VOL. LVI • NO. 7 JULY 2015
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VOL. LVI • NO. 7 JULY 2015
EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD
THE ASSOCIATION President Claude D. Brunson, MD President-Elect Daniel P. Edney, MD
MANAGING EDITOR Karen A. Evers
Secretary-Treasurer Michael Mansour, MD
PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD Ex-Officio and the Editors
Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Executive Director Charmain Kanosky
JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: 662-236-1700, Fax: 662-236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2015 Mississippi State Medical Association.
Official Publication
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SCIENTIFIC ARTICLES Indigenous Cases of Leprosy (Hansen’s Disease) in Southern Mississippi Luis A. Marcos, MD, MPH; Thomas Dobbs, MD, MPH; Sue Walker, MD; Elizabeth Rose, MD; William Waller, MD; Barbara M. Stryjewska, MD
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Beyond Respiratory Depression and Constipation: Adverse Effects of Opioids Jay P. McDonald, MD; Alan J. Torrey, MD; Mahesh P. Mehta, MD; Luiz G. R. Delima, MD
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Top Ten Facts You Need to Know about Medical Emergencies 196 While Flying Amanda M. Daggett, Claude Brunson, MD; Luiz DeLima, MD; Sloan Youngblood, MD PRESIDENT’S PAGE Let’s Measure It in Dollars and Cents Claude D. Brunson, MD
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DEPARTMENTS From the Editor- Telemedicine: The Physician’s Double-Edged Sword Lucius M. Lampton, MD
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Images in Mississippi Medicine: Gulfport Veterans’ Hospital 215 Lucius M. Lampton, MD RELATED ORGANIZATIONS Mississippi State Department of Health
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University of Mississippi School of Medicine- Match Day 2015
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William Carey University College of Osteopathic Medicine- Match Day 2015
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SPECIAL ARTICLES Spotlight on MSMA Physician Leadership Academy Kara Kimbrough MSMA Annual Report 2015
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ABOUT THE COVER – “JULY 4TH AT OLD WAVERLEY GOLF CLUB IN WEST POINT, MISSISSIPPI” There’s a traditional celebration about our country’s independence every July 4th. It includes a delicious feast, outdoor games, a parade, and a tether hot air balloon ride. Most importantly, US veteran speeches pay tributes to those who have served in the preservation of our freedom. The kids under the large American flag displayed annually are three of the Pomphrey’s grandchildren. Photo by Martin M. Pomphrey, MD, Mayhew
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F R O M
T H E
E D I T O R
Telemedicine: The Physician’s Double-Edged Sword Docs have always used evolving technology in our practices. We began using “telephone” medicine to connect with our patients soon after the telephone was invented. Our own generation’s revolution in digital-age technology is imposing itself on our patients and our practices most noticeably in the current push for Telemedicine and mobile health (mHealth). Telemedicine is our profession’s current double-edged sword, a weapon pregnant with favorable potential while also laced with dangerous consequences. It seems everything in our modern world has become electronic and digital; physicians must embrace that same technology which has consumed our patients. That said, physicians must be prudent in our choices in creating the “good” digital patient-physician relationship. So much of that ancient relationship depends on our five senses. Aren’t we diminishing it in an essential degree when we remove the physician’s actual touch? Most physicians would probably view a video follow-up with many of our patients on various problems as a positive extension of an established
patient relationship. Also, in our rural and underserved areas, primary care physicians arranging sub-specialty consultation via Telemedicine for their patients as part of their ongoing care seems a prudent and positive use. However, corporate medicine smells a profit here, and they are sure to corrupt it by using physicians or extenders in distant locales to provide disjointed, fragmented, low quality care for a price. Imagine a kiosk on your local street corner where a patient can insert $50 and ask for a prescription from a physician or nurse practitioner with no relationship other than across a phone line or video screen. Our state Board of Medical Licensure requires Telemedicine to have the same standard of care as an in-person patient encounter. Such seems a requirement to protect our patients from such snake-oil. First and always, Telehealth must be good medicine. To be good medicine, it must be utilized as part of an established patient-physician relationship. If Telemedicine provides only easy access and not high quality healthcare, any benefits are overrated or nonexistent. Contact me at LukeLampton@cableone.net. —Lucius M. Lampton, MD, Editor
JOURNAL EDITORIAL ADVISORY BOARD Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of Mississippi Medical Center, Jackson Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Thomas E. Dobbs, MD, MPH State Epidemiologist, Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford
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Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director, Mississippi Professionals Health Program, Ridgeland J. Edward Hill, MD Family Physician, North Mississippi Medical Center, Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Ben E. Kitchens, MD Family Physician, Iuka Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford
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Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport William Lineaweaver, MD Editor, Annals of Plastic Surgery Medical Director, JMS Burn and Reconstruction Center, Brandon Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD Radiologist, Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist , Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist , Jackson Health Care-Women, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson
Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine, University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon, Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer, Brentwood Behavioral Healthcare, Flowood Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson
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Indigenous Cases of Leprosy (Hansen’s Disease) in Southern Mississippi LUIS A. MARCOS, MD, MPH; THOMAS DOBBS, MD, MPH; SUE WALKER, MD; ELIZABETH ROSE, MD; WILLIAM WALLER, MD; BARBARA M. STRYJEWSKA, MD
Introduction Hansen’s disease or leprosy is a chronic infection of the skin caused by Mycobacterium leprae. It has an incubation period of about 8-12 years (or even longer),1 and it is mainly present in tropical and subtropical regions of South East Asia, sub-Saharan Africa, Latin America and the Caribbean.2 According to the World Health Organization (WHO), 232,857 new cases of leprosy were reported worldwide in 2012.3 Leprosy has also been reported in developed countries, mostly in immigrants and rarely indigenous individuals.4 For example, about 213 new cases of leprosy were reported in 2009 in the U.S.5 Approximately 75% of these reported cases occurred among immigrants and other people exposed in low resource endemic countries. Those indigenous leprosy cases reported in the U.S were mainly living in the south-central U.S., primarily in Louisiana, Florida, and Texas.5 In developing countries, the mode of transmission of M. leprae has been postulated to be mainly person-to-person (aerosol spread from infected nasal secretions).6 In the U.S., the mode of transmission seems to be different from other parts of the world. There is increasing evidence that nine-banded armadillos (Dasypus novemcinctus) are the main reservoir of M. leprae in the U.S. and they may be spreading the bacteria into the environment and transmitting infection to humans in southern states.7 The prevalence rates of M. leprae infection in armadillos in the south of the U.S. range between 3% and 6%,8 with higher rates of infection in Louisiana and Texas and lesser in Arkansas and Mississippi.9,10 Therefore, human indigenous leprosy cases have been described in the same geographic regions where infected armadillos have been reported, mainly Texas and Louisiana.5 To the best of our knowledge, only three indigenous cases of leprosy from Mississippi have been described.11 In this report, we describe 4 additional indigenous cases of leprosy in southern Mississippi seen during 2012-2014.
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Materials and Methods Study design: This is a descriptive epidemiological study of reported leprosy cases in Southern Mississippi (MS) between 2012 and 2014, using the data from the MS State Department of Health and medical records of the Hattiesburg Clinic in Hattiesburg, MS. This retrospective study was approved with an exemption of the requirement for written informed consent by the Institutional Board Reviews of MS State Department of Health (MSDH), Jackson, MS (IRB#082313) for medical records at the MSDH; and Forrest General Hospital, Hattiesburg, MS (IRB#13-002) for medical records at Hattiesburg Clinic (HC), Hattiesburg, MS. Identification of case-patients: The MSDOH and HC database were queried for all diagnosed leprosy cases meeting the following criteria: a confirmed case of leprosy based upon the identification of acid-fast bacilli in peripheral nerves on histopathological examination and having a symptomatic disease upon report or symptoms which started while living in MS. Mississippi Indigenous Case Definition: A person born in MS, who received the diagnosis of leprosy while living in MS, lived in MS in the 12 years preceding diagnosis (incubation period up to 12 years), 12 and did not travel to a foreign endemic area. Results Case 1 (year 2014). A 60- year-old Caucasian man from Pearl River County presented with a 6-month history of skin rash in upper extremities with generalized pruritus (sometimes limited to torso only) and severe neuropathic pain in upper and lower extremities. His past medical history included monoclonal gammopathy of uncertain significance and peripheral neuropathy for almost 15 years . He denied any travel overseas or contact with armadillos. On physical examination, he presented with round, erythematous, raised lesions with vague borders in upper extremities only. Torso and lower extremities were spared. Muscle atrophy and weakness were noticed in left hand (Figure 1 and 2). Loss of sensation was present in all extremities. He was sent to a dermatologist for a worsening rash after there was no improvement
ABSTRACT
H
ansen’s disease or leprosy is a chronic infection of the skin and peripheral nerves caused by Mycobacterium leprae. In the U.S, leprosy is mainly reported in immigrants, but indigenous leprosy cases have been also reported in this country, especially in semi-tropical southern states (i.e. Texas, Louisiana). The objective of this series of cases is to describe indigenous leprosy cases reported in southern Mississippi (MS) during the period 2012-2014. Information was collected from medical records at Hattiesburg Clinic and the MS Department of Health. Four cases were reported during the period of study (3 Caucasian males, 1 African-American woman). None visited an endemic leprosy country. The age ranged from 60 to 83 years (median: 75.5 years). Of the four cases, three presented with a slowly progressive erythematous rash disseminated mainly on the thorax and abdomen, with a lesser degree on the extremities. The time between onset of rash until the diagnosis ranged from 5 to 16 months (median: 7 months). Only one case had direct contact with armadillos (blood exposure).
None of these patients had a history of immunosuppression. The most common symptoms were neuropathic pain (n=2), generalized pruritus (n=2) and loss of sensation in extremities (n=2). One case had severe peripheral neuropathy with muscle weakness, atrophy in left arm, and wasting on left hand. Skin biopsies showed diffuse granulomatous infiltrate with foamy histiocytes along with acid fast bacilli by Fite stain. By Ridley-Jopling classification system, three cases were diagnosed as lepromatous leprosy, and one, borderline lepromatous. Treatment included clofazimine, dapsone and rifampin that was offered free of charge by the National Hansen’s Disease Program, Baton Rouge, LA. One patient did not tolerate therapy. In conclusion, a slowly progressive disseminated erythematous skin rash on the trunk should raise suspicion for leprosy in the elderly population in south MS.
with antifungal creams. A skin biopsy showed a diffuse granulomatous infiltrate with foamy histiocytes along with acid fast bacilli (Fite stain). Lepromatous leprosy was diagnosed. The patient was started on clofazimine, rifampin, and dapsone.
Case 3 (2013). An 83-year-old Caucasian man from Forrest County presented with a 8-month history of a rash mainly on his chest, back and abdominal areas. His travel overseas included Germany during WW II. On physical examination, many round, erythematous, macular skin lesions were symmetrically distributed on the abdomen. Some had slightly raised, vague borders, and hypopigmentation (Figure 4). The rash began as a small erythematous macule on his left leg and progressed to involve multiple areas of his body. The patient had tried antifungal creams with no improvement. Strangely enough, pruritus was present in the same location as the lesions, which had developed slowly. Initially he was thought to have an atypical presentation of pityriasis rosea and triamcinolone cream did not help. He claims he has never had any contact with armadillos. There was no peripheral-nerve involvement or loss of sensation. By histopathology, the skin-biopsy specimen revealed diffuse granulomatous infiltrate with foamy histiocytes and numerous acid fact bacilli FIG 2 were observed by the Fite stain.
Case 2 (2014). A 71-year-old Caucasian man from Stone County presented with a severe macular rash disseminated in all over his body progressively getting worse for the past 16 months along with numbness in hands and pain in his left leg not alleviated by gabapentin. His past medical history included diabetes, dyslipidemia, and hypertension. He had had contact with armadillos by killing and disposing them. Mild loss of sensation was present in lower extremities. After a dermatology consultation, a skin biopsy showed diffuse granulomatous infiltrate with foamy histiocytes and numerous acid fact bacilli (Fite stain) (Figure 3). Lepromatous leprosy was diagnosed. He was prescribed clofazimine, rifampin, and dapsone.
Key Words: leprosy, Mycobacterium leprae, Hansen’s disease, indigenous cases, Mississippi
FIGURE 1 (BELOW) (ERYTHEMATOUS RASH) AND WASTING ON LEFT HAND. FIGURE 2 (RIGHT). SEVERE PERIPHERAL NEUROPATHY WITH MUSCLE ATROPHY AND WEAKNESS IN LEFT ARM FIG 1
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FIGURE 3. SKIN BIOPSY SHOWING ACID FAST BACILLI (FITE STAIN; MAGNIFICATION 20X)
CASE 3: HE WAS DIAGNOSED AS LEPROMATOUS LEPROSY. HE WAS TREATED WITH CLOFAZIMINE, DAPSONE, AND RIFAMPIN.
FIGURE 4. ERYTHEMATOUS RASH ON TRUNK CHARACTERIZED AS ROUND, ERYTHEMATOUS, MACULAR WITH SLIGHTLY RAISED VAGUE BORDERS AND SLIGHT HYPOPIGMENTATION IN THE CENTER.
Case 4 (2012). An 80-year-old African-American woman from Forrest County presented with a 5-month history of slowly progressive non-pruritic papular skin lesions on both arms and knees. She had a history of having similar lesions about 25 years ago. A review of systems was otherwise negative. Her past medical history included hypertension. She denied any contact with armadillos or travel overseas. Physical examination was remarkable for multiple small erythematous, raised plaques on both arms (Figure 5) and around the knees. The lesions were not scaly or tender. There were no sensory deficits, and the involved skin had normal sensation. A punch skin biopsy from the left arm showed a diffuse granulomatous infiltrate with foamy histiocytes along with acid fast bacilli (Fite stain). A diagnosis of borderline lepromatous leprosy was made. Patient did not tolerate antibiotics and refused antimicrobial treatment, despite multiple attempts. Summary of cases: Four cases of indigenous leprosy were reported during 2012-2014. None visited an endemic leprosy country. Age ranged from 60 to 83 years old (median: 75.5 years). Three presented with a slowly progressive erythematous rash disseminated mainly on thorax and abdomen, with a lesser degree on the extremities. The time between onset of rash until the diagnosis ranged from 5 to 16 months (median: 7 months). One case had contact with armadillos (blood exposure). The most frequent, additional symptom was neuropathic pain (n=2), pruritus (n=2) and loss of sensation in extremities (n=2). All skin biopsies showed diffuse granulomatous infiltrate with foamy histiocytes (AFB+) by Fite stain. By Ridley-Jopling classification system, three cases were lepromatous leprosy and one, borderline lepromatous. Treatment included clofazimine, dapsone, and rifampin and was offered at no cost by the National Hansen’s Disease Program, Baton Rouge, LA. One patient did not tolerate standard therapy and refused alternative regimen. Discussion To the best of our knowledge, this is the largest case series of indigenous leprosy cases in MS to date. All cases were diagnosed in advanced age, and some potential undiscovered risk factors may be immunosuppression, genetic predisposition, environmental exposure, nutritional status, longer life expectancy, access to health care (i.e. Medicare), among others. This possible association between age and leprosy may place the elderly as a vulnera-
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FIGURE 5. MULTIPLE SMALL RAISED ERYTHEMATOUS LESIONS ON UPPER EXTREMITIES.
As the largest series of cases of indigenous leprosy cases in MS, it emphasizes the need for increased awareness among primary care providers about leprosy in south MS. Acknowledgments We thank the National Hansen’s Disease Program, Baton Rouge, LA, for supplying the treatment at no cost for our patients. Note that this program supplies medicine for leprosy in the United States at no cost to patients. References 1. Hotez PJ, Molyneux DH, Fenwick A, et al. Control of neglected tropical diseases. N Engl J Med. 2007;357:101827.
ble population for this disease. Cases with leprosy diagnosed at advanced age may not be uncommon. For example, a case of leprosy in an 87-year-old man was reported recently in Louisiana.13 Further studies are needed in order to clarify this possible association. Three out of the 4 cases reported here denied any contact with armadillos. Contact with armadillos is not necessary to acquire leprosy. In fact, a large matched case-control study found that eating armadillos was not associated with leprosy, proposing that adjustments on socioeconomic status are needed when risk factors for leprosy are assessed.14 As leprosy has been spread by armadillos in the south of the U.S., it is unclear how some of these cases acquired the infection. Whether armadillos could have had a direct or indirect contact with some of these cases is unclear. One of the most notorious clinical features of these cases is the slow progression of erythematous skin lesions over months, leading physicians to perform a skin biopsy to rule out non-infectious disease causes as main differential diagnosis such as skin cancer, autoimmune diseases, etc. Another interesting finding was the complaint of itching in two cases which resolved after treatment. The pathogenesis of pruritus in these cases is unknown, but it was potentially related to leprosy because it resolved completely after therapy. In 2 cases neuropathy was severe; one case had a severe muscle weakness with wasting syndrome in the left hand where the skin rash of leprosy was present. In this case, the neuropathy first presented almost a decade prior to the rash. Isolated neuropathy as first sign of leprosy has been reported before.15 Permanent disability is expected with delayed diagnosis and without early treatment. Conclusion In conclusion, in people above 60 years of age, a slowly progressive, disseminated erythematous skin rash on trunk or arms should raise the suspicion for leprosy in south MS. Isolated neuropathy without rash can be the initial presentation of leprosy and if not treated early on in the course of disease it may lead to permanent severe disability.
