VOL. LVII • NO. 7 • 2016 by Journal MSMA

VOL. LVII • NO. 7 • 2016

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148TH ANNUAL SESSION OF THE HOUSE OF DELEGATES

schedule of events THURSDAY 12:00 - 5:00 pm 6:00 pm FRIDAY 10:00 am 10:30 am 11:30 am 1:00 pm 2:00 pm 6:00 pm 7:00 pm 7:30 pm SATURDAY 7:00 am 9:00 am 10:30 am 11:30 am 12:30 1:00 pm 4:00 pm

Prescriber's Summit (5 CME credits) Board of Trustees, Drago's Board of Trustees Meeting Delegate Orientation Lunch + Q&A with State Board of Medical Licensure House of Delegates Reference Commitees Excellence in Medicine Awards Presidential Awards Reception MSMA Presidential Inaugural Gala

August 11-13, 2016 The Jackson Hilton 1001 East County Line Road

To register, read resolutions, buy gala tickets, and participate in online reference committees, visit www.MSMAonline.com/AnnualSession

Past Presidents Breakfast 50 Year Club Breakfast Board of Trustees Meeting Candidate Speeches Caucusing MS Chapter American College of Cardiology Meeting House of Delegates Board of Trustees

ALLIANCE EVENTS, PENTHOUSE

FRIDAY 2:00 pm 3:00 pm 6:00-7:30 pm 7:30 p.m

Executive Committee and Board of Directors’ Meeting House of Delegates, Awards Ceremony, Officer Installation Scholarship Fundraiser MSMA Presidential Inaugural Gala

SATURDAY 10:00 am

Past Presidents’ Brunch (Invitation Only)

Featuring the Inauguration of the 149th MSMA President Lee Voulters, MD

PRESIDENTIAL INAUGURAL GALA Friday, August 12, 7:30 pm Tickets $100

VOL. LVII • NO. 7 • JULY 2016

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

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

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

SCIENTIFIC ARTICLES Bedside Renal Ultrasound for the Primary Care Physician 206 Brian J. Tollefson, MD; Nicholas E. Hoda, MD, PhD; W. Ryan Miller, MD; Jim Harris, DO; James Nichols, DO Top 10 Facts You Should Know about Absence Epilepsy Salma Dawoud, M3; John Bradford Ingram, MD

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Clinical Problem-Solving Case: When the Treatment Becomes the Problem Vivek-Thomas J. Sankoorikal, MD and Janet Ricks, DO

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DEPARTMENTS From the Editor –Journal Wins National Award for Excellence 204 Lucius M. Lampton, MD, Editor Legalese - Emotion Incites Rights Fight- Sarah Mann 216 Letters– More on Immunization- Ed Dvorack, MD 242 EHRs Attributed to Physician Burnout- John P. Hey, III, MD President’s Page – The Fight Continues Daniel P. Edney, MD, MSMA President

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MSMA Nominating Committee Announces Slate of Offices 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

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MSMA Physicians Leadership Academy- Gerald M Kinney, MD 245 MSMA Physicians Leadership Academy- Angela Shannon, MD 246 c

RELATED ORGANIZATIONS UMMC Match Day Results WCUCOM Match Day Results

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ABOUT THE COVER “Baldfaced Hornet Nest (Dolichovespula maculata)”– Board-certified in emergency medicine, Brett Tisdale, MD, who practices at StatCare Urgent Care Clinic in McComb, took this photo of a hornet nesting about 10-12’ high in his neighbor’s Viburnum. Named from the ivory-white markings on the face and tail, the baldfaced hornet is a species in the genus Dolichovespula found in North America. However, it is not a true hornet; it is an aerial yellow jacket. They are beneficial insects and are usually only aggressive when protecting their gray papery nest. The nest starts off small, the size of a baseball, becoming oval-shaped as it grows. Each nest consists of a queen, worker hornets, and drones. The queen works tirelessly collecting cellulose from weathered and rotting wood, chews the wood adding her saliva, and using this paste she makes a papery material to construct the nest. She creates a few brood cells within the nest, deposits eggs in them, and feeds the larvae when they hatch. This first brood will assume the duties of nest building, food collection, feeding the larvae, and protecting the nest. As the summer progresses, the colony grows until there may be 100 to 400 workers. The workers are all female responsible for all stinging attacks and nest building. The drones are male and have no stinger. Their job is to mate with certain females whose offspring will become queens.n VOL. LVII • NO. 7 • 2016

POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2016 Mississippi State Medical Association.

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Journal Wins National Award for Excellence T

he quality of your Journal was recently recognized for national excellence: JMSMA won a silver award in the “Most Improved Magazine or Journal” category in Association TRENDS 2015 All-Media JMSMA Editor Dr. Lucius M. Lampton Contest at the 37th and Managing Editor Karen A. Evers Annual Salute to Association Excellence at the Capital Hilton in Washington, D. C. This competitive contest of national associations included over 400 entries in 22 categories. While awards aren’t necessary to prove excellence, this national recognition does underscore that our JMSMA is a rare and precious publication: a high quality physician-run and physicianproduced monthly medical journal. Our state’s profession not only should cherish it, but also be commended for supporting and nurturing its production, in its various forms, for more than a century.

Mississippi physicians have always perceived the importance of communicating and sharing ideas with their fellow physicians. One of the first acts of the Mississippi State Medical Association back at its founding in 1856 was the establishment of a “Publication Committee” whose duty it was to receive and consider voluntary written contributions and publish those “found worthy of publication.” After the Civil War, when the Association revived itself, it began printing yearly The Transactions of the Mississippi State Medical Association. The Mississippi Medical Monthly, edited by Drs. N. L. Clarke and Hugh H. Haralson of Meridian, appeared in September 1891 and by 1897 was renamed the Journal of the Mississippi State Medical Association after the Mississippi State Medical Association assumed its management, operating it monthly out of both Biloxi and Vicksburg under this and other names until 1906. From 1929-1959, The Mississippi Doctor, published by W. H. Anderson, MD, in Booneville, became the official organ of the MSMA. Since January 1960, the Journal of the Mississippi State Medical Association has been the official monthly publication of the MSMA. This journal remains an influential and nationally recognized scientific publication. It is one of the last remaining monthly medical journals in

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

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Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Nitin K. Gupta, MD Assistant Professor-Digestive Diseases, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director, Mississippi Professionals Health Program, Ridgeland J. Edward Hill, MD Family Physician, North Mississippi Medical Center, Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Daniel W. Jones, MD Sanderson Chair in Obesity, Metabolic Diseases and Nutrition Director, Clinical and Population Science, Mississippi Center for Obesity Research, Professor of Medicine and Physiology, Interim Chair, Department of Medicine Ben E. Kitchens, MD Family Physician, Iuka

Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport Lillian Lien, MD Professor and Director, Division of Endocrinology, University of Mississippi Medical Center, Jackson William Lineaweaver, MD Editor, Annals of Plastic Surgery, Medical Director, JMS Burn and Reconstruction Center, Brandon Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems Heddy-Dale Matthias, MD Anesthesiologist, Critical Care Internist, Madison Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD Radiologist, Singing River Radiology Group, Pascagoula Ann Myers, MD Rheumatologist , Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist , Jackson Health Care-Women, Flowood

Jack D. Owens, MD, MPH Neonatologist, Newborn Associates, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Shou J. Tang, MD Professor and Director, Division of Digestive Diseases, University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine, University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon, Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer, Brentwood Behavioral Healthcare, Flowood Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

the South produced by and created for its member physicians. The Journal’s mission has been to publish scientific and historical articles, pertinent news and announcements, opinions and editorials, book reviews, essays, poetry, photography, and artwork written or created by and of interest to our very diverse membership. This award offers the opportunity to recognize those so important to the Journal’s success. I especially want to acknowledge the tireless work of Karen Evers, who for more than two decades has fostered the high quality of this journal as its Managing Editor. I can’t imagine the Journal without her extraordinary vision and engaging leadership. Associate Editors Drs. Stanley Hartness and Rick deShazo also deserve special recognition for their exemplary skills and brilliant contributions. As well, our MSMA Committee on Publications (Drs. Dwalia South, Chair; Martin Pomphrey; and Philip Merideth) provides outstanding leadership and essential editing and oversight. Also, critical to the JMSMA’s success are our MSMA leadership, Board of Trustees, the Journal Editorial Advisory Board, and finally, our dedicated and talented staff. Few realize the enormous work and effort which goes into each issue. I salute all those who make our Journal what it is each month, and I look forward to its continued success. It remains one of the jewels in MSMA’s crown. With a circulation of 4,500, your Journal serves as the voice, the face, and the spirit of medicine in Mississippi!

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Bedside Renal Ultrasound for the Primary Care Physician BRIAN J. TOLLEFSON, MD; NICHOLAS E. HODA, MD, PHD; W. RYAN MILLER, MD; JIM HARRIS, DO; JAMES NICHOLS, DO Basic concepts of bedside ultrasound have been discussed in two previous articles.1,2 The focus of this article is the evaluation of the renal system with bedside ultrasound.

return precautions for symptoms of infection or uncontrollable pain and your contact information. A follow-up visit is scheduled.

Introduction

Bedside renal ultrasound is the first line imaging test to evaluate for hydronephrosis in patients with a suspected kidney stone. Other indictions include urinary retention, often with suspicion for bladder outlet obstruction or even neurogenic bladder. In these cases, one would expect to see a distended bladder, often with associated bilateral hydronephrosis.

The occurrence of urolithiasis continues rising (178 visits per 100,000 individuals in 1992 to 340 visits per 100,000 individuals in 2009) as does the use of CT for diagnosis from 21% to 71% in the same time period. It is likely that a significant proportion of those scans are for patients with recurrent stones.3 Focused bedside ultrasound to evaluate for suspected renal stones may decrease the need for the cost, time, and radiation exposure of abdominal CT scanning and provide a rapid bedside diagnosis. While bedside ultrasound is operatordependent, the time required to gain a moderate degree of diagnostic accuracy is minimal.4 This article describes the basics of performing and interpreting the focused renal system ultrasound exam. Also, when evaluating older patients with abdominal, flank, or back pain, aortic dissection and aortic aneurysm must be considered in the differential diagnosis. Bedside ultrasound evaluation of the aorta will be described in a subsequent article. Clinical Scenario A 25-year-old male presents to clinic with 2 days of intermittent severe left flank pain and hematuria. He reports that the pain is similar to past episodes of kidney stones. He denies fever, chills, nausea, vomiting, and dysuria. He has had 4 CT scans previously including a CT scan 2 months ago for a similar episode. At that time he had a 4mm ureteral stone with associated mild “kidney swelling.” He was given pain medication and tamsulosin and passed the stone about 3 days later without any residual symptoms. He has not seen a urologist due to the expense. His vital signs are within normal limits other than mild tachycardia. He is afebrile and does not appear dehydrated. He is in moderate distress and your exam is significant for left flank and CVA tenderness. A urinalysis and chemistry profile are significant only for microscopic hematuria. You consider obtaining a CT renal stone protocol but to avoid additional radiation, a bedside ultrasound is performed. You confirm the absence of hydronephrosis and visualize the presence of bilateral ureteral jets in the bladder. Since, in the absence of hydronephrosis, the likelihood of a large obstructing stone is low, an intramuscular injection of toradol is given for pain relief.5 The patient is discharged with prescriptions for scheduled NSAIDs and tamsulosin and as-needed use of opiates and ondansetron. You also provided 206 VOL. 57 • NO. 7 • 2016

Indications for Bedside Renal Ultrasonography

Technique for Bedside Renal Ultrasound Exam With the patient in the supine position, place the low frequency, curvilinear probe longitudinally along the patient’s right mid-axillary line at the level of the lower ribs with the probe marker toward the patient’s head (Figure 1). One should be able to identify the kidney as a football-shaped organ with internal hyperechoic (bright) markings of the collapsed collecting system and medullary fat and the surrounding hypoechoic (dark) renal pyramids and cortex (Figure 2). The right kidney is located deep and caudal to the liver. Turning the probe slightly off axis may be necessary to be able to more fully visualize between the ribs. Sweep through the kidney using a rocking left-right motion to visualize the kidney from the superior to inferior pole and then using a tilting up-down motion to visualize the kidney from the posterior to anterior aspects to ensure complete evaluation of the kidney. Next turn the probe 90 degrees counter-clockwise to evaluate the kidney in the transverse plane (Figure 3). The left kidney evaluation is similar except for the primary differences that the left kidney is usually positioned slightly more cephalad and posteriorly and is beneath the spleen. Technique for Bedside Bladder Exam The urinary bladder may be imaged to evaluate for the presence or absence of urine flow into the bladder and for bladder distention. To begin imaging the bladder in the transverse orientation, place the probe over the lower abdomen about 2-3cm cephalad to the pubic symphysis. The probe marker should be oriented to the patient’s right side (Figure 4). The urinary bladder appears as a hyperechoic (white), thick-walled, rectangular structure. The size of the bladder will vary depending upon the amount of urine contained in the bladder. The urine appears anechoic (black) on ultrasound. Be mindful that when the bladder is empty or near empty, it may be difficult to identify as it is collapsed.

Figure1A. Probe position to image right kidney in longitudinal plane. Place probe longitudinally along the right mid-axillary line at the level of the lower ribs. Probe marker should point cephalad. Turing the probe more parallel to the ribs may be necessary to avoid excessive rib shadow. 1B. Line drawing of probe position relevant cross-section anatomy of abdomen (RKright kidney, GB-gallbladder, Ao-aorta, IVC-inferior vena cava, VB-vertebral body, LK-left kidney). B.

Figure 2. Normal longitudinal ultrasound image of the right kidney. Normal length is 9-14cm, and normal cortex thickness is 8-10mm. The renal pelvis and calyces are normally compressed and appear hyperechoic on ultrasound.

