VOL. 57 NO. 1 2016 JMSMA by Journal MSMA

VOL. LVII • NO. 1 • 2016

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VOL. LVII • NO. 1 • JANUARY 2016

EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD

THE ASSOCIATION President Daniel P. Edney, MD President-Elect Lee Voulters, MD

SCIENTIFIC ARTICLES Top 10 Facts You Need to Know about Zika Virus Svenja J. Albrecht MD, MPH and Rathel L. Nolan, MD, MPH

A Case of Freeman–Sheldon Syndrome: Anesthetic Challenges Thomas Hamilton, MD and Madhankumar Sathyamoorthy, MBBS, MS

DEPARTMENTS From the Editor – Physician Heal Thyself Lucius M. Lampton, MD; Editor

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Michael Mansour, MD

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

Speaker Geri Lee Weiland, MD

President's Page – The Myth of the Invincible Doctor Daniel P. Edney, MD; MSMA President

Vice Speaker Jeffrey A. Morris, MD

Letters– State Opposition to Obamacare Not Based on Race

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Executive Director Charmain Kanosky

Una Voce – Medicine and Melancholy Dwalia S. South, MD POSTER INSERT Public Health Report Card 2016

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 © 2016 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

Physicians’ Health Corner Scott Hambleton, MD; MPHP Medical Director

RELATED ORGANIZATIONS World Health Organization– Mississippi Physicians Support Goal to Reduce Premature Mortality: 20 x25 Target

Mississippi State Department of Health– Infant Mortality Rates Reach All-Time Low in 2014

University of Mississippi Medical Center– Jackson Heart Study

American Medical Association– STEPS Forward™

ASCLEPIAD John C. Neill, MD; Jackson

ABOUT THE COVER

“Three certainties of life: Death, Taxes…and Obamacare?”– America’s changing political climate makes the future of the Affordable Care Act about as murky as our cover photo. A recent USA Today article reported the number of people who signed up for health insurance for 2016 on the state and federal exchanges was up to 40% lower than earlier government and private estimates, which some say is evidence that the plans are too expensive and that people would rather pay a penalty than buy them. Our patients and our profession have come to regard the program as either a boon or a boondoggle. This storefront caught the attention of Dr. Stanley Hartness as he and his family were leaving Canton’s “City of Lights.” n VOL. LVII • NO. 1 • 2016

JOURNAL MSMA

F R O M

T H E

E D I T O R

Physician Heal Thyself

Physicians are members of a profession whose “master-word” is work, to quote Sir William Osler. Thus, it is not surprising that burnout has been a hazard of the trade since Hippocrates and Galen. Dr. Osler, too, confronted the dangers of what he termed in the early twentieth century the “bogie of overwork.” He perceived the solution as the proper organization of and attention to work and life habits, what we now call work-life balance. Good diet, exercise, sleep, and a cheerful disposition were specifically mentioned in his recommendations to physicians. He also advised that marrying the right person was perhaps the most important decision one would make, citing the role of family life and support as central to a physician’s success. As well, he encouraged all physicians to pursue an avocation or hobby which would provide a needed sanctuary away from work. He concluded, “Habits which favor the corpus sanum foster the mens sana, in which the joy of living and the joy of working are blended in one harmony.” Translated from the Latin: habits which favor the healthy body foster the healthy mind.

Research shows that close to 40% of U.S. physicians suffer from burnout. Physician wellness experts recommend that every physician should prioritize what they value and arrange their lives around those priorities. Other recommendations are: learning to say “no” to certain tasks; including some weekly “down-time” just to “be” without always having to “do”; and focusing on self-care, i.e. getting enough sleep and exercise. This special issue of JMSMA focuses on physician wellness. Be sure to read Dr. Dan Edney’s superb President’s Page, “The Myth of the Invincible Doctor,” as well as Dr. Scott Hambleton’s and Dr. Dwalia South’s excellent essays. Also in this issue is our annual Public Health Report Card. Good things are happening in Mississippi, with infant mortality dropping, obesity leveling off, and vaccination rates at a national high. There is still so much work to be done, and physicians remain indispensable in the quest to advance Mississippi’s public health. Let’s improve physician wellness so our physicians can better care for their patients. Contact me at LukeLampton@cableone.net. — Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of Mississippi Medical Center, Jackson Rep. Sidney W. Bondurant, MD Retired Obstetrician-Gynecologist, Grenada Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Matthew deShazo, MD, MPH Assistant Professor-Cardiology, University of Mississippi Medical Center, Jackson Thomas E. Dobbs, MD, MPH State Epidemiologist, Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford

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Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Nitin K. Gupta, MD Assistant Professor-Digestive Diseases, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director, Mississippi Professionals Health Program, Ridgeland J. Edward Hill, MD Family Physician, North Mississippi Medical Center, Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Daniel W. Jones, MD Sanderson Chair in Obesity, Metabolic Diseases and Nutrition Director, Clinical and Population Science, Mississippi Center for Obesity Research, Professor of Medicine and Physiology, Interim Chair, Department of Medicine 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 Lillian Lien, MD Professor and Director, Division of Endocrinology, University of Mississippi Medical Center, Jackson William Lineaweaver, MD Editor, Annals of Plastic Surgery, Medical Director, JMS Burn and Reconstruction Center, Brandon Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems Heddy-Dale Matthias, MD Anesthesiologist, Critical Care Internist, Madison Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD Radiologist, Singing River Radiology Group, Pascagoula Ann Myers, MD Rheumatologist , Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist , Jackson Health Care-Women, Flowood

Jack D. Owens, MD, MPH Neonatologist, Newborn Associates, 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 Shou J. Tang, MD Professor and Director, Division of Digestive Diseases, University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine, University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon, Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer, Brentwood Behavioral Healthcare, Flowood Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

Got Questions MACM Risk Management has answers.

At Medical Assurance Company of Mississippi, we believe protecting our insureds from litigation is just as important as the service we provide after a suit is filed. The primary focus of our physician insureds is the health and well-being of their patients. Our responsibility is to help them keep that focus, while working on issues and topics that affect the delivery of healthcare in Mississippi. All of the programs and services listed below are offered at no cost to MACM insureds. •

Onsite Survey. Through these evaluations, our staff can analyze the risk management systems and documentation within your practice to offer suggestions for improvement.

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In-Service Education. With customized presentations and training, our staff can meet the needs of our individual insureds.

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Consultations by Telephone and Email. Our consultants are located in Mississippi and available to answer questions from insureds when they need timely assistance.

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Publications. Our insureds receive information that is timely through Risk Manager Alert email blasts, as well as more in-depth information through our Risk Manager magazine.

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Reference Materials. These written bulletins are available to our insureds and designed to help in specific circumstances that come up daily in a medical practice, such as withdrawal from patient care.

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Educational Opportunities. In addition to the knowledge of our in-house staff, MACM has contacts across the U.S. and makes this expertise available to our insureds through webinars and conferences.

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Presentations and Speaking Engagements. The Risk Management Staff has been a sought-after source for presentations at conferences on an array of topics related to the practice of healthcare.

If you are not currently insured by Medical Assurance Company of Mississippi, what services and educational opportunities are you missing out on?

Don’t be left out! To take advantage of the many opportunities that MACM offers its insureds, contact Tammi Arrington at (800) 325-4172 or tammi.arrington@macm.net for information and a quote on your medical professional liability needs.

JOURNAL MSMA

Top 10 Facts You Need to Know about Zika Virus Svenja J. Albrecht, MD, MPH and Rathel L. Nolan, MD, MPH Introduction There is rising concern about Zika virus among public health officials, physicians, travelers, and the public. This article summarizes ten facts providers should know about Zika infection.

This is not a novel virus. First isolated in Africa around 1950, Zika virus previously was considered endemic in parts of Africa, Asia, and the Pacific Islands.1 It is a flavivirus related to dengue, yellow fever, and West Nile viruses.

The outbreak has been rapidly spreading in the Americas. In Brazil, the first local case was documented in May 2015.2 As of January 2016, 23 countries in the Americas have reported cases and as many as 4 million people may become infected this year. Up to date information of geographic risk can be obtained from the Centers for Disease Control (CDC) Traveler’s Health site at http://wwwnc.cdc.gov/travel/page/zika-travel-information.

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Zika virus is predominantly transmitted by Aedes mosquito species. Zika virus is transmitted primarily via bites from daytime active, urban Aedes mosquitoes, the same vectors that transmit dengue and chikungunya.3 Maternal fetal transmission is the greatest concern. Transmission via transfused blood and organ transplantation is possible, although unproven.4 Recent data suggests that sexual transmission is possible.

Zika infection is generally a mild and self- limited illness in non-pregnant adults. Approximately 80% of individuals with Zika infection are asymptomatic.5 If symptomatic, a mild febrile illness with a maculopapular rash is common; myalgias, arthralgias, small joint polyarthritis, headache, retro-orbital pain, or conjunctivitis may occur. Severe illness requiring hospitalization is rare, and full recovery is the norm. Zika infection should be suspected in a patient with such symptoms who has returned within two weeks from a country experiencing transmission. The typical incubation period is 2-7 days. Dengue and chikungunya virus infection are endemic to the affected regions and present similarly.

