights and equal access to health services for African-Americans,” said Dr. LouAnn Woodward, UMMC’s associate vice chancellor for health affairs and vice dean of the School of Medicine, who nominated Shirley for the award.

Originally from Gluckstadt, Dr. Shirley completed medical school and an internship in Tennessee before entering private practice in Vicksburg. He set his sights on a pediatric residency out of state, but was invited to apply for a training slot at UMMC by then chair of pediatrics, Dr. Blair E. Batson.

After prayerful consideration, he accepted, becoming the first African-American resident and the first black learner in any program at UMMC in 1965. He went on to serve as a clinical instructor in the Department of Pediatrics for more than 40 years. His career highlights in health care include cofounding the Jackson-Hinds Comprehensive Health Center, which became a model for federally funded community health centers nationwide, and development of the Jackson Medical Mall in partnership with Jackson State University,

Tougaloo College, and UMMC. “He envisioned the empty and vandalized shopping mall in a blighted area of the city as a one-stop shop for medical care and other public services,” said Dr. Woodward. “With skill and persistence, he persuaded medical and civic leaders to invest in the restoration of a building and ultimately a neighborhood.”

Today the mall is home to the UMMC Cancer Institute and the Jackson Heart Study, the nation’s largest long-term evaluation of risk factors for cardiovascular disease in African Americans. Even in retirement, Dr. Shirley continues to be a dedicated community activist and pioneer of rural health care in Mississippi, saying he still spends a lot of time dreaming. “(I’m) trying to continue to make things better for those who need help, especially related to health care,” he said. Herbert W. Nickens, for whom the award is named, was the founding vice president of the AAMC’s Diversity Policies and Programs unit. “His passionate leadership contributed greatly to focusing national attention on the need to support underrepresented minorities in medicine,” according to the AAMC. Additionally, Dr. Shirley, recently received the National Council for International Visitors (NCIV) Citizen Diplomat Award. The Award honors individuals or institutions for their outstanding achievements in furthering the cause of international understanding and global engagement. Dr.

Shirley was recognized for his work establishing health houses in the Mississippi Delta using a model for healthcare delivery pioneered in Iran. His efforts were profiled in a New York Times Magazine cover story.

His work shows how a passion for change in concert with a high-impact exchange program can make a profound difference in people’s lives. In 2008, Dr. Shirley teamed up with Dr. James Miller and Dr. Mohammad Shabazi to implement the “rural health house” model that Dr. Miller discovered in Iran while on a professional exchange program.

Learning from Iranian doctors, the three established a series of exchanges and a partnership with Shiraz University. This led Dr. Shirley to create the HealthConnect group in 2010, consisting of 11 school-based community health centers across the Mississippi Delta aimed at reducing health disparities among poor and rural populations. NCIV President Jennifer Clinton said, “Dr. Shirley is a shining example of how each citizen can become a catalyst for global change and transform entire communities for the better. His personal commitment to solving our toughest challenges and openness to looking beyond our borders for solutions illustrate the positive impact international exchanges have not just abroad but here at home.” r

F

THE MSMA

OUNDATION, INC.

The Mississippi State Medical Association Foundation is honored to recognize our generous donors who through their gifts, support Medical School Scholarships, Continuing Medical Education, Named Funds and the Journal of the Mississippi State Medical Association.

Giving to the MSMA Foundation demonstrates leadership and a special commitment to caring, discovery, teaching, and hope. We express our appreciation to the following 2013 donors:

Orion Society

Memorials

Jim C. Barnett, M.D. Given by D. Stanley Hartness, M.D. L. H. Brandon, M.D. Given by Prairie Medical Society Grandparents Given by Seema A. Badve, M.D. Mentors Given by Loretta Jackson-Williams, M.D.