Figure 3. Normal transverse ultrasound image of right kidney (normal width 4-6cm). Transverse image obtained by rotating the probe 90-degrees counterclockwise from the longitudinal position. Probe marker should be oriented posteriorly.

Figure 4A. Probe position to image bladder in transverse plane. Place the probe transversely just cephalad to the pubic bone in the mid-sagittal line and tilt the probe about 30-degrees in the caudal direction. The probe marker should be oriented toward the patientâ&#x20AC;&#x2122;s right side. 4B. Line drawing of probe position and relevant sagittal anatomy of pelvis (PB-pubic bone). B.

Figure 5. Transverse image of the bladder with color doppler depicting a urinary jet shooting into the bladder.

To evaluate for the flow of urine into the bladder, use the doppler color mode on the ultrasound. The color mode allows for visualization of the ureteral jets as urine is injected into the bladder (Figure 5). The urine jets can be identified at the ureterovesicle junction along the posterioinferior wall of the bladder by tilting the probe slightly posteriorly. The flow may range from an almost continuously present jet to intermittent spurts of urine every few minutes depending upon the hydration status of the patient. Absence of ureteral jet unilaterally along with proximal ureteral dilation or hydronephrosis suggests complete ureteral obstruction. Absence of ureteral jets bilaterally is more indicative of severe dehydration or renal failure. If unable to visualize ureteral jets bilaterally, consider IV hydration followed by re-evaluation for ureteral jets. Additionally, compare left and right ureteral jets for grossly symmetrical flow rates. Measure the volume of the bladder by finding the largest dimension of the bladder in the transverse plane. Freeze the image and select the volume calculator function on the control panel of the ultrasound machine. Measure the maximal height and width of the bladder with the caliper function (Figure 6). To complete the bladder volume assessment, obtain a longitudinal image of the bladder by rotating the probe 90-degrees clockwise so that the probe marker is oriented cephalad. JOURNAL MSMA

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Figure 6. Transverse image of the bladder with calipers measuring the width (horizontal line) and height (vertical line).

Figure 7. Longitudinal image of the bladder with calipers measuring the length. Longitudinal image obtained by rotating the probe 90-degrees clockwise from the transverse positon. The probe marker should be oriented cephalad.

Again, freeze the image and measure the length of the bladder (Figure 7). Once the height, width and length are obtained, the ultrasound machine will calculate the volume. If your ultrasound machine does not have a volume calculator function, use the following formula to calculate the bladder volume manually: length x width x height x 0.75.6 Post-void bladder volume greater than 150-200mL is consistent with urinary retention.

Figure 8. Hydronephrosis: normally, the renal collecting system (renal pelvis and calyces) is collapsed and appears hyperechoic on ultrasound (see Figure 2). A simplified grading system for hydronephrosis is described below and displayed in the corresponding ultrasound images and drawings. The severity of hydronephrosis is graded as mild, moderate or severe based on the extent of collecting system dilitation.7

8A. Mild hydronephrosis: renal pelvis and calyces open and filled with anechoic urine; renal cortex and pyramids normal.

8B. Moderate hydronephrosis: renal pelvis and calyces open with blunting of renal pyramids; renal cortex normal.

Hydronephrosis Hydronephrosis, distension of the renal collecting system (pelvis and calices), in a patient with suspected renal colic typically indicates the presence of an obstructing stone in the ureter. Hydroureter may also develop in the segment of the ureter proximal to the obstructing stone. Patients that are significantly dehydrated my fail to develop hydronephrosis with an obstructing stone. Administration of IV fluids prior to examination may increase sensitivity of detecting hydronephrosis. Hydronephrosis is graded as mild, moderate, or severe based on the relative amount of anechoic dilation of the renal calyces and pelvis (Figure 8).7 Ultrasound is insensitive for identifying small stones with only 16% sensitivity for stones <7mm.8 A stone along with hydroureter will 208 VOL. 57 • NO. 7 • 2016

8C. Severe hydronephrosis: renal pelvis (RP) and calyces (C) “ballooned out” causing obliteration of pyramids and compression of renal cortex (Ct).

2015; 56(3):64-6.

Figure 9. Management algorithm for suspected kidney stone.6

3. Fwu C, Eggers PW, Kimmel PL et al. Emergency department visits, use of imaging and drugs for urolithiasis have increased in the United States. Kidney Int. 2013; 83(3):479-486. 4. Mandavia DP, Aragona J, Chan L. Ultrasound training for emergency physicians â&#x20AC;&#x201C; a prospective study. Acad Emerg Med. 2000;7(9):1008-1014. 5. Goertz JK, Lotterman S. Can the degree of hydronephrosis on ultrasound predict kidney stone size? Am J Emerg Med. 2010;28(7):813-816. 6. Seif D, Swadron SP. Renal. In: Ma OJ, Mateer JR, Reardon RF, Joing SA. eds. Ma and Mateerâ&#x20AC;&#x2122;s Emergency Ultrasound. 3e. New York: McGraw-Hill; 2014. 7. Noble VE, Nelson BP. Manual of Emergency and Critical Care Ultrasound. 2e. Cambridge: Cambridge Press; 2011.

most likely be visualized just proximal to the ureterovesicle junction. Stone identification is not required to make a presumptive diagnosis of kidney stone in the appropriate patient, like the one above. Hydronephrosis increases the likelihood of having an obstructing stone but does not necessarily affect the likelihood of stone passage. Ninety eight percent of stones less than 5mm have been shown to pass spontaneously but can take up to 40 days, whereas urological intervention may be required in 50% of stones greater than 5mm.9 Figure 9 details a proposed algorithm for the initial workup and disposition based upon the ultrasound findings in a patient with a suspected kidney stone. Summary Bedside ultrasound of the kidneys and bladder can be used to rapidly diagnose and treat well-appearing patients with a suspected kidney stone. In patients at low-risk for other serious abdominal pathology, the risks of an abdominal CT scan may outweigh the benefit as it will add little to the diagnosis and management. Bedside renal system ultrasonography has been associated with lower ED visit cost and decreased radiation exposure without increased missed diagnoses or increased adverse events.10 Moreover, the diagnostic accuracy of bedside US in comparison to radiology-performed ultrasound and CT scan has been shown to have similar sensitivity and specificity.11 Bedside ultrasound is a convenient modality to use in the clinical setting to aid in early diagnosis of common conditions like nephrolithiasis. It is safe, relatively easy to learn, and can potentially decrease cost and time to diagnosis. References 1. Tollefson B. The eFAST examination for trauma triage. J Miss State Med Assoc. 2014; 55(3):72-8. 2. Tollefson B, Hoda N, Graves F, et al. Bedside gallbladder ultrasound for the primary care physician. J Miss State Med Assoc.

8. Fowler KA, Locken JA, Duchesne JH, et al. US for detecting renal calculi with nonenhanced CT as a reference standard. Radiology. 2002;222:109-113. 9. Miller RF, Kane CJ. Time to stone passage for observed ureteral calculi: A guide for patient education. J Urology. 1999;162; 688-691. 10. Bindman-Smith R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med. 2014; 371(12):1100-1110. 11. Hasani SA, Fathi M, Daadpey M, et al. Accuracy of bedside emergency physician performed ultrasound in diagnosing different causes of acute abdominal pain: a prospective study. Clinical Imaging. 2015;39(3):476-9.

Author information Director of Emergency Ultrasound and Assistant Professor of Emergency Medicine at the University of Mississippi Medical Center in Jackson, MS (Dr. Tollefson). Third year emergency medicine resident at the University of Mississippi Medical Center in Jackson, MS (Dr. Hoda). Fourth year emergency medicine resident at the University of Mississippi Medical Center in Jackson, MS (Dr. Miller). Emergency physician at Maury Regional Medical Center in Columbia, TN (Dr. Harris). Emergency physician at River Oaks Merritt Health in Flowood, MS (Dr. Nichols). Corresponding Author

Brian Tollefson, MD University of Mississippi Medical Center 2500 North State Street Jackson, MS 39216. Ph: (601) 984-5144 (btollefson@umc.edu)

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Top 10 Facts You Should Know about Absence Epilepsy Salma Dawoud, M3; John Bradford Ingram, MD

Introduction Absence seizures are staring episodes characterized by impairment of consciousness.1 Absence seizures (previously known as petit mal seizures) often occur in elementary school age as a result of childhood absence epilepsy (CAE). CAE is the most commonly diagnosed form of pediatric epilepsy, and it accounts for 10 to 17% of epilepsy in children. 2 It has been reported to occur 6 to 7 times per 100,000 persons. In the pediatric population, it effects 0.4 to 0.7 per 1000 people. 3 Absence seizures may also present in later stages of development in juvenile absence epilepsy ( JAE). The cause of absence seizures is unknown but is presumed to be genetic. Family history studies show a higher incidence of CAE in children with first degree relatives who suffered the same disease.

1 2 3

Childhood absence epilepsy (CAE) presents at a young age and more often in females. Absence seizures typically appear during elementary school between two to ten years of age. The average age of onset is 6 years old.4 They present more frequently in females than males which is rare for seizure disorders.5

Absence seizures are provoked by hyperventilation. Hyperventilation triggers absence seizures in 90% of the children who suffer from absence epilepsy.1 During EEG, the seizures are activated through intervals of hyperventilation and photic stimulation.4 They often occur when the child is exercising or playing videogames.

Absence seizures are short lived. A typical absence seizure (TAS) lasts approximately 10 seconds or less but can range from 1 to 44 seconds.4 These episodes manifest with motor arrest, vacant stares, and a high impairment of consciousness. There is no aura preceding the seizure and no post-ictus.1 Seizures often occur quite frequently and abruptly but go unnoticed by parents and teachers because of their subtlety. Complex partial seizures also feature staring episodes but can be ruled out of a differential diagnosis based on the presence of a pre- and post-ictus as well as longer duration.

4 5 6

Absence seizures originate in thalamic nuclei. By definition, absence epilepsy is considered generalized. This implies that a discharge rapidly hypersynchronizes both hemispheres of the brain into a single event. Recent evidence suggests that the discharges originate in thalamic nuclei including the reticular thalamic nucleus and thalamic relay neurons.6

Absence seizures can be typical or atypical. Typical absence seizures have a short duration and an abrupt start and stop. They are the most common seizure type that occurs in absence epilepsy disorders. In contrast, atypical absence seizures have a longer duration and feature a more gradual start and stop. This seizure type often presents in forms other than absence epilepsy.1 EEGs of typical absence seizures are characterized by 3 Hz spike waves. The pattern on a typical absence seizure is a generalized bilateral synchronous discharge of 3 Hz spike-waves.7 Atypical absence seizures feature the same spike-wave form but discharge at a slower rate of 2.5 Hz or less.1

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Not all absence seizures happen in the setting of childhood absence epilepsy.

FIGURE. This EEG demonstrates the 3 Hz spike waves of typical absence seizures.

Childhood absence epilepsy (CAE) presents at an average age of 6 and features typical absence seizures.4 Other absence epilepsy syndromes do exist. Juvenile absence epilepsy ( JAE) usually presents between 9 years of age through adulthood. JAE presents with typical absence seizures in addition to other forms of generalized seizures. JAE is a disease that persists throughout the lifetime of a patient. Juvenile myoclonic epilepsy ( JME) is similar in many ways to JAE but often presents with frequent early morning myoclonic jerks. 8

Psychiatric comorbidity is common in absence epilepsies. Psychiatric disorders are present in over 50% of children with absence epilepsy with ADHD being the most common diagnosis. Worsening school performance occurs overwhelmingly in patients diagnosed with absence epilepsy and is caused by a combination of frequent spells of unconsciousness and the psychiatric issues.9 Although intellect and development are usually normal, neurocognitive testing may show that executive function is mildly impaired in these children. 10

9 10

Absence epilepsy is treated with specific anti-epileptic drugs (AEDs). Ethosuximide and valproate are the first choice drugs for controlling absence seizures. As absence seizures are a generalized epilepsy, many patients have other seizures types, including myoclonic and tonic clonic events. Valproate and lamotrigine are used to treat absence seizures alongside these other seizure types. Na+ channel blocking drugs such as oxcarbazepine, phenytoin, and carbamazepine are ineffective and contraindicated in treating absence epilepsy. 7 Prognosis is good, with many patients becoming seizure free. Remission of CAE usually occurs around the age of puberty. The diagnostic criteria for absence epilepsy has experienced several changes over the years. As a result, there is variability in reported remission rates. Some studies show remission rates as high as 90% in teens.11 Despite the good prognosis for the seizures, the psychiatric comorbidities such as ADHD can persist for a longer period in the patient. Conclusion Staring spells in children can be caused by a variety of reasons. Common non-epileptic causes include ADHD, daydreaming, autism, and childhood preoccupation. Once non-epileptic causes are ruled out, absence seizures are considered. These seizures are characterized by abrupt motor arrest and staring episodes. The condition may be documented by EEG studies. Absence seizures can occur in the juvenile years but occur more frequently in childhood. Seizure control is achieved in the majority of patients. Typically, the prognosis is better in the childhood form of the disease. More information about absence seizures and epilepsies can be found at the Epilepsy Foundationâ&#x20AC;&#x2122;s website. References 1.

Khan A., Hussain N, Whitehouse WP. Evaluation of staring episodes in children. Arch Dis Child - Educ Pract. 2012;2(4).

Olsson I. Epidemiology of absence epilepsy. Acta Paediatr. 1988;77(6):860-866.

