July
VOL. LII
2011
No. 7
Go Paperless and Get Paid Register NOW for CMS Electronic Health Record Incentives
The Centers for Medicare & Medicaid Services (CMS) is giving incentive payments to eligible professionals, hospitals, and critical access hospitals that demonstrate meaningful use of certified electronic health record (EHR) technology.
Incentive payments will include: • Up to $44,000 for eligible professionals in the Medicare EHR Incentive Program • Up to $63,750 for eligible professionals in the Medicaid EHR Incentive Program • A base payment of $2 million for eligible hospitals and critical access hospitals, depending on certain factors Get started early! To maximize your Medicare EHR incentive payment you need to begin participating in 2011 or 2012; Medicaid EHR incentive payments are also highest in the first year of participation. Registration for the EHR Incentive Programs is open now, so register TODAY to receive your maximum incentive. For more information and to register, visit:
www.cms.gov/EHRIncentivePrograms/ For additional resources and support in adopting certified EHR technology, visit the Office of the National Coordinator for Health Information Technology (ONC):
www.HealthIT.gov
Lucius M. Lampton, MD EDITOR D. Stanley Hartness, MD Richard D. deShazo, MD ASSOCIATE EDITORS Karen A. Evers MANAGING EDITOR PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors THE ASSOCIATION Thomas E. Joiner, MD President Steven L. Demetropoulos, 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© 2011 Mississippi State Medical Association
Official Publication of the MSMA Since 1959
JULY 2011
SCIENTIFIC ARTICLES
VOLUME 52
NUMBER 7
Atraumatic Rupture of a Normal Spleen: A Case Report
209
The Impetuses for Changes in Mental Health
212
Clinical Problem-Solving: Doc, I Feel Like I’m Getting Fat
216
Jim T. Harris, DO; L. Kendall McKenzie, MD; Richard Finley, MD Stephen A. Crowder, MSM, MS and Tiffany A. Owens, MS Sonya Clemmons, MD
PRESIDENT’S PAGE
The Doctor-Patient Relationship: It’s Worth Fighting For
Thomas E. Joiner, MD, MSMA President
EDITORIALS
220
Pack Your Bags and Revisit Your Journal MSMA
222
Mississippi Doctor Civics 101: Or How Mississippi Government Really Works in Areas That Affect Physicians
223
D. Stanley Hartness, MD, Associate Editor Rep. Sidney W. Bondurant, MD
MSMA
Report and Highlights of the 143rd Annual Session of the MSMA House of Delegates 2011
225
Karen A. Evers
RELATED ORGANIZATIONS
Mississippi State Department of Health Mississippi Professionals Health Program
218 232
Uncommon Thread Placement/Classified
235 236
DEPARTMENTS
ABOUT THE COVER:
Trace Cyclist — Dr. Martin M. Pomphrey, Jr. took this photograph of a bicyclist approaching the Natchez Trace Parkway near Alcorn State University. Mississippi enacted a law in 2010 requiring motorists to give cyclists at least three feet of space when passing. According to the Mississippi Department of Public Safety, since 2008, 20 people have died, and nearly 300 have been injured in the state. Last year Bike Walk Mississippi, the state’s bicycle and pedestrian advocacy group, launched a statewide educational campaign about the “3-foot law,” officially known as the John Paul Frerer Bicycle Safety Act. Cyclists also have responsibilities. As spelled out in the law, they should ride as close to the right-hand edge of the road as possible when traveling at relatively low speeds. They should give proper traffic hand signals. Except on bike paths, they should not ride more than two abreast. Cyclists should carry identification. MSMA supports legislation requiring that all riders, regardless of age, wear bicycle helmets. Dr. Pomphrey is a semi-retired orthopaedic surgeon sub-specializing in sports medicine who practiced with Oktibbeha County Hospital (OCH) Bone and Joint Clinic in Starkville. ❒
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Are you a PCP? “PHYSICIANS CARE” PROVIDER
Mississippi Physicians Care Network is your network... Strength in numbers – Our provider network is growing...currently over 3,500 physicians and allied providers, with new providers credentialed each month. Competitive statewide PPO – MPCN represents over 100,000 lives statewide and is contracted with over 50 payors. In touch with your legislative and clinic management needs – MPCN is a subsidiary of the Mississippi State Medical Association, your physician advocate organization. Physician managed organization – Your voice is heard on our Board... MPCN’s Board of Directors is physicians only.
If you’re not a “Physicians Care” Provider, join today! If you are... Congratulations, you’re with the right network. PCP ... “Physicians Care” Provider The best specialty
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Proceeds benefit the Mississippi Medical Political Action Committee. JULY 2011 JOURNAL MSMA
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• SCIENTIFIC ARTICLES •
Atraumatic Rupture of a Normal Spleen: A Case Report Jim T. Harris, DO; L. Kendall McKenzie, MD; Richard Finley, MD
A
BSTRACT
Splenic injury is a major concern in blunt abdominal trauma. Atraumatic splenic rupture is infrequent but the etiology is usually related to altered structural integrity of the spleen such as splenomegaly in infectious mononucleosis. Atraumatic rupture of a normal spleen is very rare in the published literature. We present such a case of atraumatic rupture of a normal spleen presenting as acute abdominal pain and discuss diagnostic and treatment strategies important for the emergency physician.
KEY WORDS: ATRAUMATIC SPLEEN RUPTURE, SPLENIC RUPTURE, SPLENIC INJURY, SPONTANEOUS SPLEEN RUPTURE
INTRODUCTION
Rupture of the spleen is most commonly caused by blunt abdominal trauma. In the absence of trauma, splenic rupture is rare, and the etiology is usually related to structural abnormalities of the spleen such as splenomegaly in infectious mononucleosis, malaria, or amyloidosis.1-3 There are few reports in the literature of spontaneous rupture of a normal spleen not associated with trauma or any identifiable pathology. In this report, we describe such a case of spontaneous rupture of a normal spleen. We describe the diagnostic and management strategies the emergency physician should be aware of in caring for this rare but potentially fatal condition. AUTHOR INFORMATION: Dr. Harris is house officer, post graduate year 2 in the Department of Emergency Medicine, Dr. McKenzie is assistant professor of medicine, and Dr. Finley is professor of medicine in the Departments of Emergency Medicine and Infectious Disease, all at the University of Mississippi Medical Center.
CORRESPONDING AUTHOR: Jim T. Harris, DO, University of Mississippi Medical Center, Department of Emergency Medicine, 2500 North State Street, Jackson, MS 39216. Telephone: (601)984-5570 (office) (jtharris@umc.edu).
CASE
A 42-year-old male presented to the emergency department with a chief complaint of abdominal pain. He described an acute onset with 12 hours of upper abdominal pain that radiated to the left shoulder. The pain was diffuse, dull, constant, and exacerbated by lying flat. He had a significant history of gastroesophageal reflux and alcohol abuse but denied previous abdominal surgery, recent illness, or any trauma. Examination revealed a thin black male in obvious pain who was afebrile with a blood pressure of 182/73 and a pulse of 109/min. There was moderate epigastric and left upper quadrant tenderness with involuntary guarding. Physical examination was otherwise unremarkable. Flat and upright abdominal radiographs were unremarkable while bedside emergency department ultrasound was significant for free fluid in Morrison’s pouch and the pelvis. CT scan of the abdomen demonstrated a moderate perisplenic hematoma without active extravasation of blood as shown in Figure 1. Serum hemoglobin was 13.8 gm/dl with a mild leukocytosis of 15.8 x 103/mm3. Serum chemistry, liver function tests, lipase, urinalysis, and rapid serological testing for infectious mononucleosis were unremarkable. The patient was admitted to the surgical ICU for observation, and the following day a laparotomy was performed due to progressive anemia. At surgery, a splenic rupture and associated hemoperitoneum were confirmed with an estimated 2-3 liters of blood in the abdomen. Final pathologic diagnosis revealed a 165 gram spleen in 2 fragments with disruption of the splenic capsule and hematoma without evidence of organization and unremarkable histology. The patient was monitored for 2 days postoperatively with stable blood counts and was discharged home in good condition. At 2 week follow-up the patient was doing well with no complaints.
DISCUSSION
The spleen is an intraperitoneal organ weighing approximately 150 grams lying inferior to the diaphragm in the left upper quadrant of the abdomen.4 The spleen is one of the most
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vascular organs of the body, and violation of its structural integrity is potentially life-threatening. Blunt trauma is the most common etiology, but even minor trauma or spontaneous rupture can occur in the presence of a spleen enlarged due to infectious, immunological, or infiltrative disease (Table 1). 1-3, 5-33 Rupture of a completely normal spleen in the absence of significant trauma is extremely rare in the published literature. Diagnosis of spontaneous splenic rupture requires an awareness of the condition and a high index of suspicion. The patient presentation is dependent on the degree of spleen defect and the amount of intra-abdominal hemorrhage. The spectrum of signs and symptoms vary from nonspecific, generalized abdominal pain to hypovolemic shock. The most common chief complaint is left upper quadrant pain with associated left shoulder pain resulting from subdiaphragmatic irritation (Kehr’s sign). The patient may have signs of peritoneal irritation such as involuntary guarding and rebound tenderness. If hemorrhage is significant, tachycardia, hypotension, and altered mental sta1 tus may occur. Historically, splenic rupture was a diagnosis made during intraoperative exploration based on a positive peritoneal lavage or clinical suspicion.34 With the advent of abdominal ultrasound and computed tomography, the presence Table 1. Causes of Splenic Rupture
Traumatic Hematologic
Infectious
Neoplastic
Infiltrative
Iatrogenic
Gastrointestinal
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Anatomic
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Figure 1. Computed tomography transverse section of the upper abdomen showing perisplenic hematoma and intraperitoneal hemorrhage
Blunt chest, back or abdominal trauma Penetrating chest, back or abdominal trauma Delayed trauma Hemophilia Anticoagulation Sickle cell anemia Vasculitis Erythroblastosis fetalis Infectious mononucleosis Viral Hepatitis Endocarditis Typhoid fever Tuberculosis Tularemia Malaria Bacillus Dengue virus infection Splenic angiosarcoma Lymphoma and leukemia Multiple myeloma Metastatic cancer Amyloidosis Gaucher’s disease Sarcoidosis Rheumatoid Arthritis Cyst formation Colonoscopy Hemodialysis Operative trauma Cardiopulmonary resuscitation Crohn’s disease Pancreatitis Pregnancy
and degree of spleen injury can be predicted and management decisions based on radiological findings. Definitive management has historically relied on splenectomy, but conservative management and splenic artery embolization techniques are now becoming more common.35, 36 Most patients with traumatic splenic rupture are suspected based on the history of trauma and the mechanism of injury. Patients with atraumatic rupture present a more difficult diagnostic challenge. The clinical presentation of left upper quadrant pain, especially with radiation to the left shoulder, should raise the possibility of this condition.34 The priority of care in the emergency department is expeditious diagnosis with urgent surgical consultation. The initial management strategies include rapid intravascular access, volume resuscitation with saline and blood, and appropriate treatment for coexisting conditions such as respiratory failure or cardiovascular collapse.35, 36
CONCLUSION
Atraumatic splenic rupture is uncommon and often not considered in the differential diagnosis of abdominal pain. Our patient illustrates the need for the emergency physician to be aware of the possibility of rupture of even the normal spleen. Expedient diagnosis, initial stabilization and surgical consultation are important to prevent complications secondary to acute blood loss.
REFERENCES 1.
2. 3. 4. 5. 6. 7. 8. 9.
Lieberman ME, Levitt MA. Spontaneous rupture of the spleen. Am J Emerg Med. 1989;7(1):28-31.
Gupta N, Lal P, Vindal A, et al. Spontaneous rupture of malarial spleen presenting as hemoperitoneum: a case report. J Vector Borne Dis. 2010;47:119-120.
Skok P, Knehtl M, Ceranić D. Splenic rupture in systemic amyloidosis - case presentation and review of the literature. Z Gastroenterol. 2009;47(3):292-5. Krumbhaar EB, Lippincott SW. The postmortem weight of the normal human spleen at different ages. Am J Med Sci. 1939; 197(3):344-57.
Brook, J. Newnam, PE. Spontaneous rupture of the spleen in hemophilia. Arch Intern Med. 1965;115:595-7. Blankenship JC. Spontaneous rupture complicating anticoagulation or thrombolytic therapy. Am Med J. 1993;94:433-437.
Sharma D. Sub capsular splenectomy for delayed spontaneous splenic rupture in a case of sickle cell anemia. World J Emerg Surg. 2009;6:4:17.
