March 2012 JMSMA by Journal MSMA

March

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2012

No. 3

Ellen, Cancer Patient

Ellen, Cancer Survivor

My L i f e i s P r o o f. A diagnosis of cancer changes everything for your patient. But today, there are more cancer survivors than ever before. At University Cancer Care, our first priority is comprehensive and compassionate care. Your patient will benefit from the collaboration of our multidisciplinary teams through specialized treatment plans. University Cancer Care has access to advanced research, technology and clinical trials that impact patient outcomes. And during the care of your patient, we communicate with you so when your patient returns to your practice, the continuum of care is seamless. To learn more about University Cancer Care, visit umhc.com/cancer or to talk doctor-to-doctor, call 866.UMC.DOCS. Dramatized to protect patient privacy

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD AssociAtE Editors Karen A. Evers MAnAging Editor PublicAtions coMMittEE Dwalia S. South, MD chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the editors thE AssociAtion Thomas E. Joiner, MD president Steven L. Demetropoulos, MD president-elect J. Clay Hays, Jr., MD secretary-treasurer Lee Giffin, MD speaker Geri Lee Weiland, MD vice speaker Charmain Kanosky executive director Journal of the Mississippi state Medical association (issn 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. correspondence: Journal MSMA, Managing editor, Karen a. evers, p.o. Box 2548, ridgeland, Ms 39158-2548, ph.: (601) 853-6733, fax: (601)853-6746, www.MsMaonline.com. suBscription rate: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. advertising rates: furnished on request. cristen hemmins, hemmins hall, inc. advertising, p.o. Box 1112, oxford, Mississippi 38655, ph: (662) 236-1700, fax: (662) 236-7011, email: cristenh@watervalley.net postMaster: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

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official publication of the MsMa since 1959

MARCH 2012

VOLUME 53

NUMBER 3

SCientifiC ArtiCleS

Mississippi Medicine Up-To-Date: Lyme Disease-like Illnesses in the South 68 Jerome Goddard, PhD; Andrea Varela-Stokes, DVM, PhD and Richard Finley, MD

Just Off the Press- Info You Want to Know: Aspirin for Primary Prevention

Richard “Buddy” Ogletree, PharmD

PreSident’S PAge

When a Colleague Refers a Patient, “Do the Right Thing”

Thomas E. Joiner, MD; MSMA President

SPeCiAlArtiCle

G. H. Tichenor, MD, and His Antiseptic Solution: The Mississippi Years - Part 1 of 2

Michael C. Trotter, MD, FACS

editoriAlS

Editor Interview: A Visit with Dr. Fred L. McMillan, President of Mississippi Physicians Care Network

Richard D. deShazo, MD, Associate Editor

The Catastrophe of Unwed Motherhood and Teenage Pregnancy: A Physician’s Call to Action

Heddy-Dale Matthias, MD

Electronic Medical Records and the End of Value: Physicians, Nurses, and Scribes

Carl R. (Kel) Feind, MD, FACC

relAted orgAnizAtionS

Mississippi State Department of Health

dePArtmentS

MSMA Annual Session Registration Letters Uncommon Thread Una Voce

78 87 97 98

ASClePiAd

Leonard (Len) Brandon, MD, and son, Steven Brandon, MD

100

About the Cover:

Hummingbird in nest —Will R. Locke, MD, of Starkville, photographed this hummingbird nesting in a staghorn fern on his back porch. Hummingbirds do not re-use the same nest, but often build again at the same site, occasionally right on top of the old nest. For consecutive summers, Dr. Locke has observed two successful nestings in this same location. Common materials used to build these amazing architectural creations include cotton fibers, small bits of bark or leaves, feathers, fuzz or hairs from leaves, and plant down from thistles, dandelions or cattails. Spider silk is used to bind the nest together and provides elasticity to enlarge as the hatchlings grow. These materials are woven together into a dense cup that is frequently decorated with moss, lichen or other materials for camouflage. The edge of the cup is curved inward to protect the eggs from tipping out in high winds. Upon graduation from the University of Mississippi School of Medicine in 1979, Dr. Locke completed an ob/gyn residency there in 1983. In private practice for the past 28 years, he is founding partner of Starkville Clinic for Women. r March

VOL. LIII

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March 2012 JOURNAL MSMA 65

From the Editor

pring is upon us, in all its grandeur. Already, the yellow pollen dusts our autos, and the world around us is turning green again. The warm days of February brought the blossoms of the Japanese Magnolia, the earliest harbinger of spring. Then comes the fury of the redbud, the dogwood, and the azaleas. The lifeless clinging wisteria vine awakens in its climbing purple eruption. My grandmother always said it is good that this wondrous season is so short, for it is “almost too exciting to stand.” The March Journal awakens with its own fury as well. For you medical history buffs, Dr. Michael Trotter offers an exceptional article on the Mississippian Dr. George H. Tichenor, who has been referred to as one of the most “famous medical men in America.” Tichenor’s Mississippi roots have largely been neglected, and this article explores the Mississippi background of one of the last state physicians licensed not by medical school training but rather by clinical experience. This is part one of a fascinating story well told by Greenville cardiovascular/thoracic surgeon Dr. Trotter. As well, two outstanding editorials should be read and reread. The first, by the gifted and always stimulating Dr. Heddy-Dale Matthias, a Madison anesthesiologist, explores the social and medical tragedy of unwed motherhood and teenage pregnancy and why every physician must attempt to

