June 2014 JMSMA

June

VOL. LV

2014

No. 6

GET READY FOR

ICD-10

STAY ON THE ROAD TO 10 STEPS TO HELP YOU TRANSITION The ICD-10 transition will affect every part of your practice, from software upgrades, to patient registration and referrals, to clinical documentation and billing.

CMS can help you prepare. Visit the CMS website at www.cms.gov/ICD10 and find out how to: •

Make a Plan—Look at the codes you use, develop a budget, and prepare your staff

•

Train Your Staff—Find options and resources to help your staff get ready for the transition

•

Update Your Processe—Review your policies, procedures, forms, and templates

•

Talk to Your Vendors and Payers—Talk to your software vendors, clearinghouses, and billing services

•

Test Your Systems and Processes—Test within your practice and with your vendors and payers

Now is the time to get ready. www.cms.gov/ICD10

Official CMS Industry Resources for the ICD-10 Transition

www.cms.gov/ICD10

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD Associate Editors Karen A. Evers Managing Editor

Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors The Association James A.Rish, MD President Claude Brunson, MD President-Elect Michael Mansour, MD Secretary-Treasurer R. Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices.

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

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

ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 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© 2014 Mississippi State Medical Association.

JUNE 2014

VOLUME 55

NUMBER 6

Scientific Articles Severe Ocular Trauma in the Emergency Room

176

Albert Lin, MD; Cassie Confait, MD; Madiha Ahmad; Robert Cox, MD; Ching-Jygh Chen, MD

Clinical Problem-Solving: Call the Surgeon Please

191

Lauren B. Treadwell, MD

Special Article The Mississippi State Tuberculosis Sanatorium and the Evolution of Thoracic Surgery in Mississippi

180

John B. Groves, M4 and Michael C. Trotter, MD, FACS

President’s Page More Thoughts on Medicaid Expansion

193

James A. Rish, MD; MSMA President

Editorials No Room for Error

195

D. Stanley Hartness, MD; Associate Editor

The Veterans Administration Hospital Scandal: Views of a Mississippi Physician

196

John P. Hey, III, MD

Related Organizations MACM: Securing the Future of Healthcare: Students in your Practice 198 IQH 201

Departments From the Editor: The Dishonest Math of PPACA 174 MSMA 199 Physicians’ Health Corner 200 Poetry and Medicine 203 Images in Mississippi Medicine 204

About The Cover:

“Goin’ Green”- Strong River Camp and Farm located in Pinola, MS, has served as a summer oasis for generations of campers not only from Mississippi but also from across the United States. Established by Tay Gillespie, Strong River is now under the direction of her daughter, Sarah Dabney, and features unique activities such as canoeing and tubing the Strong River, Farm Day with a log for burling, eating watermelon at Watermelon Rapids, skit night at the Ginkgo Theater, and a staff recruited from around the world. Delicious home-cooked meals feature “Mississippi biscuits” and fresh vegetables and fruits campers have picked that morning at the farm across the highway. Our cover photo was taken by Dr. Stanley Hartness last summer while he was serving his 11th stint as camp doctor. Dr. Hartness has recently assumed duties at Premier Patient 1st Clinic in Jackson. r June

VOL. LV

Official Publication of the MSMA Since 1959

2014

No. 6

June 2014 JOURNAL MSMA 173

From the Editor: The Dishonest Math of PPACA

I

f you want to see the future of medical care in our country under the Patient Protection and Affordable Care Act (PPACA), just look at the current mess ongoing at our VA Hospital System. Such is our healthcare future: too few physicians, too much work, too little money, and too many bureaucrats making too many rules. (And of course, the only ones making money in the system are the insurance companies, not those providing the care.) The problem of PPACA is that it is built on a fundamentally flawed, and at its heart dishonest, notion: that if the government provides quality medical insurance for millions of more Americans, money will be saved for the system. In order to be “affordable,” the act is eviscerating our Medicare system, which is the backbone of healthcare in the country.

President Obama has stated that PPACA is “a net reduction of our deficit…if they repealed the law it would add to the deficit.” In his words is the dishonest math inherent within the act: to cover more costs less. He asserts that to expand Medicaid massively and to provide new subsidies for purchasing private insurance are ways to shrink the deficit.

This is the fundamental flaw. Quality medical care is not free and will cost the tax-payers lots of money. Note also that I call the act PPACA. To reduce it to ACA emphasizes this false premise: that it’s affordable. The “PP” is for “patient protection,” and that is what we must Lucius M. Lampton, MD emphasize as physicians.

How will more than a half-trillion dollars in Medicare cuts impact us in Mississippi? Such a devastating hit on providers has not even been explored, much less commented on, by the media or proponents of the act. A majority of our state’s hospitals lost money last year, in large part due to these severe Medicare reductions. Everyone may get insurance, but most, including Medicare patients, will have less services provided at more individual expense. In the end, quality medical care costs money, and to pretend it doesn’t is dishonest politics.

Contact me at lukelampton@cableone.net.

—Lucius M. “Luke” Lampton, MD, Editor

Journal Editorial Advisory Board Myron W. Lockey, MD Chair, JMSMA Editorial Advisory Board Journal MSMA Editor Emeritus, Madison 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 MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, 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 Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson

Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

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Paul “Hal” Moore Jr., MD Radiologist Singing River Radiology Group, Pascagoula

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

Jason G. Murphy, MD Surgeon

Surgical Clinic Associates, 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

Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport

William Lineaweaver, MD Sharon Douglas, MD Editor, Annals of Plastic Surgery Professor of Medicine and Associate Dean for VA Medical Director Education, University of Mississippi School of Medicine, JMS Burn and Reconstruction Center, Jackson Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Michael D. Maples, MD Vice Preisdent, Chief of Medical Operations Baptist Health Systems, Jackson Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson

Darden H. North, MD Obstetrician/Gynecologist and Author Jackson Health Care for Women, Flowood Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

Medical Assurance Company of Mississippi With questions about a new practice, MACM gave her confidence.

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Reputation Above All Others June 2014 JOURNAL MSMA 175

• Scientific Articles • Severe Ocular Trauma in the Emergency Room Albert Lin, MD; Cassie Confait, MD; Madiha Ahmad; Robert Cox, MD; Ching-Jygh Chen, MD

A

bstract

To assess the nature, severity, and mechanisms of ocular trauma in the emergency room at an academic teaching hospital.

Methods:

Individual review of patients’ records involving ocular trauma in the emergency room. Severe intraocular trauma was defined as any injury that required intraocular surgery, any traumatic optic neuropathy, or total destruction of the eye.

Results:

Of 519 patients in 2010 seen in the emergency room for ocular trauma, 52 patients (10%) had severe ocular trauma.

Contusions (17) were the most common injury, followed closely by penetrating lacerations (16) and ruptures (16). In addition, 33 of these 52 patients (63.5%) had a full-thickness open globe injury, with physical assault as the most common etiology.

Conclusion:

The most common severe ocular traumas seen in the emergency room were contusions, penetrating lacerations, and ruptures. Penetrating lacerations and ruptures were the most common causes of open eye wall injuries.

Introduction

Traumatic injuries are a common cause for visits in every emergency room. However, ocular injuries are not as common in comparison, which may cause some uncertainty in treating eye injuries by emergency room physicians. At least 2.5 million new eye injuries occur in the USA every year, with 40,000 Author Affiliations: Dr. Lin and Dr. Confait are both Ophthalmology residents from the University of Mississippi Medical Center (UMMC).

Ms. Ahmad is a medical student from UMMC. Dr. Cox is a professor in Emergency Medicine at UMMC. Dr. Chen is the chair of Ophthalmology at UMMC. Corresponding Author: Ching-Jygh Chen, MD, Department of Ophthalmology, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS 39216

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to 60,000 of these injuries resulting in blindness.1 Specifically for emergency room visits, the rate of emergency room-treated eye injuries is 3.15 per 1000 population.2 Given the specialized training and resources needed to treat severe ocular injuries, patients with these injuries are often transferred to hospitals that have ophthalmology coverage with the resources to manage these eye injuries. However, some familiarity with the nature and severity of these ocular injuries for other ophthalmologists can help the clinical care and research into these types of injuries. We believe that physicians staffing emergency rooms can benefit from more general knowledge about severe ocular injuries—such as their statistics, severity, and mechanism of injury.

Communication about ocular injuries among health care professionals, even among ophthalmologists, can also be confusing due to the lack of standard classification of eye injuries.

This can cause ambiguity about urgent ocular injuries, leading to misunderstandings and misinterpretations about ocular injuries. Until recently, such a task of describing injuries in concise language was difficult and often confusing, even in published literature. The Birmingham Eye Trauma Terminology System (BETTS) was subsequently established fairly recently to create a standard set of concise and succinct clinical definitions for ocular trauma and injuries.3,4 As an academic teaching hospital, the University of Mississippi Medical Center (UMMC) treats the majority of severe ocular injuries in Mississippi, with some of these injuries requiring urgent surgery. Classifying the nature, severity, and mechanisms of these injuries can provide insight into severe ocular trauma as well as useful information about these injuries in Mississippi. In turn, this knowledge about severe ocular trauma can be helpful in preventing potentially blinding injuries.

Materials and Methods This study was a retrospective chart review of patients admitted into the emergency room for ocular trauma. Records of patients seen in the emergency room by Ophthalmology were obtained by analyzing patients seen in the emergency room from January 1st, 2010, to December 31st, 2010, for ocular trauma or

Table: BETTS classification

Results

Of 519 patients in 2010 seen in the emergency room for ocular trauma, 52 patients (10%) For clinical purposes, violation of the outermost layer Eye Wall Sclera and Cornea had severe intraocular trauma, as of the eye is considered shown in Figure 1. Of these 52 Closed Globe patients, 17 patients had closed No full-thickness wound of No through and through breach of sclera and cornea Injury eye wall globe injuries and 33 patients had open globe injuries. All the Open Globe Full-thickness wound of eye Through and through breach of sclera or cornea Injury closed globe injuries consisted wall of contusions (17). Of the open Usually due to blunt force injury, but no actual cut or globe injuries, 16 patients had opening onto the eye wall; severe contusions may No open wound of the eye Contusion ruptured globes, and 17 patients cause hyphemas, traumatic cataracts, and/or retinal wall; closed globe injury had laceration-type injuries. Of detachments. the laceration type injuries, the Partial-thickness wound of Lamellar most common was a penetrating There is a wound to the eye wall, but not through the the eye wall; closed globe Laceration injury (15). One patient suffered eye wall completely injury a perforating type injury, and one other had an intraocular foreign Full-thickness injury usually at weakest point of eye, Full-thickness wound of the Rupture usually with prolapse of intraocular contents; actual eye wall, caused by blunt body. Other injuries included wound typically not at point of intact trauma; open globe injury traumatic optic neuropathy (n=1) and complete destruction of the Full-thickness wound of the Wound is at impact site, usually with prolapse of Laceration eye (n=1). eye wall, caused by sharp intraocular contents The mechanism of each of object; open globe injury these open globe injuries wasEntrance wound present divided into five categories: 1) Sharp object enters and exits through same wound Penetrating only; type of laceration typically physical assault, 2) fall, 3) moinjury tor vehicular crash, 4) firearm Entrance and exit wound injury (accidental or intentional), An entrance and exit wound caused by same object; Perforating present; type of laceration and 5) workplace or outdoor/enoften a missile-type injury injury vironmental injuries that did not fall into the previously listed catTechnically a penetrating injury but classified Entrance wound with Intraocular differentially because surgical management is foreign body present; type egories. Of these 33 patients, 11 Foreign Body different of laceration injury patients had confirmed physical assault, 4 had fallen, 2 had suffered a firearm injury, 3 had been involved in a motor vehicle crash, and the rest (13) had suffered a ocular-involving trauma. Then, these patients’ records were workplace or outdoor environmental injury, as shown in Figure 2. individually analyzed via an electronic health records system.