McCain M, Quinet R, Davis W. Splenic rupture as the presenting manifestation of vasculitis. Semin Arthritis Rheum. 2002;31:311-6.
Coulter JB, Raine PA. Rupture of the spleen in erythroblastosis fetalis. Arch Dis Child. 1975;50(5):398-400.
10. Brichkov I, Cummings L, Fazylov R. Nonoperative management of spontaneous splenic rupture in infectious mononucleosis: the role for emerging diagnostic and treatment modalities. Am Surg. 2006;72(5):401-4.
11. Van Landingham SB. Rawls DE. Roberts JW. Pathological rupture of the spleen associated with hepatitis A. Arch Surg. 1984; 119:224-5.
12. Vergne R, Selland B, Gobel FL. Rupture of the spleen in infective endocarditis. Arch Intern Med. 1975;135(9):1265-7.
13. Julià J, Canet JJ, Lacasa XM. Spontaneous spleen rupture during ty-
phoid fever. Int J Infect Dis. 2000;4(2):108-9.
14. Safioleas MC, Stamatakos MC, Safioleas CM. Co-existence of spontaneous splenic rupture and tuberculosis of the spleen. Saudi Med J. 2006;27(10):1588-90.
15. Wells EB, Tillman C. Rupture of the spleen due to tularemia: report of a case. Ann Intern Med. 1946;25(5):852-9. 16. Aoyagi S, Kosuga T, Ogata T, et al. Spontaneous rupture of the spleen caused by a Bacillus infection: report of a case. Surg Today. 2009;39:733-37.
17. Pungjitprapai A, Tantawichien T. A fatal case of spontaneous rupture of the spleen due to dengue virus infection: case report and review. Southeast Asian J Trop Med Public Health. 2008;39(3):383-6.
18. den Hoed ID, Granzen B, Granzen B. Metastasized angiosarcoma of the spleen in a 2-year-old girl. Pediatr Hematol Oncol. 2005; 22(5):387-90.
19. Saba HI, Garcia W, Hartmann RC. Spontaneous rupture of the spleen: an unusual presenting feature in Hodgkin's lymphoma. South Med J. 1983;76:247-9.
20. Andrews DF, Hernandez R, Grafton W. Pathologic rupture of the spleen in non-Hodgkin's lymphoma. Arch Intern Med. 1980;140:11920.
21. Sherwood P, Sommers A, Shirfield M. Spontaneous splenic rupture in uncomplicated multiple myeloma. Leuk Lymphoma. 1996;20(56):517-9.
22. Piura B, Rabinovich A, Apel-Sarid L, Shaco-Levy R. Splenic metastasis from endometrial carcinoma: report of a case and review of literature. Arch Gynecol Obstet. 2009;280(6):1001-6. 23. Stone DL, Ginns EI, Krasnewich D. Life-threatening splenic hemorrhage in two patients with Gaucher disease. Am J Hematol. 2000;64(2):140-2.
24. Sharma OP. Splenic rupture in sarcoidosis: Report of an unusual case. Am Rev Respir Dis. 1967;96:101-2. 25. Peña JM, Garcia-Alegria J, Crespo M. Spontaneous rupture of the spleen in RA. Ann Rheum Dis. 1984;43(3):539.
26. Kiriakopoulos A, Tsakayannis D, Papadopoulos S. Laparoscopic management of a ruptured giant epidermoid splenic cyst. JSLS 2005;9(3):349-51.
27. Lewis SR, Ohio D, Rowley G. Splenic injury as a rare complication of colonoscopy. Emerg Med J. 2009;26:147.
28. Yu CC, Lee CC, Hsieh. Spontaneous splenic rupture in a patient who received haemodialysis: case report and a review of the literature. Emerg Med J. 2009;26:915-916. 29. Paskin DL, Weiss SM. Operative trauma to the spleen. Am Surg. 1977;43(4):200-2. 30. Stallard N, Findlay G, Smithies M. Splenic rupture following cardiopulmonary resuscitation. Resuscitation. 1997;35(2):171-3.
31. Nichols TW Jr, Wright FM, Pyeatte JC. Spontaneous rupture of the spleen- an unusual complication of Crohn's disease. A J Gastroenterol. 1981;75(3):226-8.
32. Patel VG, Eltayeb OM, Zakaria M. Spontaneous subcapsular splenic hematoma: a rare complication of pancreatitis. Am Surg. 2005;71(12):1066-9. 33. Wang C, Tu X, Li S. A rare but serious case of acute abdominal pain in pregnancy. J Emerg Med. 2010; Epub. 34. Pratt DB, Andersen RC, Hitchcock CR. Splenic rupture: A review of 114 cases. Minn Med. 1971;54(3):177-84.
35. Bessoud B, Denys A, Calmes JM. Nonoperative management of traumatic splenic injuries: is there a role for proximal splenic artery embolization? AJR Am J Roentgenol. 2006;186(3):779-85. 36. Wei B, Hemmila MR, Arbabi S. Angioembolization reduces operative intervention for blunt splenic injury. J Trauma. 2008; 64(6):14727.
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• SCIENTIFIC •
The Impetuses of Change in Mental Healthcare: Carve-Outs, Managed Care, and Systemic Effects
A
Stephen A. Crowder, MSM, MS and Tiffany A. Owens, MS
BSTRACT
There have been many changes to the mental healthcare system within the past decade. The main impetuses for these changes have been the conversion from a carvein mental healthcare system to a carve-out mental healthcare system and the advent of managed care. It appears that utilizing a managed care system produces a variety of negative effects but only marginal positive effects on the mental health industry. This creates an environment where cost-savings are not realistic, the quality of mental health services is likely to decline, and patient perceptions of the mental healthcare system overall are likely to be lower.
KEYWORDS: MANAGED CARE, CARVE-OUTS, CHANGE IN MENTAL HEALTHCARE BACKGROUND
The business of providing mental healthcare services has undergone marked changes in recent years due to its growth and monetary restrictions. One of the main catalysts of the systemic change is the increase in privatization of the mental health care system.1 This growth and privatization is due in part to the growing definition of what constitutes mental health. The main and most influential change that the system has undergone is the conversion from a carve-in mental health system to a carve-out mental health system. A carve-in system is one in which services are paid for in a fee-for-service arrangement. A carve-out system is one in which services are paid for through managed care contracts. The carve-out system has come to encompass a large portion of mental health services in recent years. A study conducted in 2000 found that 68% of the population with private AUTHOR INFORMATION: Mr. Crowder holds a Master of Science in Management and a Master of Science in Clinical Health Science and is the director of Supported Living, a mental healthcare company. Ms. Owens holds a Master of Science in mental health counseling and is a psychometrist in the Department of Psychiatry and Human Behavior at the University of Mississippi Medical Center. CORRESPONDING AUTHOR: Stephen A. Crowder, MSM, MS, 110 Stonebrook Drive, Florence, MS 39073. Telephone: (601)940-3350. (scrowder@umc.edu).
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insurance received mental health care from the carve-out system.2 These figures indicate that the number of patients who utilized this system increased almost 13% from 1999.2 Ultimately, this has led to increased costs. One study reported the average annual increase in costs for mental health services to be 7%, whereas the increase in costs over the general healthcare marketplace was between 5% and 20%.3 Some policymakers believe that due to the increased usage and costs, there must be benefit limits. Nonetheless, benefit limits are shown to have a negative effect on pediatric populations, and these populations are disproportionately affected when compared to other populations.4 This is important to note since the pediatric population already has the largest portion of unmet needs in the mental healthcare industry.5 Thus, this tremendous growth and usage has precipitated many policy changes and promoted quality mental healthcare services among all populations. Another change precipitated by the carve-out system conversion is the shift in terminology: what used to be called “mental health” is now referred to as “behavioral health.” This is largely because substance abuse treatment now falls under the jurisdiction of mental health.6 The expanded field has led to many policy changes that have had both positive and negative implications on the overall system. While one may argue that managed care causes a reduction in healthcare access, research indicates that this is actually not the case. One study found that managed care programs led to lower usage rates of mental health services but they did not have a measurable effect on access to services.7 Another study found that implementing a carve-out system led to increased use of the mental healthcare system by employees and lowered mental healthcare costs for employees and employers.3 It can be concluded from this research that this type of program does not instantly produce negative effects on the mental health system, but there are several long-term negative implications associated with it. It is important when speaking of these implications to understand what factors have driven the advent of the managed care system, cost-saving measures, and cost-saving possibilities. Undoubtedly, being aware of the negative factors associated with the managed care system will help guide mental healthcare in the right direction.
Before addressing these negative factors, it is important to first understand what changes precipitated policymakers’ utilization of a managed care system. Understandably, a focus on cost-savings has emerged within this system. Managed care came into the mental health policy mainstream because payers were forced to reduce benefits due to limited alternatives. Clearly, reducing benefits was not a feasible alternative because unions would strongly oppose that policy, and it would have been impractical to implement. Conversely, HMOs have utilized managed care to keep costs down and have experienced a great degree of success.6 Potential positive effects for mental healthcare payers include cost-savings in excess of 30% in the first year of utilizing a managed care system.6 Despite the positive effects of cost-savings, a study conducted in Florida found that implementing the mental healthcare carve-out system helped to create the shared clinical model while simultaneously creating concerns about quality of care.8 These cost-saving possibilities have been the catalyst for many recent trials of different managed care policies across the country. The major policy trial has been implementing capitation payments on mental health services. These cost-saving possibilities have been studied greatly by many policymakers across the country. In fact, several states have experimented with a variety of types of managed care contracts and concepts.9 One such policy addresses capitated contractual relationships between payers and providers.9 It appears there is a distinct cost-saving benefit for payers utilizing this system, but research indicates that there is no measurable benefit to patients because usage rates under this type of system are not affected. One study found no significant difference in usage rates among chronically mentally ill patients who were under a capitated contract system when compared with a fee-for-service Medicaid system.9 This usage rate could be due to negative perceptions regarding the system’s cost-effectiveness.
