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Have You Considered a Life Settlement For Your Old Life Insurance Policy?

What is a Life Settlement?

A life settlement is the sale of an existing life insurance policy on the secondary market to a third party investor.

Who or What May Qualify?

9 If the person insured by the policy is age 70 or older 9 If the person insured has any major medical conditions 9 If the policy has a death benefit of $250,000 or more 9 Policies including, but not limited to, universal life, term insurance, variable life insurance or whole life insurance 9 If any cash value exists in the policy, the amount is relatively small

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

Why Use a Life Settlement?

9 Term life insurance policy will expire 9 Old policy that is no longer needed or premiums cannot be paid 9 A policy that was purchased for a business buy/sell and is no longer needed 9 A policy was purchased for a business that has been sold or is not needed 9 There may be a better policy available at a lower cost

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

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

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Michael O’Dell, MD AssociAtE Editors Karen A. Evers MAnAging Editor PublicAtions coMMittEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors thE AssociAtion Tim J. Alford, MD President Thomas E. Joiner, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual).

Periodicals postage paid at Jackson, MS and at additional mailing offices.

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

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

ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548.

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

Copyright© 2010, Mississippi State Medical Association.

Official Publication of the MSMA Since 1959

JUlY 2010

volUMe 51

nUMber 7

Scientific ArticleS Management of the Substernal Goiter: A team Approach

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C. Ron Cannon, MD, FACS; Robert Lee, MD, FACS; and Ralph Didlake MD, FACS

clinical Problem-Solving: now You See it, now You Don’t

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Nahid Islam, MD

PreSiDent’S PAGe inaugural Address of the 143rd MSMA President

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Tim J. Alford, MD; MSMA President

eDitoriAl Awestruck

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Michael O’Dell, MD; Associate Editor

relAteD orGAnizAtionS Mississippi State Medical Association information and Quality Healthcare

193 201

DePArtMentS images in Mississippi Medicine Poetry in Medicine the Uncommon thread Placement/classified

200 202 203 204

AboUt tHe cover:

“StArS AnD StriPeS”- Martin M. Pomphrey, Jr., MD, a semi-retired

orthopaedic surgeon sub-specializing in sports medicine who practiced with Oktibbeha County Hospital (OCH) Bone and Joint Clinic, created this cover image from two separate photographs. The pictures were taken on July 4th, 2009 at Old Waverly Country Club in West Point, where they were offering hot air balloon rides. The rope tethered balloon did not go up very high. Dr. Pomphrey superimposed the balloon onto a picture he took of the American flag behind the bandstand. r

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An Academic Medical Center Is Not Like An Ordinary Hospital.

As a physician, you ask more of an Academic Medical Center.

You ask us to invent new ways to diagnose and treat disease.

To lead the medical research that can give us all better lives.

You ask more of University of Mississippi Health Care.

You ask us to offer the highest level of medical care to our mutual patients, every day.

To push the boundaries of what is possible.

This is University of Mississippi Health Care.

Your Academic Medical Center.

Expect more.

Talk doctor-to-doctor at 866.UMC.DOCS or learn more at umhc.com.

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• SCieNtiFiC ARtiCleS •

Management of the Substernal Goiter: A Team Approach C. Ron Cannon, MD, FACS; Robert Lee, MD, FACS and Ralph Didlake, MD, FACS

A

bStrAct

Objectives: Review the diagnosis and management of patients with substernal goiter. Study Design: Retrospective study of a series of patients treated for substernal goiter. Methods: Retrospective chart review of patients with substernal goiter (N = 16). Records were tabulated for demographics, symptoms, physical and CT findings as well as surgical management and comorbidities. Results: Substernal goiter occurs infrequently. Of the seventeen surgical procedures performed in these sixteen patients, only three required a median sternotomy. All of the patients had multinodular goiter. There were no instances of well differentiated thyroid cancer in this series. Co-morbidities were present in each patient. Conclusions: Substernal goiters are often quite large at the time of diagnosis as they enlarge slowly.

The majority of patients can be managed with a cervical approach.

Technological advancements such as the nerve integrity monitor (NIM2; Medtronic Xomed, Jacksonville, Florida) and Harmonic scalpel as well as team approach to surgery are advantageous for the patient.

KeY WorDS:

gOITeR, THyROId glANd, HypOTHyROIdISM, HypeRTHyROIdISM, SubSTeRNAl, THyROIdeCTOMy, MulTINOdulAR gOITeR

introDUction Thyroid disease is becoming much more prevalent. The manifestations are protean, one of which is the development of the substernal goiter. This entity was first described by Haller in 1749. The first resection of a substernal goiter was carried out in 1820 by Klein.1 The

definition of substernal goiter has been variously described as a gland extending 3 cm below the sternal notch.2,3 Others have described the substernal goiter as one in which 50% of the thyroid mass lies within the chest.4,5 The etiology of the substernal goiter is felt to be that of the thyroid gland descending into the chest and not that of ectopic tissue. The thyroid gland descends inferiorly into the chest as this is the path of least resistance.6 The thyroid gland is bound superiorly by the cricoid cartilage, posteriorly by the trachea, esophagus and prevertebral fascia, as well as the vertebrae which prevent upward growth of the thyroid gland. Other factors which may be related to development of a substernal goiter are those of gravity, downward traction on the thyroid gland when swallowing, as well as the negative intrathoracic pressure generated on respiration.

The substernal thyroid gland enters the superior mediastinum at the thoracic inlet. It is bounded by the manubrium in front, laterally by the pleura, posteriorly by the vertebrae, and inferiorly at the level of the fourth thoracic vertebra.7 (Figure 1) The pathology in this area may be broadly grouped together by the acronym “Terrible T’s”- namely that of thyroid disease, thymoma, (terrible) lymphoma and teratoma.

The inferior mediastinum begins at the level of the pericardium is divided into anterior, mid, and posterior compartments. fiGUre 1: CheSt x-RAy iNdiCAtiNg SubSteRNAl gOiteR. ARROwS

iNdiCAte the tRACheA.

AUtHor inforMAtion: Dr. cannon specializes in Otolaryngology – head and Neck Surgery; Primary hospital Affiliation is River Oaks hospital, Flowood, MS, Clinical Professor in the departments of Otolaryngology, Family Medicine, dentistry, and diagnostic Studies at the university of Mississippi Medical Center head and Neck Surgical group. Dr. lee specializes in Cardiovascular - thoracic Surgery; Primary hospital Affiliation is Central Mississippi Medical Center, jackson, MS. Dr. Didlake specializes in Vascular Surgery, Primary hospital Affiliation is River Oaks hospital, Flowood, MS, Professor of Surgery in the department of Surgery at the university of Mississippi Medical Center. he is also director of the Center for bioethics and Medical humanities at the university of Mississippi Medical Center. correSPonDinG AUtHor: C. Ron Cannon, Md, head and Neck Surgical group, 1038 River Oaks drive, Flowood, Mississippi uSA 39236, Office: (601) 932-5244, Fax: (601) 939-0545, email: crcannonhn@bellsouth.net

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In general thyroid masses are slow growing and may be present for many years before being noticed. Over this time interval the patients may have developed comorbidities which enter into decisions regarding management. In general the consensus is to operate unless there are medical contraindications. The surgical approach is generally via a cervical incision; in cases of a very large mass a thoracic incision may be needed as well. In terms of medical management, thyroid supplement can temporarily decrease the size of the mass, but carry the attendant risk of atrial fibrillation and osteoporosis.

Although thyroid masses are most commonly benign, cancer must be considered in the differential diagnosis. Substernal goiters have a risk of malignancy from 3-21%.8 The purpose of the current study is to evaluate the management of patients undergoing surgery for substernal thyroid, the patient’s symptoms, physical findings and radiographic findings. Other areas of study are those of the pathology, the findings at surgery as well as the treatment results. emphasis is put on evaluating the patient’s comorbidities as well as CT scan as part of the preoperative evaluation and a collaborative team effort, the use of technology, particularly in terms of use of the nerve integrity monitor and use of the Harmonic scalpel.

A complete head and neck exam including laryngoscopy was carried out. Neck masses were noted on physical exam in ten patients, the largest measured 10; the smallest measured 2 cm in diameter. One of the patients had a preoperative vocal cord paralysis which resolved after surgery. All the patients were euthyroid. Comorbidities were common and included advanced age, organic heart disease, chronic obstructive pulmonary disease, and obesity (see Table I). Radiographic studies were obtained in each patient. Chest x-ray was the initial study in four patients (Figure 1). A CT scan was obtained in all patients. CT scans commonly demonstrated impingement upon the trachea and a shift of the trachea from the midline. In fact, a shift of the trachea was present in all but three patients (Figure 2). The largest mass noted by CT scan measured 17 cm. fiGUre 2: Ct SCAN ShOwiNg SubSteRNAl gOiteR with tRACheAl COMPReSSiON

MetHoDS A review of 162 thyroidectomies performed by the senior author was carried out. patient demographics, symptoms, physical findings, radiographic findings, surgical approach (cervical or median sternotomy), pathology and complications were noted. CT scans were obtained in each patient at 5 mm intervals from the skull base to the lung hila using contrast.

reSUltS Of the 162 thyroidectomies performed in the review period, substernal goiter was diagnosed in sixteen patients (9.8%). Substernal goiter in this series of patients was defined as extension into the retrosternal area by physical exam or by CT scan. There were eight males and eight females who underwent seventeen surgical procedures (one patient underwent two procedures in a staged fashion). The average age was 62.5 years with a range of 46-84 years of age. Symptoms of the neck mass were present in only four patients. Most were unaware of any pathology. When questioned more closely regarding compressive symptoms such as dysphagia, only three patients noted complaints and shortness of breath was noted in only two patients.

None of the patients presented acutely or had stridor – a testament to the slow growing nature of these substernal goiters. tAble i: Study deMOgRAPhiCS

Patients (n=162) Substernal thyroidectomy : 17 surgical procedures in 16 patients Age 46-84 (Mean 62.5 years) Substernal Thyroidectomy: Lobectomy 13 (10 on right, 3 on left) Total Thyroidectomy 4 Pathology : Goiter (100%)

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The operative technique involved a collar incision in the neck.

The incisions were generally 4 cm or less in size initially, adhering to a minimally invasive approach.9 The nerve integrity monitor was used in all cases to ascertain the status of the recurrent laryngeal nerve (Figure 3). Magnification loupes were used to facilitate dissection in the patients who underwent a non-paralytic type anesthesia. dissection was generally by a “top-down” technique. The recurrent laryngeal fiGUre 3: NeRVe iNtegRity MONitOR. iN thiS NONiNVASiVe teChNique the NeRVe MONitOR iS AttAChed tO A SPeCiAl tyPe eNdOtRACheAl tube AS dePiCted.