impact this issue for the health benefit of our patients. Also, Dr. Kel Feind, a McComb cardiologist, presciently explores the assault on the patient/physician relationship by the electronic medical record revolution, now ongoing. We, as physicians and patient advocates, must not allow corporate and national medical oligarchs to create a system which reduces the art of medicine to a handsLucius M. Lampton, MD off game of data entry. Editor Associate Editor Rick deShazo conducts an interview with MPCN President Dr. Fred McMillan, and he also deserves a bow for two features, one new, which were his brain-children: “Mississippi Medicine Up-To-Date” and “Just Off the Press, Info You Want to Know,” both significant scientific offerings for our physician readers. The graceful columns of Drs. Anderson and South are back, and Dr. South’s column should be photocopied and shared with our patients. The Brandon father/son physician team of Starkville is pictured in “Asclepiad,” our monthly feature which presents a portrait of member physicians making a difference in our state. March closes with National Doctors’ Day on the 30th, a day to honor the many in our profession who daily serve their patients and change their lives for the better. r

Journal editorial advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian 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, FAAP, FACS Associate 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 Thomas E. Dobbs, MD, MPH Health Officer, District VII/VIII Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for V A Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist The Street Clinic, Vicksburg

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Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP Residency Program Director North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A Kirchner, MD Chief of Staff G.V. Montgomery VA Medical Center, Jackson Brett C. Lampton, MD Internist/Hospitalist Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport

Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD, FACC Clinical Cardiologist, Hattiesburg Clinic

William Lineaweaver, MD, FACS Editor, Annals of Plastic Surgery Medical Director JMS Burn and Reconstruction Center, Brandon

Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula

John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital

John E. Wilkaitis, MD, MBA, CPE, MS Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

Medical Assurance Company of Mississippi Partnership keeps physicians focused on medicine For the physicians of Biloxi Internal Medicine, Medical Assurance Company of Mississippi is not just their insurance company, but also a member of the team. MACM’s Risk Management Department is invited into the clinic for risk assessments and staff presentations on a regular basis. The physicians want to keep their focus on providing professional care and seek out MACM’s assistance to do just that. Having MACM available to them and to their office staff is just one of the benefits they realize as insureds. With MACM’s help and advice, they can improve on what they already love to do.

Left to Right: Regina C. Mills, MD Reza Motakhaveri, MD Yashashree Bethala, MD Ben W. Cheney, MD Marion J. Wainwright, MD

For over 30 years, Mississippi physicians have looked to Medical Assurance Company of Mississippi for their professional liability needs. Today, MACM is an integral part of the health care community through its dedication to risk management services for our insureds. A dedicated staff and physician involvement at every level guarantees that the interests of our policyholders remain the top priority. This, combined with the many years of loyalty and support from our insureds, is what allows us to be the carrier of choice in Mississippi. Please call on us to assist with your professional liability needs.

1.800.325.4172 • www.macm.net

March 2012 JOURNAL MSMA 67

• Mississippi Medicine Up-To-daTe •

Lyme Disease-like Illnesses in the South Jerome Goddard, PhD; Andrea Varela-Stokes, DVM, PhD and Richard Finley, MD

ntroduction

Lyme disease is a systemic tick-borne illness caused by a spirochete, Borrelia burgdorferi, specifically, B. burgdorferi sensu stricto (“in the strictest sense”) in the United States. Borrelia burgdorferi sensu lato (“in the broadest sense”) includes other organisms in the genospecies complex that are agents of human disease, namely B. afzelii and B. garinii in Europe (see Gray et al.1for an overview). Collectively, these agents are related but may differ in vertebrate host preferences and clinical spectrum. Lyme disease is solely tick-borne. In the United States it is transmitted primarily by Ixodes scapularis (black-legged tick) in the East (Figure 1) and Ixodes pacificus (western blacklegged tick) in the West. Serious sequelae from infection are rare in persons receiving appropriate early antibiotic therapy. However, if an infection goes untreated, the course of disease may be long and debilitating and may include cardiac, neurological, and arthritic manifestations. Initial symptoms include a flu-like syndrome and often a somewhat circular, painless, macular dermatitis (erythema migrans [EM]) at the bite site. The number of reported Lyme disease cases in humans has increased steadily since 1981; 38,468 cases were reported to the CDC in

Author AffiliAtionS: Department of Entomology and Plant Pathology, Mississippi State University (Dr. Goddard); Department of Basic Sciences, College of Veterinary Medicine, Mississippi State University (Dr. Varela-Stokes); Department of Medicine, Division of Infectious Diseases, University of Mississippi Medical Center, (Dr. Finley). CorreSPonding Author: Jerome Goddard, PhD; Associate Extension Professor of Medical and Veterinary Entomology, Department of Biochemistry, Molecular Biology, Entomology and Plant Pathology, 100 Twelve Lane, Clay Lyle Entomology Building, Mississippi State University, Mississippi State, MS 39762. (662) 325-2085 (JGoddard@entomology.msstate.edu).