RESEARCH
Research indicates that there is a suspicion that the carveout system is ineffective because it forces cost-shifting and hinders access to healthcare.10 This, in turn, facilitates an environment where patients are forced to satisfy their mental healthcare needs in the general healthcare marketplace.10 Clearly, these factors could play a major role in creating negative patient perceptions and higher costs in the long-term. Initially, these cost-saving possibilities appear attractive to policymakers, but there are dangers associated with this system. Research indicates that there is an initial balance of costs and subsequent higher costs in the future. However, this system actually seems to balance out costs because it lowers the cost of mental health while causing a commensurate rise in the cost of a patient’s general healthcare.10 This is a topic of tremendous importance because patients with long-term mental disturbances have higher healthcare costs than their counterparts, and these patients typically utilize primary medical care facilities for treatment of these conditions. If access to needed specialized services is lowered, then
primary care facilities are likely to be utilized more often by this patient population.10 Furthermore, research indicates other ways in which managed care affects patient perceptions negatively. A study conducted in Massachusetts found that introducing managed care created significant cost-savings and decreased continuity of care.11 It is important to note that initial negative perceptions in managed care are due to restrictions on providers and concerns about lower quality health care.11 A decrease in continuity of care could magnify these negative perceptions. Without a doubt, there is some question regarding the feasibility of utilizing a system that creates long-term adverse effects and higher costs. It is important to understand the main reasons for utilizing a capitated contractual system and the negative implications associated with these reasons. One of the primary factors driving payers to utilize a system of capitation payments is risk adjustment. Risk adjustment in mental healthcare compares populations in terms of different health-related personal characteristics.12 There are problems associated with patient care and functional use in risk adjustment. The capitation payments are set at a certain amount taking into account factors such as age, geographic location, and gender.12 Utilizing this kind of system creates an environment where healthy patients are sought after while patients with serious illnesses are avoided.12 Research indicates that there are two main functional problems with risk adjustment: the ability to set capitation rates to track mental health expenditures and the ability to set these capitation payments to carve-out only mental healthcare costs.12 Additionally, these functional problems are exacerbated by the tremendous expense associated with Medicaid. It is widely known that the Medicaid program is one of the most expensive segments in a state’s budget.13 Simply, individuals with mental disabilities cost more to treat than patients who do not have any long-term disabilities. One study found that individuals with mental disabilities had an average annual healthcare expenditure of approximately $7000 compared to those without any long-term disabilities who had an average annual healthcare expenditure of approximately $3000. This average annual expenditure increases in certain patient populations. Another study found that mental health conditions were more prevalent in adult Medicaid recipients.13 Moreover, research indicates that the amount of money spent could be significantly lower under this type of system when things are viewed on a more microeconomic level. Yet, these decreased expenditures could have some negative implications. Research has shown that managed healthcare has created much lower expenditures on a per incident basis compared to the expenditures before the system was implemented.14 This implies that financial incentives are a large factor associated with expenditures during mental health episodes. Findings suggest that financial incentives for payers have a profound effect on expenditures, whatever the extent of the financial incentives.14 In turn, these lower expenditures could have a profound effect on patient perceptions. Research indicates that these lower expen-
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ditures and cost-saving measures produce reasons for states to restrict mental health services while taking other measures that create negative patient perceptions.15 These decreased expenditures have the potential to produce negative effects not only on patients but also on mental healthcare staff. One study found that the implementation of managed care systems was associated with a decline of mental healthcare professionals at the organizations studied.16 Competition was cited as the most likely reason for this finding.16 Rural areas exacerbate the influence of managed care relationships and the carve-out mental healthcare system. Rural areas present large challenges to both the general and the mental healthcare marketplace. These challenges have caused general healthcare and mental healthcare to combine in metropolitan and urban areas. This merger is more prevalent in rural areas because of the limited resources available there. This situation has caused a greater need for community mental health services and family education and support. The literature examines mostly what services are available in these areas and the level of mental health education that families of individuals with these afflictions have. Examining these factors in rural areas is important because this is the current gold standard in mental health research. The prevalence of managed care relationships has a more profound effect on the mental healthcare system in these areas and on these factors. Individuals residing in these areas have greater access to services and lower out-of-pocket expenses due to managed care relationships. The apparently problematic nature of increased access to services exists predominantly with the belief that quality of mental health services is sacrificed. Rural areas have higher rates of individuals utilizing the mental healthcare system, so quality control is essential. It is clear that the use of the carve-out mental healthcare system creates different overall effects depending on the environment in which is it implemented. A study conducted at Johns Hopkins University found the implementation of a carve-out system in the academic psychiatry department was associated with increased access to services and decreased inpatient services.17 The study concluded that the effects from this system were positive and would create more positive mental health services in the future.17 Interestingly, academic departments of psychiatry are generally nonprofit environments so they are immune to many of the negative effects experienced by for-profit institutions. Essentially, they are not driven to treat large numbers of patients for monetary gain so they can more easily manage and maintain contractual relationships. This leads to better quality management in mental healthcare. Universally, quality management is a term used to indicate efforts to improve clinical and fiscal improvement of mental health organizations.18 Understandably, quality management is vital to the mental healthcare marketplace. The overall significant changes that the mental healthcare system has undergone in the past decade have been the catalyst for the increased need for quality management.18 These changes have been the
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development of new organizational structures, economic changes, privatization, and managed care.18 The variety of positive and negative effects associated with these changes has provided an increased need for focus on quality of services rendered. When utilized properly, quality management can help ensure that changes causing positive effects are nurtured and that changes causing negative effects are discontinued.
CONCLUSION
In conclusion, there are many different factors associated with the mental healthcare carve-out system that are both advantageous and disadvantageous depending on circumstances. These circumstances are all primarily derivations of resources within a certain geographic area: mental health budgets, the amount of specialized providers, and the amount of risk sharing. Initially, the carve-out system appears to be advantageous because it has been shown to have a positive effect on access to specialized mental health services. On the other hand, it appears disadvantageous due to a commensurate negative effect on the quality of mental health services. This reported decline in quality of care is a matter that is currently being carefully studied by mental health policymakers and researchers. Surely, efforts to improve quality should circumvent the impositions created by larger patient populations, decreased face time with providers, and the declining size of the mental health workforce. Overall, it can be concluded that the mental health carve-out system has had many positive effects on the mental healthcare system and will continue to improve access to quality mental health services. Of course, cost will continue to be an issue as well. Certainly, the future of mental healthcare policy should focus on increased access to quality care to best serve the growing mental health population.
REFERENCES 1. 2. 3.
4. 5. 6. 7. 8.
Donohue J, Frank R. Medicaid behavioral health carve outs: a new generation of privitization decisions. Harv Rev Psychiatry. 2000;8:231-241.
Garnick D, Horgan C, Hodgkin D, et al. Risk transfer and accountability in managed care organizations’ carve out contracts. Psychiatr Serv. 2001;52:1502-1509.
Grazier K, Eselius L. Mental health carve-outs: effects and implications. Med Care Res Rev. 1999;56:33-59. Peele P, Lave J, Xu Y: Benefit limits in managed behavioral health care: do they matter? J Behav Health Serv Res. 1999;26:430-441.
Tang M, Hill K, Boudreau A, et al. Medicaid managed care and the unmet need for mental health care among children with special health care needs. Health Serv Res. 2008;43:882-900. Feldman S. behavioral health services: carved out and managed. Am J Manag Care. 1998;4:59-67.
Davidoff A, Hill I, Courtot B, et al. Effects of managed care on service use and access for publicly insured children with chronic health conditions. Pediatrics. 2007;119:956-964.
Ridgely M, Giard J, Shern D. Florida’s Medicaid mental health carveout: lessons from the first years of implementation. J Behav Health Serv Res. 1999;26:400-414.
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Liu C, Manning W, Christianson J, et al. Patterns of outpatient use of mental health services for Medicaid beneďŹ ciaries under a prepaid mental health carve-out. Adm Policy Ment Health. 1999;26:401-415.
10. Cuffel B, Goldman W, Schlesinger H. Does managing behavioral health services increase the cost of providing medical care? J Behav Health Serv Res. 1999;26:372-380.
11. Dickey B, Normand S, Norton E, et al. Managed care and children’s behavioral health services in Massachusetts. Psychiatr Serv. 2001;52:183-188.
12. Ettner S, Frank R, McGuire T, et al. Risk adjustment alternatives in paying for behavioral health care under Medicaid. Health Serv Res. 2001;36:793-811.
13. Thomas M, Waxmonsky J, Gabow P, et al. Prevalence of psychiatric disorders and costs of care among adult enrollees in a Medicaid HMO. Psychiatr Serv. 2005;56:1394-1401. 14. Huskamp H. How a managed behavioral health care carve-out plan affected spending for episodes of treatment. Psychiatr Serv. 1998; 49:1559-1562.
15. Stout M. Impact of Medicaid managed mental health care on delivery of services in a rural state: An AMI perspective. Psychiatr Serv. 1998;49:961-963.
16. Schefer R, Ivey S. Mental health stafďŹ ng in managed care organizations: a case study. Psychiatr Serv. 1998;49:1303-1308.
17. Fagan P, Schmidt C Jr, Cook B. A model for managed behavioral health care in an academic department of psychiatry. Psychiatr Serv. 2002;53:431-436.
18. Hermann R, Regner J, Erikson P, et al. Developing a quality management system for behavioral health care: the Cambridge Health Alliance experience. Harv Rev Psychiatry. 2000;8:251-260.
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• CLINICAL PROBLEM-SOLVING •
Doc, I Feel Like I’m Getting Fat
Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair
A
Sonya Clemmons, MD
36-year-old African-American female presented for a routine breast and pelvic examination with Papanicolaou smear. Her most recent examination had been performed approximately 14 months earlier, and she denied any history of an abnormal Papanicolaou smear. Her previous reported sexual activity occurred 4 months ago, and she was taking oral contraception. Her last menstrual cycle occurred one month ago. She related that her menses was not heavy, but she had noticed increased cramping and blood clots. She denied vaginal discharge, itching, or rash and had been treated for trichomoniasis 4 years ago. When prompted about additional concerns that needed to be addressed, the patient incidentally mentioned, “Doc, I feel like I am getting fat.” She thought her abdomen had been increasing in size and getting “harder” over the preceding several months. She reported occasional abdominal pain unrelated to oral intake of food or liquids or menses. She denied diarrhea, constipation, or hematochezia. The remainder of the review of systems was unrevealing. The patient seems to be describing increasing abdominal distention. This is commonly caused by the five f’s: fat, feces, fetus, flatus or fluid.1 Given this patient’s age and gender, I am thinking, prior to examination, that her complaint is likely related to actual weight gain or perhaps bloating or constipation. I would be less concerned about pregnancy since she reports oral contraception usage, no recent sexual activity and a recent menstrual cycle. However, since she reports more painful menses and blood clots, perhaps she might have a uterine leiomyoma. This is the most common tumor of the female reproductive tract and tends to have a higher incidence and be larger and more symptomatic in black women.2 The history does not reveal the exact cause of this distension, and I need to gain more information from the physical examination. Breast examination revealed no masses, skin changes or nipple discharge. The genitourinary examination revealed normal external genitalia, urethra, vagina, and
AUTHOR INFORMATION: Dr. Clemmons is a third year resident in the Department of Family Medicine at the University of Mississippi Medical Center in Jackson.
CORRESPONDING AUTHOR: Sonya Clemmons, MD, Department of Family Medicine, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216. Telephone: (601)984-6800 (office) Fax: (601)984-6812 (sclemmons@umc.edu).
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cervix. The bimanual examination revealed a large pelvic/abdominal mass that extended from the pelvis up to about 10 centimeters above the umbilicus just below the liver. No cervical motion was appreciated upon palpation of the mass. The adnexa could not be well appreciated due to the size of the mass. The remainder of the examination was unremarkable. The patient’s age, gender, mass size, and lack of systemic symptoms do not point me toward an intra-abdominal solid organ as the origin of the mass.3 I am instead thinking the mass is likely of pelvic origin. Since the palpation of the mass does not cause cervical motion, a uterine source seems less likely. An ovarian cause actually seems more likely due to the large size of the mass; the differential diagnosis is broad.4 Ovarian cancers may present as large masses reaching sizes of greater than 20 centimeters but uncommonly occur in premenopausal women.4,5 The patient also has few risk factors for this type of malignancy. A benign ovarian neoplasm such as a germ cell, epithelial or stromal tumor could be possible as well. These can reach 20 to 40 centimeters in size and can become large enough to fill the entire abdomen and pelvis.4,6,7 They may also be hormonally active. Other considerations in the differential diagnosis of very large pelvic masses would be functional ovarian cysts and tumors and ovarian endometriomas; however, these rarely exceed 15 centimeters.8,12 Uterine leiomyomas may also cause very large pelvic masses, reportedly reaching sizes as large as 60 centimeters but are usually smaller and palpable at the size of a 1214 week uterus.9 I now need more diagnostic tests to further characterize the mass. Transvaginal ultrasound is the standard diagnostic tool for initial evaluation of suspected adnexal mass and has similar sensitivity and specificity to that of computed tomography.5,10 Transabdominal and transvaginal ultrasounds were subsequently performed. A mass was identified in the lower abdomen and pelvis that extended posterior to the uterus; it was described as a large mixed solid and cystic mass measuring up to 21 centimeters in transverse dimension. Multiloculated cystic components were also identified, the largest measuring up to 10 x 6 centimeters. The right ovary could not be identified, and the mass was thought to arise from the unidentified ovary. Computed tomography (CT) was recommended for further evaluation. Unilocular ovarian cysts, irrespective of patient age or cyst size, as well as multilocular lesions without papillary pro-
• SCIENTIFIC •
jections or solid components are usually thought to represent benign findings. However, the presence of an ovarian mass with solid components is in general concerning for malignancy, except in the case of dermoid cysts and fibromas. I am still favoring the ovary as the origin of the mass, especially given its appearance and size, and need additional imaging to further characterize and localize the lesion. A CT with intravenous contrast was subsequently obtained. A large, well circumscribed, complex mass was described in the lower abdomen and pelvis extending cephalad to the lower border of the liver. Fluid as well as soft tissue components were noted in addition to calcification and scattered areas of fat. The mass measured 21.6 centimeters transverse and 11.5 centimeters anteroposterior. No abnormality of the solid abdominal viscera was seen, and the gastrointestinal tract was normal. The appearance of the mass seemed most consistent with that of a complex dermoid cyst or large teratoma but an ovarian epithelial malignancy could not be ruled out. The CT finding that is diagnostic for mature cystic teratomas is the presence of fat within the cyst.11 Calcifications may also be present in addition to hair and teeth. Imaging, however, cannot rule out the possibility of malignancy, though malignant degeneration is rare and occurs only in 1-2% of cases.11,12 The imaging findings and the large size of the mass warrant immediate referral.5 The patient was referred to an obstetrician/gynecologist for further evaluation and treatment. An exploratory laparotomy was subsequently performed with right salpingo-oophorectomy and left tubal ligation as the patient did not desire fertility. The mass was noted to involve the right ovary and fallopian tube. Postoperative pathology confirmed the diagnosis of benign cystic teratoma (dermoid cyst) weighing 5.8 pounds and measuring 24 x 22.5 x 11.0 centimeters. The benign cystic teratoma or dermoid cyst is the most common ovarian neoplasm.4,11 It is typically less than 10 centimeters in size, and approximately one half are diagnosed in women ages 25 to 50 (mean patient age 30).4,11 This patient is near the age of average presentation but exhibited an uncommonly large mass. Tumors are composed of well-differentiated tissue components derived from at least two germ layers and can contain multiple tissue types originating from the ectoderm (sweat and sebaceous glands, teeth, hair follicles, and neural tissue), mesoderm (bone, cartilage, muscle, adipose tissue), and endoderm (thyroid tissue and bronchial and gastrointestinal epithelium). In this case, both hair (ectodermal derivative) and fat (mesodermal derivative) were present. Dermoid cysts are usually slow growing and on average grow at a rate of 1.8 millimeters per year. The patient reports rapid appearance of symptoms over the course of several months. However, it is difficult to ascertain from history alone the exact rate of growth of the mass. Dermoid cysts may also be bilateral in 8-15% of patients, but this particular mass was unilateral.12 Though most benign cystic teratomas are asympto-
matic, nonspecific symptoms such as abdominal pain can occur as was the case for this patient.11 The patient’s seemingly casual remark and nonspecific symptoms seemed to point toward common non-worrisome causes of abdominal distension. Complaints of “getting fat” are often related to actual increase in adipose. However, one must remember that perceived “fat” could have many possible causes.