Serious sequelae of infection include adverse pregnancy outcomes and a possible increased risk of Guillain-Barre syndrome (GBS). Reported rates of microcephaly have significantly increased in affected areas and the virus has been isolated from amniotic fluid.6 Virus has also been isolated from tissue in fetal losses but causation is unclear. An increase in GBS cases has been reported from Brazil but a causal relationship is unproven.2

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Laboratory testing is available at the CDC and some state labs. There is no commercially available diagnostic test.2 Suspected cases should be reported to the Mississippi State Department of Health Division of Epidemiology 601-576-7725 to coordinate testing. Laboratory confirmation utilizes either serology or nucleic acid detection via reverse transcription polymerase chain reaction (RT-PCR). There is no proven effective antiviral medication and no preventive vaccine. Treatment consists of supportive care including hydration, rest, antipyretics and analgesics.2 Acetaminophen should be used instead of aspirin or nonsteroidal inflammatory drugs (NSAIDs) among pregnant women and in all others until dengue has been excluded.

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FIGURE. This is a transmission electron micrograph (TEM) of Zika virus, which is a member of the family Flaviviridae. Virus particles are 40 nm in diameter, with an outer envelope, and an inner dense core. Photo Credit: CDC /Cynthia Goldsmith. Centers for Disease Control and Prevention, Office of the Associate Director for Communications, Division of Public Affairs.

Prevention and Control measures focus on mosquito bite avoidance. Travelers should be counseled to wear long-sleeved clothing, stay in places with air conditioning or screens, use Environmental Protection Agency (EPA)-approved insect repellents, and treat clothing with permethrin.2 Infected persons are viremic in the first week of illness and should avoid mosquito bites. Other control measures include limiting mosquito breeding habitats, specifically standing water reservoirs in close proximity to human dwellings.3

Obstetricians should counsel their patients pre travel, and specific testing is indicated for exposed mothers and for any infants born to infected mothers. Until more is known about the exact risk for microcephaly, obstetricians should counsel pregnant females in any trimester to postpone travel to areas with active transmission.7 Male partners who travel to endemic areas should refrain from sex or use condoms with any pregnant partners for the remainder of the pregnancy.8 Pregnant women do not appear to have increased susceptibility to Zika nor more severe disease. All pregnant women should be questioned about travel, and those with two or more consistent symptoms during or within 2 weeks of travel to an endemic area or those whose fetal ultrasounds show intracranial calcifications or microcephaly should be referred for testing. Any asymptomatic pregnant women with travel to an area with Zika transmission should be screened at 2 to 12 weeks after return. If laboratory testing confirms maternal infection, serial fetal ultrasounds every 3-4 weeks should be considered. After delivery, histopathology and RNA testing of placenta and umbilical cord specimens and cord serum antibody testing may be done. Neonatal testing is indicated for infants with microcephaly or intracranial calcifications whose mothers visited an area with transmission during pregnancy and for those whose mothers had positive or indeterminate laboratory results infection.9

Person-to-person spread of Zika infection could potentially occur in MS, but a large scale outbreak is unlikely. Several Aedes mosquito species are capable of transmitting Zika virus,3 and the two main vectors, Ae. aegypti and Ae. albopictus, exist in the Southern US, including MS. Home construction with window screening and use of central air conditioning, widespread mosquito control measures, and less population density in urban centers compared to Brazil decrease the likelihood of a widespread outbreak. Conclusion: The rapid rise of Zika cases in the Americas and the concern for adverse fetal outcomes warrant awareness among all providers. Pregnant women should be counseled against travel to endemic areas, and mosquito prevention strategies should be emphasized for all others. Persons suspected of infection should be referred for testing to the MS Health Department. Large scale outbreak activity is considered unlikely in MS. n

Author Information: Dr. Albrecht is assistant professor-clinical infectious diseases, and Dr. Rathel “Skip” Nolan is professor of infectious diseases and head of the Division of Infectious Diseases at the University of Mississippi Medical Center. References 1. Hayes EB. Zika virus outside Africa. Emerg Infect Dis. 2009 Sep. Available from: http://wwwnc. cdc.gov/eid/article/15/9/09-0442. 2. Hennessey M, Fischer M, Staples JE. Zika Virus spreads to new areas — Region of the Americas, May 2015–January 2016. MMWR Morb Mortal Wkly Rep. 2016;65:55–58. DOI: http://dx.doi.org/10.15585/mmwr.mm6503e1. 3. Lanciotti RS, Lambert AJ, Holodniy M, Saavedra S, del Carmen Castillo Signor L. Phylogeny of Zika virus in Western Hemisphere, 2015. Emerg Infect Dis. 2016 May. DOI: http://dx.doi. org/10.3201/eid2205.160065. 4. Foy BD, Kobylinski KC, Foy JLC, Blitvich BJ, Travassos da Rosa A, Haddow AD, et al. Probable non–vector-borne transmission of Zika virus, Colorado, USA. Emerg Infect Dis. 2011 May DOI: http://dx.doi.org/10.3201/eid1705.101939. 5. CDC. Recognizing, managing, and reporting Zika virus infection in travelers returning from Central America, South America,the Caribbean, and Mexico. CDC Health Advisory. Atlanta,

GA: US Department of Health and Human Services, CDC; 2016. http://www.cdc.gov/zika/ symptoms/index.html. 6. Schuler-Faccini L, Ribeiro EM, Feitosa IM, et al. Possible association between Zika Virus infection and microcephaly — Brazil, 2015. MMWR Morb Mortal Wkly Rep. 2016;65:59–62. DOI: http://dx.doi.org/10.15585/mmwr.mm6503e2. 7. Petersen EE, Staples JE, Meaney-Delman, D, et al. Interim Guidelines for Pregnant Women During a Zika Virus Outbreak — United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:30–33. DOI: http://dx.doi.org/10.15585/mmwr.mm6502e1. 8. Oster AM, Brooks JT, Stryker JE, et al. Interim Guidelines for Prevention of Sexual Transmission of Zika Virus — United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65(Early Release):1–2. DOI: http://dx.doi.org/10.15585/mmwr.mm6505e1er 9. Staples JE, Dziuban EJ, Fischer M, et al. Interim Guidelines for the Evaluation and Testing of Infants with Possible Congenital Zika Virus Infection — United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:63–67. DOI: http://dx.doi.org/10.15585/mmwr.mm6503e3.

JOURNAL MSMA

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A R T I C L E

A Case of Freeman–Sheldon Syndrome: Anesthetic Challenges THOMAS HAMILTON, MD and MADHANKUMAR SATHYAMOORTHY, MBBS, MS

Abstract Patients with Freeman-Sheldon Syndrome (FSS) often need multiple surgical procedures. We present a case of FSS and discuss the anesthetic challenges associated with the case. Case Presentation A 10-week-old female with FSS presented for elective Nissen fundoplication and gastrostomy tube insertion. She had a history of difficult intubation at birth. General anesthesia with inhalational anesthetic and spontaneous respirations technique was used. Fiber optic bronchoscope (FOB)- assisted nasal intubation was successful after failed attempts with a Miller blade, GlideScope, and intubation through a laryngeal mask airway (LMA). She did not exhibit any signs of malignant hyperthermia (MH) during or immediately after the procedure. Discussion Challenges to the anesthesiologist in a case with FSS include establishing IV access, intubating the trachea, risk of MH and MH-like symptoms, and postoperative pulmonary complications. Proper multidisciplinary preoperative planning is essential for optimum care of these patients, preferably in a tertiary care center. Key Words: Freeman-Sheldon Syndrome, malignant hyperthermia, hypermetabolism, difficult intubation Introduction FSS is a rare constellation of congenital defects and is the most severe form of the distal arthrogryposes (DAs). Common to all the DAs are widespread contractures of the musculature which occur most prominently in the distal joints of the hands and feet. Contracture of facial muscles and other craniofacial abnormalities, such as a long, thin philtrum and downwardslanting palpebral fissures, are common to FSS and SheldonHall syndrome (SHS), known as DA2A and DA2B, respectively. The facial contractures are responsible for a small oral orifice spanning only a few millimeters, which provides the distinctive 6 VOL. 57 • NO. 1 • 2016

“whistling facies.” Because of their similar presentations, diagnostic criteria were created to distinguish between the two syndromes. While both FSS and SHS require at least 2 of the major characteristics, the differentiation comes in the subtlety of the craniofacial attributes. FSS requires a small pinched mouth, prominent nasolabial folds, and “H-shaped” dimpling of the chin, whereas those with SHS tend to have a larger oral opening and lack the distinctive chin dimpling.1 Consequently, it should not come as a surprise that many surgeries are required from early development onward. This poses a unique set of challenges to the anesthesiologist, such as difficult IV cannulation, difficult intubation, and risk of malignant hyperthermia (MH). We present a case of FSS and discuss the anesthetic challenges associated with the case. Case Report The patient was a 10-week-old female, 39-weeks postmenstrual age, weighing 2.1kg, who was scheduled for an elective Nissen fundoplication and gastrostomy tube insertion. She exhibited severe microstomia with whistling facies and contractures of the distal extremities. At birth, she required intubation for surfactant therapy which was difficult and required multiple attempts by the neonatologists without success. An ENT surgeon was consulted and, intubation was done with the help of a flexible FOB. On the day of the scheduled surgery, the patient was brought into the operating room (OR) after discussing the anesthetic plan and obtaining consent from the parents. She had a 24 gauge (G) working intravenous (IV) catheter in her scalp vein. After standard monitors such as pulse oximetry, EKG, and noninvasive BP cuff were applied, general anesthesia was induced with sevoflurane in a 50% oxygen (O2)/ 50% nitrous oxide (N2O) mixture. While still breathing spontaneously, adequate depth of anesthesia was established and confirmed by a lack of response to a five-second jaw thrust maneuver and midline position of the eyes. With ventilatory status secured, successive intubation attempts were made, first with a GlideScope® AVL size 0 and then with a fiberoptic bronchoscope (FOB) through