Analysis of each patient’s record included the patient’s final diagnosis, the type of traumatic injury sustained, the mechanism Discussion of injury, and if the patient required surgery for the injury. InThe definition of severe ocular surgery as any injury rejuries that were sustained in 2010 but required surgery in 2011 quiring intraocular surgery was chosen because these injuries were also counted in this study. would have led to vision loss otherwise unresolvable with medSevere ocular trauma in this study was defined as any ical therapy alone. Though this definition includes open globe traumatic injury that required intraocular surgery at any point injuries, it also includes other diagnoses such as traumatic lens (whether immediately during the time of diagnosis or in the fusubluxation, medically-uncontrollable hyphemas, and retinal ture at any point), any traumatic optic neuropathy, and complete detachments. For retinal detachments and traumatic lens subdestruction of the eye. Injuries were also classified by the BETluxations, surgery may not necessarily be required at the time of TS, described in the Table. Injuries were divided into two catdiagnosis in the emergency room but is eventually required for egories – open and closed globe injury. Each type of injury was the patient to ensure the best visual recovery and rehabilitation. also then sub-divided into more specific categories. In addition Over a third of open globes were caused by injuries to classifying the injuries, the mechanism of each open globe outdoors or at the workplace. This statistic is consistent with injury was obtained through the patient’s history of injury. recent epidemiologic data reporting most serious eye injuries occurring at home or at an industrial premise.1 From a public Term

Clinical Definition

Comment

June 2014 JOURNAL MSMA 177

Figure 1

Conclusion In conclusion, the most common severe intraocular traumas seen in the emergency room were contusions, penetrating lacerations, and ruptures, which combined made up 92.3% of severe ocular traumas. Penetrating lacerations and ruptures were the most common types of open globe injuries. Physical assault and workplace or outdoor/environmental injuries were the most common etiologies. Characterizing the most common types and etiologies of these injuries will not only contribute to medical education and treatment regarding these injuries but also address these injuries from a public health viewpoint.

References 1. The Epidemiology of Serious Eye Injuries From The United States Eye Injury Resitery. May DR, Kuhn FP, Morris RE, Witherspoon CD, Danis RP, Matthews GP, Mann L. Graefe’s Arch Clin Exp Opthalmol. 2000;238:153157.

health viewpoint, the easiest way to reduce accidental injuries to the eye is to stress eye protection and environment awareness when performing dangerous tasks that may possibly lead to eye injury. Eye protection should especially be stressed, since is a cheap and effective way to prevent costly, blinding injuries.

Fall precautions should obviously apply to those at risk of falling; in addition, the risks of eye injuries should also be discussed with those at higher risk of falling. When dealing with patients with severe ocular trauma, informing ophthalmologists of the type of severe ocular trauma may reduce the time from injury to surgery, which may improve the prognosis of severe ocular trauma.

Since this study was limited to the year 2010, the injuries in this study only partially represent recent severe ocular injuries in Mississippi. Future studies on severe ocular trauma in Mississippi will aim to study these injuries over a five or even ten year period. With the transition of medical records at UMMC to an electronic health records system, we anticipate data collection will be easier and more efficient. With more data, more specific research can be performed on these injuries.

Figure 2. Open Globe Etiologies (n=33)

178 JOURNAL MSMA June 2014

2. Incidence of Emergency Department-Treated Eye Injury in the United States. McGwin G Jr., Owsley C. Arch Ophthalmolgy. 2005 May;123:662666.

3. A standard classification of ocular trauma. Kuhn F, Morris R, Witherspoon CD, Heimann K, Jeffers JB, Treister G. Ophthalmology. 1996 Feb; 103(2):240-243.

4. Kuhn F. Ocular Traumatology. New York, NY: Springer; 2007:1-10.

Pen > Sword

E

xpress your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses, or telephone numbers, we do verify authorship, as well as clarify ambiguities, to protect our letterwriters. You can submit your letter via email to: KEvers@MSMAonline.com or mail it to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.

June 2014 JOURNAL MSMA 179

• Special Article • The Mississippi State Tuberculosis Sanatorium and the Evolution of Thoracic Surgery in Mississippi John B. Groves, M4 and Michael C. Trotter, MD

I

ntroduction

The Mississippi State Tuberculosis Sanatorium (MSTS) holds a unique place in Mississippi’s medical history. The story of the MSTS (‘The San’) has been chronicled from nonfiction as well as historical fiction perspectives.1,2,3 This contribution examines the historic role of thoracic surgery at the MSTS and the pioneering individuals who practiced this emerging specialty of surgery. Their practices likely represent the earliest experience in thoracic surgery as a defined specialty in Mississippi.

The sanitarium methodology for the treatment of tuberculosis (TB, phthisis, consumption, great white plague) in the United States originated with Edward L. Trudeau, MD, (18481915), who established the Adirondack Cottage Sanitarium at Saranac Lake, New York, in 1885. Trudeau himself had contracted TB and had received the “rest cure” that had been successful in Europe. He championed the sanitarium movement in this country.4 ‘Sanitarium’ refers to a health resort; ‘sanatorium’ refers to a hospital facility and was adopted for use in 1904 by the National Tuberculosis Association.1 After the Saranac Lake experience, other states followed.

began his 47- year marriage to Iola Saunders.7,8 He served as a field director for the department until 1917.5,7 In 1912 Boswell began a lobbying campaign for a TB sanatorium in Mississippi and was determined to end this disease.8 He promoted his idea in every county in the state and would be remembered as a master in public relations and lobbying lawmakers.5,10 In 1916 the state legislature appropriated $25,000 to build a state sanatorium to treat TB.1,2,8,11,12 Boswell was instrumental in selecting a site just outside the town of Magee in Simpson County as the ideal location because it was the highest elevation between Jackson and the Gulf Coast.1,13 The citizens of Magee and the lumber company Eastman, Gardiner, & Co. of Laurel, Mississippi, responded to the effort by donating a total of 240 acres of land that had been longleaf pine forest.1,2 Boswell himself worked to clear the land with one assistant, Julius ‘Preacher’ Buchanan, who would work with Boswell at the MSTS for many years and is recognized as “Pioneer Aide at the Sanatorium.”1,6,8,13,14,15 The facility opened on February 4, 1918, and was made the Bureau of Tuberculosis Control of the Mississippi State Health Department.1,6,7 Boswell had been made Superintendent and Director in 1917 and would serve in that capacity for 40

Henry Boswell and ‘The San’ In Mississippi the MSTS was created largely through the efforts of Henry Boswell, MD, (1884-1957) (Figure 1).

Boswell, an Alabama native, graduated from the University of Nashville Medical Department in 1908. He interned in Nashville and worked as a house physician at Providence Hospital in Mobile, Alabama, before relocating to Laurel, Mississippi in 1909 in private practice.1,5,6,7,8 He then contracted TB and received the “rest cure” in either Colorado or El Paso, Texas.5,6,8,9 Following treatment in 1910 Boswell became associated with the Mississippi State Department of Health and Author Information: William Cary University College of Osteopathic Medicine, Hattiesburg, MS (Mr. Groves). Delta Regional Medical Center, Greenville, MS (Dr. Trotter).

Corresponding author: Michael C. Trotter, MD, FACS, 221 Crittenden Street, Greenville, MS 38701. Ph: (662) 347-9588 (mdatrotter@gmail.com).

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Figure 1. Henry Boswell, MD, circa 1930’s (Courtesy of the Archives and Records Services Division, Mississippi Department of Archives and History) and in 1951 (Courtesy of the Sanatorium Museum).

years.1,6,7,16 He briefly and temporarily resigned in 1924 in protest of a law that would prohibit him from accepting consulting fees and payments outside his annual salary of $5000. At the time Alabama had offered him $12,000 to start a TB sanatorium in that state.17, 18

Figure 2. Mississippi State Tuberculosis Sanatorium in 1937 (Courtesy of the Archives and Records Services Division, Mississippi Department of Archives and History).

Figure 3. Certification from the American College of Surgeons, circa 1934-1935 (Courtesy of the Sanatorium Museum).

By 1920 the legislature had appropriated $1,000,000 to enlarge the institute, and another appropriation in 1928 further enlarged the facility to a 450 bed capacity1,2 (Figure 2). Boswell developed the MSTS with the care and welfare of the TB patient as its highest priority. This focus was manifested by the following: the MSTS roads were the first to be paved in Simpson County with assistance from Works Progress Administration (WPA) funds due to the fact that Boswell believed dust from the gravel roads was detrimental to the TB patient;2,13 tunnels were built connecting the cafeteria, main hospital, and other buildings in order for patient meals to be unexposed to outside air as well as to minimize the non-clinical staff contact with patients;1,13 service tunnels for hot water pipes and electric wires also connected the main buildings;1 patients were given disposable pocket sputum flasks to curtail expectoration on the ground;13 the MSTS ensured self-sufficiency with its own farm, water supply, and power plant.1,13 Sanatorium, Mississippi, became an unincorporated community with its own post office and train depot.1 The MSTS became a full-time charge of the Methodist church in 1928.1 The facility was approved by the American College of Surgeons (ACS) Hospital Standardization Program in 1927 and in subsequent years19,20 (Figure 3). This was significant because this program of the ACS was the precursor to the Joint Commission on Accreditation of Hospitals (JCAH).21 Additionally a unique facility called the Preventorium was built for underprivileged children at risk for TB exposure.1,22 Interestingly the building was unintentionally constructed in the shape of the Lorraine Cross, the symbol for the crusade against TB.22 The MSTS alleviated the suffering of Mississippi TB patients. When it opened in 1918, there were about 3300 cases of TB from a population of approximately 1,750,000; by 1949 the number of TB cases had decreased to 581 in a population of 2,250,000 due to the efforts at the MSTS.14 In 1950 Boswell spoke to the Jackson Optimist Club and stated that heart disease was killing more people than TB.9 Boswell initially utilized rest therapy for TB treatment, but he attacked the disease on every front possible. The issue of race and TB treatment and its evolution at the MSTS is interesting and not unexpected. As noted previously, patient care appears to have been Boswell’s highest priority. In segregated Mississippi support staff positions (cooks, waiters, maids, and orderlies) at the MSTS were filled by African-Americans.23 Boswell obtained an appropriation from the state legislature to build a small facility for African-American citizens in 1922 and the 40-bed unit opened in 1924.8,24,25 In 1946 more state funding allowed the construction of a new larger infirmary for African-American patients and the 204-bed unit opened in 1951.1,24,25 Nursing care had always been segregated with African-American nurses providing care in the African-American units.23,25 In 1968 racially segregated patient care facilities were integrated.24,26 Boswell stated, “In the campaign against tuberculosis in Mississippi it is conceded that in order to make it effective it must deal with all of the citizens of the state, and especially that of the colored population.