KEY WORDS: TERATOMA, DERMOID CYST, OVARIAN REFERENCES 1.
2. 3. 4. 5. 6. 7. 8. 9.
NEOPLASM, PELVIC NEOPLASM
Abdomen. In: Moore KL, Dalley AF. Clinically Oriented Anatomy. 4th ed. Canada: Lippincott Williams & Wilkins; 1999:186. Evans P, Brunsell S. Uterine fibroid tumors: diagnosis and treatment. Am Fam Physician. 2007;75(10):1503-1508.
Doherty G. Way L. Current Surgical Diagnosis and Treatment. 12th ed. United States: Lange Medical Books/McGraw-Hill; 2006.
Hacker N, Moore JG, Gambone JC. Essentials of Obstetrics and Gynecology. 4th ed. Philadelphia, PA: Elsevier Saunders; 2004.
Givens V, Mitchell G, Harraway-Smith, Reddy A, Maness D. Diagnosis and management of adnexal masses. Am Fam Physician. 2009;80(8):815-820. Donnadieu AC, Deffieux X, LeRay C, Mordefroid M, Frydman R, Fernandex H. Unusual fast growing ovarian cystic teratoma during pregnancy presenting with intracystic fat floating balls appearance. Fertil Steril. 2006;86(6):1758-1759.
Yourn HS, Cha DS, Han HK, Park EY, Hyon NN, Chong Y. A case of huge sclerosing tumor of the ovary weighing 10 kg in a 71 year old postmenopausal woman. J Gynecol Oncol. 2008;19(4):270-274. Donnez J, Nisolle M, Gillet N, Smets M, Bassil S, CasanaxRoux F. Large ovarian endometriomas. Hum Reprod. 1996; 11(3):641-646. Oelsner G, Elizur SE, Frenkel Y. Giant uterine tumors: two clinical cases with different clinical presentations. Obstet Gynecol. 2003;101(5):1088–1091.
10. Agency for Healthcare Research and Quality. Management of adnexal masses. Evidence Report Technology Assessment, no. 130. Rockville, MD.: Agency for Healthcare Research and Quality; February 2006. Available at http://www.ahrq.gov/clinic/tp/adnextp.htm. Accessed May 4, 2010. 11. Outwater EK, Evans SS, Hunt JL. Ovarian teratomas: tumor types and imaging characteristics. Radiographics. 2001;21(2):475-90.
12. Atri M, Nazarnia S, Bret P, Aldis A, Kintzen G, Reinhold C. Endovaginal ultrasound appearance of benign ovarian masses. Radiographics. 2004;14:747-760.
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• MSDH • Mississippi Reportable Disease Statistics
April 2011
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For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com JOURNAL MSMA JULY 2011
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• PRESIDENT’S PAGE •
The Doctor-Patient Relationship: It’s Worth Fighting For
M
y dad didn’t talk about the war much, and when he did, it was about the fun things he did…like the time my aunt sent eggs and powdered milk, and they arrived unbroken and unspoiled. He and a buddy snuck off into the hills of Guam and made ice cream. They had to get away from the others so they would have some left to eat themselves. When the war was over, they were given the choice of returning home with their B-29 unit or catch a ride on a Navy ship. If he waited for the Army Air Force ride it would be December before getting to the states so on the ship it was! And what did a bunch of guys that didn’t have anything to do on a ship do? Play poker! Well, I guess Dad was good at it as he won enough money to buy a service station in THOMAS E. JOINER, MD Crawfordsville, Arkansas. From there he bought the Bulk plant, started farming, met my 2011-12 MSMA PRESIDENT mom, moved to the Mississippi Delta when farmland was opening up, had three boys and a girl, and the rest is history. My mom and dad didn’t believe in children with nothing to do so we all had jobs early on, one of the first I can remember being delivering for Chaney’s Drugs in Greenwood. What it taught me is that to get paid you have to do something. To get something of worth, you have to give something of worth. I guess I am a simpleton but I understood this concept well. That is what I prepared for in life, and it is what has served me well. And it seems to me to be what has made America great. Which is why I just don’t get this Patient Protection and Affordable Care Act (PPACA) and accountable care organization (ACO) stuff! I do not understand the concept of being paid for something other than direct patient care. In addition, I have never seen it work overall anywhere else. HMO’s tried it, and it didn’t work! We have all seen it to some degree in various forms, various names, various guises, but never has it been so successful as to take on the dominate form of health care delivery in the United States– nor should it! It is still early in the game, and we do not entirely understand how these things are going to be set up, who the primary “managers” will be: docs vs. hospitals vs. business execs, government, insurance and third party payers, or “others.” The rules were just published April 1, and we are in a “question and answer” period for 60 days. What I do know is that docs are good at doctoring, business execs and third party payers are good at setting up and running businesses, and the two have two different primary interests: the patient vs. business success (profits). I also know that, outside of medical practice, docs are usually poor businesspersons, and businesspersons are poor docs, and that our primary concern, the patient, seems to have been lost in the shuffle. This is why my primary concern has been and remains the patient, the “doctor-patient relationship,” and getting paid for delivery of my services to my patients. It just seems this is the most logical and efficient system for health care delivery thus far devised and has resulted in the greatest health care system in history. This is what I am determined to fight for and preserve for our children and citizens. Having said that, we all have to recognize that things are changing, and we need to be prepared for such. We cannot take a stance, no matter how wrong or right we may be, and ignore what else others are trying to accomplish. We may find ourselves on the outside looking in. This is where our MSMA is so valuable to us! Our staff does a great job being on top of the ever-changing political and business climate, ready to assist with latest regulations, as well as fighting those intrusions into our doctor-patient relationships. Their results are tangible, with tort reform now a much more level playing field, and a behind-the-scenes constant presence at the State Capitol keeping those reforms in place. Now, if we can just get the AMA to understand the same concepts and that they are worth fighting for, we will be going in the right direction. I think they may be getting that message. Keep up the good fight!
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• EDITORIALS •
Pack Your Bags and Revisit Your JOURNAL MSMA
S
ticks and stones may break my bones, but words…well, let’s just say there are words, and then there are words that evoke the irritating “s-k-r-i-t-c-h” of fingernails on a chalkboard. And when those words are directed at MY Journal MSMA—OUR Journal MSMA, I tend to react as if someone has just made disparaging remarks about my mama’s cooking or my granddaughter’s dance recital performance. Published monthly since 1960, the Journal MSMA is the official publication of our association and missionly strives to advance the art and science of medicine, promote the D. STANLEY HARTNESS, MD ideals of MSMA, encourage scholarship and good will among Mississippi physicians, and ASSOCIATE EDITOR disseminate information specifically applicable to the healthcare of our patients. Did you know that MSMA is only one of ten state medical associations that publish and print a monthly medical journal? Karen Evers does a “yeowoman’s” job as managing editor. Think about it…riding “deadline” herd on her physician editor and his two physician associate editors each of whom is responsible for producing an editorial every three months as well as critiquing and editing scientific submissions (well, actually the entire contents of each issue). Karen is also charged with reconciling the varied (and often strong) opinions of the Committee on Publications (again, physicians) which implements MSMA Board instructions and policies relating to the Journal. In addition, this committee in turn recommends to the Board policy proposals concerning organization and production of the Journal. Remember that these busy physicians DONATE untold hours in this effort because of a commitment to producing a reputable document coupled with a fascination with the written word. The fact that Mississippi physicians share unique problems, a unique history, and a unique bond at a time when the practice of medicine is changing exponentially makes our Journal MSMA more relevant than ever to our members. The call by one member at our recent MSMA Annual Session for radical revamping of the Journal to include “original research in the biomedical sciences, updates in ‘best practices,’ stimulation of discussion of matters important to Mississippi physicians, new solutions for old problems, informing physicians of current political challenges in our practice of medicine, aiding physicians in improving the health of our patients and the residents of this state, sharing and saving important historical information of Mississippi’s physicians, and serving as an instrument of cohesiveness, camaraderie, and communication” is puzzling since these are the very regular departments and feature articles which comprise each issue of the Journal. To this end, a call for original scientific material with explicit guidelines for authors appears regularly in the back of most issues and can also be found on the website. Additionally, a call for scientific manuscripts is sent to academic department chairs encouraging submissions. We provide explicit instructions on how to prepare case reports, original research and descriptive data manuscripts, clinical practice guidelines, as well as articles for our “up-to-date” and “top 10 facts you should know” series, and we promote our interest in receiving letters to the editor. Clearly, no publisher can ignore the inevitable shift to electronic delivery, but those who prophesy the end of journal publishing in the next few decades are probably wide of the mark. While the Journal MSMA is now searchable through a free online content provider service: issuu.com, previously our PDF’s were only available to MSMA members using their password to access the content behind the firewall. Since Issuu has gone mobile, the Journal is accessible from anywhere and its contents shared with colleagues. Alternatively, anyone can access the JMSMA on the MSMAonline.com Journal tab. Additionally, a link to the latest Journal issue is displayed prominently on every weekly e-newsletter: MSMA Physicians’ Position. While visiting exhibitors at our annual session, our managing editor spoke with Southern Medical Association (SMA) staff about their online journal and learned about members’ concerns because they have to log out of the SMA website to log in separately to the Southern Medical Journal site maintained by Lippincott Williams and Wilkins requiring a separate password. Presently there are many electronic-only journals, but it seems that no print journals have ceased in favor of their electronic equivalents. When this July issue of our Journal MSMA arrives at your office, you’re invited to visit once again—with pride—the pages of this venerable yet still viable and vital publication which seeks to educate, enlighten, engage, and entertain our varied membership. ❒
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Mississippi Doctor Civics 101: Or How Mississippi Government Really Works in Areas That Affect Physicians [Dr. Bondurant is a gynecologist in private practice in Grenada. He was elected to the House of Representatives for District 24 in 2003 and is currently running for re-election. For the last four years he has been the only physician in the Mississippi Legislature. Dr. Bondurant attended his first MSMA meeting when it was held at the Broadwater Beach Hotel in Biloxi. He is one “of us” and our great warrior at the Legislature!]—LL
T
his is election year for Mississippi. Many offices in state and county government come up for the voters to decide on who gets to occupy which office. From constable to Governor it is campaign season. The signs are REP. SIDNEY W. BONDURANT, MD going up, and the media ads are being heard and seen all over the state. R-MS, CALHOUN, GRENADA, For many years the August primary was essentially the election. Almost all the YALOBUSHA candidates ran as Democrats, and the Republican Party could “hold its convention in a phone booth.” The winner of the Democrat primary in August automatically would win the general election in November since there was generally no Republican in the race. About thirty years ago that began to change. There are now Republican primaries that will essentially decide who the winner will be in November. Many races will have multiple candidates running in both the Democrat and Republican primary elections to see who will be each party’s candidate in November. Mississippi has become a multi-party state. The Governor: Mississippi has traditionally had what political scientists call a “weak” Governor. Our Governor does not get to appoint directly the heads of many political institutions in the state. He does appoint many of the board members who govern those agencies, but he does not appoint all of those members. The board members then hire the agency head. One example is the State Board of Health and the State Health Officer. Some state agency heads are appointed by the Governor, and he thus has direct responsibility for them. An example of this is the Division of Medicaid and its Director. One power the Governor does have is that he is the only one who can call a Special Session of the Legislature, and he has the power to limit the agenda of that Special Session as narrowly as he wants. He can veto a bill if he does not like it, and the Legislature has to have a two-thirds vote to override the veto. The Lieutenant Governor: This office does a lot more than just “stand by” to take over if the Governor is out of the state or incapacitated. The Lieutenant Governor is the person who appoints the members and chairmen of all Senate committees, decides which bills go to which committees, and appoints many board and commission members just like the Governor does. The Speaker of the House: All voters get to vote for Governor and Lieutenant Governor Candidates. The Speaker of the House has a much smaller number of constituents, the 122 members of the House of Representatives. The Speaker is elected only by those 122 members as one of the first things they do in January after the November elections. It is the most important vote those 122 members will make during their four year term. The office is just as powerful as the Governor and Lieutenant Governor, and the Speaker has essentially the same responsibilities for chairs and committee members in the House of Representatives as the Lieutenant Governor does in the Senate. He also decides on which committee a bill will go to, a decision that can spell survival or death for a bill. Committee Chairmen: This is one of the least understood offices outside of the Capitol building. Chairmen have the power of life and death for legislation. It is practically impossible to get a bill out of the chairman's hands if he or she does not want that bill to come to a vote. The chairman can let a bill die without it ever being seen by the committee, have a bill discussed but not voted on, or bring it to a vote and pretty well be assured it will pass the committee and go on to the full Senate/House to be put on the agenda. But even if it is on the agenda the chairman does hot have to bring the bill to the body of the Senate/House for a vote if he does not desire this. The chairmen work closely with the Lieutenant Governor and Speaker so generally these decisions are made jointly. Chairmen have a lot of power. Committee Members: Some committees have lots of power and do things that affect everyone in the state. Membership on these committees comes only with seniority and established relationships with legislative leadership. Other committees rarely get bills assigned to them and may never even meet during the session. A membership on a powerful committee usually carries with
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â&#x20AC;˘ EDITORIAL â&#x20AC;˘
it responsibility and an expectation of work with lobbyists/trade associations/citizens who will be affected by legislation brought to that committee. Members assigned bills by the chairman are expected to refine a bill, have it discussed with parties who will be affected by it, and go over the bill with the chairman to be sure he or she is fully aware of all it does before bringing it for a vote in the committee. Sometimes that member will also â&#x20AC;&#x153;handleâ&#x20AC;? the bill when it comes to the Senate/House for a debate and vote. This has been a brief description of the offices of government that have direct effects on legislation that will affect physicians in Mississippi. Physicians are educated, respected, intelligent citizens who can and should be leaders in their communities. Get to know your candidates and understand where they stand on the issues and offices important to medicine. Then support those candidates who support your issues. Do that through MSMA, MMPAC, and by getting out to VOTE! The last election for Speaker of the House in Mississippi would have had a different result if ELEVEN people in Jackson County had voted for a different candidate in the House of Representatives. Your vote counts. â?&#x2019;
Why join the AMA? The future of medicine should be decided by physicians themselvesâ&#x20AC;&#x201D;not legislators or private interests like insurance companies. The most effective way you can address the greatest public health and professional issues facing medicine today is by joining the nation's largest physician association, the AMA. By becoming an AMA member, you gain powerful representation that works for your interests, as well as those of your patients, your practice, your specialty and your state. Learn more at www.AMA-assn.org.