a size 0 LMA Classic,™ both of which were unsuccessful. An ENT surgeon was present during induction in the OR, in the event an emergency surgical airway was needed, given the patient’s history of difficult intubation. However, oxygenation and adequate facemask-assisted ventilation were achieved between intubation attempts. The trachea was successfully intubated nasally with a 2.5mm ID (inner diameter) uncuffed Sheridan® tube using a 2.2mm Storz® FOB. Total intravenous anesthesia (TIVA) with propofol could have been employed through the IV in the scalp, but the anesthesiologist elected for an inhalational induction in this case. It should be noted that in neonates and infants, it is difficult to titrate propofol to attain a deep level of anesthesia without increasing the risk of apnea. In this case, the anesthesiologist decided that the risk of not being able to ventilate the patient outweighed the possibility for MH-like symptoms. Alternatively, ketamine could have been used for induction while maintaining spontaneous respiration while avoiding risks of MH. After successful intubation, the patient was closely monitored during the surgery for signs of MH such as muscle rigidity, hyperthermia, or hypercapnia, but the patient did not exhibit any signs of MH. The procedure was completed uneventfully, and the patient was taken to the Neonatal Intensive Care Unit (NICU) intubated. She was extubated uneventfully on the second postoperative day and was discharged from the hospital a month later. Since the initial surgery, the patient has had FIGURE. Perioperative management algorithm of a case of Freeman-Sheldon Syndrome

additional surgeries to the extremities. FOB was used to intubate the trachea, and inhalational gas was used in each anesthetic without any problems. Her last procedure was a tracheostomy for respiratory failure. Discussion IV Cannulation Establishing IV access in patients with FSS can be difficult. Reasons for difficult IV cannulation include presence of contractures, thickened subcutaneous tissue, and frequent extremity surgery.2 Since contractures tend to be more common in younger patients,3 it is not always possible to have an IV placed before the procedure. Consequently, this will change the anesthetic plan, i.e. whether an inhalational induction or intravenous induction will be used. Agritmis et al preferred an inhalation induction as a result of difficulty establishing IV access.4 Nguyen et al, however, elected to secure IV access prior to induction in the event emergency drugs were needed.5 In patients at risk of MH, inhalational anesthetic is usually avoided. As patients with FSS demonstrate a risk of MH, the anesthesiologist may opt to insert an IV catheter before induction of anesthesia and utilize a trigger-free anesthetic technique.2 With the use of ultrasound for vascular access, patients with difficult intravenous access such as FSS patients have become less of a problem for the modern day anesthesiologists. Airway Management Of all the challenges presented to the anesthesiologist in a case of FSS, the most common is difficult intubation. Reasons for difficult intubation include a small mouth opening (microstomia) and a small, receding chin (micrognathia), both of which contribute to poor visualization of the vocal cords during direct laryngoscopy.4 Poor neck extension and a short epiglottis, two additional features common to patients with FSS, only heighten the difficulty.6 To meet this challenge, multiple techniques have been described including direct laryngoscopy after deep inhalation induction without muscle relaxants,4 blind intubation using an LMA as a guide,7 FOB intubation with and without use of an LMA as a guide,5,6 and laryngoscopy and LMA insertion in an awake patient after topicalization of oropharynx with 2% Lidocaine jelly.5 Short procedures that do not require intubation can be managed with facemask ventilation, LMA, and TIVA techniques.2,3 Postoperative complications, including pneumonia, respiratory insufficiency and respiratory tract infections, are also a threat. Etiology for lung disease is thought to be caused by associated myopathy, pulmonary hypoplasia, and rib cage and spine deformities.8 These patients may need aspiration prophylaxis due to poor airway reflexes and GERD.3 Malignant Hyperthermia-Like Symptoms In cases with FSS and other arthrogryposis subtypes, there have been a range of symptoms reported in the literature, from isolated incidents of hypermetabolism and muscle rigidity to fullblown MH.1,3,8,9,10 Agents used in these cases include both known JOURNAL MSMA

MH-triggering agents as well as non-triggering agents. The two main MH triggering agents are halogenated vapor anesthetic and succinylcholine. Most of the reported cases of MH in cases with FSS are with halothane. Sevoflurane is the most commonly used inhalational gas in modern day pediatric anesthesia, while halothane is seldom used. No definitive cause or underlying genetic defect responsible for MH or hypermetabolic response has been identified in these patients. MH-like symptoms may be an exaggerated metabolic response to anesthesia or surgical stress that is distinct from MH and independent of the type of anesthetic used.3,9 The hypermetabolic response responds to active cooling, while MH requires treatment with dantrolene. Many pediatric anesthesiologists prefer the advantage of spontaneous ventilation with inhalational induction for securing a difficult airway. However, this technique must be weighed against the risk of potential symptoms of hypermetabolism or MH. These patients need to be monitored closely for symptoms of MH or other signs of hypermetabolism if inhalational gases or succinylcholine were used during the case. Conclusion Patients with FSS present many challenges to the anesthesiologist throughout the perioperative course. Thus, a tertiary care centerwith its resources to manage possible complications is the best place to manage these patients. More often, these patients need close monitoring in an intensive care unit postprocedure. Proper preoperative assessment and planning is imperative. A multi-disciplinary meeting between the surgeon, anesthesiologist, otolaryngologist, pulmonologist, and intensivist before the procedure is necessary to manage any perioperative complications and optimize outcome. The anesthesiologist should be prepared to deal with a range of challenges, from trouble establishing IV access to difficulty intubating the trachea to possible MH. n References 1. Stevenson DA, Carey JC, Palumbos J, Rutherford A, Dolcourt J, Bamshad MJ. Clinical characteristics and natural history of Freeman-Sheldon syndrome. Pediatrics. 2006; 117(3):754-62. 2. Cruickshanks GF, Brown S, Chitayat D. Anesthesia for Freeman-Sheldon syndrome using a laryngeal mask airway. Can J Anaesth. 1999; 46(8):783-7. 3. Martin S, Tobias JD. Perioperative care of the child with arthrogryposis. Paediatr Anaesth. 2006; 16(1):31-37. 4. Agritmis A, Unlusoy O, Karaca S. Anesthetic management of a patient with Freeman-Sheldon syndrome. Paediatr Anaesth. 2004; 14(8):874-877. 5. Nguyen NH, Morvant EM, Mayhew JF. Anesthetic management for patients with arthrogryposis multiplex congenita and severe micrognathia: case reports. J Clin Anesth. 2000; 12(3):227-230. 6. Sivaci R, Balci C, Maralcan G, Kuru I. Management of difficult airway in a child with arthrogryposis multiplex congenita during general anesthesia. Saudi Med J. 2005; 26(10): 1657-1659. 7. Rabb MF, Minkowitz HS, Hagberg CA. Blind intubation through the laryngeal mask airway for management of the difficult airway in infants. Anesthesiology. 1996; 84(6):1510-1511. 8. Duggar RG, Jr., DeMars PD, Bolton VE. Whistling face syndrome: general anesthesia and early postoperative caudal analgesia. Anesthesiology.1989; 70(3):545-547. 9. Hopkins PM, Ellis FR, Halsall PJ. Hypermetabolism in arthrogryposis multiplex congenita. Anaesthesia. 1991; 46(5):374-5. 10. Jones R, Dolcourt JL. Muscle rigidity following halothane anesthesia in two patients with Freeman-Sheldon syndrome. Anesthesiology. 1992; 77(3):599-600.

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Acknowledgment: This report was previously presented, in part at the NYSSA, 68th Post Graduate Assembly in Anesthesiology, New York, Dec1216, 2014 (P7050), submitted as a research report. This is a case report with no patient identifying information. Hence written consent was not obtained. Author Information: Resident in Anesthesiology training (PGY2) at the University of Mississippi Medical Center (Dr. Hamilton). Assistant Professor of Anesthesiology at the University of Mississippi Medical Center (Dr. Sathyamoorthy). Corresponding Author: Madhankumar Sathyamoorthy, MBBS, MS University of Mississippi Medical Center Department of Anesthesiology, 2500 N State Street, Jackson, MS 39216 Phone: (601) 984-5900 FAX: (601) 984-6283 Email: msathyamoorthy@umc.edu

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Physician Wellness: The Burnout Antidote Change is Necessary SCOTT HAMBLETON, MD MEDICAL DIRECTOR, MISSISSIPPI PROFESSIONALS HEALTH PROGRAM

t seems that most medically related news these days includes information about physician burnout. This is justified because physician burnout is increasing every year and is now present in the majority of American physicians.1 In 2011, 45.5% of physicians reported burnout compared to 54.4% in 2014, according to a recent study published in Mayo Clinic Proceedings.1,2 Additionally, satisfaction with work-life balance also declined from 48.5% in 2011 to 40.9% in 2014.1 However, during the same time period, minimal changes were observed in rates of burnout or satisfaction with work-life balance in probability-based samples of working American adults.1 Physicians on the front line of care, such as family physicians and internists, are at greatest risk, and burnout is reported in almost 65% of emergency medicine physicians.2 There are many manifestations of physician distress, including emotional exhaustion, generalized fatigue, and decreased career satisfaction.2,3 More harmful manifestations of distress include substance use disorders, depression, disruptive behavior, and suicide.2,4,5 However, burnout is one of the most common manifestations of distress.6 Burnout also affects patient care negatively and is directly linked to decreased patient satisfaction, higher rates of physician and staff turnover, medical errors, and malpractice risk, resulting in an overall decrease in quality of patient care and increased potential for patient harm.7 Part of the problem is that physicians tend to minimize the negative impact of burnout and generally believe that stress and burnout are a normal part of being a physician.3 Worse still, physicians have poor ability to reliably calibrate their own level of distress relative to colleagues.3

