January 2015 JMSMA

January

VOL. LVI

2015

No. 1

Earn up to 17 CME hours at MSMA’s

CME in the Sand

May 22 to 26, 2015 · Sandestin, FL CME Topics Include National Healthcare Update · Risk Management · Diabetes · HIV · Prescription Drug Abuse · Telehealth Medicine · Dermatology· Youth Sports Injuries ·Orthopaedic Oncology Gastroenterology and more!

CME Speakers Congressman Gregg Harper · Drs. Robert Brodell· Daniel Edney ·Jennifer Barr · Michael Manning · Christopher Boston · Annette Low · · Rob Jones, JD and more!

Visit MSMAonline.com for a list of children’s activities, social events and resort amenities!

REGISTER TODAY!

STEP 1: Reserve your resort.

STEP 2: Register with MSMA.

STEP 3: Pack your (beach) bags!

www.MSMAonline.com Book online now at www.Sandestin.com OR call 800‐320‐8115.

Group code: 22Y138

OR register by mail/fax with form below.

Registration Fee: $300

Don’t forget shades and flip‐flops!

Registration Form

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

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

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

Sun. 5/22 Welcome Reception Mon. 5/24 Family Dinner

# A du l t s / # Ki ds ______ / ______ ______ / ______

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

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 and the Editors

The Association Claude D. Brunson, MD President Daniel P. Edney, MD President-Elect Michael Mansour, MD Secretary-Treasurer Geri Lee Weiland, MD Speaker Jeffrey A. Morris, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548.

(ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices.

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

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

ADVERTISING RATES: furnished on request.

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

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

Copyright© 2015 Mississippi State Medical Association.

Official Publication of the MSMA Since 1959

JANUARY 2015

VOLUME 56

NUMBER 1

Scientific Articles Pheochromocytoma Presenting as Acute Non-ST Elevation Myocardial Infarction Following Elective Hysterectomy 4 William B. Horton, MD; Lane M. Frey, MD; Urseline A. Hawkins, MD; and Shema R. Ahmad, MD

Top 10 Facts You Need to Know: Pitfalls to Avoid in Treating the ESRD Patient

7

H. Allen Gersh, MD; Lucius M. Lampton, MD; Nabil Baddour, MPH; Jeremy Rainey, DO

Related Organizations Mississippi State Department of Health

11

President’s Page Physicians Must Continue to Fight the Good Fights

13

Claude D. Brunson, MD; MSMA President

Departments From the Editor: Battling Mothers for Measles 2 Letters 10 Physician’s Bookshelf: The Goals of Medicine: The Forgotten 16 Issues in Health Care Reform Legal Ease 21 New Members 22 In Memoriam 24 Poetry and Medicine 28

About The Cover: Windsor Ruins: A Silent Sentinel to the Magnificent South

The Windsor Ruins are located about ten miles southwest of Port Gibson in Claiborne County near Alcorn State University. Windsor was built in 1859-61 by Smith Coffee Daniell, II, a wealthy planter who had extensive properties in the Mississippi Delta. Daniell was born in 1826, the son of an Indian fighter-turnedfarmer and wealthy landowner. In 1849 he married his cousin, Catherine Freeland, and the couple would have seven children, three of whom would survive to adulthood.

In 1859, the couple began to build the Greek Revival style mansion utilizing New England craftsmen and slave labor on their 2,600 acres plantation that overlooked the Mississippi River in the distance. The couple spared no expense in architecture, furnishings, and details. The four-story home, which borrowed Italianate and Gothic architectural styles, would include 25 rooms when completed, each having its own fireplace fronted with marble mantels.

Waiting patiently and overseeing many of the details for two years, Daniell would not live to enjoy his new home. Just a few weeks after it was completed, he passed away at the age of 34.

That same year, the Civil War would erupt, and Windsor, like so many other plantations in the South, would find itself in the midst of it. A Yankee soldier was shot in the front doorway of the home. During the Civil War the mansion was used as an Union hospital and observation post, thus sparing it from being burned by the Union troops.

After the Civil War, during a party on Feb. 17, 1890, a guest left a lit cigar on the upper balcony, and Windsor burned to the ground. Everything was destroyed except the 23 columns, balustrades, and iron stairs. Photo by Martin M. Pomphrey, MD, Mayhew. r January

VOL. LVI

2015

No. 1

January 2015 JOURNAL MSMA 1

From the Editor: Battling Mothers for Measles

W

hat makes Mississippi’s public health superior to the third world are two simple public health accomplishments: high vaccination rates and the separation of waste from drinking water. Despite the extraordinary success of these principles, state legislators year after year are pressured to relax state laws regarding both. This year’s session was no different, with an aggressive assault on the state’s highly touted school entry vaccine law. House Bill 130 garnered significant momentum despite emerging during a national outbreak of more than 120 cases of measles across 17 states. The bill proposed changing the current immunization law to include philosophical exemptions and to allow any physician in the United States to grant Mississippi citizens a medical exemption.

When Dr. Edward Jenner began vaccinating patients with pus from a cowpox pustule at the end of the eighteenth century, many of his patients feared it would make them grow cow-like body parts. Much of the mythology of later skeptics derives from a discredited 1998 study published in the Lancet which claimed a link between vaccinations and autism. Here in our state, the small but vocal Mississippi Parents for Vaccine Rights

battles fiercely to overturn the state’s immunization law. Despite their sincere convictions, physicians rightly see the mortal danger of their efforts. One physician friend jokingly termed them, “Mothers for Measles.”

Mississippi physicians have assumed that the general public and politicians understand as we do the proven science and clear wisdom of immunizations. For Lucius M. Lampton, MD too long we have allowed some parents to ridicule centuries of evidence of vaccine safety and efficacy and to conclude that they can send their kids merrily to school unvaccinated. The nineteenth century English biologist Thomas Huxley wrote, “If [my next-door neighbor] is to be allowed to let his children go unvaccinated, he might as well be allowed to leave strychnine lozenges about in the way of mine.” Physicians must increase public and legislative awareness of the importance and safety of immunizations, as well as the serious dangers to the public health of philosophical and nonmedical exemptions.

Contact me at LukeLampton@cableone.net. r

Journal Editorial Advisory Board Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic

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

Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland

Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson

J. Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo

Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson

Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic

W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel

Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

Ben E. Kitchens, MD Family Physician, Iuka Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

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

Professor of Medicine and Associate Dean for VA William Lineaweaver, MD Education, University of Mississippi School of Medicine, Editor, Annals of Plastic Surgery Associate Chief of Staff for Education and Ethics, Medical Director G.V. Montgomery VA Medical Center, Jackson JMS Burn and Reconstruction Center, Brandon 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 Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

2 JOURNAL MSMA

January 2015

Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist Jackson Health Care-Women, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson

Michael D. Maples, MD Chris E. Wiggins, MD Medical Director Orthopaedic Surgeon Medical Assurance Company of Mississippi, Ridgeland Bienville Orthopaedic Specialists, Pascagoula Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson

John E. Wilkaitis, MD Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

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

Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

macm INSURANCE SERVICES

Complementing the Products of Medical Assurance Company of Mississippi MACM Insurance Services, Inc., a wholly owned subsidiary of Medical Assurance Company of Mississippi, is dedicated to meeting the insurance needs of health care providers and organizations. We pride ourselves in providing prompt and reliable service to our clients as we deliver products tailored to minimize risk.

Products

Billing E&O / Regulatory Liability Employment Practices Liability Directors & Officers Liability Workers’ Compensation Professional Liability Hospitals • Physicians • Clinics Ambulatory Surgery Centers Imaging Centers

Our professionals have access to numerous insurance companies which offer added flexibility in pricing, products and expertise.

Regardless of the sector in the medical community, we are committed to finding a solution for your needs.

404 West Parkway Place Ridgeland, MS 39157

601-605-4882 www.macm.net/mis_home.html

Shaw P. Singleton, Account Manager shaw.singleton@macm.net

January 2015 JOURNAL MSMA 3

• Scientific Articles • Pheochromocytoma Presenting as Acute Non-ST Elevation Myocardial Infarction Following Elective Hysterectomy William B. Horton, MD; Lane M. Frey, MD; Urseline A. Hawkins, MD; and Shema R. Ahmad, MD

A

bstract

Introduction Studies have shown patients with pheochromocytoma have a 14-fold higher rate of cardiovascular events than patients with essential hypertension.

Case Presentation A 47-year-old female was found to have elevated troponins and marked ST depression following elective hysterectomy. The patient underwent cardiac catheterization, and labile blood pressures with a narrow-complex tachycardia were noted during the procedure. No evidence of coronary artery disease or wall motion abnormality was found.

After catheterization, the patient complained of abdominal pain with difficulty passing gas. CT abdomen/pelvis revealed a 4.3 x 5 cm left adrenal mass. Plasma metanephrines and 24hour urine catecholamines suggested pheochromocytoma. She underwent left total adrenalectomy, and pathology confirmed pheochromocytoma. At 3-month follow-up, she was asymptomatic and required only one agent for blood pressure control.

Discussion Suspecting pheochromocytoma in patients with an unexpected myocardial event and labile hypertension can lead to prompt diagnosis and appropriate preoperative management as well as avoidance of unnecessary procedures.

Key Words: Pheochromocytoma; Catecholamines; Metanephrine; Troponin Author Affiliations: PGY-I at the University of Mississippi Medical Center (Horton). PGY-5 Endocrinology Fellow at the University of Mississippi Medical Center (Frey). Assistant Professor of Medicine in the Department of Medicine, Division of Endocrinology at the University of Mississippi Medical Center (Hawkins). Assistant Professor of Medicine in the Department of Medicine, Division of Endocrinology at the University of Mississippi Medical Center (Ahmad).

Corresponding Author: William B. Horton, MD; University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216 (wbhorton@umc.edu).

4 JOURNAL MSMA

January 2015

Introduction Pheochromocytomas are rare catecholamine-secreting neuroendocrine tumors arising from chromaffin tissue in the adrenal medulla. Episodic release of catecholamines classically causes paroxysmal signs and symptoms such as anxiety, hyperglycemia, hypertension, and tachyarrhythmias. Studies have shown patients with a pheochromocytoma have a 14-fold higher rate of cardiovascular events than patients with essential hypertension.1 Various cardiovascular manifestations such as cardiomyopathy, arrhythmia, left ventricular hypertrophy, and congestive heart failure have been observed in patients with a pheochromocytoma.2,3 Myocardial infarction as the initial manifestation of pheochromocytoma is a rare event, occurring in only 4% of cases.4 Here we present the case of a 47-year-old female who presented with elevated troponins and EKG findings consistent with non-ST elevation myocardial infarction following elective hysterectomy. Cardiac catheterization found no evidence of coronary artery disease and the patient was eventually diagnosed with pheochromocytoma.