2. Britton WJ, Lokcwood DN. Leprosy. Lancet. 2004;363:1209-19. 3. Leprosy, 2014. World Health Organization (WHO). Fact sheet N°101, Updated January 2014. Accessed on February 14, 2014 from http://www.who.int/ mediacentre/factsheets/fs101/en/. 4. Ooi WWW. Moschella SL. Update on leprosy in immigrants in the United States: status in the year 2000. Clin Infect Dis. 2001;32:930-7. 5. Truman R. A Summary of Hansen’s Disease in the United States – 2009. Washington, DC: U.S. Department of Health and Human Services, National Hansen’s Disease Program, Health Resources and Services Administration Registry Report, 2011; 1–31. 6. Scollard DM, Adams LB, Gillis TP, et al. The continuing challenges of leprosy. Clin Microb Rev 2006;19:338--81. 7. Truman RW, Singh P, Sharma R, et al. Probable zoonotic leprosy in the southern United States. N Engl J Med. 2011;364:1626-33. 8. Loughry WJ, Truman RW, McDonough CM, et al. Is leprosy spreading among nine-banded armadillos in the southeastern United States? J Wildl Dis. 2009;45:144-52. 9. Howerth EW, Stallknecht DE, Davidson WR, et al. Survey for leprosy in nine-banded armadillos (Dasypus novemcinctus) from the southeastern United States. J Wildlife Dis 1990;26:112–115. 10. Truman R. Leprosy in wild armadillos. Lepr Rev. 2005;76:198-208. 11. Abide J, Webb R, Jones H, Young L. Three indigenous cases of leprosy in the Mississippi delta. South Med J. 2008;6:635-38. 12. Rodrigues LC, Lockwood DN. Leprosy now: epidemiology, progress, challenges, and research gaps. Lancet Infect Dis. 2011;11:464-70. 13. Muzny C, Robinson J, Swiatlo E. Slowly Progressive Annular Skin lesion in an Elderly Patient. Clin Infect Dis. 2011;52:1342 14. Schmitt JV, Dechandt IT, Dopke G, et al. Armadillo meat intake was not associated with leprosy in a case control study, Curitiba (Brazil). Mem Inst Oswaldo Cruz. 2010;105:857-62. 15. Vital RT, Irramendi X, Antunes SL, et al. Isolated median neuropathy as the first symptom of leprosy. Muscle Nerve. 2013;48:179-84.
Author Information Infectious Diseases, Hattiesburg Clinic, Hattiesburg, MS (Dr. Marcos). Epidemiologist, Health Department of Mississippi, Jackson, MS (Dr. Dobbs). Pathology Department, Hattiesburg Clinic, MS (Dr. Walker). Dermatology Department, Hattiesburg Clinic, MS (Dr. Rose and Waller). National Hansen’s Disease Program, Baton Rouge, LA (Dr. Stryjewska). Corresponding Author Luis A. Marcos, MD, MPH. Hattiesburg Clinic, Hattiesburg, MS. Email: marcoslrz@yahoo.com.
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Beyond Respiratory Depression and Constipation: Adverse Effects of Opioids JAY P. MCDONALD, MD; ALAN J. TORREY, MD; MAHESH P. MEHTA, MD; LUIZ G. R. DELIMA, MD Department of Anesthesiology and Pain Management, University of Mississippi Medical Center
ABSTRACT
T
he numbers of opioid prescriptions have skyrocketed over the last two decades. Adverse effects of opioids are difficult to diagnose because the usual presenting complaints is persistence of severe pain and decreased function leading to chronic usage of medication with minimal benefit to patients. This concise review discusses the adverse effects of opioids to appropriately diagnose and treat patients on opioid therapy. We emphasize less commonly known adverse effects and the controversial use of opioids in non-cancer pain. Introduction Between 1991 and 2009 the number of prescriptions written for opioids has tripled.1 In a 2009 survey, it was reported that opioids were prescribed by medical providers in many specialties, including family practice, internal medicine, dentistry, emergency medicine and orthopedics. Primary care physicians who see the brunt of initial pain presentation prescribed 42% of immediate release opioids and 44% of long-acting opioids with the remaining percentage spread among surgical specialties, pain management, dentistry and emergency rooms physicians. This review on opioids discusses the lesser known adverse effects of this category of drugs and the issues associated with opioid usage, knowledge of which would benefit both prescribing physicians and patients. Opioids and Sleep Apnea It is widely known that opioids can cause respiratory depression. However, the relationship between opioids and sleep apnea (obstructive and central) may not be widely appreciated. A 2010 study 2 showed that opioid use resulted in increased requirements for assisted ventilation in patients with known sleep apnea. In fact, continuous positive airway pressure (CPAP) was shown to be inadequate, and many of these patients required bi-level positive airway pressure (BIPAP). BIPAP measures the number of breaths per minute and if the time between breaths exceeds the set limit, the machine temporarily increases the airway pressure to initiate a breath in an individual. The increasing prevalence of obesity (a known risk factor for obstructive sleep apnea) means that many may have this condition and this should be considered when administering opioids. Opioid-Induced Hyperalgesia Opioid-induced hyperalgesia (OIH) is a clinical syndrome in which patients on long term chronic opioid therapies become sensitive to
Key Words: opioids, adverse effects Reprints: Mahesh P. Mehta, MD, Department of Anesthesiology and Pain Management, University of Mississippi Medical Center, 2500 N. State St.., Jackson, MS 39216.
pain as a result of taking opioids.3 It is characterized by a) an increase in pain intensity over time b) spreading of pain to locations different from original site of pain c) increased pain sensation to external stimuli. It can be distinguished from tolerance in which reduced analgesia that develops over time and the intensity of pain are not altered from what was initially reported. Though the mechanism of OIH is not understood, it is believed that the opioids and their metabolites sensitize the N-methyl-D-aspartate (NMDA) receptors that increase the calcium enhancing neuron excitability. Once OIH is diagnosed, a number of treatment options may be considered. One option is to discontinue the offending opioid. This should be done gradually to avoid withdrawal effects. Hyperalgesia may worsen early during the tapering process. The clinician must assure the patient that their pain may get worse before resolving. Another option is to substitute the offending opioid with a COX-2 inhibitor that may decrease the pro-nociceptive receptors and antagonize the NMDA receptor by blocking glutamate, an excitatory neurotransmitter in the brain.4 Other medications to treat OIH include buprenorphine, methadone, ketamine, and dextromethorphan.4 Narcotic Bowel Syndrome Another common side-effect of opioids is constipation. With the increased usage of opioids, a relatively new phenomenon known as narcotic bowel syndrome (NBS) has been recognized.5 The cardinal symptom is severe to very severe abdominal pain that develops during opioid use and paradoxically increases despite continued or escalating dosage of narcotics. This syndrome has been seen in patients with no preexisting gastrointestinal disease as well as in patients being treated with opioids for known gastrointestinal problems such as irritable bowel syndrome. NBS is primarily seen in white, literate young to middle aged females with significant psychosocial impairment. The definitive treatment is discontinuation of opioids. Other successful treatment JULY 2015 • JOURNAL MSMA
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adjuvants include tricyclic and SNRI antidepressants, temporary benzodiazepine use, and clonidine.5 This syndrome is currently somewhat rare, but with the increased use of opioids, it should be considered in patients who develop intractable abdominal pain while taking opioids. Opioid-induced Androgen Deficiency Opioids can induce a multitude of hormonal changes, resulting in a condition called opioid endocrinopathy. A variety of hormones are affected, including total testosterone, free testosterone, estrogen, luteinizing hormone, gonadotrophic releasing hormone, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfates (DHEAS), adrenocorticotropic hormone (ACTH), corticotrophin-releasing hormone (CRH), and cortisol. 6 These effects are observed in men and women. Following withdrawal from opioids in drug users, serum hormone levels return to normal.7 A subset of opioid induced endocrinopathy called opioid-induced androgen deficiency (OPIAD) can occur in men taking opioids and is manifested clinically by erectile dysfunction, decreased libido, fatigue, hot flashes, and depression. Physical findings may include reduced facial and body hair, anemia, decreased muscle mass, weight gain, and osteopenia. 8 In females, testosterone and DHEAS deficiency are increasingly recognized in both premenopausal and post-menopausal women consuming opioids.9 These groups of women typically demonstrate diminished libido and menstrual abnormalities. Acute administration of opioids results in lower testosterone levels one to four hours later and return to baseline within twenty-four hours.10 Chronic administration of opioids induces dose-related decreases in total and free testosterone but the effect in sexual function is variable.11 Buprenorphine appears to cause less sexual dysfunction and is associated with higher testosterone levels as compared to methadone.12 Both men and women with OPIAD may be treated with androgen replacement therapy. Any patient who is offered testosterone replacement should be educated about potential side effects that include polycythemia, sleep apnea, local site reaction, and reduction in serum high density lipoprotein.12 Immune System There is a large amount of scientific evidence that highlights the role that both therapeutic and chronic uses of opioids compromise the optimal functioning of the immune system. Intravenous (IV) opioid drug users have higher rates of pulmonary and central nervous system infections, hepatitis, HIV, and skin abscesses. Unfortunately, confounding factors among IV drug users like needle sharing, multiple drugs of abuse, poor medical care and non-compliance have made the exact relationship difficult to establish between opioids and immune system.13 It has been shown that opioids exert their immunosuppressive effects via Mu-opioid receptors present on cells throughout the immune system.14 Chronic administration of opioids decreases the proliferative capacity of macrophage by both decreasing their progenitor cells and inhibiting their ability to ingest pathogens. Morphine has also been shown to decrease neutrophil recruitment and activation as well as inhibit antigen presentation by B and T cells. Surprisingly, morphine withdrawal can also cause immunosuppression by decreasing the cytokine expression on antigen presenting cells. Finally, the immunosuppressive effect of morphine has been hypothesized to play a critical and potentially devastating role in tumor development. Immune cells constantly scan and phagocytize 194
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developing tumor cells, and with their inability to function effectively, many animal models show increased tumor development and metastasis.15 Recent animal research has revealed that not all opioids induce the same immunosuppressive effects, and evaluating each opioid profile is important for appropriate analgesic selection in management of cancer patients. Fentanyl, a potent opioid, exerts relevant immunosuppression while buprenorphine appears to have more favorable immune profile. Osteoporosis and Osteopenia Osteopenia and osteoporosis due to chronic opioid usage can affect both males and females.16 With opioid usage in females, bone densities were in the osteoporotic range prior to age 40 at a higher rate than expected while in men, osteopenia was observed before the age of 50. Men frequently have low testosterone associated with osteopenia and diminished muscle mass. The lower bone mineral density is associated with a two-fold increase in relative risk of fractures in this population.17 Though the exact mechanism is not fully known, opioids may interfere with bone formation. Research supporting this includes the presence of a large concentration of opioid receptors in osteoblasts, inhibition of the growth of osteoblasts in cell cultures in the presence of small concentration of opioids, and lowered serum osteocalcin in narcotic addicts.18 Psychiatric Comorbidities Opioids have powerful anxiolytic as well as analgesic properties. While opioids are not indicated for the treatment of mental health disorders, their anxiolytic effects are readily appreciated by the anguished patient. Psychic distress may exacerbate nociceptive (physical) pain or be confused for physical pain. In high school, the most common reason for illicit use of opioid is for relief of anxiety. Increased opioid misuse, opioid related accidents and accidental opioid overdose death are observed in many mental health disorders. 19 Post-traumatic stress disorder, childhood sexual trauma, depression and anxiety disorders (including personality disorder, generalized anxiety disorder, phobic disorder and panic disorder) are known to increase the risk of opioid misuse and harm. Childhood attention deficit hyperactivity disorder is a risk for later narcotic misuse. A mental health condition does not preclude opioid use for pain, but doctors prescribing opioids for pain should carefully consider if the pain reported is a surrogate for psychiatric illness. Patients with mental health disorders should be educated that they will experience euphoric relief from the opioids – and that this relief is not the intended purpose of the pain medication. Patients with untreated or undertreated mental health disorders should be offered safe and appropriate psychiatric care. Central Nervous System Side effects Opioids commonly cause sedation and drowsiness when initiated, but tolerance to this adverse effect develops rapidly. In some patients, opioids impair cognitive function leading to decreased attention span, disorientation, restlessness, agitation, hallucinations and delirium. Those with significant risk factors for opioid-induced delirium include the elderly; polypharmacy - especially benzodiazepines, advanced liver and/or kidney disease; and patients with prior episodes of delirium. In terminally ill and palliative patients receiving opioids, the incidence of delirium may be between 28-88% and 20 to 44%, respectively. 20 Opioids differ in their ability to cause cognitive impairment with the highest incidence associated with meperidine, then hydromorphone and less with morphine.
Morphine inhibits central cholinergic activity creating an imbalance between cholinergic/dopaminergic systems leading to delirium. These anticholinergic effects may be related to morphine metabolites particularly in patients with renal impairment. These factors need to be considered prior to prescribing an opioid, and the patient and his/her family educated of these risks. Patients, especially elderly ones, on initial dosing of opioids are at an increased risk for falls and other accidental trauma from sedation or cognitive impairment. Some guidelines suggest prescribing half the normal initial dose when treating the elderly. Other CNS depressants such as anticholinergic medications, alpha adrenergic blockers, and benzodiazepines will compound the risk of falls and fractures in patients on opioids. Opioid Withdrawal
Conclusions In conclusion, this article highlights many of the negative effects of opioids. These negative effects contribute to numerous health issues that are detrimental. However, in the proper setting, opioids can and should be utilized for both cancer and non-cancer pain. Healthcare providers can make that judgment and decision to prescribe opioids after weighing their benefits and adverse effects. References 1. 2.
Many physicians are placed in a precarious position and are unable to discontinue or withdraw opioids. Opiate withdrawal is generally considered less likely to produce severe morbidity or mortality compared with barbiturates and benzodiazepines. Safe withdrawal from opioids is termed detoxification and can be performed as outpatient or inpatient therapy, depending upon the presence of comorbid medical and psychiatric problems and availability of social support. Methadone, buprenorphine, and clonidine are commonly used pharmacologic methods of detoxification. 21 The use of methadone and buprenorphine is based on the principle of cross-tolerance in which one opioid is replaced with another and then slowly withdrawn. Clonidine appears to be most effective in suppressing signs and symptoms of abstinence mediated by autonomic nervous system but is less effective for subjective symptoms. Buprenorphine is associated with fewer adverse effects than clonidine, and patients are more likely to complete detoxification programs with buprenorphine compared with clonidine. Buprenorphine was as effective as methadone for withdrawal, but withdrawal symptoms appeared to resolve more quickly with buprenorphine.
3.
Opioid and Non-Cancer Pain
12.
Opioids are a mainstay in the treatment of cancer pain, and very few would argue against their use in this patient population. However, opioid use for non-cancer pain has become quite debatable.22 Proponents of opioid use for patients with pain not related to cancer feel that if opioids are the only effective treatment, then opioid use should be considered. Others argue that the negative effects of opioids on both an individual basis and on the public health as a whole preclude their use in anyone other than the terminally ill. This issue cannot be addressed with such a polarized view. A bedridden patient with multiple sclerosis or a patient with BMI of 55, and bilateral collapse of the femoral heads who responds well to opioids must be viewed in a different light from a 25-year-old otherwise healthy patient with acute onset back pain. Opioids have their place in non-cancer pain control, and it is up to us as healthcare providers to be able to recognize their appropriate use. The danger in legislation that denies opioid access to all will restrict it from those patients who benefit from opioids appropriately. Recently, many physicians have felt coerced not to provide opioids for treatment of pain because of increased scrutiny by state medical boards, insurance companies, and both the state and federal governments. Common sense and medical training should be at the forefront of the decision making process on when to utilize opioids as part of a treatment plan.