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3. Berg AT, Shinnar S, Levy SR, Testa FM. Newly diagnosed epilepsy in children: presentation at diagnosis. Epilepsia. 1999;40(4):445-452. 4. Sadleir LG, Farrell K, Smith S, Connolly MB, Scheffer IE. Electroclinical features of absence seizures in sleep. Epilepsy Res. 2011;93(2-3):216220. 5. Larsson K, Eeg-Olofsson O. A population based study of epilepsy in children from a Swedish county. Eur J Paediatr Neurol. 2006;10(3):107113. 6. Futatsugi Y, Riviello JJ. Mechanisms of generalized absence epilepsy. Brain Dev. 1998;20(2):75-79. 7. Matricardi S, Verrotti A, Chiarelli F, Cerminara C, Curatolo P. Current advances in childhood absence epilepsy. Pediatr Neurol. 2014;50(3):205-212. 8. EpilepsyDiagnosis.org. https://www.epilepsydiagnosis.org/. Accessed July 8, 2015. 9. Caplan R, Siddarth P, Stahl L, et al. Childhood absence epilepsy: Behavioral, cognitive, and linguistic comorbidities. Epilepsia. 2008;49(11):1838-1846. 10. Loring DW. School achievement in childhood absence epilepsy. Epilepsy Curr. 2014;(6):68-70. 11. Callenbach PMC, Bouma PAD, Geerts AT, et al. Long-term outcome of childhood absence epilepsy: Dutch study of epilepsy in childhood. Epilepsy Res. 2009;83(2-3):249-256.

Author Information Assistant Professor, School of Medicine, University of Mississippi Medical Center, Department of Pediatrics, Division of Pediatric Neurology, jingram@umc.edu (Dr. Ingram). Corresponding Author Salma Dawoud, 3975 I-55 N. Jackson, MS 39216. ph: (601) 307-2745, salma.dawoud@gmail.com n

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When the Treatment Becomes the Problem VIVEK-THOMAS J. SANKOORIKAL, MD AND JANET RICKS, DO

47-year-old white male with a 5-year history of type 2 diabetes mellitus presented to clinic with uncontrolled hyperglycemia, weight loss, and body aches that impeded his ability to work and sleep. He had initially controlled his diabetes successfully with weight loss and exercise. However, in the previous 6 months he had noticed unintentional weight loss. He was evaluated at another clinic where he was prescribed sitagliptin/ metformin (Janumet) for his uncontrolled hyperglycemia. After 6 weeks his blood glucose had not significantly improved, and an endocrinologist prescribed insulin glargine (Lantus) and insulin aspart (NovoLog). About 3 days later he developed migratory joint pains and myalgias. After some weeks his insulin regimen was changed to insulin detemir (Levemir), and his myalgia symptoms briefly improved but then worsened. He experienced tingling of his feet that caused increasing difficulty sleeping. A patient with a history of diabetes controlled with diet and exercise that becomes uncontrolled with no changes in diet or exercise makes one think about worsening resistance to insulin. Neuropathy in his feet could indicate clinically worsening diabetes. Moreover, he is having trouble controlling his blood glucose with oral diabetic medications. An initial differential includes congenital resistance and natural worsening of type 2 diabetes as well as diseases that may decrease the pancreas’s ability to create insulin, such as autoimmune, cancer or infectious diseases. One must also consider inconsistent medication use. However, his hyperglycemia coupled with his weight loss and arthralgias/ myalgias complicate the matter somewhat. The differential for weight loss could include malignancy, celiac disease, peptic ulcer disease, endocrine diseases (hyperthyroidism or diabetes), illicit drug use or psychiatric disorders. The nonspecific migratory joint pains can indicate a systemic response to rheumatological conditions, autoimmune causes, infection, fibromyalgia or cancer. There is overlap in the possible causes of each of his problems. However, is there a common process that may explain the various components of his presentation? The temporal relationship of his myalgias and arthralgias with his insulin use indicates another possibility: an allergic response to insulin. An allergic response to insulin would present a disturbing clinical conundrum — how do you treat a poorly controlled diabetic if he/she is allergic to insulin? However, more history needs to be obtained.

His review of systems was remarkable for fatigue, weight loss, polydipsia, polyphagia, polyuria, myalgias and arthralgias, numbness and tingling of both feet, and difficulty sleeping. The patient denied fever and chills, abdominal pain, nausea, vomiting, and diarrhea. He had a past medical history of diabetes mellitus and hypertension. He had no surgical history. He denied a family history of diabetes, hypertension or heart disease in mother or father. He denied use of tobacco, alcohol or illicit drugs. He has symptoms of worsening diabetes as seen by his increased urination and thirst as well as neuropathy of his feet. A physical exam could help to narrow the major causes for hyperglycemia, weight loss and arthralgias. To look for signs of hyperglycemia, an exam can focus on skin changes such as rashes or fungal growth. One can also look for acanthosis nigricans, a skin darkening that can indicate uncontrolled diabetes. A constitutional exam can reveal signs of weight loss from uncontrolled diabetes and dehydration as evidenced by muscle mass or lack thereof. An abdominal exam would give information on the size of his liver and spleen as well as tenderness or masses that could be signs of cancers or insulinomas, a mass that can cause increased insulin secretion. Finally, a joint exam may reveal swelling or redness of his joints as well as difficulty moving his joints, which can help us differentiate between allergic, rheumatologic or infectious causes. Upon initial physical examination, the patient was noted to have an oral temperature of 98.7°F, blood pressure of 183/108 mm Hg and a pulse of 108 beats per minute. His weight was noted to be 150 pounds, and he had a body mass index of 21 kg/m2. He appeared slightly undernourished. His cardiovascular exam was significant for mild tachycardia, regular rhythm, and no murmurs. His abdominal exam revealed normal bowel sounds and a soft, non-tender abdomen without palpable masses. His skin exam was significant for scaling of right thigh and fungal changes of both great toenails. Lung, joint, and monofilament exams were normal. His psychiatric exam was significant for appearing somewhat anxious. His previous Hgb A1C from another clinic was 13.8%. Mild tachycardia with regular rhythm could indicate dehydration. He denies chest pain or shortness of breath, so a cardiac cause of tachycardia is lower on the differential. Another cause of mild tachycardia is hyperthyroidism; however, the JOURNAL MSMA

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patient has no other symptoms of hyperthyroidism such as heat intolerance, thyroid enlargement or pain, or palpitations. Another important part of his initial examination is that he had no tenderness or frank masses on palpation. This does not rule out a pancreatic mass or cancer, but it does make it somewhat less likely. His skin exam shows no evidence of hives, though he has scaling of his right thigh and fungal changes. Fungal changes of toenails can be an indirect marker of worsening diabetes control. A basic metabolic panel will investigate his electrolyte status as well as his kidney function, and a complete blood count could investigate for infections. Given his weight loss and arthralgias, an erythrocyte sedimentation rate, C-reactive protein, and anti-nuclear antibody would evaluate for autoimmune causes. His seemingly worsening glucose control as evidenced by his Hgb A1C could be explored by obtaining insulin, C-peptide, and glucagon concentrations. His basic metabolic panel was significant for a sodium of 132 mmol/L, chloride of 90 mmol/L, a glucose of 352 mg/dL, a bicarbonate of 21 mmol/L, and an anion gap of 20 mmol/L. His complete blood count was significant for a white blood cell count of 2800 per cm3. An elevated blood glucose with an elevated anion gap can indicate diabetic ketoacidosis. Diabetic ketoacidosis is caused by the body’s inability to control blood glucose concentrations from either insulin deficiency or insulin resistance and may lead to a metabolic acidosis due to severe dehydration.1 Diabetic ketoacidosis can be extremely dangerous, depending on the degree of dehydration. Patients with diabetic ketoacidosis are typically treated in an inpatient setting with a combination of intravenous fluids and insulin.2 However, if he didn’t tolerate conventional insulin formulas, what can he be treated with? Moreover, the leukopenia is worrisome for immunodeficiency which warrants viral studies and further autoimmune studies. Because of these electrolyte derangements and decreased bicarbonate along with an elevated anion gap, we will hospitalize the patient to treat his diabetic ketoacidosis and investigate his low white blood cell count. The patient was treated with intravenous fluids to correct his anion gap and intermittent insulin lispro (Humalog) by sliding scale every 4 hours. By the next morning his anion gap had normalized. His hypertension was addressed, and he was restarted on his previous valsartan (Diovan). Moreover, his leukopenia resolved the next day. Viral study results (human immunodeficiency virus, hepatitis, mononucleosis/Epstein Barr virus) were negative, and his leukopenia resolved. An abdominal ultrasound to investigate for a possible pancreatic mass was unremarkable. Vitamin B12 and folate tests were within normal limits. Autoimmune studies (erythrocyte sedimentation rate, C - reactive protein, cyclic citrullinated peptide anti-nuclear antibody) proved to be negative as well. His serum insulin concentration was measured to be 2.0 µUnits/mL (normal 2-25). His serum C-peptide concentration was 0.74 ng/mL (normal 0.78-5.19). As 214 VOL. 57 • NO. 7 • 2016

his anion gap closed and he was clinically stable, he was discharged on a lispro sliding scale and neutral protamine hagedorn insulin, different insulins than he had been treated with as an outpatient, per the consultant endocrinologist’s recommendations. His hospital investigations for his arthralgias and weight loss did not indicate infectious or autoimmune diseases or pancreatic mass/cancer; however, his insulin concentration was low-normal, 2.0 µUnits/mL. This combined with his low C-peptide concentration (a byproduct of endogenous insulin production) indicates that he is becoming a type 1 diabetic. As a type 1 diabetic, he requires insulin to control his glucose and prevent diabetic ketoacidosis. The fact that his symptoms always start on initiation of insulin therapy strongly suggest an allergic reaction to insulin. The endocrinologist recommends attempting other types of insulin to identify the specific antigen causing his allergic reaction. Two weeks after discharge, the patient returned to clinic for his routine hospital follow up. His arthralgias had resumed after initiation of his new insulin treatment. The effects usually occurred 2-3 hours after taking his insulin. He was referred to an allergist for further investigation of post-insulin reactions. The estimated prevalence of reactions to insulin is 2%, and insulin allergy is a rare complication of insulin treatment.3,4 In most cases, allergic reactions to insulin are restricted to the skin and are often self-limited.4 Most allergic reactions to preservatives appear within a few minutes of injection. These reactions can include red rash, induration, itching, burning sensations, flushing, and urticaria.6 His clinical features of initial leukopenia and myalgias/arthralgias, which improved when he stopped using insulin, seemed compatible with immune complex disease, either to insulin or the insulin preservatives, or a hypersensitivity reaction. There are 4 types of hypersensitivity. Type I or IgE mediated reactions, the most common type, is characterized by an immediate (within minutes) local (mild itching) or systemic (anaphylaxis) response. Type II hypersensitivity, or cytotoxic hypersensitivity, is indicated by localized reactions to antigens on the patient’s cell surfaces causing acute inflammation destroying cells, e.g. autoimmune hemolytic anemia. Type IV hypersensitivity reactions are a T-cell mediated response that can take 1-2 days to develop and causes localized inflammation such as contact dermatitis. Type III hypersensitivity, which is what this patient is thought to have because of the time course and systemic nature of his symptoms, is caused by immune complex formation that is characterized by a localized Arthus reaction (deposition of antigen/antibody complexes in vascular walls). This may cause inflammation that leads to myalgias and arthralgias.4 Possible insulin preparation allergens include additives such as zinc and protamine, solvents (such as meta cresol, glycerol, phenol, sodium phosphate), local disinfectants, and latex.5 After consulting with the allergist, the patient was evaluated by an endocrinologist who specialized in

treatment of insulin allergies. He prescribed metformin (Glucophage), canagliflozin (Invokana), and exenatide (Bydureon) to reduce the patient’s insulin requirement. In addition, he was prescribed insulin glulisine (Apidra) with low dose dexamethasone via insulin pump. With this combination of medications, his hyperglycemia and control of diabetes greatly improved as well as his myalgia and neuropathy. His Hgb A1C improved to 6.9%, and his symptoms had abated to the point where he could return to work. There are 3 main ways to achieve glycemic control while preventing allergic symptoms. The first method is to reduce insulin requirements by maximizing oral and non-insulin treatments for diabetes. Another method is to induce tolerance with the application of small amounts of insulin as a continuous subcutaneous infusion.6 The rationale behind continuous insulin is to prevent single large doses of insulin to help reduce the likelihood of an immune response. Finally, one can suppress the body’s immune response to insulin through the use of steroids or hydroxychloroquine (Plaquenil).6 For this patient, a combination method was chosen. First, a reduction of his insulin requirements was obtained with non-insulin methods (i.e. canagliflozin and exenatide). As he still required some insulin, combining his continuous insulin with a steroid helped to suppress his immune system to reduce the chance that the insulin will cause a reaction. For this patient, this combination worked very well and allowed him to live and work with his diabetes while tolerating his insulin. Key words: insulin, allergy, preservatives, myalgias References 1. Ripsin C, Kang H, Urban R. Management of blood glucose in type 2 diabetes mellitus. Am Fam Physician. 2009;79(1):29-36. 2. ADA Standards of medical care in diabetes. Diabetes Care. 2015;38, Supplement 1:80-85. 3. Fidalgo O, Jorge S, Veleiro B, Isidro M. A case of skin, and secondarily generalized, reaction to insulin injection. Clinical Diabetes. 2014;32(3):127-129. 4. Akinci B, Yener S, Bayraktar F, Yesil S. Allergic reactions to human insulin, a review of current knowledge and treatment options. Endocrine. 2010;37(1):33-39. 5. Bodtger U, Wittrup M. A rational clinical approach to suspected insulin allergy: status after five years and 22 cases. Diabet Med. 2005;22(1):102106. 6. Heinzerling, L, Raile K, Rochlitz H, Zuberbier T, Worm M. Insulin allergy: clinical manifestations and management strategies. Allergy. 2008;63(2):148-155.