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Realizing this, the institution for the treatment of tuberculosis in this state was built with the idea of handling all of the races under one management.”24 In the Mississippi Delta where a large population of African-American citizens was concentrated, four counties (Bolivar, Sunflower, Washington, and Coahoma) accounted for 4 of the top 7 counties for TB deaths in 1937 and 1938.27 The evolution of the growth of the patient care facilities at the MSTS followed the culture of separate and unequal to complete desegregation. Patient care appears to have been egalitarian throughout this evolution.

Boswell’s life spanned many evolutions of TB management and his career evolved professionally from “phthisiologist/phthisiotherapist” to specialist in pulmonary medicine. He was a pioneering pulmonologist and master medical politician.

He gained national visibility for his crusade against TB on multiple platforms of organized medicine. His memberships included Central Medical Society, Southern Medical Assn., American Medical Assn., American College of Physicians (Fellow), American Public Health Assn., International Union of Tuberculosis Assns., American Lung Assn. (Executive Committee), and Alpha Kappa Kappa medical fraternity. His Presidencies included: Mississippi State Medical Assn. (1921-1922), Mississippi Tuberculosis Assn., Mississippi Hospital Assn., Mississippi State Commission on Hospital Care (Chairman, 1951-1957), Southern Tuberculosis Assn. (1925-1926), Southern Thoracic Society, Southern Sanatorium Assn., American Sanatorium Assn. (1928-1929) [later, American Thoracic Society], and National Tuberculosis Assn. (1930-1931) [later, American Lung Assn.].1,5,7,8,16,28 Boswell died in 1957 at age 73 of metastatic lung cancer and chronic emphysema.29 He is buried on the grounds of the MSTS along with his wife at a favorite site he had selected. A Karl Wolfe portrait of Boswell hangs today at University Medical Center in Jackson, having been moved there from the MSTS when it closed in 1976.16 Boswell realized the contribution of thoracic surgery to TB treatment and began a surgical program at the MSTS. Two of the surgeons, John S. Harter, MD and Watts R. Webb, MD, were prominent in the surgical treatment of TB at the MSTS. They would be among the early pioneers who helped develop and evolve thoracic surgery as a specialty.

Thoracic Surgery and Tuberculosis Thoracic surgery can be considered to have three distinct evolutionary periods that were pathology related. The first period was related to pleuropulmonary suppuration and is linked with World War I and the 1918 influenza epidemic. The second period is characterized by the surgical treatment of TB followed by that for lung cancer and occurred in the period surrounding World War II. Finally the third period followed the evolution of the TB surgeons into cardiovascular surgery and the surgical treatment of coronary artery disease.30 Some consider this the point where the specialty began the divergence into the distinct pathways of general thoracic surgery, cardiac surgery, and vas-

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cular/endovascular surgery that are well known today.

Building upon the experience in Europe and at Saranac Lake, New York, John Alexander of the University of Michigan published his classic work on surgery for pulmonary tuberculosis in 1925.31 Remarkably, Alexander wrote the prize-winning text during his protracted hospitalization at Saranac Lake for treatment of TB, a disease that would impact the remainder of his life personally and professionally.32 The book was the first in the English language, comprehensive, evidence-based, and data-driven. The sanatorium methodology of rest therapy was predicated on the belief that lung tissue at rest would heal. This belief was extrapolated by the addition of pulmonary compression for TB treatment, again allowing lung tissue to do less work and allow healing. Artificial pneumothorax, or medical pulmonary compression, was receiving increasing utilization.

Surgical compression and the variety of procedures by which it was accomplished were in their early stages.

The surgical armamentarium of operations included thoracoplasty (paravertebral, extrapleural, subscapular, parasternal), phrenicotomy, pneumolysis (extrapleural, intrapleural), cavity drainage, effusion/empyema/fistula management, thoracoscopy, and various combinations of these. One other factor critical in the development of thoracic surgery was pioneered by an individual with close ties to Mississippi and perhaps the greatest surgeon this country has ever produced.33,34 Rudolph Matas, MD, of New Orleans and Tulane University School of Medicine is known as the ‘Father of Modern Vascular Surgery.’35 He also actively participated in the development of thoracic surgery from its beginning and was one of the first to utilize intratracheal insufflation and positive pressure ventilation and anesthesia to alleviate the deleterious effects of surgical pneumothorax and allow safe intrathoracic surgery.30,36 His many accolades include the presidency of thoracic surgery’s original professional organization, the venerable American Association for Thoracic Surgery in 1920.36 John Spencer Harter John Spencer Harter, MD (Figure 4), a native of Indiana, came to the MSTS in 1936 exceptionally well trained. 27,37,38 He had graduated from medical school at Washington University in 1928 and then trained in pathology at the University of Minnesota for six months. In January 1929 he began an internal medicine internship at Barnes Hospital in St. Louis for eighteen months. In July 1930 he undertook a surgical internship at Strong Memorial Hospital in Rochester, New York, for a year and in July 1931 he began a surgical fellowship at Harvard for eighteen months. In January 1933 he became a surgical house officer at the Massachusetts General Hospital and completed this in February 1935. He then became associated with the Lahey Clinic in Boston.27,37,38 He remained there in clinical practice until August 1936 when he came to the MSTS. Interestingly Harter’s application for Mississippi medical licensure in 1936 was marked “slight irregularity” because of “no med

society memberships.”37 Three years later he was a member of the Central Medical Society, Mississippi State Medical Association, American Medical Association, Southern Medical Association, American Academy of Tuberculosis Physicians, American College of Chest Physicians, and American Association for Thoracic Surgery.27 During his training in Boston his colleagues included Champ Lyons, MD who gained renown during World War II and become a surgical giant during his career at the Ochsner Clinic and the University of Alabama at Birmingham.39,40,41 Additionally Harter had been associated with pioneer thoracic surgeon Richard Overholt, MD at the Lahey Clinic.42,43 As such Harter was professionally well positioned and in the right place at the right time for a new and attractive opportunity. As the non-surgical approach to treating pulmonary TB began to wane in favor of surgical approaches in the 1930s and early 1940s, minor procedures (artificial pneumothorax, endoscopic adhesiolysis) evolved from the principles of collapse therapy or pulmonary immobilization.44 Major procedures such as thoracoplasty soon followed (Figure 5) and sanatoria provided venues for ample caseloads for thoracic surgeons to make a living, albeit often in an ‘itinerant surgery’ model.44 Pulmonary resection was beginning to be considered and practiced, although not without controversy.44,45 Streptomycin would not come on board until 1944 and become generally available until 1948. 44,45 Harter and his surgical niche fell into this window of TB treatment. He was the first thoracic surgeon in Mississippi and was well thought of by both physicians and patients.1 He likely surprised his Boston colleagues with the decision to move to Mississippi, and they likely questioned his decision. It is reasonable to consider that Boswell played a key role in Harter’s recruitment. Boswell was well connected nationally with those individuals and groups concerned with the advancement of thoracic healthcare. After a few inquiries, we can speculate that

Figure 4. John S. Harter, MD, circa 1936-1939 (Courtesy of the Archives and Records Services Division, Mississippi Department of Archives and History) and in 1958 (Photo courtesy of the Southern Thoracic Surgical Association).

Harter came highly recommended. Boswell was acutely aware of what resources he needed to further his cause at the MSTS and was adept at obtaining it.

Another consideration for Harter’s relocation to the MSTS was professional and economic opportunity in the aftermath of the Great Depression. With his Figure 5. Chest X-ray post training and backthoracoplasty, 1939 (Courtesy of the Sanatorium Museum). ground the opportunity to practice his specialty in an established venue with no shortage of patients was certainly attractive. There was also opportunity to build a program from the ground up and educate and cultivate a statewide referral network. The construction of operating rooms and other facilities, hiring of staff, acquisition of necessary instruments and supplies, and making provisions for postoperative care were likely similar to the machinations involved in the 1990s and early 2000s when community hospitals embraced starting new cardiac surgery programs to support the proliferation of cardiac cath labs. The economics of the Mississippi move would seem to have worked in Harter’s favor. Thoracic surgeons could now make a living practicing their specialty.44 MSTS had obtained national recognition and prominence as an outstanding medical institution and was supported by the medical profession, the public, state government, newspapers, and service organizations.1,2 By 1936, however, legislative funding was being decreased and bed numbers were being reduced. The new surgical program would keep the MSTS at the forefront of TB treatment and offered Harter the resources of state-of-theart therapy and facilities and a positive economic impact.2 Harter appears to have embraced the opportunity. He and his wife, Peg, moved from Boston and their son, John Burton Harter (renowned New Orleans artist), was born in Jackson during Harter’s tenure at the MSTS.1 He provided the full spectrum of surgical treatment for pulmonary TB. He also conducted clinical research and remained academically productive with presentations at local, regional, and national professional meetings and publications in multiple professional journals.46,47,48,49,50,51,52 Additionally the MSTS provided the venue for thoracic surgery training prior to formation of the American Board of Thoracic Surgery in 1948 and creation of approved training programs in 1950.53 Allen A. Lilienthal, MD served a three year residency under Harter from 1938-1941. He then served as a staff surgeon prior to enlisting in the Army in 1942. Following World War II

June 2014 JOURNAL MSMA 183

Lilienthal would have a long career in thoracic surgery in the San Francisco Bay Area before passing away in 2001 at age 89.54 Harter taught medical students from University of Mississippi School of Medicine at the end of their second year and spoke at nearly every medical society in Mississippi.38 These activities served to elevate the profile and activities of the MSTS regionally and nationally.

In 1946 Harter moved to Louisville, Kentucky, where he would remain for the rest of his career. He served as Chief of Surgical Service, Kentucky State Sanatorium and Chief of Thoracic Surgery at the University of Louisville Medical School. In 1953 he received national recognition and an Alfred I. duPont Foundation citation for his televised removal of a cancerous lung.55 He served as president of the Kentucky Medical Association and the Jefferson County (KY) Medical Society.55,56 He was a founding member of the Southern Thoracic Surgical Association in 1954 and the fifth President in 1958.57,58,59 He produced 32 more publications during his faculty service in Louisville.60 He died in 1982 at age 78 and was remembered for his pleasant and courteous ‘Southern gentleman’ personality whose career was dedicated to the crusade against an ancient scourge (TB) and a modern one (lung cancer).55,61 Watts Rankin Webb Watts Rankin Webb, MD (Figure 6) came to the MSTS in July 1952 as Chief Surgeon. There was no overlap between him and Harter and they never actually met. Although a native of Kentucky, he graduated from Gulfport High School in 1939 and the University of Mississippi in 1942. He received his medical degree from Johns Hopkins in 1945. He completed a surgical internship at Barnes Hospital in St. Louis and then continued as a surgery resident at the VA Hospital in Biloxi from 1946 to 1948. He then returned to Barnes for a residency in general and thoracic surgery from 1948 to 1952.62 In 1952 the University of Mississippi School of Medicine in Oxford was a two-year school but the planning and organization of the new four-year school in Jackson was well underway. The MSTS opportunity was suggested to Webb while awaiting the development of the 4-year school and its training programs. This occurred in 1955.63 Webb was on the original full-time Department of Surgery faculty in 1955 under James D. Hardy, MD.45 Webb remembers his time at the MSTS well with pleasant memories. He lived on campus and his caseload was full – lobectomies and pneumonectomies as well as thoracoplasties.63 This clearly reflects the continuing evolution of thoracic surgery with a shift from collapse therapy to pulmonary resection.