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2009 with 29,959 of them confirmed.2 Cases are reported in most states and the District of Columbia, but the majority occur in the northeastern and north-central United States (Figure 2). recent developments Increasingly, controversy surrounds the issue of Lyme disease worldwide. Some activists have portrayed the illness as an ubiquitous, insidious, difficult to diagnose, and almost incurable disease, which leads patients to try to find “Lyme literate medical doctors” to help them fight the illness.3 Likewise, there is controversy about the extent that Lyme disease occurs in the southern United States. Some states such as Florida and portions of North Carolina have even been declared endemic for Lyme disease, although the American Lyme Disease Foundation states that Lyme disease-infected ticks in the southern states are “rare.” Certainly, numerous cases are reported to state health departments and the CDC each year. In Mississippi, for example, there are about 10 to 30 physician reports of Lyme disease submitted to the state health department annually, although these are almost never officially confirmed. While confirmed cases of Lyme disease may be uncommon in the southern United States, the agent, B. burgdorferi, vector I. scapularis, and reservoir hosts, white-footed mice and cotton rats/mice, are all present in the South.4, 5 Interestingly, to date B. burgdorferi sensu stricto has not been isolated in culture from any human patient in the southern United States. STARI. Reports have persisted for years about a Lyme disease-like illness in the South which the CDC often labels as “southern tick-associated rash illness” (STARI) or Master’s disease.6, 7 Like Lyme disease, the characteristic feature is a skin lesion resembling EM, as well as flu-like symptoms (Figure 3). In contrast to Lyme disease, which is associated with I. scapularis, STARI is associated with the lone star tick, Amblyomma americanum, which is found commonly throughout the southern U.S. including Missis-

• scienTific arTicle • sippi (Figure 4). Given the lack of confirmed Lyme disease in the southern states, including Mississippi, it is possible that these cases may have been misdiagnosed STARI cases. Researchers originally implicated a spirochete, Borrelia lonestari (Figure 5), occurring in A. americanum as the cause of STARI, and the agent has been linked to at least one case of Lyme-like illness.8,9 However, in a study by Wormser and colleagues,10 B. lonestari was not detected by PCR or culture from skin biopsies of patients in Missouri with EM. Patients also were seronegative to B. burgdorferi suggesting another cause of the lesions. Lastly, Philipp and colleagues found that STARI patients from Missouri were negative on the C6 Lyme enzyme-linked immunosorbent assay to detect antibodies to B. burgdorferi.11 Thus, evidence of a borreliosis in STARI patients is lacking based on typical assays for B. burgdorferi.

Figure 3. This rash, which resembles erythema migrans, developed following a tick bite in a person in the southern United States. (Photo courtesy Worth Williams, used with permission.)

Figure 1. The adult female Ixodes scapularis is the primary vector of Lyme disease. (Photo courtesy of Dr Blake Layton, Mississippi State University. Used with permission.) Figure 4. The adult female lone star tick, Amblyomma americanum, may be the primary cause of southern tickassociated rash illness. (Photo courtesy of Dr. Blake Layton, Mississippi State University. Used with permission.)

Figure 2. Distribution of Lyme disease cases, by county – United States, 2005 (CDC).

Figure 5. This fluorescent antibody stain demonstrates Borrelia lonestari using a monoclonal antibody to the flagellin antigen. (Photo courtesy of Dr Andrea VarelaStokes, Mississippi State University.)

March 2012 JOURNAL MSMA 69

O’Brien & Family Law Group

James

P.O. Box 2623 682 Towne Center Blvd. Ridgeland, Mississippi 39158 (601) 952-0050 (Office) •(601) 952-0904 (Fax) office@jamesandobrien.net James & O’Brien Family Law Group consists of five attorneys, L.C. James, Danna A. O’Brien, David E. James, Alicia C. Baladi and Kim D. McCormack, who specialize in domestic law cases of all types, with a particular emphasis on divorce and custody. The Firm has earned and maintained an “AV” rating (very highest) in Martindale-Hubble Law Directory for more than a quarter century, and its senior member, L.C. James, is one of only 1,397 attorneys in the nation and the only family law attorney in Mississippi who has been listed in every publication of “Best Lawyers in America” since its inception in 1983. The law firm is dedicated to each client as he or she deals with divorce. We strive to earn the respect and approval of each client, for we fully understand that our reputation for excellence has been established over these many years through the judges, our peer group of fellow attorneys, but most importantly, our clients.