Because of these facts, the American Medical Association and state medical associations, including our MSMA, are looking for solutions to this complex issue. What exactly is burnout? The AMA describes burnout as a long-term stress reaction characterized by depersonalization, including cynical or negative attitudes toward patients, emotional exhaustion, a feeling of decreased personal achievement and a lack of empathy for patients.8 Â A burned-out physician is a distressed physician lacking sufficient resiliency to maintain a state of wellness. These physicians often suffer from an underlying sense of perfectionism and rigidity which contribute to significant dissatisfaction both professionally and personally.2,9 Characteristics such as perfectionism may enable physicians to perform competently and are desirable in that sense. However, in cases involving distressed, burned-out physicians, these characteristics become liabilities. Disruptive physician behavior Stress and burnout may also contribute to disruptive physician behavior, which the Joint Commission defines as behaviors that undermine a culture of safety.10 The AMA defines these behaviors as personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care.11 Ultimately, these behaviors contribute to a hostile work environment which impedes patient safety.8 Examples of disruptive physician behaviors include delayed responding, chronic tardiness, or incomplete charting. The spectrum of disruptive behaviors progresses with the risk

JOURNAL MSMA

of negatively affecting patient care and includes excessive sarcasm, inappropriate charting, undermining other providers, or bullying. The most severe examples of disruptive behavior include behaviors that create imminent risk of harm to patients or staff, such as refusing to heed a clear warning that a medical error is about to occur, physical aggression, sexual harassment, or assault.8

Depression and suicide: Occupational hazards?

external forces involving the culture of medicine and the current practice and training environment play a dominant role in the genesis and propagation of disruptive behavior as well as burnout.12,13 In many cases, disruptive behavior is generated in response to legitimate problems in the system, although this does not excuse the behavior.12,13 Ultimately, disruptive behavior and burnout are manifestations of ineffective stress management.3,12,13

“The health and life of my patient will be my first consideration “

Psychological testing is high in empathy and altruism for students entering medical school; however, personal distress, cynicism, and loss of empathy, which are hallmarks of burnout, increase throughout the educational process.15,16 Interestingly, depression, which is a major risk factor for suicide, occurs at a rate of 22%35% for physicians in training, compared to a rate of 17% in the While the incidence of general population.15 However, MPHP IS A CONFIDENTIAL RESOURCE CREATED BY physicians who engage suicide rates for physicians in PHYSICIANS FOR PHYSICIANS. WE ARE HERE TO HELP! in disruptive behavior is training are lower compared to PLEASE VISIT OUR WEBSITE AT MSPHP.COM approximately 3-5%,12 which their same age cohorts in the is much less than the incidence OR CALL 601-420-0240 FOR QUESTIONS. general population,15,16 while of physicians experiencing practicing physicians commit burnout1, many of the behavioral suicide at a higher rate than any other profession.17 In fact, on characteristics which contribute to burnout also contribute to most days, at least one physician commits suicide.18 Considering disruptive behavior.12,13 Examples of these internal or behavioral this data, it appears that depression and suicide are occupational factors include lack of emotional insight and awareness, lack of hazards for physicians.15,19 clear boundaries and poor conflict resolution skills.12,13 However,

Distressed physicians and resilience Many physicians describe the practice of medicine as a higher calling, and the reward of helping our patients heal is immensely gratifying for most of us and a primary reason we chose this profession. However, the practice of medicine is becoming more challenging. Issues related to electronic health records, managed care and shrinking reimbursement are requiring significantly more time while our autonomy as physicians seems to decline continuously. Physician shortages of more than 90,000 physicians are expected by 2020, and this will certainly add to the workload of practicing physicians.14 Successfully dealing with these changing conditions is a cause of significant distress for most of us. Additionally, the characteristics of medical work itself can become a breeding ground for distress. Long hours, requirements for complex decision making, ambiguous and disappointing outcomes and a need for constant empathy and compassion can exact a heavy toll on even the most balanced physicians. We often suffer from unrealistic expectations of ourselves, and most of the physicians I have encountered agree that somewhere in the process of becoming physicians we learn to hide any signs of vulnerability or weakness. Throughout our training and careers, we minimize and ignore our own needs and put the needs of the patient first. Resilience is the ability to tolerate and successfully adapt to a stressful environment or situation, and physicians are expected to be resilient. Unfortunately, resiliency is a physician characteristic that is typically not taught.8 10 VOL. 57 • NO. 1 • 2016

This vow, which is part of the Hippocratic Oath, has been a guiding principle of physicians since the 5th century BC. Unfortunately, this has also been a justification which enables us to not provide adequate care for ourselves! In essence, physicians have assumed that it should be possible to fulfill the fiduciary duty to the patient in any environment, even an environment that stifles wellness. However, in my estimation, our fiduciary duty to our patients mandates that we remain healthy. Unfortunately, at times, especially during training, it is simply not possible to fulfill basic requirements for exercise, healthy meals and adequate sleep. However, considering the alarming rates of physician burnout, it appears that we may have reached critical mass in our ability to function effectively without adequate sleep, nutrition and recreation, which are the essential elements of resilience and wellness. It is apparent that we need to apply the mandate to “First do no harm” to ourselves as well as to our patients. In fact, changes to the entire culture of medicine may be necessary to facilitate any type of significant and lasting measures to reduce physician burnout. The silent paradigm of sacrificing individual wellness for the sake of our patients has to be challenged so that wellness and adequate self-care can become viable and accepted professional boundaries for mainstream medicine. Physicians have “true grit”! The ability to endure the rigors of medical education and training requires true grit! Physicians have a tremendous capacity to tolerate high levels of stress. However, rates of burnout continue to increase, and more and more physicians are being affected. In addition to depression and suicide, it appears that burnout is also an occupational hazard for physicians.2,15 However, it is not appropriate to discount the seriousness of burnout or to attribute

it entirely to vulnerable physicians lacking the “grit” necessary to effectively cope with stress. Nor is it appropriate to minimize the harmfulness of burnout by simply acknowledging that it is an occupational hazard for physicians. It is clear that the culture of medicine accords low priority to physician mental health, and this needs to change.19

References 1.

Shanafelt T, Hasan O, Dyrbe LN, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015; 90(12): 1600 – 1613.

Shanafelt T, Boone S, Tan L, et al. (2012). Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med. 172(18):1377-1385. doi:10.1001/archinternmed.2012.3199.

Shanafelt T,Kaups K, Nelson H, et al. An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons. Ann Surg. 2013; 00(00): 1-7.

Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012; 147(2):168-174.

Shanafelt T, Balch CM, Dyrbye LN, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011; 146(1):54-62.

Shanafelt T, Sloan J, Habermann T. The well-being of physicians. Am J Med. 2003;114:513–517.

Drummond D. (2015). Physician burnout: its origin, symptoms, and five main causes. Fam Pract Manag. 22(5):42-7.

Okanlawon T. Practice transformation series: physician wellness: preventing resident and fellow burnout. Release Date: October 8, 2015. Available at: https://www.stepsforward.org/modules/physician-wellness.

Kearney M. (2009). Self-Care of Physicians Caring for Patients at the End Of Life. JAMA. 301:1155-1164.

Barriers to treatment Physicians generally have difficulty adapting to the role of actually being a patient which makes treatment more complicated, and specialized staff is often necessary, especially for treatment of physicians with substance use disorders.20 Asking for help for mental health issues is typically not rewarded during our training, and throughout our careers, the fear of being stigmatized or punished is a major concern preventing us from receiving assistance for these conditions.16 Discrimination by regulatory boards and credentialing committees, with subsequent loss of professional advancement is a very legitimate concern.19 Institutional policies and professional attitudes need to be changed and barriers need to be removed in order to facilitate treatment of medical students, residents and physicians. Wellness is the burnout antidote! Unfortunately, there is no panacea for physician burnout. It is an extremely complex problem, and the entire culture of medicine needs to be examined so that the current trends in physician health can be corrected. One certainty is that the solution to the problem involves physician wellness,8 which is a state of optimal physical, mental, and social health.8 Achieving wellness is a dynamic, self-directed and evolving process.8 Conversely, burnout and diminished resiliency are a consequence of lack of wellness. All of the manifestations of distress, including substance use disorders, depression, disruptive behavior and burnout, are improved with treatment which includes adequate sleep, nutrition, and recreation. Therefore, treatment of burnout involves restoration and maintenance of factors necessary for wellness. In essence, wellness is the burnout antidote. The Mississippi Professionals Health Program The Mississippi Professionals Health Program is a confidential resource created by physicians for physicians. We are a not-forprofit subsidiary of the Mississippi State Medical Association. We are Mississippi’s designated Physician Health Program, and we have assisted over 900 physicians recovering from potentially impairing, treatable conditions such as addictive disorders. More information will be provided in upcoming issues of this journal about the identification and treatment of burnout, as well as preventative strategies for all physicians to utilize in order to achieve and maintain wellness. We are here to help! Please visit our website at www.MSPHP.com or call 601-420-0240 for questions. n

10. The Joint Commission. Leadership standard clarified to address behaviors that undermine a safety culture. 2012. Available at: http://www. jointcommission.org/assets/1/6/Leadership_standard_behaviors.pdf. 11. American Medical Association. Opinion 9.045—Physicians with disruptive behavior. 2000. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code. Accessed January 4, 2016. 12. Leape L, and Fromson J. Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144(2):107-115. 13. Reynolds NT. Disruptive physician behavior: use and misuse of the label. J Med Regul. 2012;98:8-19. http://www.psychiatrictimes.com/mood-disorders/psychiatric-conditions-affecting-physicians-disruptive-behavior/ page/0/2#sthash.RUgskOCo.dpuf 14. Kirch DG. Physician workforce projections in an era of health care reform. Annu Rev Med. 2012;63:435-445. doi: 10.1146/annurev-med-050310-134634. 15. Daskivich T, Jardine D, and Tseng J et al. Promotion of wellness and mental health awareness among physicians in training: perspective of a national, multispecialty panel of residents and fellows. JGME. 2015; 7(1): 143-147. 16. Dunn LB, Green Hammond KA, Roberts LW. Delaying care, avoiding stigma: residents’ attitudes toward obtaining personal health care. Acad Med. 2009; 84(2):242-250. 17. Frank e, Biola H, Burnett C. (2000). Mortality Rates and Causes Among U.S. Physicians. Am J Prev Med. 19(3):155-159. 18. American Foundation for Suicide Prevention. Available at: www.afsp.org. Accessed January 4, 2016. 19. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003;289(23):3161-3166. (doi:10.1001/jama.289.23.3161). 20. Earley PH. Persons in safety-sensitive occupations. In: Mee-Lee DE. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies; 2013: 240-349.