In 1955 he began his position as Instructor in Surgery at the University of Mississippi School of Medicine and quickly rose to Professor of Surgery (1958-1963). The surgical training program and thoracic surgery residency created the situation where thoracic surgery residents rotated through

184 JOURNAL MSMA June 2014

the MSTS. With resident manpower onsite, Webb and other faculty surgeons staffed the cases on a rotating basis. Despite issues with financial resources and anesthesia coverage, this arrangement continued until surgical treatment of TB dwindled due to improved medical/antibiotic therapy.45,63 The MSTS supported teaching components throughout its history. Prior to 1939 postgraduate training in TB management had been available to Mississippi physicians at no cost. University of Mississippi medical students were taught TB diagnosis and treatment. TB nursing was taught as a six-month post-graduate nursing course.1 Physicians throughout the United States and abroad (India, South America) took advantage of the learning opportunity offered at the MSTS.64,65,66 As noted previously the MSTS participated in thoracic surgery training both before and after board certification and formal training programs in the specialty were established. The thoracic surgery residency of the University of Mississippi School of Medicine under James Hardy included the MSTS as a core rotation.45,63,67 In 1966 this was a 6-month rotation during the two year residency with significant independent operating experience.67 Thoracic surgery continued its evolution from the lungs and into the heart. This was occurring at the University of Mississippi, and Webb and Hardy began an open-heart surgery program. In 1956 they began working with cardiopulmonary bypass in the animal lab. Webb was primarily responsible for organizing and setting up the pump oxygenator. The first case for congenital pulmonic stenosis was successfully performed on January 27, 1959.45 Webb became more involved with Hardy in the burgeoning arena of heart surgery and organ transplantation both in the lab and clinically in Jackson.45,68,69 Others assumed the responsibilities of staffing at the MSTS. These included Lee R. Reid, MD, T. K. Williams, MD, Gus Neely, MD, Jesse Wofford, MD, and Hans Karl Stauss, MD (coincidentally, Boswell’s son-in-law).25,67,70 A remarkable insight into the organization, structure, and workings of the thoracic surgical service at the MSTS can be gained by a visit to the Mississippi Department of Archives and History (MDAH) in Jackson. Housed there are “Operat-

Figure 6. Watts R. Webb, MD, at the MSTS in 1953 (Courtesy of the Sanatorium Museum) and in 2014 (Courtesy of Joseph Basha).

Association.1 In 1986 Hardy described him as “most effective in accepting responsibility and generating competent leadership in clinical surgery, teaching, research, and administration.”45 Epilogue After Boswell’s death Clyde A. Watkins, MD became director and led the MSTS until 1975 when regional centers for TB Figure 7. Sanatorium Museum today (Courtesy of the Sanatorium Museum). treatment and control were established in ing Room Records, 1954-1973.”71 This is a collection of five Greenville, McComb, and Tupelo.1 With boxes containing 13 Operating Room Record books for thoracthe treatment of TB finally evolving to modern standards, the ic surgery from April 1, 1954 to December 31, 1973. Patients, MSTS closed in 1976 and the training component for thoracic surgeons, assistants, operations, procedures, anesthetists, and surgery ended. Many senior Mississippians today are living other details were carefully handwritten with monthly totals proof of the great benefit served by the MSTS. The Ellisville of the operations and procedures. These books show the treState School, which had utilized the Preventorium as a satellite mendous depth of thoracic surgery experience by staff surgeons after its closure in 1972, recommended that the MSTS resources and resident surgeons at the MSTS. This training experience in be made available to the Board of Mental Health for specialized Mississippi is remarkable and extensive by today’s standards. programs for adults with intellectual and developmental disFurther insight is gained by reviewing “Surgical Staff Notes, abilities and this was done through the state legislature.1 Today 72 1970-1975,” also at the MDAH. This one box contains the it is the Boswell Regional Center, Mississippi Department of typewritten reports of the weekly thoracic surgical staff conferMental Health, and provides comprehensive care for these Misences from November 19, 1970, to June 25, 1975. All surgical sissippians. The Mississippi State Sanatorium Museum (Figure candidates were reviewed for operation and a disposition made.

7) on the campus was opened in May, 2012, and is maintained The reports are extremely well organized concise clinical sumby the Boswell Regional Center and the Mississippi Departmaries with surgical or non-surgical dispositions detailed. ment of Mental Health. It is very well done, easily accessible, Webb began a series of upward professional moves in and well worth a visit.

1964. These included Professor and Chairman, Division of Harter and Webb both held the office of President, SouthThoracic and Cardiovascular Surgery, University of Texas ern Thoracic Surgical Association. They were instrumental in Southwestern Medical School, Dallas, 1964-1970; Profesthe growth and development of that prestigious organization sor and Chairman, Department of Surgery, State University and are remembered and noted as such in the association arof New York, Upstate Medical Center, Syracuse, New York, chives. Both were pioneer leaders in thoracic surgery in this 1970-1977; Professor and Chairman, Department of Surgery, state and nationally with a common thread: the MSTS. Finally Tulane University School of Medicine, New Orleans, 1977two related observations peripheral to this story merit mention: 1989.62 Following his time at Tulane he has remained involved Boswell’s life and experiences are only briefly summarized in academic medicine and clinical teaching. His extensive Curhere and it is hoped that his definitive biography will be written riculum Vitae lists 31 professional society memberships, 315 in the future and added to the annals of Mississippi’s medical published articles, 35 book chapters, 10 books, 8 surgical vidhistory; James D. Hardy’s remarkable story has been written eos, and numerous awards and honors.62 Likely reflecting the and is highly recommended reading.45,73 MSTS experience, his publications include 41 articles between 1952-1965 related to TB and pulmonary pathology.62 Today, at Conclusion age 91, he has continued to impact and mentor students with Thoracic surgery was not merely a vicissitude of minimal his tremendous knowledge, wisdom, and experience by seeing importance in the treatment of TB as some have suggested.2 patients and teaching at the Huey P. Long Medical Center in Rather it was an important and significant component in the Pineville, Louisiana, a teaching affiliate of Louisiana State Unievolutionary progression of the treatment of this historic disease. versity Health Sciences Center in Shreveport until it closed on 63 Additionally the place of thoracic surgery in the treatment of March 31, 2014.

TB built the cornerstone for the development of modern day Thoracic and cardiovascular surgery as we know it today 44 thoracic and cardiovascular surgery. evolved from the surgical treatment of pulmonary TB. Webb’s The MSTS holds a unique place in Mississippi’s medical career exemplifies this evolutionary paradigm and demonstrates history.

It is an important part of the story of TB and its treatremarkable contributions, productivity, and longevity. In 1963 ment as well as the progressive evolution in the development Webb was described as an “investigator of international acof pulmonary medicine and thoracic surgery. The pioneering claim, a superb surgeon and teacher” by the Mississippi Heart

June 2014 JOURNAL MSMA 185

individuals who participated in this effort deserve recognition for their significant contributions. Mississippi can be justifiably proud of them and their important role in our state’s medical heritage.

Acknowledgements The authors gratefully acknowledge the assistance and support of Mr. Craig Kittrell, Director of Support Services, Boswell Regional Center, and Mr. Joseph Basha, CCP, during the development of this manuscript.

33. Matas, R. The soul of the surgeon. Trans Miss State Med Assn. 1915.48:149-175.

34. Dr. Rudolph Matas. Mississippi Doctor. 1941.18(12).

35. Trotter, MC: Rudolph Matas and the first endoaneurysmorrhaphy: “A fine account of this operation.” J Vasc Surg. 2010. 51: 1569-1571.

36. Trotter, MC: Rudolph Matas, M.D.: Contributions to Thoracic Surgery and Beyond. John L. Ochsner Medical History Lecture. The New Orleans Conference - VII. New Orleans, LA. June 13, 2013.

37. Harter, JS: Mississippi State Board of Health. Application for State Medical License. MDAH. Jackson, MS. 38. Faculty Record Form. Harter, John Spencer. 2/14/46. History Collections, Kornhauser Health Sciences Library, University of Louisville. Louisville, KY. 39. Harter, JS; Lyons, C: Surgical application of the Schilling differential blood count.

Surg Gynecol Obstet. 1933. 56:182-186.

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1. Calder, MR. Mississippi State Sanatorium. Tuberculosis Hospital. 1916-1976. Florence, MS: The Messenger Press. 1986. 17, 18, 25, 39-40, 45, 51, 96, 110-118, 136, 145-146, 239, 242, 261- 262, 269-273, 293, 319-320, 378-380.

41. Trotter, MC: Champ Lyons, Holt McDowell and the evolution of vascular surgery at the University of Alabama at Birmingham: A personal perspective. Am Surg.

2010. 76(12):1368-1376.

2. Baggett, A. “The Rise of the Surgical Age in the Treatment of Pulmonary Tuberculosis: A Case Study of the Mississippi State Sanatorium.” Master’s thesis, Louisiana State University, 2010.

42. Harter, JS; Overholt, RH; Perkin, HJ: The lung volume after thoracoplasty. J Thorac Surg. 1938. 7:290-301.

3. Drake, M. Sanatorium Girl. New York: iUniverse, Inc. 2005.

43. Berger, RL; Dunton, RF; Ashraf, MN; et al. Thoracic surgery and the war against smoking: Richard H. Overholt, M.D. Ann Thorac Surg. 1992. 53:719-725.

4. Bliss, M. William Osler: A Life in Medicine. Toronto: University of Toronto Press.

1999. 281-283.

44. Naef, AP: The 1900 Tuberculosis epidemic – starting point of modern thoracic surgery. Ann Thorac Surg. 1993. 55:1375-1378.

5. “Dr. Henry Boswell.” The Thermometer. Sanatorium, MS. 2(6): 1-2. Sept. 1926.

45. Hardy, JD: The World of Surgery, 1945-1985. Memoirs of One Participant. Philadelphia: University of Pennsylvania Press. 1986. 160, 202-204, 213-214, 233.

6. “Dr. Henry Boswell’s Work.” Jackson Daily News. Dec. 19, 1957.

7. Youngberg, AF. “Boswell, Henry.” Biographical Sketch. Subject File. Mississippi Department of Archives and History (MDAH). Jackson, MS. 8. Black, PC; Owen, M. “Dr. Henry Boswell Nomination for the Mississippi State Hall of Fame.” Subject File. MDAH. Jackson, MS. 9. “Must Be Optimist to Survive ‘TB’ Boswell Declares.” Jackson Daily News. July 10.

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10. “Dr. Boswell Resigns.” Mississippi Doctor. 1957(7):170.

11. Mississippi: Tuberculosis. Notification of Cases. Establishment and Maintenance of State Sanatorium. (Ch. 109, Act Mar. 25, 1916). In: Public Health Reports (1896-1970), 1916. 31(45):3146-3147. http://www.jstor.org/stable/4574255. Accessed July 5, 2013.

12. Mississippi: Tuberculosis. Notification of Cases. Establishment and Maintenance of State Sanatorium. (Ch. 109, Act April 5, 1916). In: Public Health Reports (1896-1970), 1916. 31(45):3147-3148. http://www.jstor.org/stable/4574256. Accessed July 5, 2013.

46. Harter, JS: Fallacies in the Use of Artificial Pneumothorax in the Treatment of Pulmonary Tuberculosis. So Med J. 1940. 256-258.