Case Presentation A 47-year-old African-American female presented to an outside facility for elective hysterectomy. The patient reported a long history of hypertension which was poorly-controlled on three medications prior to the procedure. Post-hysterectomy: the patient had extreme variations in blood pressure (systolic blood pressures ranging from 90 to 220 mmHg) as well as left arm numbness and mild dyspnea. Electrocardiography (EKG) demonstrated marked ST depression in the anterior precordial and lateral limb leads (Figure 1). Troponins were significantly elevated (11.5 ng/mL) and the outside hospital transferred the patient to our facility for cardiac catheterization. During the procedure, recurrent episodes of a narrow complex tachycardia and labile blood pressures were noted. No evidence of coronary artery disease, wall motion abnormality, or cardiomyopathy was found, and left ventricular function was normal.

Figure 1. EKG demonstrating marked ST depression in anterior precordial and lateral limb leads.

After catheterization, the patient complained of abdominal pain with difficulty passing gas. Computed tomography (CT) of the abdomen and pelvis with contrast revealed a heterogeneously enhancing 4.3 x 5 cm left adrenal mass (Figure 2).

Plasma fractionated metanephrines were more than 4 times the upper limit of normal, and 24-hour urine fractionated catecholamines and metanephrines were more than 2 times the upper limit of normal (Table 1), suggestive of pheochromocytoma.

The patient was administered phenoxybenzamine for 10 days and underwent left total adrenalectomy. She tolerated the procedure well, and pathology revealed a 5 cm pheochromocytoma of the adrenal medulla.

At 3-month follow-up, she was asymptomatic and required only one agent for blood pressure control. Repeat plasma metanephrines were within normal limits. She continues to do well and remains symptom-free to this day.

Figure 2. CT abdomen/pelvis revealed a 4.3 x 5 cm left adrenal mass (white arrow).

Discussion Various cardiovascular manifestations such as cardiomyopathy due to sustained catecholamine exposure,5 ventricular hypertrophy and congestive heart failure due to prolonged hypertension,6 and rarely acute myocardial infarction7,8 have been observed in patients with pheochromocytoma. A recent study evaluating cardiac complications as initial manifestation of these tumors examined records of 76 patients diagnosed with pheochromocytoma over a 16-year time frame. Of those 76 patients, 9 (12%) presented with any cardiovascular manifestation, and only 3 (4%) presented with myocardial infarction.4 Table 2 demonstrates the frequency of cardiac complications as initial manifestation of pheochromocytoma.

Acute catecholamine secretion may induce chest pain and segmental myocardial dysfunction, mimicking an acute ischemic event in patients with pheochromocytomas.9 One mechanism suggested is that excess norepinephrine impairs both endothelium-dependent as well as smooth muscle-dependent vasodilatation, possibly leading to coronary spasms.10 During a pheochromocytoma crisis, a myocardial oxygen demandsupply mismatch also occurs due to increased afterload (vasoconstriction) and catecholamine-driven tachycardia and coronary vasopasms. This can precipitate myocardial ischemia with concomitant electrocardiographic abnormalities, even in the absence of coronary atherosclerosis.8 Prompt diagnosis and preoperative management are key but can be a challenge as demonstrated in this case. Our patient’s pre-test probability for pheochromocytoma was high based on her presenting signs of tachycardia, labile blood pressure, and myocardial infarction triggered by a surgical procedure coupled with the fact that up to 12% of patients with pheochromocytoma can present with cardiac complications.4 Plasma free metanephrines should be used as the initial screening test when pheochromocytoma is suspected, as the sensitivity is nearly 100%. If the initial screening test is positive, a confirmatory test with high specificity such as fractionated 24-hour

Table 1. Pre-operative 24-hour urine studies

Total volume (mL)

1464

Urine creatinine (0.72-1.51 g/24 hrs)

1.02

Metanephrine (24-96 mcg/24 hrs)

7603

Normetanephrine (15-80 mcg/24 hrs)

3982

Epinephrine (0-20 mcg/24 hrs)

747

Norepinephrine (15-80 mcg/24 hrs)

915

Dopamine (65-400 mcg/24 hrs)

348

January 2015 JOURNAL MSMA 5

Table 2. Frequency of cardiac complications as initial manifestation of pheochromocytoma.

Cardiac Manifestation

Associated Signs and Symptoms

Presentation Rate

Acute Heart Failure

Dyspnea

3%

Cardiogenic shock Left Ventricular Thrombus

Stroke

1%

Myocardial Infarction

Chest pain

4%

Severe Arrhythmia

Palpitations

4%

Syncope Adapted from Yu R, Nissen NN, Bannykh SI. Cardiac complications as initial manifestation of pheochromocytoma: frequency, outcome, and predictors. Endocr Pract 2012; 18(4): 483-492.

Adapted from Yu R, Nissen NN, Bannykh SI. Cardiac complications as initial manifestation of pheochromocytoma: frequency, outcome, and predictors. Endocr Pract 2012; 18(4): 483-492.

urinary metanephrines should be performed.11 In our case, both laboratory values were greatly increased, essentially clinching the diagnosis.

The main goals of preoperative management are normalization of blood pressure, heart rate, and organ function along with prevention of surgery-induced catecholamine storm and its consequences on the cardiovascular system.12 Our patient received phenoxybenzamine for ten days prior to surgery, which led to improved blood pressure control. After left adrenalectomy was performed, EKG changes normalized and the patient required only one agent for blood pressure control at three month follow-up. Follow-up testing after resection of a solitary sporadic pheochromocytoma should include baseline postoperative biochemical testing with plasma free metanephrines two weeks post-operatively to ensure complete resection followed by plasma free metanephrines annually to ensure no recurrence or metastasis is identified.13 Suspecting pheochromocytoma in patients with an unexpected myocardial event and labile hypertension can lead to prompt diagnosis and management, resulting in a successful outcome.

References 1. Stolk RF, Bakx C, et al. Is the excess cardiovascular morbidity in pheochromocytoma related to blood pressure or to catecholamines? J Clin Endocrinol Metab 2013; 98(3): 1100-1106.

2. Lenders JW, Eisenhofer G, Mannelli M, Pacak K. Phaeochromocytoma. Lancet 2005; 366(9486): 665-675.

3. Schurmeyer TH, Engeroff B, Dralle H, von zur Muhlen A. Cardiological effects of catecholamine-secreting tumours.

Eur J Clin Invest 1997; 27(3): 189-195.

4. Yu R, Nissen NN, Bannykh SI. Cardiac complications as

6 JOURNAL MSMA

January 2015

initial manifestation of pheochromocytoma: frequency, outcome, and predictors. Endocr Pract 2012; 18(4): 483492.

5. Magalhaes LC, Darze ES, Ximenes A, Santana O, et al.

Acute myocarditis secondary to pheochromocytoma. Arq Bras Cardiol 2004; 83(4): 346-348.

6. Serfas D, Shoback DM, Lorell BH. Phaeochromocytoma and hypertrophic cardiomyopathy: apparent suppression of symptoms and noradrenaline secretion by calcium-channel blockade. Lancet 1983; 2(8352): 711-713.

7. Garg A, Banitt PF. Pheochromocytoma and myocardial infarction. South Med J 2004; 97(10): 981-984.

8. Menke-van der Houven van Oordt CW, Twickler TB, et al. Pheochromocytoma mimicking an acute myocardial infarction. Neth Heart J 2007; 15(7-8): 248-251.

9. Darze ES, Von Sohsten RL. Pheochromocytoma-induced segmental myocardial dysfunction mimicking an acute myocardial infarction in a patient with normal coronary arteries. Arq Bras Cardiol 2004; 82(2): 178-180.

10. Higashi Y, Sasaki S, Nakagawa K, Kimura M, et al. Excess norepinephrine impairs both endothelium-dependent and –independent vasodilation in patients with pheochromocytoma. Hypertension 2002; 39(2): 513-518.

11. Lenders JW, Pacak K, Walther MM, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA 2002; 287(11): 1427-1434.

12. Pacak K. Preoperative management of the pheochromocytoma patient. J Clin Endocrinol Metab 2007; 92(11): 40694079.

13. Galati SJ, Said M, Gospin R, et al. The Mount Sinai clinical pathway for the management of pheochromocytoma.

Endocr Pract 2014; 8: 1-33.

• Top 10 Facts You Need to Know • Pitfalls to Avoid in Treating the End-Stage Renal Disease Patient H. Allen Gersh, MD; Lucius M. Lampton, MD; Nabil Baddour, MPH; Jeremy Rainey, DO

E

nd-stage renal disease (ESRD) has become epidemic in Mississippi and continues to increase among the population. Dialysis patients are becoming more common in the primary care practice setting, from the clinic to the hospital to the nursing home, and many practicing primary care physicians have received little formal training in managing these highly complex, chronically ill patients. These complicated patients are often diabetic, geriatric, rural, poor or minority, non-compliant and with cognitive deficits. Mississippi’s primary care physicians are overworked and isolated. In many cases they find themselves without sub-specialty input to assist in managing ESRD patients with multiple comorbid conditions.

Good medical care of these patients involves addressing their diverse illnesses, which range from depression to pain to infections to coronary disease, while recognizing that the medical management of these patients requires expertise and considerations uncommon in dealing with the average patient.

Never is physician-to-physician communication more important than with the patient with ESRD. Primary care physicians and nephrologists are encouraged to establish easy routes of communication in managing their shared patients with ESRD. What follows are the top 10 pitfalls a primary care physician needs to avoid in treating ESRD and dialysis patients:

1. Do not underestimate the importance of fever in ESRD patients.

If a patient has chills, sepsis must be excluded, and if he/she has a line, always put line sepsis at the top of the differential list. It is best to exclude line sepsis before diagnosing another cause. Blood cultures may be obtained from peripheral veins and do not have to be drawn from a catheter.1 MRSA must always be covered when treating

Author Affiliations: Nephrologist practicing at Hattiesburg Clinic in Hattiesburg (Gersh). Associate Clinical Professor of Family Medicine at Tulane School of Medicine practicing at Magnolia Clinic in Magnolia (Lampton). Fourth year medical student at William Carey University School of Osteopathic Medicine in Hattiesburg (Baddour). PGY-1 training in anesthesiology at UMMC (Rainey).