Mark Your Calendar

A Summit on Prescription Drug Abuse in Mississippi Wednesday, July 18, 2012 8:00 a.m. - 5:00 p.m. Mississippi Trade Mart Building, West Wing, Jackson SPONSORED BY: U.S. Attorney’s Office, Southern & Northern Districts of Mississippi CO-SPONSORED BY: DREAM of Jackson Drug Enforcement Administration Gulf Coast HIDTA Office of National Drug Control Policy Mississippi Academy of Physician Assistants Mississippi Bureau of Narcotics Mississippi Department of Mental Health

Mississippi Department of Public Safety Mississippi State Medical Association Mississippi Nurses Association Mississippi Pharmacists Association Mississippi Independent Pharmacies Association Mississippi Dental Association Pine Grove Behavioral Health and Addiction Services St. Dominic Hospital

NOTIFICATION WILL BE SENT WHEN REGISTRATION OPENS 70 JOURNAL MSMA

March 2012

Table 1. Recommended antibiotics for 14-21 day treatment of Borrelia burgdorferi infection

Drug Amoxicillin Doxycycline Cefuroxime axetil Allergic reactions to tick bite. Further complicating our understanding of Lyme disease in the South is an apparent hypersensitivity reaction to saliva of the lone star tick that sometimes occurs 1 to 3 days following a bite. This hypersensitivity reaction may resemble EM and is often up to 8 cm in diameter, ring-like, raised, and vesicular. Studies of such lesions are lacking; nevertheless, the lesions are probably not true EM because there is little or no incubation period, lesions often fade in a few days, and they are raised (often vesicular). In southern states where physicians do not see many cases of true Lyme disease, these hypersensitivity reactions could be misdiagnosed as Lyme disease. Recent evidence of rapid development of IgE antibodies to tick salivary proteins (after tick bite) in people residing in areas where Amblyomma americanum occurs supports the idea of hypersensitivity reactions.12 Co-infection in Ixodes vectors. Ixodes scapularis, the vector of Lyme disease, is also the vector for the agent of human granulocytic anaplasmosis, Anaplasma phagocytophilum, as well as human babesiosis, Babesia microti. Although there is greater likelihood of encountering Ixodes vectors singly infected with B. burgdorferi, ticks co-infected with two organisms may represent over a quarter of sampled ticks in highly endemic areas of the northeastern U.S.13 Polymicrobial infections in ticks with more than two organisms, including Borrelia miyamotoi and Powassan virus, are rare but have also been reported.14 Humans may become co-infected by transmission from a single co-infected tick or by transmission from multiple ticks infected with different organisms. Lyme disease patients co-infected with Babesia are more likely to have more severe, longer-lasting illness, and there is evidence to suggest the same in Lyme disease patients co-infected with A. phagocytophilum.13 diagnosis and treatment Although research to-date indicates that Lyme disease does not commonly occur in the southern United States, it is impossible to exclude infection with the Lyme disease agent or possibly a related Borrelia species. In persons presenting with a Lyme disease-like illness comprised of one or more EM lesions with or without the presence of systemic symptoms, it would seem most prudent to follow current Lyme disease treatment guidelines as published by the Infectious Diseases Society of America (IDSA).15 Patients with Lyme disease usually have negative serological tests at the acute stage of the disease in which EM manifests, and patients with STARI are less likely to show serologi-

Adult Dose 500 mg tid 100 mg bid 500 mg bid cal evidence of Borrelia infection, so the diagnosis and decision to treat must be based on clinical evaluation and not laboratory testing. If there is a history of tick bite at the site within the previous 1 to 3 days, it is possible that the rash is a hypersensitivity reaction and not EM. The patient can be reassured and instructed to return to the clinic if the rash enlarges after another 48 to 72 hours or if systemic symptoms (e.g., fever or myalgias) appear. If the rash appears after a delay of more than 3 days or if there is no history of tick attachment but the patient had possible exposure to ticks, particularly if systemic symptoms are present, then antibiotic therapy should be offered. The usual treatment is amoxicillin or doxycycline, although cefuroxime is an alternative (see Table 1). IDSA guidelines suggest treatment for 14 to 21 days. There is no evidence that parenteral therapy offers additional benefit. Since it may be associated with treatment complications and higher costs, it should be avoided.3 One can reassure the patient that likelihood of a complete response to therapy is high, and recurrence is rare. Chronic sequelae such as arthropathy, carditis, or neuropathy are rare in Lyme disease when treated in a timely manner. Some evidence suggests that STARI is less pathogenic, responds more quickly to antibiotic therapy, and is less likely to be associated with systemic complications.16 However, no long-term or carefully controlled studies have been done with STARI. conclusions Lyme disease-like illnesses continue to be reported from the South, although they may or may not be true Lyme disease. Persons who suspect that they have Lyme disease should seek a thorough evaluation by an empathetic physician (preferably an infectious disease doctor). Physicians should objectively consider the history, physical exam, and laboratory findings to guide their diagnosis and treatment based on clinical and laboratory evidence. Hopefully, further research using serology, culture of lesions, and PCR assays of patients, ticks, and other non-human hosts will eventually unravel the mystery of Lyme diseaselike illnesses in persons living in the southern United States. acknowledgement This article has been approved for publication as Journal Article No. J-11810 of the Mississippi Agricultural and Forestry Experiment Station, Mississippi State University.