47. Harris, R; Harter, JS; Night blindness and Vitamin A deficiency in pulmonary tuberculosis. So Med J. 1940. 33(10):1064-1068.

48. Harter, JS; Lilienthal, AA: Extrapleural pneumolysis in artificial pneumothorax. J Thor Surg. 1940. 10:14-26.

49. Harter, JS: Significance of collapse therapy in the Mississippi State Program for the Control of Tuberculosis. So Med J. 1941. 34:665-668.

50. Harter, JS: Dyspnea. Mississippi Doctor. 1941. 12(19): 348-350.

51. Harter, JS: The prevention of empyema following lobectomy. Proc Am Fed Clin Res. 1944. 1:21-22.

52. Carr, D; Harter, JS: Lobectomy and Pneumonectomy in Pulmonary Tuberculosis.

Dis Chest. 1946. 12:387-393.

13. Kittrell, C. Personal communication. July 11, 2013.

53. www.abts.org. Accessed April 10, 2014.

14. Briggs, FB: “Dr. Boswell Takes Bow for 33 Years Service in Fight Against ‘TB’ ” Jackson Daily News. Aug. 5, 1950.

54. “Lilienthal, Allen A., M.D.” www.sfgate.com/news/article/LILIENTHAL. Accessed April 6, 2014.

15. “Julius ‘Preacher’ Buchanan – Pioneer Aide at the Sanatorium.” Sanatorium Museum.

Boswell Regional Center (BRC). Mississippi Department of Mental Health (MDMH).

55. “Pioneering Surgeon John Harter Dies at 78.” The Courier-Journal. Louisville, KY. April 9, 1982. B 4.

16. “Mississippi’s Conqueror of White Death” JMSMA. 47(11): 321, 327. 2006.

56. Johnson, K. Email to B. Groves, July 9, 2013.

17. “Boswell Tells Why He Resigns.” Times-Picayune. New Orleans. April 5, 1924. 25.

57. Seiler, HH. The early years of the Southern Thoracic Surgical Association. Ann Thorac Surg. 1972.14(2):113-122.

18. “Mississippi Press Pungent Comment on Live Issues”. Times-Picayune. New Orleans.

April 13, 1924. 5.

19. Barber, D. Email to M. Trotter. April 2, 2014.

20. American College of Surgeons: ACS Yearbook. Chicago, IL: ACS, 1935. ix, 104.

21. Stephenson, GW. The college’s role in hospital standardization. Bull Am Coll Surg.

1981.66(2):17-29.

22. Mengis, P. “The Preventorium”. Dixie. Times-Picayune States Roto Magazine. New Orleans. Dec. 10, 1950. 5-6.

58. Alford, WC. The heritage of the Southern Thoracic Surgical Association. Ann Thorac Surg. 1997. 63:305-308.

59. Miller, JI. A brief history of the Southern Thoracic Surgical Association and a synopsis of the presidential addresses. Ann Thorac Surg. 2003. 76:69-84.

60. Biographical File. Dr. John S. Harter. History Collections, Kornhauser Health Sciences Library, University of Louisville. Louisville, KY. 61. Pate, JW. Email to B. Groves. July 17, 2013.

23. “The Sanatorium and the African-American Community. Part 1 – The People.” Sanatorium Museum. BRC. MDMH.

62. Webb, WR. Curriculum Vitae. Watts R. Webb, M.D. July, 2013.

24. “The Sanatorium and the African-American Community. Part 2 – Facilities.” Sanatorium Museum. BRC. MDMH.

64. Lovett, L. “Sanatorium Expansion Program to Afford Better T.B. Care.” Jackson Daily News. Feb. 5, 1950.

25. Encalade, L. “Sanatorium played important role.” The Magee Courier. March 21, 1924.

65. Norman, G. “Sanatorium to Honor Ex-Prentiss Health Officer, Dr. Henry Boswell” Tupelo Journal. Oct. 3, 1954.

26. “To Integrate Facilities at State Sanatorium.” Clarion-Ledger. Jackson, MS. April 21, 1968.

27. Mississippi State Sanatorium: A Book of Information About Tuberculosis and Its Treatment in Mississippi. Sanatorium, MS: Mississippi State Sanatorium and Mississippi Tuberculosis Association. 1939. 38, 39, 93.

28. “Boswell, Dr. Henry.” The Southerner. A Biographical Encyclopedia of Southern People. New Orleans: Southern Editors Assn. 1940. 80.

29. Williams, EL. “Dr. Henry Boswell.” Obituary prepared for L. J. Clark, M.D. and the American College of Physicians. Subject File. MDAH. Jackson, MS. 30. Naef, A. “Early History of Thoracic Surgery.” In: Shields, T., ed., General Thoracic Surgery, Fourth Edition, Vol. I, Baltimore. Williams & Wilkins. 1994. 1-9.

31. Alexander, J. The Surgery of Pulmonary Tuberculosis. Philadelphia and New York.

Lea & Febiger. 1925.

32. Sloan, H: Historical perspectives of the American Association for Thoracic Surgery: John Alexander (1891-1954). J Thorac Cardiovasc Surg. 2005. 129:435-436.

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63. Webb, WR. Personal communication to M. Trotter. July 11, 2013 and April 10, 2014.

66. “Death Claims Sanatorium’s Dr. Boswell” Jackson Daily News. Dec. 17, 1957.

67. Weissberg, D. I Have Chosen Surgery (A Surgeon’s Memoir). Rehovot, Israel.

2002. http://dovweissberg.com/chosen/chapter4.html. Accessed December 5, 2013.

68. Hardy, JD; Webb, WR; Dalton, ML; et. al.: Lung homotransplantation in man.

Report of the index case. JAMA. 1963. 186(12):1065-1074.

69. Hardy, JD; Chavez, CM; Kurrus, FD; et. al.: Heart transplantation in man. Developmental Studies and Report of a Case. JAMA. 1964. 188(13):1132-1140.

70. “Dr. Lee R. Reid.” Clarion Ledger. Jackson, MS. May 18, 1987.

71. Operating Room Records, 1954-1973, by Mississippi State Tuberculosis Sanatorium. Series 2089. Box 9725, 9726, 9727, 9728, 9729. MDAH. Jackson, MS. 72. Surgical Staff Notes, 1970-1975, by the Mississippi State Tuberculosis Sanatorium.

Series 2062. Box 9733. MDAH. Jackson, MS. 73. Hardy, JD. The Academic Surgeon. An Autobiography. Mobile, AL: Magnolia Mansions Press. 2002.

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A RECORD YEAR IN MEDICINE MSMA 146th Annual Session of the House of Delegates

August 15-16, 2014  Jackson

THURSDAY AUG 14 JACKSON HILTON

FRIDAY  AUG 15 UMMC STUDENT UNION

SATURDAY  AUG 16 UMMC STUDENT UNION

7:30 – 11:00 Board of Trustees Meeting

8:00-10:00 Board of Trustees Meeting

……………………………………

11:00-12:00 CME Transitioning to ICD-10

10:00-10:45 Excellence Awards

2:30 -3:00 Jackson Hilton Clean Air Coalition news conference

12:00-1:00 CME Physicians for Smoke-Free Air

10:45-11:45 Candidate Speeches

12:00 at UMMC

UMMC Medical Students Lunch with AMA President

3:00-5:00 Jackson Hilton American Cancer Society Palliative Care Policy Forum 5:00-7:00 Jackson Hilton Welcome Reception with AMA President Robert M. Wah, MD Host: Central Medical Society ……………………………………….

ALLIANCE SCHEDULE 10:45 Friday, Fairview (invitation only) Past Presidents’ Luncheon 2:00 Friday, UMMC Alliance Board Meeting 8:30 Saturday, Jackson Hilton Alliance House of Delegates 11:00 Saturday, Jackson Hilton Installation Luncheon

Secretary of State Delbert Hosemann Boxed lunch provided

1:00-2:00 House of Delegates

Late resolutions, President’s Address

2:00-5:00 Reference Committee Hearings

FRIDAY  AUG 15

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1:00-4:00 House of Delegates 4:00-4:30 Board of Trustees Meeting

………………………………

JACKSON HILTON

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6:30 Jackson Country Club UMMC Alumni Dinner

OFFICIAL INAUGURATION

CLAUDE D. BRUNSON, MD ………………………………

147TH PRESIDENT OF MSMA 

7:30-8:00 Alliance Scholarship Fundraiser

8:00–11:00 Gala with Soul

Dinner Dance tickets $100 pp

190 JOURNAL MSMA June 2014

11:45-1:00 Caucuses

Reference committee orientation will be held prior to Annual Session via Go-to-Meeting.

The reference committee hearings and both sessions of the House of Delegates will be distributed by streaming video.

Delegates must be present to introduce late resolutions and speak at the reference committee hearings.

Delegates must be present to vote.

• Clinical Problem-Solving • Call the Surgeon Please Lauren B. Treadwell, MD

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n 18-year-old white female presented to the emergency department with a complaint of lower abdominal pain that had begun 3 hours prior to arrival. This pain was described as sudden in onset, excruciating and sharp. The pain was fairly constant but intermittently worsened in severity. There was associated nausea but no vomiting, diarrhea, hematochezia or melena.

She also denied fever, vaginal discharge and urinary symptoms but did report vaginal spotting for the past several weeks since starting oral contraceptives. The patient had a past medical history of migraine headaches and recurrent ovarian cysts. Her surgical history included bilateral ovarian cystectomies. Her only medication was a daily low dose oral contraceptive which she had started taking several weeks ago. She denied the use of tobacco, alcohol and illicit drugs. She also denied sexual activity.

Abdominal pain is a common presenting complaint in emergency department settings. It is estimated that 5% of visits to emergency departments are for evaluation of abdominal pain.1 The differential diagnosis for abdominal pain is quite broad and is often narrowed according to pain location. Lower abdominal pain, as present in this patient, may have a gastrointestinal source such as appendicitis, diverticulitis, gastroenteritis, colitis, bowel obstruction and mesenteric ischemia, or a genitourinary source such as cystitis and nephrolithiasis or ureterolithiasis. In females presenting with pain in the lower abdomen, ovarian torsion, hemorrhagic or ruptured ovarian cysts, ruptured ectopic pregnancy, pelvic inflammatory disease, endometriosis and tuboovarian abscess must also be considered.

Women of child bearing age are of special concern as their potential for serious complications is high.1

Author Information: Dr. Treadwell was a resident in the Department of Family Medicine at the University of Mississippi Medical Center in Jackson.

Corresponding Author: Lauren B. Treadwell, MD; Baptist Medical Clinic Northtown, 6250 Old Canton Road #100 Jackson, MS 39211 Ph.: (601) 957-1015.

Her initial vital signs included a temperature of 98.4°F, heart rate of 112 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 136/94 mmHg and oxygen saturation of 99% while breathing room air. The patient was well developed, well nourished and appeared uncomfortable. Her head, eyes, ears, nose, throat, neck, pulmonary, neurologic and psychiatric examinations were unremarkable. Her cardiovascular exam was remarkable for tachycardia and a regular rhythm without murmurs or gallops. Her abdominal exam revealed a soft and non-distended abdomen. Bowel sounds were present and normal.

There were 3 healing laparoscopy surgical scars without surrounding erythema or induration on the lower abdomen. There was moderately severe tenderness to palpation in the right lower quadrant. The lower abdomen was otherwise mildly diffusely tender. Her genitourinary examination revealed normal female external genitalia. On speculum exam, the vaginal mucosa appeared normal although there was blood in the vaginal vault. No vaginal discharge was otherwise present. No cervical discharge was evident.