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JOURNAL MSMA JULY 2011
• MSMA • Report and Highlights of the 143rd Annual Session of the MSMA House of Delegates 2011
THOMAS E. JOINER, MD INAUGURATED PRESIDENT
During a “Run for the Roses” themed dinner/dance held the evening of Saturday, May 21, 2011, MSMA members inaugurated their new president at the association’s 143rd Annual Session held in Tupelo. Dr. Thomas E. Joiner of Jackson, who served as president-elect over the past year, was inaugurated as president. MSMA President Dr. Joiner spoke fondly of his profession during the inauguration ceremony. “I knew as early as elementary school I wanted to be a doctor. I don’t know why; I just knew. I never wanted to be anything else and there’s not a day in my life that I have regretted that decision. I love my patients; I love my practice,” he said. Dr. Joiner added, “But, regrettably, I do not love what I see happening to my profession. It saddens me to see the most pristine parts of our profession - the sanctity of the patient/physician relationship and our ability to choose how we practice medicine - under attack,” and he vowed to support doctors and patients in the wake of government regulations, third-party payer disputes, and threats of expanding scopes of practice for non-physicians. He added, “We must continue and escalate the fight to protect a physician’s right to take care of patients without interference from government, payers, and other health professionals” in order to “preserve what makes American medicine the gold standard for the world.”
Board-certified family medicine physician Thomas E. Joiner, MD of Jackson was inaugurated 2011-12 MSMA President. Above: Immediate Past-President Dr. Timothy J. Alford places the president's medallion on Dr. Joiner while his wife Deborah and granddaughter Cameryn observe. Below: Members of Central Medical Society escorted Dr. Joiner to the podium and witnessed the oath of office administered by MSMA Board of Trustees Chair Dr. James A. Rish to become the 144th president.
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Dr. Joiner, originally from Greenwood, completed both undergraduate and medical degrees from the University of Mississippi and serves the medical community through involvement with the Central Medical Society, the American Medical Association, 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 Medicaidâ&#x20AC;&#x2122;s Review of Medical Necessity, and pastpresident of the Central Medical Society. He is a former chief resident at University of Mississippi Medical Center and former chief of staff at Central Mississippi Medical Center.
PRESIDENT-ELECT, OTHER OFFICERS CHOSEN
Elections were held Sunday morning, May 22 to chose the president-elect and other leadership for the 20112012 term. Dr. Steve Demetropoulos of Pascagoula was selected by his peers as president-elect to represent MSMA as president in 2012-2013. MSMA PresidentElect Dr. Demetropoulos is an emergency physician at Singing River Health Systems Steve Demetropoulos, MD where he serves as MSMA President-Elect President and Group Administrator. He has held all leadership positions within his local component society, the Singing River Medical Society. He is a past-president of the Mississippi Chapter of American College of Surgeons and currently serves as president of the State Emergency Physicians Association. His service to the MSMA includes six years on the Board of Trustees, six years on the Council on Legislation, six years on the Council on Public Information, and 10 years on the Mississippi Medical Political Action Committee Board of Directors. Dr. Demetropoulos has also been a member of the Medical Assurance Company of Mississippi Board of Trustees since 2002. In addition to selecting their president-elect, MSMA members elected the following physicians to these respective offices: Speaker of the House: Lee Giffin, MD Vice Speaker of the House: Geri Lee Weiland, MD Trustee, District 6: Jeff Morris, MD Trustee, District 7: Daniel Edney, MD Trustee, District 8: Lee Voulters, MD Trustee, Resident: P. Brent Smith, MD
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Trustee, Student: Andrew Weeks Editor, Journal MSMA: Lucius Lampton, MD Associate Editor, Journal MSMA: Richard DeShazo, MD Council on Budget and Finance: Jennifer Gholson, MD Council on Constitution and Bylaws: Philip Merideth, MD Council on Legislation, District 6: Chris Mauldin, MD Council on Legislation, District 7: Ann Rea, MD Council on Legislation, District 8: Lee Voulters, MD Council on Legislation, Resident: Tal Hendrix, MD Council on Legislation, Student: David Weiland Council on Medical Education, Distict 1: Edgar Donohoe, MD Council on Medical Education, District 3: Laura Gray, MD Council on Medical Service, District 1: Alfio Rausa, MD Council on Medical Service, District 2: Sidney Bondurant, MD Council on Medical Service, District 3: Murray Estess, MD Council on Medical Service, Resident: Jason Stacy, MD Council on Medical Service, Student: Phillip Sandifer Council on Public Information, District 4: Jennifer Bryan, MD Council on Public Information, District 5: DeWitt Crawford, MD Council on Public Information, District 6: Christy Thornton, MD
Mississippi State Board of Medical Licensure District 1: Patrick Barrett, MD; Randy Easterling, MD; Camille Jeffcoat, MD District 2: Virginia Crawford, MD; George Bush, MD; Tom Carey, Sr., MD District 3: William Mayo, DO; Michael H. Carter, MD; John F. Lucas, III, MD
2011-2012 AMA Delegation Lucius Lampton, MD; Daniel Edney, MD; Timothy J. Alford, MD; J. Clay Hays, Jr., MD; Randy Easterling, MD; James Rish, MD; Hugh A. Gamble, III, MD; Thomas E. Joiner, MD
EXCELLENCE IN MEDICINE AWARDS Dr. Bradford J. Dye, III Dr. James C. Waites Leadership Award
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. The Waites Award recipient for 2011, Bradford J. Dye, III, MD, of Oxford, is an active member of the association, serving as an MSMA Board of Trustees member since June 2009 and serving as President of the MSMA Young Physicians Section. In his local North Mississippi Physicians Association he
Bradford J. Dye, III , MD
has been a member of the Board of Directors, Vice President (2003), President (2004 - 2007), and Treasurer (2007 - present). The North Mississippi Medical Society has also benefited from Dr. Dye’s leadership as he served as President of this component society from 2006 to 2007, and he has sought to improve and strengthen physician/insurer relations through membership on the Mississippi Physicians Care Network Board of Directors since November 2007. Dr. Dye also serves as a member of the Mississippi Tobacco Control Advisory Council, a thirteen-member board appointed by state and university officials which advises the State Board of Health on the development and implementation of anti-tobacco programs in the state. Aside from his Oxford-based practice and leadership in organized medicine, Dr. Dye is a beat writer for the Magnolia Gazette and serves as a team physician for the University of Mississippi athletic program. He is a 1995 University of Mississippi School of Medicine graduate.
Dr. John Robert “Bob” Ford MSMA Community Service Award
Dr. Bob Ford, recipient of the 2011 MSMA Community Service Award, maintains a full family practice in Vicksburg treating patients regardless of their insurance coverage or ability to pay. In addition to his medical practice he is a licensed Methodist minister and pastor of Wesley United Methodist Church. Weekly Dr. Ford provides health care services gratis at the local Good Shepherd Clinic, a John R.“Bob” Ford , MD “free clinic.” An organizer of an area soup kitchen, Dr. Ford also volunteers weekly by serving food to the needy in his community and helps in the administration of a Vicksburg homeless shelter. He takes a medical mission trip to Mexico each summer, has served on the school board for the Vicksburg Warren School District for several terms, and has been a team physician for the local high school football team.
Linda Fondren, Founder of Shape Up Sisters / Shape Up Vicksburg MSMA Award for Excellence in Wellness Promotion
The 2011 MSMA Excellence in Wellness Promotion award winner Linda Fondren is a 55-year-old mother and real estate developer who, since her sister’s death in 2006 after a lifelong struggle with obesity, has led a battle against the disease. Fondren, also of Vicksburg, is the founder of Shape Up Sisters, an all female exercise facility offering free nutrition and exercise classes to women in the community, and Shape Up Vicksburg, a citywide 17-week weight loss
challenge that has seen over 2,500 area participants including the town mayor, police chief, school cafeteria workers, teachers, and restaurant owners. She has promoted wellness in her community by offering free fitness and nutrition classes, convincing many of the city’s restaurants to add healthy items to their menus, and establishing a communitywide walking club and various weigh-in stations at Wal-Mart, the local medical center, and on a free website Linda Fondren which allows participants to track their weight loss in person or online. Participants have lost over 15,000 pounds through these activities which are offered free of charge to the community. The success of the facility and program has garnered statewide and national acclaim and recognition for Fondren for her efforts to end obesity in Mississippi including being featured on the “CBS Evening News” with Katie Couric in 2010; chosen by theGrio (an international African American news service organization) as a member of the 2011 Class of the “Top 100 History Makers in the Making;” and chosen as a Top 10 Hero of the “CNN Heroes 2010” class.