Calling All Mississippi Physician-Photographers

Enter the JMSMA 2017 cover photo contest

Film or Digital Shoot anything you can capture as a high-resolution image. Subjects given the highest consideration are those indicative of Mississippi. Photos of original artwork are also acceptable. The MSMA Committee on Publications will judge the entries on the merits of quality, composition, originality, and appropriateness to the JMSMA. Specifications: Color slides, digital files & photos (at least 300 DPI/PPI). A hard copy print is required for judging. Please include a brief description of the image and information about the physican/photographer. Size: Vertical format 5 x 7” or 8 x 10” Deadline: November 28, 2016 For more info contact: Karen Evers, Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com

Author Information Family medicine resident PGY III (Dr. Sankoorikal); associate professor, residency director, osteopathic family medicine, and associate residency director, family medicine (Dr. Ricks); University of Mississippi Medical Center, Department of Family Medicine, 2500 North State Street, Jackson, MS, 39216. Phone: (601)984-6800 (Office) Fax: (601)984-6811 (vsankoorikal@umc.edu).

Mail to: P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to MSMA headquarters 408 W. Parkway Place, Ridgeland, MS 39157

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L E G A L E S E

Emotion Incites Rights Fight: When Your Personal Liberty Infects Mine

Sarah Mann

Many of you may have seen in the news or social media that a vaccination bill passed in the House of Representatives this session, but died in the Senate.1 This was an unprecedented win for vaccination rights advocates. The bill would have deleted the Department of Health from any oversight and would have allowed any United States licensed physician to provide a letter to the parent claiming the child is exempt for reasons of health or well-being. The parent would then give the physician letter to the school, and the school would be required to accept the exemption. Each school would then be responsible for storing and tracking vaccination waivers, a responsibility the schools likely don’t want.

The bill gave no indication that the physician needs to be familiar with communicable diseases nor did it address if the physician must have a license in Mississippi, if the physician must see the child in person, or if an actual physical examination is even required. Only an “examination” would have been sufficient. While the bill was touted as a medical exemption, the language in the bill left the door wide open for philosophical or religious exemptions thus rendering the required vaccination system useless. So why the sudden push for a change in Mississippi’s vaccination laws? Mississippi is leading the nation with its strict vaccination policy. The current law gives no philosophical or religious exemptions, only an exemption for medical necessity that then must be approved by the Department of Health. As measles hotspots are increasingly popping up, many states, like California, are contemplating tighter restrictions on exemptions in the hopes of curtailing these outbreaks. Vaccination rights activists have argued in the past that vaccinations may cause autism or other illnesses. This argument never gained much traction and has primarily been abandoned.2 However, with the rise of individual liberty sentiment and the election of Tea Party members, older arguments have resurfaced. The arguments of personal liberty and freedom from government intrusion used by vaccination rights activists today were actually some of the first arguments made against mandatory vaccinations.3 These principles were challenged in courts throughout the country at the turn of the century and were deemed too weak to outweigh the public’s interest in protecting the majority from communicable diseases. Thus, the movement against vaccinations has shifted from scientific assertions to arguments that have already been addressed. To understand this new push and combat it successfully, one must understand why this has yet again become an issue for our legislators. Personal liberty and government intrusion were some of the major issues that swayed many legislators who have formerly been physician-friendly and supportive of mandatory vaccinations. Many legislators expressed the sentiment that freedom of choice outweighed government intrusion into the family decision-making process of whether to vaccinate or not. But again, courts across the country have already established that issues of free exercise of religion, parental rights, and body autonomy all must be balanced against the government’s interest in keeping the community free from communicable diseases.4 The vast majority of courts have held that the government’s interest in protecting society outweighs the individual’s interest and that states have the authority to mandate vaccinations for entry into schools. Religious Freedom Many believe that states have no legal right to force someone to receive shots that may go against their religious beliefs. Government accommodation of religious practices has long been an essential element of religious liberty in the United States. When state policies burden religious practices, governments are often called upon to carve out exemptions for those that are burdened. While religious accommodations are seen throughout the law, the principle becomes difficult when weighed against the government’s interest in protecting the public. To some, these competing interests are not strong enough factors to compel a citizen to relinquish these rights. Because all 50 states require some form of immunizations to enter public schools and every child is required to attend school, many feel that vaccinations are a violation of their First Amendment rights under the free-exercise clause because a child is compelled to perform an action (forced vaccinations) that is abhorrent to their religious beliefs, creating a significant undue burden on their freedom to exercise their religious beliefs. Many states have acknowledged this burden and created personal, philosophical, or religious belief exemptions to vaccinations. However, these exemptions raise concerns for hotspot outbreaks and decreased efficacy of herd immunity. To combat the religious or philosophical argument, a simple reminder of other people’s rights is helpful. The freedom to exercise one’s religious beliefs extends only so far as to not infringe on another’s rights. Because vaccinating as many children as possible protects those who cannot, for medical reasons, undergo vaccinations, the alleged right to be free from vaccinations infringes upon the rights of those who cannot protect themselves. Herd immunity is an interest the government has every right to protect because the competing interests of religious beliefs and public safety weigh more heavily in favor of those who are unable to undergo vaccinations. 216 VOL. 57 • NO. 7 • 2016

Parental Choice Another argument vaccination rights advocates purport is their constitutionally protected parental rights. The Supreme Court has upheld a parent’s right to direct their child’s upbringing and gives the parent the right to determine how their child will be educated. Since homeschooling or private school may not be an option for many parents, some feel that compelled vaccinations violate their protected rights to determine the education and upbringing of their child. While this argument is a compelling one, it can be negated by explaining to the parent that their decision ultimately does not affect just the upbringing of their child alone. It can affect other parents’ upbringing of their children if the child is medically unable to vaccinate. Additionally, it is in the best interests of the child to get vaccinated. Similar to child labor laws, state governments can supersede some parents’ decisional rights when the future health and well-being of society is threatened. Courts have found that vaccinations, like child labor laws, fall into this category. 5 Medical Necessity Lastly, many dissenters view the mandatory vaccinations as antiquated. The legal precedent on which the states rely is over 100 years old. The social climate when mandatory vaccinations for children entering school began is much different than today. When the first case came about in 1905, smallpox was a rampant disease that devastated communities.6 The infection rates were dangerously high, and the public outcry for government intervention was strong. States began mandating vaccinations for entry into public schools, and some individuals objected to injecting foreign substances into their child’s body. The Supreme Court determined the government interest in protecting the public from smallpox outweighed the rights of the individual.7 But with the decline in smallpox infections, the public’s desire for government intervention declined as well. Some see the dangers and risks of outbreaks significantly decreased in present day and believe the government’s interests are not applicable any more. Unfortunately, the reason many feel vaccinations are outdated is due to the overwhelming success of vaccinations. Reminding your patient why they don’t see these diseases anymore and showing them photos of the diseases may be a useful tool in changing their minds. Realities of Vaccinations in Mississippi Since the vaccination bill died in the Senate, many of your patients may be unsure why it failed. After all, medical exemptions should be allowed if there is a medical complication with a child receiving the vaccinations. Many of your patients may not realize Mississippi has a medical exemption for vaccinations already. In fact, this school year alone, the Department of Health issued 137 exemptions to children in kindergarten through twelfth grade. The process to receiving an exemption is fairly straightforward. A Mississippi licensed pediatrician, family physician, or internist can request a medical exemption for any medical reason. The physician would fill out a Mississippi Department of Health Medical Exemption Request (Form 139), send it to the District Health Officer in the public health district where the child will attend school, and, if the request is granted, a Certificate of Medical Exemption (Form 122) is mailed to either the parent or the physician. You can access the forms on the Department of Health’s website, www.MSDH.MS.gov. Medical exemptions have been slightly on the rise in Mississippi since 2011. While some media attention has centered around the parent’s inability to get a medical exemption, the Department of Health issued over 100 exemptions in 2011 and has increased that number ever since. For calendar year 2015, of the 138 medical exemptions requested, 137 were approved. Only two (not included in the total number) were philosophical exemptions requested on the medical form. Only 2 additional forms are outstanding because the Health Department requested additional information. Dr. Thomas Dobbs, State Epidemiologist, Mississippi State Department of Health, says, “The vast majority of parents understand the benefits of immunizations, both for the child and community. Unfounded fears about links to autism have frightened a small minority of patients. Extensive study has identified no such link. We encourage parents to discuss any fears or concerns with their child’s primary provider.” When asked why exemptions are on the rise, Dr. Dobbs answered, “The vast majority of children in Mississippi are immunized (>99%). The increase in Mississippi is attributable in large part to the changes in policies that allow the child’s physician to determine when an exemption is appropriate. The success of immunizations has allowed many to be aware of the devastating consequences of these diseases. In many parts of the country, particularly California, recognition of the risk of vaccine preventable illnesses is boosting immunization numbers.” As the medical professional, understanding the concerns faced by your patient who opposes vaccinations is of the utmost importance. It is not enough to simply assume those who wish to reject vaccinations as misinformed or uneducated in communicable diseases. While science is on the side of vaccinations, using science as your only argument may not be enough to win over a patient who is not vaccinating their child for philosophical or personal beliefs. By understanding and empathizing with these concerns and then educating the patient as to why all medically able children should receive vaccinations, you will be better able to alleviate these concerns. If parents realize that dangerous, vaccine-preventable JOURNAL MSMA

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illnesses are still an immediate problem in America as well as worldwide and can return if too many people are not vaccinated, then perhaps you can impress upon them that the need for vaccinations overrides their personal beliefs. Their actions have consequences that can affect more than just their immediate family. If a patient’s argument is personal liberty, then you can educate them on how it is not just their child that will be affected but society as a whole. Leading up to the 2017 legislative session, MSMA will work to facilitate educating the public and legislators on the importance of vaccinations. MSMA is working in conjunction with the Department of Health and other stakeholders to create an education campaign emphasizing the importance of vaccinating Mississippi’s children. Your prompt responses to legislative calls to action were a major factor in stopping House Bill 938. The active participation of Mississippi’s physicians, nurses, and other healthcare workers will be imperative in this ongoing debate. References 1.

H.R. 938, 2016 Reg. Sess., (MS 2016).

Lisa Greene, Two Sides Unable to Bridge Gap, St. Petersburg Times, Nov. 24, 2008, at 1A (stating that autism occurs in 1 out of 150 children, and if vaccines were the cause, scientists would have noticed).

Blue v. Beach, 56 N.E. 89, 91 (Ind. 1900), (holding that an “outrage upon personal liberty” doesn’t deter a state’s interest in mandatory vaccines).

Bellotti v. Baird, 443 U.S. 622, 634-38 (1979), Prince v. Massachusetts, 321 U.S. 158, 166 (1944). Brown v. Stone, 378 So.2d 218 (Miss 1979) (deeming religious exemptions unconstitutional).

Powell v. Alabama, 287 U.S. 45, 50, 57-58 (1932) (comparing child labor laws to religious minorities), see also Wisconsin v. Yoder, 406 U.S. 205, 221 (1972) (ruling that education is necessary to prepare citizens to participate in society effectively and intelligently, and to prepare individuals to be self-reliant and selfsufficient in society).

Jacobson v. Massachusetts, 197 U.S. 11 (1905) (plaintiff alleged that the mandatory immunization law was an invasion to his body and liberty because he could not care for himself as he saw best), see also, Blue v. Beach, 56 N.E. 89, 91 (Ind. 1900), (holding that an “outrage upon personal liberty” doesn’t deter a state’s interest in mandatory vaccines).

Jacobson v. Massachussetts.

Author Information Sarah Mann is a native of Clinton, Mississippi. She graduated with a Bachelors of Science in Political Science and earned a Masters of Social Science in History and Political Science, both at Mississippi College. She is attending Mississippi College School of Law and plans to work in *AD - MSMAJ - 3.75X4.875_Layout 1 5/19/16 9:26 AM Page 1 Healthcare Law when she graduates in the spring of 2017.

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Our vision is to be an essential part of every Mississippi physician’s professional life. 2 0 1 6 S T R AT E G I C P L A N

CORE VALUES • Ethics, integrity and professionalism are essential elements of good medical practice. • Physician advocacy that protects the doctor-patient relationship is essential for patient care. • In the interest of our patients and our communities, physicians should provide leadership in matters affecting healthcare. • The physician-patient relationship is the cornerstone of our healthcare system. MISSION: MSMA is a physician organization serving as an advocate for physicians and their patients. GOAL 1: ENGAGE MORE MEMBERS IN MORE WAYS MSMA empowers membership groups to increase physician engagement. Members are the life blood of MSMA. Our highest priority is to be an essential part of every Mississippi physician’s professional life in order to maintain and enhance the physician’s position as the voice of medicine in our state. Watch for new efforts to engage physicians based on personal interests like specialty, employment status, state politics and elections, immunizations and/or CME in family-friendly destinations. MSMA is earnestly reaching out to employed physicians, international medical graduates, women physicians and other interest groups seeking their impact on MSMA policies and benefits. GOAL 2: : LEVERAGE HIGH-TECH MARKETING TOOLS TO EDUCATE AND COMMUNICATE At a time when technology is having profound implications on education and healthcare, MSMA is expanding communication avenues to meet the information needs of more members more often. This includes leveraging technology to make the physician’s voice stronger and to make it easy to enhance your social media presence. GOAL 3: LEAD BY EXAMPLE AND BE INCLUSIVE MSMA advances its leadership efforts, especially targeting diverse groups of members. MSMA has a long history of leadership in healthcare in Mississippi, and in the changing environment members expect MSMA to not only maintain its efforts, but to expand into new arenas. By expanding the Physician Leadership Academy, MSMA will create ambassadors for component and specialty societies, provide more leadership opportunities to younger members and international medical graduates, and continue to provide members with timely information on changes in payment models, regulations and quality indicators. GOAL 4: GIVE PHYSICIANS A MEGAPHONE As the leaders of the healthcare team physicians have a lot to say about laws and regulations that protect the doctor-patient relationship, weaken the quality of healthcare or allow inappropriate application of technology. MSMA has a long history of success at the State Capitol and on Capitol Hill. To sustain this success MSMA will forcefully push policy makers to protect the physician as the leader of the healthcare team making the voice of physicians heard loudly and clearly. MSMA will embrace all groups within organized medicine to leverage the influence and lobbying power of more physicians to improve the practice environment and ensure the physician’s place at the head of the healthcare team while protecting the physician-patient relationship. GOAL 5: STRUCTURE FOR AN EFFECTIVE FUTURE Enhance organization efficiency and effectiveness to better serve a more diversified membership. MSMA must have an efficient organization and sufficient resources to capitalize on emerging technologies, provide meaningful communication with a growing and diverse membership and, above all, have a sound and sustainable financial footing.