JOURNAL MSMA

MISSISSIPPI STATE MEDICAL ASSOCIATION W O R L D

H E A L T H

O R G A N I Z A T I O N

P.O. Box 2548 • Ridgeland, Mississippi 39158 • 408 West Parkway Place 39157 • 601.853.6733 • www.MSMAonline.com

Mississippi Physicians Support Goal to Reduce Premature Mortality: The WHO 20 x 25 Target Fellow Mississippians: P.O. Box 2548 • Ridgeland, MS 39158 • 408 West Parkway Place 39157 • 601.853.6733 • www.MSMAonline.com

P R ES I DE NT Daniel P. Edney, MD Vicksburg

We are proud to report in this edition of the 2016 Public Health Report

P R ES I DE NT - EL EC T ccording to the Organization (WHO), noncommunicable (NCDs)health are estimated to account for Lee Voulters, MDWorld HealthCard that Mississippi’s physiciansdiseases and public officials are joining 88%Pass of total deaths in the United States—approximately 2,337,280 in 2014. Christian

the 25x25 initiative and our goal is a 25% reduction of premature – primarily diseases, from cancersnoncommunicable and diabetes – are the world’s largest killers, with an estimated S T P RES I D ENT heart and lung P ANCDs mortality diseases by the year 2025. 38

Claude D. Brunson, MD Of these deaths, 16 million are premature (under 70 years of age). If we reduce the global impact of risk million deaths annually. Jackson factors– tobacco use, physical inactivity, unhealthy diet and the harmful use of alcohol – we can go a long way toward reducing the number of deaths worldwide, and we Noncommunicable can begin in our home state.diseases (NCDs) include four main types of

S EC R ET A RY - T R EA S UR ER Michael Mansour, MD Mississippi consistently Greenville

ranks at the bottom of public health studies, S P EA K ER Gerirates Lee Weiland, and our of heartMD disease, obesity,Vicksburg smoking and diabetes B OA RD O F T RUS T E ES are among the highest in the nation. To make J. Clay Hays, Jr., MD Chair, our state’s future aJackson healthier one, we need William M. Grantham, MD to begin looking at our Vice Chair, Clinton health habits and asking ourselves howHorne, we canMD W. Mark change. Secretary, Laurel Timothy Reduce yourBeacham, risk of MD Greenville premature death by making smarter choices: Brett C. Lampton, MD drink in moderation Oxford (up to 1 drink per day for women up toMD John R.and Mitchell, 2 drinks per dayPontotoc for men), reduce your Dwight S. Keady, Jr., MD sodium intake (less Meridian than 5 grams of salt), and make a part Josephexercise D. Austin, MD Vicksburg of your daily routine. If you smoke, stop now. If W. David McClendon, MD you’re a parent, model Ocean Springs healthy habits to your children, andJ.teach Jennifer Bryan, MD them to make healthy YPS, Flowood decisions while they are Nicole M. Lee, MD young. n Resident/Fellow, Jackson

Brock N. Banks Medical Student, Jackson E XEC UT I VE D I REC T OR Charmain Kanosky 12 VOL. 57 • NO. 1 • 2016

diseases such as cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as COPD and asthma) and diabetes which account for 88% of total deaths in the United States— approximately 2 million in 2014.

The global target for a 25% reduction mortality Mississippi consistently ranks at the bottominofpremature public health studies, from noncommunicable and our rates of heart disease, obesity, smoking and diabetes are diseases by 2025

among the highest in the nation. We can delay hundreds of premature deaths if Mississippians start exercising, eat healthily, and stop smoking The WHO 25x25 Target is an effort to reduce and excessive drinking.

premature death from non-communicable disease by 25% by the year 2025. Non-communicable This report card presents six targets forcanreducing healthinrisks, each diseases be grouped together four main diseases heart accompanied by a corresponding categories: statistic cardiovascular provided by the like Mississippi attacks and stroke; diabetes; cancers of all kinds; State Department of Health. As you can see, we have our work cut and chronic respiratory disease such as COPD and out for us; but, we know where asthma. we are going, and ofwe are working These four groups non-communicable together to get to a healthier state. diseases account for 88% of total deaths in the United States—approximately 2 million preventable deaths in 2014. The 2016 Public Health Report Card presents a map Yours in Making Mississippi Healthier, of six targets to reduce health risks with a corresponding statistic that shows where Mississippi currently stands.

The path toward achieving these targets will be complicated. Success will require legislators to Daniel P. Edney, MD make a priority of access to care, address health President, Mississippi State Medical Association inequity, continue to invest in the medical school and fund graduate medical education. It will require employers and business owners to provide a healthy workplace and ban smoking in indoor public places. Schools must also teach the Mary Currier, MD, MPH importance of diet and exercise for students and State Health Officer, Mississippi State Department of Health parents alike.

PUBLIC HEALTH IN MISSISSIPPI 2016

10%

ALCOHOL MISUSE

33% OF HIGH SCHOOL STUDENTS CONSUMED ALCOHOL THIS MONTH2

reduction

PHYSICAL INACTIVITY

32% OF ADULTS REPORTED ZERO PHYSICAL ACTIVITY THIS MONTH1

10% reduction

reduction TOBACCO USE 23% OF ADULTS SMOKE1

30%

BELOW ARE THE 6 GLOBAL TARGETS AND HOW MISSISSIPPI STACKS UP.

25X25: The World Health Organization’s goal for a 25% reduction in premature mortality from noncommunicable diseases by year 2025.

PUBLIC HEALTH IN MISSISSIPPI

2016 REPORT CARD

RAISED BLOOD PRESSURE

SALT / SODIUM INTAKE

5% OF ADULTS REPORTED A STROKE IN THE LAST YEAR1

30%

reduction

SOURCES : 1. Mississippi Behavioral Risk Factor Surveillance System (BRFSS) 2014 2. Mississippi Youth Risk Behavior Surveillance System (YRBSS) 2013 3. Mississippi Behavioral Risk Factor Surveillance System (BRFSS) 2013

The 2016 Public Health Report Card is brought to you by the Mississippi State Medical Association and the Mississippi State Department of Health.

HYPERTENSION3

40% OF ADULTS HAVE

25% reduction

OBESITY / DIABETES

13% OF ADULTS HAVE BEEN DIAGNOSED WITH DIABETES1

increase

MISSISSIPPI STATE MEDICAL ASSOCIATION P.O. Box 2548 • Ridgeland, Mississippi 39158 • 408 West Parkway Place 39157 • 601.853.6733 • www.MSMAonline.com P.O. Box 2548 • Ridgeland, MS 39158 • 408 West Parkway Place 39157 • 601.853.6733 • www.MSMAonline.com P R ES I DE NT Daniel P. Edney, MD Vicksburg P R ES I DE NT - EL EC T Lee Voulters, MD Pass Christian P A S T P RES I D ENT Claude D. Brunson, MD Jackson S EC R ET A RY - T R EA S UR ER Michael Mansour, MD Greenville S P EA K ER Geri Lee Weiland, MD Vicksburg B OA RD O F T RUS T E ES J. Clay Hays, Jr., MD Chair, Jackson William M. Grantham, MD Vice Chair, Clinton W. Mark Horne, MD Secretary, Laurel Timothy Beacham, MD Greenville Brett C. Lampton, MD Oxford

Fellow Mississippians: We are proud to report in this edition of the 2016 Public Health Report Card that Mississippi’s physicians and public health officials are joining the 25x25 initiative and our goal is a 25% reduction of premature mortality from noncommunicable diseases by the year 2025. Noncommunicable diseases (NCDs) include four main types of diseases such as cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as COPD and asthma) and diabetes which account for 88% of total deaths in the United States— approximately 2 million in 2014. Mississippi consistently ranks at the bottom of public health studies, and our rates of heart disease, obesity, smoking and diabetes are among the highest in the nation. We can delay hundreds of premature deaths if Mississippians start exercising, eat healthily, and stop smoking and excessive drinking. This report card presents six targets for reducing health risks, each accompanied by a corresponding statistic provided by the Mississippi State Department of Health. As you can see, we have our work cut out for us; but we know where we are going, and we are working together to get to a healthier state.