Corresponding Author: H. Allen Gersh, MD, 415 South 28th Avenue, Main Clinic, 4th Floor, Hattiesburg, MS 39401.

(Allen.Gersh@gmail.com)

line sepsis, and vancomycin is a frequent choice. If blood cultures are positive and line sepsis is diagnosed, the line may need to be removed and tip cultured. Because these lines are usually cuffed, a surgeon or interventional radiologist typically removes them. Obviously, the patient will require a new catheter before the next dialysis. If the patient has a Gortex Graft or AV fistula, this is a common site of infection.

2. Avoid placement of PICC lines and protect patient access points for dialysis use. These are lifelines.

Dependable vascular access is vital for patients with ESRD. PICC lines risk damaging vessels and rendering them unusable for hemodialysis. If access is absolutely necessary, consider: • Placement of a small-bore tunneled internal jugular line.

•

Use of the dorsal veins in the hand for purposes of phlebotomy or peripheral venous access.2

•

Do not allow any nursing or other non-physician personnel who have not had specialized training in hemodialysis vascular access to use dialysis catheters or dialysis fistulas.3

3. Decreased renal clearance merits consideration for antibiotic choice in patients with ESRD.

When dosing antibiotics in ESRD patients, the initial dose does not need to be modified. However, subsequent doses need to be modified if the drug has significant renal clearance. There is no easy answer on dosing, and it is often necessary to review dosing recommendations for each antibiotic. Drugs such as vancomycin can be given post dialysis, and the patient will not require interim doses.

4. Try not to admit ESRD patients to a hospital that does not offer in-house dialysis.

Minor issues can become more serious, even deadly, with these patients in a manner much different than a “regular” hospital patient. You may only expect a short term admission, but these patients frequently deteriorate rapidly with a poor outcome. A higher level facility with in-house dialysis is almost always the best decision for hospital treatment of the ESRD patient. These are complex patients who require a higher level of acute care when ill.

January 2015 JOURNAL MSMA 7

the patient is actively bleeding or unstable.

5. Do not treat ESRD patients for osteoporosis.

ESRD patients develop uremic bone disease, and it is difficult to diagnose osteoporosis in this setting. Traditional therapy including calcium supplements may do harm.

There is no need to get densitometry studies since they will have no effect on outcome.4 Biophosphates are especially harmful since they may induce low turnover bone disease.

Most of the research on risk and therapy of osteoporosis does not look at ESRD patients.

6. Do not get MRIs with Gadolinium contrast.

Gadolinium can cause Nephrogenic Fibrosing Dermopathy, which is a potentially fatal disease.5,6,7 There may be situations where only MR studies with contrast can make a diagnosis. In these circumstances, the risk of using contrast must be outweighed by the risk of not making the diagnosis. Contrast dye can be used for CT scans in ESRD patients not on peritoneal dialysis.

7. Use caution when prescribing anti-depressants in patients.

Cymbalta (duloxetine) and its metabolites are excreted from the body primarily via renal clearance. Patients with ESRD are subject to increased exposure to duloxetine and its metabolites, and its use is therefore discouraged.8 First generation anti-depressants such as tricyclics and monoamine oxidase inhibitors can cause unsafe drops in blood pressure in patients on dialysis (In fact, hypertensive control and volume status in general are best addressed by a nephrologist; such agents as Labetalol and Catapres can also cause unsafe drops in blood pressure.).

Depression should, however, be carefully managed, as it is a common marker for poor clinical outcomes.9 Wellbutrin is a good choice. SSRI antidepressants are acceptable options, but be aware that higher doses of Lexapro and Celexa may put patients at risk for cardiac arrhythmias. Dialysis patients frequently respond to cognitive therapy, and its use should be encouraged.

Try to avoid transfusing more than one unit packed red blood cells (PRBCs) at a time, unless the patient is actively bleeding or unstable. Dialysis patients are commonly anemic, but transfusion is not necessary unless they are symptomatic or have a falling hematocrit. If they are receiving erythropoietin, adjusting the dose may be the best approach. If patients are potential transplant candidates, transfusions may cause antibodies that may make donor kidneys incompatible. Over-transfusion can result in pulmonary edema.

10. Do not consider free air under the diaphragm as a sign of a perforated viscus when treating a patient receiving peritoneal dialysis.

Peritoneal dialysis catheters can serve as access points for air to enter the peritoneal cavity. Catheter-related peritonitis should be considered in all peritoneal dialysis patients who have abdominal pain.13 A central premise of ESRD patient management is that primary care physicians and the patient’s nephrologist need to communicate directly about many medical issues, including these. If in doubt, communicate. Both physicians should exchange contact telephone numbers for after-hours emergencies.14 References 1.

Venkat A, Kaufmann K, Venkat K. Review: Care of the end-stage renal disease patient on dialysis in the ED. American Journal of Emergency Medicine [serial online]. January 1, 2006; 24:847-858. Available from: Science Direct, Ipswich, MA. Accessed July 13, 2014.

2.

Hoggard J, Saad T, Schon D, Vesely T, Royer T. Guidelines for venous access in patients with chronic kidney disease. A Position Statement from the American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access. Seminars In Dialysis [serial online]. March 2008; 21(2):186-191. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed July 13, 2014.

3.

Centers for Disease Control and Prevention Dialysis Safety page. Infection Prevention in Dialysis Settings, A Continuing Education (CE) Training Course for Outpatient Hemodialysis Healthcare Workers. http:// www.cdc.gov/dialysis/clinician/CE/infection-prevent-outpatient-hemo. html. Accessed July 12, 2014.

4.

Cunningham J, Sprague S. Osteoporosis in chronic kidney disease. Am J Kidney Dis. [serial online]. March 2004; 43(3):566-571. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 13, 2014.

5.

Grobner T. Gadolinium--a specific trigger for the development of nephrogenic fibrosing dermopathy and nephrogenic systemic fibrosis? Nephrology, Dialysis, Transplantation: Official Publication Of The European Dialysis And Transplant Association - European Renal Association [serial online]. April 2006; 21(4):1104-1108. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed July 13, 2014.

6.

Moschella S, Kay J, Mackool B, Liu V. Case 35-2004: a 68-year-old man with end-stage renal disease and thickening of the skin. NEJM [serial online]. November 18, 2004; 351(21):2219-2227. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 13, 2014.

7.

Baron P, Cantos K, Concepcion W, et al. Nephrogenic fibrosing dermopathy after liver transplantation successfully treated with plasmapheresis.

Am J Dermatopathol. [serial online]. June 2003; 25(3):204-209. Avail-

8. Clear established guidelines are not always

available for reducing cardiovascular morbidity and mortality in ESRD patients.

Coumadin therapy is not always indicated in ESRD patients with atrial fibrillation, as it can be associated with an increased risk of bleeding.10 Likewise, it is important to balance the adverse effects of statin therapy with its benefits in treating dyslipidemia for ESRD patients.11 While statins have proven beneficial in patients with early CKD, they have demonstrated little benefit in those with ESRD, whose problems lie in cholesterol metabolism rather than biosynthesis.12

9. Try to avoid transfusing more than one unit packed red blood cells (PRBCs) at a time, unless 8 JOURNAL MSMA

January 2015

able from: MEDLINE with Full Text, Ipswich, MA. Accessed July 13, 2014.

8.

Lobo E, Heathman M, Knadler M, et al. Effects of varying degrees of renal impairment on the pharmacokinetics of duloxetine: analysis of a single-dose phase I study and pooled steady-state data from phase II/III trials. Clinical Pharmacokinetics [serial online]. 2010; 49(5):311-321.

Available from: MEDLINE with Full Text, Ipswich, MA. Accessed July 13, 2014.

9.

Kurella Tamura M, Yaffe K. Dementia and cognitive impairment in ESRD: diagnostic and therapeutic strategies. Kidney International [serial online]. 2011; 79(1):14-22. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed July 13, 2014.

10. Reinecke H, Brand E, Breithardt G, et al. Dilemmas in the management of atrial fibrillation in chronic kidney disease. Journal of the American Society of Nephrology (JASN) [serial online]. April 2009; 20(4):705711. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed September 24, 2014.

11. Ojha J. Review article: Management of dyslipidemia in CKD, dialysis and renal transplant recipient. Clinical Queries Nephrology [serial online]. July 1, 2012;1:191-197. Available from: ScienceDirect, Ipswich, MA. Accessed December 13, 2014.

12. Epstein M, Vaziri N. Statins in the management of dyslipidemia associated with chronic kidney disease. Nature Reviews Nephrology [serial online]. April 2012; 8(4):214-223. Available from: Academic Search Premier, Ipswich, MA. Accessed September 24, 2014.

13. Imran M, Bhat R, Anijeet H. Pneumoperitoneum in peritoneal dialysis patients; one centre’s experience. NDT Plus [serial online]. 2011; 4(2):120-123. Available from: Academic Search Premier, Ipswich, MA. Accessed July 13, 2014.

14. Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients. National Kidney Foundation Website. http://www.kidney.org/professionals/kdoqi/guidelines_cvd/guide12.htm. Published 2005. Accessed July 12, 2014.

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

OR Physicians to review Social Security disability claims at the

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

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

DISABILITY DETERMINATION SERVICES 1-800-962-2230 January 2015 JOURNAL MSMA 9

• Letters •

How to Eliminate the “Perverse Incentive” in Medicine: Health Savings Accounts Dear JMSMA Editor, You are absolutely correct [Lampton L. “Eliminating the Perverse Incentive,” Editor’s Note, J Miss State Med Assoc., 2014:55(9);282]. In an attempt to control costs, third parties reward doctors for providing less care which is often dangerous and “perverse.” for iPhone, iPad, Android, andand all web-enabled mobile devices You ask how to keep spending under control, you correctly answer it: eliminating third party bureaucracy. But you don’t say how.

The answer is in Ecclesiastes: “There is noinnew under the sun.”

It’s that nearly pejorative term called “capitalism” Put the Journal MSMA thething palm of your hand. which is sometimes camouflaged the term “market forces.”

It eliminates third parties and preserves the best instruments to Full as color.

Flip-page.