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references 1.

Gray J, Kahl O, Lane RS, G. S. Lyme Borreliosis: Biology, Epidemiology, and Control. New York: CABI Publishing; 2002.

CDC. Summary of notifiable diseases, United States, 2009: CDC, MMWR, 58(53):1-104; 2011.

Auwaerter PG, Bakken JS, Dattwyler RJ, et al. Antiscience and ethical concerns associated with advocacy of Lyme disease. Lancet Infect. Dis. 2011;11(9):713-719.

Oliver JH, Gao L, Lin T. Comparison of the spirochete Borrelia burgdorferi S. L. isolated from the tick Ixodes scapularis in southeastern and northeastern United States. J. Parasitol. Dec 2008;94(6):1351-1356.

Rudenko N, Golovchenko M, Grubhoffer L, Oliver JH, Jr. Borrelia carolinensis sp. nov., a new (14th) member of the Borrelia burgdorferi Sensu Lato complex from the southeastern region of the United States. J Clin Microbiol. 2009;47(1):134141.

Felz MW, Chandler FW, Jr., Oliver JH, Jr., Rahn DW, Schriefer ME. Solitary erythema migrans in Georgia and South Carolina. Arch Dermatol. 1999;135(11):1317-1326.

Masters EJ, Donnell HD. Lyme and/or Lyme-like disease in Missouri. Missouri Med. 1995;92(7):346-353.

Varela AS, Moore VA, Little SE. Disease agents in Amblyomma americanum from northeastern Georgia. J Med Entomol Jul 2004;41(4):753-759.

James AM, Liveris D, Wormser G, Schwartz I, Montecalvo MA, Johnson B. Borrelia lonestari infection after a bite by an Amblyomma americanum (L.). J Infect Dis. 2001;183:18101814.

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10. Wormser G, Masters EJ, Liveris D, et al. Microbiologic evaluation of patients from Missouri with erythema migrans. Clin Infect Dis. 2005;40:423-428. 11. Philipp MT, Masters E, Wormser GP, Hogrefe W, Martin D. Serologic evaluation of patients from Missouri with erythema migrans-like skin lesions with the C6 Lyme test. Clin Vaccine Immunol. 2006;13(10):1170-1171. 12. Commins SP, James HR, Kelly LA, et al. The relevance of tick bites to the production of IgE antibodies to the mammalian oligo saccharide galactose-alpha-1,3-galactose. J Allergy Clin Immunol. 2011;127(5):1286-1293 13. Belongia EA. Epidemiology and impact of coinfections acquired from Ixodes ticks. Vector Borne Zoonotic Dis Winter 2002;2(4):265-273. 14. Tokarz R, Jain K, Bennett A, Briese T, Lipkin WI. Assessment of polymicrobial infections in ticks in New York state. Vector Borne Zoonotic Dis. Apr 2010;10(3):217-221. 15. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis Nov 1 2006;43(9):1089-1134. 16. Wormser GP, Masters E, Nowakowski J, et al. Prospective clinical evaluation of patients from Missouri and New York with erythema migrans-like skin lesions. Clin Infect Dis. Oct 1 2005;41(7):958-965.

• JUsT off The press - info YoU WanT To KnoW • [It is really difficult to keep up with what is going on in clinical therapeutics. It seems that every day there is a letter in the mail about a potential problem with an existing drug and promotional material on a new “wonder drug,” that is coming out. Fortunately, in the digital age, analysis of clinical trials using modern statistical methods (meta-analysis) have produced high quality studies, which are very useful in reaching meaningful conclusions about specific therapies. The University of Mississippi Medical Center School of Pharmacy has clinical programs on the UMC campus. In keeping with the trends for team healthcare, we have incorporated the Doctors of Pharmacy into our educational programs at a number of levels. One of these is the weekly presentation of a clinical therapeutics update that has been a hit with all of us. We thought you would like to have the excellent material put together by the for pharmacy interns and their mentor, Dr. Richard “Buddy” Ogletree, Aspirin Primary Prevention PharmD. We hope this will be helpful in your day to day practice. Please let us know your thoughts for this new series we have called,Article: “Just Off the Press-Info You Want Know.”] —Richard deShazo, MD,onAssociate Seshasai S, Wijesuriya S, toSivakumaran R, et al. D. Effect of aspirin vascular Editor and nonvascular outcomes: meta-analysis of randomized controlled trials. Arch Intern Med; Jan 2012:E1-8.

Aspirin for Primary Prevention

Background: The overall benefit of aspirin in the primary prevention of CVD and nonvascular events (primarily cancer) compared to the risks is currently unclear.