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Membership BY THE NUMBERS 4,741 members as of July 1, 2016 62% practicing physicians 14% students

11% retired 13% residents

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

+/-

2016

Paid Active Members

2,887

2,890

2,872

2,2691

3,059

3,141

3,146

3,129

3,047

2,750

+184

2,934

Retired Members

444

468

444

511

505

486

461

495

523

539

-15

524

Student Members

328

353

377

433

596

532

554

570

633

737

-75

662

Residents & Fellows

148

149

103

469

476

449

536

586

635

-14

621

3,087

3,860

3,796

3,709

4,629

4,635

4,610

4,710

4,789

4,661

+80

4,741

TOTAL

PARTNERS Exclusive HIPAA safe messaging system DocBook MD is a secure messaging application for smartphone and tablet devices free to MSMA members. MSMA is the exclusive source in Mississippi for DocBookMD—the nationally recognized leader in secure messaging to your medical care team. (PS – It was invented by physicians for physicians.)

Stay in Compliance — at a discounted rate This management solution for physician practices provides a comprehensive compliance program that saves time/money and mitigates risks for physicians in private practice, those responsible for managing compliance in hospital networks, health systems, skilled nursing facilities and for healthcare billing companies.

Lowest rate anywhere for air-medical transport Keep yourself and your family safe when traveling in US or abroad with MedJet Assist, the premier air-medical transport membership program for travelers. MedJet Assist arranges medical transfer when you are injured or hospitalized 150 or more miles from home from anywhere in the world to the hospital of your choice in your home country. Traveling overseas or planning a ski vacation? MedJet Assist can be a lifesaver for you and your family.

Mississippi Drug Card Can be used for savings of up to 75% on prescription drugs at over 56,000 pharmacies nationwide including almost every pharmacy in Mississippi. The program has no membership restrictions, no income limits, no age limitations and there are no applications to complete. Cards are available for your patients and other groups in your community, and they’re free. Request a supply of discount cards today.

Mississippi Physicians Care Network Provides the broadest choice of physicians and facilities in the state at competitive, network negotiated rates. MPCN offers webbased claim pricing, allowing customer and provider access to re-price claims online.

Randall Commercial Group, LLC Buying or selling medical real estate requires a special eye. Randall Commercial Group, LLC is a commercial real estate investment brokerage specializing in healthcare real estate.

Events CME on the Slopes FEBRUARY 18-22, 2016

iPASS

OXFORD: MAY 13, 2016 | JACKSON: MAY 11, 2016

CME in the Sand MAY 27-31,2016

Annual Session AUGUST 14-15, 2015

AMA Annual Meeting JUNE 10-15, 2016

JOURNAL MSMA

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Creating leaders in healthcare PHYSICIAN LEADERSHIP ACADEMY Founded in 2014, the MSMA Physician Leadership Academy seeks to equip early-career physicians with the skills and tools necessary to become the future leaders of organized medicine. The program is structured around six day-long sessions, each focused on an aspect of leadership. Experts coach participants on speaking to media, working effectively with colleagues, political advocacy, negotiation, conflict resolution and more. The Class of 2016 consists of eleven physicians from nine different specialties and four cities. Graduates of the program will be invited to serve as mentors to future Physician Leadership Academy scholars. For more information or to apply, visit www.MSMAonline.com/Leadership

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Advocating for physicians and patients MSMA physicians worked hard during the 2016 Legislative Session to protect the practice of medicine: We saved the best immunization law in the U.S. Mississippi has the best and strongest school age immunization rate in the nation and we aim to keep it that way! MSMA linked arms with the State Health Department to stand up to a small (but very vocal) group of anti-immunize parents trying to eliminate or at least weaken Health Department oversight of vaccine requirements. Sympathetic legislators immune from scientific facts will likely continue to try to weaken the nation’s strongest school entry immunization requirements. MSMA paved a path through licensure bureaucracy. New legislation paved the way for Mississippi to join the Interstate Medical Licensure Compact and create an expedited path to license out-of-state physicians wanting to practice in Mississippi. Physicians recruiting partners and facilities recruiting physicians have needed a way to put physicians to work faster, and the compact offers an alternative for those seeking licensure within compact states. We killed a bad telemedicine bill to ensure our patients’ quality of care. Looking on telemedicine as an “electronic physician-extender,” MSMA is at the State Capitol and on Capitol Hill pushing laws that ensure good medicine via technology. Commercial telemedicine companies want the legislature to validate their telephone-only care model for direct-to-consumer encounters. State House leadership bought into the out-ofstate companies’ push to “increase access” for insured patients and those with a credit card. MSMA seeks not only to increase access to physicians for those patients who can’t travel to a large medical center for care or a consult, but also to embrace physician-patient encounters using technology in a way that replicates an in-person encounter.

DOCTOR OF THE DAY

Dozens of MSMA physicians each year volunteer to be the Doctor of the Day at the State Capitol during the legislative session. Each volunteer physician works with MSMA’s Capitol nurse to treat a variety of common maladies presented by lawmakers and Capitol staff.

WHITE COAT RALLY

Scores of medical students and physicians descended en masse on the State Capitol in February to oppose a telemedicine bill designed to allow out-of-state physicians (holding a Mississippi license) to diagnose and treat patients in Mississippi without being able to see the patient. Physicians and medical students led by MSMA President Dr. Daniel Edney held a news conference and met with lawmakers.

PUBLIC HEALTH REPORT CARD

The 2016 Public Health Report Card was structured around the World Health Organization’s 25x25 campaign to lower premature death from non-communicable diseases by 25% by the year 2025. MSMA President Daniel Edney, MD, and State Epidemiologist Thomas Dobbs, MD, presented the card publicly at the State Capitol. JOURNAL MSMA

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Financial Report Expenses 2015

EXPENSES

DOLLARS

Event Expenses Accreditation CME Communication Government Journal, MSMA MPHP Contribution Specialty Management Travel, Meals & Meetings Building & Equipment Administrative & General

335,360 65,757 47,517 169,724 350,254 183,367 25,000 34,948 128,917 166,728 962,760

Total MSMA Expenses

Misc Revenue 1% Admin & Mgmt Fees 2%

Event Expenses 14%

MPCN Dividend

Communication 7%

Admin & Gen'l 39%

Government 14% Bldg & Eqpt 7%

Travel, Meals & Specialty Mgmt Meetings 1% 5%

Journal, MSMA 7%

MPHP Contribution 1%

2,470,332

REVENUE

Revenue 2015

Rental Income 2%

MACM 1% Sponsorship 6%

Accreditation 3% CME 2%

Subsidiary Svc 8%

Event Revenue 15%

CME 2% Accreditation 2% Journal, MSMA 2%

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Membership Dues 59%

DOLLARS

Membership Dues Journal, MSMA Accreditation CME Event Revenue MACM Sponsorship MPCN Dividend Administrative & Management Fees Rental Income Miscellaneous Revenue Subsidiary Services

1,457,682 46,904 59,275 39,701 370,715 150,000 35,000 44,600 59,848 24,918 194,867

Total MSMA Revenue

2,483,510

Looking Ahead

Learn more at MSMAonline.com

CME WITH MICKEY MOUSE MSMA is hosting its first professional develop-

ment event at Walt Disney World on November 19-22, 2016. Physicians and nurse practitioners can earn up to 10 CME credits on a variety of topics.

ALL-NEW MSMAONLINE.COM This year, MSMA launched its completely re-

designed website with increased user functionality. Members can pay dues online, sign up for events, view their council, committee and society information, and access exclusive resources quickly and easily.

COMPONENT SOCIETY RESCUE MSMA President Dr. Daniel Edney has

launched a Component Society Rescue program as an effort to reignite interest in local component societies and ease the administrative burden on officers. For a flat fee, MSMA staff will create customized Component Society Rescue plans tailored to participating society’s needs, including organizing meetings, sending invitations, lining up speakers, and arranging CME events.

IMMUNIZATION COALITION The Department of Health is reactivating the

Mississippi Immunization Coalition as an effort to keep our state’s vaccine policy strong. MSMA has invested $50,000 in the project, which will include a web-driven public health campaign and advocacy statewide.

PHYSICIAN’S POSITION: POLICY-MAKER EDITION Our new email news-

letter for Mississippi policy makers and government leaders keeps MSMA’s advocacy efforts visible year-round. Each newsletter can be accessed at MSMAonline. com/Advocacy.

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HER INSURANCE MUST BE WITH MACM What’s one way to guarantee a few extra minutes of R&R? Know that Medical Assurance Company of Mississippi is working to protect you and your medical practice. MACM insureds don’t worry when it comes to decisions regarding their professional liability coverage. For 40 years, Mississippi physicians have depended on the security and financial stability of MACM. And, even now, we remain an organization governed by physicians helping protect those who have put their faith and trust in us. Tammi M. Arrington

Marketing Representative

(800) 325-4172 tammi.arrington@macm.net

230 VOL. 57 • NO. 7 • 2016

If you are anxious over your current professional liability coverage, call Tammi Arrington for information and a quote. Let us help you relax.

U N I V E R S I T Y

O F

M I S S I S S I P P I

S C H O O L

O F

M E D I C I N E

Match Day and Commencement Summon Moments of Inspiration

oing to medical school just because you have brains is like running a marathon just because you have muscles.

him: “It was time for me to step up to the plate and help all these people who had supported me.”

Without motivation and desire, you’ll probably collapse long before the finish line.

Eventually, Jean Chamberlain became sick as well. If her son still had doubts about becoming a doctor, his reticence vanished in the fog of this family crisis.

No one knows this better than members of UMMC’s School of Medicine Class of 2016, who reached a personal and professional milestone on Residency Match Day at Jackson’s Thalia Mara Hall. The ubiquitous medical school ritual reveals to these imminent graduates where they’ll spend the next several years of their lives as they train for a specialty. Among them are Nicholas Chamberlain and a married couple, Eden and Sam Yelverton: three future residents whose inspiration to earn an M.D. at one time lay buried under layers of self-doubt or denial or lack of dedication.

“I was in medical school when my sister and I took care of my mom. It was an experience that you can’t get from textbooks,” he said. “There wasn’t a whole lot sleeping then. It was always something. But you never know how strong you are until you have to be that way.” During this time he learned what being a physician really meant, or what it means to him: “It’s not just giving out medicine. It’s showing compassion, not just to the patient, but also to the patient’s family.

No one would question their commitment now. Nicholas Chamberlain was no more than 4 when he heard he was going to be a doctor. This baffled him then and in the years to come. “I didn’t really know what that meant,” he said. “I didn’t know any doctors.”

“I was able to explain to my own family what was going on with their treatment. Otherwise, they’re just left in the dark. I don’t think anyone expects doctors and nurses to work miracles, but they do want you to keep them in the loop.”

Still, the person who made the prediction, Mattie Kelly, was not someone you dismissed lightly. She was his grandmother, a woman whose character was as strong as her body was weak.

As a physician, whenever he sees a patient, he’ll picture his mom; he’ll picture his grandmother. “I’ll think, ‘This is someone’s mother, this is someone’s child. How would you want your mother to be treated?’”

In fact, Chamberlain’s mother, Jean Chamberlain, moved her family from Columbus to Jackson in 1999 to take care of her. She was faithful to her mom in other ways as well. When it came to her son’s future, Jean Chamberlain was on board with Mattie Kelly’s prophecy. “For one thing, she pushed me to go to math and science camps,” Nicholas Chamberlain said. Her insistence paid off. Chamberlain excelled at Jim Hill High School, rising to battalion commander of Jackson Public Schools’ Junior Reserve Officer Training Corps. He was also a member of the International Baccalaureate Program. He was accepted to Brown University, where he studied for a bachelors’ degree in human biology. It was in his third year at the Providence, Rhode Island school that he fully embraced his destiny. “That’s when I made a conscious decision to go to medical school,” he said. But other factors shaped his decision subconsciously. Among them was watching many of his relatives suffer from illnesses. Lingering in the back of his mind was something his mom had once said to

Nicholas Chamberlain of Jackson, who finished medical school in May, discovered his passion for medicine through his own family’s experiences with illness.

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Chamberlain plans to do his residency in internal medicine. But his grandmother and mom won’t be there for his graduation in May. Mattie Kelly passed away right after he finished high school. Jean Chamberlain passed away about a year ago.

Left: Amanda Daggett, of Jackson, is recipient of the Waller S. Leathers Award for the medical student with the highest academic average for four years.

“They won’t see me walk across the stage; that’s the hardest part of all this,” he said, “but that confirms that this is what I need to do.” Eden Johnston, the daughter and granddaughter of two family doctors, didn’t know what she was going to be; she just knew what she wouldn’t be: a doctor. “My dad, who’s a physician in a small town, worked all the time. Many times, he was absent or had to leave different events in my life due to his work,” she said. “When you’re a child, you want your dad to be there. I could not understand that sacrifice, why the job was so worth it.” Sam Yelverton, the son and grandson of two general surgeons, thought becoming a physician “might be a good idea.” His grades during his first semester at Mississippi College said otherwise. It was as students at Mississippi College that Eden, of Mt. Olive, and Sam, of Jackson, met and fell in love - thanks to organic chemistry. Eventually, they were married - in medical school. Apparently, when it came to their chosen careers, something had changed Eden’s mind and Sam’s motivation. In each case, it was this: a taste of their dad’s medicine. “My grades in college were not good at first,” Sam Yelverton said. “Then I saw my first surgery.” The surgeon was someone he knew well. “My dad operated on a patient who had cancer; a week later, I got to see him give the family the news: the cancer was gone. They were so relieved, they broke down.