13.
4. 5.
6. 7.
8. 9. 10. 11.
14. 15. 16. 17. 18.
19.
20. 21. 22.
Analysis of opioid prescription practices finds areas of concern. National Institutes of Health. NIH News. Apr 5, 2011. Guillemin Ault C, Cao M, Yue H, Chawla P. Obstructive Sleep Apnea and Chronic Opioid Use. Lung 2010:188(6):459-468. Lee M, Silverman S, Hansen H, Patel V, Manchikant L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician 2011;14(1):145-161. Bottemiller S. Opioid-induced hyperalgesia: An emerging treatment challenge US Pharm 2012 37:HS2-HS7. Grunkemeier D, Cassara JE, Drossman DA. The Narcotic Bowel Syndrome: Clinical Features, Pathophysiology and Management. Clin Gastroenterol Hepatol 2007; 5(10):1126-1122. Seyfried O, Hester J. Opioids and endocrine dysfunction. Br J Pain 2012; 6(1) 17-24. Mendelson JH, Mello NK. Plasma testosterone levels during chronic heroin use and protracted abstinence. A study of Hong Kong addicts. Clin Pharmacol Ther 1975; 17: 529-533. Daniell HW. Hypogonadism in men consuming sustained action oral opioids. J Pain 2002; 3:377-384. Daniell HW. Opioid endocrinopathy in women consuming prescribed sustained-action opioids for control of nonmalignant pain. J Pain 2008; 9: 28-36. Woody G, McLellan AT, O’Brian C, et al. Hormone secretion in methadone-dependent and abstinent patients. NIDA Res Monogr 1988; 81: 216-223. Bliesener N, Albrecht S, Schwager A, et al. Plasma testosterone and sexual function in men receiving buprenorphine maintenance for opioid dependence. J Clin Endocrinol Metab. 2005;90:203-206. Daniell HW, Lentz R, Mazer NA. Open-label pilot study of testosterone patch therapy in men with opioid-induced androgen deficiency. J Pain 2006;7:200-210. Roy S. Opioid drug abuse and modulation of immune function: consequences in the susceptibility to opportunistic infections. J Neuroimmune Pharmacol. 2011;6:42-65. Ninkovic K, Roy S. Role of the mu-opioid receptor in opioid modulation of immune function. Amino Acid. 2013;45:9-24. Afsharimani B, Cabot P, Parat MO. Morphine and tumor growth and metastasis. Cancer Rev. 2011;30:225-38. Daniel HW Opioid osteoporosis. Arch Intern Med. 2004;164:338. Vestergaard P, RejnmarkL, Mosekilde L. Fracture risk associated with the use of morphine and opiates. J Intern Med. 2006;260: 76-87. Perez-Castrillon JL, Olmos JM, Gomez JJ et al. Expression of opioid receptors in osteoblast like MG-63 cells and effects of different opioid agonists on alkaline phosphatase and osteocalcin secretion by these cells. Neuroendocrinology 2000;72:187-194. Cicero TJ, Wong G, Tian Y et al. Co-morbidity and utilization of medical services by pain patients receiving opioid medications: data from an insurance claims database. Pain 2009;144(1) 20-27. Vella-Brincat J, Macleod AD. Adverse effects of opioid on central nervous system of palliative care patients. J Pain & Palliative Care 2007;21(1):15-25. Nicholls L, Bragaw L, Ruetsch C. Opioid dependence treatment and guidelines. J Manag Care Pharm 2010; 16(1-b):S14-21. Franklin GM. Opioids for chronic noncancer pain. Neurology 2014; 83(14)12771284.
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Top Ten Facts You Need to Know about Medical Emergencies While Flying Amanda M. Daggett, M4; Claude Brunson, MD; Luiz DeLima, MD; Sloan Youngblood, MD
1 2 3
Are physician passengers likely to encounter in-flight medical emergencies? Doctors fly on commercial flights requiring medical assistance 40-90% of the time, according to airline surveys.3 While there is no central collection agency, MedAire, a ground based medical consulting service based in Phoenix, AZ, reports an average of 17,000 cases per year in the United States with a medically trained person volunteering 62% of the time.5 According to the Bureau of Transportation Statistics, over 800 million passengers flew in the United States in 2013.6 Additional data reports the incidence of medical emergencies to be one occurrence per 14,000 passengers or 350 occurrences per day.2 In-flight emergencies on international flights, as reported by British Airways’ data, occur 4:1 over domestic flights, and others assess the incidence at 1 in 50 international flights.3 What are the duties and obligations of physician passengers in in-flight medical emergencies? U. S. law does not require a physician to render assistance during in-flight medical emergencies, but some doctors say it is their ethical duty to do so.5 Doctors, however, may be reluctant to identify themselves for a number of reasons including fear of legal ramifications and crises outside their area of expertise.3 In 1998, the Aviation and Medical Assistance Act introduced the Federal Good Samaritan Law.6 This limited Federal and State liability for individuals and airlines responding to in-flight medical emergencies.4 For protection to apply, the volunteer must be “medically qualified” and receive no payment. The minimum standard of care is expected to approximate that rendered by a physician trained similarly.2 As of 2013, no physicians have been sued for volunteering during in-flight medical assistance.5 What types of assistance are available? Airlines no longer rely on the chance that medically qualified passengers will be onboard in the event of an in-flight emergency. Most airlines contract with 24-hour ground-based medical consulting services including, but not limited to, MedAire, First Call, and the University of Pittsburgh’s StatMD.5 The volunteering physician should work with the cabin crew, who are trained, and the ground-based service. If a disagreement arises between the onboard volunteer and the ground-based service as to the proper direction therapy should take, the captain ultimately has final say and usually sides with the ground-based service.2 Throughout the entire flight, the pilot has final authority on the airplane.
4
What are the guidelines for patient interactions? There are suggested approaches for doctors volunteering prior to providing assistance in an in-flight emergency. Recommendations when approaching an in-flight incident are to properly introduce oneself to the cabin crew, while notifying crew members if you’ve had alcohol or taken sleep or anxiety medications.2 It is also advised to explain one’s level of expertise and qualifications and be prepared to show documentation. In regards to the patient, asking them for permission, if possible, before any physical contact is made and using an interpreter if needed and available are other endorsed approaches. When possible, it is advised to treat in the seat, due to space limitations and concerns about the ability of the passengers and crew to move throughout the cabin. Finally, documenting findings and treatments given, working with the crew and ground response center, and asking for flight diversion when appropriate are supported guidelines, as well as staying within one’s scope of expertise.5,9 Additionally, the flight captain has final authority over flight diversions, regardless of the advice or opinion of the on-board physician.
5
What equipment is on board for emergencies? The Federal Aviation Administration (FAA) requires that aircraft carrying passengers and a payload of more than 7,500 pounds with at least one flight attendant must have at least one autonomic external defibrillator (AED) and at least one medical kit (EMK).4 This usually includes aircraft with greater than 30 seats. Also, all flights with U.S. registration must carry first aid kits for situations not needing the full EMK.2 Flight crews are required to be certified in CPR and the use of AED devices every two years.5 Therefore, some airlines restrict the use of AED devices to crew members only.2 Their contention is that volunteer physicians may not be up-to-date on proper use of the device. Oxygen is available in limited supplies. Aircraft must carry enough to supply 2% of the passengers the entire flight. Their cylinders at approximately 8,000 feet can deliver an inspired oxygen concentration of 28%.2 The contents of the standard EMK as required by the
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Introduction
A
ccording to Air Transport and Action Group (ATAG), over 3 billion passengers flew commercial airlines worldwide for the year 2013.1 Air travel is increasing every year; as such, it also includes an increasingly older population. This population group is more likely to suffer from chronic illnesses impacted by conditions found flying at altitudes of 24,000 to 40,000 feet. Although traveling by air is safe, several factors including stress, carrying baggage long distances, high altitude, jet lag, and crowded conditions can
precipitate illness while flying. In addition, newer, larger airplanes are being introduced into airline fleets creating flights with as many as 800 passengers on board at any given time.2 It is also important to remember crew members when discussing in-flight emergencies. Some reports indicate the flight crew-to-passenger accident ratio is almost 4 to 1.3 Doctors need to be aware of the uniqueness of emergencies in-flight and the physiologic stress induced by high altitude aviation.4
FAA are listed in Table 1 (next page). Of special consideration is the pregnant flyer, and fortunately, in-flight deliveries are uncommon. In 2009, the American Congress of Obstetricians and Gynecologists (ACOG) issued a committee opinion stating that pregnant women without medical or obstetrical concerns can follow the same flying considerations as the general population.11 Airlines, on the other hand, set their own policies and should be consulted before flying after 36 weeks gestation.4 In most cases, the decision to fly is a decision between the mother and her physician. As such, labor and delivery in flight are infrequent but real possibilities, with space limitations and limited supplies in the emergency medical kit for onboard deliveries being significant concerns.
6
How does hypoxia at high altitude when flying affect passengers and crew? All passengers and crew experience a certain amount of mild hypobaric hypoxia4 (an oxygen deficit as a result of low oxygen pressure at altitude). Commercial airplanes use a cruising altitude of between 29,000 and 39,000 feet. The air is cold and dry (relative humidity 10%) requiring heating and pressurization of the cabin. Airlines pressurize to an altitude of around 8,000 ft., a “best practice” compromise,8 roughly the altitude of Aspen Colorado (approx.7,800 feet). At this altitude, the inspired partial pressure of oxygen (PO2) drops from 149 mmHg (at sea level) to 108 mmHg. This corresponds to an arterial partial pressure (PaO2) of 50-60 mmHg and an arterial oxygen saturation of 88-90% for healthy passengers who usually tolerate this uneventfully.2
7
What are the effects of gas expansion due to a decrease in cabin pressure? Boyle’s Law states that at a constant temperature, the volume of gas in an enclosed space varies inversely with pressure. Decreased in-flight cabin pressure can increase gas volume by as much as 30%. This affects the inner ear, the sinuses, the gastrointestinal (GI) tract, and the pulmonary system. Examples include ear and sinus pain, bloating and abdominal pain (from distended loops of bowel), post-surgical wound dehiscence, and ruptured bullae and blebs leading to pneumothorax. Problems from gas expansion can also affect tracheostomy and feeding tubes.2
8
How does flying affect passengers and crew with cardiovascular disease? Changes in altitude can pose a risk to patients with pre-existing cardiovascular disease. This would include patients with coronary artery disease, congenital and valvular heart disease, congestive heart failure, and sickle cell disease. The normal cardiac physiologic response to hypoxia is tachycardia resulting in increased cardiac output, blood pressure, and increased myocardial oxygen demand. For passengers with limited reserves, a decrease in the PO2 may precipitate a crisis. In-flight cardiopulmonary arrest is rare, but survival is dependent on successful use of the AED in virtually all cases.10,12, 13
9
How does flying affect passengers and crew with pulmonary disease? High altitude can pose a risk for patients with preexisting pulmonary disease. This would include patients who are chronic smokers and those with chronic obstructive pulmonary disease (COPD), interstitial lung disease, reactive airway disease, and pulmonary hypertension. Clinically, patients with limited reserves may experience shortness of breath, cough, weakness, drowsiness, agitation, and cyanosis. In addition to decreased barometric pressure inside the cabin, air quality is also a concern. Cabin air is recirculated, mixed with 50% fresh air, then heated and compressed where it enters through the air intake. Despite filtering, the cabin air may contain quantities of fuel, lubricating fluid, deicing fluid, and other contaminants.2 This can cause patients with limited pulmonary reserve or reactive airways to decompensate.
10
What are the most common in-flight emergencies? Airlines are required by the U. S. Department of Transportation to allow passengers with disabilities to fly, as well as those requiring supplemental oxygen, continuous positive airway pressure (CPAP), and artificial airways, but there are exemptions2 for passengers who present a danger or health concern to the other passengers. There is no central database to collect information on the number of in-flight emergencies,4 so studies are used which rely on reviews by flight attendant’s reports, unscheduled landings data, and information from involved physicians. British Airways has issued their own numbers which are as follows.3 (Table 2)
continued next page
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6
sizes necessary to administer required medications) ets, 325 mg
4 4 a TABLE 1.1.Emergency Medical TABLE Emergency Medical Kit 4 mg, (single dose ampule or equivalent) 2 CONTENTS 2 dose ampule or equivalent) Sphygmomanometer 4 Stethoscope ered dose inhaler or equivalent) 1 Airways, oropharyngeal (3 sizes): 1 pediatric, 1 small adult, 1 large adult or equivalent le, (single 10. dose ampule orOther equivalent) 1 continued... sources Self-inflating manual resuscitation device with 3 masks (1 pediatric, 1 small adult, 1 large ectable, (single dose ampule or equivalent) 2 indicate syncope, GI complaints, adult or equivalent) njectable, (single dose ampule or equivalent) 2 and respiratory problems as the CPR mask (3 sizes), ectable (single dose ampule or equivalent) 2 1 pediatric, 1 small adult, 1 large adult, or equivalent most common in-flight medical IV Admin Set: Tubing 10 w/ 2 Y connectors emergencies. These numbers, Alcohol sponges he drugs inprovided the kit below, are from airline 1 Adhesive tape, 1-inch standard roll adhesive studies, not from a much-needTape scissors ed Circular centralized database, and ion Advisory 121-33B Appendix A Tourniquet therefore show wide-ranging Saline solution, 500 cc differences (Table 3). Needles (2-18 ga., 2-20 ga., 2-22 ga., or sizes necessary to administer required medications) Syringes (1-5 cc, 2-10 cc, or sizes necessary to administer required medications) TABLE 2. British Airways Analgesic, non-narcotic, tablets, 325 mg percentage of in-flight 4 Antihistamine tablets, 25 mg ercentage of in-flight emergencies emergencies3 Antihistamine injectable, 50 mg, (single dose ampule or equivalent) Atropine, 0.5 mg, 5 cc (single dose ampule or equivalent) Stress and Anxiety 16% Aspirin tablets, 325 mg Bronchodilator, inhaled (metered dose inhaler or equivalent) Cardiovascular 15% Dextrose, 50%/50 cc injectable, (single dose ampule or equivalent) Epinephrine 1:1000, 1 cc, injectable, (single dose ampule or equivalent) Epinephrine 1:10,000, 2 cc, injectable, (single dose ampule or equivalent) Alimentary 12% Lidocaine, 5 cc, 20 mg/ml, injectable (single dose ampule or equivalent) Nitroglycerine tablets, 0.4 mg Respiratory 10% Basic instructions for use of the drugs in the kit a
QUANTITY 1 1 3 1: 3 masks 3 1 2 1 1 pair 1 1 6 4 4 4 2 2 4 1 1 2 2 2 10 1
Federal Aviation Administration Advisory Circular 121-33B Appendix A14
Table 3. In-flight emergencies by diagnosis5 1Federal
TABLE 3. In-flight emergencies by diagnosis5 Crit Care 2009 J Travel Med 2008 E Med Journal 2005 Aviation Space, Env Med Resuscitation 2001
Syncope
52.10% 14.60% Table 25.20% 15.00% 16.30%
Aviation Administration Advisory Circular 121-33B Appendix A Neuro Respiratory Allergic GI CV (Dizziness, Trauma CVA, Seizures, HA) 12.60% 6.60% 2.50% 3.50% 2.30% 2.20% 9.40% percentage 4.70% of in-flight 8.40% emergencies 6.80% 4 3.70% 2.35.60% British Airways 7.80% 9.10% 0.20% 7.30% 13.60% 0.00% 12.00% 11.00% 11.00% 12.00% 11.00% 2.80% and Anxiety 15.50% 11.80% 9.20% Stress 5.30% 3.70% 16% 2.40%
OB/GYN
Psych/ Intox
0.60% 1.60% 0.20% 1.40% 3.90%
6.00% 3.10% 60.00% 3.00% 9.20%
Adapted from Chandra, Amit, and Shauna Conry. “In-flight Medical Emergencies.” Western J of Emerg Med 14.5 (2013): 499-504. Chandra, Shauna Conry. "In-flight Medical Emergencies." Western Journal of Emergency Medicine 5 Cardiovascular 15% 14.5 (2013): 499-504. Web. 13Amit, Nov.and 2014. Web. 13 Nov. 2014. 5
Conclusion
Alimentary
References 12%
1. Leisure and business air travel continue to grow each year and includes greater numbers of Respiratory older passengers as well as those with more diverse sets of disabilities. Medical emergencies in flight create unique circumstances for the volunteer assisting with medical care. Understanding 2. the challenges of high altitude medical emergencies and the unique physiologic changes is important. For the physician in this situation, it is important to be mindful of his or her scope of expertise and not feel compelled to intervene in ways that are outside that capacity. The goal is to stabilize the patient, assisting the crew and ground-based medical service as necessary.