Objective: To assess the safety efficacy of on vascular nonvascular outcomes in trials primary rticle: Seshasai S, Wijesuriya S, and Sivakumaran R,aspirin et Results: Nineand randomized placebo-controlled were evalprevention. al. Effect of aspirin on vascular and nonvascular outuated. The mean follow-up period was 6 years and involved

comes: meta-analysis of randomized controlled trials. Design: Meta-analysis of randomized controlled trials Arch Intern Med; Jan 2012:E1-8.

over 100,000 patients. 46% of patients were male, and the pooled weighted mean (SD) age at baseline was 57 (4) years. Aspirinup was to reduce CVD eventstobyCHD, 10% (OR Methods: MEDLINE and the Cochrane Library were searched to shown June 2011 usingtotal terms related Background: The overall benefit of aspirin in the primary pre0.9; 95% CI, 0.85-0.96; NNT 120). The reduction CVD, cancer, nonvascular events, all-cause mortality, aspirin, and primary prevention. Three independentin CVD vention of CVD and nonvascular events (primarily cancer) events was drivenbleeding primarilyrisk by with a reduction in reductions. nonfatal MI reviewers were utilized. Risks and benefits were evaluated by comparing CVD risk compared to the risks is currently unclear. (OR 0.8, 95% CI 0.67-0.96, NNT 162). No significant reResults: 9 randomized placebo-controlled trials were evaluated. The mean follow-up period was0.85-1.15) 6 years and duction in CVD death (OR 0.99; 95% CI, or canObjective: To assess the safety and efficacy of aspirin on vasinvolved over 100,000 patients. 46% of patients were male the pooled weighted mean (SD) age baseline cerand mortality (OR 0.93; 95% CI 0.84-1.03) wasatseen. An incular was and nonvascular outcomes primary prevention. 57 (4) years. Aspirin in was shown to reduce total CVDcreased eventsrisk by 10% (OR 0.9; 95% CI, 0.85-0.96; of nontrivial bleeding events was seenNNT (OR120). 1.31; The reduction in CVD events was driven primarily by a reduction in nonfatal MI (OR 0.8, 95% CI 0.67-0.96, NNT 95% CI, 1.14-1.50; number needed to harm 73). Design: Meta-analysis of randomized controlled trials 162). No significant reduction in CVD death (OR 0.99; 95% CI, 0.85-1.15) or cancer mortality (OR 0.93; 95% CI 0.84-1.03) wasand seen. An increased risk of nontrivial eventsAlthough was seenaspirin (OR 1.31; 95% CI, 1.14-1.50; Conclusion: prophylaxis was shown to reMethods: MEDLINE the Cochrane Library were searched bleeding number needed to harm 73). duce nonfatal MI, use in patients without prior CVD does not up to June 2011 using terms related to CHD, CVD, cancer, reduce cardiovascular or cancer mortality. Due to the risk of nonvascular events, all-cause mortality, aspirin, and primary Conclusion: Although aspirin prophylaxis was shown toclinically reduce nonfatal MI,bleeding, use in patients without prior CVDfor significant the routine use of aspirin prevention. Three independent reviewers were utilized. Risks does not reduce cardiovascular or cancer mortality. Due to the risk of clinically significant bleeding, the routine primary prevention should be considered on a case-by-case and benefits were evaluated by comparing bleeding use of aspirin for primary prevention shouldrisk be with considered on a case-by-case basis. basis. CVD risk reductions. Figure 1. Effect of aspirin on vascular and nonvascular outcomes or death. CHD indicates coronary heart Effect of aspirin on vascular and nonvascular outcomes or death. CHD indicates coronary heart disease; CVD, disease; CVD, cardiovascular disease; and MI, myocardial infarction. cardiovascular disease; and MI, myocardial infarction.

Non‐trivial bleeds Total bleeds All‐cause mortality Noncancer, nonvascular mortality Cancer mortality Non‐CVD mortality CVD mortality Total CHD events Stroke Total CHD Fatal MI Nonfatal MI 0

0.5

Favors placebo

1 Odds Ratio

1.5

Favors aspirin

2.5

Adapted from: Seshasai S, Wijesuriya S, Sivakumaran R, et al. Effect of aspirin on vascular and nonvascular outcomes: meta-

Adapted Seshasai S, Wijesuriya Sivakumaran R, et al. Effect of aspirin on vascular and nonvascular analysis of from: randomized controlled trials. ArchS, Intern Med; Jan 2012:E1-8. outcomes: meta-analysis of randomized controlled trials. Arch Intern Med; Jan 2012:E1-8.