James Cooper, M.D. S. Randy Easterling, M.D. Dr. and Mrs. Robert Heath H. Read Jones, M.D. Jeanne Ann Rea, M.D. Dr. Ram & Mrs. Sheela Takkallapalli

Honorariums

Henry B. Pace, M.D. Given by A. Hailman Doyle, M.D. Glen Graves, M.D. Given by Mary Anne Kosek, M.D. Frank T. Marascalco, M.D. Given by MAJ. Christopher Marascalco Cummins, M.D. Philip G. Rhodes, M.D. Given by Mary Anne Kosek, M.D. Helen Turner, M.D. Given by Ann Meyers, M.D.

February 2014 JOURNAL MSMA 61

Mollie J. Pontius

• MSMA Alliance • MSMAA President When Life Presents a Lemon, Make Lemonade Mollie J. Pontius, MSMAA President, Ocean Springs

A

dmittedly, I was an ‘eye roller’ when it came to that cliche’...“when life presents a lemon, make lemonade.”

Well, it is time to start squeezing and add sugar!!!

Traditional volunteerism and membership as a whole have taken a new direction in our busy world. The first three months of my service as president of Mississippi State Medical Association Alliance (MSMAA) have reflected this metamorphosis. The clarity of Bob Dylan’s words, “the times they are a changin’” are prophetic.

Here is the scoop...

On the Positive Side: 1. MSMAA still has a heartbeat and a purpose. We have a small population of dedicated and loyal members. Without Lee County and South Mississippi (Hattiesburg) Alliances we would be on Life Support!

2. MSMAA held our First Focus Conference in September to concentrate on defining the duties and responsibilities of leadership roles when one assumes an office in MSMAA. Discussion groups focused on mentoring and encouraging new leaders in the Alliance in the areas of membership, scholarship, legislation, and health programs. This conference was an inspiration of Karen Morris of South Mississippi Medical Alliance, former Past president of MSMAA, and President-Elect of Southern Medical Association Alliance. It was a successful First!

3. MSMAA past Presidents Susan Rish and Karen Morris have been installed as President and President Elect of Southern Medical Alliance (SMAA) at the SMAA Annual Meeting in November. These former MSMAA leaders have assumed key leadership roles in this organization. In addition to Susan’s and Karen’s executive positions Mississippi was awarded the coveted Health Education and Medical Heritage Awards.

4. The MSMAA Health Project is a beacon of hope as it addresses the important topic of ‘planning’ end-of-life decision making. This topic is discussed in a brochure entitled “Reaching the

62 JOURNAL MSMA February 2014

Capitol Screening Initiative (CSI) IX was held January 16, 2014 in conjunction with the release of Mississippi’s annual public health report card.

Finish Line With Dignity.” The brochure includes a check list and glossary in lay persons terms to inform and encourage “the Conversation” concerning end-of-life decisions. This is a sensetive issue and a much needed dialogue everyone must address as it is an inevitable part of life.

Additionally, MSMAA will partner with Mississippi State Medical Association (MSMA) with our 4th addition to the “Did You Know” series. MSMAA will highlight the health education component in this segment of a series of eight components for coordinated school health. Previously addressed in the “Did You Know” series has been nutrition, physical education, and health services. This supports MSMA’s Healthy Schools Campaign 2013 and the Public Health Report Card presented to the state legislature last month.

5. The Capitol Screening Initiative (CSI) IX was held January 16, 2014 in Jackson and continues to be a worthy means of exhibiting MSMAA’s active voice in legislative and public health advocacy issues.

6. Active MSMAA County Alliances have kicked off their year with a variety of novel meetings. Particularly, Coast Counties Alliance with a Bra-haha meeting in recognition of Breast Cancer Awareness, a November couples meeting hosting Mike Chaney, Mississippi Insurance Commissioner as guest speaker, and a Christmas at Beauvoir gathering. South Mississippi Medical Alliance has dedicated their November meeting to “Give Thanks and Give Back” to raise funds for the Hattiesburg Domestic Abuse Shelter, pediatric Santa visits at the local hospitals, and helping the women of Uganda. Singing River Medical Alliance has focused its November meeting on Adrienne’s House and Gulf Coast Women’s Center for Nonviolence.

On the Flip Side: 1. Membership is down.