“Facts and Figures.” Air Transport Action 10% (ATAG). N.p., Apr. 2014. Web. 15 Group Nov. 2014. <http://www.atag.org/>. Ruskin, K. J., MD, Hernandez, K. A., MD, & Barash, P. G., MS. (2008). Management of In-flight Medical Emergencies. Anesthesiology, 108(4), 749-755. Retrieved November 15, 2014.
3. Mills JF, Harding MR. Medical Emergencies in the air I: Incidence and legal aspects. Br Med J 1983;286:1131-2
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4. Aeropsace Medical Association, Medical Guidelines Task Force, Medical Guidelines for Air Travel 2nd edition, Avia Space Environ Med 79(5), Section II, A1-A19, 2003. 5. Chandra, Amit, and Shauna Conry. “In-flight Medical Emergencies.” Western J of Emerg Med 14.5 (2013):499504. Web. 13 Nov. 2014. 6. Stewart PH, Agin WS, Douglas SP. What Does the Law Say to Good Samaritans? Chest. 2013;143(6):1774-1783. 7. “Transtats Passengers All Carriers-All Airports.” RITA | BTS | Bureau of Transportation Statistics, n.d. Web. 13 Nov. 2014. <http://www.transtats.bts.gov/>. 8. Aerospace Medical Association, Aviation Safety Committee, Civil Aviation Subcommittee. Cabin Cruising Altitudes for regular transport aircraft. Aviat Space Environ Med 79(4):433-439, 2008. 9. Gendreau MA, DeJohn C. Responding to Medical Events During Commercial Airline Flights N Engl J Med 2002; 346:1067-1073.
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10. Graf J, Stüben U, Pump S: In-flight medical emergencies. Dtsch Arztebl Int 2012; 109(37):591–602. 11. ACOG Committee Opinion No. 443: Air travel during pregnancy. - PubMed - NCBI. http://www.ncbi.nlm.nih. gov/pubmed/19888065. Accessed December 17, 2014. 12. Highlights of the 2010 American Heart Association Guidelines for CPR and ECC. 2010. 13. Advanced Cardiovascular Life Support Provider Manual. 2010. 14. Federal Aviation Administration Advisory Circular 12133B Appendix A.
Author Information Fourth year medical student at the University of Mississippi Medical Center (Ms. Daggett). Anesthesiologist and Senior Advisor to the Vice Chancellor for External Affairs at the University of Mississippi Medical Center (Dr. Brunson). Professor in the Department of Anesthesiology at the University of Mississippi Medical Center, where he currently practices. (Dr. DeLima). Assistant Professor and Assistant Medical Director, ISC, in the Department of Anesthesiology at the University of Mississippi Medical Center (Dr. Youngblood). Reprint requests: Amanda Daggett, Department of Anesthesiology, University of Mississippi Medical Center, 2500 N. State St.., Jackson, MS 39216. (amdaggett1@gmail.com).
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M I S S I S S I P P I
S T A T E
D E P A R T M E N T
O F
H E A L T H
Two New Members Appointed to the State Board of Health T
he oath of office is administered by an official court reporter. There are two new appointments including B.J. Phillips and Dr. Dwalia South; three are reappointments. Shown l. to r.: Sammie Rea, RN; B.J. Phillips, DrPH; Dwalia South, MD; J. Edward Hill, MD and Thad Waites, MD.
B.J. Phillips, DrPH, of Brandon, and Dwalia South, MD, FAAFP, of Ripley, were sworn in as the two newest members of the Mississippi State Board of Health at the quarterly meeting held June 8. Both were appointed to the Board by Governor Phil Bryant. Board Chairman Dr. Luke Lampton looks forward to working with both new members. “Governor Bryant has made two outstanding appointments to the Board. Both recognize the serious problems facing public health in our state and are committed to making a difference. On behalf of our Board, I welcome them with much excitement,” he said.
MISSISSIPPI Phillips’ career in public health began in 1965 as a microbiologist with the Mississippi State Department of Health (MSDH) after earning her NT OF H EALTH Bachelor of Science degree from the Mississippi University for Women.
She earned her Master of Public Health and Doctorate of Public Health from the University of North Carolina before returning to MSDH for two more decades to serve as Director of Clinical Laboratories, Director of Office of Health Regulations, and Deputy State Health Officer before retiring in 1998. Dr. South graduated from the University of Mississippi School of Medicine before completing her family practice residency at the University of Tennessee. She has been a family medicine physician at Ripley Health Care Associates, a satellite campus of North Mississippi Primary Health Care, since 1995. “It is a tremendous honor and privilege to be chosen by Governor Bryant for this position and to take the reins from Dr. Kelly Segars who has served the state in this capacity for many years,” she said. “Working with the Mississippi State Department of Health will present both great challenges and grand opportunities to make a positive impact on the health of all Mississippians.” South has served her community as a member of several civic organizations and has been recognized for her work in the field: in 2003 she was named Mississippi Family Physician of the Year and was listed as one of America’s Top Family Doctors of the Year in 2004-2005. Three current board members – J. Edward Hill, MD, FAAFP, of Tupelo; Sammie Rea, RN, of Flora; and Thad Waites, MD, of Hattiesburg – were reappointed for another term ending in 2021. “Although we will miss our previous Board members, our two new Board members, Dr. Dwalia South and Dr. B.J. Phillips, have already dedicated themselves to the improvement of health in the state, and their Board membership is just one more way for them to help,” said MSDH State Health Officer Dr. Mary Currier. “Also, the reappointment of our Board members whose terms were ending is very much to the benefit of health in the state. We are very lucky to have such a knowledgeable, capable, and service-oriented Board.”
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“I wish helping my patients who
have prediabetes was as simple as writing a prescription.”
Now it is.
Visit preventdiabetesstat.org to learn more and download a free toolkit that physicians and care teams can use to: • Screen and test patients for prediabetes (A1C 5.7-6.4/FPG 100 -125) • Refer eligible patients to CDC-recognized diabetes prevention programs • Follow patients’ progress in the program
Use this toolkit to Screen, Test, Act – Today.
Use a proven prevention model to help patients prevent or delay type 2 diabetes.* Diabetes prevention programs that are part of the Centers for Disease Control and Prevention’s National Diabetes Prevention Program teach patients how to make lifestyle changes, and are based on research that has been proven to prevent or delay the development of type 2 diabetes in high-risk patients. * Establishing systematic identification and referral can help you meet Meaningful Use and Patient Centered Medical Home objectives.
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P R E S I D E N T ’ S
P A G E
Let’s Measure It in Dollars and Cents CLAUDE D. BRUNSON, MD ~ 2014-15 MSMA PRESIDENT
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had the great fortune to attend this year’s Mississippi Rural Physicians Scholarship Program Scholarship Awards Ceremony. Along with Philip Gunn, the Speaker of the Mississippi House of Representatives, it was my honor to present the scholars with their monetary awards. Dr. James Keeton, who served our state admirably as the Vice Chancellor and Dean of the School of Medicine at the University of Mississippi Medical Center before his recent retirement, was the keynote speaker. Vice Chancellor Keeton spoke of the investment Mississippi is making in these young physicians in training and thanked the Speaker and legislative colleagues for making this a high priority. Specifically, he mentioned the return on investment the state could expect to receive by training and placing physicians in communities across the state. As the Vice Chancellor has stated on numerous occasions, “The ROI on a physician far exceeds the ROI from any other business investment the state makes.” I believe he is spot on with that sentiment. The health and medical benefits we provide to Mississippians as primary caregivers and leaders of the healthcare team are an integral part of our state’s sustainability. But our value doesn’t end there. On average, each of us stimulates $2 million in economic benefits for our individual cities, towns and communities. To say that we are the economic backbone of Mississippi is not an understatement. Overall, Mississippi physicians generate more than $6 billion in economic activity for the state, according to a recent study released by the Mississippi State Medical Association and the American Medical Association. The report also found that physicians contribute more to the national economy than higher education, legal services, and other healthcare fields including home healthcare, nursing, and residential care. We already know we play a vital role in the quantity - and quality - of care received by patients in medical offices, hospitals, academic medical centers, urgent care and community health centers and other sites of medical service. But here’s a fact that is often not discussed when determining a physician’s worth. Our presence in cities, towns and municipalities
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across the state enhances the quality of life for residents and creates a tremendous economic boost for local and state economies. Breaking the impressive numbers down, here are some ways each of us makes a difference throughout the state. • Jobs: On average, each physicians generates 9 jobs for more than 45,000 physician-related jobs statewide. • Tax revenue: We support $45,069 in local and state tax revenues and contribute an average $221 million in local and state tax revenues statewide. • Wages and benefits: An average $733,725 is provided for annual payrolls of more than $3.6 million in wages and benefits to 45,000 employees.
AS FORMER VICE CHANCELLOR KEETON STATED ON NUMEROUS OCCASIONS, “THE ROI ON A PHYSICIAN FAR EXCEEDS THE ROI FROM ANY OTHER BUSINESS INVESTMENT THE STATE MAKES.” I BELIEVE HE IS SPOT ON WITH THAT SENTIMENT.
And while the ripple effect – or perhaps I should call it the tidal wave - of our presence can’t accurately be recorded, we do know that every dollar spent with a physician supports an average $1.62 in other industries. While these numbers are impressive, no dollar value can accurately reflect the professional clinical services we provide to millions of Mississippians. We carry tremendous responsibility as leaders of the healthcare team, professional confidants, community supporters and patient advocates. The level of responsibility we shoulder is rare in most industries, including those with impressive economic impact figures.
Collectively, our power in numbers impacts the national economy. Nationwide, physicians generate $1.6 trillion for the national economy, according to the American Medical Association (AMA). All told, physicians support almost 10 million jobs and $775.5 billion in wages and benefits to communities across the country, according to the AMA’s Economic Impact Study
Medley & Brown POINTS OF DISTINCTION Focused: A singular long-term, value-driven investment philosophy Rational: Thoughtful investment selection
BREAKING THE IMPRESSIVE NUMBERS DOWN, HERE ARE SOME WAYS EACH OF US MAKES A DIFFERENCE THROUGHOUT THE STATE:
Responsive: Exceptional client service Committed: Our money invested alongside yours
JOBS-45,000 TAX REVENUE- $45,069 LOCAL AND STATE
Proven: History of investment performance
WAGES AND BENEFITS-3.6M + The next time you question your worth after a particularly trying day of practicing medicine, think back to these impressive numbers. Without your presence, your patients and, most especially, your city, town or community would suffer in innumerable ways without you. You not only make a difference in your patients’ lives – you mean big business.
MEDLEY & BROWN, LLC F I N A N C I A L
Call us at 601-982-4123
Let’s keep up the good work – and take pride in our impact on our patients and the great state of Mississippi. M&B MSMA Feb'15.indd
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Contact: Wayne Johnson 601-955-5906. JULY 2015 • JOURNAL MSMA
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On Match Day, Suspense Reigns as Med Students Reveal Residency Fates
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here were 1,000 seats at the Jackson Convention Complex for Friday’s School of Medicine Match Day 2015, and a large chunk of them were filled by Eric and Heather McDonald’s children. All six of them. Ranging in age from 8 years to eight weeks, they may not have known exactly why they were there, but the oldest knew this much, McDonald said: “It’s a special day for daddy.” It was a special day for hundreds of dads, moms, grandparents, siblings and others - but, most of all, for the fourth-year medical students who, like McDonald, learned where they’ll complete their medical education as residents training in 21 different specialties, such as pediatrics, surgery, emergency medicine, family medicine, internal medicine and more. “It feels like it’s been a long time coming,” said McDonald, who lives in Florence and grew up in Clinton. “But it’s been different from what I expected - I knew there would be all the excitement, but then I realized that a bunch of close friends are about to get dispersed across the country.” Nationwide, more than 27,000 first-year residency positions were filled simultaneously in this year’s Main Residency Match involving the nation’s 141 medical schools. Almost 35,000 U.S. and international students applied, reported the Association of American Medical Colleges. UMMC’s Match Day list included more than 120 names.
the National Resident Matching Program; it uses a computerized mathematical system to try and pair the institutional preferences of the students with those of residency program directors. “I’ve never been in a situation where everything is so up-in-the-air like it is now,” said aspiring pediatrician Jarrett Morgan of Madison as the matching was about to commence. “I believe I’m a good enough student to stay here, but you never know.” As it turned out, he was good enough. Match Day is an especially nerve-wracking time for students like Zach and Kelly Pippin, who married during their third year of medical school and who, of course, aspired to match matches. “They put everything into a computer, and I’ve heard it takes only 17 seconds,” said Kelly Pippin who, like her husband, plans on a residency in internal medicine. “In a matter of 17 seconds, our fate is determined.” In a ritual once described by a UMMC student as a combination of the Academy Awards and the NFL draft for nerds, the name of each student, or couple, was drawn, one at a time. Keeton, who only recently stepped down as vice chancellor, was selected by the students to draw the first name; it belonged to Kristie Alvarez, a future family medicine resident at UMMC.
John Bridges, senior class president, acknowledged that Match Day is steeped in emotion and suspense. “For a lot of us, this is our first job offer,” he said to the convention center crowd. For her part, Dr. LouAnn Woodward acknowledged the contributions of the students’ family and friends. “We want the people in this room to understand that the students wouldn’t be here without you,” said Dr. Woodward, recently named UMMC’s vice chancellor for health affairs and dean of the School of Medicine. She urged those who matched outside UMMC to return to Mississippi one day, as did Dr. James Keeton, her predecessor, in his remarks. After nearly a year of travel and interviews at multiple institutions, along with expenses and angst, the students put everything in the hands of
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Eric McDonald, the father of six children ranging in age from 8 years to about 8 weeks, announces his residency match to UMMC in emergency medicine.
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When Julie Dhossche tore open medical school’s version of the fortune cookie, she gasped into the microphone. The daughter of Dr. Dirk Dhossche, UMMC professor of psychiatry, she had been holding hands, somewhat pensively, with her fiancé Tyler Baker, an engineer, shortly before she took the stage. At the podium, her words tumbled out: dermatology, Oregon Health & Science University, Portland. It was her first choice. “On one hand I didn’t think it would actually happen,” she said afterward. “It’s a good feeling.” Kelly and Zack Pippin read their Match Day fates together.
Dr. Loretta Jackson-Williams, associate dean for academic affairs, drew the remaining names from the Match Box, calling the students to stand before the audience, open an envelope containing a slip of paper and announce their fate.
Dhossche could claim the match farthest from Jackson - tied with Madiha Ahmad, an internal medicine resident-to-be at Providence St. Vincent Hospital, also in Portland, Ore. As McDonald noted, many in the Class of 2015 will be “dispersed” - to Wisconsin, California, Massachusetts, Virginia and so forth.
TO ADD MORE DRAMA TO THE AFFAIR, EACH YEAR THE LAST STUDENT CALLED IS AWARDED A TRADITIONAL DOCTOR’S BAG STUFFED WITH A $5 CONTRIBUTION FROM EACH OF HIS OR HER CLASSMATES. THE DAY’S WINNER: BRAD NESBIT. “It’s a good day,” said Nesbit, another internal medicine prospect staying put at the Medical Center. “I make money before I sign the contract.” Most of the students appeared to be pleased during the big reveal.
Brad Nesbit holds his cash-filled bag as he announces his match.
But a plurality will stay in Mississippi: 52 of the graduates, or 41.6 percent, with 48 remaining at UMMC. They include the Pippins. “We’re pretty pumped about it,” Zach Pippin said in the aftermath. “We interviewed all over and thought we wanted to leave Jackson. But we couldn’t find a place that was better. We went to some great places. UMMC had everything we wanted.” “I couldn’t be happier,” Kelly Pippin said. “These are the people I want to be with and practice medicine with.” The stay-at-homers include McDonald as well. The emergency medicine resident-in-waiting also said he’s glad to preserve ties with his medical “family” - a concept the father of six should know something about.