March 2012 JOURNAL MSMA 73

• Msdh • Mississippi Reportable Disease Statistics

January 2012 Figures for the current month are provisional

† Totals include reports from Department of Corrections and those not reported from a speciﬁc district. For the most current MMR ﬁgures, visit the Mississippi State Department of Health web site: www.HealthyMS.com. 74 JOURNAL MSMA

March 2012

Mississippi Second in the Nation to Implement Life-Saving Cardiovascular Emergency Response Plan

Dr. Thad Waites (front left) and State Public Health Officer Dr. Mary Currier (front center) announce the STEMI Care Plan. It is only the second statewide system in the nation created to treat heart attacks where a coronary artery is completely blocked by a blood clot - known as STElevation Myocardial Infarction, or STEMI. The first was North Carolina. With this new system in place, Dr. Waites of Hattiesburg, who serves on the state Board of Health, said a person suffering a STEMI heart attack in Rolling Fork, almost 90 miles from Jackson, stands a better likelihood of survival than someone in the middle of Los Angeles.

he Mississippi Healthcare Alliance (MHCA) and the Mississippi State Department of Health (MSDH) are implementing a new statewide plan to save critical time and greatly increase the chance of survival for one of the deadliest types of heart attacks. An ST-Elevation Myocardial Infarction (STEMI) is a type of heart attack where the coronary artery is completely blocked by a blood clot. As a result, the heart muscle supplied by the affected artery begins to die. A STEMI heart attack involves a major vessel that carries the blood supply to the heart and is the least recognized by potential victims and their caregivers. A STEMI heart attack needs specialized treatment – percutaneous coronary intervention (PCI) – within 90 minutes for the greatest success rate.

Currently, only 26 percent of acute care hospitals in the country are PCI-capable. Mississippi is the second in the nation (behind North Carolina) to implement a specific plan streamlining response to cardiovascular emergencies. So far, 19 Mississippi hospitals are taking part in the program, including four Jackson hospitals: Central Mississippi Medical Center, Baptist Medical Center, St. Dominic Hospital, and University of Mississippi Medical Center. Other PCI-capable hospitals include the following: Baptist Memorial Hospitals – Desoto, Golden Triangle, and North Mississippi; Delta Regional Medical Center, North Mississippi Medical Center, Magnolia Regional Health Center, Jeff Anderson Regional Medical Center, River Region Medical Center, Rush Health Systems, Forrest General Hospital, Gulfport Memorial

March 2012 JOURNAL MSMA 75

• Msdh •

Harper Stone, MD, President, Mississippi Healthcare Alliance, said the Alliance hopes next to tackle improving the care of those suffering strokes. Upon arriving, paramedics can give a stroke victim a “blood clot buster.”

Hospital, Singing River Health Systems (Ocean Springs/Pascagoula), Southwest Mississippi Regional Medical Center, and Wesley Medical Center. “These hospitals have physicians, staff, and equipment capable of opening a blocked artery with a balloon or stent 24/7,” said Dr. Harper Stone, president of the MHCA. “The STEMI plan will expedite the diagnosis and treatment of this type of cardiovascular event. Time is muscle. The longer the delay, the worse the outcome.” The STEMI Care

Plan will facilitate the immediate diagnosis of STEMI events; identify PCI and non-PCI facilities in the state; and establish protocol for rapid transfer of patients to PCI facilities, which in turn will ensure better outcomes for patients. “Mississippi ranks first nationwide in heart disease deaths. More Mississippians die from cardiovascular disease than from all types of cancer, traffic injuries, suicides, and AIDS combined,” said MSDH State Health Officer Dr. Mary Currier. “It is vital that we fight back, and to be among the first to implement a STEMI response system is an enormous step.” The American Heart Association estimates that as many as 400,000 people will have a STEMI heart attack each year in the United States. Many Mississippians drive themselves to the hospital, rather than calling 911, and that means treatment starts much later. Mississippians who think they may be suffering from a heart attack are urged to call 9-1-1 for immediate assistance so treatment can begin. If 911 is called promptly, treatment begins in an average of 32 minutes, officials say. Without 911, treatment begins in an average of 72 minutes. For more information on the STEMI Care Plan, visit the MHCA website at www.mshealthcarealliance.org or call Heather Sistrunk at 601-968-1297. r

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76 JOURNAL MSMA

March 2012

BRANDON BYRAM CANTON CLINTON JACKSON LAUREL MADISON PEARL RICHLAND RIDGELAND SPILLWAY VICKSBURG

• presidenT’s page • When a Colleague Refers a Patient, “Do the Right Thing”