StiMulAtiON OF the ReCuRReNt lARyNgeAl NeRVe (RlN) ReSultS iN MOVeMeNt OF the VOCAl CORd whiCh iS theN deteCted by the NeRVe iNtegRity MONitOR tO PROVide iNStANt iNFORMAtiON ON the FuNCtiON OF the

RlN.

nerve was identified by ligating the superior thyroid vessels. The nerve was identified as it enters the larynx and dissected inferiorly in a retrograde fashion. The substernal portion of the thyroid gland is elevated out of the mediastinum using blunt dissection keeping the recurrent laryngeal nerve in sight as the inferior thyroid artery is ligated. The Harmonic scalpel, which causes hemostasis by friction, was used to ligate vessels and aid in the dissection. The parathyroid glands were identified and preserved during the dissection. After the surgical specimen was removed, the posterior aspect of the gland was closely examined and if any devitalized parathyroid tissue present, it was implanted into the sternocleidomastoid muscle (three patients).

Four of the patients underwent total thyroidectomies. The remainder underwent lobectomies. There were ten complete lobectomies performed on the left and three on the right. One patient had a vocal cord paresis noted by nerve integrity monitor at the time of the initial surgery, in which a sternotomy was required. This patient later underwent a completion right thyroidectomy at a later date when the contralateral gland increased in size and the patient developed tracheal compressive symptoms.

Three patients underwent a median sternotomy as part of the procedure. In two of these patients, the substernal goiter was on the left and one on the right side.(Table I) None of these patients underwent a total thyroidectomy out of concern for development of recurrent laryngeal nerve palsy and also their other comorbid conditions. Of the median sternotomy patients, one had a temporary vocal cord paralysis which later resolved. fiGUre 4: MultiNOdulAR gOiteR AS SeeN AFteR exCiSiON

A multinodular goiter was uniformly found in all patients (Figure 4). Additionally, one patient was found to have a focus of ectopic thyroid tissue in her mediastinum. None of the patients had well differentiated thyroid cancer. There was no tracheomalacia noted despite the extrinsic pressure upon the thyroid gland by the enlarged thyroid gland. All of the patients’ vocal cords were examined postoperatively in an office setting. One patient has had a persistent paralysis of his right vocal cord. This is the same patient who had a transient left-sided vocal cord paralysis after his initial median sternotomy procedure. Another patient had a transient left vocal cord paralysis which had resolved without incident by six months postoperatively. There was one patient in the series that had a preoperative left vocal cord paralysis which resolved after removal of a large goiter stretching the recurrent

laryngeal nerve. There were two patients with transient hypocalcemia which resolved without the need for long term calcium therapy.

DiScUSSion Most of the patients in this series were relatively asymptomatic, indicating slow growth of the substernal goiter and the accommodation by the body to this gradual enlargement. patients with stridor, dyspnea and cough are more likely to have significant tracheal narrowing

by CT scan.10 Symptoms of stridor are generally poorly related to CT findings. CT findings such as percent of the mass which is substernal, goiter size at the thoracic inlet, ratio of goiter size to the vertebral body at the thoracic inlet are not related to clinical symptoms. However, symptoms of stridor and shortness of breath should be promptly evaluated including a laryngeal examination and imaging studies such as a chest x-ray or CT scan.

A special mention is made of fine needle aspiration. Fine needle aspiration is considered to be the gold standard in the evaluation of neck masses and also thyroid nodules. However, FNA was not routinely performed in patients in this series. The primary reason is that most of the pathology is in the chest and fine needle aspiration in this area carries the risk of damage to the major vasculature. The clinical decision to operate in these cases was made by findings other than that of fine needle aspiration.

A chest x-ray is a good screening tool in the diagnosis of substernal goiter. However the CT scan is invaluable in the management of the substernal goiter. An axial CT scan demonstrates the size, location and anatomic peculiarities of each substernal goiter. If contrast is used, the relation of the thyroid gland to the surrounding vasculature can be studied. Most goiters are anterior to the center of the trachea, but can be posterior or complex (both anterior and posterior to the trachea).1 A posterior mass raises the index of suspicion for more difficult dissection. Review of the CT scan helps in surgical planning and facilitates discussion of operative considerations with the patient. Additionally, newer CT software packages may allow for imaging in the coronal plane, thus giving further helpful information. CT scan is felt to be more valuable than MRI in evaluating these patients. Other studies generally used in evaluation of thyroid nodules such as thyroid scan and ultrasound are not generally helpful.

Complications of thyroidectomy are well known and include those of recurrent laryngeal nerve palsy and hypocalcemia.(Table II) The rates of transient recurrent laryngeal nerve palsy are 3-15%, the incidence of permanent paralysis is 4-5%.5, 11, 12 In this series, there were two patients with temporary recurrent laryngeal nerve paralysis (12%) and one with permanent paralysis (6%). One of the patients had a preoperative vocal cord paralysis which resolved postoperatively. The rates of hypocalcemia range from 3.4 to 38% in patients undergoing substernal thyroidectomy. permanent rates of hypocalcemia are generally in the range of 2.6%.5, 11, 12 In this series, there were two patients with transient hypocalcemia, but none with permanent hypocalcemia.(11.7%) There were no differences in complications in patients tAble ii: COMPliCAtiONS RLN Palsy

Temporary 12% (2)

Permanent 6% (1)

Hypocalcemia

Temporary 11.7% (2)

Permanent 0% (0)

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with the cervical or sternal splits in the study. This finding is consistent with a study of thirty-five patients with a substernal goiter, of whom twelve underwent sternotomy.12 There were no cases of wound infection, hematoma or death. Indications for a sternal split are generally those of size, cancer, and atypical anatomy, dense scar from previous surgery or inability to deliver the thyroid gland into the neck.13 Surgeries were carried in combination by Otolaryngologist- Head and Neck Surgeon (eNT) and cardiothoracic surgeon. The overlap of skill sets, knowledge of anatomy of different areas and compilation of surgical techniques aid in these difficult surgeries, surgeries which were carried out in a collegial atmosphere. Newer technology in the form of use of the nerve integrity monitor and Harmonic scalpel proved to be of value. For example, after completing a lobectomy if the thresholds using the nerve integrity monitor are elevated (suggesting damage to the recurrent laryngeal nerve), surgery on the opposite side can be deferred. tAble iii: CO-MORbid MediCAl CONditiONS

Cardiovascular * n = 16 Diabetes Mellitus n = 5 Obesity n = 4 Arthritis n = 4 Pulmonary # n = 4 Previous neoplasm n = 3 Miscellaneous + n = 6

1.

2.

3.

4.

5.

7.

8.

9.

every patient in this series had several comorbidities. (Table III) The most common of these included organic heart disease, diabetes mellitus and obesity. There was also one patient who had polio in the distant past. despite these varied and potentially serious medical problems, there were no deaths in the series, complications from these comorbidities, or prolonged hospital stay. It does pose the question of proceeding with a total thyroidectomy with the advantage of avoiding further surgery in the future versus performing a lobectomy only and thus avoiding potential surgical complications and allowing for a shorter anesthesia time.

Our tendency has been to perform a lobectomy; however, as further operative experience is gained there may be a trend to total thyroidectomy. Netterville et al have advocated total thyroidectomy with good results.1 Others have recommended total thyroidectomy, total lobectomy or subtotal lobectomy, depending on the clinical situation.14 Regardless of the the procedure advocated, the literature suggests surgical excision as the treatment of choice. There have been few complications and a low morbidity rate in this series of patients. Not surprisingly the rate of complications is higher in patients undergoing substernal thyroidectomy.15

conclUSion Substernal goiters are often asymptomatic due to their slow growth and may be quite large at the time of diagnosis. Of the varied diagnostic tests, a CT scan is the most valuable as it provides data on size, location and anatomic vagaries. patients with substernal goiter commonly have multiple comor-

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6.

* Includes hypertension, coronary artery disease, hyperlipidemia, organic heart disease, atherosclerosis # Includes COPD, ROAD and pulmonary embolus + Includes osteoporosis gout, polio, renal disease, hepatitis, peptic ulcer

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bid conditions. despite this, surgery is the recommended treatment to avoid tracheal and vascular compromise as well as to exclude the possibility of well differentiated thyroid cancer. Surgery can be carried out with low morbidity and mortality, most commonly via a cervical approach.

A team approach with the use of advanced technology such as the nerve integrity monitor and Harmonic scalpel are valuable adjuncts in the management of patients with substernal goiter.

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10.

11.

12.

13.

14.

15.

Netterville Jl, Coleman SC, Smith JC, et al. Management of substernal goiter. Laryngoscope. 1998; 108:1011-7. batori M, Chatelou e, Straniero A, et al. Substernal goiter. EUR Rev Medial Pharmaco Sci. 2005; 9(6):355-9. batori M, Chatelou e, Straniero A. Surgical treatment of retrosternal goiter. EUR Rev Medial Pharmacol Sci. 2007; 11(4):265-8.

Chow Tl, Chan TT, Suer dT, et al. Surgical management of substernal goiter: local experience. Hong Kong Medical J. 2005; 11(5):360-5.

Agha A, glockzin g, ghali N, et al. Surgical treatment of substernal goiter: An Analysis of 59 patients. Surgery Today. 2008; 38(6):505-1p. lahey FA, Suinton MW. Intrathoracic goiter. Surg Gynecol Obstet. 1934; 59:627-37. gardner e, gray dJ, O'Rahilly R. Anatomy, 3rd ed. philadelphia, Toronto, london: W.b. Saunders Company; 1969:297-298.

Cohen Jp. Substernal goiters and sternotomy. Laryngoscope. 119:683688, April 2009.

Terris dJ, bonnett A, gourin Cg, et al. Minimally invasive thyroidectomy using the sofferman technique. Laryngoscope. 2005; 115(6):1104-8.

Mackle T, Meeney J, Tirem C. Tracheoesophageal compression associated with substernal goiter. Correlation of symptoms with cross sectional imaging findings. J Laryngo Otol. 2007; 121(4):358-61. ben Nun A, Soudack M. Retrosternal thyroid goiter:15 years experience.

ISR Med Assoc J. 2006; 8(2):106-9.

Sancho JJ, Kraimps Jl, Sanchez-blanco JM, et al. Increased mortality and morbidity associated with thyroidectomy for intrathoracic goiters reaching the carina tracheal. Arch Surg. 2006; 141(1):82-5. de perrot M, Fadel e, Mercier O. Surgical management of mediastinal goiters: when is a sternotomy required? Thoracic Cardiovasc Surg. 2007; 55(1):39-43. possetto b, liquori g, Rombola F. Substernal goiter: A diagnostic and therapeutic problem. (Report of 39 surgically treated cases). Ann Star Chir. 1999; 70(1):29-35. pieracci FM, Fahey TJ. Substernal thyroidectomy is associated with increased morbidity and mortality as compared with conventional cervical thyroidectomy. Am J Surg. 205(1):1-7, July 2007.

PLEASE TELL OUR ADVERTISERS THAT YOU FOUND THEM IN THE

• CliNiCAl PRObleM-SOlViNg • Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair

Now You See It, Now You Don’t Nahid Islam, MD

A

70-year-old African-American male presented to the emergency department with chest pain. The pain was located in the middle of his chest with no radiation, and the duration of the pain was about 2 days. The pain was described as an intermittent burning sensation, and each episode lasted about 5-6 minutes, 2 to 3 times daily. The intensity was 10/10. He reported shortness of breath and excessive sweating but could not specify any relieving or aggravating factors. He also complained of a dry cough and unusually rapid beating of the heart. He had similar episodes of chest pain last year but those were not as severe. He had lost about 40 pounds during the previous 8 months. He denied fever, headache, nausea, vomiting, abdominal pain or hemoptysis.