Cervical os was closed. On bimanual exam, there was no cervical motion tenderness or adnexal tenderness, although the uterus was mildly tender. The patient was given intravenous fluids and narcotics for pain.

The presenting vital signs were remarkable for tachycardia and mild blood pressure elevation, which were both attributed to pain. Although the patient was not febrile, infectious causes still must be considered. The physical exam finding of a tender uterus raises concern for a genitourinary source for this patient’s abdominal pain, although a gastrointestinal cause is certainly still in the differential. The blood in the vagina is also concerning for genital tract pathology, but there is significant consideration that this vaginal bleeding is breakthrough bleeding from recent onset of oral contraceptive use and may possibly be unrelated to the current presentation of lower abdominal pain. Her recent surgical history raises some concern for wound infection; however, the examination of these scars was benign.

Further investigation is necessary to elucidate the source of the patient’s symptoms.

June 2014 JOURNAL MSMA 191

Initial laboratory values included hemoglobin and hematocrit of 13.5 g/dL and 40%, respectively. White blood cell count was 18.4 K/uL and segmented neutrophils were elevated at 77%. Her platelet count was normal, and her complete metabolic panel was unremarkable. Urinalysis showed the presence of leukocyte esterase, trace bacteria and numerous red blood cells. A wet prep was negative for yeast and trichomonads; clue cells were not seen. Her urine ß-human chorionic gonadotropin was negative. Samples from the uterine cervix were obtained to test for the presence of Chlamydia trachomatis and Neisseria gonorrhea species.

The laboratory finding of leukocytosis is concerning for an infectious cause of abdominal pain. The urinalysis may be suggestive of cystitis. The negative pregnancy test makes ectopic pregnancy unlikely. There is still concern that this could be appendicitis because of the location of her tenderness and the presence of leukocytosis. To determine if the abdominal or pelvic viscera displayed any abnormalities, a computed tomography (CT) scan of the abdomen and pelvis is needed. CT imaging has been found to be the most sensitive imaging for detecting urgent causes of abdominal pain.4 Abdominal and pelvis CT scan revealed unremarkable lung bases, liver, spleen, pancreas and gallbladder. The kidneys and bladder appeared normal. There was a large amount of fecal material throughout the colon, and the appendix appeared unremarkable. The uterus was noted to be midline, and small ovarian cysts were present bilaterally.

The findings on computed tomography are relatively benign and cannot explain the source of this patient’s pain. Constipation, as suggested by the large amount of fecal material in the colon, could certainly cause abdominal pain but is not likely to result in leukocytosis or acute-onset abdominal pain as in this case. The ovarian cysts are likely an incidental finding, as they are very common in women of child-bearing age and are frequently asymptomatic unless ruptured or hemorrhagic. Although the patient had recently undergone ovarian cystectomy and had a history of recurrent cysts, the presence of cysts on CT imaging is not alarming.

She was admitted to the hospital for further management. Gentle hydration and IV pain control were given.

Ceftriaxone (Rocephin) and doxycycline were given intravenously to cover for genitourinary pathogens. A pelvic ultrasound was ordered for further evaluation, as this is the imaging modality of choice for acute pelvic pain in women.2 The pelvic ultrasound revealed a 1.4cm area of mixed echogenicity in the right ovary, which could represent recurrent or residual dermoid cyst, and a small volume of nonspecific free fluid in the pelvis.

The ultrasound findings could not explain this patient’s severe abdominal pain and leukocytosis. There is concern that a structural abnormality or infection in the abdomen or pelvis that cannot be visualized on either ultrasonography or computed tomography is responsible for this patient’s discomfort and

192 JOURNAL MSMA June 2014

laboratory abnormalities. A diagnostic laparoscopy is needed to arrive at a diagnosis.

General surgery was consulted, as the patient continued to experience abdominal pain and tenderness and the imaging studies failed to identify a source of her leukocytosis. A diagnostic laparoscopy of the abdomen was unremarkable. The appendix appeared unremarkable as well.

The surgeon noted blood in the pelvis and after retracting the bowel superiorly, a defect was noted in the posterior vaginal wall. The area was both chronically and acutely inflamed. Gynecology was consulted intraoperatively, and the posterior vaginal laceration was repaired laparoscopically; the vaginal mucosa was subsequently reinforced. The patient was taken to recovery in stable condition. Post operatively, she experienced a dramatic improvement in her pain. The remainder of her hospital course was uneventful.

Cervical studies for Chlamydia trachomatis and Neisseria gonorrhea were negative, and she was discharged home on post-operative day 2.

Vaginal lacerations are an uncommon cause of lower abdominal pain in women. They are commonly secondary to trauma. Most trauma of the lower reproductive tract in women is secondary to complications arising during childbirth. This was not the case for this patient, as she was a gravida 0. Nonobstetrical genital tract injuries are another common cause of vaginal lacerations. This typically encompasses penetrating trauma, including penetration by foreign objects, coitus, hydraulic forces and fractures of the pelvis. These injuries can cause significant hemorrhage, which may require blood transfusions.3 Further history obtained from this patient did not elucidate known trauma as a precipitating factor.

Acute pelvic pain in women may potentially be life threatening. Appendicitis, ruptured ectopic pregnancy and ovarian torsion may all be accompanied by significant morbidity and mortality.

If initial history, physical exam, laboratory studies and diagnostic imaging do not indicate a cause for the pain, a diagnostic laparoscopy may be warranted. Some women with acute pelvic pain and a normal pelvic ultrasonography experience complete resolution of their symptoms without significant intervention.5 However, it may be difficult to distinguish these women from those who are likely to deteriorate rapidly without intervention.

Key Words: Non Obstetrical Genital Tract Injury (NOGTI), Acute pelvic pain.

References 1. Kamin, et al. Pearls and pitfalls in the emergency department evaluation of abdominal pain. Emerg Med Clin North Am. 2003; 21(1): 61-72.

2. Kruszka P, Kruszka S. Evaluation of Acute Pelvic Pain in Women. Am Famy Physician. 2010; 82(2): 141-147.

3. Jana N, Santra D, Das D, Das AK, Dasgupta S. Nonobstetric genital tract injuries in rural India. Int J Gynecol Obstet. 2008; 103(1): 26-29.

4. Lameris W, van Randan A, van Es H, et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: a diagnostic accuracy study. Br Med J. 2009; 339:29-33.

5. Harris RD, Holtzman SR, Poppe AM. Clinical outcome in female patients with pelvic pain and normal pelvic US findings. Radiol. 2000; 216:440-443.

• President’s Page • More Thoughts on Medicaid Expansion

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James A. Rish, MD 2013-14 MSMA President

alk of Medicaid always sparks a spirited debate. There is much discourse about the economic impact that expansion of Medicaid under the Affordable Care Act would have on the State of Mississippi. This important discussion cannot be ignored. It is estimated that the influx of federal dollars associated with Medicaid Expansion would result in approximately 9,000 jobs when fully implemented. The state investment would bring an estimated annual amount of $426 million in 2014 to $1.2 billion dollars by 2025 according to the Center of Mississippi Health Policy. That would create new demand in the economy.

Also requiring careful consideration is the Disproportionate Share Hospital (DSH) payments which bring vital revenue to hospitals treating uninsured individuals. These DSH payments will be significantly reduced whether or not Mississippi expands its program. Without Medicaid expansion, hospitals will be forced to find other revenue streams to cover the growing cost of uncompensated care.

What about the cost of Medicaid expansion? The Medicaid program is the largest line item on the state budget costing upwards of $5 billion. In January, Medicaid officials announced a projected $100 million shortfall for this fiscal year alone before any consideration of the cost of Medicaid expansion. The cost to the taxpayers of Mississippi will be driven by three factors according to the Institutes of Higher Learning Report: 1. Number of new enrollees 2. Expenditure per enrollee 3. Decline in the Federal Medical Assistance Percentage (FMAP) One must remain mindful that these incremental costs are much easier to define and quantify than the incremental benefits when so many variables are in play.

It is estimated that up to 300,000 uninsured adults would be added to the Medicaid rolls depending on the participation rate.

One must also factor in the Woodwork Effect in which eligible enrollees, who have not participated prior to expansion of the program for whatever reason, will sign up amid growing awareness of opportunities.

The expenditure per enrollee is likely the most difficult cost to predict. The administrative cost (i.e. need for increased office staff, equipment and space) is often left out of the discussion when considering the cost of Medicaid Expansion; yet, it is of significant concern. It is estimated that the administrative cost ranges at least 2.5% and as much as 5%. That is no small change in a program of the scale of Medicaid and should be carefully considered in the big picture.

The federal government’s share of the medical cost under Medicaid Expansion is 100% until 2016, followed by 95% in 2017, 94% in 2018, 93% in 2019, and 90% every year thereafter. Medicaid’s cost for expansion would range from approximately $2.5 million in 2014 to $159 million in 2025. Again, this is not small change when officials already project significant shortfalls.

Adequate physician work force is also a serious consideration when discussing Medicaid expansion. The fact that one has health insurance does not equate to access to primary health care in Mississippi. Mississippi already has the lowest number of physicians per capita than any other state in the nation. According to Dr. Ronald Cossman’s research at the Social Sciences Research Center at Mississippi State University, up to half of primary care physician offices are not currently accepting new Medicaid patients. Access to specialty care is already difficult at best under the current construct of the Medicaid program.

June 2014 JOURNAL MSMA 193

Regardless of what degree Medicaid is expanded we would have to have physicians to see these patients. I am astonished to hear that some of the most vocal physicians calling for Medicaid Expansion do not see Medicaid patients in their own practices. One has to ask the question, “Why is this?”

MSMA has long supported and will continue to encourage our physician members to participate in the Medicaid program as the safety net for thousands of Mississippians who have no other insurance. At one time nearly 90% MSMA members “participated” in the Medicaid program; yet many of those no longer take new Medicaid patients.

Whether or not the Medicaid program is expanded, you can be sure MSMA has been and will continue working diligently to improve our Medicaid system. This is an enormously complex issue and screams for bi-partisan efforts to chart the ultimate course of action. We at MSMA do not envy our law makers who are the ones called upon to increase access to medical care in the current fiscal environment. Not only must it work in the current fiscal environment but also be sustainable over future economic landscapes. MSMA supports greater access to medical care for those in need. As citizens of this great state, we likewise want to preserve important social programs while keeping taxes affordable.

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DISABILITY DETERMINATION SERVICES 1-800-962-2230 194 JOURNAL MSMA June 2014

• Editorial • No Room for Error D. Stanley Hartness, MD, Associate Editor

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he message was brief but its urgency wasn’t lost on me. With only five physicians signed up for the conference celebrating the passage of the Tort Reform Law of 2004, I felt obligated to quickly post my registration on-line.

A later memo provided more promising statistics, citing 225 participants. “Wow,” I thought, “my colleagues have really risen to the occasion!” On the morning of the conference, I contacted MSMA headquarters to inquire about proper attire and was told that doctors were being encouraged to wear their always impressive white coats.

When I arrived at the Jackson Convention Center, I suddenly felt like the Pillsbury Dough Boy– the only white coat in the cavernous meeting room and one of only a few more than “the original 5” physicians in attendance.