2. Fundraising for the scholarships and the Mississippi Professional’s Health Program is underway. Discovering a unique approach to fund raising is and will always be a challenge.

Resourcefulness in crafting a means to convince an individual or group to happily part with their money for ‘a cause’ takes creativity.

These two projects depend upon contributions, and contributions are dependent on membership.

3. Finally, the pocket of loyal members has been overworked.

This dedicated group has “without malice aforethought” brought their talents to Southern Medical Association Alliance (SMAA) ...NOT A BAD THING, MIND YOU ... for SMAA is a most respected organization ... but the psychology here makes sense...

Simply put, people like to be associated with and offer their talents to an organization that has a stable membership and worthy mission!

Let’s take this as a lesson! We must work to regain the image that once attracted participation in MSMAA. “Reaching the Finish Line With Dignity”- This brochure includes a check list and glossary in lay person’s terms to inform and encourage conversation concerning end-of life decisions. To obtain copies of the brochure contact an Alliance member.

There you have it... that’s the picture... the positives and negatives of the 2013-1014 year for MSMAA thus far.

I’m off to ‘stir the pitcher’....where there is a will there is a way...we just have to improve on this recipe ... we welcome suggestions! r

February 2014 JOURNAL MSMA 63

• Poetry and Medicine • [This month, we print another poem from “Coronary” by Benjamin A. Morris, a Mississippi born poet who lives in New Orleans. Morris is the son of Hattiesburg urologist and MSMA member Dr. Toxey M. Morris. “Sedation” provides a family view of the alien world of medicine when a loved one is hanging on for dear life. Published in 2011, “Coronary” includes 24 sonnets all centered on a similar theme: his personal experience of his father Toxey’s illness and hospitalization. (Toxey is in good health today!) The lovely volume includes original artwork by Dr. Morris on its cover. Now in its third edition, copies are available at independent bookstores in the New Orleans area and at Main Street Books in Hattiesburg. Benjamin is the author of numerous works of poetry, fiction, nonfiction, and drama. He has received many honors for his writing, including a fellowship for poetry from the Mississippi Arts Commission. More information, including how to purchase “Coronary,” is available at benjaminalanmorris.com. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net]—Ed.

Sedation The cables snake down from the racks and coil around your chest. Slender, quiet, bearing fluids whose names all end in ―zine, they feed these sallow, unctuous oils into places we can’t see: first into your wrist, then into your heart, which staggers loosely forward with their help. You’re asleep. Mostly we are too―asleep as we drive as fast as possible to the hospital every time the nurses let us, asleep as we eat dinner or stir our idle drink, asleep as we make the calls: no change. But we dream and know it, Dad, as strange as it seems.

Every day you’re under you grow thinner.

64 JOURNAL MSMA February 2014

—Benjamin A. Morris, New Orleans

Race against time?

Are medical journals becoming extinct? Not on your life. Scientific medical publications continue to be a solid source for up-to-date data for physicians in all specialties. Your Journal of the Mississippi State Medical Association is alive and running. Slow down. Read the Journal online or in print. Contact us today for information on cost-efficient advertising opportunities to reach an upscale audience of physicians statewide with our monthly medical magazine.

Karen A. Evers, Managing Editor, 601.853.6733

• MSMA Board of Trustees • From left: President James A. Rish, MD President-Elect Claude C. Brunson, MD Immediate Past President Steve Demetropoulos, MD

From left: Secretary-Treasurer Michael Mansour, MD District 1 Trustee S. Carlton Gorton, MD District 2 Trustee Brett C. Lampton, MD

From left: District 3 Trustee Steven C. Brandon, MD District 4 Trustee William M. Grantham, MD District 4 Trustee J. Clay Hayes, Jr., MD

From left: District 5 Trustee Dwight S. Keady, MD District 6 Trustee Jeffrey A. Morris, MD District 7 Trustee Daniel P. Edney, MD

From left: District 8 Trustee Lee Voulters, MD Young Physician Trustee W. David McClendon, MD Resident Trustee Jane Beebe Jones, MD