He had a past medical history of hypertension (HTN) and tobacco dependence. He denied any other medical illness including diabetes or prior cardiac problems. His medications included atenolol (Tenormin) 25mg and an angiotensin converting enzyme inhibitor/hydrochlorothiazide (Zestoretic) 10/12.5 mg for his blood pressure. He denied any cocaine or other illicit drug use. based on his age, sudden onset of chest pain, shortness of breath and diaphoresis, a diagnosis of angina pectoris or myocardial infarction (MI) should be on the top of the differential diagnoses. patients with gastrointestinal disorders such as esophageal reflux, esophageal spasm, esophagitis and peptic ulcer disease may present with chest pain. For an acute presentation, pancreatitis and cholecystitis are likely. Acute abdominal pain is a common ed presentation, and related chest pain is not unusual. patients with pulmonary embolism can present with acute chest pain and diaphoresis. given his negative chest radiograph and the absence of fever, pneumonia is unlikely. Other conditions such as chest wall pain or panic attack should also be in the differential.

We established IV access and gave oxygen by nasal cannula.

AUtHor inforMAtion: nahid islam, MD is a third year resident in the department of Family Medicine at the university of Mississippi Medical Center. correSPonDinG AUtHor: Nahid islam, Md, 2500 N. State Street, department of Family Medicine, university of Mississippi Medical Center, jackson, MS 39216; telephone: 601984-5826 (office), Fax: 601-984-6889, e-mail: nislam@medicine.umc.edu

On physical examination, his vital signs were within normal limits except for his heart rate of 58 beats per minute and an elevated blood pressure of 172/79 mm Hg. Cardiac examination revealed a regular rate and rhythm and no jugular venous distension. Pulmonary and abdominal examinations did not show any abnormality. EKG showed sinus bradycardia, left anterior fascicular block and ST/T wave abnormality. When compared with previous EKG, no significant changes were noticed. CBC, serum amylase and lipase, and the first set of cardiac enzymes were within normal limits. Chest radiograph showed mildly prominent interstitial markings in the lower left lung. His blood urea nitrogen (21 mg/dL) and creatinine (1.6 mg/dL) were elevated.

The initial treatment was a mixture of Maalox, Donnatal, and Xylocaine (GI cocktail) for presumed esophageal reflux; this provided no relief. He was also treated with aspirin 325 mg orally, morphine 2 mg and hydralazine 10 mg intravenously. He became somewhat drowsy but his pain was not relieved. The addition of nitroglycerin spray provided much pain relief. We noticed that his pulse increased to 140 beats per minute each time the pain started and normalized as the pain was relieved.

The patient has no history of reflux or other gastrointestinal problems and experiences no symptom relief from the gI cocktail; therefore, our index of suspicion for reflux is lowered. pancreatitis or cholecystitis is not apparent, as serum amylase and lipase are within normal limits, pain is non-radiating and Murphy’s sign is absent. With costochondritis, point tenderness is common. His normal oxygen saturation, chest radiograph and absence of pain related to breathing did not indicate pulmonary embolism, pneumonia or pleurisy, although these possibilities are not excluded. Though the initial cardiac enzymes and eKg did not differentiate between acute myocardial ischemia and non-cardiac cause of chest pain, we decided to pursue further investigation for unstable angina.

The cardiology consultant ordered a catheterization that required administration of eptifibatide (Integrilin); therefore, the patient was admitted to the Coronary Care Unit. The patient was given nothing by mouth and was started on a nitroglycerin infujuly

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sion at 3cc/hr, eptifibatide (Integrilin) per protocol and simvastatin (Zocor). He was also treated with low molecular weight heparin (Lovenox) one time only. His lisinopril was held due to his elevated BUN and creatinine but aspirin and atenolol were continued. An echocardiogram, basic metabolic panel (BMP), lipid panel and another two sets of cardiac enzymes were scheduled for the next morning. The repeat cardiac enzymes were normal, and his BMP was within normal limit except for elevated BUN (28 mg/dL) and creatinine (1.8 mg/dL). Lipid panel showed a normal triglyceride, total cholesterol and LDL; his HDL was 30 mg/dL. Echocardiogram showed left ventricular hypertrophy with ejection fraction of 70% and aortic valve sclerosis. As no obvious cause of pain could be found, the cardiologist recommended cardiac catheterization and stent placement if indicated. The patient continued to have chest pain, and on each episode his heart rate increased.

Cardiac catheterization done the following day showed a critical mid circumflex stenosis, smooth type (70%) within a large middle left anterior descending artery and concentric 70% stenosis within the proximal right coronary artery. based on these findings, our diagnostic impression is 3 vessel coronary artery disease (CAd).

The cardiologist prepared to place stents primarily in the middle left anterior descending (LAD) artery. Before placing the stents, he performed balloon inflation and repeated flush out. Astonishingly, no apparent lesion was detected in the LAD. To exclude Prinzmetal’s angina the cardiologist gave intracoronary nitroglycerin at a dose of 200 mcg. This resulted in the total disappearance of middle LAD stenosis.

The total disappearance of middle lAd stenosis after giving vasodilators such as nitroglycerin is not consistent with 3 vessel CAd. CAd is characterized by the presence of atherosclerotic plaque in the coronary arteries that narrows the lumen and impairs the blood flow.

The disappearance of middle lAd stenosis is more consistent with coronary artery spasm.

Our patient is a 70-year-old male smoker with no history of cocaine use who presented with chest pain. His eKg on admission did not show any significant changes in his ST segment. during coronary catheterization, the middle lAd stenosis seen initially was relieved with nitroglycerin infusion. This finding confirmed the diagnosis of coronary artery vasospasm (prinzmetal’s angina). As such, the patient's presenting complaint of chest pain was likely the cause of vasospasm as opposed to diffuse coronary artery disease. beta blockers are used for treatment of HTN, MI, and arrhythmia as well as angina. Selective beta blockers are chosen for their specific action on the heart. but a beta blocker is contraindicated in prinzmetal’s angina as it only works on the beta 1 receptor. It can exacerbate coronary vasospasm by exposing the heart to unopposed alpha stimulation.1 Our patient had been prescribed metoprolol, a nonselective beta blocker, as a first line treatment for hypertension. He had intermittent mild chest pain while taking this medication. He was switched to atenolol, a selective beta blocker 2 weeks before he started having severe episodes of chest pain. The use of the selective beta blocker could have lead to worsening of his chest pain.

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Our patient tolerated the coronary angiography well and was prescribed nitrites, a calcium channel blocker and aspirin per cardiology recommendation. The following day he did not have chest pain. He was discharged home with these medications and follow up appointments with both the primary care physician and cardiologist were set for 2 weeks. The patient was seen in clinic 2 weeks after discharge. He had 2 more episodes of chest pain, which were relieved with nitroglycerin spray, and he was feeling much better. prinzmetal’s angina, also known as variant angina, was initially described by dr. Myron prinzmetal.2 It is a spontaneous episode of chest pain at rest secondary to myocardial ischemia.3 usually it is a focal coronary artery vasospasm, although diffuse spasm has also been described.4 The natural history of this disease is not fully understood.3 The prevalence of variant angina is unknown but it appears to be noticeably less common than typical stable angina and unstable angina at rest.14 Japanese people have higher relative incidence and more diffuse spasm than others. Men represent 69-91% of reported cases with a mean age of 51-57 years.13 Cigarette smoking is a common risk factor.5,6 It may be associated with MI, Raynaud’s phenomenon and migraine or its treatment.7 The autonomic nervous system as well as endothelial dysfunction play a role in the pathogenesis of prinzmetal’s angina. Abnormality of normal vasodilator function and hypersensitivity of the coronary arteries to mediators of vasoconstrictors also have been reported.6 Investigations include eKg, which can show transient ST segment elevation; exercise tolerance test; coronary angiography, which is the standard procedure; dobutamine echocardiography, which is more sensitive and specific than other tests;8 Holter monitor and provocative test.9 prinzmetal’s Angina is treated by vasodilators such as nitrites, calcium channel blockers and cholesterol lowering agents such as statins. percutaneous coronary intervention might be helpful if obstructive coronary disease is present.10 Medications contraindicated are beta blockers, aspirin and sumatriptan. estrogen has beneficial effect on endothelium but it is not recommended due to the adverse effect it has on cardiovascular system.11 The prognosis of prinzmetal’s angina is good with more than 95% overall survival at 5 years if no obstructive coronary artery disease is present. A worse prognosis is associated with concurrent coronary artery disease and complications of arrhythmia. Calcium channel blockers may improve survival and symptoms.12

KeY WorDS:

CHeST pAIN, eleCTROCARdIOgRAM, beTA blOCKeR

referenceS 1.

2.

3.

yasue H, Touyama M, Kato H, Tanaka S, Akiyama F. prinzmetal's variant form of angina as a manifestation of alpha-adrenergic receptormediated coronary artery spasm: documentation by coronary arteriography. Am Heart J. 1976; 91:148-155. prinzmetal M, Kennamer R, Merliss R, Wada T, bor N. Angina pectoris: I- A variant form of angina pectoris; preliminary report. SM J Med. 1959;27:375-388.

Mishra pK. Variations in presentations and various options in

management of variant angina. Eur J Cardiothorac Surg. 2006;29:748759.

Okumura K, yasue H, Matsuyama K, et al. diffuse disorder of coronary artery vasomotility in patients with coronary spastic angina.

Hyperreactivity to the constrictor effects of acetylcholine and the dilator effects of nitroglycerin. J Am Coll Cardiol. 1996;27(1):45-52.

Sugiishi M, Tkatsu K. Cigarette smoking is a major risk factor for coronary spasm. Circulation.1993; 87:76-79. yasue H, Kugiyama K. Coronary spasm: clinical features and pathogenesis. Intern Med. 1997; 36 (11):760-765.

Nakamura y, Shinozaki N, Hirasawa M, et al. prevalence of migraine and Raynaud's phenomenon in Japanese patients with vasospastic angina. Jpn Circ J. 2000;64(4):239-242.

Kawano H, Fujii H, Motoyama T, Kugiyama K, Ogawa H, yasue H. Myocardial ischemia due to coronary artery spasm during dobutamine stress echocardiography. Am J Cardiol. 2000;85(1):26-30. previtali M, Ardissino d, bargeris p, et al. Hyperventilation and ergonovine tests in prinzmetal’s variant angina pectoris in men. Am J Cardiology. 1989;63:17-20.

Corcos T, david pR, bourassa Mg, et al. percutaneous transluminal coronary angioplasty for the treatment of variant angina. J Am Coll Cardiol. 1985;5(5):1046-1054.

Rossouw Je, Anderson gl, prentice Rl, et al. Risks and benefits of the estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial.