Right: Sarah Ali, is the recipient of the Jimmy Waites, MD, Student of the Year Award, sponsored by the Mississippi Physicians Care Network and the Medical Alumni Chapter. The award honors the memory of Dr. Waites who was a longtime family physician in Laurel and a member of the School of Medicine’s second graduating class. The award is presented to a graduating senior medical student selected by the senior class in recognition of those qualities most desired in a physician which Dr. Waites so exemplified.

“This person got a second chance at life. It still gives me chill bumps. I thought, ‘This is what I get to do? This is awesome.’ From then on, it was all A’s.” Eden, who shadowed her dad at his family medicine clinic in Mt. Olive, finally understood his sacrifice; she discovered why the job was worth it and what he meant to people of the town she grew up in. “Of course, it’s about serving people through science, through medicine,” she said, “but you’re also serving them at the scariest time of their life. “It’s being there for them in a way you cannot in most professions. My dad has impacted many people in my hometown and the area around it.” Seeing this, she knew what she wanted to do. Sam and Eden Yelverton entered medical school together; they were engaged their first year and married during their second, on Dec. 28, 2013, during Christmas break and long after they had realized, as Sam Yelverton put it, “we couldn’t do anything else but this.” As much or more than anyone else, two people were responsible for this epiphany. During a commencement day ritual, Dr. Richard Yelverton Jr. of Ridgeland, a general surgeon, placed a hood over future surgeon Sam Yelverton, his son; and Dr. Word Johnston of Mt. Olive hooded future OB-GYN Eden Johnston Yelverton, his daughter.

Eden and Sam Yelverton, who are from medical families, discovered their love of medicine by watching their fathers’ relationships with patients.

232 VOL. 57 • NO. 7 • 2016

In UMMC’s 60th Commencement held May 27, 2016, at the Mississippi Coliseum in Jackson, the School of Medicine conferred 128 Doctor of Medicine (M.D.) degrees.

University of Mississippi School of Medicine 2016 Match Results Sam Abbas - Internal Medicine

Established in 1993 by the MSMA Foundation, Raleigh Clark Cutrer and Emily Shannon Deaton share the honor of the Carl Gustav Evers, MD Award, given to a senior medical student who has demonstrated qualities of scholarship, peer-to-peer support, and exceptional leadership in student activities of the AMA and the MSMA.

The 2016 graduates included SOM graduate Zach Johnson, who’s headed to the University of Texas Southwestern in Dallas to complete a residency in neurosurgery. It’s a dream that Johnson, born in Greece while his dad was stationed there in the U.S. Air Force, has had for some time.

Medical University of South Carolina

Charleston, South Carolina

Sumner Abraham IV - Internal Medicine

University of Virginia

Charlottesville, Virginia

Sarah Ali - Internal Medicine

Kaiser Permanente Medical Center

San Francisco, California

Mikey Arceo IV - Emergency Medicine

University of Mississippi Medical Center

Jackson, Mississippi

Majdouline Asher - Obstetrics-Gynecology

“My grandfather died of a brain tumor when I was younger, so I had a passion for it,” said Johnson, 26, who attended high school in Ocean Springs and graduated from Mississippi College in Clinton. “I started medical school and wasn’t sure what I wanted to do, but I’ve always been interested in surgery because I love to work with my hands, and I love the complexities of neuroscience.”

University of North Carolina Hospital

Chapel Hill, North Carolina

Neurosurgery is a plum residency for any School of Medicine graduate. Johnson will spend seven years as a resident. “I had peace knowing I’d done everything I could up to that point,” he said of interviewing with the Dallas medical center. “It’s an incredibly humbling experience.” —UMMC Public Affairs Neal Simmons Boone is recipient of the Virginia Stansel Tolbert Award, sponsored by the MSMA given to a medical student who has demonstrated superior scholarship and leadership in campus activities. Additionally, the recipient must exhibit interest in issues which affect the profession and willingness to devote time and effort to those matters.

Khush Aujla - Medicine Preliminary

University of Mississippi Medical Center

Jackson, Mississippi

Radiation Oncology

University of Rochester/Strong Memorial

Rochester, New York

Summer Bailey - Obstetrics-Gynecology

University of Mississippi Medical Center

Jackson, Mississippi

John Ball - Medicine Preliminary

Jackson Memorial Hospital

Miami, Florida

Radiology

Icahn School of Medicine St. Luke’s-Roosevelt

New York, New York

Brett Barlow - Internal Medicine

University of Alabama Medical Center

Birmingham, Alabama

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Constance Barnes - Pediatrics

University of Mississippi Medical Center

Jackson, Mississippi

Andrew Benefield - Internal Medicine

Wake Forest Baptist Medical Center

Winston-Salem, North Carolina

IT WORKS!

Marlaina Berch - Pediatrics

University of Mississippi Medical Center

Jackson, Mississippi

Andrew Bingham - Emergency Medicine

University of Louisville School of Medicine

Louisville, Kentucky

Baker Boler - Internal Medicine

University of Mississippi Medical Center

Jackson, Mississippi

David Borzik, Jr. - Pathology

Johns Hopkins Hospital

Baltimore, Maryland

Andrew Brown - Internal Medicine

University of Mississippi Medical Center

Jackson, Mississippi

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Any products and services featured in this advertisement have not been independently evaluated by nor endorsed by MSMA. Raymond James is not affiliated with and does not sponsor, authorize, or endorse MSMA. * Other administrative fees and fees associated with the underlying investments may apply. Advisory fees are in addition to the internal expenses charged by mutual funds and other investment company securities. A list of additional considerations, as well as the fee schedule, is available in the firm’s Form ADV Part II as well as the client agreement.

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4/14/16 9:29 AM

U M M C

S C H O O L

O F

M E D I C I N E

M A T C H

R E S U L T S

Turner Brown - Orthopedic Surgery

Emily Deaton - Pediatrics

University of Mississippi Medical Center

Vanderbilt University Medical Center

Jackson, Mississippi

Nashville, Tennessee

Emily Bufkin - Medicine-Pediatrics

Cheshil Dixit - Internal Medicine

University of Alabama Medical Center

University of Mississippi Medical Center

Birmingham, Alabama

Jackson, Mississippi

Tyler Butts - Internal Medicine

Ashley Doucet - Pediatrics

University of South Alabama

University of Arkansas

Mobile, Alabama

Little Rock, Arkansas

Nick Chamberlain - Internal Medicine

Jessica Douglas - Family Medicine

University of Mississippi Medical Center

Jackson, Mississippi

Kimberly Chesteen - Internal Medicine

Matthew Dove - Pediatrics

Oregon Health and Science University

Vanderbilt University Medical Center

Portland, Oregon

Nashville, Tennessee

Clark Cutrer - Internal Medicine

Jonathan Ebelhar - Pediatrics

University of Mississippi Medical Center

Emory University School of Medicine

Jackson, Mississippi

Atlanta, Georgia

Amanda Daggett - Medicine Preliminary

Bryan Estill - Anesthesiology

Cedars-Sinai Medical Center

University of Washington Hospital

Los Angeles, California

Seattle, Washington

Dermatology

Logan Fair - Surgery-General

Tulane University

University of Mississippi Medical Center

New Orleans, Louisiana

Jackson, Mississippi

Cherie Dahm - Internal Medicine

Jonathan Feng - Medicine Preliminary

Vanderbilt University Medical Center

University of Mississippi Medical Center

Nashville, Tennessee

Jackson, Mississippi

Crystal Daigle - Medicine Preliminary

Ophthalmology

University of Mississippi Medical Center

Jackson, Mississippi

Ophthalmology

Nathan Freeman - Pediatrics

University of Alabama Medical Center

University of Mississippi Medical Center

Birmingham, Alabama

Jackson, Mississippi

Ellie Dauterive - Internal Medicine

Susan Frichter - Family Medicine

University of Mississippi Medical Center

North Mississippi Medical Center

Jackson, Mississippi

Tupelo, Mississippi

Chris Davis - Anesthesiology

Tracie Fullove - Family Medicine

Texas A&M College of Med.-Scott and White

University of Arkansas for Medical Sciences

Temple, Texas

Fayetteville, Arkansas

JOURNAL MSMA

235

Emily Gilbert - Medicine Preliminary

Katye Herring - Pediatrics

Baptist Health System

University of Mississippi Medical Center

Birmingham, Alabama

Jackson, Mississippi

Bill Gilbert, Jr. - Internal Medicine

Daniel Hester - Medicine-Pediatrics

University of Virginia

Rutgers-New Jersey Medical School

Charlottesville, Virginia

Newark, New Jersey

Reed Gilbow - Otolaryngology

Mitchell Hobbs - Pediatrics

University of Virginia

University of Mississippi Medical Center

Charlottesville, Virginia

Jackson, Mississippi

Ben Googe - Plastic Surgery

Daniel Holleyman - Emergency Medicine

University of Mississippi Medical Center

University of Arkansas

Jackson, Mississippi

Little Rock, Arkansas

Beau Grantier II - Emergency Medicine

Sara Claire Hutchins - Pediatrics

University of Mississippi Medical Center

Jackson, Mississippi

James Gray III - Family Medicine

Troy Jackson - Family Medicine

Providence Hospital-D.C.

Mountain Area Health Education Center

Washington, D.C.

Asheville, North Carolina

David Green - Family Medicine

Zach Johnson - Neurological Surgery

University of Mississippi Medical Center

University of Texas Southwestern Medical

Jackson, Mississippi

Dallas, Texas

Joey Griggs - Emergency Medicine

Connell Knight - Internal Medicine

San Antonio Military Medical Center

George Washington University

San Antonio, Texas

Washington, D.C.

Mallory Grove - Psychiatry

Noah Landy - Internal Medicine

Pine Rest Christian Mental Health Services

Loyola University Medical Center

Grand Rapids, Michigan

Maywood, Illinois

Jordan Gunn - Internal Medicine

Giles Langston - Emergency Medicine

Mayo School of Graduate Medical Education

University of Mississippi Medical Center

Rochester, Minnesota

Jackson, Mississippi

Stephanie Harrell - Pediatrics

Freda Lindsey - Pediatrics

Eastern Virginia Medical School

LSU School of Medicine

Norfolk, Virginia

New Orleans, Louisiana

Sam Harris - Internal Medicine

Ben Long - Internal Medicine

Texas A&M College of Med.-Scott and White

Medical University of South Carolina

Temple, Texas

Charleston, North Carolina

Anna Jade Hartzog - Surgery-Preliminary

Lance Majors - Internal Medicine

Vanderbilt University Medical Center

University of Mississippi Medical Center

Nashville, Tennessee

Jackson, Mississippi

Justin Hebert - Anesthesiology

Ryan Marshall - Otolaryngology

University of Mississippi Medical Center

University of Alabama Medical Center

Jackson, Mississippi

Birmingham, Alabama

236 VOL. 57 â&#x20AC;˘ NO. 7 â&#x20AC;˘ 2016

Brent McCaleb - Family Medicine

Erin Peeden - Medicine-Pediatrics

Bayfront Medical Center

University of South Alabama

St. Petersburg, Florida

Mobile, Alabama

Morgan Miller - Family Medicine

Sam Peeples - Internal Medicine

Forrest General Hospital

University of North Carolina Hospital

Hattiesburg, Mississippi

Chapel Hill, North Carolina

Brian Mitchell - Internal Medicine

John Russell Penick III - Internal Medicine

Virginia Commonwealth Univ. Health System

University of Alabama Medical Center

Richmond, Virginia

Birmingham, Alabama

Kris Mitchell - Family Medicine

Jason Pickett - Emergency Medicine

North Mississippi Medical Center

University of Mississippi Medical Center

Tupelo, Mississippi

Jackson, Mississippi

Peter Mittwede - Orthopedic Surgery

Mark Pinkerton II - Internal Medicine

University of Pittsburgh Medical Center

Barnes-Jewish Hospital

Pittsburgh, Pennsylvania

St. Louis, Missouri

Kathleen Moffitt - Internal Medicine

Brandon Pruett - Anesthesiology

Providence Health-Oregon

Ohio State University Hospital

Portland, Oregon

Columbus, Ohio

Teresa Moll - Medicine-Pediatrics

Victoria Purvis - Surgery-General

University of Mississippi Medical Center

University of South Alabama

Jackson, Mississippi

Mobile, Alabama

Meghan Moroux - Medicine Preliminary

Michael Rewis II - Internal Medicine

Washington Hospital Center

Carolinas Medical Center

Washington, D.C.

Charlotte, North Carolina

Ophthalmology

Daniel Robbins - Medicine-Pediatrics

Georgetown University Hospital

LSU School of Medicine

Washington, D.C.