John R. Mitchell, MD Pontotoc Dwight S. Keady, Jr., MD Meridian

Yours in Making Mississippi Healthier,

Joseph D. Austin, MD Vicksburg W. David McClendon, MD Ocean Springs Jennifer J. Bryan, MD YPS, Flowood Nicole M. Lee, MD Resident/Fellow, Jackson Brock N. Banks Medical Student, Jackson E XEC UT I VE D I REC T OR Charmain Kanosky

Daniel P. Edney, MD President, Mississippi State Medical Association

Mary Currier, MD, MPH State Health Officer, Mississippi State Department of Health

P R E S I D E N T ’ S

P A G E

The Myth of the Invincible Doctor

he statistics regarding physician health and wellness describe a mixed bag of facts. All-cause mortality for physicians is lower than the general population and yet we score very poorly in terms of mental health issues. Our profession has the highest rate of suicide of all professions and runs about twice that of the general population with female physicians having a quadrupled rate compared to women in the general population. True to our type A personalities, physicians are much better at committing suicide as our completion rate is far higher than the general population. The prevalence of depression is higher and yet we tend not to present for treatment. We suffer from bumout at higher rates than other American workers which causes too many of us to leave clinical practice prematurely. Smoking is virtually nonexistent among physicians; however, rates of substance use disorders mirror that of the general population and prescription drug abuse outpaces the general population. Aggravating all of the issues that affect our health is the fact that 35% of American doctors do not have a primary care physician. This means we are less likely to keep up with our needed screening measures and are less likely to seek help for issues with depression, bumout, or substance use disorders. For me, these are more than just issues that affect individual members of our profession. These facts affect the entire physician workforce. It takes the equivalent of over three average medical school graduating class sizes to replace the average number of physicians lost each year in our country to suicide. It takes several more classes to replace the doctors lost to the work force from death and disability from alcoholism/ addiction, bumout, and from preventable illnesses. With Mississippi being 50th in the nation in numbers of doctors per capita, we cannot ignore these statistics. Thankfully, there are resources available to help us with these issues. Mississippi has been selected to serve as a pilot project state for the AMA Steps Forward program with a major component being preventing physician bumout. Individual doctors and clinics can and should use the resources of the Steps Forward program to combat this major issue in our lives and careers. The Mississippi Professionals Health Program (MPHP) is our single best resource in facilitating the treatment and rehabilitation of our doctors who suffer from the illness of substance use disorders. The data is impressive. With the current treatment and monitoring facilitated by PHPs across the country, the sustained remission rates for the disease of addiction increase from around 15-25% in the general population to greater than 85% at five years. The MPHP saves doctors’ lives, their families, and their careers. Because of the good work of the PHP, over 120 doctors are actively practicing with appropriate treatment and monitoring with over 500 graduates who are still in active practice. That’s 10% of the licensed physicians in our state who are still working due to the success of our PHP. Our PHP is truly a jewel in the crown of MSMA. Our health and wellness is critically important. It’s important to our families. It’s important to our patients. Our health influences the health of our communities and our state. We are very difficult to replace so we must not take our health issues for granted. We are not invincible. n

Daniel P. Edney, MD MSMA President

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State Opposition to Obamacare Not Based on Race Dear JMSMA Editor, If I had just first read two of the articles in the October issue of our Journal of the MSMA without seeing the cover, I would have thought it was from a left leaning political organization, perhaps from Socialist Democrat Bernie Sanders or a race-baiter, but maybe just the AMA party line. It’s insulting to the Journal’s readership and the people of Mississippi that two articles suggest to varying degrees that racism is at the root of some of Mississippi’s health issues or for just opposing Obamacare, in spite of the remarkable progress Mississippi has made in its race relations. Dr. deShazo’s article, “Mississippi Children and Pragmatic Politics,” digs up old skeletons from bygone eras to suggest that continued racism may be to blame if Congress, including Mississippi’s delegation, doesn’t fund or increase funding for the Summer Food Service Program referred to in another article in this same issue. $6,110,086 was spent on this program in 2014 according to the article but there was only an 8.9% participation rate. Does this suggest that enough, at least, is already being spent and that there may be some waste? Supplemental food spending has already increased exponentially during President Obama’s tenure. Dr. Lineaweaver’s article “Segregation Then, Poverty Now: Disparities Forever?” goes even further in the realm of insults, and it is disgusting and inappropriate to equate George Wallace’s racist stands to the economic reasons, not related to race, why our Governor and Legislature don’t embrace Obamacare and Medicaid expansion. The vast majority of Mississippi physicians, and I feel safe to say, most of the physicians in the USA, unless they’re professional AMA conventioneers, oppose Obamacare. The author extols Massachusetts’s health plan but I have read that this plan is very expensive and not popular. Governor Romney tried to distance himself from this plan during his Presidential run and certainly didn’t endorse the so-called Affordable (to whom?) Care Act. I personally know of Mississippians who are just above poverty level, but work, who have had their premiums go up under Obamacare. William Ford, MD; Columbus

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Mississippi Infant Mortality Rates Reach All-Time Low in 2014

nsuring that babies sleep in safe environments, on their backs, and in cribs, is just one of the factors that helped Mississippi’s infant mortality rate drop to an all-time low in 2014 of 8.2 infant deaths per 1,000 live births.

Mississippi State Department of Health (MSDH) officials report a significant downward trend in the state’s infant mortality rate between 2005 and 2014. Mississippi’s 2014 infant mortality rate showed a 15 percent decrease from 2013 and a 28 percent decrease since 2005 when it was 11.4 per 1,000 live births. A disproportionate number of black infants still die in Mississippi annually, however. The 2014 black mortality rate was 11.2 per 1,000 births versus the white mortality rate of 5.9. “Mississippi continues to have one of the highest rates of infant mortality in the United States,” said State Health Officer Dr. Mary Currier. “Thanks in part to special funding provided by the state legislature, Mississippi is doing more than ever to address the issue of infant mortality by working with partners to reduce preterm births, eliminate tobacco use by and around pregnant women, and prevent sleep-related deaths.” Within the past few years there were notable declines in infants born electively before 39 weeks. Most Mississippi hospitals have signed a pledge to eliminate early elective deliveries unless medically necessary. Having fewer babies born too early is one of the most important ways to reduce infant deaths. The preterm birth rate (births at less than 37 weeks) is at an all-time low for Mississippi. As a result, Mississippi recently received the March of Dimes Virginia Apgar Award for successfully lowering the preterm birth rate by 11 Journal of the Mississippi percent since 2009. Preterm births are the leading cause of infant mortality in Mississippi.

State Med

1 The Division of Infectious Diseases in the Department 2 of Medicine, at The University of Mississippi Medical 3 Center, is recruiting a full-time infectious diseases 4 academic physician at the assistant professor level. 5 “We know that much work must still be done, but Mississippi has 6 the potential to continue our successful trend,” Dr. Currier said. “We 7 Job Description: The Division of Infectious Diseases continue to work to improve our birth outcomes through outreach, 8 in the Department of Medicine, at The University of education, and improved access to care.” n Mississippi Medical Center, is recruiting a full-time 9 infectious diseases academic physician at the assistant 10 professor level. This position is focused on the 11 Journal of the Mississippi State Medical Association establishment of a service dedicated to treatment of 12 bone and joint infections and expansion of an existing 13 service dedicated to outpatient antibiotic administration Amy Grissett 14 Nephrology Practice at our 650 bed tertiary referral medical center. The 15 Medical Practice Solutions in Jackson is seeking two board-certified/ position also requires 16 1600 N. State St., Ste 400participation on inpatient board-eligible nephrologists to join the consultative services with teaching/supervision of 17 Jackson, MS 39202 practice. Competitive salary and benefits fellows and residents. 18 with partnership track. Please email CV to 19 601-944-1717 agrissett@mpsbilling.com. The University of Mississippi Medical Center is an 20 Journal of the Mississippi State Medical Association equal opportunity employer, M/F/D/V. 21 22 Direct Contact Information: 23 Heather R. Butler Hospitalist Physician Practice Please send yourAdministrator resume to Dr. Rathel L. Nolan, 24 Professor of River Medicine, Division of Infectious Diseases, Health Region Merit Health River Region in Vicksburg, MS 25 Merit DearHighway Ms TheGrissett, University of Mississippi Medical Center, is seeking Hospitalists. 61 North 26 2100 2500MS North39183 State Street, Jackson, MS 39216: 27 Vicksburg, Contact Physician Recruiter at Fax (601) 815-4014 or email: Thank you for your interest in rnolan@umc.edu the 28 Office: (601) 883-5187 601-883-5392 JOURNAL MSMA. Your ad is typeset 29 Fax: (601) 883-6916 30 for a one column 7 line b/w ad at the

In its most recent report on infant mortality in the U.S, the March of Dimes ranks Mississippi as one of the states where improvement in infant mortality is most needed.

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rate of $5.50 per line ($38.50) plus an www.MyMeritHealth.com additional typesetting charge of $25

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Correa Named Leader of Renowned Jackson Heart Study

ollowing a national search, Dr. Adolfo Correa, a physician-scientist with a strong record of clinical care, population-based research and leadership, has been appointed director and principal investigator of the Jackson Heart Study (JHS).

Dr. Correa was the unanimous choice of the chief executive officers of the study’s three participating institutions: Jackson State University, Tougaloo College, and the University of Mississippi Medical Center. Their recommendation has been acknowledged by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH), which provides funding support for the JHS. “The NHLBI is confident in Dr. Adolfo Correa’s capacity to provide excellent leadership and stewardship over this important national study at this pivotal time in epidemiology and public health,” stated Dr. Gary H. Gibbons, director of NHLBI. “Moreover, we look forward to continuing to work closely with Dr. Correa to advance an evidence-based elimination of health inequities in the US and around the world – beginning with the Jackson Heart Study.”