JAMA. 2002;288:321-333. yasue H, Takizawa d, Nagoa M, et al. long term prognosis of patients with variant angina and influetial factors. Circulation. 1988;78:1-9.

Mesari A, Severi S, Nes Md, et al. “Variant” angina: one aspect of a continuous spectrum of vasospastic myocardial ischemia. pathogenetic mechanisms, estimated incidence and clinical and coronary arteriographic findings in 138 patients. Am J Cardiol. 1978;42(6):10191035.

Mayer S. Hillis ld. prinzmetal’s variant angina. Clin Cardiol.

1998;21(4):243-246.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

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There’s a lot going on in organized medicine so it’s easy to miss something if you’re on the go. To help you stay in touch no matter where you are, MSMA is now communicating via “Twitter.”

In about three minutes, you can set up a free Twitter account for yourself. Simply visit www.twitter. com and submit your name, email address and mobile phone number (optional, standard text messaging rates apply). Once you’re signed up with Twitter, you can add MSMA by going to the following web page http://twitter.com/ MSMA1 and clicking “Follow” next to the MSMA icon.

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• PReSideNt’S PAge •

Inaugural Address of the 143rd MSMA President

I

t is a singular honor to speak to you this evening as the newly installed president of the Mississippi State Medical Association. Our Association is engaged on so many fronts but this evening I shall limit my comments to three areas: children’s education, the Medical Home, and physician workforce. before I get too far into this I want to thank Mary Al, my wife, senior editor, and best friend for her understanding and support over the past 30 years. Mary Al tiM J. AlforD, MD inherited her mother and father’s intellect, but more than that their strong sense of 2010-11 MSMA PreSiDent service. If Mary Cobb had not been a public health nurse, I believe that she would have been a nun. She is the best Catholic I know! but Alton won out and Mary Al is appropriately named for both. you know of so many of Alton’s accomplishments, but you may not know that he is soon to be a great-grandfather. I apologize to Timothy, leah, and John paul for getting short-changed by their father because of the competing forces of a busy medical practice.

It goes without saying that dr. Randy easterling has worked tirelessly in his role as president this year. A special thanks to Janie, his devoted wife and Matt and Megan. Also, thank you to Charmain and her executive Staff for going above and beyond to work for the betterment of this organization. Thanks to Sondra pinson and the Alliance for all of their work this past year including the “did you Know- go” campaign. I look forward to working with louise lampton as the Alliance takes their Healthy Food for Children Campaign to the next level.

Also, thanks to Steve demotropolis, Chairman of the MSMA board, who helped the board work through its share of challenges. your board of Trustees is now ready to help this organization move our state off the bottom with regard to Mississippi’s overall health status.

Tonight I hope you will think along with me as I talk about a strategy to begin this “lift-off.” Some have called for an action plan but action plans leave room to fail so I prefer to consider a “do-list.” This list is short but doable. First, be more actively involved in the comprehensive school education curriculum. Second, encourage implementation of county pilot programs for the patient centered medical home. Third, assist uMC with continued efforts to enhance the statewide physician workforce as expeditiously as possible. before I share details of these three items, let me digress for a moment to my early memories from childhood and MSMA. I think it will help for you to understand why I am moved in such a direction.

My first act as a member of the Mississippi State Medical Association was to deliver the invocation at a winter meeting some 25 years ago at the Holiday Inn in downtown Jackson. Shortly after the prayer an 18-foot tall partition door came off its hinges falling like a great oak tree and striking dr. John Fair lucas’ late wife, Sethelle, on the head. John Fair held pressure as dr. Richard Miller arranged for one of his house staff to sew her up. As she was coming to, Sethelle looked up at me and said, “Timmy, that was one hell of a prayer!” Her affectionate use of “Timmy” gave our history away as we both shared the hometown of greenwood, Mississippi. greenwood was considered more of a town than a village but in terms of the proverb, Sethelle lucas had helped raise me. Her husband, dr. John Fair lucas, is one of many remarkable physicians living in greenwood, immersing himself in a community during a most combustible time in Mississippi history – the fifties and sixties. Another notable greenwood physician was dr. Reed Carroll who had completed his surgical residency at Johns Hopkins. A Renaissance man, dr. Carroll was also a finalist for the National Forestry Award and graduated a whole army of eagle Scouts into our midst in

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greenwood. His wife, evelyn, a former Ob nurse at Hopkins, with her steely, soft voice, had a calming effect on the many children who frequented their household on River Road in greenwood – myself included.

When I was around two years old dr. Howard Nelson, also of greenwood, was elected president of the Mississippi State Medical Association. This was in 1957-58. later on in the 1960’s I recall riding with my dad, dr. John Alford, to make a special delivery to the Nelson Home. dad brought a load of cow fertilizer from his farm in Carroll County to be used in Howard and elma Nelson’s immaculate flowerbeds. dad and dr. Nelson stood across a split rail fence from one another and argued. I remember it as if it were yesterday. dr. Nelson always animated his words – sharp, terse and humorous. Their discussion must have been along political lines. The reason I know this is that one was a democrat, the other a Republican and there was a load of manure involved.

It was during this time that greenwood, Mississippi, and the American Medical Association confronted the issue of racism. In the book, The Good Doctors, John dittmer speaks of the AMA’s refusal to deal with racial and religious discrimination. The Massachusetts Medical Society had submitted a resolution at the annual meeting to banish or eliminate any medical society that excluded physicians on racial or religious grounds. The AMA leadership held fast to its position of “no action necessary” because in the words of the AMA president, “We cannot find a single society where discrimination exists.”

It was Mississippi’s MSMA president, dr. Howard Nelson, who rose to sway and stir the audience by stating that Mississippi’s two-man delegation supported the anti-discrimination resolution presented by Massachusetts. Following a round of applause, the House of delegates overrode the reference committee and took the first official steps toward ending discrimination. A two-man delegation from all places – Mississippi – in the midst of the civil rights strife of the 1960’s provided leadership within the country’s leading medical organization.

These were turbulent times growing up in the Mississippi delta. As the courts moved to enforce Brown v Board of Education, massive white flight ensued within the greenwood public schools – and in public schools throughout Mississippi. My parents made certain that my brother peter and I did not fly anywhere and dr. Carroll’s family did as well. We stayed grounded in the public schools and this stand brought much ridicule from the local citizens’ council. My mother wrote a piece in the greenwood Commonwealth in support of public education.

Afterwards our phone would ring every fifteen minutes after bedtime. These frightening, harassing phone calls ceased when dad spoke with the head of the Citizens Council who also happened to be his patient! you must be wondering why I present these stories of my formative years in greenwood. Several significant life lessons are derived from this reflection and sometimes the future is forged by the lessons of our past. First, it does not really matter with which political party we are affiliated. We should acknowledge the bad and seek the good in both even if we find ourselves dealing with a pile of manure from time to time. Secondly, a two-man delegation has proven to be effective in doing the right thing. This is important because our own MSMA delegation is about to go from 7 members to two as a result of the recent house action to de-unify. Thirdly, like dr. Carroll, we must exemplify positive involvement in our communities even if we don’t produce an eagle Scout. Our influence and example are far-reaching. perhaps the most important lesson learned is that mothers often speak softly but mean what they say. I can still hear my own mother reminding me almost daily, “Timmy, be ye kind one to another.” Timothy, leah, and John paul, our children, heard the New Revised Standard Version each and every day as they departed for school, as Mary Al’s admonition was “be kind to others.”

These lessons derived from my home front are what inspire me to lead this Association at this time and from which I derive my commitment to health education, the Medical Home, and our medical teaching programs.

My entry into organized medicine began twenty-five years ago as a member of the young physicians Section of the AMA during its formative time. I apprenticed with an AMA delegation then that saw dr. Sidney graves as Chairman – also known as “The godfather.” Other notable members of the delegation included doctors elmer Nix, lamar Weems, Mal Morgan, Carl evers, Jimmy Waites, bill gates, ed Hill and Alton Cobb. Since dr. lamar Weems had given me a 79 as a final grade on my urology exam in medical school, I took pleasure in observing The godfather put lamar in his place more than once.

This distinguished delegation and those that came fore and aft contributed to the betterment of health in the united States and Mississippi.

For more than 160 years the AMA work has remained focused on its founding principles of the advancement of science, ethics, and the public’s health. Without the influence and leadership of the AMA, we might still see the health landscape ravaged by such threats to the public health as small pox, polio, and tuberculosis. Without the AMA’s leadership, would we have legal limits for driving under the influence of alcohol?

Would we have seatbelt restraint laws or airplanes that are not smoke filled? Absent the AMA’s leadership, would the tobacco industry have open access into the minds of young children with a modern version of the Marlboro Man? july

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To de-unify from the very organization that gave us life saddens me. For decades AMA members have found the wisdom and courage to work through their differences for the greater good in health care. I recognize that many in this association do not share this historical perspective. However, as population dynamics play even more into the public health equation, it is naïve to assume that a strong national organization will not become more relevant.

Over the past year dr. Randy easterling has provided MSMA a steady hand through very turbulent waters. I believe that dr. easterling encouraged the House of delegates to make the right call under the circumstances. As a result, our MSMA membership has increased in contrast to many other states. This is in large part due to the efforts of doctors Claude brunson and James Keeton at uMC and dr. Fred McMillan with the Mississippi physicians Care Network (MpCN) who worked tirelessly along with Charmain to deliver the uMC faculty into the ranks of our membership- some 400 members - pushing our total membership to over 3,850. I trust we will remember dr. easterling’s consistent message during those days – we must keep a strong state medical organization, which is essential to the health of our patients. It must be said that every MSMA board member has maintained AMA membership because of the reality that this organization remains the strongest collective voice for medicine in our country.

We do have our problems, though and according to our own public Health Report Card, more than our fair share! We are first in the nation in adult obesity and our patients are the least physically active in the country; second in the nation in heart disease mortality, diabetes, and hypertension; highest in the nation in traffic fatalities; and ¼ of our children have not been sufficiently immunized.

I am sure that you have heard variations on this list ad nauseum. We are very good at documenting our failures but two years in a row of publicity from these statistics begs for a plan of action. So once again, here is my suggested “to-do” list: 1) Further enhance comprehensive health education for all of our children.

2) embrace the new model of care, the patient Centered Medical Home.

3) Assist our medical center in meeting our physician workforce needs statewide.

Remembering one former AMA president’s refrain that “knowledge doesn’t change behavior, good habits do” we should recognize that the Office of Healthy Schools is implementing the Comprehensive School Health education Curriculum – the same one that dr. ed Hill spoke of ten years ago. The Amory School district among other districts, reports marked improvement in reading comprehension and state test scores with the implementation of fully unadulterated comprehensive school health curriculum. So, early education improves public health and in turn good public health improves a child’s capacity to learn. dr. Hill’s vision is literally bearing fruit as real fruits and vegetables are presented on school lunch trays so that kids will really eat them. Sugar beverages have been eliminated and physical activity and education is more coordinated and organized, not just a coach twirling his whistle in study hall. As a part of this plan there are health councils in each school district looking for direction from local physicians. This comprehensive curriculum addresses each one of the indicators I cited earlier – obesity, physical activity, and safety and we should do all that we can to support this initiative. This is where the Alliance will play a key role by helping school food service staffs revolutionize food quality and presentation.