New Orleans, Louisiana

Danny Mullins - Pediatrics

Alley Ronaldi - Surgery-General

University of Mississippi Medical Center

Walter Reed General Hospital

Jackson, Mississippi

Bethesda, Maryland

Sarah Nobles - Radiology-Diagnostic

Ben Ross - Internal Medicine

Virginia Mason Hospital

Naval Medical Center

Seattle, Washington

Portsmouth, Virginia

Adrienne Paige - Obstetrics-Gynecology

Alex Ruhl - Family Medicine

University of Mississippi Medical Center

St. Joseph Hospital SCL Health

Jackson, Mississippi

Denver, Colorado

Neal Pavlov - Internal Medicine

Logan Rush - Dermatology

University of Arkansas

Little Rock, Arkansas

Angela Payne - Family Medicine

Jamie Scott - Emergency Medicine

North Mississippi Medical Center

University of Tennessee College of Medicine

Tupelo, Mississippi

Chattanooga, Tennessee JOURNAL MSMA

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Katie Scott - Surgery-General

Martha Claire Thomas - Obstetrics-Gynecology

University of Mississippi Medical Center

Jackson, Mississippi

Victoria Scott - Pediatrics

Eric Tillotson - Pathology

University of Alabama Medical Center

University of Mississippi Medical Center

Birmingham, Alabama

Jackson, Mississippi

Taylor Scruggs - Anesthesiology

Ethan Tillotson - Family Medicine

University of Alabama Medical Center

North Mississippi Medical Center

Birmingham, Alabama

Tupelo, Mississippi

Mary Sessums - Pathology

Harrison To - Transitional Year

University of Mississippi Medical Center

Scripps Mercy Hospital

Jackson, Mississippi

San Diego, California

David Short - Medicine Preliminary

Anesthesiology

University of Mississippi Medical Center

UC San Diego Medical Center-CA

Jackson, Mississippi

San Diego, California

Brittany Simpson - Pediatrics-Medical Genetics

Chris Tucker - Internal Medicine

Cincinnati Children’s Hospital

University of Mississippi Medical Center

Cincinnati, Ohio

Jackson, Mississippi

Taylor Smith - Surgery-Preliminary

Stefanie Vamenta - Internal Medicine

University of Mississippi Medical Center

University of Alabama Medical Center

Jackson, Mississippi

Birmingham, Alabama

Radiology-Diagnostic

Nick Watkins - Pediatrics

University of Tennessee College of Medicine

Memphis, Tennessee

Toi Spates - Internal Medicine

Jared White - Plastic Surgery

Duke University Medical Center

University of Florida COM Shands Hospital

Durham, North Carolina

Gainesville, Florida

Jennie Stanford - Family Medicine

Parker White - Orthopedic Surgery

University of Alabama School of Medicine

University of Mississippi Medical Center

Huntsville, Alabama

Jackson, Mississippi

Jamie Stanford II - Otolaryngology

Steven Wilkening - Psychiatry

University of Mississippi Medical Center

University of Cincinnati Medical Center

Jackson, Mississippi

Cincinnati, Ohio

Aimee Sundeen - Surgery-Preliminary

Jake Wilson - Family Medicine

University of Mississippi Medical Center

University of Alabama School of Medicine

Jackson, Mississippi

Huntsville, Alabama

Mina Tahai - Pediatrics

Carrie Wynn - Internal Medicine

Oregon Health and Science University

University of Mississippi Medical Center

Portland, Oregon

Jackson, Mississippi

Renee Taylor - Family Medicine

Edward Yang - Medicine Preliminary

University of Mississippi Medical Center

University of Alabama Medical Center

Jackson, Mississippi

Birmingham, Alabama

238 VOL. 57 • NO. 7 • 2016

Anesthesiology

University of Alabama Medical Center

Birmingham, Alabama

W I L L I A M C A R E Y U N I V E R S I T Y C O L L E G E O F O S T E O P A T H I C M E D I C I N E 2 0 1 6 M A T C H R E S U L T S

Eden Yelverton - Obstetrics-Gynecology

Carolinas Medical Center

Charlotte, North Carolina

Alex Balmir - Internal Medicine

Sam Yelverton - Surgery-General

Carolinas Medical Center

Charlotte, North Carolina

Thomas Nathan Bell - Internal Medicine Magnolia Regional Health Center - Corinth, Mississippi Jeremy James Benoit - Emergency Medicine

Cole Young - Emergency Medicine

University of Mississippi Medical Center

Jackson, Mississippi

Olive View-UCLA Medical Center

Sylmar, California

University Hospital - Jackson, Mississippi

Moumita Biswas - Family Medicine East Central Health Net Regional Rural-

Christian Zayek - Internal Medicine

Western Reserve Hospital - Cuyahoga Falls, Ohio

Meridian, Mississippi Brittney Joelle Brown - OBGYN Osceola Regional Medical Center - Kissimmee, Florida Roderick Seth Brown - Internal Medicine University Hospital - Jackson, Mississippi Tyler Brooks Byrd - Psychiatry University of Alabama Med. Ctr. - Birmingham, Alabama Joshua Britt Calcote - Family Medicine North MS Medical Center - University Hospital & Clinics Tupelo, Mississippi Emily Read Charlie - Internal Medicine University Hospital & Clinics - Lafayette, Louisiana Lindsey Erin Chasan - Family Medicine Florida Hospital East Orlando, - Orlando, Florida

2016 Match Results

Sam Saliba Dabit - Internal Medicine Merit Health Wesley - Hattiesburg, Mississippi

Sarah Angela Adams - Anesthesiology

Nicholas M. Dâ&#x20AC;&#x2122;Alesio - Diagnostic Radiology

University Hospital - Jackson, Florida

Shruti Agarwal - OBGYN

Billy Ray Davis - Psychiatry

Osceola Regional Medical Center - Kissimmee, Florida

The Medical Center - Bowling Green, Kentucky

Aubrey Brian Allen - Urological Surgery

DMC Osteopathic - Commerce, Michigan - Preliminary Surgery

Detroit Medical Center/ WSU - Commerce, Michigan

John Brandon Allison - Internal Medicine

St. Bernards Medical Center - Jonesboro, Arkansas

Malathi Priya Amarnath - Family Medicine

LECOMT/UH Regional Hospitals Richmond Heights, Ohio

Grandview Hospital & Medical Center - Dayton, Ohio

Eric Allen Dean - Pediatrics

SUNY HSC - Brooklyn, New York Kyle Derouen - Emergency Medicine

NY Methodist Hospital - Brooklyn, New York

Suchita Hemantkumar Desai - Pediatrics Our Lady of the Lake Reg Medical Center Baton Rouge, Louisiana Swathi Dhulipala - Internal Medicine Ochsner Clinic Foundation - New Orleans, Louisiana JOURNAL MSMA

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W C U C O M

2 0 1 6

M AT C H

Jessica Paige Meador - Emergency Medicine

Mason Daniel Dyess - Neurology

Comanche County Mem. Hospital - Lawton, Oklahoma

Larkin Community Hospital - South Miami, Florida Mitchell Robert Elgin - Traditional Rotating Internship St. Johns Episcopal Hospital - Far Rockaway, New York Sara Miriam English - Traditional Rotating Internship Meadville, PA Kathryn Ellen Fitch - Emergency Medicine Arnot Ogdon Medical Center - Elmira, New York Andrew Michael Frey - Prelim. Surg. Baptist Health System - AL, Birmingham, Alabama Alex Philippe Gauthier - Internal Medicine Merit Health Wesley - Hattiesburg, Mississippi Christopher Ryan Hagenson - Family Medicine Univ. Tennessee Grad SOM - Knoxville, Tennessee Spencer Thomas Hatch - Internal Medicine University Hospital - Jackson, Mississippi Joshua Mackenzie Holifield - General Surgery Good Samaritan Reg. Medical Center - Corvallis, Oregon

R E S U LT S

Kelsey Lynn Moody - Emergency Medicine

LSUHSC - Shreveport, Louisiana

Jacob DouglasMoulds - Psychiatry

Larkin Community Hospital - South Miami, Florida

Linda Nguyen - Family Medicine

Northwest Integris Baptist - Enid, OK

Michael TrentNorman - Internal Medicine

Sacred Heart Health System - Pensacola, Florida

Jenisus Owens - Family Medicine

East Central Health Net Regional Rural -

Meridian, Mississippi

Ankit Patel - Internal Medicine

Riverside Medical Center - Kankakee, Illinois

Ricky Ronnie Patel - Internal Medicine

Southeastern Health - Lumberton, North Carolina

Allison Marie Patten - Pediatrics

Derek Jacob Carver Hunt - Emergency Medicine

Merit Health Wesley - Hattiesburg, Mississippi

Benjamin Daniel Pettigrew - Surg. Prelim.

Jeremy Michael Johnson - Internal Medicine

University Hospital - Jackson, Mississippi Brian Shappley Jones - Family Medicine Univ. Tennessee COM - Memphis, Tennessee Erum Sana Khalid - Family Medicine Plaza Medical Center of Fort Worth - Fort Worth, Texas Dustin Richard Kilpatrick - Internal Medicine Blue Ridge Healthcare - Morganton, North Carolina Kaushik Ram Kommaraju - Internal Medicine Johnston Memorial Hospital - Abingdon, Virginia

Geisinger Health System - Danville, Pennsylvania UTHSC - Memphis, Tennessee

Lee Nguyen Phan - Internal Medicine

North Broward Hospital District - Ft. Lauderdale, Florida

Muhaiminur Rahman - Psychiatry

University Hospital - Jackson, Mississippi

Amalia Rastogi - Internal Medicine

Plaza Medical Center - Fort Worth, Texas

Ebony Nicole Raymond - Internal Medicine

Wright Center for GME - Scranton, Pennsylvania

Stephen Clark Richardson - Psychiatry

Cory Jacob Lemoine - Family Medicine

Jeffrey Paul Roan - Internal Medicine

Baton Rouge Gen Med Ctr- Baton Rouge, Louisiana

Stacy Amanda Lindsey - Psychiatry

Florida Dept. of Corrections, Fort Lauderdale, Florida

Jared Steven Magee - Internal Medicine

University of Alabama Med Ctr - Birmingham, Alabama

Southeastern Regional Medical Center,

Lumberton - North Carolina

Kristen Lea Roberson - Internal Medicine

Madigan Army Medical Center (Ft. Lewis) -

Unity Health-White County Medical Ctr, -

Tocoma, Washington

Searcy, Arkansas

Laura Tobin Mansfield - Family Medicine

East Jefferson Gen Hospital - Metairie, Louisiana

Brian Christopher McMaster - Emergency Medicine Florida Hospital - Orlando, Florida 240 VOL. 57 â&#x20AC;˘ NO. 7 â&#x20AC;˘ 2016

Aditya Sabharwal - Internal Medicine

University Hospital - Jackson, Mississippi

Shiraz Saleem - Family Medicine

The Wright Center - Scranton, Pennsylvania

Ali Majid Sawal - Family Medicine

Bay Area Corpus Christi Medical Center - Texas

Pranay Saxena - Traditional Rotating Internship

Rowan-SOM / Care Point Health Bayonne Med. Ctr.,

Bayonne, New Jersey

John Ryan Schaub - Internal Medicine

University Hospital - Jackson, Mississippi

Edwin Gregory Seelye - Internal Medicine

Southeastern Health CUSOM -

Lumberton, North Carolina

Selim Wahhab Sheikh - Family Medicine

Ohio State University Med Ctr. - Columbus, Ohio

Wyatt Clifton Deloney Snellgrove - Internal Medicine

Arnot Ogdon Medical Center - Elmira, New York

School of Medicine Reunions August 26 & 27, 2016

Honoring Classes of

1966, 1971, 1976, 1986, 1991, 1996, 2006

Bobby Joe Swinney - Internal Medicine

St. Bernards Medical Center - Jonesboro, Arkansas

Steven Thebaud - Anesthesiology

Univ. of Cincinnati Medical Center - Cincinnati, Ohio

Chelsea Lee Thompson - Family Medicine

UAMS-Regional Programs - Jonesboro, Arkansas

Make plans now to attend!

Registration will be available in June. Hotel information and event updates are available now on umc.edu/alumni. Questions? Concerns? Please contact us at 601-984-1115 / 800-844-5800 or alumni@umc.edu

Hailey Elizabeth Thompson - Family Medicine

Univ. of Alabama Tuscaloosa - Tuscaloosa, Alabama

Jon Lee Thompson - Family Medicine

UAMS-Regional Programs - Jonesboro, Arkansas

John-Paul Tortorich - Phys Med & Rehab

Univ. of Alabama - Birmingham, Alabama

Thu Thien Tran - Pediatrics

Texas Tech U Affil. - Amarillo, Texas

Katie Melanie Tucker - Pediatrics

Charleston Area Medical Center, West - Virginia

Joshua Rhian Turner - Internal Medicine

Arnot Ogden Medical Center - Elmira, New York

Binh Quang Vu - Pediatrics

Florida Hospital - Orlando, Florida

Ngoc-Dung Tona Vu - Family Medicine

Conroe Reg Med Center - Conroe, Texas

Susan Renee Walker - Family Medicine

Houston Healthcare - Warner Robbins, Georgia

Hillary Michelle Ward - Emergency Medicine

Lehigh Valley Health Network - Allentown, Pennsylvania

Adam L. Whitaker - Emergency Medicine

T he Pen is Mightier

than the Sword.

Express your opinion in the JMSMA

through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention its headline and issue date in your letter. Guest editorials or comments may be longer, with an average of 600 words, including no more than 10 references. Also, include your contact information. While we do not publish street addresses, e-mail addresses, or telephone numbers, we do verify authorship, as well us try to clear up ambiguities, to protect our letter-writers. You should submit your letter via email to KEvers@MSMAonline.com or mail to the JMSMA office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.