Leslie F. Mason, MD Robert S. Caldwell, MD Award
Since 1982, Medical Assurance Company of Mississippi has presented the Robert S. Caldwell, MD Award to the top resident at the University of Mississippi Medical Center. The Caldwell Award is given in memory of the late general surgeon from Tupelo who was instrumental in the founding of MACM. Dr. Caldwell served on MACM’s first Board of Directors and was elected the Company’s first Secretary. In addition, he was President-elect of the Mississippi State Medical Association at the time of his death. The Caldwell Award is Leslie F. Mason , MD given each year in recognition of excellence in medical care, record keeping, leadership, and the teaching of medical students and fellow residents – characteristics that MACM deems valuable in a young physician. The recipient
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is selected by an ad hoc committee of faculty members at UMMC. This year’s Caldwell Award winner is Leslie F. Mason, MD, an ob/gyn resident. She was nominated for this award by the department because of her exemplary performance throughout her residency training. She excels in all areas including patient care, doctor/patient relationships, and medical record keeping. In August 2011, Dr. Mason plans to enter private practice in Madison County. She hopes to provide services to women who may not have always had access to good quality patient care. She is a member of the American College of Obstetrics & Gynecology and Alpha Omega Alpha. She was recipient of the 2010 UMC Leadership & Service Award.
RESOLUTIONS OF THE HOUSE OF DELEGATES
Resolution 1, In Memoriam (adopted) Resolution 2, Study the Impact of University Physicians (Referred to the Board of Trustees) RESOLVED, that MSMA conduct a study and report its findings regarding the financial and economic impact of University of Mississippi Health Center on the private practice of medicine in the central Mississippi region. Resolution 3, Encouraging Individual Responsibility to Own Health Insurance with Tax Incentives (adopted) RESOLVED, that our Mississippi State Medical Association support legislation deeming the purchase of health insurance a matter of individual responsibility to be encouraged by the use of tax incentive and other non-compulsory measures rather than a federally imposed mandate requiring individuals to purchase health insurance. Resolution 4, Rescind the Patient Protection and Affordable Care Act (PPACA) (referred to the Board for decision) RESOLVED, that MSMA call on the Senators and Representatives to the U.S. Congress from the State of Mississippi to honor their oath to obey the U.S. Constitution and rescind “The Patient Protection and Affordable Care Act.” Resolution 5, Electronic Polling and Voting (adopted) RESOLVED, that the MSMA Board of Trustees study and report back to the House of Delegates on the feasibility and appropriate application of utilizing online Internet-based tools to increase communication to and participation of members. Resolution 6, Expanding Tort Claims Act Protection to All Physicians (not adopted) RESOLVED, that MSMA support legislation to expand the protection of the Mississippi Tort Claims Act to all physicians so that the $500,000 limit on total damages apply to all medical liability claims. Resolution 7, Legalization of Medical Marijuana (not adopted) RESOLVED, that MSMA support legislation to legalize medical marijuana use in the state of Mississippi. Resolution 8, Prescription Drug Abuse, Diversion and Overdose (adopted) RESOLVED, that MSMA support legislation and other outreach efforts which will 1) educate physicians regarding addiction as a brain disease, 2) raise
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awareness of prescription drug abuse and diversion in Mississippi, 3) encourage physician use of Mississippi’s Prescription Drug Monitoring Program (PMP), and 4) clarify and improve physician reporting requirements for incidents of prescription drug diversion and drug overdose incidents. Resolution 9, Creation of MSMA Obesity Committee (adopted) RESOLVED, that the MSMA Board of Trustees create the MSMA Obesity Advisory Committee composed of member physicians to study the challenges for Mississippi created by obesity related illnesses and prepare a report including recommendations which may be the basis for future legislative efforts in the state of Mississippi. Resolution 10, Medical Bioethics (not adopted) RESOLVED, that a physician’s use of narcotics in paralyzed and compromised cancer patients who might go into remission is not ethical nor accepted professional behavior in the field of medicine and MSMA should support and advocate policies that discourage the perceived proliferation of unethical practices. Resolution 11, Physician Autonomy to Direct Medical Care (referred to the Board of Trustees for decision) RESOLVED, that the MSMA delegation submit a resolution to the AMA directing the AMA to study and produce a report discussing the complexities of this problem and strategies to preserve physician authority to practice state-of the-art medicine. Resolution 12, Corporatization as a Disfranchising Force in Medical Care (referred to the Board for decision) RESOLVED, physicians must be ever vigilant to being embroiled and enmeshed in a playing field where hospitals, under the cloak of hired physician groups, succeed financially by providing the least expensive but most defective care. Resolution 13, Physician Leadership of State Medical Agencies (referred to the Board of Trustees) RESOLVED, that MSMA 1) take steps to gain commitments of candidates currently running for Governor that they will ensure that the chief executives of the Department of Mental Health and the Division of Medicaid be licensed state physicians; and 2) that MSMA work to obtain legislation to require such agency heads be licensed physicians by statute and that the Chair of the Board of Mental Health also be required by statute to be a licensed physician or psychiatrist in the state. Resolution 14, Simplification and Reimbursement of Prior Authorization Process and Required Formulary Paperwork in Mississippi and the United States (adopted) RESOLVED, that MSMA 1) take steps to require or ensure that physicians in the United States are paid appropriately and promptly for any and all services performed for their patients required by any insurance companies, Medicaid, or Medicare; and be it further, 2) that MSMA and AMA encourage not only appropriate payment to physicians for physician and staff work and time with the prior authorization and other restrictive formulary processes, but also simplification of forms and streamlining of the procedure to reduce physician and staff workload and time expended.
Resolution 15, Making GME Financing and Reform a Priority for AMA (referred to the Board for decision) RESOLVED, that our AMA 1) recognize that GME is in crisis in the U.S. and that meaningful and comprehensive reform is urgently needed, 2) urgently work to expand medical residencies in a balanced fashion based on needs throughout our nation to produce a balanced, geographically distributed, and appropriately sized physician workforce; and 3) make increasing support and funding for GME programs and residencies a priority in its national political agenda. Resolution 16, Creation of Mississippi Health Care Workforce Office (adopted) RESOLVED, that MSMA 1) work in collaboration with the Mississippi State Department of Health and other appropriate parties to create an Office of Health Professional Workforce responsible for addressing changes impacting the health professional workforce in Mississippi which is to be funded with state funds in the manner of the Office of Nursing Workforce and 2) that this office’s focus on physician workforce have physician oversight and monitor the physician workforce by specialty, define the state needs per specialty, and make suggestions for addressing the state’s physician workforce needs. Resolution 17, Opposition to Censorship of Medically Relevant Information (adopted as amended) RESOLVED, that MSMA oppose any state legislative efforts to prevent any physician from asking about and/or recording any medically relevant information. Resolution 18, Encouraging the AMA to ask the Robert Wood Johnson Foundation to Substantiate Report Findings Regarding Nurse Practitioners (adopted) RESOLVED, that MSMA request that the American Medical Association (AMA) ask the RWJF to: 1) re-evaluate the role of nurses in the context of a physician-led, patient-centered medical home model; 2) consider the current demographic distribution of nurses in independent practice states as an indicator that there are no true market barriers to competition in healthcare, rather there are other factors that influence where nurses and doctors practice; and 3) ask the RWJF to require the rigor of scientific control measures when comparing outcomes of two different care groups, nurse practitioners and physicians. Resolution 19, Preserving Federal Funding for Critical Services of the Mississippi State Department of Health (adopted) RESOLVED, that our Mississippi State Medical Association (MSMA) work to protect federal funding for essential medical services provided by MSDH; and RESOLVED, that our American Medical Association (AMA) work to protect federal funding for essential medical services and public health departments in rural and underserved areas and states in the U.S. Resolution 20, Issuing a Postage Stamp to Commemorate the Centennial of the Groundbreaking Public Health Experiments on Pellagra by Joseph Goldberger, MD in Mississippi (adopted) RESOLVED, the MSMA delegation submit a resolution to the AMA House of Delegates requesting
that the AMA urge the Citizens’ Stamp Advisory Committee to recommend that a postage stamp be issued in 2015 to commemorate the 100th anniversary of the Mississippi Pellagra Experiment at the Rankin Farm of Joseph Goldberger, MD by sending a letter to the Citizens' Stamp Advisory Committee with endorsements by those national medical specialty societies, state medical associations and other appropriate health organizations that agree to sign on. Resolution 21, Medicaid Pilot with Physician-Led Patient-Centered Medical Home and Assessment of Problems with MississippiCAN (adopted as amended) RESOLVED, that our Mississippi State Medical Association (MSMA) work to establish a Medicaid pilot program genuinely based on the concept of the physician-led, patientcentered, medical home; and RESOLVED, that the MSMA Council on Medical Service review, monitor, evaluate and make recommendations to the Mississippi Division of Medicaid regarding the MississippiCAN program. Resolution 22, Recognizing the Contributions of Dr. Ben Earl Kitchens for his Blog during Tort Reform Crisis (adopted) RESOLVED, that our MSMA provide a framed copy of this resolution to Dr. Kitchens to express our membership’s great appreciation.
REPORTS OF THE BOARD OF TRUSTEES
Other relevant business reports to the House of Delegates adopted included: Location and Dates of future Annual Sessions- May 23-26, 2013 Grand Sandestin, May 29 – June 4, 2014 Beau Rivage. Report F of the Board of Trustees: Recommendation 1: That MSMA seek legislation requiring health insurers and plans to make payments directly to a physician or his clinic when the insured patient has assigned his benefits. Recommendation 2: That MSMA seek legislation opposing all products clauses unless clearly specified in the physician’s contract. Recommendation 3: That MSMA seek legislation clarifying that disclosure requirements for changes in coding and bundling may not be waived, voided, or nullified by contract. Recommendation 4: That MSMA intensify efforts seeking “Truth in Advertising” legislation based on AMA model legislation to address patient confusion over provider qualifications when making health care choices. Recommendation 5: (adopted as amended) That MSMA take all necessary actions to make insurers doing business in Mississippi aware of the AMA Health Insurer Code of Conduct, to encourage compliance with the Code, and to report instances of unfair practices to the Mississippi Department of Insurance or other appropriate entity. Recommendation 6: (adopted) That MSMA establish a closer working relationship with the Division of Medicaid. ❒
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Address of the President Timothy J. Alford, MD
M
143rd Annual Session MSMA House of Delegates BancorpSouth Conference Center, Tupelo • May 20, 2011
r. Speaker, fellow officers and Directors, Members of the Association, Ladies and Gentlemen. The membership of the MSMA is now at its high water mark, serving over 4,583 medical students and physicians statewide. Executive Director Charmain Kanosky has assembled an energetic staff that has brought great competence and efficiency as they execute the will of the Board and its membership. This morning I shall offer some recommendations for this assembly and our members. Over this past year I have learned to ask a critical question taught me by one Dr. Hugh Gamble who now leads our diminished AMA delegation. The question is simple, “What does THAT have to do with the practice of medicine?” I have found this a useful question to navigate the sea of issues confronted by organized medicine. On the other hand, the health care services that we provide account for only 10-15% of the actual health of individuals. The remaining 85% is broken down as follows: 40% to behavioral patterns and choices, 30% to genetic predisposition, and 20% to social and environmental exposure. Hugh’s question calls for us to concentrate on the 10-15%, and yet as one considers the overall health of a population we must at least recognize these other determinants. I cited three items of concern at the outset of my Presidency as “to do” items: 1) Heighten support for comprehensive health education for all of our children. 2) Embrace the new model of care for the Patient Centered Medical Home. 3) Assist our Medical Center in meeting our workforce needs statewide. Did I hear Dr. Gamble ask, “What does that have to do with the practice of medicine?” Even though our efforts were diverted elsewhere in some instances this year, several of the events of the legislative session highlighted the importance of the above named concerns. Let me explain. The nurse practitioners mounted a trial run at what will be an eternal quest for independent practice authority. They sought legislation that would abolish the need for collaborative agreements with physicians. Defeating this legislation consumed considerable time and energy from our staff as well as many of the rest of us. The question is, will our best play on this issue remain a defensive one? The nurses will be back next year, armed with even more data and resolve. As in any endeavor, it takes much more energy to play defense. Those states that are using the new model of care called the Patient Centered Medical Home (PCMH) find that the nurse practitioners’ pursuit of independent practice is much ado about nothing. For example, in North Carolina, where the PCMH model has deep roots, this is a physician run and physician driven system. Through 13 community care networks the whole healthcare team is incentivized to achieve better outcomes. As a result, patients are happy and physicians are happy. Nurse practitioners work within the team. In addition, this established model has outcome-based standards that inherently handle nurse practitioner aggression.