I believe the second component of my “to do” list will be revealed with the new model of care now surfacing on Mississippi’s health horizon called the patient Centered Medical Home. Medical Home legislation House bill 1192 was delivered quietly and without fanfare by MSMA and will empower the establishment of medical homes throughout the State through public/private collaboration with the State department of Health. dr. Currier at the Health department has already initiated a work group in this regard. This physician driven model has proven successful in several states including North and South Carolina, both of which have similar demographics to Mississippi. It is obvious that it is in the best interest of Mississippi for all citizens to receive their health care in the most cost effective way and for each patient to have a medical home. you will be hearing more about the medical home concept, but in the meantime please know that the American College of physicians, the American Academy of pediatrics, the American Osteopathic Association, and the American Academy of Family physicians have agreed upon joint principles of care that are common to the medical home model. lest I watch all of your eyes glaze over as I recite these principles, I will spare you at this time and I ask you for a moment to think of your own homes. Can we all agree that home is where we learn good habits? At least for me, home was where I learned to eat fresh fruits and vegetables. Home is a place to seek refuge where you are accepted, broke or broken. If you don’t come home, someone comes to find you! Home is where relationships begin. In the patient Centered Medical Home, the doctor-patient relationship is the main commodity. If this sounds too lofty and undoable, consider this. Corporations such as IbM have seized upon this concept and help constitute a 500-member primary care collaborative of employers, insurers and other consumers of health care. In these transformed practices healing has begun in a fragmented and fractured system. ladies and gentlemen, “this is a big deal.”

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For too long we have been bogged down in the intractable question, “Is health care a right or a privilege?” A more relevant question may be “Is it in the best interest of communities for every individual to have a personal relationship with a primary care physician?”

The final item on the to-do list is enhanced communication with our medical center so that the health workforce needs are of the highest priority. A larger, stronger, better-trained physician workforce is needed even if that includes decentralizing training to other parts of the state. dr. Richard Roberts, former AAFp president and president-elect of the World Organization of Family doctors, has long held that the Mississippi delta cries out for a community based family medicine residency program. Also, rural tracks for such training could be part of the solution.

The Rural Scholars program, a collaborative effort between MAFp and MSMA, is providing a solution to one of the great deterrents to medical student specialty choice – tuition! Janie guice continues to lead this program on a most successful path and thanks to her leadership and the support of MAFp and MSMA, the fund was not only reappropriated by the legislature but also significantly increased in this session.

Thirty scholarships at $30,000 per student per year go a long way toward addressing the crisis of primary care access in our State. Our job will be to assure the next level of funding for this essential program.

In closing tonight, I would like to share some words from dr. Howard Nelson of greenwood. In addressing the MSMA House of delegates as Vice-Speaker, dr. Nelson said, “We are challenged to make our best even better, our vision keener, our policies more penetrating and farther reaching. Shall we say that we are unique among people in the burdens we bear? Hardly so, for we are caught up in a time which defies definition, frustrates logic, and casts aside the new for the newer, even before it becomes the familiar.”

It is my hope that we can move beyond mere recitation of our plight and laying blame. While our problems are not unique, solutions are at hand but action is required. We are privileged to follow in the footsteps of so many quiet but courageous physicians who sought the best for their patients and their communities. let us remain committed to their legacy of healing. l.V. Hull, folk artist, philosopher, and one of my patients, died last spring. Frequently she would come to the office with a basket full of art ranging from painted Clorox bottles to shoes to pieces of lumber. She would share with patients and office staff alike and her artwork still decorates our office. I believe l.V. gave generously to all of us in our office because she knew this was a place where she could receive comfort and rest although she was not always completely satisfied with her medical home! In one of her last visits she presented me with a plaque – words colorfully painted on an old board that stated, “To dr. Alford, thank you for being a verb!” What I think l.V. meant is that nouns are just things and verbs show action – they are doers. If l.V. were alive today I would commission her to create a similar piece for all of us, “MSMA, be a Verb for your patients!” let us get on with the “do” list. Thank you for affording me the privilege of being your president.

Tim J. Alford, MD President, Mississippi State Medical Association

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• editORiAl •

Awestruck

I

am in awe of the national anthem. I am a patriot, having served my country for over two decades in the Navy Reserve and retiring as a Navy Captain (O-6).

My patriotism, however, is not what provokes my feelings of awe regarding the “Star Spangled banner.” To explain my feeling of awe, consider as an example the singing of the national anthem at a Royals game. I am awestruck by 30,000 plus people doing the same thing, at the same time, for a common purpose.

Over eight years ago, I joined North Mississippi Health Services (NMHS). Much of my attraction to NMHS was the sense of common purpose regarding the organization’s commitment to serving the people of the region. The sense of serving neighbors and family is emotionally palpable at NMHS. being at NMHS has been rewarding and fulfilling in this regard. Six-thousand five-hundred people work together successfully to better the health of people in the region. I am awestruck again.

Tupelo, Mississippi is a community that understands “better Together.” Having enjoyed living in various areas of our country, it is natural for me to compare communities. I place Tupelo well in the lead in community unity and purposefulness. The we CONgRAtulAte JMSMA ASSOCiAte editOR Dr. MicHAel o’Dell ON the biRth OF hiS FiRSt sense of togetherness, shared destiny, and commitment, so apparent in Tupelo, have gRANdSON, ANd wiSh hiM well AS he RetuRNS tO provided me many moments of pleasure. I am awestruck again. hiS Old StOMPiNg gROuNdS hAViNg ACCePted the Various medical leaders conspired in developing Mississippi’s Rural physicians POSitiON OF ChAiR OF the dePARtMeNt OF FAMily Scholarship program, created by the legislature in 2007. Members of the legislature, ANd COMMuNity MediCiNe At uNiVeRSity OF MiSSOuRi At KANSAS City. dR. O’dell ObtAiNed university of Mississippi Medical Center, and medical leaders found common ground, hiS MediCAl degRee FROM the uNiVeRSity OF helping rural students and rural communities satisfy needs for development of physicians KANSAS SChOOl OF MediCiNe. he beCAMe A PROud to serve rural patients. Janie guice and members of the committee that lead this program gRANdFAtheR with the biRth OF gRANdSON, now have dozens of interested students and scholars working towards returning as AubRey. AubRey wAS bORN juNe 27 tO hiS dAughteR Kelly ANd heR huSbANd eRiC whO liVe physicians to their rural communities. The legislature has recognized the value of this iN hOuStON, texAS. MSMA PReSideNt dR. tiM effort and provided funding even in tough times. This experience for me may go beyond AlFORd APPOiNted dR. RiCK deShAzO tO Fill dR. being awestruck. It seems work of the divine to me!

Odell’S POSitiON AS ASSOCiAte editOR FOR the Mississippi can accomplish most anything when leaders work together in this state, JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION, eFFeCtiVe AuguSt 1, 2010. in my opinion. Mississippians working together bear no likeness to the mindless partisan counterproductive belligerence that is poisoning much of the rest of the country. good work and service require respect for others and a commitment to working together, attributes that I have seen so many times in Mississippians.

Clearly, I have deep affection for Mississippi and Mississippians. Many of you know I am leaving though, having accepted the position of Chair of the department of Family and Community Medicine at university of Missouri at Kansas City. I admire yogi berra’s Zen-like knack for holding two opposing concepts together in one statement. So here is my yogi-ism on leaving for Kansas City: “If I were not so happy, I would be sad.” leaving behind Mississippi would have been very difficult for me but for returning home to Kansas City and to a position I have long wished to serve. My affection for Mississippi is unabated.

I have been inspired by living in Mississippi, made stronger, and I hope I have become wiser through my experiences here. I leave with this wish and hope for my fellow physicians in Mississippi. May you increase your joy through working together, bringing forth countless inspired works of service for Mississippians. I will be awestruck by you once again.

—Michael O’Dell, MD Associate Editor

The Pen is Mightier than the Sword! express 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 try to clear up ambiguities, to protect our letter-writers.

you can submit your letter via email to Kevers@MSMAonline.com or mail to the Journal office at MSMA headquarters: p.O. box 2548, Ridgeland, MS 39158-2548.

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• MSMA • Richard D. deShazo, MD Appointed JMSMA Associate Editor MSMA president dr. Tim Alford has appointed dr. Richard d. deShazo to fill the unexpired term of dr. Michael O’dell as associate editor of the Journal of the Mississippi State Medical Association.

“There is no one more capable of bringing good science to the MSMA journal than Rick. Moreover, he understands our unique Southern culture and where and how we can apply that science smartly,” dr. Alford said.

Added Journal editor dr. luke lampton: “Rick is one of the brightest minds in Mississippi medicine. He’s a practicing academic physician who has an extensive background in medical journalism, serving in editorial positions at various medical publications across the country. He is currently associate editor of both the American Journal of Medicine and the Southern Medical Journal. besides his editorial expertise, he’s also a skilled and cognitive writer. I admire very much his outstanding public radio program Southern Remedy. He understands the positive influence this journal can have on our profession and our state’s public health. Rick can help us take ricHArD D. DeSHAzo, MD the Journal to a higher level.” dr. deShazo, Md is billy S. guyton distinguished professor, professor of Medicine and pediatrics in the department of Medicine at the university of Mississippi Medical Center. He also has an active medical practice as a clinical immunologist and cares for patients with allergic and rheumatic disorders. dr. deShazo, a graduate of birmingham-Southern College in birmingham, Alabama, received the Md degree from the university of Alabama at birmingham. He completed an internship in pediatrics at the Children’s Hospital of the university of Alabama at birmingham, residency in internal medicine and fellowship in adult and pediatric allergy/immunology at the Walter Reed Army Medical Center and a research fellowship at the Walter Reed Army Institute of Research in Washington, d.C. He served as the uS Army’s only clinical immunologist for four years after his training and was a guest scientist at the National Institutes of Health during that period. He is board certified in the medical specialties of internal medicine, allergy-immunology, rheumatology and geriatrics. before becoming Chair at the university of Mississippi, he served on the faculties of the uniformed Services university of the Health Services, the university of Colorado School of Medicine, Tulane university and was Chair of Medicine at the university of South Alabama. dr. deShazo has served as a board member of the American board of Allergy and Immunology, the American board of Internal Medicine, the American board of Medical Specialists and the Association of professors of Medicine. He is past president of the Association of professors of Medicine and the Southern Society for Clinical Investigation. He has served on the Council of Academic Specialists of the American Association of Medical Colleges for over 10 years. He is the author or co-author of more than 200 scientific publications in the areas of clinical immunology and has served on the editorial boards of four scientific journals, several NIH study sections and a Federal drug Agency (FdA) Advisory panel. In addition to his two associate journal editorships, he serves on the editorial board on the American Journal of the Medical Sciences and the Annals of Allergy. He has served on the boards of the Alabama Quality Assurance Foundation, Information for Quality Health, and the Mississippi physicians Care Network.