Every month. control costs, i.e. mutual decisions between buyers and sellers.

It works well in cosmetic surgery and cataract surgery, etc., which have seen a dramatic reduction in costs because third parties are eliminated. Competition and market forces worked well in my native Canada before being replaced by an Obamacarelike program that forced costs skyward because of third parties, which lead to severe rationing.

Today, 40 years later, Canada is now reforming and privatizing, using market forces and competition to control costs. Medical Savings Accounts are still the best way to contain both third parties and costs. Bureaucrats, of course, hate them, but we should love and promote them!

—Cal Ennis, MD; Pascagoula

[Any physician is invited to submit editorials or letters to the editor for publication in the Journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.] —Ed.

You’re busy, Get the app.

for iPhone, iPad, Android, and all web-enabled mobile devices

Put the Journal MSMA in the palm of your hand.

Full color. Flip-page. Every month.

MSMA Mobile

for iPhone, iPad, Android, and all web-enabled mobile devices

Put the Journal MSMA in the palm of your hand.

Full color. Flip-page. Every month.

Loads of otherLoads features: news,features. events, membership. of other Scan Scanthe thecode codewith withyour yourmobile mobiledevice device or or download at

www. NaylorNetwork.com/MSMAmobile

10 JOURNAL MSMA

January 2015

Loads of other features.

Scan the code with your mobile device or download at

• Mississippi State Department of Health • Mississippi Provisional Reportable Disease Statistics December 2014

January 2015 JOURNAL MSMA 11

Mississippi Now the First in the Nation with Three Statewide Systems of Care in Place

W

ith the recent addition of the Stroke System of Care at hospitals throughout the state, Mississippi is now the first in the nation to have a third statewide system of care in place to save time in medical procedures and help save the lives of its residents.

The Stroke System of Care joins the ST-Elevation Myocardial Infarction (STEMI) Care Plan and the Trauma Care System as a statewide system in place to treat patients more quickly and efficiently.

These statewide systems establish a common protocol for first responders to identify certain life-threatening conditions, provide specialized treatment in the field, and transport the patient to the facility best able to render appropriate care quickly.

Such integrated systems of care have been shown to save lives in critical circumstances compared to conventional first responder procedures.

“This third statewide system of care has been facilitated through leadership of the Mississippi Healthcare Alliance,” said Jim Craig, MSDH Director of Health Protection. “Mississippians have greatly benefited from the STEMI and Trauma systems by being transported to the appropriate facility for treatment, based on the nearest facility’s capability of care. With the Stroke System, the same principle is in place.”

Hospitals can designate themselves as “stroke ready,” meaning the facility has 24/7 CT capability and a specific type of drug available to break up blood clots. Stroke centers must have a neurologist available 24/7, and comprehensive stroke centers must have the capability to conduct interventional neurology.

After an initial examination, blood work, and CT scans, initial therapy is given at designated “stroke-ready” hospitals before transition to an official stroke center.

Currently there are two Level 1 comprehensive stroke centers in Mississippi and four Level 2 stroke centers. The majority of the hospitals in Mississippi are Level 3 “Drip and Ship” hospitals, meaning ability to diagnose and stabilize a patient for transfer to a Level 1 or 2.

Stroke is the fifth leading cause of death in Mississippi, with nearly one in five stroke deaths occurring in those 65 and younger. Mississippi’s stroke mortality rate is the fifth highest in the nation, and the stroke death rate is more than 23 percent above the overall U.S. rate. The Stroke System of Care is a collaborate effort between the MSDH, the Mississippi Healthcare Alliance, the Mississippi Hospital Association, and the American Heart Association.

Mississippi Recognized for Highest Kindergarten Vaccination Rates Nationwide

M

ississippi has the highest rate of vaccination coverage for kindergarten students nationwide, according to a recent Morbidity and Mortality Weekly Report published by the Centers for Disease Control and Prevention (CDC).

The 45,719 kindergarten students enrolled in public and private kindergarten classrooms throughout the state during the 2013–2014 school year had 99.7 percent vaccination coverage, greater than the national median of 93.3–95 percent for the measles, mumps, and rubella (MMR) vaccine; the diphtheria, tetanus, and pertussis (DTap); and the varicella vaccine.

Mississippi requires five different vaccines to be administered prior to entering first grade. “We continue to be very proud of our vaccination rates,” said MSDH State Health Officer Dr. Mary Currier. “Mississippi’s strong school entry immunization law is protecting Mississippi residents from outbreaks of measles and other vaccine-preventable diseases that other states have experienced.”

The MSDH grants all requests for medical exemptions submitted by a licensed Mississippi pediatrician, family physician or internist. Mississippi is one of 31 states that do not allow philosophical exemptions for children attending school or daycare. The Mississippi Supreme Court deemed religious exemptions unconstitutional in 1979.

“Vaccines not only protect the children who are vaccinated but also protect those around them who may be too young to be fully immunized or those with weakened immune systems,” said Dr. Currier. “Mississippi children continue to die unnecessarily from vaccine-preventable diseases. Two children died from whooping cough in 2008 and 2012, which is preventable through vaccination.”

In fact, for U.S. children born between 1994 and 2013, immunizations are estimated to prevent more than 300 million illnesses, 21 million hospitalizations, and 732,000 deaths.

12 JOURNAL MSMA

January 2015

• President’s Page • Physicians Must Continue to Fight the Good Fights

F

or physicians like us it’s hard to imagine why the Mississippi Legislature is just so hard headed when it comes to scientific facts that we know to be true. The immunization battle is one such mystifying issue.

Claude D. Brunson, MD 2014-15 MSMA President

We know the dangers of measles, rubella, pertussis and other preventable diseases. We know how fast an outbreak can spread. We have watched the news reports as one child visiting Disneyland infected more than a hundred others in more than a dozen states in just a few weeks. Mississippi has the best immunization rate in the nation – this is one thing Mississippi does really well and we congratulate State Health Officer Dr. Mary Currier and the Department of Health for this milestone.

So, how is it that a State Legislature made of up of lawyers, realtors, farmers, businessmen and women - who are all presumably bright - can ignore the science in favor of a few misguided parents? In the same vein, our efforts to get a statewide ban on smoking in indoor public places are largely swept under the rug. Despite all of the statistics against secondhand smoke, many legislators just don’t seem to care.

MSMA held a press conference January 27 at the State Capitol to show legislators the names of thousands ... continued next page...

Claude Brunson, MD, left, president of MSMA, unrolls the 100-foot list containing 10,000 signatures of Mississippians that want to live in a smoke-free state.

Pictured at right is Steve Demetropoulos, MD, pastpresident of MSMA.

Claude Brunson, MD, center, presides at the press conference to announce the success of the “Physicians for a Smoke-Free Mississippi” campaign. Holding the list of 10,000 signatures is left, Steve Demetropoulos, MD, past-president; and Clay Hays, Jr., MD, MSMA Board of Trustees.

January 2015 JOURNAL MSMA 13

of physicians, patients and others who support a ban on smoking in indoor public spaces. More than 10,000 signatures were collected in MSMA’s “Physicians for a Smoke-Free Mississippi” campaign to illustrate the widespread support for a comprehensive statewide smoking ban. Senator Briggs Hopson of Vicksburg and Representative Bryant Clark of Pickens each introduced a comprehensive bill that would ban smoking in indoor public places. Neither was considered by its respective Public Health Committee where similar bills have died for many years.

Points of Distinction Focused: A singular long-term, value-driven investment philosophy Rigorous: Comprehensive research and analysis Rational: Thoughtful investment selection Responsive: Exceptional client service

The most creative strategy was implemented by Representative Hank Zuber of Pascagoula who worked closely with MSMA and offered an amendment in the Medicaid Committee chaired by Bobby Howell of Kilmichael. The Zuber amendment would have bypassed the legislature and placed the smoking ban question on the ballot for voters to decide. Alas, this effort was ruled “not germane” and it, too, died.

Seasoned: Experienced team with a breadth of disciplines Committed: Our money invested alongside yours Proven: Solid history of investment performance

In summary, my message to all physicians is this: “Stay the course. Fight the good fight.” We know medicine and the science of healing. We know the benefits of reducing secondhand smoke. Let’s all pull together – every physician, every specialty society, from every city and county. We can – and eventually will – make this happen.

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

Call us at 601-982-4123

A D V I S O R S

www.medleybrown.com

M&B MSMA Nov'14.indd 1

11/17/14 10:46 AM

Thank you!

Magnolia Health would like to thank the Mississippi Medical Association for its support. Your continuing efforts are helping to build a healthier Mississippi for all of us.

1-866-912-6285 MagnoliaHealthPlan.com 14 JOURNAL MSMA

January 2015

DJà{ TÇÇâtÄ VÉÇyxÜxÇvx Southern Association FOR THE

History of Medicine & Science  JACKSON MARRIOTT

MARCH 12-14, 2015 REGISTER NOW ONLINE

www.SAHMS.net

Co-hosts include the Mississippi State Medical Association, William Carey University College of Osteopathic Medicine, & the University of Mississippi Medical Center.

Keynote: “A Yankee in King Arthur’s and King James’ Mississippi Court” (Douglas R. Bacon, MD). Plus, Bogus Drugs, Quackery, and Rivalry: The Role of the Georgian Apothecary Yellow Peril/Yellow Fever: Disease and Immigration  Diagnosing, Institutionalizing & Financing Mental Illness in the 20th-Century South  Trends in Psychological Diagnoses in the 19th and 20th Centuries: The Case of the South Carolina Lunatic Asylum  Renaissance European Vitalism, Clap & Cures  Fevers, Plagues, and Poisons in German Discourses of Care, 1300-1650  Separate But (Un)equal: Tuberculosis Treatment in Mississippi During the Jim Crow Era  C-Sections, Slavery, Cancer & Contraception in Women’s Health  Sisterhood of Shared Suffering: Enslaved Women as Gynecological Surgical Subjects in Antebellum Alabama  Revisiting Nostalgia: Professional and Popular Understanding of the Psychological Trauma of War During the Civil War and the Spanish-American War  Discoveries During the Cold War  A History of Medicare Financing of Graduate Medical Education: 1965 to Present  Saving Limbs, Saving Lives: The Evolution of Battlefield Medicine of the Last Forty Years This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Mississippi State Medical Association Foundation, Inc. and the Southern Association for the History of Medicine and Science.