RECOMMENDATIONS:
Further promote the PCMH model of care and augment the Health Department’s pilot initiative on PCMH. Also, request that the MSMA Council on Medical Service draft standards for Board approval consistent with the PCMH model that consider reasonable applications of collaborative agreements with nurse practitioners. Finally, that MSMA attempt to find common ground with advanced nurses wherever possible, including educational activities. The single greatest accomplishment of this organization over several decades remains in the passage of medical malpractice reform in the years 2002-2004 which provided a more favorable medical legal environment and ended the outward migration of physicians from our state. Tort reform gave us a fighting chance to do better than last among other states in numbers of physicians per thousand patients. The physician shortage problem in this state will be solved not only by growing more of our own but also by recruiting competent out of state physicians as well. Much of MSMA’s political action effort goes toward the maintenance of a fair judiciary lest erosion of critical elements of reform be struck down by the courts. This past election cycle, nine of thirteen judicial elections were deemed favorable by MSMA. This shows that our political action committee does both its homework and its legwork. Recommendation: Keep up the good work MMPAC! A few years ago this association recognized that our State Department of Health was experiencing a crisis of leadership. As a result, chronic disease management and prevention efforts that were once a model to our country were being systematically dismantled. MSMA seized the opportunity to show the need for new leadership and furthermore led the reconstruction of the
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Board of Health so that Mississippi would never be left in such a lurch again. As the new Board was being formed, Dr. Randy Easterling had the presence of mind to suggest in a most timely fashion that the Chair of the State Board of Health must be a medical doctor. This resulted in one of the rising stars of public health in our country being hired to take the reins of our State Department of Health. Is it any wonder that Mississippi moved from 17th in the United States to number one in childhood immunization rates this past year? Recommendation: Continue to work with our Department of Health to forge public/private initiatives where possible for the good of our patients such as the PCMH. I applaud this organization for casting light upon Mississippi’s abysmal health indicator list. Problems must be clearly illuminated before they can be solved. Our Journal is the best instrument to forge solutions to many of the failing grades on our health care report card. The new Editorial Advisory Board will serve to strengthen the quality of the Journal but we are a long way from fully harnessing the intellect and writing capacity found amongst physicians across our state. Recommendation: Continue encouraging our editors and staff to further modernize the Journal and begin the transition from hard copy to electronic media sooner rather than later. We have the talent to make our Journal a superior tool and to be the flagship medical journal of the South. This Association must put its resources and personnel behind our Journal. Early this spring, MSMA in conjunction with AMA released economic data on physician impact moving to a community. Many communities have designated health services as their number one development opportunity. Recommendation: The Council on Medical Service work in conjunction with UMC, the State Department of Health, and the Social Science Research Center to increase Mississippi’s physician workforce by at least 1,000 physicians by the year 2025. Further, that MSMA work to delineate a sole authority on healthcare workforce. A resounding theme that I have often heard from our past President Dr. Edward Hill is that efforts to turn the tide of chronic disease in Mississippi will never be successful unless we initiate greater efforts toward prevention. As I have spoken to component societies around our state I have mentioned this Association’s ability to assist where possible in the implementation of comprehensive health education for all of our children. Physicians occupy the best bully pulpit to encourage school officials to embrace and carry out the requirements of the Healthy Schools Act of 2007. After all, how hard would it be for us to take a moment during our practice day to call our local school superintendent or principal and ask them how things are going with regard to the Healthy Schools Act? The law stipulates that there be Health Councils within each school district. Perhaps you could lead such a council. We must start early, before the obesity horse gets out of the barn. Unless we work to correct these problems our workforce will be looked upon by industrial prospects as unfit, and they will simply go elsewhere. Finally, many of you have had the pleasure of listening to Dr. Rick deShazo’s Southern Remedy program on Wednesday morning and evenings on Mississippi Public Broadcasting. This MEA Medical M di l Clinics Cli i program has an extensive audience and is educational, offering foor Board Board Certified Certified Announces Openings for solutions for the health indicators we are dealing with in our every Phhysicians in our Family Medicine Physicians day practices. He gives special emphasis to the comprehensive Jackson and Lau rel e Area Area Clinics Laurel health education of our children. Your Board in partnership with 'UARANTEED "ASE #OMPENSAT #OMPENSATION TION s )NCENTIVE "ONUS UMC is now joining MPB to further augment Dr. DeShazo’s P PrOFIT rOFIT O 3HARING s &LEXIBLE 3CHEDULING 3CHED DULING s #-% !LLOWANCE efforts as he takes this effective program on the road. -ALPRACTICE )NSURANCE s (EALTH )NSURANCE s ,IFE )NSURANCE So what does all of this have to do with the practice of $ISABILITY )NSURANCE s -UCH -Ore! -Ore! medicine? Everything! Our reach must extend beyond the confines of our workplace. MSMA must tip the balance toward being more pro-active, less defensive. We have great influence in our communities and thus a great opportunity to lead by example. It has been my pleasure and honor to serve you this past year. The work of the Association never ends but I am confident that the team assembled, including your newly elected BBRANDON R A N D O N BYRAM B Y R A M CANTON CLINTON C L I N TO N JJACKSON AC K S O N LAUREL L AU R E L leadership, will continue to do good work. Tom Joiner and I sat MADISON MADISON PEARL PEARL RICHLAND RICHLAND RIDGELAND RIDGELAND together in high school band and battled over the first chair Wee look fo W forward r waard to he hearing earing ffrom rom you! position. Tom, I gladly relinquish this chair. You will do an 1-800-844-6503 T Toni oni Jordan Rachel Williamso Williamson on Recruiter@mms-ms.com excellent job. 601-898-7535 601-898-7527 Thank you for affording me the opportunity to serve. ❒ www.meamedicalclinics.com w ww.meamedicalclinics.com
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Overcoming the Stigma of Addiction
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ne of the most common concerns of family and friends of physicians and other health care providers with addictive disorders is how to deal with the shame of addiction. One MPHP participant recently told me, “I don’t know how I can face my family. I don’t know how I will be able to face my partners. I hope I still have a job when I get back from treatment.” Unfortunately, the diagnosis of chemical dependence continues to elicit significant social stigma which can be even more pronounced in physicians with the condition. The fear of being held in contempt, rejected, or professionally marginalized becomes a major obstacle to recovery and perpetuates active addiction. Scott L. Hambleton, MD Significant progress is being made in terms of education regarding Medical Director addiction as a brain disease; however, the stigma continues negatively to Mississippi Professionals Health Program affect recovery. In my opinion, the relatively limited allocation of resources for effective treatment in the United States is directly related to the stigma of addiction. According to the Office of National Drug Policy and Substance Abuse and Mental Health Services Administration, the annual costs of addiction are approximately $590 billion. Over 100,000 addiction related deaths occur, each year. This number is greater than 430,000 if tobacco related deaths are included. According to the National Institute on Drug Abuse, in 2007, 23.2 million Americans needed treatment for substance use disorders, yet, less than 4 million received treatment. Although insurance companies are being forced, legislatively, by mental health parity laws to increase coverage for treatment, adequate treatment is beyond the reach of most Americans. One of the reasons that Physician Health Programs are tremendously successful is because of the requirement that health care professionals receive quality treatment, typically for 90 days. The Federation of State Physician Health Programs has published guidelines on minimum requirements for treatment centers to be approved to treat impaired physicians. Very few facilities are capable of offering the required services, and most treatment centers consider it an honor to be included in the approved list of providers. In Mississippi, the State Board of Medical Licensure considers a facility and votes whether or not to include it as a Mississippi provider. Quality treatment centers address cognitive distortion and denial, the hallmarks of addiction, as primary objectives of treatment. The treatment process facilitates healing of the brain. The individual gains insight and recovers. This healing process begins with the immediate introduction of the individual to the group therapy process. Multiple groups dealing with various issues are attended each day. Two of the most frequently discussed topics are the shame and the stigma of addiction. Not surprisingly, one of the markers of recovery and treatment success is the reduction of shame in the patient, with decreased fear of being stigmatized. Ironically, one of the easiest ways to decrease the shame of addiction in a treatment setting is by facilitating open, honest communication, specifically related to the harms done to others because of addiction. Instead of ignoring these issues, they are explored in depth, on a daily basis, in a group setting. A unique characteristic of addiction is the way that it commonly manifests itself in the addicted individual, with dishonest and self-destructive behaviors which are harmful to everyone associated with the addicted person. Active addiction results in deprivation of all forms of security, including emotional and physical security. Families and friendships are disrupted by chaos, uncertainty, and even terror. As addiction progresses, everything else becomes less important to the addicted person, including relationships with loved ones or a medical career. Existence for the addicted person becomes terrifying as their life unravels. This causes an even greater need for “relief” which results in more substance use and worsening problems. Careers are lost, health is lost, and sweet, loving relationships become remote memories for the addicted person. Family and friends become angry with the addicted person. The constant barrage of lies and broken promises often evokes a powerful response. However, many times, family and friends become numb to any feelings. Ambivalence about which course of action to take becomes constant. Guilt
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about personal obligation to the addicted person can become overwhelming, resulting in a loss of serenity. Pressure to take care of the addicted person and to “rescue” him or her from the consequences of addiction becomes progressively more intense. A painful cycle of active substance use, negative consequences, and enabling by family and friends becomes engrained and difficult to break. Deprivation of a peaceful existence is one of the most common consequences described by family members living with a person in active addiction. Unfortunately, these behaviors describe “garden-variety addiction” and occur, at least in part, in every addicted patient, including physicians. The stories of addicted individuals, including physicians, are markedly similar. I know with absolute certainty that an individual with untreated addiction will continue to suffer. They may be able to abstain for a period of time, but without treatment, their condition will worsen, as will the consequences of their continued use, in a predictable fashion. Untreated addiction progresses and destroys life. This knowledge is actually great news because acceptance of it is one of the most powerful ways to decrease the shame and stigma of addiction. One of the primary responsibilities of a Physician Health Program is to provide this information about addiction so that treatment and recovery become the focus and not judgment and punishment. Early intervention and treatment make it possible for addicted persons to recover and make amends for their harmful behaviors. In fact, it is highly unlikely that addicted persons will maintain long-term sobriety unless they become willing to make amends and accept responsibility for their behaviors. Recovery is not about escaping consequences and “hiding out.” Recovery is about restoration, responsibility, and “giving back.” These characteristics are also the hallmarks of 12-step recovery. In treatment, the patient is taught about the progressive and harmful course of addiction, the characteristic behaviors of a person with untreated addiction, and the negative consequences of addiction, including the victimization of others. Negative consequences such as DUI, marital separation, or work related problems are eventually viewed as life-saving events because they precipitate treatment and recovery. Patients take responsibility for harmful behaviors and become willing to make amends for their actions. Treatment enables the patient to realize that there is hope and forgiveness. Recovery enables individuals to realize the truth about their condition and about themselves, that they used substances, couldn’t stop using them, and hurt themselves and others because of addiction, and not because they are weak, stupid or morally defective. As each person in recovery realizes that his/her behaviors are the typical behaviors of any person with an addictive disorder, they are able to change their self-destructive and harmful behaviors, and the shame and stigma of addiction diminishes. In summary, the best way to overcome the stigma of addiction is to treat addiction! ❒
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• UNCOMMON THREAD •
I
’m back.