He received a Special Service Award from the American Academy of Allergy, Asthma and Immunology in 1993 for his work as editor of the Primer of Allergy and Immunology and a second Special Service Medal for overall contributions to the specialty in 2006. He was named a distinguished Fellow of the American College of Allergy, Asthma, and Immunology in 2006. Other awards include the u.S. Army Meritorious Service Award, the Hoff Medal of the Walter Reed Army Institute of Research, the Mayor’s Award for Special Service from the City of New Orleans, the bernard berman and Harold Nelson lectureships from the American College of Allergy, Asthma and Immunology, the dr. Robert d. and Alma W. Moreton Original Research Award of the Southern Medical Association and the Founders’ Medal of the Southern Society for Clinical Investigation. He was elected a distinguished Alumnus of birmingham-Southern College, has been consistently listed in best doctors, and is listed in Marquis’ Who’s Who in American Medicine, Who’s Who in the united States and Who’s Who in the World. dr. deShazo has been active in a number of community, civic and religious groups working toward racial reconciliation and has served as an elder in the presbyterian Church and a steward in the Methodist Church. He and his wife, gloria, have three children and four grandchildren.

The deShazo’s enjoy singing in their church choir, gardening, boating, and spending time with friends and family. july

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• MSMA •

thRee yeARS OF the ASSOCiAtiON’S PReSideNCy ARe RePReSeNted, FROM LEFT, Dr. rAnDY eASterlinG OF ViCKSbuRg, iMMediAte PASt PReSideNt, 2009-10; Newly iNAuguRAted PReSideNt Dr. tiMotHY J. AlforD OF KOSCiuSKO, 2010-11; ANd Dr. tHoMAS e. Joiner OF jACKSON, PReSideNt-eleCt, 2011-12.

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MSMA Election Results Announced

uring the 142nd Annual Session of the House of delegates, held in Natchez, June 3-6, our MSMA inaugurated its president and chose its president-elect and other leadership for the 2010-2011 term. dr. Tim J. Alford, who served as president-elect over the past year, was inaugurated as president, and dr. Thomas e. Joiner was elected to serve as president-elect and will represent MSMA as president in 2011-2012. dr. J. Clay Hays, Jr. of Jackson won a second term as secretary of the association. during the inauguration ceremony, president dr. Alford, a Kosciusko native, acknowledged Mississippi’s health issues, including obesity, heart disease, and diabetes, and encouraged MSMA members to be proactive for the sake of patients. “It is my hope that we can move beyond mere recitation of our plight and laying blame. While our problems are not unique, solutions are at hand but action is required,” he said. dr.

Alford’s goals for his tenure include enhancing comprehensive health education for children, establishing public/private collaborative patient medical homes throughout the state, and improving and enlarging the physician workforce through better communication with our state medical center. He is a member of the American Academy of Family physicians, where he served as chairman of the Commission on legislation for two years, the Mississippi Academy of Family physicians, and the American Medical Association (AMA). employed by premier Medical Management of the Kosciusko Medical Clinic, he is past chairman of the pharmacy Review board of Mississippi division of Medicaid, a former member of the Mississippi Trauma Advisory Council, and a former member of the Mississippi Foundation for Medical Care. He is a graduate of Millsaps College and the university of Mississippi School of Medicine.

MSMA president-elect dr. Joiner practices family and industrial medicine in the Jackson area. Originally from greenwood, dr. Joiner completed both undergraduate and medical degrees from the university of Mississippi. He serves the medical community through involvement with the Central Medical Society, the American Medical Society, the Mississippi Academy of Family physicians, the American Academy of Family physicians, and the Southern Medical Association. dr. Joiner is a former MSMA board of Trustees member, former member of the division of Medicaid’s Review of Medical Necessity, and past-president of the Central Medical Society. He served as chief resident at university of Mississippi Medical Center and as chief of staff at Central Mississippi Medical Center.

MSMA members also elected the following physicians: • • • • • • •

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James A. Rish, Md, Tupelo – Chair of the board of Trustees daniel p. edney, Md, Vicksburg – Vice-Chair of the board of Trustees Claude brunson, Md, Jackson – Secretary of the board of Trustees bradford J. dye III, Md, Oxford – Trustee, dist. 2, 2010 -2013 William M. grantham, Md, Clinton – Trustee, dist. 4, 2010-2013 dwight S. Keady, Jr., Md, Meridian – Trustee, dist. 5, 2010-2013 patrick brent Smith, Md, Jackson – Resident Representative to the board of Trustees

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• • • • •

Sam Holdiness, brandon – Medical Student Representative to the board of Trustees J. Clay Hays, Jr., Md, Jackson – AMA delegate, 2010-2012 James A. Rish, Md, Tupelo – AMA delegate, 2010-2012 Mary gayle Armstrong, Md, Madison – Alternate AMA delegate, 2010-2012 Claude brunson, Md, Jackson – Alternate AMA delegate, 2010-2012

The result of other races follows: • Stanley Hartness, Md, Kosciusko - Associate editor, JOURNAL MSMA, 2010 – 2012 • Marty Tucker, Md, Jackson – Council on budget & Finance, 2010-2013 • Jennifer J. bryan, Md, brandon – Council on budget & Finance, 2010-2013 • edwin d. Meeks II, Md, Columbus – Council on Constitution & bylaws, 2010 -2013 • Michael Mansour, Md, greenville – Council on legislation, dist. 1, 2010-2013 • brett lampton, Md, Oxford – Council on legislation, dist. 2, 2010-2013 • laura A. gray, Md, Tupelo – Council on legislation, dist. 3, 2010-2013 • landon e. Argo, Md, Jackson – Council on legislation, Resident, 2010-2011 • Tal Hendrix, Jackson –Council on legislation, Student, 2010-2011 • Tom Carter, Md, Kosciusko – Council on Medical education, dist. 2, 2010-2013 • Shirley d. Schlessinger, Md, Jackson – Council on Medical education, dist. 4, 2010-2013 • John d. Voss, Md, Meridian – Council on Medical education, dist. 5, 2010-2013 • John Wilkaitis, Md, Jackson – Council on Medical Service, dist. 4, 2010-2013 • dwight S. Keady, Jr., Md, Meridian – Council on Medical Service, dist. 5, 2010-2013 • Jason d. Stacy, Md, Jackson – Council on Medical Service, Resident, 2010-2011 • Andrew Weeks, Jackson – Council on Medical Service, Student, 2010-2011 • Scott e. Nelson, Md, Cleveland – Council on public Information, dist. 1, 2010-2013 • June A. powell, Md, Walnut – Council on public Information, dist. 2, 2010-2013 • C. Kenneth lippincott, Md, Tupelo – Council on public Information, dist. 3, 2010-2013

MSMA Awards: Community Service, Leadership, and Wellness Promotion Project Honored

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he Mississippi State Medical Association (MSMA) honored two physicians and a wellness promotion project during the ceremony for the 2010 excellence in Medicine Awards. Recipients and respective honors include:

• • •

Dr. Jennifer D. Gholson – Dr. James C. Waites Leadership Award Dr. Ralph L. Brock – MSMA Community Service Award “Fit 4 Change” Fitness Challenge by Victory Sports Foundation – MSMA Award for Excellence in Wellness Promotion

The dr. James C. Waites leadership Award honors one physician under the age of 50 who is an outstanding leader in organized medicine and community affairs. dr. gholson, a Summit native, has served in leadership positions with MSMA, the Mississippi Academy of Family physicians, the American Medical Association, the Medicaid pharmacy and Therapeutics Committee, and the Mississippi department of Health. Named as a “Top 40 under 40” business leader by the Mississippi Business Journal, she has practiced in Tylertown and Magnolia and currently is employed by peak Healthcare in Summit.

2010 Dr. JAMeS c. WAiteS leADerSHiP AWArD reciPient Jennifer D. GHolSon— the AwARd wAS iNStituted iN 2001 tO ReCOgNize the MANy CONtRibutiONS OF dR. wAiteS, tO hiS COMMuNity ANd tO ORgANized MediCiNe. eACh yeAR the bOARd OF tRuSteeS SeleCtS ONe PhySiCiAN uNdeR the Age OF 50 whO iS AN OutStANdiNg leAdeR iN ORgANized MediCiNe ANd COMMuNity AFFAiRS.

dr. brock, a family physician in McComb, was presented with the MSMA Community Service Award, which recognizes participation in civic activities for the betterment of the community. He designated the Rotary Club as the recipient of the $500 contribution to a community organization. The award is designed to provide recognition to members of the association who are actively engaged in the practice of medicine and for the many and varied services above and beyond the call of duty which they render to their respective communities. dr. brock serves the McComb community in many organizations including the Rotary Club, polio plus program, pike County Arts Council, Southwest Mississippi genealogy Society, pike-Amite-Walthall library System, McComb public Schools Infirmary Foundation, Southwest Mississippi Community College, McComb Chamber of Commerce, and McComb parents league. july

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JAMeS GrAnt tHoMPSon MeMoriAl PASt-PreSiDent’S Pin — 2010-11 MSMA PReSideNt dR. tiM j. AlFORd (R.) PiNS the jAMeS gRANt thOMPSON MeMORiAl PASt-PReSideNt’S PiN ON MSMA iMMediAte PASt PReSideNt dR. RANdy eASteRliNg (L.).

The Victory Sports Foundation, a nonprofit organization promoting amateur sports and fitness in Mississippi, and athletic trainer paul lacoste hosted the “Fit 4 Change” project during the 2010 legislative session.

This 11-week fitness challenge was designed to help participants, which consisted of four teams of state legislators, governor’s office employees, and civilians, make personal lifestyle changes in the areas of diet, exercise, and healthy living. Many of the co-sponsors had an active role in the flow of the program.

However, MSMA Alliance past president Angela ladner (Mark ladner, Md) and lacoste were primary planners who coordinated the program and worked together to see it succeed. The team captains also played a high profile role for their team members by communicating program instruction and encouraging them to work hard to attain their personal goals. Notably State Sen. Terry burton (R-Newton), Chair of the Mississippi Senate public Health and Welfare Committee, and State Rep. Steve Holland (d-plantersville), Chair of the Mississippi House public Health and Welfare Committee, led the bipartisan effort to get the leaders of the Mississippi state legislature moving and fit.

The success of the program, with a total weight loss of 1,401 pounds by 105 participants, led “Fit 4 Change” to be named winner of the MSMA Award for excellence in Wellness promotion.

MSMA coMMUnitY Service AWArD — MSMA PASt PReSideNt dR. RAlPh l. bROCK (L.) wAS 2010 MSMA COMMuNity SeRViCe AwARd by ChAiR OF the COuNCil ON PubliC iNFORMAtiON dR. hugh A. gAMble, ii (R.).

PReSeNted the

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Address of the MSMA President 2009-2010 S. Randy Easterling, MD

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come before you this Friday morning overcome by a virtual plethora of emotion. It is a spirit of thanksgiving in my heart that I ask for a few moments of your time, and I can assure that I am learning day by day that brevity is a treasured commodity.

While I feel no obligation to thank neither this House nor the 3,800 members of the Mississippi State Medical Association who sent you here today, I am compelled to do so by an overwhelming sense of gratitude and respect for each of you and for those whom you represent.