The MSMA Foundation, Inc. is accredited by the ACCME to provide continuing medical education for physicians.

The MSMA Foundation, Inc. designates this live activity for a maximum of 25.5 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

January 2015 JOURNAL MSMA 15

• Physician’s Bookshelf • The Goals of Medicine: The Forgotten Issues in Health Care Reform Edited by

Mark J. Hanson and Daniel Callahan Georgetown University Press; Washington D.C. 2000, 256 pp Review by Nabil Baddour, MPH, MS4, William Carey University School of Medicine

“...medicine ought not to become the hireling of societies, existing simply to do their bidding and to put its skills to whatever purpose they may decree. Medicine must have its own vital inner life and its own clear distinction.”

T

he past several years have seen resurgence in discussion about our nation’s health care structure. This culminated most notably in the passage of the PPACA, as well as subsequent and ongoing challenges in the Supreme Court regarding its parameters. Dialogue has centered on the constitutionality of its provisions, as well as debate surrounding the efficacy of the policies it has put forth in both addressing rising health care costs in this country and providing an environment to ensure access for our population.

What has been missing in these discussions is an exploration of the goals of medicine upon which we ultimately base our reforms. With this in mind, The Goals of Medicine: The Forgotten Issues in Health Care Reform is an invaluable contribution to the current discourse. The text was a product of the Hastings Center, a non-profit, independent, and nonpartisan bioethics research center based out of New York. Though published in 1999, it should not dismissed as dated; it addresses universal and timeless questions, and its relevance today is a testament to the quality of its content.

In setting out the premise of their book, editors Mark Hanson and Daniel Callahan state, “It makes no sense to talk about the financing and organization of health care systems unless we understand the purpose of the enterprise.” It is in this context that they set out to explore the goals of medicine as a foundation for that discourse.

To address these questions, the Hastings Center convened an international panel to work on a 4-year project designed to identify a consensus on what the ends of health care should be, and in doing so, set forth priorities for reform moving forward.

Leaders from fourteen countries produced working groups from the fields of medicine, philosophy, theology, public health, administration, and politics (to name only a few). The groups met once a year to discuss their findings, and the results of those meetings form the basis for the first part of the book.

The panel juxtaposes the noble foundations of medicine against the political and economic force it has become, largely as a result of its own unprecedented progress. Among their concerns is a nascent paradigm shift in which “modern scientific medicine seems to have elevated some goals of medicine- its intent to save and preserve life, for instance- over other important goals, such as the relief of suffering and the pursuit of a peaceful death.”

Many of the topics discussed in this seminal portion of the book are not new concepts in ethics. The authors address the power of genetic engineering for example, and ask us to explore the line between what is acceptable for medicine, genetic

16 JOURNAL MSMA

January 2015

screening in prenatal diagnosis for example, against the other more grey areas of genetic enhancement. Their exploration of endof-life care offers one of the more thoughtful and pertinent analyses in the text but, again, is a topic of much current discussion.

In other areas, the topics considered are more nuanced. A discussion on the “Medicalization of Life” asks the reader to consider the place of medicine in addressing problems that are not typically thought of as medical but rather a natural offshoot of the societies in which we live. “If life produces existential anxiety and sadness, as it does, should there be a pharmaceutical remedy?

If societies produce violence and social pathology, should medicine use its knowledge and clinical skills to remedy them? If human nature itself seems flawed, should it be enhanced genetically?”

Elsewhere, they extol the advances brought about by the biomedical research model while also praising public heath constructs that identify social factors including class, income, and education as having a profound impact on incidence and prevalence of disease. In doing so they ask the reader to consider a number of questions: Is the role of medicine to prevent disease or treat disease?

Is it a combination of the two, and if so how should research funding be allocated in order to best address these goals? In this way, the issues posed in the first part of the book unroll effortlessly into a rich tapestry of questions, brilliantly and thoughtfully examined, while leaving the reader to define their own answers, their own view of medicine.

The first portion of the book concludes with consensus recommendations of the working groups regarding four essential goals of medicine: 1) the prevention of disease and injury and the promotion and maintenance of health, 2) the relief of pain and suffering, 3) cure of those with a malady, and care for those who cannot be cured, and 4) the avoidance of premature death and the pursuit of a peaceful death. Thematically, they call for those of us in medicine to take a more pronounced role in defining its future, a future which they suggest should be characterized by a “temperate, prudent medicine” that is “affordable... sustainable...socially sensitive...equitable” and respectful of human choice, and dignity. Although these may seem elementary endpoints, the text that precedes their pronouncement succeeds in dissecting the complex nature of what should and should not be included in each of these declarations. In this vein, considerations regarding financing, distribution, and education all find a place in the discussion.

The second portion of the book consists of a series of relevant essays designed to explore further many of the previously introduced concepts. The diverse nature of the contributors, with each essay assigned to a leader in the respective field, elevates the discussion to a realm not often seen in examinations of medicine and science, drawing on historical, literary, and religious allusions to provide for an engrossing, multidisciplinary, yet largely accessible exploration.

A conceptual framework for health enhancement is introduced against the historical backdrop of Emperor Augustus’ efforts to address water sanitation in the 1st century BC Roman Empire. Medical historian David Gracia utilizes excerpts from the Old Testament and the texts of Hippocrates in creating a narrative to explore the values of medicine. Physician and public health professor Eric Cassel introduces the concept of pain and suffering by relating the myth of Philocetes, a Greek soldier abandoned by his countrymen on the Island of Lemnos after being bitten by a snake. “He is emblematic of the problem of pain and suffering,” Cassell contends, “of pain because of his wound, of suffering because he has been abandoned.” The reintegration of public health and medicine, reform of medical education, and the role of medicine in society, introduced in the first portion of the book, are given additional focus here and explored with effortless prose.

As a whole, the text at times flirts with an excessive philosophical tone, but in most cases this is quickly rectified. The second portion of the book allows the reader to peruse those topics and writing styles that appeal to them and skip those that don’t without losing any narrative place. Editors Daniel Callahan and Mark Hanson, both leaders in their field of bioethics, are well qualified to produce the text, and their examination of the outcome of the international working groups is thought provoking while still offering enough substantive proposals to maintain integrity.

Still, in places it is lacking. A discussion on the role of the market place in health care, for example, effectively explores the doubtless benefits of the market (more than adequately addressing its shortcomings), but the authors stop short of fleshing out any potential solution, offering instead that “the interplay between market theory and ideology with medicine is a crucial and stillunfolding story.” Similar examples of a non-committal stance can be found throughout the text.

In fairness to the authors, however, their purpose was to initiate a much-needed dialogue about the goals of medicine as a context for reform rather than to promote policy. Their position is clear: “The profitability of modern medicine, its capacity to give people that which unaided nature does not give them, and its power to evoke dreams of human transformation sometimes make it exceedingly hard for medicine to find its own way.” But they urge that way can be found “if medicine begins with its own history and traditions, and continually returns to its original impetus.”

For those looking for a text full of concrete solutions, this book is unlikely to quench your thirst. For anyone interested in questions of why health care policy is such a complex and treacherous road, The Goals of Medicine: The Forgotten Issues in Healthcare Reform is an indispensable starting point. r

January 2015 JOURNAL MSMA 17

18 JOURNAL MSMA

January 2015

• MSMA •

Avoid the Social Networks: A Mobile Communication Platform Should Provide a Secure, Efficient Workflow Tracey Haas, DO, MPH; Chief Medical Officer, DocbookMD

Mobile communication is an integral and growing part of every aspect of modem life, including health care. Fast and secure communication among care team members can measurably improve clinical efficiency as well as patient outcomes - this is a given. In addition, federal and state requirements for electronic health record-keeping are pushing many medical professionals to aggressively begin updating and integrating their electronic health records and communications.

However, many physicians and health care organizations still rely on multiple technologies and information systems for their communications. The time it takes to monitor multiple communication portals can take away from time spent with patients and can allow important messages to slip through.

The Problem Several products are on the market to address the need for HIPAA-compliant mobile messaging among medical professionals. However, many of these solutions have serious flaws: They are social networks that make their money by selling physicians’ information to recruiters, or they are siloed solutions that only help those who work inside a hospital system. Physicians need a mobile communication solution that is not only HIPAA-secure but also shields their personal information and works regardless of practice type or location.

The Solution The ideal messaging application for health care providers should include: • Efficient and instantaneous physician-to-physician communication; • A secure community to share patient information and collaborate with medical colleagues, in a HIPAA-secure manner; • Ability to send medical images securely between physicians; • Built-in local physician and pharmacy directories; • Ability to scale from small groups to hospitals, all the way to large multi-enterprise organizations like ACOs; • Widespread adoption among medical professionals; • Availability across platforms including smartphones, tablets and the Web; • Data that reside on secure servers, not users’ devices; • Ability to remotely disable the app on a device that has been lost or stolen; • Long-term message archive compliant with HITECH recommendations; and • Ability to integrate with other health IT solutions.

When all the information is at a physician’s fingertips, faster and richer discussions on patient treatment and care can result. Also, with local physician and pharmacy directories built into a secure messaging app, the time physicians spend finding colleagues or tracking down a local pharmacy is cut from hours to minutes.

January 2015 JOURNAL MSMA 19

A Secure Gateway The only HIPAA-secure instant messaging application that meets all these requirements is DocbookMD. Designed by physicians, for physicians, it creates a secure community to share patient information and collaborate with medical colleagues as well as third-party services such as radiology, labs, answering services, even health plans.

Dr. Tim Gueramy and I began developing DocbookMD out of our own need for more efficient and instantaneous physicianto physician and physician-to-care team communication. Since then, DocbookMD has experienced incredible growth, now serving more than 25,000 physician users across 42 states, including Mississippi.

In addition, DocbookMD offers CareTeam, a feature that allows physicians to invite members of the patient’s direct care team – including nurses, PAs, administrators, care coordinators, and other staff - to join them on DocbookMD to communicate in a secure, fast and efficient way through their mobile devices.

DocbookMD is a free benefit of membership in the Mississippi State Medical Association.

Use Cases With DocbookMD, health care providers of all kinds can communicate with colleagues rapidly and securely, with the confidence that their privacy and data integrity will be maintained. Here are some exemplary use cases based on users’ testimonials: • A dermatologist can send the ENT surgeon an image of a complicated skin lesion to be removed. The surgeon is able to make a more efficient plan for surgery and reconstruction ahead of time.