A Free Man
Yep, I met with the Editor, and they’ve decided to keep me on. So I’ll be writing this thing for another year. I guess that’s good, or bad depending on if you like the stuff I write or not. This year will be a little different though; for the first time since I started stringing together words for the JOURNAL I’m unencumbered. Well, I’m still encumbered by nutty thoughts that ping around in my brain, but what I mean to say is I’m not tied up by being on R. Scott Anderson, MD the board of trustees or the AMA delegation or anything official, so if I say stuff you don’t like you can’t hold it against State Medical. You’re welcome to hold it against me, but you shouldn’t expect I’ll lose a lot of sleep at night just because you think I’m an idiot. I’m used to that. I have a whole family that thinks I’m an idiot from time to time. The unencumbered stuff is only partly an accident, I guess. Most of it was my own doing. I did run to be re-elected to our rapidly diminishing AMA delegation…I lost, but I got to give one of the most fun to give campaign speeches I could ever imagine giving. It was one of those things that comes to you when you’re driving a pretty long way, like Meridian to Tupelo, and you have time to let things roll around inside your head, getting bigger and bigger as you drive. Usually, after you get to wherever it is that you’re going, common sense takes over, and you write a real speech, but I didn’t get that chance. See, I’d had to run back home in the middle of the meeting to treat an emergency patient, an old friend, who had developed a spinal cord compression in the mid-thoracic spine. Not wanting him to be paralyzed from the waist down for what life he had left, there wasn’t a lot of choice. Anyway, I got back to Tupelo, got out of the car and gave the speech, about that fast. Here it is, as best as I remember: Our inaugural theme for this year is “A Night at the Races,” so in keeping with that theme, I’m going to talk about this election in racing terms. See, as far as medical politics goes, the AMA meeting is the Kentucky Derby. It’s our chance to shine in the national spotlight, and up to now we have. You, the Mississippi State Medical Association, are the riders, and we, the AMA delegation have been the horse that runs the race. Well, next year you’ve decided that it will be best for Mississippi to enter the Kentucky Derby riding on a two-legged pig. By quitting the AMA you’ve left your delegation with only one delegate and one alternate delegate, the same size as the delegations from Puerto Rico and the gay and transgender physician section. So what this election is all about is deciding what two legs you think you need on that pig. Do you want a couple of hams? We surely have our share of hams on the delegation. We can harness the power of those hams and go plowing along through the dirt trying to get around that track. Maybe we need a couple of strong shoulders; we have plenty of those on the delegation too, a little more dignified perhaps. They can pull us along. Or maybe you all want one ham and one shoulder. We can try to find a way to balance ourselves and not fall over in the dirt. None of these, I submit, is a good alternative. It is a shame is what it is. You want to tell me that the AMA doesn’t represent you, that the delegation isn’t important to you? Well the work of this delegation is directly responsible for your getting checks for 8.1% of your entire gross federally derived income last year. By fighting to require CMS to abide by the Congressionally mandated geographic price correction, we prevailed. That meant something to you. You put that money in your pocket. Nobody called to say, “I’m not taking this damned money, the AMA got it, and I don’t approve of the AMA.” Destroying this delegation, just to make a political point when you’re benefitting from the work that it does, is shortsighted and stupid. My friends have told me that this is a suicide speech. If it is…then so be it. Somebody has to tell you the truth. If we get 1001 members of this association, one fourth of our members, to re-join the AMA at least we’d have two delegates and two alternates. While we still probably won’t win the Kentucky Derby on a four-legged pig, I’m betting we’ll eat a lot less dirt. It was a great time. I got to pound on the lectern, point at A Free Man continued next page
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â&#x20AC;˘ UNCOMMON THREAD â&#x20AC;˘
A Free Man continued from previous page people, and tell the truth. Who could possibly ask for more? The election turned out fine. We decided on two strong shoulders, Luke Lampton and Danny Edney. I couldnâ&#x20AC;&#x2122;t have asked for a better outcomeâ&#x20AC;Śunless, of course, those of you out there reading this listen to what it is Iâ&#x20AC;&#x2122;ve said and do what itâ&#x20AC;&#x2122;s going to take to get us a couple more legs to run on. See ya next time, One of the hams 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 motionpicture industry as a screen-writer, helping form P-32, an entertainment funding entity.
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• INSTRUCTIONS FOR AUTHORS •
The Journal of the Mississippi State Medical Association (JMSMA) welcomes material for publication submitted in accordance with the following guidelines. Address all correspondence to the Editor, Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS, 391582548. Contact the managing editor with any questions concerning these guidelines.
STYLE: Articles should be consistent with JAMA/ JMSMA style. Please refer to explanations in the AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford University Press; 2007. JAMA and JMSMA style differs from APA style. JAMA: http://jama.ama-assn.org/misc/ifora.dtl Quick reference quide: http://www.docstyles.com/amastat.htm Any manuscript that does not conform to the AMA Manual of Style, 10th edition will be returned for revision. MANUSCRIPTS should be of an appropriate length due to the policy of the Journal to feature concise but complete articles. (Some subjects may necessitate exception to this policy and will be reviewed and published at the Editor’s discretion.) The language and vocabulary of the manuscript should be understandable and not beyond the comprehension of the general readership of the Journal. The Journal attempts to avoid the use of medical jargon and abbreviations. All abbreviations, especially of laboratory and diagnostic procedures, must be identified in the text. Manuscripts must be typed, double-spaced with adequate margins. (This applies to all manuscript elements including text, references, legends, footnotes, etc.) The original and one duplicate hard copy should be submitted. In addition, the Journal also requires manuscripts in the form stated above be supplied in IBM-compatible digital format. You may email digital files as attachments to KEvers@ MSMAonline.com or supply a compact disk with the files burned to to the CD. All graphic images should be included as individual separate files in TIFF, PDF or EPS format. Please identify the word processing program used and the file name. Pages should be numbered. An accompanying cover letter should designate one author as correspondent and include his/her address and telephone number. Manuscripts are received with the explicit understanding that they have not been previously published and are not under consideration by any other publication. Manuscripts are subject to editorial revisions as deemed necessary by the editors and to such modifications as to bring them into conformity with Journal style. The authors clearly bear the full responsibility for all statements made and the veracity of the work reported therein.
REVIEWING PROCESS: Each manuscript is received by the managing editor, and reviewed by the Editor and/or Associate Editor and/or other members of the MSMA Committee on Publications and its review board. The acceptability of a manuscript is determined by such factors as the quality of the manuscript, perceived interest to Journal readers, and usefulness or importance to physicians. Authors are notified upon the acceptance or rejection of their manuscript. Accepted manuscripts
become the property of the Journal and may not be published elsewhere, in part or in whole, without permission from the Journal MSMA.
TITLE PAGE should carry [1] the title of the manuscript, which should be concise but informative; [2] full name of each author, with highest academic degree(s), listed in descending order of magnitude of contribution (only the names of those who have contributed materially to the preparation of the manuscript should be included); [3] a one- to two-sentence biographical description for each author which should include specialty, practice location, academic appointments, primary hospital affiliation, or other credits; [4] name and address of author to whom requests for reprints should be addressed, or a statement that reprints will not be available.
ABSTRACT, if included, should be on the second page and consist of no more than 150 words. It is designed to acquaint the potential reader with the essence of the text and should be factual and informative rather than descriptive. The abstract should be intelligible when divorced from the article, devoid of undefined abbreviations. The abstract should contain: [1] a brief statement of the manuscript’s purpose; [2] the approach used; [3] the material studied; [4] the results obtained. Emphasize new and important aspects of the study or observations. The abstract may be graphically boxed and printed as part of the published manuscript.
KEY WORDS should follow the abstract and be identified as such. Provide three to five key words or short phrases that will assist indexers in cross indexing your article. Use terms from the Medical Subject Heading list from Index Medicus when possible. Available at: http://www.nlm.nih.gov/mesh/ meshhome.html.
SUBHEADS are strongly encouraged. They should provide guidance for the reader and serve to break the typographic monotony of the text. The format is flexible but subheads ordinarily include: Methods and Materials, Case Reports, Symptoms, Examination, Treatment and Technique, Results, Discussion, and Summary.
REFERENCES must be double spaced on a separate sheet of paper and limited to a reasonable number. They will be critically examined at the time of review and must be kept to a minimum. You may find it helpful to use the PubMed Single Citation Matcher available online at: http://www.ncbi.nlm.nih. gov/ entrez/query/static/citmatch.html to find PubMed citations. All references must be cited in the text and the list should be arranged in order of citation, not alphabetically. Reference numbers should appear in superscript at the end of a sentence outside the period unless the text cited is in the middle of the sentence in which case the numeral should appear in superscript at the right end of the word or the phrase being cited. No parenthesis or brackets should surround the reference numbers. Personal communications and unpublished data should not be included in references, but should be incorporated in the text.
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Contact managing editor Karen Evers to request an easy-to-follow sheet of examples on how to follow JMSMA / JAMA reference citation format. The following form should be followed: Journals: [1] Author(s). Use the surname followed by initial without punctuation. The names of all authors should be given unless there are more than three, in which case the names of the first three authors are used, followed by “et al.” [2] Title of article. Capitalize only the first letter of the first word. [3] Name of Journal. Abbreviate and italicize, according to the listing in the current Index Medicus available online at http:// www.nlm.nih.gov/bsd/aim.html. [4] Year of publication; [5] Volume number: Do not include issue number or month except in the case of a supplement or when pagination is not consecutive throughout the volume. [6] Inclusive page numbers. Do not omit digits. Do not include spaces between digits of the year, volume and page numbers.
Example: Bora LI, Dannem FJ, Stanford W, et al. A guideline for blood use during surgery. Am J Clin Pathol. 1979;71:680-692.
Books: [1] Author(s). Use the surname followed by initials without punctuation. The names of all authors should be given unless there are more than three, in which case the names of the first three authors are used followed by “et al.” [2] Title. Italicize title and capitalize the first and last word and each word that is not an article, preposition, or conjunction, of less than four letters. [3] Edition number, [4] Editor’s name. [5] Place of publication, [6] Publisher, [7] Year, [8] Inclusive page numbers. Do not omit digits. Example: DeGole EL, Spann E, Hurst RA Jr, et al. Bedside Examination, in Cardiovascular Medicine, ed 2, Smith JT (ed). New York, NY: McGraw Hill Co; 1986:23-27.
FIGURES require high resolution digital scans to be provided. Printed copies should also be submitted in duplicate in an envelope (paper clips should not be used on illustrations since the indentation they make may show on reproduction). Legends should be typed, double-spaced on a separate sheet of paper. Photographic material should be high-contrast glossy prints. Patients must be unrecognizable in photographs unless specific written consent has been obtained, in which case a copy of the authorization should accompany the manuscript. All illustrations should be referred to in the body of the text. Omit illustrations which do not increase understanding of text. Illustrations must be limited to a reasonable number. (Four illustrations should be adequate for a manuscript of 4 to 5 typed pages.) The following information should be typed on a label and affixed to the back of each illustration: figure number, title of manuscript, name of senior author, and arrow indicating top.
TABLES should be self-explanatory and should supplement, not duplicate, the text. The brief descriptive title, usually written as a phrase rather than a sentence, appears above to distinguish the table from other data displays in the article. Data should be aligned horizontally not to exceed 6.5". Tables should be numbered and supplied on individual pages separate from manuscript body text with placement indicated within. See Section
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4 of the "AMA Manual of Style" for specific Figure and Table components and proper presentation of data.
ACKNOWLEDGMENTS are the author’s prerogative; however, acknowledgment of technicians and other remunerated personnel for carrying out routine operations or of resident physicians who merely care for patients as part of their hospital duties is discouraged. More acceptable acknowledgements include those of intellectual or professional participation. The recognition of assistance should be stated as simply as possible, without effusiveness or superlatives.
SUBMISSIONS TO JMSMA SCIENTIFIC SERIES Top 10 Facts You Need to Know Series The purpose of this series of articles is to provide referenced information on clinical management of medical conditions in a concise fashion. The submissions should be directed toward practitioners who do not have specialty training on the specific topic as a matter of general information. The author of the best submission for each year will receive a prize. Guidelines: 1) Articles should consist of 10 numbered paragraphs. Each of the paragraphs will begin with a fact that physicians need to know and a brief explanation of why. Facts will be referenced for each of the 10 points. 2) Suggested organization of manuscript is Introduction, Point 1, Point 2, etc., Conclusion, and References. 3) Articles will be about 3 pages (about 700 words) in length written at a level that can be easily understood by a practicing physician of any specialty. 4) A reference supporting the fact offered should be provided for each of the 10 points. Citations should not be review articles. 5) If there are specialty society guidelines in the area being discussed, the essential features of the recommendations should be included in the official guidelines cited in the references.
UpToDate Series The purpose of this series of articles is to provide brief reviews on topics of general interest to the practicing physicians of Mississippi in areas where recent developments in diagnosis or treatment have occurred. Guidelines: 1) Articles should be practical and useful to physicians in office or hospital practice. 2) Suggested organization of manuscripts is Introduction, Diagnosis, Recent developments, Conclusion, and References. 3) Articles will be about 6 pages (1500 words) or so in length written at a level that can be easily understood by a practicing physician of any specialty. 4) Only those references that will be used to those physicians who desire further information in the area. Five to eight references that will be useful to those who desire further information should be included. 5) Figures are great as are “callouts,” i.e., boxes with key points to remember emphasizing the “take home” messages. 6) If there are specialty society guidelines on the topic, the essential features of the recommendations should be summarized in the text and the official guidelines should be cited in the references. GALLEY PROOFS will be emailed to the principal author for review. Corrections should be clearly marked and returned promptly. To order reprints, request a price quote and place your order when you return your galley proof. ❒
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