I will begin by simply saying thank you. Thank you for honoring me and my family far more than we ever earned. you allowing me to serve as your president this past year has been the event of a lifetime. Rest assured, these past twelve months will never be forgotten.

I shall long remember and never forget the component societies, each one with their own unique places and personalities. your warmth and hospitality have forever been imprinted in my heart. After all, who could ever forget the Meridian meeting? We were in the largest room in the historic Weidmann’s restaurant, standing room only. It was weeks after the AMA had come out in public support of HR3200 and you could cut the tension with a knife. As president of the Mississippi State Medical Association and also an AMA delegate, it took very little intelligence and/or imagination on my part to arrive at the conclusion that someone might not leave that room in one piece. Since Steve and Charmain rAnDY eASterlinG, MD were both younger and faster than I, it was blatantly obvious for whom they were sharpening the 2009-10 MSMA PreSiDent guillotine. Maybe it was just my imagination, or perhaps that flood of catecholamines surging through my body, but I swear to this day that prior to my introduction, the inviting aroma of steaks on the grill waffling from the kitchen was overcome by the smell of hot tar.

After a brief and polite introduction, the president of the Component Society reached under the podium as I approached and said “Here I think you may need this.” He then gave me a football helmet. It was a great ice breaker, we had a good time, great food, and an excellent discussion. each meeting was unique, a reflection of your personalities but more so your communities. Who could ever forget that quaint little restaurant off of town square in Kosciusko? good, down home cooking, and Stanley Hartness boot-legging wine through the back door. Then there was McComb, good crowd, warm reception, good food, this meeting was held in a bar. I am not sure to this day if anyone heard or cared what I had to say, but we all had a good time that night.

Sometimes getting to the meetings was more exciting than the meetings themselves. Having Neely Carlton as your driver is an experience in and of itself. I mean, with Steve and Charmain, it had been a particularly long day and a long trip to the component’s society, I had no reservations about taking a short nap on the way home. Not so with counselor Carlton. Riding with Neely was akin to say, riding shot gun with a Kamikaze pilot. I will never forget the trip to pascagoula. We met at the parking lot of Kroger grocery store in Richland, just south of Jackson. I swear we were pulling into the restaurant parking lot 1½ hours later. One thing was for sure with Neely, the only thing more exciting than the drive was the conversation. The constant conversation.

Well, long story short, we made it. The year has come rapidly to an end. If I were to sum it up in descriptive prose, I would say it has been a year of dialogue. A year of debate. A year of definition. A year of coming to grips with who we are as physicians and persona. A year of serious reflection on the role we play individually as an association with the American Medical Association, and in the grand scheme of how we fit into the all familiar “Health System Reform.”

It has been a year that has brought out the best in most of us and the worst in a few of us.

Make no mistake about it, regardless of the emotion, the rancor, the accomplishments, and the failures, I am convinced that we are better for the experience. Our association is strong, our relationships healthier, our staff more committed, and most important of all our patients better served.

While this body’s decision in October of last year to deunify from the AMA has resulted in a precipitous drop in AMA membership by Mississippi physicians (over 3,000), I am proud to stand before you and report that the Mississippi State Medical Association’s membership will have increased by the end of this year by close to an estimated 500. These numbers speak, not so much, in my opinion, to our disapproval of the AMA, but more so to the affection, respect, and love, that we all have for the Mississippi State Medical Association. I have said it from the Coast to Corinth, from Vicksburg to Meridian, and I will repeat it time and time again. do what you will with the AMA, that is a personal decision. I for one plan to stay with the AMA as does your entire board of Trustees. but for god’s sake, don’t leave the Mississippi State Medical Association.

We have accomplished much in the past few years: Tort Reform bills in 2002 and 2004 (the 2004 bill being known as landmark legislation and the most significant tort reform since MICRA in California 30 years ago), fully funding Medicaid, scope of practice issues, rural scholars program, tobacco tax, reshaping the Mississippi State board of Health, putting in statutes that the Chair of the Mississippi State board of Health must be a physician, a yearly report card on the state of health that has become the benchmark by which we fight obesity, hypertension, coronary artery disease, stroke, etc., electing friendly judges to the Mississippi Supreme Court, increasing the medical class from 100 to 120 to hopefully 150, maintaining a well respected voice in the Mississippi legislature, a pAC second to none, a journal published monthly that is second to none, and most recently, Senate bill 2127, the Fair and equitable Claims process Act. This bill is one of the few pieces of legislation to ever pass both bodies of the Mississippi legislature without a single dissenting vote, and due to the imagination, hard july

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work, and determination of Charmain Kanosky, dr. Fred McMillin, dr. Claude brunson, dr. Jimmy Keeton, for the first time in the history of our organization, every physician faculty member at the university of Mississippi Medical Center will be a member of the Mississippi State Medical Association.

These things did not happen by accident. It takes untold hours of hard work, planning, scheming, and a staff with a single minded determination unmatched anywhere in this country.

One evening while we were at the Capitol during the 2004 tort battle (It was one of those late night marathons. everyone was exhausted, tired, hungry, and emotions frayed.), I asked Charmain, “Why do you do this?” After all, I know that you are a great lobbyist and you could make a lot more money working for someone else. Her answer has stayed with me until this day.

Simply put she said, “I like coming to work every day, going to the Capitol, wearing a white hat. I like working for the good guys who always take the high road.”

I have learned through the years that being right is often not enough to win, but is a hell of a lot better than being on the winning side of the wrong issue.

While our accomplishments have been many, make no mistake about it, our work is far from done.

In the words of the poet, Robert Frost, “I have promises to keep and miles to go before I sleep and miles to go before I sleep.”

Allow me to call your attention to a few issues: upcoming elections, especially the Mississippi Supreme Court. It would serve us well as a constant reminder that this very minute as we are having this meeting, the trial lawyers are planning to dismantle our caps on non economic damages.

Limas v Double Quick is a premises liability case that will be heard by the Mississippi Supreme Court in the next month. We must be ever diligent, failure to do so will surely result in our being thrust back into a judicial hell hole that will be even hotter than before. It has already happened in Illinois and georgia, and other cases are pending all over the country.

To be very frank with you, I have little patience and/or affection for those of us who in the doctor’s lounges all over this state and country, day in and day out, continue to bitch, moan, and complain about the state of affairs in medicine, but do absolutely nothing to better the course.

If you are not comfortable going to the Capitol, talking to officials, being in press conferences, that is okay. I understand, there are enough of us who can carry that torch. but all of us can do a very few simple things.

1. Come to your component society and be supportive.

2. give support both money and otherwise, to local, state, and federal elected officials who are patient and medicine friendly. (If you don’t know who they are call the office and we can tell you.)

3. Continue to support the Mississippi State Medical Association every way possible.

4. last but not least, give to our pAC. everyone can at least write a check.

I was talking not long ago with one of our physician members who is a highly compensated medical subspecialist. He was rejoicing the fact that our 2004 tort reform bill was saving him over $20,000 a year in malpractice premiums. Our response, well I am sure you will be equally as pleased to donate at least $1,000 to our pAC. He looked at me as if I was crazy. give money to politicians, are you kidding? Well, no I am not kidding. Whether we like it or not, agree or disagree, money is a mother’s milk of politics. As crazy as it may seem, politicians be it at the state level or the national level, define what we do, how we do it, what we get paid to do, and how we care for our patients every single minute of every day. I wish it weren’t so, but it is.

The passage of HR3590, the patient protection Affordable Act, signed in by president Obama on March 23rd of this year, is our most prime example.

In one of our Capitol Club luncheons at the AMA one and a half years ago, Stu Rosenburg was the guest speaker. dr. Rosenburg is a nationally known political analyst, editor of the Rosenburg Report, and a weekly commentator on Fox, NbC, CbS, AbC, etc. during the question and answer session after his speech, a physician member from California asked, “What is the single most effective tool we can use to get our message across in Washington?” Without reservation, he said, “Join and support your pAC.” Well, enough of my ranting.

I want to say a few thank yous. First, dr. Jim Rohack, thank you for coming again. you were in Oxford last year. As tough as this last year has been for me and our Mississippi State Medical Association, I cannot begin to imagine what you and other AMA leadership have been through this last year.

I want all of you to know, regardless of how you feel about the American Medical Association and her position on issues, especially Health System Reform, the AMA has been responsive to Mississippi this past year.

1. Cecil Wilson, president-elect of AMA, came to Jackson in August and spent several hours in a townhall type meeting.

2. dr. Rohack came to the Hattiesburg Clinic in late October or early November to discuss issues with the Hattiesburg Clinic.

3. As an association, you need to hear that in the mist of all this debate and dialogue, while Mississippi physicians may not see eye to eye with the AMA leadership, the AMA continues to support our efforts to be informed and engaged. Thank you Jim. Thank you for what you have done and continue to do. To our staff, your patience, your kindness, your support, your advice, your willingness to always go the extra mile, I salute you all.

4. To Charmain, Neely, Steve, Karen, and the rest of you all who make the train run on time, I will never, ever forget you and what you have come to mean to me. you are simply the best.

5. To Janie, what can I say that I have not already said time and time again? you have been patient beyond reason, understanding beyond what could be expected, and loving beyond my wildest dreams. As exciting and fulfilling as most of this year was, the highlight of everyday was, always hands down, coming home to you. I love you.

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There are many who have asked, what are you going to do after this is over? Well, several things.

1. Sleep for about a week.

2. Janie and I are going to europe for about 10 days.

3. I have purchased a thesaurus and I am going to spend several months trying to figure out what the hell all those e-mails Kenn beemon sent me meant.

The work of your association is far from done. The Mississippi State Medical Association is much bigger than any one person or groups of persons. Our mission should always transcend personality and ideology. Our ultimate goal, always, without question is to serve our patients.

In a few short hours the mantle of leadership will be passed to dr. Tim Alford. Without question, you will give him the same level of support and encouragement that you have given presidents before him. you will do so not so much because he is president, but because he has earned it.

As a father, husband, and physician, Tim is thoughtful, caring, and dedicated. He will serve our association and our patients well.

As I move on to other opportunities and challenges that lie before me, whatever they may be, please hear from this day forward, from me personally, the distance from Oxford to Natchez will never again be measured in miles or time traveled. Minutes and miles will never ever be adequate to describe this journey. Oxford to Natchez will forever more be a collage of emotion and memory. A snap shot in time, when you and I joined hands, tethered not by background or belief, income or interest, personality or politics, but held together by that internal flame that drives us all to care for our patients. because you see, the lot that you and I have chosen as Mississippi physicians is unique. Our challenges are different and more difficult than others, but by the same token, our opportunities are unlimited.

Come Monday morning, when you and I go to work, we will get up earlier than most, stay up later than most. We will work harder than most and get paid less than most. We will hold more hands than most and mean more to others than most. Our patients will be sicker than most and will require more attention than most. They will be poorer than most and have less access to quality care than most. Our patients will be fatter than most and exercise less than most. They will have higher rates of hypertension, diabetes, and coronary artery disease than most.