Jarrett Morgan is one of the 48 students who will do residency training at UMMC - as denoted by the mass of push pins on the map.
Morgan, the aspiring pediatrician, was also satisfied with his day, except for one thing: He missed winning the bloated black bag by only a handful of draws. ”I really wanted that money,” he said.
–Gary Pettus, UMC Public Affairs
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University of Mississippi School of Medicine 2015 Match Results Katherine Abell - Pediatrics St. Louis Children’s Hospital, St. Louis, MO
Elizabeth Bui - Internal Medicine University of Mississippi Medical Center, Jackson
Madiha Ahmad - Internal Medicine Providence St. Vincent Hospital, Portland, OR
Tory Cannon - Neurology University of Mississippi Medical Center, Jackson
Luke Ainsworth - Radiology-Diagnostic University of Mississippi Medical Center, Jackson
Daniel Carson - Medicine Preliminary Univ. of Tennessee College of Medicine, Memphis, TN Radiology-Diagnostic Baptist Memorial Hospital, Memphis, TN
Kristie Alvarez - Family Medicine University of Mississippi Medical Center, Jackson Mike Anderson - Psychiatry University of South Alabama, Mobile, AL Austin Baker - Emergency Medicine University of Louisville School of Medicine, Louisville, KY Andrew Bartlett - Internal Medicine University of Mississippi Medical Center, Jackson Will Berlin, Jr. - Medicine Preliminary University of Mississippi Medical Center, Jackson Radiology-Diagnostic Univ. of Colorado School of Medicine, Aurora, CO
Zach Chancellor - Surgery-General University of Virginia, Charlottesville, VA Sarika Chandak - Internal Medicine University of Mississippi Medical Center, Jackson Stephen Clark - Pediatrics University of Alabama - Birmingham, Birmingham, AL Clifford Coile - Internal Medicine University of Mississippi Medical Center, Jackson Tasha Coleman - Pediatrics University of Mississippi Medical Center, Jackson
Josh Black - Family Medicine Self Regional Healthcare, Greenwood, SC
Jeremy Courtney - Internal Medicine University of Mississippi Medical Center, Jackson
Jonathan Blossom - Internal Medicine University of Mississippi Medical Center, Jackson
Josh Cousin - Pediatrics Baylor College of Medicine, Houston, TX
Cody Branch - Medicine Preliminary University of Mississippi Medical Center, Jackson Radiology-Diagnostic University of South Carolina, Charleston, SC
Khang Dang - Orthopedic Surgery Univ. of Texas Health Science Center, San Antonio, TX
Emily Brandon - Family Medicine North Mississippi Medical Center, Tupelo John Bridges - Medicine-Pediatrics University of Mississippi Medical Center, Jackson Adams Briscoe, Jr. - Internal Medicine East Tennessee State University Johnson City, TN Kelly Brister - Surgery-General University of Mississippi Medical Center, Jackson Beth Brownlee - Pediatrics University of Mississippi Medical Center, Jackson
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Ryan Davidovich - Anesthesiology Medical College of Wisconsin Affiliated Hosp., Milwaukee, WI J.R. Davidson - Family Medicine North Mississippi Medical Center, Tupelo Will Davis - Family Medicine North Mississippi Medical Center, Tupelo Kristen Dent - Family Medicine Univ. of Tennessee College of Medicine Memphis, TN Julie Dhossche - Pediatrics-Preliminary Children’s Mercy Hospital-UMKC, Kansas City, MO Dermatology Oregon Health & Science University, Portland, OR
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Wayne Dowden - Pediatrics University of Arkansas, Little Rock, AR
Lauren Hayward - Internal Medicine University of Mississippi Medical Center, Jackson
Lauren Dowden - Medicine-Pediatrics University of Arkansas, Little Rock, AR
Carolita Heritage - Obstetrics-Gynecology Aurora Health Center, Milwaukee, WI
Joel Duff - Surgery-Preliminary University of Mississippi Medical Center, Jackson Urology University of Mississippi Medical Center, Jackson
Jay Hogg, III - Obstetrics-Gynecology Carolinas Medical Center, Charlotte, NC
Hal Flowers, IV - Medicine-Preliminary University of Virginia, Charlottesville, VA Dermatology University of Virginia, Charlottesville, VA Barrett Ford - Internal Medicine Louisiana State University - New Orleans, New Orleans, LA Phil Fortenberry, Jr. - Internal Medicine Naval Medical Center, Portsmouth, VA Brooke Furrh, IV - Psychiatry Louisiana State University - New Orleans, New Orleans, LA Lauren Gabreski - Pediatrics Wright Patterson Air Force Base Hospital, Dayton, OH Ben Gilliland - Family Medicine St. Vincent’s East, Birmingham, AL Tamara Glenn - Psychiatry University of Mississippi Medical Center, Jackson Amber Googe - Pediatrics University of Mississippi Medical Center, Jackson Brannan Griffin - Pathology Northwestern McGaw Medical Center, Chicago, IL Deani Haggerty - Pediatrics University of Mississippi Medical Center, Jackson Brooke Harris - Emergency Medicine Eastern Virginia Medical School, Norfolk, VA Danny Harris - Internal Medicine Eisenhower Army Medical Center Fort Gordon, GA Linley Harvie - Pediatrics University of Tennessee College of Medicine, Memphis, TN Emily Hawkinson - Pediatrics University of Mississippi Medical Center, Jackson
Jessica Hollingsworth - Internal Medicine Wake Forest Baptist Medical Center, Winston-Salem, NC Jeff Hooker - Radiology-Diagnostic University of Mississippi Medical Center, Jackson Tara Hughes - Surgery-General University of Mississippi Medical Center, Jackson Leland Husband, Jr. - Preliminary Surgery University of Mississippi Medical Center, Jackson Radiology-Diagnostic University of Tennessee School of Medicine, Knoxville, TN Justin Hyde - Otolaryngology University of Virginia, Charlottesville, VA Jordan Ingram - Family Medicine Forrest General Hospital, Hattiesburg Mallory Jacobs - Psychiatry University of Texas Southwestern Medical Ctr., Dallas, TX Rachel James - Transitional Year University of Tennessee College of Medicine, Memphis, TN Jorge Jiménez - Medicine Preliminary & Ophthalmology University of Mississippi Medical Center, Jackson Uchi Jira - Anesthesiology Cleveland Clinic Foundation, Cleveland, OH Anna Johnson - Orthopedic Surgery University of South Alabama, Mobile, AL Jazz Kaur - Pathology University of Mississippi Medical Center, Jackson Sarah Kerut - Internal Medicine University of Mississippi Medical Center, Jackson Jon Dray Lee - Family Medicine University of Mississippi Medical Center, Jackson
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Catherine Lowe - Internal Medicine University of Mississippi Medical Center, Jackson CC Martin, IV - Anesthesiology University of Mississippi Medical Center, Jackson Warren Masterson, III - Anesthesiology University of Mississippi Medical Center, Jackson Brad McCay - Emergency Medicine University of Illinois-St. Francis Medical Center, Peoria, IL Eric McDonald - Emergency Medicine University of Mississippi Medical Center, Jackson Heather McLemore - Emergency Medicine University of Arkansas, Little Rock, AR Jay Mefferd - Pediatrics University of Mississippi Medical Center, Jackson Teddy Millette, II - Pediatrics Medical University of South Carolina, Charleston, SC Jayce Miskel - Psychiatry University of Mississippi Medical Center, Jackson Kati Mitchell - Medicine-Pediatrics University of Mississippi Medical Center, Jackson Anna Kate Moen - Pediatrics Vanderbilt University Medical Center, Nashville, TN Lee Moore - Medicine Preliminary & Ophthalmology University of North Carolina Hospital, Chapel Hill, NC Jarrett Morgan - Medicine-Pediatrics University of Mississippi Medical Center, Jackson Hugh Muse - Internal Medicine University of Mississippi Medical Center, Jackson Brad Nesbit - Internal Medicine University of Mississippi Medical Center, Jackson Mary Oâ&#x20AC;&#x2122;Hear - Emergency Medicine University of Massachusetts Medical Center, Worcester, MA Achint Patel - Family Medicine Carolinas Medical Center-Northeast-Cabarrus, Concord, NC Nikhil Patel - Internal Medicine University of Mississippi Medical Center, Jackson
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Rupesh Patel - Medicine Preliminary University of Tennessee College of Medicine, Memphis, TN Radiology-Diagnostic Baptist Memorial Hospital, Memphis, TN Anna Pavlov - Plastic Surgery University of North Carolina Hospital, Chapel Hill, NC Lam Pham - Surgery-Preliminary University of Mississippi Medical Center, Jackson Megan Pike - Pediatrics Duke University Medical Center, Durham, NC Kelly Pippin - Internal Medicine University of Mississippi Medical Center, Jackson Zach Pippin - Internal Medicine University of Mississippi Medical Center, Jackson Stephen Powell, III - Psychiatry Medical College of Georgia, Augusta, GA Rae Quigley - Pediatrics University of Mississippi Medical Center, Jackson Kevin Randolph - Emergency Medicine University of Cincinnati Medical Center, Cincinnati, OH Allison Rogers - Internal Medicine University of Alabama - Birmingham, Birmingham, AL Mary Rosenblatt - Pathology New York Presbyterian-Columbia, New York, NY John Ross - Family Medicine East Tennessee State University, Johnson City, TN Lauren Rowe-Hobbs - Pediatrics University of Mississippi Medical Center, Jackson Charles Runyan, III - Medicine Preliminary Maricopa Medical Center, Phoenix, AR Radiology-Diagnostic Maricopa Medical Center, Phoenix, AR John Rushing - Obstetrics-Gynecology University of Mississippi Medical Center, Jackson Evan Sanford - Otolaryngology University of Texas Health Center, San Antonio, TX
Rachel Saunders - Surgery-General Grand Rapids Medical Education Partners, Grand Rapids, MI
Jay Thompson - Child Neurology University of Mississippi Medical Center, Jackson
Grant Saxton - Pediatrics Vanderbilt University Medical Center, Nashville, TN
Ann Robin Tucker - Obstetrics-Gynecology Duke University Medical Center, Durham, NC
Nicholas Schoenbachler - Obstetrics-Gynecology Wake Forest Baptist Medical Center Winston-Salem, NC
Jay Webb - Radiology-Diagnostic Aurora St. Lukeâ&#x20AC;&#x2122;s Medical Center, Milwaukee, WI
Corey Sivils - Medicine Preliminary University of Mississippi Medical Center, Jackson Radiology-Diagnostic University of Alabama - Birmingham, Birmingham, AL
Elliott Welford - Internal Medicine University of Cincinnati Medical Center, Cincinnati, OH
Andrew Smith - Neurological Surgery University of Mississippi Medical Center, Jackson
Alison Williams - Anesthesiology University of Mississippi Medical Center, Jackson Frazier Williams - Oral Maxillofacial Surgery University of Mississippi Medical Center, Jackson
Joshua Smith - Psychiatry University of Virginia, Charlottesville, VA
Paul Williams - Orthopedic Surgery University of Mississippi Medical Center, Jackson
Megan Storm - Emergency Medicine Stanford University, Stanford, CA Ashley Sullivan - Pediatrics Virginia Commonwealth Univ. Health System, Richmond, VA Sam Sullivan - Internal Medicine Virginia Commonwealth Univ. Health System, Richmond, VA Lauren Tardo - Neurology University of Texas Southwestern Medical Ctr., Dallas, TX
Diantha Williamson - Family Medicine Utah Healthcare Institute, Salt Lake City, UT Lucas Wilson - Pediatrics University of Virginia, Charlottesville, VA Marianne Wilson - Internal Medicine University of Virginia, Charlottesville, VA
Diana Tate - Pediatrics University of Mississippi Medical Center, Jackson
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Carey Medical College Graduates Second Class
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he second class of the William Carey University College of Osteopathic Medicine, the second medical school in the state of Mississippi and the first school of osteopathic medicine, graduated during commencement exercises in Smith Auditorium on the Hattiesburg campus on May 23. Ninety-one new doctors of osteopathic medicine, more commonly known as DOs, received their degrees during commencement. The keynote speaker was Dr. William G. Anderson, a past president of the American Osteopathic Association. During his address, Dr. Anderson called the new doctors “the future of osteopathic medicine” and encouraged them to always be mindful of making not only right decisions but also ethical decisions.
Carey’s newest class of DOs will now move into multi-year residency programs across the United States in areas as far away as New York and California and in institutions such as the Mayo Clinic in Minnesota. The class had a 98 percent residency match, which is above the national average for medical schools. The new DOs will join a growing workforce of more than 88,000 DOs in the United States, a number that has more than doubled since 2000.
Pictured at the May 23 commencement exercises for the second graduating class of the William Carey University College of Osteopathic Medicine are (left to right) Dr. James Turner, dean of the medical college; Dr. Tommy King, president of the university; Dr. William G. Anderson, commencement speaker and a past president of the American Osteopathic Association; and Dr. Richard Calderone, a 2014 medical college graduate and president of the medical college’s alumni association. During commencement, 91 students graduated with the Doctor of Osteopathic Medicine, or DO, degree.
Dr. Alexis Cates (left) of Mandeville, La., a new graduate of the William Carey University College of Osteopathic Medicine, received the President’s Award from Carey President Dr. Tommy King during an awards banquet recognizing the 91 new graduates of the medical college at Southern Oaks House and Gardens in Hattiesburg on May 22. The President’s Award is given to a graduating student demonstrating the merits of an outstanding DO in scholarship, leadership and integrity.
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Prior to commencement, the new DOs were honored at a reception sponsored by Trustmark Bank and at an awards banquet at Southern Oaks House and Gardens in Hattiesburg on May 22. During the dinner, awards were presented for academic excellence and leadership. Graduating students honored with Outstanding Achievement Awards included Megan Dodge of Harahan, La., for osteopathic principles and practice; Jonathan Chan of Spring, Texas, for clinical sciences; and Nandini Mehta of Harrison, Ohio, for pre-clinical sciences.
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Nicholas Swindle of Katy, Texas, received the Physiology Award. Jamie Bishop of Prattville, Ala., received the Mississippi Osteopathic Medical Association Graduating Student Award. Justin Lay of Brandon received the Dean’s Award, which is given to a graduating student for outstanding accomplishments in service, leadership and dedication to the medical college. Alexis Cates of Mandeville, La., received the President’s Award, which is given to a graduating student demonstrating the merits of an outstanding DO in scholarship, leadership and integrity. The Donna Jones Moritsugu Memorial Award was presented to Elizabeth Walley, wife of new medical graduate Robert Walley, by the medical college’s Student Advocate Association. The award is given to the partner of a graduating osteopathic medical student who shows strong support not only to their partner but also to the osteopathic profession. Dr. Henry Pace of Oxford, a pioneer of osteopathic medicine in Mississippi, was recognized by the Carey medical college and also by the state osteopathic medical association with a Lifetime Achievement Award for his dedication to the profession. Additionally, Dr. Paul Chastain, an assistant professor of biomedical sciences, was recognized with the medical college’s Researcher of the Year Award. Dr. Chastain was also awarded the university-wide Faculty Research Award in April for his work with multiple National Institutes of Health and Patient-Centered Outcomes Research Institute grants.
Dr. Justin Lay (left) of Brandon, a new graduate of the William Carey University College of Osteopathic Medicine, received the Dean’s Award from Dr. James Turner, dean of the medical college, during an awards banquet recognizing the college’s 91 new graduates at Southern Oaks House and Gardens in Hattiesburg on May 22. The Dean’s Award is given to a graduating student for outstanding accomplishments in service, leadership and dedication to the medical college.
The Carey medical college was established in 2010 to address the severe shortage of physicians in Mississippi and surrounding states and to impact the health care of rural Mississippians. The inaugural class of 94 students graduated in May 2014.
The William Carey University College of Osteopathic Medicine and the Mississippi Osteopathic Medical Association presented a Lifetime Achievement Award to Dr. Henry Pace of Oxford, a pioneer of osteopathic medicine in Mississippi, during an awards banquet recognizing the 91 new graduates of the medical college at Southern Oaks House and Gardens in Hattiesburg on May 22. Pictured at the banquet are (left to right) Dr. James Turner, dean of the medical college; Dr. Pace; and Dr. Ed Williams, executive director of the State Osteopathic Medical Association.