Business owners and legislators made up most of the audience. Looking around the room, I was reminded of the quote by George Santayana, noted Hispanic-American philosopher: “Those who cannot remember the past are condemned to repeat it.”

Gov. Haley Barbour’s opening remarks took on a personal poignancy as he recalled how, prior to passage of tort reform, Kosciusko family physicians—that was me—were forced out of the business of delivering babies when our medical liability premiums skyrocketed to more than $100,000 per physician per year. In the decade since passage of what the Wall Street Journal dubbed “the most comprehensive tort reform law in the nation”, our profession has continued to reap the benefits of meaningful civil justice reform. Mississippi has been recognized for its improved business climate, and the hemorrhage of physicians to neighboring states has been tourniqueted, hopefully racheting up access to and quality of healthcare.

However, speaker after speaker cautioned that while physicians have enjoyed ten years of relatively clear sailing,

storm clouds are gathering on the not-too-distant horizon as at least two law suits have been filed by trial lawyers challenging the constitutionality of the caps of $500,000 on non-economic damages for medical malpractice and $1,000,000 in all other civil causes of action, possibly ominous harbingers of the future of tort reform.

My concerns about this potentially temporary respite from “jackpot justice” are several. Even though I can safely say there were probably no trial lawyers in attendance at the tort reform conference, you can bet they know who WAS there, and I hope they don’t see our poor attendance as complacency on an issue that literally changed the climate for the practice of medicine in our state. Second, the Mississippi challenges to caps on non-economic damages have been remanded from the Fifth Circuit Court of Appeals to the Mississippi Supreme Court whose justices face periodic elections with candidates for these posts often receiving unlimited financial support from our plaintiff attorney friends with whom we have significant philosophical differences. Finally, although it has been only ten years since this historic tort reform was enacted, that is ten years of new young physicians who have never known the angst of receiving the registered letter from a trial lawyer’s office making you question why you ever entered the profession.

Edmund Burke, 18th century Irish statesman remembered for his support of the cause of American Revolutionaries, provided an excellent assessment of our current situation, “The only thing necessary for the triumph of evil is for good men to do nothing.” So I call on all the good men and women of MSMA to remain ever vigilant as our tort reform gains come under renewed attack from a relentless adversary. As with the care of our patients, the protection of our successes on the tort reform front leaves no room for error. r

June 2014 JOURNAL MSMA 195

• Editorial •

The Veterans Administration Hospital Scandal: Views of a Mississippi Physician John P. Hey, III, MD; Greenwood

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s a Vietnam veteran who received some of my early medical school training at a Veterans Administration (VA) hospital, and with a half century of practice in Family Medicine, I believe I can offer some insight into the scandal now rocking the VA medical system nation-wide. Way back in the early 1960s in medical school, we med students used to joke that they must rotate us through the VA hospital in order to immunize us against socialized medicine! Each of us saw during our time at the VA how horrible a government-run medical system actually was.

It still is.

To understand why, we have to distinguish between the medical staff and the administration at the VA. Generally speaking, the actual medical service was and is quite good.

There are many physicians and nurses at the VA who are dedicated to serving our veterans with skill and compassion.

It is the monstrous and oppressive administrative bureaucracy atop it all that neither the medical staff nor the patients can navigate. A centralized, socialized system does not, and never will, work. However, it seems that this same centralized, socialist system has now been mandated by Obama’s “Unavailable Care Act” to assume control of the rest of medicine!

Before our very eyes, hospitals and practices are already being destroyed by the unfunded mandates of the President’s unworkable law. Inevitably, they will be replaced with federal facilities along VA lines, complete with the same administrative nightmares. Once VA-like conditions of systemic inadequate and unavailable care take hold nationwide, the public will understand why medical insiders refer to the President’s misnamed “Affordable Care Act” as the “Unavailable Care Act!” While training at the VA, I recall the weeks-long wound Staph infections that took hold in most post-op patients despite increasingly scrupulous care taken by the surgical team.

Finally, they found that no one was sterilizing the surgical packs used in surgery.

I remember the old veteran who, after hours waiting in the x-ray department, was strapped into a wheel chair, pushed into the freight elevator, and dispatched to the top floor with the push of a button. Allegedly, the orderly called the nursing station and told them the patient was coming up. Three days later, someone opened the elevator and found the poor man unconscious and profoundly dehydrated.

196 JOURNAL MSMA June 2014

Recently, there were reports of a Mississippi VA facility’s radiology department where the radiologists all quit in disgust due to mismanagement from above. No problem– management hired another radiologist, and three and a half years later, they discovered that their new hire allegedly never actually read any of the x-rays!

Just this year I helped someone whose husband had returned home from Afghanistan having lost his leg. For over a year, they had been unable to obtain his VA health benefits and disability payments. The VA bureaucrats had given them the usual run-around, repeatedly losing their documents, telling them his name wasn’t in the system, etc. They were about to lose their home and didn’t know what to do. Their Senator finally had to intervene personally to secure what they were entitled to.

I believe that all this is due to the structure of the VA, which is basically like all other government programs: bureaucratic centralized planning, coupled with incompetent and indifferent administrative leadership. This isn’t really all that surprising since almost all projects run by the government fail miserably for the exact same reasons.

Take a look at the government-run public school system, and you can see how the VA operates and how Obamacare will operate. Unaccountable power always leads to failure and then tragedy, all with no mechanism for reform. Even when the misconduct crosses the line into the criminal, no one is prosecuted, and everybody has sovereign immunity from civil liability.

I would like to make several suggestions, any one of which would get our veterans the care they deserve: 1. Abolish the VA medical system and replace it with a healthcare card that veterans can use at any hospital or doctor or clinic. Maybe it could provide the same coverage and benefits as our Congressional representatives have given themselves!

2. Turn the VA over to the military to run. The military already requires any facility that is receiving patients to be under the command of a medical officer who is a physician. The military has the training, discipline, and integrity to run a veterans’ medical system well.

For example, in lieu of all the VA hospitals that our government has closed, veterans could be treated

We specialize in the business of healthcare

• • • • • • • •

• Editorial • at the medical facilities that already exist at every military base.

Comprehensive Management 3. Place every VA medical center under the command of a physician. He would be the CEO and would Comprehensive Consulting have administrative staff to assist. Business sense Billing & Accounts Receivable Management isn’t enough to manage medical care; medical Coding & Documentation expertise is the paramount necessity. Incidentally, Practice Assessments & Revenue Enhancement this would be a good policy to rescue our struggling Profitability Improvement civilian hospitals also!

Practice Start-ups for iPhone, iPad, Android, and all web-enabled mobile Idevices recognize there will be violent resistance to any of Personnel Management the above suggestions, especially by all those perched in

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1600 North State Street Suite 400 Jackson, MS 39202 Telephone: 601.944.1717 WATS: 1.800.355.4231 www.mpsbilling.com

patronage in the first place and not due to demonstrated competence.

Hopefully, this crisis will create such an uproar that change will be forced down the throats of the big government czars. We can only hope. r

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

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June 2014 JOURNAL MSMA 197

• MACM • Securing the Future of Healthcare: Students in your Practice

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Maryann Wee, RN, Director of Risk Management Medical Assurance Company of Mississippi s professionals in health care today, we all have a duty to educate future health care professionals and help prepare them for the real life experience of a medical practice. This on-the-job training is an important part of any student’s education and helps to prepare them for the real world.

At Medical Assurance Company of Mississippi, we regularly receive questions about the liability of having medical students working in a practice environment. And, while we do support and recognize the importance of this training, there are some risks involved. Please consider the check list below of risk management strategies to assist you and your clinic in making this a rewarding experience for everyone involved:

1. Know what is expected. What are your responsibilities as a mentor and what is to be accomplished during the student’s

rotation? Ask the school questions. Have a clear understanding of the professional level of student, i.e., Are they a student or resident? Do they have a professional license? Are they an RN? , etc. What will be the student’s scope of practice? Will the student just be shadowing you and your staff or have actual hands-on experience with the patients in your practice?

2. Have a Written Agreement. It is important to have all this information in a written agreement with the school. Most

likely, the school will provide an affiliation agreement that will spell out the obligations of the school, the student and your clinic. The agreement should also include a provision whereby the school indemnifies you and your clinic for any act of negligence committed by the student while training at your facility.

3. Check Insurance Coverage. You should be certain that the student is covered by a policy of liability insurance by

obtaining a copy from the school, including the limits carried. Also, check with your own insurance carrier to see whether your professional liability and the clinic’s policies cover this activity. If the student will be doing actual hands-on practice, you should see if your insurance will cover you for that exposure.

4. Set Policies and a Checklist. Develop a short written policy of how the students will interact in your practice. The students should have a formal orientation checklist. The checklist should include a review of basic office policies including HIPAA policies. All members of the office should be made aware of the policy and checklist and assist in the orientation.

5. Privacy Concerns. Impress upon the student the need to protect patient privacy. The best way to accomplish this is to have a confidentiality statement signed after it has been reviewed with the student. It should include a strongly-worded section on not disclosing any information on social media. The student should be cautioned about not disclosing information about the patients, clinic and staff. The consequences of violating this policy should also be explained and enforced, if necessary.

6. Identify Students. Identify the student clearly to your patients by means of a nametag.

7. Patient Interactions. Always verbally ask the patient’s permission for the student to work with or be with them.

Remember, they have the right to refuse.

8. Role in Documentation. Establish how or if the student will be entering information in the chart. Review the CMS rules on this to assure that you are in compliance, especially with medical and osteopathic students.

9. Cell Phones. Have firm rules on the use of cell phones. They should be off and in the student’s pocket and under no

circumstances should the student be taking photographs or videos in the clinic! Remember, you are dealing with a generation for whom the cell phone is a natural extension of their lives. They WILL USE IT inappropriately without thinking.

With some careful preparation, clear rules, and good communication, the presence of a student in your clinic should be a valuable experience for everyone involved. r

198 JOURNAL MSMA June 2014

• MSMA • MSMA Nominating Committee Announces Slate of Officers

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elegates attending the 146th MSMA Annual Session August 15-16, 2014, in Jackson will cast ballots to fill new terms of office for a number of association posts. A chart follows listing the vacancies that will be filled by election at the 146th Annual Session in 2014. Nominating Committee: The Nominating Committee is composed of the nine most recent Past Presidents of the association residing in Mississippi: Steve Demetropoulos, MD; Tom Joiner, MD; Tim Alford, MD; Randy Easterling, MD; Pat Barrett, MD; Dwalia South, MD; Eric Lindstrom, MD; Helen Turner, MD and Steve Parvin, MD.

MSMA VACANCIES 2014 OFFICERS & TRUSTEES

NOMINEES

INCUMBENT

President-Elect

Claude D. Brunson

Dan Edney

Dwight Keady

Trustee Dist 4

Clay Hays, Jr.

Clay Hays, Jr.