• A family doctor in a rural area can collaborate over X-rays with an orthopedic surgeon in the nearest city. The specialist is able to determine if an urgent surgery or just a cast is necessary, saving the patient time, extra office visits, and travel.

• A radiologist can communicate test results immediately to the ordering physician who can, in turn, notify the patient and bring in for treatment, if needed, much more quickly.

• An emergency physician is able to rapidly receive and send messages, images, and test results to consultants and referring doctors during a busy shift. They are also able to coordinate transfer of care with outpatient primary care or inpatient hospitalists, thereby streamlining transitional patient care and closing the loop on any ER visit.

Physicians report improved workflow with the ability to do the same work in far less time. For example, a traveling cardiologist’s assistant can send the doctor lower extremity Doppler studies and EKGs for a patient who may be hundreds of miles away. The cardiologist is able to make treatment decisions without having to return, and the patient receives much quicker and more responsive care.

Selecting a Platform Ultimately, when choosing a secure instant messaging application for medical communications, physicians and health care organizations must carefully consider their professional needs as well as the potential to improve patient care. What features are absolute must-haves? What app characteristics would eliminate an app from consideration? Is the solution scalable? Is it cost-effective? Can it be integrated into existing health IT solutions?

Answering these questions and others will help physicians evaluate messaging apps and select the right fit for their organizations. A HIPAA-secure mobile medical communication solution should put physicians firmly in control of whom they connect with and who can send messages to them. Any other model opens physicians up to unwanted contacts and wasted time.

DocBookMD partners with MSMA to bring members a free, HIPAA-secure messaging app that uniquely provides extra security to Mississippi physicians. r 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. DocBookMD is available in Mississippi only to actively practicing MSMA members. Membership is open to any MD or DO licensed to practice in Mississippi.

20 JOURNAL MSMA

January 2015

• Legal Ease • MS UR: An All-but-Forgotten Law Pushed by MSMA Dusted Off as Use of Utilization Review Increases

M

J. Conner Reeves, MSMA General Counsel

any Mississippi physicians have encountered utilization review procedures at some point in their practice. UR can often be an exceptionally sore subject for physicians who see a large number of Medicaid patients. In this environment of excessive UR and pre-authorization procedures, it is important that physicians (and insurance companies) know about existing laws intended to protect physician’s rights.

Existing Law One such law provides that UR must be conducted by a physician licensed to practice in Mississippi and, if requested, by a physician trained in the same specialty or sub-specialty as the submitting physician (see below). Additionally, the physician has the right to discuss any adverse determinations with the reviewing physician, but the submitting physician must make this request.

MSBML Safeguards These important requirements ensure that claim denials are being reviewed by physicians who are in good standing with the State Board of Medical Licensure and who will be held accountable in Mississippi for any rules violations. Additionally, this law safeguards against claims being reviewed by physicians who may lack knowledge about a particular practice area. Yet, these protections aren’t automatic. Physicians must proactively engage with UR programs to receive some of the benefits of this law.

Reducing Rejected Claims Though physicians may experience problems with UR companies, some complications can be moderated through physician action, says Thomas Joiner, MD, who works for a UR company in Jackson, Mississippi. Dr. Joiner explains that one such approach is to increase physician/staff communications regarding treatment and procedures. By providing staff with additional details to include in UR requests, UR companies will have fewer reasons to reject the claim based on inadequate paperwork.

High rates of office staff turnover or absences may contribute to complaints associated with UR because inexperienced staff may unknowingly omit pertinent information on submissions. Physicians can also reduce headaches associated with UR by discussing rejected claims with the reviewing physician and determining if repeated rejections are the result of serial submission errors.

If you have any questions regarding this law or other laws and regulations, please contact Conner Reeves at 601-853-6733.

MS Code § 41-83-31 (2013)

Any program of utilization review with regard to hospital, medical or other health-care services provided in this state shall comply with the following: (a) No determination adverse to a patient or to any affected health-care provider shall be made on any question relating to the necessity or justification for any form of hospital, medical or other health-care services without prior evaluation and concurrence in the adverse determination by a physician licensed to practice in Mississippi. The physician who made the adverse determination shall discuss the reasons for any adverse determination with the affected health-care provider, if the provider so requests. The physician shall comply with this request within fourteen (14) calendar days of being notified of a request. Adverse determination by a physician shall not be grounds for any disciplinary action against the physician by the State Board of Medical Licensure. (b) Any determination regarding hospital, medical or other health-care services rendered or to be rendered to a patient which may result in a denial of third-party reimbursement or a denial of precertification for that service shall include the evaluation, findings and concurrence of a physician trained in the relevant specialty or subspecialty, if requested by the patient’s physician, to make a final determination that care rendered or to be rendered was, is, or may be medically inappropriate.

January 2015 JOURNAL MSMA 21

• New Members • ALLMAN, RUSSELL ELBEY, Gulfport;

HOMSOMBATH, BOUNTHAVY, Jackson;

Diagnostic Radiology

General Surgery

AZMI, SYED SHEHZAD, Southaven; Medical Oncology

HUNTER, STEPHEN EUGENE, Louisville; Emergency Medicine

BELL, WILLIAM B., Jackson; Orthopedic Surgery BROWN, JAMES JAY, Jackson; Ophthalmology BROOKS, JOHN CARL, Pearl; Emergency Medicine BURGESS, DERRICK, Laurel; Orthopedic Surgery BUTTS, D. WAYNE, Pontotoc; Emergency Medicine CAMPBELL, JAMES, Gulfport; Gastroenterology

INGELMO, CHRISTOPHER P., Oxford; Electrophysiology JOHNSON, ERIC, Oxford; Electrophysiology JOHNSON, HOLLYE R., Jackson; Neurology JONES, MELISSA, Natchez; Obstetrics & Gynecology KABIR, AZAD, Biloxi; Internal Medicine

CANTRELL, JOHN AARON, Tupelo; Emergency Medicine

KELLER, VERN ANTOINE, Jackson;

CARBAJAL, SCOTT ANDREW, Tupelo; Diagnostic Radiology

LAFFERTY, CASEY ELIZABETH, Meridian;

Cardiothoracic Surgery

Family Medicine CHEEMA, QASIM, Jackson; Cardiovascular Disease LESSMANN, ERIK PAUL, Indianola; Family Medicine DAVIS, GARY M., Jackson; Nephrology LIMANSKY, JOHN MICHAEL, Jackson; DECKER, CHRISTOPHER HALE, Tupelo; Gastroenterology FERGUSON, EDWARD, Tupelo; Cardiovascular Disease GATLIN, J. LUKE, Jackson; Radiology GENTRY, JAMES D., Louisville; Family Medicine GRAY, DAVID J., Hattiesburg; Plastic Surgery

Internal Medicine MAGEE, MICHAEL JOSEPH, Southaven; Hematology/ Oncology MARCOS-RAYMUNDO, LUIS A., Hattiesburg; Infectious Disease MATTHEWS, EMILY KATE, Meridian; Diabetes MAY, JUSTIN ANTHONY, Oxford;

GREASER, RAYMOND DALE, Oxford; Anesthesiology

Cardiovascular Disease

GREWAL, GAGANDEEP SINGH, Hattiesburg;

MCINTOSH, NATHAN P., Madison;

Internal Medicine 22 JOURNAL MSMA

January 2015

Emergency Medicine

MCCALLUM, DANIEL M., Natchez;

SERIO, NAHUM VALENTINO, Hattiesburg;

Orthopedic Surgery

Emergency Medicine

MCINTOSH, NATHAN P., Madison;

SHIPP, LYNDSAY R., Oxford; Internal Medicine

Emergency Medicine SKELTON, TIMOTHY BENJAMIN, Biloxi; MELOELAIN, JAMIL ALI, Meridian; Internal Medicine

Internal Medicine

MILES, SONYA MITCHELL, Tupelo; Ophthalmology

SMITH, JUDITH WILSON, Biloxi; Orthopedic Surgery

MIR, HAARIS, Jackson; General Surgery

SMITH, TAYLOR F., Jackson; Ophthalmology

MONTZ, NANCY COLETTE, Biloxi; Internal Medicine

STEVENS, MATTHEW SCOTT, Tupelo; Otolaryngology

MOORE, WILLIAM, Ocean Springs;

SWIFT, CHRISTOPHER, Meridian; Internal Medicine

Obstetrics & Gynecology TARBUTTON, GEORGE LESTER, Laurel; MUENCH, RICHARD J, Flowood; Anesthesiology

Occupational Medicine

MYERS, JESSICA LEIGH, Philadelphia;

TAYLOR, DAVID PROVOSTY, Gulfport;

Emergency Medicine

Obstetrics & Gynecology

OLUTADE, TUNDE, Jackson; Nephrology

THERRIEN, DAVID S., Oxford; General Surgery

OLUTADE, BABATUNDE OLUSINA, Jackson;

TINCHER, STEVEN W., Canton; Internal Medicine

Internal Medicine TROTTER, TIMOTHY, Vicksburg; Thoracic Surgery PATLOLA, RAGHOTHAM R., Hattiesburg; Internal Medicine

TUREL, BURGESE KEKI, Laurel; Internal Medicine

RALPH, JERMAINE, Meridian; Gastroenterology

TURNER, LINDSEY M., Flowood; Obstetrics & Gynecology

RAO, ARUN R, Southaven; Hematology/Oncology TURNER, D. MICHAEL, Amory; REED, RUSSELL J., Ocean Springs;

Obstetrics & Gynecology

Cardiovascular Disease VIDWAN, SIMARPREET KAUR, Olive Branch; REYNOLDS, JOEL C., Meridian; Nephrology

Family Medicine

RICHIE, HEATHER L., Hattiesburg; Internal Medicine

WOODALL, JAMES W., Jackson; Orthopedic Surgery

ROSE, ELIZABETH R., Hattiesburg; Diabetes

WOODSON, ANNA, Columbus; Dermatology

SCALISE, PETER P., Meridian; Cardiovascular Disease

January 2015 JOURNAL MSMA 23

• In Memoriam • The JMSMA encourages families, friends, and our readers to submit obituaries and photos of Mississippi physicians for inclusion in the pages of our Journal. Email to kevers@msmaonline.com or slow mail to JMSMA. —Ed. Claude L. Austin, MD Hattiesburg Dr. C. L. Austin, MD, age 95, of Hattiesburg, passed away at his home on February 20th, 2014, and was buried at Roseland Cemetery. A native of Montgomery County, Dr. Austin was born on January 4th, 1919, in Winona. He attended the University of Mississippi and then went on to medical school at Jefferson Medical College in Philadelphia, PA. Growing up as one of eleven children, Dr. Austin was torn between becoming a minister or a doctor. He briefly followed his mother’s footsteps teaching high school Biology in Lexington. Ultimately, he decided he could help more people by becoming a physician. He moved to Hattiesburg in 1947 to practice medicine and shared an office with his father-in-law, Dr. C. C. Hightower, Sr. He opened his own practice in the early 1950’s and later opened Medical Plaza where he lovingly cared for his patients until 1991.