What they will have, however, is a gift of divine proportion. They will have you as their doctor.

May god bless you all and god bless the Mississippi State Medical Association.

S. Randy Easterling, MD President 2009-2010

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• iMAgeS iN MiSSiSSiPPi MediCiNe •

THE TABORIAN HOSPITAL, MOUND BAYOU— This photo is of the Taborian Hospital in Mound Bayou. It is the front of a postcard dated July 14, 1946 and the back of the cards reads: “The Taborian Hospital, Mound Bayou, Mississippi.

Seventy-five beds; all modern equipment; built at a cost of $100,000; is sponsored by the Knights and Daughters of Tabor, leading Negro Fraternal Order of Mississippi. $100,000.00 Hospital Expansion Campaign in Progress.” The one-story Taborian Hospital was opened on February 1, 1942 with forty-two beds by the Knights and Daughters of Tabor and situated in the historic “all-black” town of Mound Bayou. Dr. W. L. Smith of Clarksdale and Dr. Phillip M. George of Mound Bayou were the original directors of the hospital, assisted by Dr. Theodore Howard as surgeon-in-chief. From 1947 to 1974, Meharry Medical College sent residents and interns as part of their training to the hospital. This was one of the earliest rural training programs established at any American medical school. Meharry also trained many of the hospital workers and technicians. The Taborian holds historic importance as one of the two most successful black fraternal hospitals in Mississippi. The other, also located in the Delta but established earlier in 1928, was the Afro-American Sons and Daughters Hospital in Yazoo City. Anyone with additional information on The Taborian Hospital is asked to contact Dr. Lampton. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please contact the Journal or me at lukelampton@cableone.net.

—Lucius Lampton, MD, Editor

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• iqh • Dr. Frothingham Named Recipient of the A. A. Derrick Physician Quality Award

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r. Rodney Frothingham of Ruleville has been named the recipient of the A. A. derrick physician Quality Award given by Information & Quality Healthcare (IQH). The award was announced at the 39th Annual Meeting of the Medicare quality improvement organization. dr. Frothingham was recognized for giving outstanding support to quality improvement, becoming the 19th recipient of the award that was established to honor the late dr.

Arthur Aaron derrick Jr. of durant. dr. Frothingham’s name has been placed with the other physicians who are listed on the permanent derrick Award plaque on display at IQH. The award is traditionally made at the IQH Annual Meeting, held in conjunction with the Mississippi State Dr. roDneY frotHinGHAM (R.) OF RuleVille ReCeiVeS Medical Association Annual Session. dr. James S. McIlwain, CONgRAtulAtiONS FROM Dr. JAMeS S. McilWAin, iQH PreSiDent (l.)

FOR beiNg NAMed the ReCiPieNt OF the A. A. deRRiCK PhySiCiAN president, announced the award and also named the newly quAlity AwARd. dR. FROthiNghAM’S NAMe hAS beeN PlACed with elected board members, John dawson of Kosciusko, dr. the OtheR PhySiCiANS whO ARe liSted ON the PeRMANeNt Thomas Skelton of Jackson, and dr. Frank Wade Jr. of Magee. deRRiCK AwARd PlAque ON diSPlAy At iqh.

He recognized outgoing board members, dr. Frothingham and dr. peggy davis of Jackson.

In announcing the award, dr. McIlwain said, “dr. Frothingham’s support is demonstrated as we look back on the past six years he has served on the IQH board of directors. He was very much involved in the Circle of Champions effort that featured hospital quality improvement staff nominating physicians who showed an interest in and participated in quality improvement efforts within their hospitals. dr. Frothingham received enthusiastic nominations in the endeavor to familiarize physicians with techniques for bringing meaningful change with a minimum of time and effort. His participation has been valuable in the various aspects of the quality improvement program. We at IQH are very appreciative of the time he has given to the mission of supporting quality medicine.” dr. Frothingham is currently serving on the consulting staff with North Sunflower Medical Center. Formerly the chief medical officer at delta Regional Medical Center from 2003 to 2007, dr. Frothingham was chief administrative officer of the West Campus of delta Regional Medical Center, 2007-08, and active staff 1974-2008. He served as medical director of the Acute Rehabilitation Center from 2000 to 2008. His practice affiliations have included the Neurosurgical Associates, p. A., in greenville, SC, and the greenville Neurosurgical Clinic in greenville, MS. The recipient of numerous recognition awards, dr. Frothingham was named “doctor of the year” by the Mississippi Society of Medical Assistants and was elected to membership in the Sigma Xi scientific research society. He is chairman of the Ruleville Methodist Church Council and is also a certified lay speaker. Among his military achievements, he has served as commanding officer, 134th Combat Support Hospital, 2nd detachment at Camp McCain. He is a recipient of the u. S. Army legion of Merit and the Mississippi Magnolia Cross. dr. Frothingham has also served on numerous medical and community service advisory committees.

In accepting the award, dr. Frothingham said, “I am very pleased and humbled to have been recognized in such a way as to receive the Arthur A. derrick Memorial Award. It is always a pleasure to serve IQH and the advancement of healthcare in Mississippi.” dr. Frothingham, a native of Rolling Fork, received a degree in chemistry from Mississippi College and pursued graduate studies in biological chemistry prior to earning his M. d. degree from the university of Mississippi Medical Center (uMMC).

His surgical internship was completed at duke university Medical Center and his residency in neurological surgery at uMMC. The late dr. derrick, a founder of IQH, was active with the State Medical Association, serving as president and chairman of the board as well as chairman of the IQH board. After dr. derrick died in an automobile accident in March 1993, the tradition of recognizing a physician who has been outstanding in the support of quality medicine was begun in his honor each year. july

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• POetRy iN MediCiNe • [This month, we print a poem by John D. McEachin, MD, a Meridian pediatrician. This poem, written recently, was inspired by one of his friends who witnessed this event in the late 1940s. Dr. McEachin writes the editor that he is in charge of the choir music and program at Spring Hill Church, outside Grenada, each third Sunday in May. This church was attended by his ancestors. He adds: “It opens one day a year. We have upgraded ‘Dinner on the Grounds’ with PORTA-POTTIES in recent years!

Ha!� For more of Dr. McEachin’s poetry, see past JMSMAs and look for more in coming months. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email him at lukelampton@cableone.net.] —ED.

The Macon Post-season Glee Club When football season was finished, Macon boys looked for things to do.

What better choice than glee Club; pretty girls were there to woo. glee Clubs hit the road To sing in towns nearby; district Festivals were special, More pretty girls! Oh my!

The boys could get by it seems, When they “auditioned� at home base; but when they went to district, Muted notes prevailed to save face! guest choral conductors—big Shots Were prone to challenge voices; yes! One after the other, and Then, some shocking choices.

One fateful day in louisville, A conductor went down the line, Asking each young man in order, “Section? Sing a note! Whine!�

Some of the boys knew just enough To respond with the parts they sang— “Tenor! bass! bass! Tenor!�

With assurance, replies rang.

Then came the last, a gangly lad Frantic, voice cracking and hoarse, eyes glancing down at the music he held, “Sir, I sing MIXed CHORuS!�

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— John D. McEachin, MD Meridian

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• the uNCOMMON thReAd •

Creative Writing r. Scott Anderson, MD

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got thrown for a loop the other day. One of the girls in the Tumor Registry sent a copy of the JOURNAL version of “Squirrel Story” to the inspector from the American College of Surgeons that was coming to do our cancer center certification. She had great intentions. She wanted to show him how well rounded we were. I understand that and I’m happy for it. That’s not what threw me.

What did was what the inspector said the morning he showed up.

He was from pennsylvania, and I guess there they don’t put goofballs writing about squirrels in their medical journals. What he said that startled me was that it was amazing they included something like this in a state medical journal at all, but he could understand it because Mississippi had such a rich tradition of good creative writing.

That was just the thing to send me into a full-fledged neurotic meltdown.

At my age, I’ve spent most of my life trying to figure out what good writing is supposed to be. I’ve spent a lot of time studying it and reading authors that are recognized as being good writers. I’m starting to get a fair idea of what people say really great writing is supposed to change to look like and how great writers are supposed to write. unfortunately, I’ve also come to the unavoidable conclusion that I’m not one of them. lord knows, I’ve tried to be a better writer, but all of that thrashing about trying to say things in as convoluted and descriptive a manner as possible is exhausting. Not only that, after all that work, I don’t even like to read it.

I know, I know. you’re supposed to grow and develop as you keep on, but every time I try, it doesn’t sound like me anymore. It sounds like me being an idiot is all. The other problem is, it’s as boring as hell.

I tried reading some Hemingway again, to give me an idea of where I should go. everybody knows that he’s a great writer, and it’s been years since I’ve tried to read any of his short stories. Not because I have anything against him, but he is dead, and he hasn’t been coming out with very many new books lately, at least not since his demise anyway. If I remember right from college, from the book on ernest …what made Hemingway revolutionary was a return to the use of short direct sentence structure. problem is, where the sentences are going is anything but.

Why can’t we just have people with names in the stories who were just doing something, without their past crowding them around to the point you can’t tell what they were doing in the first place? Over time it’s gotten worse. lord knows, I’m not picking on anyone, but since then, modern short story writers can’t seem to tell a story. They get so tied up with descriptions and feelings that they forget to tell the story. It’s kind of like a flash of lightning at night. And while that sort of thing can be intriguing, to me it’s never quite enough. I like to have some idea of what it is that I’m seeing. Maybe I lack imagination, but the flavor of the story comes from a little bit of chewing, not simply the quick swallow. Some of it comes from knowing where the proper starting point is, and july

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going on until you reach the stopping point. every author is gonna come up with a different starting point and stopping point. Thatâ&#x20AC;&#x2122;s okay, as long as you get enough in it to make the reader say, â&#x20AC;&#x153;I like that,â&#x20AC;? and not â&#x20AC;&#x153;What the hell was that?â&#x20AC;?

There is a natural pressure here to want to try and become a better writer. Itâ&#x20AC;&#x2122;s the expectation of the place. Mississippi has a rich tradition of storytelling. you can say anything you want about the relative merits and literary skills of our writers, but by gosh, theyâ&#x20AC;&#x2122;ve always known how to tell a story.

Something about that makes it hard to be a writer who just so happens to be in Mississippi. Thereâ&#x20AC;&#x2122;s a lot to live up to. even saying the name Faulkner is enough to make anything I write seem worthless by comparison. When you throw in names like eudora Welty, Willie Morris, ellen gilchrist, and modern writers like grisham and Iles, this can turn into an absolute creative paralysis. It was scary enough for me that I wrote both of my first two novels based in someplace other than Mississippi, just to keep from having to face it.

I think from now on, especially in this little column, Iâ&#x20AC;&#x2122;m just going to have to give up on trying to be some kind of a â&#x20AC;&#x153;Mississippi writerâ&#x20AC;? and just keep on telling some little stories. Who knows?

Some of them may even end up being true.

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R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian and past vice chair of the MSMA Board of Trustees. Additionally, he is an accomplished oil-painter and dabbles in the motion-picture industry as a screen-writer, helping form P-32, an entertainment funding entity.

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