Dr. Italo Subbarao (center), an associate dean and associate professor at the William Carey University College of Osteopathic Medicine, and Carey medical students Guy Paul Cooper Jr. and Violet Yeager recently published a four-part series of articles about the effectiveness of social network Twitter as a communications tool in crisis situations. The articles, entitled “Twitter as a Potential Disaster Risk Reduction Tool,” were originally published in June in PLOS Currents: Disasters, a peer-reviewed scientific journal, and have since been shared widely on social media, in other publications and by governmental agencies, including the United Nations. The articles are available to the public for free at: http://currents. plos.org/disasters/article_tag/twitter/. Ms. Yeager a fourthyear Carey medical student from New Orleans, is a recent graduate of MSMA’s Physician Leadership Academy.
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William Carey College School of Osteopathic Medicine 2015 Match Results Syed Ahmed - Internal Medicine Bay Area-Corpus Christi Med Ctr., Corpus Christi, TX
Alexis Cates - Emergency Medicine Albert Einstein Med Center, Philadelphia, PA
Mohammed Ali - Traditional Rotating Internship St. Johnâ&#x20AC;&#x2122;s Episcopal Hospital, Far Rockaway, NY
Jonathan Chan - Traditional Rotating Internship Larkin Community Hospital South, Miami, FL
Amanda Allen - Traditional Rotating Internship Riverside Methodist-OH, Columbus, OH
Jason Charrier - Internal Medicine University Hospital & Clinics-LA, Lafayette, LA
Osman Amin - Family Medicine Arnot Ogden Medical Center, Elmira, NY
Elizabeth Clair - Emergency Medicine University of Mississippi Medical Center, Jackson
Brent Arnold - Emergency Medicine Adena Health System, Chillicothe, OH
Audra Cole - Obstetrics / Gynecology Osteopathis Medical Education Consortium of Oklahoma, Inc, Tulsa, OK
Asha Ayyagari - Internal Medicine Plaza Medical Center, Forth Worth, TX Nabil Baddour - Internal Medicine Tulane University SOM-LA, New Orleans, LA Jason Bavarian - Emergency Medicine Botsford Hospital, Farmington Hills, MI Jamie Bishop - Family Medicine Cahaba Medical Care-AL, Centreville, AL Heather Borchert - Internal Medicine / Pediatrics AR UAMS-Little Rock, Little Rock, AK Justin Broadhead - Traditional Rotating Internship University of South Alabama Hospitals, Mobile, AL Megan Burns - Emergency Medicine Memorial Hospital, York, PA Charlie Busby - Family Medicine University of Tennessee COM-Memphis, Memphis, TN Kristin Campbell - Traditional Rotating Internship Peconic Bay Medical Center, Riverhead, NY Matthew Capalbo - Traditional Rotating Internship Clarion, PA Meagan Carney - Family Medicine Forrest General Hospital, Hattiesburg, MS Shannon Carroll - Family Medicine Nassau University Medical Center, East Meadow, NY
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Robert Dillard III - General Surgery Plaza Medical Center, Forth Worth, TX Chad Dowell - Family Medicine Mayo School of Grad Med Eluc-MN, Rochester, MN Kelsey Dowell - Family Medicine Mayo School of Grad Med Eluc-MN, Rochester, MN John Elliott - Internal Medicine Baptist Health Systems-AL, Birmingham, AL Sarah Epps - Obstetrics / Gynecology Osteopathis Medical Education Consortium of Oklahoma, Inc, Tulsa, OK Jason Eversole - Family Medicine Texoma Medical Center, Denison, TX Stephen Fletcher - Internal Medicine University of Mississippi Medical Center, Jackson Jonathan Flowers - Family Medicine University of Mississippi Medical Center, Jackson James Fussell - Internal Medicine University of South Alabama Hospitals, Mobile, AL Greta Seiriol Gania - Family Medicine Floyd Medical Center, Rome, GA Robert Greer - Internal Medicine University of Mississippi Medical Center, Jackson
R E L A T E D
O R G A N I Z A T I O N S
Daniel Griffin - Internal Medicine Magnolia Regional Health Center, Corinth, MS
Justin Lay - Pediatrics University of Mississippi Medical Center, Jackson
Mary Griffin - Internal Medicine Magnolia Regional Health Center, Corinth, MS
Donald Lemieux - Internal Medicine University of South Alabama Hospitals, Mobile, AL
Martin Hardy - General Surgery St. Mary’s Hospital of Blue Springs, Blue Springs, MO
Brett Lile - Physical Medicine / Rehabilitation University of Arkansas-Little Rock, Little Rock, AK
Hunter Harrison - Family Medicine Plaza Medical Center, Forth Worth, TX
Whitney Lynch - Family Medicine East Central Health Net Reg Rural, Decatur, MS
Amy Harsh - Internal Medicine University of Texas HSC-Tyler, Tyler, TX
Navin Mangroo - Family Medicine UAMS-Regional Programs-AR, Jonesboro, AR
Ashlee Hendry - Family Medicine University of TN COM, St. Frances, Memphis, TN
Jodie McDonald - Traditional Rotating Internship Manatee Memorial Hospital, Bradenton, FL
George Hinnant - Internal Medicine Northside Hospital and Heart Institute, St. Petersburg, FL
Matthew Meece - Family Medicine University of Mississippi Medical Center, Jackson
Christopher Hinson - Internal Medicine University of Mississippi Medical Center, Jackson
Nandini Mehta - Internal Medicine North Shore-LIJ Health Sys-NY, New York, NY
Sandi Holden - Family Medicine Arnot Ogden Medical Center, Elmira, NY
David Metzger - Family Medicine Baylor Med Ctr-Garland-TX, Garland, MS
Jason Hollis - Family Medicine ETSU/QUILLEN College of Medicine, Johnson City, TN
Joel Moore - Family Medicine North Mississippi Medical Center, Tupelo, MS
Christopher Huckle - Family Medicine Houston Healthcare, Warner Robins, GA
Andrew O’Kelley - Family Medicine UAMS-Regional Programs AR, Texarkana, AR
Sarah Hudgins - Emergency Medicine St. Luke’s University Hospital, Bethlehem, PA
Caitlin Prickett - Internal Medicine University of South Alabama Hospitals, Mobile, AL
Alexander Jones - Family Medicine Lewis Gale Hospital -Montgomery’s Family Medicine Residency, Blacksburg, VA
Matthew Prudhomme - Internal Medicine University Hospital & Clinics-LA, Lafayette, LA
Carl Juers - Traditional Rotating Internship Buffalo, NY Grady Kaiser - Family Medicine STILL OPTI/Wright Center for GME, Washington, D.C. Jennifer Kennard - Internal Medicine University of Mississippi Medical Center, Jackson Whitney King - Internal Medicine Wellington
Judd Reynolds - Family Medicine Forrest General Hospital, Hattiesburg, MS Christopher Richard - Family Medicine North Mississippi Medical Center, Tupelo, MS Matthew Roberts - Family Medicine East Central Health Net Reg Rural, Decatur, MS Janee’ Routh - Family Medicine EC HealthNet Meridian, MS (Pending Pass CE)
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W I L L I A M C O L L E G E O F
C A R E Y U N I V E R S I T Y O S T E O P A T H I C M E D I C I N E
Stewart Rowell - Family Medicine UAMS-Regional Programs-AR, Pine Bluff, AR
Stephen Wilkerson - Family Medicine North Mississippi Medical Center, Tupelo, MS
John Scott - Internal Medicine U Alabama Med Ctr-Montgomery, Montgomery AL Christa Sikes - Family Medicine Spartanburg Regional Health System, Spartanburg, SC Aviral Singh - Internal Medicine University of Texas HSC-Tyler, Tyler, TX Matthew Snead - Internal Medicine Southeastern Health, Lumberton, NC Joshua Stake - Family Medicine McLennan County Fam Med-TX Jordan Steele - Family Medicine North Mississippi Medical Center, Tupelo, MS Nicholas Swindle - Internal / Emergency Medicine Aria Health, Philadelphia, PA
We specialize in the business of healthcare
Tyler Tait - Family Medicine LECOMT/St. John’s Episcopal Hospital Program, Far Rockaway, NY Tarah Talakoub - Internal Medicine Plaza Medical Center, Forth Worth, TX Terri Teague-Ross - Traditional Rotating Internship St. John’s Episcopal Hospital, Far Rockaway, NY Brian Tessaro - Emergency Medicine Marietta Memorial Hospital, Marietta, OH
• • • • • • • •
Comprehensive Management Comprehensive Consulting Billing & Accounts Receivable Management Coding & Documentation Practice Assessments & Revenue Enhancement Profitability Improvement Practice Start-ups Personnel Management
Dena Thompson - Internal Medicine Southeastern Health, Lumberton, NC Erin Wagner - Family Medicine CMC-Northest Med Ctr/Cabarrus-NC, Concord, NC Robert Walley - Internal Medicine Largo Medical Center, Largo, FL Amanda Watlington - Emergency Medicine Marietta Memorial Hospital, Marietta, OH
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1600 North State Street Suite 400 Jackson, MS 39202 Telephone: 601.944.1717 WATS: 1.800.355.4231 www.mpsbilling.com
I M A G E S
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M I S S I S S I P P I
M E D I C I N E
Gulfport Veterans’ Hospital 1935-8 LUCIUS M. “LUKE” LAMPTON, MD • JMSMA EDITOR
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wo More Images of Veterans’ Hospital, Gulfport, 1935-8—Follow up to the May JMSMA Images of the Gulfport Veterans’ Hospital in 1924, these two images present different views of the same hospital from a little later, the 1930s. The top image is of the Chief Medical Officer’s quarters from the mid-1930s. The bottom image shows the entrance to the hospital in 1938, much changed from the 1924 image. The core of this hospital would be built between 1923-1946 and is located at 200 E. Beach Blvd in Gulfport and listed on the National Register of Historic Places. The historic campus sustained extensive damage from Hurricane Katrina’s storm surge in 2005, which resulted in its closing and transfer of services to the Biloxi VA system and the property to the city of Gulfport. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@ cableone.net or by snail mail to the Journal.
CURRENTLY THE PROPERTY IS PART OF GULFPORT VETERANS ADMINISTRATION MEDICAL CENTER HISTORIC DISTRICT, ALSO KNOWN AS “CENTENNIAL PLAZA.”
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SPOTLIGHT ON:
Physician Leadership Academy By Kara Kimbrough
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Last installment of the series of features on the participants in MSMA’s first Physician Leadership Academy.
Photos and diplomas of the three generations of family physicians, including his father and grandfather, line the walls of Dr. Joe Austin’s medical clinic, Vicksburg Women’s Care.
Third-generation physician Joe Austin, MD, finds satisfaction in carrying on the family trade When deciding on a career, Joe Austin, MD, didn’t have to look any further than his own family tree. His father, William Darrell Austin, MD, was a successful otolaryngologist in Greenville. His paternal grandfather, William Taylor Austin, MD, had taken care of patients as a Tennessee family medicine physician. Knowing his family history, an eighth grade teacher set him firmly down the same path. “I had grown up going on house calls with my dad, driving around town in a car with no air-conditioning and seeing firsthand the dedication it took to be a physician,”
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said Dr. Austin, a Vicksburg obstetrician-gynecologist. “But neither my dad nor grandfather pushed me toward their career. My path was firmly set when my teacher sat me down and said, ‘If you’re going to be like your Dad, you’ve got to start planning and get all the science courses you can.’ From then on, I never looked back.” After high school, Dr. Austin enrolled at Millsaps College, graduating with a bachelor’s degree in biology. A seamless transition into medical school at UMMC provided the knowledge he had made the right decision but not necessarily the easiest. “The course work was difficult and it was a challenging experience,” he recalls. “I did enjoy the camaraderie with
classmates and others with whom I have maintained friendships. Beyond that, I was ready at the end of four years to complete the journey and begin my medical career.” During his surgery rotation, he developed a keen interest in gynecologic oncology surgery. Seeing near-immediate results, including patient feedback regarding less pain and discomfort following a procedure made him seriously consider obtaining additional training. “I really liked the fact that surgeons were able to pinpoint the source of the problem, take care of it and move on to the next patient,” said Dr. Austin. “The interest was there from the beginning of my rotation and it seemed apparent to me this was a career in which I would be able to make a difference in patients’ lives.” The last week of May 1991 was a busy one for Dr. Austin. He married his wife Stephanie on May 25, then graduated from medical school the following day. The new couple packed up and moved to Dallas to complete residency and internship at Parkland Hospital. His path seemed set until calls from “back home” began flooding in. “I began getting calls from people and hospitals in Mississippi saying, ‘Please come home. We need ob-gyns here,’” said Dr. Austin. “After a while, the temptation to move back to our home state and begin practicing a little sooner was too much to overcome. I sometimes wonder ‘what if?’ I’d gone on with my original plan, but overall I made the right decision.” In August, Dr. Austin will celebrate the 20-year anniversary of the opening of his clinic, Vicksburg Women’s Care. After delivering thousands of babies, performing innovative robotic surgery techniques and caring for women of all ages, he’s excited to be at the mid-point of his career. At this important milestone, Austin is reflective of the changes that have impacted his field. Unlike many physicians who work as solo practitioners for years before becoming employed by large healthcare organizations, Dr. Austin is enjoying being his own boss after hospital employment. “I do not look back on my years of employment as a bad experience, but I prefer owning my own clinic and making my own decisions,” he said. “I can manage my operations and change direction as I think best. There’s no bureaucracy or red tape. I simply make a decision and it is implemented very quickly.” Applying to MSMA’s Physician Leadership Academy was another business decision Dr. Austin was quick to make. It’s one of the best things he’s done for his career in recent years, he says.
“I always felt like I was someone who had ideas, but I never felt like I could express them in a way that would make them acceptable to others,” he explained. “Especially after being elected to MSMA’s Board of Trustees, I felt it was very important that I possess the skills to communicate in a professional manner. The leadership academy has helped me improve my negotiating and presentation skills. I’m very happy with the results I’ve achieved.” Dr. Austin and his wife have two children: daughter Morgan, 21, and son Paxton, 19, both students at Mississippi State University. The family enjoys participating in outdoor activities, including fishing and hunting.
Childhood dream of becoming a doctor became reality for Barbara Saunders, DO It’s rare to find a physician who actually proclaimed her calling “to help people” before she could string sentences together. Barbara Saunders, DO, is living proof those stories actually have merit. “My mother always told me that I was born a grownup,” said Dr. Saunders, a developmental-behavioral pediatrician on the faculty at the University of Mississippi Medical Center. She is also an assistant professor of pediatrics and the director of resident and medical student education for the Division of Child Development. “Starting as early as two, she claims I said I wanted to be doctor when I grew up,” said Dr. Saunders, a native of Alabama. “So I suppose I was born with the desire to become a physician and it’s gratifying that I was able to live out my dream.” Receiving an excellent secondary and prep school education at Montgomery schools was an important first step in reaching her goals, Dr. Saunders believes. Math and science courses along with a little Latin for good measure gave her a good foundation for even more rigorous course work as a biology major at University of Mobile. After college, she headed to Oklahoma, where she earned her D.O. at the Oklahoma State University College of Osteopathic Medicine in 2007. She then completed an internship in pediatrics and a pediatrics residency, both at the Oklahoma State University College of Osteopathic
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Medicine/Oklahoma State University Medical Center. From 2010-2013, she was a developmental-behavioral pediatrics fellow at the University of Arkansas for Medical Sciences, where she also earned a graduate certificate in Clinical and Translational Science in May 2013 “I always said I would never choose pediatrics as a specialty, but that’s exactly what I decided to do,” said Dr. Saunders. “Now, I love it and can’t imagine being in any other field.” Raising a son, now 11, with developmental delays has proven to be instrumental in her professional life as she seeks to improve the lives of children. She finds her medical career and chosen specialty “immensely rewarding,” she says. “We have our niche and that’s making sure everything we do is geared to help children, whether it be through treatment of the mind or body,” said Dr. Saunders. “I try to look at everything as interconnected and my experiences in caring for my son have definitely made me a better physician for children and communicator with other parents.” Moving to Mississippi after several years of living in adjacent states has been fortuitous for the entire family, which in addition to her son includes her husband and eight-year-old daughter. “Mississippi has great schools and churches and joining UMMC has been a great career move for me,” she said. “The entire family considers this home and has settled in nicely.” In her specialty, serving as a strong leader of the care team is vitally important Learning to improve her leadership skills was one of the main reasons she applied to MSMA’s Physician Leadership Academy. She was very pleased with the outcome, Dr. Saunders said. “I feel I’m well on my way to becoming a more effective leader,” she said. “Another great side benefit was the chance to meet other physicians from around the state, both specialty-wise and geographically. I also enjoyed our day at the State Capitol and having the opportunity to meet legislators. Overall, it was a great experience; one I’d recommend to another physician seeking to improve any aspect of his or her practice.”