Dr. Austin loved being out on the open sea riding the waves and spent every weekend possible at his camp on the coast until he moved there permanently in the early 90’s.

Anyone who knew Dr. Austin knew of his heart to help those who struggled with addiction. Upon retiring, he served on the board of directors at the Home of Grace in Vancleave and helped develop the first on-campus volunteer medical clinic there, volunteering as a physician for 15 years. Even at the age of 94, he was driving 85 miles one way, once a week, to the Home of Grace for his Monday shift at the clinic. Along with a passion to help those struggling with addiction was a passion to prevent addiction by educating young people. He invented and funded the DAAPE (Drug and Alcohol Awareness Prevention Education) mobile, which is a mobile art exhibit in a converted school bus that fully illustrates the devastating effects of addiction and has been viewed by hundreds of students across the Gulf Coast region.

Dr. Austin is survived by his wife of 23 years, Merry Lowry Austin of Hattiesburg; son Richard Austin of Hattiesburg, stepson Dr. Michael Lowry (Charlotte) of Overland Park, KS, stepdaughters Deborah Lowry Rice (Randy) of Hattiesburg, Merry Lynn Donner (Steve) of Van Nuys, CA, and Lisa Lowry Howell (Jimmy) of Hattiesburg; four grandchildren, Christie Austin Christenson of St. Petersburg, FL., Leigh Ann Hightower Cannon of Tampa, FL., Shelley Paige Austin, and Laurie Austin Kittrell both of Hattiesburg. Also, 13 grandchildren from his marriage to Merry Austin, Haley Rice Wachdorf of San Antonio, TX,

24 JOURNAL MSMA

January 2015

Aaron Randall Rice of Jackson, Charles Ryan Rice of Austin, TX, Hannah Rice Meigs of Nashville, TN, Audrey Rice Milam of Birmingham, AL, Shelley Howell Wood, Lauren Ashley Howell, Lindsay Michelle Howell, and Courtney Nicole Howell of Hattiesburg, Matthew Ian Lowry of Oxford, Adrain Michelle Lowry of Hattiesburg, Kristin Brown Lanz of Houston, TX, and Caroline Brown Jones of Baltimore, MD, and 15 great grandchildren. He was preceded in death by his parents, Luther Barksdale Austin and Cora Claudine Austin, his first wife of 47 years, Elizabeth (Libba) Hightower Austin, and his son Larry Austin. He was truly an extraordinary man who deeply loved his family and spent his life serving humanity and the Lord. He will be greatly missed by all who knew him. The family requests that memorials be made to: Home of Grace, Donor Services, PO Box 5009, Vancleave, MS 39565 (Include the memo “Donation”).

Durward L. Blakey, MD Raymond Dr. Durward Lacey Blakey, 92, passed away on Saturday, December 6, 2014, at Hospice Ministries in Ridgeland, Mississippi. Burial was at Raymond Cemetery. Dr. Blakey was born in Paxton, FL on March 31, 1922, to Claude C. and Katie Marie Blakey.

He grew up in Florala, AL, and after graduating Florala High School earned his BA in Pre-Med at the University of Alabama in Tuscaloosa and went on to graduate as a Doctor of Medicine at Louisiana State University in New Orleans. It was in New Orleans that he met his wife to be, Rosemary Nichols of McComb. Upon finishing his internship at Jefferson-Hillman Hospital in Birmingham, he and Rosemary returned to Mississippi where he served the State Department of Public Health for one year. During this time they were blessed with a son, Kenneth Tyler. In 1948 his call into the U.S. Army came. He was stationed at Fort Sam Houston in TX and Camp Chaffee, AR, before being posted to Japan in 1949. His wife and son joined him there and after a wonderful year, just prior to their return home, his orders were cancelled. War broke out in Korea where Dr. Blakey was assigned, and he served two years on the front lines with the 8055 Mobile Army Surgical Hospital (MASH) achieving the rank of Major. These doctors and nurses saved countless lives and laid the foundation for all modern ER procedures today.

Rosemary and Kenneth stayed in Japan another year before returning to Mississippi where Dr. Blakey joined them after his discharge.

Following the war, Dr. Blakey accepted the position as Director of the Coahoma County Health Department in Clarksdale. The Blakeys enjoyed life in Clarksdale for six years and were active in church and civic affairs. As president of the Civic Music Association, Dr. and Mrs. Blakey were privileged to have the artists and musicians who performed there as guests in their home. In 1956/57 he furthered his education by earning his Masters Degree in Public Health at Tulane University in New Orleans and was then asked to join the Mississippi Department of Public Health in Jackson where he acted as Director of the Division of Preventable Disease and State Epidemiologist until his retirement in 1989. The new position in Jackson brought the Blakey family to Raymond in 1957 where they made their permanent home, and they joined the Raymond Methodist Church at the behest of Pastor Clay Lee. During these years, Dr. Blakey served as Associate Clinical Professor of Public Health at The University of Mississippi Medical Center in Jackson. He served as Director of numerous health programs including Chronic Disease, Immunization, Diabetes, Cardiovascular and Migrant Laborer Advisory Committees, to name a few, and was widely published in state and national medical publications. Dr. Blakey was preceded in death by his parents Claude C. and Katie Marie Blakey, and his brother Carroll Blakey. He is survived by his wife Rosemary Blakey; son Kenneth Tyler Blakey; and grandson Noah Jon Blakey. It was his wish that memorials be made to Gateway Mission or the Salvation Army.

Rex Wilson Collins, MD Laurel Rex Wilson Collins passed away on January 1, 2015, following a brief illness. A native of Houston, MS, Rex attended Houston High School and the University of Mississippi. He graduated from the University of Mississippi Medical Center in 1963 and completed a rotating internship at the Duval Medical Center in Jacksonville, Florida. He did his dermatology residency at the University Hospital in Little Rock, Arkansas, from 1966-1969 and practiced dermatology in Laurel for thirty years. He was a member of the First Baptist Church of Laurel and enjoyed hunting, fishing, and reading.

Rex was a loving husband, father, and grandfather, who enjoyed spending time with his family and friends. He will be greatly missed.

He was preceded in death by his wife of 54 years, Mary Moore Collins.

He is survived by his son, William Scott Collins of Long Beach; daughter, Angela Collins LaPorte and husband, Reid of Birmingham, Alabama; and five grandchildren, Ross LaPorte, Rhett LaPorte, Eric LaPorte, Melanie LaPorte, and Maren LaPorte, all of Birmingham, Alabama.

In lieu of flowers, memorials may be made to the Laurel Animal Rescue League, P. O. Box 2671, Laurel, MS 39442.

William Lynch, Jr., MD Madison Dr. William (Bill) Frederick Lynch, Jr., age 81, died in his home on February 1, 2015, in Ridgeland, Mississippi.

Bill was born January 30, 1934, in Jackson, Mississippi, the son of William Frederick Lynch and Frances Evelyn Howie. Bill is the nephew of Edgar Howie, who lived with Bill’s family after his father passed away when Bill was 6 years old. Bill graduated from Jackson Central High School in 1952 where he was elected to the All Big 8 Football Conference and was a scholar athlete. Bill was elected Most Handsome of the class of 1952. Bill went on to attend Millsaps College where he was a member of the Kappa Alpha fraternity.

After college, Bill attended medical school where he was a member of the first 4-year graduating class of the University of Jackson (later becoming UMMC). Bill graduated as one of the top 3 in his medical school class and was a member of Phi Chi fraternity. He was also a member of Alpha Mu Medical Honor Society, AOA Honor Society, Guardian Society, and he was chosen to receive the Mosby Scholastic Excellence Award.

While in medical school, Bill married Mary Gwen Wilson.

Soon after, Bill and Gwen had children - Mary Frances Lynch and William Frederick Lynch, III. After medical school, Bill joined the Navy where he served for 10 years. He was initially stationed in Balboa Naval Hospital in San Diego where he received training and took part in a vascular fellowship. Bill and his family then moved to Pensacola, FL, where he completed his flight surgeon training.

In 1960, Bill and Gwen had twin boys - James Wilson Lynch and John Edgar Lynch- before he was sent to Vietnam where he served for 13 months with the Marine Helicopter Squadron.

During his service in Vietnam, Bill received the Naval Commendation Medal.

After Vietnam, Bill and his family moved to New York where he trained as a radiologist for 3 years. While in New York, their youngest son - Thomas Howie Lynch - was born.

Following his training in New York, Bill moved back to San Diego with his wife and 5 children. After serving for 3 years in San Diego, Bill retired as a lieutenant in the Navy and a Board Certified Radiologist.

Upon retiring from the Navy, Bill and his family moved back to Jackson, MS, where he began working with the Central Mississippi Medical Center. After working for 35 year with CMMC hospital, Bill retired and began serving as an associate professor with the UMMC Neuro-Radiology Department.

Bill enjoyed spending time with his family, reading, and playing sports. He coached little league baseball, was an avid boater, and an excellent racquetball player. He was a member of Madison United Methodist Church, a founder of The Courthouse, and a member of Annandale Golf Club.

January 2015 JOURNAL MSMA 25

Bill was preceeded in death by his parents and his son William Frederick Lynch, III. Bill is survived by his wife of 60 years, Mary Gwen Wilson Lynch of Jackson; his daughter, Mary Frances Lynch Turner (Rick) of Jackson; his daughter-in-law, Cindy Lynch Barth of Ridgeland; his son, James Wilson Lynch of New Orleans; his son, John Edgar Lynch (Helen) of Brookhaven; his son, Thomas Howie Lynch (Lisa) of Baton Rouge; his sister,Frances Lynch Van Zant of Jackson; 10 grandchildren; Rachel Turner Wilkins (Lloyd) of Jackson; William Frederick Lynch, IV of Jackson; Ryan Walker Lynch of Jackson; Grady Wilson Lynch (Rachael) of Ridgeland; Amanda Lynch Williams (Alan) of San Antonio, Texas; Mary Gwen Lynch Sagen (Scott) of New York City, New York; John Edgar Lynch, Jr. of New York City, New York; Betsy Lynch Hood (Stewart) of Jackson; William Cole Lynch of Jackson; Taylor Melissa Lynch of Morton; and 5 great-grandchildren.