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Supported by funding from the NIH since 2000, the JHS is renowned for its important scientific findings about the risk factors for cardiovascular disease in African-Americans. A population study that has followed the health of 5,000 participants, the study has produced a treasure trove of data that continues to yield insights into the underlying causes of cardiovascular disease. “I see the position of director of the JHS as a unique challenge and an exciting opportunity to work on an important public health issue, using big data and collaborating with other major studies and researchers around the country and the American Heart Association. The vision of the JHS from its inception has been to elucidate the reasons for the high burden of cardiovascular disease among African Americans. Our task is now to make this vision a reality,” Dr. Correa said. Dr. Correa joined the JHS as chief science officer in 2011 and has served as interim director since the departure of Dr. Herman Taylor in 2013. He is a professor in the UMMC Departments of Medicine and Pediatrics. Born in Mexico, Dr. Correa earned a bachelor’s degree from San Diego State University and master’s and medical degrees from University of California San Diego. He also holds a master’s of public health and a Ph.D. in epidemiology from the Johns Hopkins University School of Hygiene and Public Health. He earned an MBA from the University of Georgia in 2010. He completed a residency in pediatrics at the University of California San Francisco Medical Center and San Francisco General Hospital, including serving as chief resident. He also completed a residency in general preventive medicine at the Johns Hopkins School of Hygiene and Public Health. He spent two years with the Centers for Disease Control’s Epidemic Intelligence Service.

AMONG THE UNIVERSITY’S MOST PRESTIGIOUS AND LONGSTANDING RESEARCH PROJECTS IS THE JACKSON HEART STUDY. UMMC RESEARCHERS ARE COLLABORATING WITH TOUGALOO COLLEGE AND JACKSON STATE UNIVERSITY ON THE WORLD’S LARGEST LONG-TERM STUDY OF CARDIOVASCULAR RISK FACTORS IN AFRICAN-AMERICANS. IN 2013, THE UNIVERSITY JOINED THE AMERICAN HEART ASSOCIATION AND BOSTON UNIVERSITY FOR “HEART STUDIES V2.0,” WHICH WILL EXPAND UPON THE LANDMARK FRAMINGHAM AND JACKSON STUDIES TO IMPROVE THE PREVENTION, DIAGNOSIS, AND TREATMENT OF CARDIOVASCULAR AILMENTS.

Dr. Correa has held several scientific leadership positions with the CDC as well as academic appointments with Johns Hopkins. He currently holds adjunct/associate faculty appointments with the schools of public health at Johns Hopkins and at Emory University. Dr. Correa’s transition from interim director to director was effective December 21, 2015. In 2013, the National Heart, Lung, and Blood Institute, and the National Institute of Minority Health and Health Disparities, each a part of the NIH, announced renewed funding for the study. At about the same time, the American Heart Association announced a new collaborative research relationship intended to build a biobank of research data that bridges the Jackson Heart Study and the landmark Framingham Heart Study. This venture has accelerated genomic investigations using the JHS and FHS databases. “I have complete confidence in Dr. Correa’s ability to maximize the potential of the Jackson Heart Study to contribute to these exciting new opportunities to understand and ultimately prevent heart disease and to support the development of the next generation of medical scientists,” said Dr. LouAnn Woodward, vice chancellor for health affairs and dean of the School of Medicine at UMMC. JSU President Carolyn W. Meyers said, “Dr. Correa’s appointment underscores our commitment to ensure that the Jackson Heart Study continues the phenomenal work being done in the area of cardiovascular risk factors research. We are delighted by the leadership he has already demonstrated and are equally excited and energized about the opportunity to make a difference in health outcomes for minority populations for generations to come.” “Tougaloo College fully supports Dr. Correa’s appointment. He is the consummate professional who brings a strong medical and scientific background to the Study. He has demonstrated commitment to the Jackson Heart Study, increasing productivity, and understanding of the importance of the study in helping to inform the social determinants that adversely impact a significant percentage of African Americans. He also supports our efforts to increase the pool of minorities in epidemiology and other health care professions,” said Dr. Beverly Hogan, president of Tougaloo College. n

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REFORM Thousands of Mississippi physicians have saved millions in liability premiums since 2002. Most are now paying the rates of 1996. SPECIALTY SOCIETY MANAGEMENT MSMA offers management services to a growing number of state specialty societies. Services include administration, management of membership databases, dues billing, communications and event planning. ADVOCACY MSMA boasts one of the strongest lobbying teams at the Capitol. As a concerted voice for Mississippi physicians, MSMA supports legislation to protect your practice and defeat legislation such as scope of practice and attacks on tort reform. MMPAC The Mississippi Medical Political Action Committee creates relationships with elected officials, making MSMA the voice of physicians at the Capitol and in Washington. OFFICE OF PHYSICIAN WORKFORCE This important office studies the physician population in the state by reviewing geographic disparities as well as specialty disparities.

MSMA Member Benefits: At a Glance Mississippi State Medical Association is proud to be the state’s oldest and largest physician association. We are committed to serving our physician members by offering continuing education opportunities, practice management tools and legislative advocacy. For over 150 years, MSMA has endeavored to serve as an advocate for members, patients and the public health. The association promotes ethical, educational, and clinical standards for the medical profession and the enactment of just medical laws.

LIVE CME EVENTS CME conferences designed for and by medical professionals feature the latest advances in healthcare and networking opportunities. ONLINE CME Online CME allows physicians to obtain CME credits when it is convenient for them, at an affordable cost. RURAL PHYSICIANS SCHOLARSHIP PROGRAM Since implementation of this vital program in 2007, 102 rural physician scholars are in the pipeline and are either practicing, or will soon be practicing in small towns across Mississippi. LEADERSHIP DEVELOPMENT The MSMA Physician Leadership Academy recently completed its first year with 12 scholars soon to be named “Doctors of Distinction.” The program combines mentoring, organizational education, and skills training to prepare MSMA members for future leadership positions. PHYSICIANS’ POSITION Delivered straight to your email inbox each week, Physicians’ Position offers a recap of trending national healthcare news, state medical headlines and the latest development opportunities for members. JOURNAL MSMA Each month, MSMA publishes a scientific Journal, containing submissions from MSMA members. The JMSMA serves as the voice, the face, and the spirit of medicine in Mississippi. It is free to members, an $83 benefit. iPASS SUMMIT The “Insurance Payment Advocacy Solutions Summit” for clinic staff offers information on billing, insurance and claims issues. CAP COMMITTEE The Claims Advocacy for Physicians (CAP) Committee assists MSMA members in resolving claims issues of common concern with insurance companies, HMOs, Medicare, Medicaid, or other third party payers. JOB BANK Members are offered a free, convenient way to post medical job openings and search for employment opportunities. PRACTICE STRATEGIES Answers to regulatory and legal issues, reimbursement, coding/billing and documentation can be overwhelming and time consuming for physicians and their staff. MSMA has a team of experts to assist you in these and many other areas related to your practice. DOCBOOKMD This free, HIPAA-compliant app allows members to share patient files and contains many other benefits.

JOURNALMSMA MSMA 23 173 JOURNAL

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AMA Launches STEPS Forward™ to Address Physician Burnout Ambitious new initiative offers physicians strategies to revitalize their medical practices and improve patient care

Building on its prominent study with RAND Corp. confirming that the administrative burden of modern medicine is a root cause of physician burnout, the American Medical Association (AMA) has launched an ambitious new effort aimed at helping physicians redesign their medical practices to minimize stress and reignite professional fulfillment in their work. AMA STEPS Forward is an interactive practice transformation series offering innovative strategies that will allow physicians and their staffs to thrive in the evolving health care environment by working smarter, not harder. Physicians looking to refocus their practice can turn to AMA STEPS Forward for proven, physician-developed strategies for confronting common challenges in busy medical practices and devoting more time to caring for patients. While doctors are inclined to always do what is necessary to take care of patients, the AMA-RAND report found that the satisfaction physicians derive from their work is eroding as they spend more time on grueling administrative rules, regulations and paperwork than caring for patients. The report noted that many physicians say that the bureaucratic obstacles to providing patients with high-quality care are major contributors to symptoms of burnout, including emotional fatigue, depersonalization, loss of enthusiasm and early retirement. “Research shows that rates of overall burnout among U.S. physicians approach 40 percent, more than 10 percentage points higher than the general population, which is why the AMA is taking a hands-on approach to meeting their day-to-day concerns through a new online practice transformation series called AMA STEPS Forward,” said AMA Executive Vice President and CEO James L. Madara, MD. “Physicians can find transformative solutions for their medical practices that can foster professional fulfillment by freeing them to enjoy one of the central reasons they chose a career in medicine - to spend more time with their patients and ensure they receive the highest-quality care.” Physicians can access the collection of interactive, online educational modules to help address common practice challenges at www. STEPSforward.org, and also earn continuing medical education credit. There are about 27 modules that include steps for implementation, case studies and downloadable videos, tools and resources. Current modules address four key areas: •Practice efficiency and patient care •Patient health •Physician health •Technology and innovation AMA STEPS Forward is the latest initiative in the AMA’s ongoing strategic commitment to lead and advance the delivery of high-quality and affordable health care. From revitalizing medical practices to ensuring that digital health helps provide high-quality patient care, our goal is to help physicians navigate and succeed in a continually evolving health care environment. Learn more at www.ama-assn.org/go/psps. n

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Medicine and Melancholy “For so your doctors hold it very meet, Seeing too much sadness hath congealed your blood And melancholy is the nurse of frenzy. Therefore they thought it good you hear a play And frame your mind to mirth and merriment, Which bars a thousand harms and lengthens life.” The Taming of the Shrew, Introduction, ii, 133 William Shakespeare [1564-1616]

Dwalia S. South, MD; Ripley

or this month’s themed Journal MSMA, our Managing Editor Karen Evers asked me to do a column reprising the four-part series of “Una Voce” articles done in 2006 on Physician Stress and Burnout. They were perhaps in some respects naively entitled “Never Let Them Call You a Provider.” We dusted off the ten-year-old columns to see how much might be rehashed into a pertinent missive for 2016.