Merit Health Wesley - Hattiesburg, Mississippi n JOURNAL MSMA

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L E T T E R S

More on Immunizations Dear JMSMA Editor, I just read your letter from the editor on the recent measles cases [Lampton L. “Measles in Memphis,” J Miss Med Assoc. 2016;58(5)136], and it certainly is more of an article which raises questions rather than providing answers. I’m not sure blaming the “antivaccine movement” as you call them is a panacea for what seems to be an increasingly complex public health problem that faces the children of Mississippi today. Incidentally, my children have always received not only the recommended childhood immunizations, but also any immunizations recommended for travel. You state “the route of introduction is usually importation by unimmunized travelers outside of the United States.” Does that provide any fertile ground for public policy discussion? Does reducing the number of index cases that are allowed into the country have an effect on the incidence of said disease? Do we need better screening of these “travelers?” Does our current policy of completely open borders or the recent massive influx of immigrant children have any effect? The children of our state deserve advocates that are willing to have both an honest and thorough discussion of problems that face them. I look forward to a more comprehensive dialogue in future issues and have enjoyed your editorials. Ed Dvorak, MD; Ocean Springs

EHRs Attributed to Physician Burnout Dear JMSMA Editor, Don’t we have a great journal? I was so glad to see the article in the April issue by Dr. Robert Herndon, professor of neurology at UMMC, on EHR as a major cause of the epidemic of physician burnout [Herndon RM. “EHR is a main contributor to physician burnout.” J Miss Med Assoc. 2016;57(4):124]. In preparing a presentation on burnout by physicians, what he said is what I’m finding. We are losing great talent and skill because of this. I wrote an article in our Journal previously [Hey III JP. “A glimmer of hope in the electronic medical records plague.” J Miss Med Assoc. 2014;55(7):241-2.] and helped develop a resolution that would have solved this scourge. Everyone seemed to like it, but when it was presented to our House of Delegates, the leaders pulled it out from a vote and sent it off to hyperspace never to be heard from again. We can stop this dysfunctional and useless loss if physicians stand up and demand a solution, but it will take more than AMA type leadership to do it. John Hey, III, MD; Greenwood Editors’ Response: Dr. Hey’s points are well taken, and we agree. This has become a national problem affecting physicians in many practice environments. How to prevent it is not yet known, but it is a worthy subject of further research and discussion. How to deal with it remains a puzzle. Some of the key factors appear to include loss of autonomy, inflexible work requirements, productivity quotas, decreasing reimbursement, constant audits, and the electronic medical record. UMMC has just developed a “Burnout Taskforce” for physicians and plans to develop programs for medical students and house staff. We hope more readers will share their stories on this topic. Your JMSMA Editors

242 VOL. 57 • NO. 7 • 2016

M S M A

P R E S I D E N T ’ S

P A G E

The Fight Continues

s I write this, yet another measles outbreak has occurred in our country. This time it’s in Arizona and as of today, involves nine unvaccinated immigration detainees and four employees of the Eloy Detention Center, bringing the total to 22 cases tied to the facility . This follows quickly on the heels of the Shelby County, Tennessee, outbreak recently and also the California outbreaks. What do these three states have in common? They all have weaker school age vaccination laws than does Mississippi and therefore lower rates of vaccinations for their children. In fact, the CDC reports from January 2 to July 8, 2016, 28 people from 9 states (Arizona, California, Georgia, Hawaii, Illinois, Massachusetts, Minnesota, Tennessee, and Texas) were reported to have measles. However, thanks to the expertise and commitment of our public health colleagues, Mississippi enjoys a vaccination rate of school age children exceeding 98%. Because of this high rate of vaccinations and the vigilance of our public health partners, we have been spared the drama, risk, and associated cost to our state related to treating and containing such an outbreak. Thus far, these outbreaks have been limited to measles which is bad enough and brings significant mortality risk for chronically ill children, but having a polio, pertussis, or diphtheria outbreak would be worse. Logic dictates that unless vaccination rates go up in other states then these outbreaks will likely happen as well. Which is why we must continue to fight to protect our children. Learning from the politics of “vaccination rights” we faced at the State Capitol this year, MSMA is beginning now to prepare for the next phase of the vaccine battle. Our Board of Trustees at its recent meeting demonstrated its commitment to children’s health by voting to invest $50,000 from our legislative action fund to develop educational tools and messaging for our doctors to use in educating our patients and the public. We plan to take a page from our tort reform playbook and apply it here. MSMA will continue to coordinate and lead the coalition of healthcare entities in our state such as Pediatricians and Family Physicians, Mississippi Department of Public Health, Mississippi Hospital Association, our medical schools, and others. This coalition was powerfully effective in winning the fight this year and will be critical in 2017. MSMA has developed a new communication tool which is basically a “Physician’s Position” targeting our legislators to educate them on the issues important to medicine and where we stand on these issues. As an example of its utility, we developed a legislative physician’s position with this latest measles outbreak helping legislators understand the importance of preserving our excellent vaccination laws. I am grateful that our legislative leaders including Lt. Governor Tate Reeves, Speaker Phillip Gunn, Chairman of House Public Health Committee Rep. Sam Mims, and Chairmen of Education and Public Health in the Senate-Senators Tollison and Kirby were willing in the end to listen to the opinion of Mississippi’s doctors and are voicing a better understanding of this important issue. MSMA appreciates their friendship and their service to our state, and we continue to encourage them to consult us when difficult issues of public health arise. However, the most powerful weapon MSMA has at its disposal is our mighty membership. All of you are our “ace in the hole.” It was your phone calls and legislative contacts that turned the tide in 2016, and you will be the deciding factor in 2017. To win this upcoming battle in 2017 and going forward, we must all do our part to strengthen our relationships at the Capitol. That means we must be members of MMPAC and we must cultivate good relationships with our local legislators. I know that it’s tiring having to keep writing checks, serving as Doctor of the Day, making phone calls, making visits, etc. but there is no one other than ourselves who can lead in this fight. Physicians are the only ones who can protect our children in this way and never forget that we are “ The Physicians Who Care for Mississippi.”n

Daniel P. Edney, MSMA President

JOURNAL MSMA

243

M S M A

MISSISSIPPI STATE MEDICAL Nominating Committee Announces SlateASSOCIATION of Election Offices Dr. Claude Brunson, Chair of the 2016 Nominating Committee, announces the the following list of will be presented Dr. Claude Brunson, Chair of the 2016 Nominating Committee, announces following listcandidates of candidates will be to the MSMA House of Delegates for vacancies that will occur this year. Elections will be held during the 148th of the presented to the MSMA House of Delegates for vacancies that will occur this year. Elections will be heldmeeting during the th House of Delegates August 12-13, 2016 at the Jackson Hilton Hotel. 148 meeting of the House of Delegates August 12-13, 2016 at the Jackson Hilton Hotel. AT LARGE 1 PRESIDENT-ELECT 2 SECRETARY 3 BUDGET & FINANCE 4 BUDGET & FINANCE 5 CONSTITUTION & BYLAWS 6 CONSTITUTION & BYLAWS 7 CONSTITUTION & BYLAWS 8 CONSTITUTION & BYLAWS 9 ACCREDITATION 10 ACCREDITATION 11 ASSOCIATE EDITOR 12 POSITION 1 DELEGATE 13 POSITION 2 DELEGATE 14 POSITION 3 DELEGATE 15 POSITION 4 ALTERNATE 16 POSITION 5 ALTERNATE 17 POSITION 6 ALTERNATE 18 POSITION 7 TEAM 19 POSITION 8 TEAM 20 POSITION 9 TEAM 21 POSITION 10 TEAM 22 POSITION 11 TEAM 23 POSITION 12 TEAM DISTRICT 1 24 LEGISLATION 25 PUBLIC INFORMATION DISTRICT 2 26 TRUSTEE 27 LEGISLATION 28 MEDICAL EDUCATION 29 PUBLIC INFORMATION DISTRICT 3 30 LEGISLATION 31 PUBLIC INFORMATION DISTRICT 4 32 TRUSTEE 33 MEDICAL EDUCATION 34 MEDICAL SERVICE DISTRICT 5 35 TRUSTEE 36 MEDICAL EDUCATION 37 MEDICAL SERVICE RESIDENTS 38 TRUSTEE 39 LEGISLATION 40 MEDICAL SERVICE STUDENTS 41 TRUSTEE 42 MEDICAL SERVICE 43 LEGISLATION

244 VOL. 57 • NO. 7 • 2016

INCUMBENTS Michael Mansour Susan Chiarito Chip Holbrook John Cross J. Martin Tucker Crystal Tate Victor Pang Lori Marshall Crystal Tate Stanley Hartness Sharon P. Douglas J. Clay Hays, Jr. Claude Brunson Randy Easterling Lucius Lampton James Rish, MD R. Lee Giffin Lee Voulters Jennifer J. Bryan Thomas Joiner Geri Lee Weiland Hugh Gamble, II

NOMINEES BILL GRANTHAM MICHAEL MANSOUR SUSAN CHIARITO CHIP HOLBROOK JOHN CROSS J. MARTIN TUCKER CRYSTAL TATE VICTOR PANG LORI MARSHALL CRYSTAL TATE STANLEY HARTNESS

NOMINEES GERALD McKINNEY MISTY SHARP LEE ENGLAND PAGE BRANAM ED RIGDON REBECCA ROBERTS STEVE STOGNER SHARON McDONALD HEDDY MATTHIAS

CLAUDE BRUNSON JENNIFER J. BRYAN SHARON DOUGLAS RANDY EASTERLING DAN EDNEY HUGH GAMBLE, II SCOTT HAMBLETON J. CLAY HAYS, JR. THOMAS JOINER LUCIUS LAMPTON JEFF MORRIS JAMES RISH LEE VOULTERS GERI WEILAND

Michael Mansour Robert Suares

KATIE PATTERSON BRENT SMITH

Brett Lampton B. Pearson Windham DeWayne Gammel Son G. Lam

BRETT LAMPTON SON LAM JUNE POWELL CHET LAKE

J. Murray Estess Charlotte Magnussen

KEN THOMAS CHARLOTTE MAGNUSSEN

CHARLES MILES JAYANT DEY

Bill Grantham Jonathan Jones J. Anthony Cloy

JENNIFER BRYAN JONATHAN JONES J. ANTHONY CLOY

MICHELLE OWENS DANIEL VENARSKE CHASITY TORRENCE

Dwight Keady John Voss Michael Shrock

ANTHONY THOMAS MATT CASSELL MICHAEL SHROCK

LEE VALENTINE

Nicole Lee James Wilkinson Jonathan Buchanan

RYAN MCGAUGHEY DOUGLAS TUCKER PHILLIP DIXON

JOHN S. RUSHING DAY SMITH LENNEP DAVID SMITH

Brock Banks Daniel Hester Neal Boone

NEAL BOONE

DANECA DIPAOLO

TROY CAPPLEMAN

CASEY CHINN

KENDRA COURTNEY VY MAI CRAIG MOFFAT

COLE RICHARDSON

BRITTNEY BROWN LOGAN RAMSEY

M S M A

This is part of a spotlight series on the MSMA Physician Leadership Academy class of 2016.

Gerald McKinney, MD

erald McKinney, MD is a board-certified general surgeon specializing in single-site laparoscopy and is experienced in robot-assisted minimally invasive surgery. His practice interests include complex inguinal and abdominal wall hernias as well as upper digestive systems procedures, such as anti-reflux operations, treatment of achalasia, and hiatal hernia repair. Dr. McKinney’s interest in medicine was initially sparked by a neighbor during his childhood in Chicago. “My friend’s father was a pediatrician-- that excited and intrigued me,” he says. “In the early to mid-1970’s, the game Operation was fairly popular. Also around that time, Ben Carson was well-known and admired. As an active child that loved to use my hands for drawing, playing musical instruments and sorts, I thought the combination would be great [for surgery]. I was intrigued by science and anatomy and this appeared to be the best of both worlds.” Now, as a practicing surgeon, he is thankful for the path he took. “The most rewarding aspect of my profession is the immediate difference I can make in a patient’s life. The most challenging would be finding the balance between helping and hurting in the patient with multiple health issues and a potentially life-threatening surgical issue.” Throughout his career, Dr. McKinney has found mentorship from several physicians. “During medical school, I had Dr. Tapas Das Gupta as a mentor. He was a surgical oncologist and he allowed me to work in his lab as well as shadow him in the operating room. I learned more about the life of an academic surgeon. During residency it was Dr. Vernon Henderson. He was integral in showing me how to be a more efficient surgeon.” Through the Physician Leadership Academy, Dr. McKinney hopes to learn to navigate the political landscape of medicine and become a part of the team in improving overall patient care. “As a surgeon, I believe what we do is often misunderstood and misrepresented. We are often looked upon as money grabbing specialists whose interests lie in wealth and not patient care. I feel we need more surgeons involved [in organized medicine] to protect our interests and patient involvement.” As for his more significant accomplishment as a physician, Dr. McKinney points to “the affect I can have on a patient’s life and health through successful surgery, counseling, and teaching.” n JOURNAL MSMA

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M S M A

This is part of a spotlight series on the MSMA Physician Leadership Academy class of 2016.

Angela Shannon, MD

ngela Shannon, MD is the “pediatrician with no patience” but lots of patients.

Dr. Shannon knew she wanted to become a physician in junior high school, around 7th grade. “My love for children and concern for their well-being were huge driving forces. I knew I lacked the level of patience required to be a teacher, so I figured I could help young people be healthy!” A pediatric gastroenterologist at GI Associates and Endoscopy in Jackson, Dr. Shannon earned a bachelor’s degree in biology at Millsaps College and attended medical school at the University of Mississippi Medical Center. During her residency in general pediatrics at UMMC, Dr. Shannon found her niche in pediatric gastroenterology. “My mentors during residency had a lot to do with my decision to go into my specialty. It’s a nice combination of general pediatrics, my first love, and complex gastroenterological conditions, so the days are definitely varied and interesting,” she says. After residency, Dr. Shannon completed a fellowship in pediatric gastroenterology and nutrition at the Cleveland Clinic Children’s Hospital in Ohio. Now practicing in Jackson, Dr. Shannon is passionate about the well-being of children. “I think children often provide the perfect opportunity to practice preventative medicine at its finest,” she says. “Though I have a busy general GI practice, I am always looking for opportunities to tackle the overweight and obesity epidemic that is ravaging the young people of Mississippi. I am hopeful that our children can overcome this problem with the proper resources, education and support.” As a Physician Leadership Academy scholar, Dr. Shannon hopes to become a more effective listener and a stronger voice for her patients. She is also learning to balance the many hats she wears daily. “I am a healer, a teacher, a businesswoman, a confidante, a politician, an advocate… a leader,” she explains, “and I have yet to perfect every role. Yes, some come much easier than others, but I know that each facet of the doctor character must be sharpened and polished in order for the character as a whole to be its best.” n

246 VOL. 57 • NO. 7 • 2016

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