Accident led John Cross, MD to the medical field Adding “car accident victim” to one’s life story is never a good thing, but in the case of John Cross, MD, it’s an event that caused him to consider a medical career. “When I was fourteen, I was in a car accident and received what could have been serious, 218
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but turned out to be non-life-threatening injuries,” said Dr. Cross, an internist at University Physicians Grants Ferry location in Flowood, “Dr. Donald Faucett, a local ophthalmologist, stitched my eyelid in the middle of the night in the emergency room. After that experience, I realized that doctors can really make an impact in the lives of others. From then on, I set the goal of making it my life’s work.” If the accident hadn’t occurred, there’s no guarantee he would have entered the medical field, Dr. Cross feels. As a student at Northwest Rankin schools, he did well in math and science courses but had no family members in the medical profession. His mother was a teacher, and his father was a pilot in the Mississippi National Guard and worked in state government. He is grateful for parents who challenged him to set high goals and encouraged his interests every step of the way. “My dad was always leading and encouraging me,” said Dr. Cross. “He is a great leader that led by example with compassion, hard work, and a great sense of humor. He has always been my role model. My older brother is a fireman and community servant who also looked out for me along the way.” Following a successful high school career, he attended Mississippi State University and completed a degree in biological engineering. He enjoyed his years at MSU, learning valuable educational lessons in the School of Engineering classroom, along with service and leadership lessons in campus organizations. “Campus organizations taught me the importance and value of serving others,” said Dr. Cross. “I was blessed with a mentor, Dr. Jimmy Abraham, who reinforced the values of self-discipline, hard work and humility that my parents taught me. I also learned valuable lessons in service and leadership in the Kappa Sigma Fraternity.” Just as he’d planned since that night in the ER, University of Mississippi School of Medicine was the logical next step. He found medical school “challenging,” but just as MSU had provided a well-rounded experience, the next step of the journey had the same effect. “During those four years, I was required to find my own personal balance as a young husband, student and professional,” said Dr. Cross. “Despite the challenges, I did enjoy some aspects, including developing relationships with my medical school classmates. Many of them became my closest friends.” Close to the end of medical school, Dr. Cross settled on internal medicine as his specialty. Although surgery was exciting initially, he found himself drawn to the long term relationships and chronic management of complex conditions that internal medicine provided. He completed a residency in internal medicine at UMMC and has never regretted the decision. “I could collect all the information, solve the puzzle, and make a plan,” he explains of his decision to choose internal
medicine as a career. “Then I could see how the plan unfolded within a couple of weeks or several years down the road. I could follow someone for years and build a relationship with them.” Besides utilizing his medical training and skills, Dr. Cross feels he is called to be much more than a medical caregiver. “Sometimes in the practice of medicine, doctors cannot find the problem,” he said. “Diseases like dementia and cancer are unfortunately all too common. Sometimes the patient needs emotional and spiritual support to be encouraged through the treatment. Sometimes the family or caregiver just needs encouragement or someone to listen to the struggles. I consider this an important part of what I do.” Another enjoyable aspect of his field is the ability to form relationships with patients. “Internal medicine and primary care allow me to really know my patients,” he said. “As I was taught in medical school, many times the patient will tell you the diagnosis if you just listen to the symptoms.” Reflecting on the lessons he learned as a member of MSMA’s Physician Leadership Academy, Dr. Cross listed a number of benefits. “Physicians are respected members of the community,” he said. “People value your opinion. Physicians are patient advocates, small business owners, and taxpayers. I enjoyed the lessons on leadership, negotiations and communication. Those lessons can be used in many different parts of life.” Dr. Cross and his wife Catherine have three children: Thomas, 9, Caroline 7, and Andrew, 4. He serves as volunteer physician at Mission First Clinic in Jackson and has enjoyed taking his children with him to expose them to community service. He is a member and deacon at Pinelake Church in Brandon and enjoys coaching and volunteering with youth sports and other community activities.
Different career paths, support of family led Carlos Latorre, MD to medicine It’s not uncommon for a physician to enter medical school later in life as a non-traditional student or to work in an ancillary field prior to practicing medicine. However, it’s rare to find one whose CV reads, “10 years as a research geologist.” Carlos Latorre, MD admits it’s a bit unusual. Even with a strong family background of medical professionals, he chose another path before giving in to his destiny. “I have always liked medicine but I had other interests,” said Dr. Latorre, a family medicine physician in Vicksburg. “After high school in Arecibo, Puerto Rico,
Dr. Latorre is pictured with his wife Nalina and daughter Alana after receiving the James Waites Leadership Award at 2014 Annual Session’s Excellence in Medicine awards program.
I decided to pursue those other interests at the University of Southern Mississippi as a geology student. However, medicine has always been a big part of my life. My father, Adolfo Latorre, MD, was a primary care physician and my mother was a social worker. Later my brother Hector became an emergency room physician and my sister Maria a medical technologist.” In the summer of his junior year at Southern Miss he was selected to participate in a summer research project at the U.S. Army Corps of Engineers Research and Development Center in Vicksburg. The summer research job turned into a contract student job for the fall semester and the beginning of his life in Vicksburg. It would prove to be a pivotal turning point in many ways. “After completing my undergraduate degree in 1992 I relocated to Vicksburg to work as a research geologist,” said Dr. LaTorre. “In 1994, I met my wife Nalini, also a research geologist, at work and we eventually got married.” The couple enjoyed Vicksburg life, both continuing to work while Dr. Latorre obtained a master’s degree in geology from Southern Miss. Just before completing the degree, a long-buried desire to become a physician began to surface. He’s grateful that his wife and co-workers supported the new plan at this stage of his career and life. JULY 2015 • JOURNAL MSMA
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“Once I had my wife’s blessing, I contacted my parents, brothers and sister to tell them what I was planning on doing and they were extremely supportive,” said Dr. Latorre. “It was like the prodigal son was finally coming back home. “ Looking back, Dr. Latorre realizes the interest and desire to become a physician was always there. However, he was not emotionally prepared to embark on the journey until his late 20’s. After several years of additional education to complete prerequisites, he was admitted to his father’s alma mater, University of Puerto Rico School of Medicine. He chose to return to his home country because of the strong academic program and to be near family during the years ahead. Despite initial misgivings upon realizing the majority of students were “at least 10 years younger than me,” and boy, it is going to be a rough four years,” Dr. Latorre recalls of the first day of medical school in 2002, he now counts them as some of the best years of his life. “Even with 3-4 hours of sleep per day the first two years, I would not change those experiences for anything,” he said. “The bonds you create with your classmates are incredible and long-lasting. I always felt that our faculty was very invested in us and wanted us to succeed.” Bearing out his belief that “all good things come in pairs,” his wife became pregnant with their daughter Alana at the beginning of his first semester of medical school. He credits his wife and family for holding everything together after his daughter was born during his second semester while he got acclimated to medical school. He experienced terrible personal losses during his final years, including the passing of several close family members and the devastating loss of Briana, the couple’s second daughter. Looking back, he feels channeling the strength and determination needed to deal with the tragedies while juggling medical school shaped him into the physician he is today. “Through adversity, I have learned to be a stronger, more patient, empathic, compassionate, and understanding person,” said Dr. Latorre. “I believe those experiences have made me a better son, father, husband, brother, friend and person which in turn has influenced the type of physician I am.” Dr. Latorre entered medical school knowing he wanted to become a primary care physician but wasn’t sure
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if internal medicine, pediatrics or family medicine would be his specialty. As he progressed through medical school, he realized his heart and interests aligned with family medicine. “I spent four weeks in a small primary hospital in Castañer Puerto Rico during my third year family medicine rotation,” he said. “The hospital is located in an underserved mountainous area and provides services to rural sections of three neighboring towns. This rotation challenged my clinical reasoning and skills and exposed me to the role of educator and to the practice of preventive medicine.” Dr. Latorre and his wife still considered Mississippi “home,” so returning to their adopted state was always a goal. He contacted UMMC officials and requested a fourth year rotation to learn more about the program. After one week in UMMC-Family Medicine, he knew “this was the place for me,” he remembers. “I am very thankful I matched at UMMC for residency,” he said. “In addition to an excellent academic program I had the opportunity to participate in multiple committees and professional organizations. With the support of numerous mentors at UMMC, MAFP, MSMA and of course, my family, thus began my involvement in organized medicine and medical education.” Dr. Latorre calls his participation in the MSMA Leadership Academy “a wonderful experience.” “I am a lot more confident and feel more effective when discussing medical issues now than I was a year ago,” he said. “My classmates were excellent and their participation made the courses even better. Just like medical schools turn students into doctors, the leadership academy turns physicians into leaders.”
Legacy of respected small town physicians proved inspirational for Chris Schwartz, MD Growing up in the small Alabama town of Citronelle, Chris Schwartz, MD was exposed to caring family physicians. As youngsters often do, he took notice of the fact that the medical professionals were held in the highest esteem by everyone in town. That was reason enough for him to decide, “I want to grow up and become like them.” “That childhood memory was really all the justification I had when I graduated from college and was
“Then on Friday night if we had a break, we were free to go to CS’s and enjoy our time off together.” During a third-year family medicine rotation at Centreville’s Field Memorial Hospital, Dr. Schwartz was exposed to the practice of family medicine and knew he’d found his specialty. “I was fortunate to have been exposed to committed and caring family physicians and soon realized I’d found my calling,” he said. “From that time on I’ve known I am where I’m supposed to be and doing what I need to be doing.” Following medical school, the couple returned to his home state, where he completed a residency in family medicine. After a brief stint in private practice in McComb, they moved to Jackson. He worked for MEA for 10 years before being asked to return to his alma mater. “I was friends with Dr. Virginia Crawford, director of Southern Miss’ Student Health Services and was asked by her to come down and serve as assistant director,” said Dr. Schwartz. “She’s brilliant and personable and I was hoping some of that could rub off on Chris Schwartz, MD, left, is pictured with his wife Robin, also me. I stayed in this position for eight years and really an MD, at the December 2014 South Mississippi Medical enjoyed my time there.” Society meeting held at their alma mater, Southern Miss. Two years ago Dr. Schwartz made the move to the considering the next step,” said Dr. Schwartz, a family Laurel clinic. He’s enjoying the variety of seeing pamedicine physician at South Central Urgent Care and tients as young as six months up to octogenarians. Industrial Medicine in Laurel. “Perhaps the best reason The clinic serves a vital role by allowing patients to was that I was getting married to my wife Robin right be treated for illnesses and injuries in a clinic setting after graduation and her goal was to enter medical rather than the hospital emergency room. school. We shared the same goals and dreams so it was “This morning, I’ve sutured someone’s head, reonly natural that we would become physicians togeth- moved a foreign body from another person’s eye and er.” treated another for pneumonia,” he said. “I never know After high school, Dr. Schwartz had followed his what’s going to come through the door and that’s one father to the University of Southern Mississippi. of the most enjoyable aspects for me.” After meeting Robin there his freshman year, the two Just as he entered medical school with his wife, Dr. aligned their biology and chemistry classes as much Schwartz joined her in MSMA’s Physician Leadership as possible. It was a close partnership that continued Academy. He is more than satisfied with the lessons following graduation and marriage and into their four and skills provided during the year-long sessions. years together at University of Mississippi School of “If we’re expected to be the leaders and coordinators Medicine. of the healthcare team – and I do see that increasingly “I really enjoyed all four years of medical school,” becoming true - we need to possess advanced leaderrecalls Dr. Schwartz. “It was a lot of work, but sharing ship skills,” he said. “I feel my communication, conflict the experience with my classmates, especially my wife, resolution, listening, and teamwork skills have been was a very enjoyable part of it.” strengthened as a result of the leadership academy. I Looking back, Dr. Schwartz feels he had an easiwould recommend it to anyone who’s serious about er experience of being married to another medical their role as a healthcare team leader.” student than some of his classmates whose spouses weren’t sharing the same experience. To learn more about becoming a member of the next “It worked out great for us because we had the same Physician Leadership Academy class, contact classes, schedules and study requirements,” he said. Phyllis Williams at 601-853-6733.
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REFORM Thousands of Mississippi physicians have saved millions in liability premiums since 2002. Most are now paying the rates of 1996. SPECIALTY SOCIETY MANAGEMENT MSMA offers management services to a growing number of state specialty societies. Services include administration, management of membership databases, dues billing, communications and event planning. ADVOCACY MSMA boasts one of the strongest lobbying teams at the Capitol. As a concerted voice for Mississippi physicians, MSMA supports legislation to protect your practice and defeat legislation such as scope of practice and attacks on tort reform. MMPAC The Mississippi Medical Political Action Committee creates relationships with elected officials, making MSMA the voice of physicians at the Capitol and in Washington. OFFICE OF PHYSICIAN WORKFORCE This important office studies the physician population in the state by reviewing geographic disparities as well as specialty disparities.
MSMA Member Benefits: At a Glance Mississippi State Medical Association is proud to be the state’s oldest and largest physician association. We are committed to serving our physician members by offering continuing education opportunities, practice management tools and legislative advocacy. For over 150 years, MSMA has endeavored to serve as an advocate for members, patients and the public health. The association promotes ethical, educational, and clinical standards for the medical profession and the enactment of just medical laws.
LIVE CME EVENTS CME conferences designed for and by medical professionals feature the latest advances in healthcare and networking opportunities. ONLINE CME Online CME allows physicians to obtain CME credits when it is convenient for them, at an affordable cost. RURAL PHYSICIANS SCHOLARSHIP PROGRAM Since implementation of this vital program in 2007, 102 rural physician scholars are in the pipeline and are either practicing, or will soon be practicing in small towns across Mississippi. LEADERSHIP DEVELOPMENT The MSMA Physician Leadership Academy recently completed its first year with 12 scholars soon to be named “Doctors of Distinction.” The program combines mentoring, organizational education, and skills training to prepare MSMA members for future leadership positions. PHYSICIANS’ POSITION Delivered straight to your email inbox each week, Physicians’ Position offers a recap of trending national healthcare news, state medical headlines and the latest development opportunities for members. JOURNAL MSMA Each month, MSMA publishes a scientific Journal, containing submissions from MSMA members. The JMSMA serves as the voice, the face, and the spirit of medicine in Mississippi. It is free to members, an $83 benefit. iPASS SUMMIT The “Insurance Payment Advocacy Solutions Summit” for clinic staff offers information on billing, insurance and claims issues. CAP COMMITTEE The Claims Advocacy for Physicians (CAP) Committee assists MSMA members in resolving claims issues of common concern with insurance companies, HMOs, Medicare, Medicaid, or other third party payers. JOB BANK Members are offered a free, convenient way to post medical job openings and search for employment opportunities. PRACTICE STRATEGIES Answers to regulatory and legal issues, reimbursement, coding/billing and documentation can be overwhelming and time consuming for physicians and their staff. MSMA has a team of experts to assist you in these and many other areas related to your practice. DOCBOOKMD This free, HIPAA-compliant app allows members to share patient files and contains many other benefits.
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MSMA ANNUAL REPORT 2015
Mississippi State Medical Association • 408 West Parkway Place • Ridgeland, MS, 39157 • 601-853-6733 • MSMAonline.com
Each Mississippi physician generates more than 9 jobs.
Office-based physicians in Mississippi generated:
$222 million
in local/state tax revenue and nearly
$4 billion in wages/benefits to
22,737 employees That’s $733,725 average payroll and 9+ jobs per doctor.
Results from a recent study demonstrate the economic impact that physicians generate for Mississippi’s economy. The study clearly shows that creating an environment which attracts new and retains existing physicians to meet expanding healthcare demands has the added benefit of increasing the number of good jobs in Mississippi and improving the health of the local economy. IMS Health conducted the study for MSMA/AMA.