From the Prologue: “The times, they are a changing. Celebrating MSMA’s sesquicentennial at our annual session in Vicksburg in June, one of our speakers was reflecting on the dramatic evolution of medicine over the 150 years since MSMA was born. He then made the prediction that if a physician were to leave medicine today and return after a ten-year hiatus, he would find his world of clinical practice unrecognizable. I don’t find this either difficult to believe or the least bit scary…Now if someone had told me twenty years ago (1986) that in a very short time I would no longer be delivering any babies, setting fractures, or first-assisting at surgery, I would have told him he was absolutely crazy. Full-service general practice medicine was my calling in life and what I was trained to do. Who or what could ever change that? Twenty years ago the idea that my scope of practice would seem limited to the office-based care of intractable back pain, depression, colds, and acid reflux would have been intolerable to me…”

Fast forward and here we are ten years later without the benefit of the ‘hiatus’ (or even a real two week vacation) spoken of earlier and our practices are even more beleaguered and stressful. Some of the infamies and insults to our daily lives that have occurred in these past ten years include: the forced shift to electronic medical records, Obamacare and the headaches incumbent to that debacle, the looming threat of “Meaningful Use” sanctions, Medicare cuts, ICD-10 insanity, and more frequent bureaucratic hoops to jump through with insurance companies (prior approvals, pre-certifications of referrals and procedures). Throw in the strain of the petulant, never-satisfied employers of physicians pressuring for higher quality measure scores and higher volumes of encounters in the ever shrinking ten minute time allotted our poor patients. Throw in the unsavory dealing with the influx of narcotic seeking doctor-shoppers. Throw in whatever other mentally exhausting irritant you can name, and then understand why so many physicians want to throw in the towel. It gives me a headache just thinking about it.

It is worth quoting Dr. Robert M. Wah, President of the AMA, on Physician Wellness and Burnout: “Physicians want to provide our patients with the best care possible, but there are confusing, misaligned, and burdensome regulatory programs that take away the critical time that physicians could be spending to provide high quality care for their patients.”

Let us remind ourselves once again what “physician burnout” really is. The AMA defines it as “a severe state of mental and physical exhaustion and depression, typically the result of excessive and sustained stress, most common to direct care-giving professions.”

JOURNAL MSMA

Burnout usually progresses in three stages: 1. STRESS AROUSAL…evidenced by increased irritability, anxiety, forgetfulness, mood swings, inability to focus or concentrate; stress hormones and blood pressures begin to rise, sleep disturbances become more frequent. 2. CHANGING ENERGY LEVELS…marked by constant fatigue, chronically late and procrastinating tasks, resentment over minor slights, social withdrawal, apathy, reduced libido, headaches, excessive use of caffeine, alcohol, or other substances to get through the day. 3. EMOTIONAL AND PHYSICAL EXHAUSTION…experiencing deep sadness, profound and disabling fatigue, chronic headaches, deterioration of relationships with family, friends and co-workers, progressive worsening of substance misuse and abuse, recurring thoughts of suicide. Since the Journal MSMA printed the physician burnout articles and their accompanying statistics 10 years ago, the problem just keeps getting worse. Not surprisingly, a 2012 national survey published in the Archives of Internal Medicine reported that physicians suffer burnout at a much greater rate than any other American workers do. This year in the Medscape Physician Lifestyle Report published that 46% of physicians across all specialty spectrums responded that they were “BURNED OUT” with the practice of medicine, the highest figure ever. The statistic was even higher for front-line physicians in the primary care, emergency medicine and critical care physician group where a staggering 65% of those surveyed admitted that were indeed suffering from some degree of burnout. But, what can be done about the problem? Dr. Scott Hambleton has done a wonderful job illuminating the problem in this month’s Journal MSMA in his well-written “Physicians’ Health Corner” wellness article. Please read and share it with your colleagues.

•

Around four years ago, my friend Dr. Mark Horne of Laurel was the program chair for the MSMA Young Physicians Section (YPS) “CME in the Sand” meeting. Mark had heard me give a presentation on “Physician Wellness and Burnout Prevention” at that same meeting back during my MSMA Presidential rounds in 2007 and he asked if I would repeat the performance at the Destin meeting that summer. At the time, I was wrestling with too many stressors and literally didn’t know if I was coming or going. As an employed physician (read “provider”), our office had just moved to a brand new clinic building which alone would have been a major trauma transferring 25 years worth of the accumulated sundry detritus of a medical practice. However, then there was the simultaneous edict that all paper charts would disappear to an incinerator with the move and I would have to master the EHR or be left out in the cold. To boot, my eldest son was embroiled in a custody battle for his daughter following a bitter divorce. The angst over that had so upset my 91-year-old Mother that she suffered a stroke, which left her demented, agitated, and unmanageable. My only sibling and her husband were unable to help me much in that situation as I was beginning to realize that she was developing memory loss and personality changes which later proved to be Alzheimer’s disease. Well, there’s more, but I won’t belabor my case. Let’s just say I had to tell Dr. Horne “Thank you, I’m honored, but, no, thank you!” to his request for me to lecture on “Burnout Prevention.” He graciously understood. I told Mark that it would have been a totally hypocritical sermon coming from one teetering on the brink of burnout herself. This experience illuminated to me that often it is not just what’s going on in our medical practice that triggers burnout; there is a cumulative effect from the whole spectrum of the day-to-day dysfunction of our lives. Add to the mix that we ourselves are aging right along with our patients. We suffer many of the same painful physical ailments and chronic debilitating diseases as do they. Very often, our own personal tragedies can be the final straw that breaks the overburdened camel’s back.

•

But here I sit, in January of 2016, a snow day off clinic work here in North Mississippi…by my warm fireside… at my computer…a day granted me by the fortune of foul weather to write this column…a day in which a hundred years earlier I would likely never have been given the opportunity to even become a physician… and if I was, I would be out on my horse seeing patients in the sleet and snow today…out in the 21 degree weather in the rugged hill country tonight… delivering babies in drafty dogtrot houses with wailing gravid mothers and clenching my own chattering teeth. I don’t think doctors 100 years ago would bemoan ‘burnout.’ Most of them didn’t have much time to think about the concept. The beloved country doctor simply worked himself into an early grave. I shall complain no more tonight. n Next time: PHYSICIAN SELF-HELP STRATEGIES FOR BURNOUT

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Pen > Sword

xpress your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. 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 clarify ambiguities, to protect our letterwriters. You can submit your letter via email to: KEvers@MSMAonline.com or mail it to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.

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JOHN C. NEILL, MD, OF JACKSON— This month’s

physician portrait is of Dr. John Chalmers Neill of Jackson, a widely admired neurosurgeon and a longtime member of our MSMA. After 29 years of active neurosurgical practice, he retired last June from New South Neurospine. Born in Jackson to Dr. Charles L. and Mary McCallum Neill, he attended local schools and went to college at Ole Miss, where he studied English. He then got his MD at UMMC, performed an internship at the University of Arkansas at Little Rock, then residencies in surgery at LSU in New Orleans (back when Charity would supply an up and coming surgeon plenty of “blood and guts.”). He then returned to UMMC to begin his extended training in Neurosurgery, which was complemented by a year of neurosurgical work in Toronto, Canada at the Sick Children’s Hospital. John’s father Charles and his uncle Walter Neill were among the first neurosurgeons in Mississippi. A fifth generation physician and a second generation neurosurgeon, John married Olivia Watson, the daughter of the first neurosurgeon in Arkansas (Charles Robert Watson, MD, of Little Rock). A couple well-matched, they have two sons, Bob and Jack. Bob is a Dartmouth and Vanderbilt educated businessman living in South America, and Jack is a Rhodes, Mississippi College, and UMMC educated physician following his father into surgery, now training at UMMC. (I have often reflected privately that Hippocrates and Sir William Osler would have smiled happily on the union of John and Olivia: the daughter of a doctor marrying a doctor who was the son of a doctor, probably the best sort of couple to mother, father, and rear future physicians.) John jokes that he always tried to follow the “Frank Buck School of Neurosurgery” mantra about patients and surgery: “Bring them back alive.” Besides his exemplary surgical skills, John possessed a reputation for excellent patient interaction and bedside care, skills often deemphasized in modern specialty training. I frequently quote to my medical students his caveat that “the best diagnostic test is a follow-up exam,” with hopes that in their future practices they will understand that the right answers in medicine aren’t usually apparent or achievable on first encounter. The only reason John is allowing me to publish his photograph is his interest in medical history and where this photograph is taken. John is shown here at the grave of the father of modern Neurosurgery, Dr. Harvey Williams Cushing (1869-1939), who is buried with an unpretentious marker among his family members at the historic and lovely Lake View Cemetery in Cleveland, Ohio (Section 10, Lot 57). In addition to his brilliant career founding the modern profession of neurosurgery, Cushing is also remembered as the great biographer of his teacher Osler. John and I both highly recommend Cushing’s massive Life of Osler to modern physicians as the greatest physician biography ever written. (The book won a Pulitzer Prize for Cushing in 1926!) A somewhat recent Cushing biography, Harvey Cushing: A Life in Surgery by Michael Bliss (2005) published by Oxford University Press, is also highly recommended. This photo is by Olivia Neill. —Lucius M. Lampton, MD; JMSMA Editor

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