From left: Medical Student Trustee Savannah Duckworth Speaker of the House R. Lee Giffin, MD

66 JOURNAL MSMA February 2014

• Uncommon Thread • Vegetarian Hunting in Garlandsville, Mississippi

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ome of you may recall I wrote a piece a few years ago, when I was writing Una Voce, called “My Kind of Hunting Story” [Anderson RS. My kind of hunting story- Part 1. J Miss Med Assoc. 2008;49(2):63-64 and Part 2. 2008;49(3):95-96]. If you don’t, or if you never got a chance to read it, the gist is: I took three R. Scott Anderson, MD small children deer hunting in a 4’x 4’ box stand that was sitting on the Meridian ground, the front legs broke off the cheap plastic chair I was sitting on and the back legs “sproinged” up against the door, pinning me against the front wall with the three kids wedged in around me. I ended up kicking the door off the hinges to get free, and still got a chance to draw down on an eight point buck…then the screaming started. Remember now? Well the story’s in the Uncommon Thread book if you need more than that, but the things you need for this story are that Maddie was six then, she was a shooting whiz, and she still is now. She still loves going hunting, and she still (by her account) has never shot a deer.

Last year, after a few of her friends had killed their first deer she decided that she might, perhaps, want to shoot one. When a single doe came into the field I gave her my standard “first deer” instructions.

“We’re both going to aim our guns. When you’re ready count down 3…2…1 and then we’ll both pull the trigger.”

It’s worked pretty well that way through the years. Well, there was that time with one of the older boys that the sequence went 3-2-BAM and the next two hours were spent looking for an uninjured deer. Thirty minutes after dark, after I’d stepped in a hole and twisted my ankle, then hooked a foot in a root and slid down a ditch face first, I asked the child, “What was the last thing you saw in the scope before you pulled the trigger?”

And they answered, “Dirt. I didn’t want to shoot him, so I just shot at the dirt instead.”

There was only one possible response on my part, “You couldn’t have mentioned that an hour and a half ago? When I could still walk.”

Anyway, back to Maddie Lynn, the countdown went perfectly, the deer dropped straight down in it’s tracks….then it had a seizure. It was hit well, it was dead, but it wasn’t pretty.

We climbed down out of the high stand and stood together over the fallen doe. There was only one entrance wound.

“I didn’t have anything to do with this,” she whispered.

And as far as I know, she didn’t. She could have been aiming at dirt for all I know, but I didn’t bother asking. That ended the idea of actually shooting a deer for Maddie, so this year we came up with something different, “vegetarian hunting.”

Now, I have to admit, there are some compromises. The vegetables don’t move much, there’s a very limited chance that they’re going to run away if you make noise, and it doesn’t much matter which way the wind’s blowing or if you had onions for lunch. In fact, onions may be one of the species of prey you’re shooting for.

Basically, you go to the market and ask the vegetable guy what he’s got that’s on sale, the stuff that will be bad tomorrow if he doesn’t sell it today. Then you take it out to the farm and scatter it around at appropriate distances. Maybe some apples at eighty yards, an acorn squash at one hundred, a pineapple at one-fifty, and some pumpkins at two hundred and twenty-five.

February 2014 JOURNAL MSMA 67

Then you go and sit on the porch swing and drink some tea while you talk for a while. “Okay, you get to shoot first. You’ve got three shots. See if you can hit that brownish apple. If you miss, I get a chance to shoot at it. If you hit it, you get to pick out one of the chunks for me to shoot at.”

That sort of stuff.

I always end up losing in the end. Maddie ups the ante as she gets to set the bets. “Okay, see that white pumpkin?

That’s my pumpkin. Yours is that little one. You can only shoot the stem. Double or nothing.”

It’s a good day. We talk a lot, shoot some, swing without talking, and drink some tea. Then we go out to a deer stand until dark and watch the deer come in. r Dr. Anderson is in the private practice of Radiation Oncology in Meridian and is the Editor of the literary journal China Grove, see Chinagrovepress.com.

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