Meredith Travelstead

Trustee Dist 6

Jeffrey Morris

Mark Horne

Steve Stogner

Stephen Beam

Trustee Dist 7

Daniel P. Edney

Blane Mire

Joe Austin

Susan Chiarito

Trustee Dist 8

Lee Voulters

Lee Voulters

John Pappas

Trustee, Resident/Fellow

Jane Beebe Jones

Jane Beebe Jones

Rishi Roy

Trustee, Student

Savannah Duckworth Jordan Ingram

Craig Moffat

Speaker of the House

Lee Giffin

Geri Weiland

Chip Holbrook

Tim Beacham

Vice Speaker

Geri Weiland

Jeffrey Morris

Michelle Owens

Brent Smith

Editor

Luke Lampton

Luke Lampton

Heddy Matthias

Associate Editor

Stanley Hartness

Stanley Hartness

Philip Levin

Budget & Finance at large Jennifer Gholson

Jennifer Gholson

Rod Givens

Andrew Weeks

HOUSE OF DELEGATES

JOURNAL MSMA

COUNCILS

Const. & Bylaws at large

Philip Meredith

Victor Pang

Legislation Dist 6

Chris Mauldin

William Waller

William Sullivan

Legislation Dist 7

Ann Rea

Ann Rea

David Smith

Legislation Dist 8

Lee Voulters

David Sawyer

Larry Leake

Legislation Resident

Julia Thompson

Julia Thompson

Andrew Weeks

Legislation Student

Luke Ainsworth

Luke Ainsworth

Logan Rush

Medical Education Dist 1

Katherine Patterson

Katherine Patterson

Daneca DiPaola

Medical Education Dist 3

Murray Estess, Jr.

Murray Estess, Jr.

Dennis Smith

Medical Service Dist 1

Alfio Rausa

Abhash Thakur

Andrea Smith

Medical Service Dist 2

Bill Mayo

Bill Mayo

Jacob Whelan

Medical Service Dist 3

Laura Gray

Laura Gray

Jayant Dey

Medical Service Resident

Tal Hendrix

Tal Hendrix

David Smith

Medical Service Student

Emily Brandon

Emily Brandon

Warren Masterson

Public Information Dist 4

Jennifer Bryan

Chris Boston

David Wheat

Public Information Dist 5

Dewitt Crawford

Dewitt Crawford

Lee Valentine

Public Information Dist 6

Christie Thornton

Stephen Beam

Bobby Proctor

Nathan Williamson

Mary Armstrong Christy Vowell

Heddy Matthias

Michael Trotter



June 2014 JOURNAL MSMA 199

• Physicians’ Health Corner • Dr. Scott Hambleton Answers Your Questions Scott Hambleton, MD, Medical Director, Mississippi Professionals Health Program

S

everal times a week I am asked the question, “What is a physician health program?”

This is a question that I always look forward to answering, because I know that the services we provide have the potential to restore even the most seemingly hopeless situations. I have the privilege of working directly with physicians who are suffering and in need of assistance, and I have witnessed the dramatic transformations and healing that routinely occurs in these individuals, their families and medical practices. Careers are restored and lives are saved. However, unfortunately, many physicians do not know about our program.

Physician health programs (PHPs) are organizations which provide support and advocacy to physicians and other health care professionals who suffer from issues related to potential or real impairment from addiction, substance induced problems, psychiatric conditions or personality issues. We also offer assistance to distressed physicians who may suffer from problems related to personality issues or burnout.

We were founded by the MSMA in 1978, and our operations are defined in a written memorandum of understanding with the Mississippi State Board of Medical Licensure. We are enabled to provide initial evaluation, appropriate treatment, and ongoing monitoring to assure that a physician remains healthy. This ultimately protects the public, while at the same time, provides another physician for underserved Mississippi citizens. Mississippi consistently ranks 49th or 50th in active physicians per 100,000 population, so rehabilitation of our physicians is a necessity.

An obvious concern relates to public safety and the possibility of physicians monitored by PHPs practicing while impaired. In Mississippi, any case which involves direct patient harm is reported within 24 hours to the Medical Board.

Physicians practicing while impaired are immediately removed from patient care, until they are appropriately evaluated and treated.

Additionally, a 2013 study of 818 physician health program monitored physicians published in Occupational Medicine revealed that actively monitored physicians had a 20% lower malpractice risk than the matched cohort.

Further, the risk of post monitoring malpractice claims is actually lower than matched controls who did not utilize PHP services! The problem of higher risk of malpractice claims involves physicians who need treatment, prior to their involvement with PHPs. When a physician becomes involved with the Mississippi Professionals Health Program, not only are their lives and careers saved, but also, Mississippi is provided with a healthier and safer physician workforce.

If you have questions for Dr. Hambleton about MPHP you may contact him at (601)420-0240 or email shambleton@msprofessionalshealth.org. Anonymous questions are also permissable. Send your inquiry to the attention of “Physicians’ Health Corner” at the Journal address.

200 JOURNAL MSMA June 2014

• Information & Quality Healthcare • Dr. Ed Bryant Receives Derrick Award

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r. Edward E. Bryant of Kosciusko is the 2013 recipient of the Information & Quality Healthcare (IQH) A. A. Derrick Quality Award in memory of Dr. Arthur Derrick of Durant. In announcing the award, Dr. James S. McIlwain, IQH president of medical affairs, cited Dr. Bryant’s contributions to Medicare’s quality improvement program, including outstanding dedication to the organization’s board of directors as well as his service to his community and patients.

“From his busy schedule, Dr. Bryant has made time for supporting quality improvement,” said Dr. McIlwain. “He was an active member of our state’s quality improvement organization prior to his being elected to its board of directors in 2009. As chairman of the board, he has worked toward strengthening and supporting the quality projects underway in the state.”

Dr. Bryant’s degrees include the B.A. degree from the University of Mississippi, M.S. degree in physiology from Louisiana State University and the PhD n anatomy from the University of Mississippi Medical School. He earned the M.D. degree at the University Medical Dr. James McIlwain presents Dr. Edward E. Bryant the Center School of Medicine, with his internship and residency in family plaque designating him as the 22nd recipient of the special practice completed at the USAF Medical Center, Wright-Patterson quality recognition in memory of Dr. A. A. Derrick.

AFB, Ohio. His military career included serving as director of medical education, visiting lecturer, and consultant to the USAF Surgeon General. This included serving at the American Embassy in Moscow, USSR, in 1980. In 1983, he was named “Outstanding Family Physician in the Service” and received the USAF Meritorious Service Award. Dr. Bryant served as director of the Family Practice Residency in Carswell Air Force Base, Texas.

Returning to private practice in Kosciusko in 1983, he founded the Family Medicine Clinic. He has continued as a preceptor with the University of Mississippi School of Medicine, Department of Family Medicine. A certified medical review officer, he has donated time and service to professional organizations, including the American Academy of Family Physicians, serving as a state delegate to the national convention and serving as president and holding various offices with both the Mississippi Academy of Family Physicians and the State Medical Association.

Becky Roberson Named IQH CEO

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ecky Roberson has assumed the duties of chief executive officer of IQH. Serving as senior vice president since 2007, she succeeds Dr. James S. McIlwain, who is now serving as president of medical affairs. A Certified Public Accountant, Ms. Roberson has been with IQH for 26 years during which time she has served as vice president of operations and chief financial officer of the company that also operates the Mississippi Tobacco Quitline.

Holding a B.S. degree in accounting from Belhaven University, she is a member of the Mississippi Society of Public Accountants and the North American Quitline Consortium, serving as secretary of the board of directors. She chaired the American Health Quality Association finance and human resources network.

June 2014 JOURNAL MSMA 201

• IQH • Dr. James McIlwain to Retire from IQH July 31

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ver 20 years of service with IQH will be brought to a close July 31 as Dr. James S. McIlwain leaves the company in a retirement that is to be highlighted with his continuing various duties as a physician. “It’s so hard to say goodbye to yesterday, but it’s time to close out this chapter of my career that has meant so much over the years,” said Dr. McIlwain, who served as a review physician, medical director, principal clinical coordinator, and finally chief executive officer and president since 1991.

Under his leadership, the Mississippi Foundation for Medical Care (MFMC) became Information & Quality Healthcare (IQH) in order to better define the work of the organization.

Dr. James S. McIlwain

His tenure has seen various names describe the program, including Professional Standards Review Organization, Peer Review Organization, and Quality Improvement Organization. The Medicare work of the company has been with the Health Care Financing Administration (HCFA) that became the Centers for Medicare & Medicaid Services (CMS).

Call for Nominations

Excellence in Medicine Awards Each year, MSMA presents two deserving members of the medical community with awards – the MSMA Excellence in Wellness Promotion Award and the MSMA Community Service Award.

Award recipients will be present to accept the award in person on Saturday morning, August 16, 2014, at the 146th Annual Session of the MSMA House of Delegates in Jackson.

Complete the nomination form from our website: MSMAonline.com. Mail to the attention of Kara Kimbrough at PO Box 2548, Ridgeland, MS 39157 or fax to 601-856-6746.

For additional information call 601-853-6733, ext. 324 or email: KKimbrough@MSMAonline.com.

202 JOURNAL MSMA June 2014

• Poetry and Medicine • (This month, we print a poem by Robert Ray “Bob” McGee, MD, a Clarksdale internist. McGee writes under the pseudonym of Thomas Browne, MD. He recently published a lovely and brilliant volume of poetry entitled “Case Reports and Other Epiphanies,” printed by the Old Man’s Press of Clarksdale. He’s an accomplished and talented poet, publishing poems as early as 1980 in such publications as the “Annals of Internal Medicine” and “The Pharos.” A selection of his writing was also included in Dr. Trey Emerson’s “Avocation of Compassion,” published in 1989. To obtain a copy of his poetry collection, go to lulu.com or write to Dr. McGee directly at 303 Cypress Avenue, Clarksdale, MS 38614. This poem offers up a reflection on a physician’s diagnostic abilities becoming an art over time via experience. “If you have seen the beast\ You will recognize him,” he accurately reflects. Look for more of his poems in coming journals. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.) —Ed.

Diagnosis I knew what was the matter with him As soon as he walked in the room.

Don’t ask me how.

I knew.

Before he said a word Or asked a question.

Before I examined him.

The look on his face, The way he walked.

It must have been something, Because I knew at once.

But don’t ask me how.

Tests, X-rays, scans Help.

The pattern that mimics the textbook Helps.

But there is no substitute for having Been there before.

If you have seen the beast You will recognize him.

—Thomas Browne, MD, Clarksdale June 2014 JOURNAL MSMA 203

• Images in Mississippi Medicine •

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EATH OF DR. BENJAMIN RUSH (1746-1813)— This is an early newspaper report of the death of the great American physician Dr. Benjamin Rush. The National Intelligencer was published in Washington, D. C., then called Washington City, and as was the custom, it reprinted on April 22, 1813 this first report of Rush’s death from the Philadelphia Freeman’s Journal. The obituary, printed with a traditional black mourning border top and bottom, notes the significance to American medical history of the famed patriot and physician. Although Rush was not a Mississippian, his medical career, both as a researcher with yellow fever to teaching hundreds of medical students, influenced the medical profession in Mississippi significantly. Rush, who lived in Pennsylvania, was not only a prominent and respected physician, he was also a writer, educator, and humanitarian. He was a signer of the Declaration of Independence, a longtime medical professor at the University of Pennsylvania, an early opponent of slavery and capital punishment, and the “father of American psychiatry.” In 1812, he published the first American medical book on mental illness, approaching it as medical in origin and encouraging the humane treatment of the insane. Like many of his peers, Rush encouraged bloodletting and calomel therapy in his treatment for yellow fever, which ravaged Philadelphia in the 1790s. If you have an old or even somewhat recent photograph or historic image which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal MSMA.

204 JOURNAL MSMA June 2014

—Lucius M. “Luke” Lampton, MD JMSMA Editor

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

What is a Life Settlement?

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

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

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

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

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

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