The family requests that memorials be sent to The 1848 Society - University of MS Medical Center in remembrance of William Frederick Lynch, III, or the charity of your choice.

Howard Hunter Nichols, MD Ridgeland Dr. Howard Hunter Nichols died peacefully January 24, 2015, at The Orchard in Ridgeland, 12 days after the death of his wife and soulmate of 70 years, Betty Jane Martin Nichols. He was a beloved father, grandfather, greatgrandfather, brother, uncle and physician to generations of children and families in Mississippi.

Dr. Nichols was born October 27, 1922, in Nashville, TN, to Ruth Blakemore and Sidney Howard Nichols. He attended Duncan School in Nashville, where he was class president. He received both his BA and MD degrees from Vanderbilt University. He did his pediatric residency at Children’s Hospital in Boston, MA. He served as a captain in the Medical Corps during World War II and the Korean War. Dr. Nichols was the personal military physician to General Joseph Stillwell and Major General Frank Merrill of Merrill’s Marauders.

On July 1, 1946, he married Betty Jane Martin, the love of his life, and in 1953, they moved to Jackson. Together they were founding members, teachers and ruling elders of Covenant Presbyterian Church. They have been members of Briarwood Presbyterian Church since 2008. Dr. Nichols practiced pediatrics with the Children’s Clinic of Jackson 1953-1984. He was Chief of Staff at MS Baptist Medical Center and after retiring from private practice, he served as the Director of the Outpatient Pediatric Clinics at University Medical Center. In 1986, senior medical students chose him as the Clinical Professor of the Year, the highest teaching honor at the University. From 1972-1992 he was Examiner and

26 JOURNAL MSMA

January 2015

Vice-President of the American Board of Pediatrics, and he served as the pediatric representative on the American Board of Family Practice.

Dr. Nichols was a Board Member of the Mississippi Symphony and the United Way of Jackson. For many years, he was a reader to the blind for Radio Reading Service of Mississippi. He led devotional services at Lakeland Health Center.

“Dr. Nick,” as he was affectionately known, loved children and was an advocate for their health and well-being, physically, emotionally and spiritually. After long days in the hospital and office, he often made house calls in the evening to those who could not afford medical care. He championed the Head Start program in Mississippi and tirelessly worked for the adoption of the Child Safety Restraint Law. He was preceded in death by his parents; wife; son, Howard Hunter Nichols; brother, Robert and nephews, Marshall and Mike Nichols. He is survived by his children Nancy McCurley (Tom) of Nashville, TN and Janie Nichols of Columbus, GA. Dr. Nichols is also survive by grandchildren, Joseph and Katrine McCurley of Oslo, Norway and Greer and Sarah McCurley of Lincoln, NE. He was great grandfather to Markus and Kaya, Olivia and Thomas McCurley. He is survived by brother, Allen (Dot) Nichols of Nashville TN; brothers-and sisters-in laws, Raymond and Margery Martin of Jackson MS and Ed and Hazel Martin of Lake Charles, LA, and numerous nieces and nephews. In lieu of flowers, the family requests any memorial gifts be given to Stewpot Ministries Prescription Fund established in his honor by his grandson.

Lee H. Rogers, MD Tupelo Dr. Lee Hartwell Rogers, 80, of Tupelo, Mississippi, died Sunday, February 8, 2015, at Sanctuary Hospice House in Tupelo. He was born in New Albany, Mississippi, on December 29, 1934, to Leander Sims Rogers (“Lee”) and Lucy Spencer Rogers. He was a graduate of New Albany High School, the University of Mississippi, and University of Mississippi Medical School. He received pre-residency training in Ophthalmology at Harvard Medical School in Boston.

He completed his surgical internship and his residency in Ophthalmology at the University of Tennessee in Memphis, TN. He served in the U.S. Public Health Service and the U.S. Coast Guard for two years. Dr. Rogers joined Dr. Leighton Pettis and Dr. Tom Wesson at Tupelo Eye Center in 1969 where he practiced ophthalmology until his retirement in 2000. His 31 year career of service to the medical community allowed him to better the lives and vision of many patients in North Mississippi. He served as chief of staff at North Mississippi Medical Center in 1985. He also worked to

improve medical care in Mississippi by actively participating in the Mississippi State Medical Association throughout his career and retirement, serving as Chairman of the Board of Trustees of the state medical association. He also served as President of Northeast Mississippi Medical Society and was elected Councilor of the Southern Medical Association.

He was President of the University of Mississippi Medical Center Alumni and a member of The Guardian Society. He was a member of the American Medical Association and the American Academy of Ophthalmology. A devoted Christian and dedicated member of First United Methodist Church, he served as an usher, Sunday school teacher and on the administrative board. He was a proud Eagle Scout and worked as an advisor with Boy Scout Troop 12 and Camp Yocona. He was an active member of the Sigma Chi Alumni Association.

He served as President of Tupelo Rotary Club, was selected as Rotarian of the Year 2009, and was a Paul Harris Fellow. His kind heart, keen wit, and quick smile uplifted the lives of his family, patients, and many friends.

A loving husband, father, and grandfather, he is survived by his wife of 44 years, Merrell Liveakos Rogers; daughter, Sims Rogers Polk (Chad) of Nashville, Tennessee; and son Lee Hartwell Rogers, Jr. (Kate) of Nashville Tennessee; sister Ann Rogers Dillard (John) of Memphis, TN; grandchildren Bentley Polk, Knox Polk, Jack Rogers, Gus Rogers, and Margaret Rogers; brother in law Richard Liveakos (Gloria Lind) of Pensacola, Florida, and sister in law Laura Liveakos Collatrella of Tupelo. He was preceded in death by his parents.

Memorials may be made to Sanctuary Hospice House; PO Box 2177; Tupelo, MS 38803 or Rotary Foundation; PO Box 1143; Tupelo, MS 38802 or First United Methodist Church; 412 West Main; Tupelo, MS 38801.

The PEN is greater than the SWORD

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.

We specialize in the business of healthcare • • • • • • • •

Comprehensive Management Comprehensive Consulting Billing & Accounts Receivable Management Coding & Documentation Practice Assessments & Revenue Enhancement Profitability Improvement Practice Start-ups Personnel Management

1600 North State Street Suite 400 Jackson, MS 39202 Telephone: 601.944.1717 WATS: 1.800.355.4231 www.mpsbilling.com

OR PRINT or ONLINE The choice is yours...

F

ree online access to the Journal MSMA is available to current members of the Association. If you would prefer to receive only the online version and not the print version of the JMSMA let us know. If you would like to opt out of receiving the print version, please contact Managing Editor Karen Evers, KEvers@MSMAonline.com or 601.853.6733, ext. 323.

The price for membership will not change whether you wish to receive the print version or not.

January 2015 JOURNAL MSMA 27

• Poetry and Medicine • [This month, we print a poem submitted by Charles D. Guess, MD, a family physician and widely known artist now of Madison. Charles grew up in McComb as a close friend of the prominent Gillis family. Pharmacist Norman Gillis, Sr., born in Fayette in 1907, established Gillis Drug Store in downtown McComb in 1939. The establishment was a popular preWorld War II drug store, containing a full soda fountain. Serving sandwiches, colas, and ice cream, the store was the social hub of the community. Mr. Gillis was known to reward the local football team’s success as champions with a free chocolate milkshake for every player, a coveted treat in the McComb of that era. Gillis was also known as a generous and competent pharmacist, providing medications at no charge for black and white customers unable to pay. As a pharmacist and as a partner to the local physicians, Gillis understood the dependence and desire of patients for a magic pill to cure any illness or ache. He wrote this poem over 50 years ago reflecting on that wonderful “Little Pill.” Besides his pharmacy career, he was involved in multiple business side-lines, including large construction projects such as the Grenada Dam (1945) and levees on the Mississippi River. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.]—Ed.

Little Pill Little pill, here in my hand, I wonder how you understand Just what to do or where to go, To stop the ache that hurts me so?

Within your covering lies relief, You work alone in unbelief.

You sink in regions there below, And down my throat you quickly go!

But what I wonder little pill, How do you know where I am ill?

And just how do you really know Just where you are supposed to go?

I’ve got a headache that is true, My broken ribs need attention too.

So how can anything so small, End my aches in no time at all?

Do you work alone or hire a crew To do the good things that you do?

I’m counting on you mighty strong, To get in there where you belong.

Don’t let me down and please don’t shirk, But do your undercover work; Go down my throat and on your way, And end my aches another day.

Don’t make a wrong turn is my plea, Cause I can’t take another til after three!

—Norman Gillis, McComb (1907-1984)

28 JOURNAL MSMA

January 2015

What’s Your Specialty?

Our specialty is NETWORKING...

TPAs Physicians

Hospitals

M

I

S

S

I

S

S

I

P

P

I

Physicians Care N E T W O R K

Employer Groups

Ancillary Providers Insurance Companies

MPCN - THE OBVIOUS CHOICE Change Networks. Not Doctors.

601-605-4756 • www.mpcn-ms.com Sponsored by the Mississippi State Medical Association

PARTICIPATE IN MSMA’S DOCTOR OF THE DAY PROGRAM

Every year, MSMA staffs the Capitol Medical Unit during the legislative session with a full time nurse and a volunteer physician each day. The Doctor of the Day program runs from January through March and allows MSMA members to participate in the legislative process by being front and center at the state capitol. Doctors of the Day are only asked to provide minimal health care services to legislators and capitol staff. Doctors of the Day volunteer for half days on Monday and Friday while Tuesday, Wednesday, and Thursday are full day commitments. As Doctor of the Day, you will be introduced in the House and Senate chambers by your local legislators and thanked for your service. This is a perfect opportunity to not only “give back,” but have valuable personal time with your legislator and voice support for pro-medicine policies.

To participate in MSMA’s Doctor of the Day program, please use the interactive calendar found on MSMAonline.com. please contact Blake Bell at BBell@MSMAonline.com.