Physicians Mean Business
Physicians create jobs everywhere they go. MISSISSIPPI
NATIONAL
4,917
720,421
Direct Jobs Supported by Mississippi Physicians
22,737
3,336,077
Indirect Jobs Supported by Physician Industry
22,730
6,632,265
45,467
9,968,342
9.3
13.8
TOTAL PATIENT CARE PHYSICIANS JOBS
Mississippi Jobs Supported by Physician Industry
TOTAL
Average Number Jobs Supported by Each Physician SALES REVENUE Sales Revenue Generated by Physician Industry
$6.1 Billion
$1.6 Trillion
WAGES& BENEFITS Total Wages & Benefits Supported by Physician Industry
$3.6 Billion $775.5 Billion
LOCAL & STATE TAX REVENUE Total Local & State Tax Revenue Generated by Physicians $221.6 Million $65.2 Billion Source: The State Level Economic Impact of Physicians Report (IMS Health, March 2014).
FINALLY! After 17 annual patches the 2015 Congress repealed the flawed SGR formula creating a path for new payment models.
HEALTH MATTERS. Legislation effecting health matters. The 2015 Mississippi Legislature passed several important laws to improve the health of citizens and improve access to health care. Texting while Driving Ban: The new law that bans texting while driving was pushed by MSMA and Mississippi pediatricians. This will save lives, reduce accidents and protect everyone on the road. Immunizations: Mississippi is still number one in the nation for getting students vaccinated before they start kindergarten. Legislation sought to create a philosophical exemption so parents could opt out of the requirement. A vigilant coalition led by the Department of Health was bolstered by MSMA’s strong voice at the Capitol. The Legislature did the right thing keeping the immunization law in tact to protect all children. Any Willing Provider: Physicians want to honor the doctor-patient relationship but narrow insurance networks bench good doctors diverting patients to a specific physician or facility. MSMA strives to protect that all-important physician-patient relationship and your access to your patients. Legislators failed to pass protections to protect physicians from narrow networks. Lawmakers then gave the ok for a middleman to decide which surgeon and which hospital state employees must use. The result could force a Biloxi schoolteacher to go to Tupelo for his surgery. MSMA monitors the oversight board to deter any implementation of this option. SmokeFree Mississippi: With one bill the Legislature could have instantly made Mississippi healthier—just by banning smoking in indoor public places to protect everyone from second-hand smoke. A statewide ban on smoking in indoor public places would instantly start decreasing cardiovascular disease, strokes, pneumonia, asthma and other debilitating diseases. Making all Mississippi workplaces 100% smoke-free would prevent 14,000 youth from becoming smokers, and in five years, save an estimated $42 million in costs to treat lung cancer, heart attacks and strokes. Some 36,000 could be expected to quit smoking and the number of smoking–related deaths would drop by 22,000… if the Legislature can be convinced to ban indoor public smoking. MSMA will keep pushing the legislature to deter all tobacco use. STEMI and Stroke: By funding Mississippi’s ground-breaking STEMI protocol it will save lives and speed up medical intervention for some of the deadliest heart attacks. This stream-lined response to cardiac emergencies puts Mississippi above the national norm in heart attack survival rates. Mental Health: A mental health task force could recommend best practices to improve the mental health system. That bill died but the legislature did create a jail diversion program using holding facilities instead of jail cells to detain mentally ill patients. Physician Workforce: Thousands of rural Mississippi patients will have a new physician in a few years. The legislature funded medical school tuition for six more Rural Physician Scholars bringing the number of rural doctors in this pipeline to 60. Funding for the Office of Physician Workforce was provided but the legislature failed to grant MSMA’s request for $4 million for residency training positions.
MSMA MESSAGE It’s time to put health first. Ban smoking. Protect everyone with immunizations. Protect physicians from narrow networks. Improve the mental health system with best practices. Build the physician workforce.
It’s the right thing to do for all Mississippians.
Members mean the world to MSMA.
MEMBERSHIP AMBASSADORS
Keep an eye out for MSMA’s Membership Ambassadors – a team of former presidents calling on individuals and groups of physicians who have let their membership lapse or have never joined the state’s largest and oldest physician association. Interested in having an ambassador visit you? Just call the MSMA headquarters at 601-853-6733 and we’ll set it up.
STAT STUDENT SCHOLARS
To encourage medical students to participate in advocacy activities MSMA’s STAT program, short for Student Advocacy Training, exposes students to organized medicine and recognizes their achievement at Annual Session. Activities engage the student supplementing his/her clinical training while actively supporting patients and the practice of medicine. STAT Students select six activities during the four-year academic period and at least twelve activities are offered annually. STAT Scholars are MSMA MEMBERSHIP 2004 - 2014 recognized in the Journal MSMA and at Annual Session.
SPECIALTY MANAGEMENT
MSMA’s professional staff provides a full range of management services to specialty societies and local medical societies. From billing to annual meetings, MSMA can handle as many or few services as needed. Let MSMA book speakers for your meetings, host CME programs, negotiate hotel contracts for your annual specialty society meeting, print/electronic mailers, programs or newsletters, notices and invitations. Fees are customized based on services needed. For details or to request a proposal contact Conner Reeves at CReeves@MSMAonline.com.
Membership 2004 Category Paid Active Members
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2,884 2,889 2,887 2,890 2,872 2,691 3,059 3,141 3,146 3,129 3,047 2,971
Dues-Exempt Members
450
455
444
468
444
511
505
486
461
495
523
a539s
Student Members
254
234
328
353
377
433
596
532
554
570
633
737
Residents & Fellows
81
95
148
149
103
74
469
476
449
536
586
635
TOTAL
3,669 3,673 3,807 3,860 3,796 3,709 4,629 4,635 4,610 4,738 4,789 4,882
RESOURCES
REVENUE
Dollars
Membership Dues 1,483,628 Events (HOD, iPASS, YPS, workshops, etc.) 378,141 MACM Sponsorship 150,000 Subsidiary Services 101,216 Management Fees 82,200 CME Online 57,727 Accreditation CME Providers 55,775 Rental Income 52,348 Journal Advertising & Sales 39,771 MPCN Dividend 35,000 Miscellaneous (interest, royalties, web adv.) 8,352 TOTAL REVENUE
2,444,158
EXPENSES Admin (salaries/benefits, IT, D&O, building insurance) Government Affairs Events (Annual Session, iPASS, YPS, workshops, etc) Journal Building (taxes, operations, mortgage interest) Communications Travel, Meals & Meetings Accreditation (fees, travel, stipends) CME Online Specialty Management Contribution to MPHP TOTAL EXPENSES
908,502 327,361 285,683 192,531 158,862 147,885 136,522 74,749 32,914 36,346 20,000
2,321,355
Your success is our goal.
Patients can’t get well if they can’t get their prescriptions.
PHYSICIAN LEADERSHIP ACADEMY: “I wish they taught this in medical school…” That’s the number one comment we hear from physicians at the MSMA Physician Leadership Academy. And, it’s why your MSMA stepped up to offer the specific leadership training you need to thrive in the changing world of medicine. Physicians need skills to influence the medical environment, to collaboratively lead multi-disciplinary teams, to use media/communications to advance ideas, to convincingly voice the physician’s position with lawmakers. Physicians wanting to prepare for and lead organizations (practice groups, medical staffs, management teams, MSMA councils and committees) will find solutions at the Physician Leadership Academy. Participants gain valuable perspective and core aptitudes so they can excel in leadership positions within their own practice, in organized medicine, and the public policy arena. Only a dozen scholars are chosen annually. Each commits to six sessions and a project. Grads are honored as Doctors of Distinction at the annual Excellence in Medicine Awards and recognized in MSMA publications. For an application contact Phyllis Williams at PWilliams@MSMAonline.com. iPASS GETS ANSWERS FOR PAYER PROBLEMS. More than 160 physicians sent office staff to sit down with troubleshooters from the big payers to resolve reimbursement problems and get insider tips on claims processing. A one-day iPASS – Insurance Payment Advocacy Solutions – summit was held in Gulfport, Raymond and Oxford with more than 30 health plan reps at each meeting. Novitas Solutions, Humana (Medicare Advantage, Health Insurance Exchange), Wellcare, Medicaid, eQHealth Solutions, Medical Transportation Management, MedSolutions, Xerox, Magnolia Health Plan (MississippiCAN, CHIP, Ambetter) and United Healthcare (MississippiCAN, CHIP) were all on hand to answer claims questions. Phyllis Williams (PWilliams@MSMAonline.com) can sign up your staff for the next one. FREE PRESCRIPTION DISCOUNT CARD FOR YOUR PATIENTS. Patients who need financial assistance with prescription medications can now get a FREE drug discount card made available by the state’s largest association of physicians. The Mississippi Drug Card can save patients up to 75% on prescriptions at hundreds of participating pharmacies statewide. The discount card helps uninsured and under-insured residents afford medications. MSMA is committed to helping patients get the medications they need. Discounts are available to patients whose health insurance does not cover prescription benefits. Those who do have prescription coverage can use this program to get discounts on medications that are not covered by their insurance plan. Mississippi residents can create a free card, search drug pricing, and locate participating pharmacies at MississippiDrugCard.com or MSMAonline.com. Contact Conner Reeves (CReeves@MSMAonline.com) to get free discount cards for your patients. CME IN THE SAND PROMPTS CME ON THE SLOPES. CME in the Sand has been so successful MSMA is adding additional CME opportunities in the mountains and online. Attendance at CME in the Sand skyrocketed from 25 in 2002 to 158 physicians in 2015 who booked more than 700 room nights in Sandestin. By the end of 2015, MSMA will have sponsored more than nine live event hours on the conversion to ICD-10 and more hours are available online. For more information on CME programs contact Jenny White at JWhite@MSMAonline.com.
MSMA VISION
… to be an essential part of every Mississippi physician’s professional life GOAL 1 INCREASE PARTICIPATION, ENGAGEMENT. To boost attendance at local medical society meetings MSMA mailed postcards and electronically notified members of visits by the president and expanded capacity to manage local societies. E-invitations to Annual Session and real-time broadcasts allow members to monitor the House of Delegates and the reference committees. Resolutions and reports are posted for a ten-day comment period to allow members to voice his/her opinion. Councils and committees continue to invite participation.
GOAL 2 EFFECTIVELY COMMUNICATE TO MEMBERS AND OTHER STAKEHOLDERS. Weekly e-news is supplemented by faxes to push news and event info to members across the state. A mobile app expands communications with iPad, smart phones and androids. MSMA remains the exclusive source for the secure medical messaging system known as DocBookMD. Messaging through social media increased and councils employed audio and/or video conferencing to boost participation. A planning session and weekly calls are hosted by Council on Legislation and specialty societies are invited to join in.
GOAL 3 SIGNIFICANT PROGRESS ON WORK FORCE ISSUE. MSMA continues to work closely with Office of Physician Workforce and Rural Physician Scholarship Program to successfully increase state funding for RPSP. For the second year MSMA initiated requests for state funding for residency slots. MSMA continues to promote physicians as drivers of the state economy to the Mississippi Economic Council, Healthcare Solutions Institute municipalities and counties.
GOAL 4 PHYSICIAN AS THE LEADER OF MEDICAL CARE TEAM. MSMA vigorously monitors the rules and regulations of the State Board of Medical Licensure, the State Nursing Board and other regulatory agencies insisting on strict oversight of collaborative practices. MSMA’s Physician Leadership Academy was designed to equip physicians with tools to thrive in new practice places. MSMA publicly positions the physician as the leader of the medical team using social media and earned media. Physicians are encouraged to participate on local civic boards, school committees and to lead local Smoke-Free efforts.
GOAL 5 ADVOCATE QUALITY HEALTH CARE. MSMA is the voice of Mississippi physicians at the State Capitol and with the Mississippi congressional delegation. MSMA pushes against narrow networks that jeopardize the physician-patient relationship, redirects patients or interferes with the physician’s decision making authority. Physicians collected more than 10,000 signatures to show the State Legislature support for a ban on smoking. Specialty societiesand the Primary Care Coalition annually meet with Council on Legislation and MSMA leaders also participate in the MHA Leadership Committee.
GOAL 6 ORGANIZATIONAL IMPROVEMENT. Reserve funds have increased and a development director was hired to solicit charitable contributions. Ad hoc committees like the Commission on Health Equity are focusing on targeted issues. Meetings with the auditor are conducted online and one-day meetings reduce leaders’ time away from their practices. MSMA is assisting the Alliance to recruit members by encouraging physicians to join and has offered to produce leadership workshops. MSMAA will host the AMA Alliance Southern Regional meeting in January 2016.
2012 – 2016 Strategic Plan
LOOKING AHEAD ...
What have we done for you lately?
The short answer is “LOTS.” MSMA focuses on services for physicians and physicians in training. Here’s a short list of ongoing projects. Membership is the lifeblood of MSMA. To bring in new members and retain lapsed members, we’re enlisting former presidents to be physician outreach ambassadors who can share firsthand knowledge of MSMA initiatives and can call on potential members. We’re expanding online CME and on-site CME and adding a five-day CME on the Slopes event in Snowbird, Utah in February 2016.
PHYSICIAN LEADERSHIP ACADEMY 2015-16 6 SESSIONS
1. 2. 3. 4. 5. 6.
NOV 11, 2015 Physician Leadership Skills OCT 30, 2015 Communication Skills for Leaders JAN 15, 2016 Conflict Resolution SPRING 2016 Advocacy Strategies at the Capitol APRIL 22, 2016 The Art of Negotiation JUNE 24, 2016 Collaboration and Influence
CME EVENTS 2015 - 2016 DATES
CME on the Slopes, Snowbird, Utah FEB 18-22, 2016 CME in the Sand, Grand Sandestin MAY 27-31, 2016 AUG 12-13, 2016 CME at Annual Session ICD-10 TRAINING -FREE
(sponsored by MPCN)
ICD-10 for Physicians (1 hr. CME @ 6:30 pm) ICD-10 for Physicians (1 hr. CME @ 6:30 pm) ICD-10 for Coders & Billers (1-5 pm)
JULY 29, 2015 AUG 5, 2015 JULY 24, 2015
iPASS “Insurance Payment Advocacy Solutions’ Gulfport/Biloxi Jackson Metro Oxford
MAY 6, 2016 MAY 11, 2016 MAY 13, 2016
ANNUAL SESSION HOUSE OF DELEGATES House of Delegates Reference Committees Excellence Awards & Inaugural Gala House of Delegates Elections
AUG 12, 2016
Focusing on the future MSMA engages students and residents in council work, advocacy and all aspects of organized medicine. STAT Student Scholars are recognized for achievements and stay involved. Leadership training equips young-ish members with skills and tools to lead councils and committees as well as practice groups, medical care teams and MSMA. It’s one more way MSMA protects the autonomy of the physician as the leader of the medical care team. MSMA is the only Mississippi source for the exclusive DocBookMD, the HIPAA compliant messaging app and, best of all – it’s FREE to MSMA members. DocBookMD is perfect for consults and sharing status reports with partners. MSMA makes the FREE Mississippi Drug Card available to all physicians and patients. The discounts are especially designed to help patients without drug coverage to get their meds at significant savings. Weekly i-friendly e-news alerts include Mississippi headlines from across the state, the latest events, state and federal advocacy updates, MMPAC endorsements, CME events and practice strategy tips. If you don’t like email, just let us know and you can get the info by fax. The Journal MSMA is edited by physicians for physicians and contains peer-reviewed scientific research and popular commentaries. The Journal is available online and is printed monthly. MSMA is helping members prepare for the conversion to ICD-10 with live and online CME. Mississippi-trained medical students go out of state when there aren’t enough residency slots available. MSMA initiated a push for state funding for more residency slots and continues to pursue state dollars to keep medical students and residents in our state. Thanks,
AUG 12, 2016 AUG 13, 2016
Charmain Kanosky, Executive Director
What’s Your Specialty? Our specialty is NETWORKING... TPAs Physicians
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MPCN - THE OBVIOUS CHOICE Change Networks. Not Doctors. 601-605-4756 • www.mpcn-ms.com Sponsored by the Mississippi State Medical Association
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Join us in the beautiful Utah mountains to ski and earn CME credits. The slopes are just outside your door at Snowbird Ski Resort! Besides earning CMEs, thereâ&#x20AC;&#x2122;s plenty of time for:
Join us at 2016 CME on the Slopes Call Becky, Jenny, or Conner February 18-22, 2016 today at 601-853-6733 to register!
d shopping n a g n i n Skiing at Snowb Fine di | ird and a p S e Alta resorts | Relaxing at th