n last month’s Journal of the MSMA there was an article [editorial] concerning professionalism that I encourage all to read.1 In my mind, there is no other profession other than the clergy that lends itself to such high standards as that of medicine. However, the higher the standards the farther the fall when those standards are not upheld. We have all witnessed this in the news, and we have all seen this among our friends and coworkers, not only in our ThoMas e. Joiner, Md medical profession but also in all others including, law, law enforcement, and the clergy. I think this defines us as human, but in no way can it be used as an excuse. 2011-12 MsMa presidenT If you went to school at the University of Mississippi School of Medicine at any time through the 1990s, you were taught everything you needed to know about medical professionalism from one man who embodied that concept; we just didn’t know it at the time. We were so naive that we in no way understood the simple quote that was used to answer almost all the questions we asked. It was only after time and years of practice that experience began to allow us to appreciate Dr. Thomas Blake’s advice to “do the right thing.” In fact, the older we all get the more we realize how sage this advice is. I wish we could all go back and thank him personally for some of the most important advice and guidance we could have received. Now all we have to do is to follow that advice at all times. And by all times I mean at all levels. Doctor to patient as well as doctor to doctor. We doctors do expect certain performance from each other and are greatly disappointed when we do not get it or see it. I guess how I deal with it is to alter my referral patterns until my patients and myself receive the return we expect. This “path of least resistance” approach serves me well although I do not think it serves the “system” well. It just bypasses those that probably should be made aware of the feelings and expectations of fellow physicians. With multiple levels of providers, we are at a time in the evolution of medicine that this is taking on a more important role. I think that, like me, physicians who refer patients for evaluation expect an evaluation of equal or greater professional content or an evaluation consistent with the training and expertise of the consultant. It is a slap in the face to receive less. This didn’t used to be a problem; we just didn’t repeat the process. With the coming of fixed referral sources secondary to third party constraints (PPOs, etc.), the path of least resistance is not available in many cases. This is where we must employ Dr. Blake’s advice and “do the right thing.” The right thing is to provide the highest professional product our training and experience enables us to provide, and we must expect it in return. Update from Jackson: Your legislative team is hard at work at the capitol on the agenda set by the House. We are in daily contact with the House and Senate, as well as higher-ups, making sure the Office of Physician Workforce and Patient Centered Medical Home are foremost on their minds. We have had great success with Truth in Advertising legislation as well as others pertaining to medical practice and will continue to watch out for issues that affect all of us. On a lighter note, the Run for the Roses is taking shape, but the picture will clear greatly with the running of the Rebel and Arkansas Derby in Hot Springs, the Louisiana Derby, Florida Derby, and the Santa Anita Derby in California. I think the best pick so far includes Hansen, Union Rags, and any Bob Baffart-trained colt that makes the cut. Whom do you like today? Next month I am going to tell you who will win the Kentucky Derby! 1. Didlake R, Smith PO. Focusing on professionalism. J Miss Med Assoc. 2012;53(2):54.

March 2012 JOURNAL MSMA 77

Join us for the Inaugural Gala honoring MSMA’s 145th President Steve Demetropoulos, MD

A BIG FAT

GREEK GALA President’s Inaugural Reception and Dinner-Dance Saturday, June 9 | 6:30 PM | $120 per ticket Live Authentic Greek Music by Nick Demos and the Greek Islanders

Register now at MSMAonline.com for the 145th MSMA Annual Session! June 7 – 10, 2012 · Point Clear, Alabama Questions? BWells@MSMAonline.com or 601-853-6733, Ext. 340

78 JOURNAL MSMA

March 2012

MSMA Annual Session Schedule Thursday, June 7 (Registration 1pm – 5pm) 8:30 10:30 CME Presented by MACM (2hrs CME) 11:00 until MACM Golf Tournament Grand Marriott Golf Club 3:00 5:00 Medical Affairs Forum (2hrs CME) 5:30 7:00 MSMA / UMC Welcome Reception 7:30 until Committee on Publications Meeting/Dinner Friday, June 8 (Registration 7am – 5pm) 7:00 8:00 MSMA Board of Trustees 7:30 9:30 Breakfast with Exhibitors 7:30 8:30 Reference Committee Orientation/Breakfast 9:00 11:30 House of Delegates 11:30 1:00 Lunch with Exhibitors 11:30 12:30 MPCN Executive Committee Meeting 12:30 1:30 MPCN Board of Directors Luncheon 1:00 1:30 MSMA Board of Trustees Meeting 1:30 3:30 Reference Committee Hearings 3:30 4:30 Journal Editorial Advisory Board Meeting 3:30 4:30 MMPAC Board of Directors Meeting 3:30 4:30 YPS Business Meeting 3:30 4:30 Women in Medicine Business Meeting 3:30 5:00 MSMA Surveyor Training Workshop/ Council on Medical Education 6:30 8:00 President’s Reception – Crawfish Boil 8:00 9:00 Southern Medical Ice Cream Social Saturday, June 9 (Registration 6:30am – 5pm) 6:30 8:00 Breakfast 7:00 12:30 Medical Affairs Forum (5hrs CME) 12:30 1:30 Candidate Speeches to Caucuses/ Boxed Lunch 1:30 2:30 Specialty Society Meetings 2:30 4:30 Guest Speakers with Book Signing Topic: World War II 3:30 5:30 MSMA Board of Trustees 6:30 7:30 MSMA Reception and Alliance Raffle 7:30 11:00 President’s Inaugural Dinner Dance Tickets: $120 per person Sunday, June 10 (Registration 7am – 11am) 7:15 7:45 Worship Service 7:30 9:00 Voting 7:30 9:00 Continental Breakfast 8:00 9:00 VIP Breakfasts: 50-Year Club and Past-Presidents’ 8:00 9:00 MSMA Board of Trustees 9:00 11:00 House of Delegates 11:00 11:15 MSMA Board of Trustees

MSMA ALLIANCE SCHEDULE Friday, June 8 10:00 am 12:00 pm

Pre-Convention Board Meeting Luncheon (Dutch Treat)

Saturday, June 9 8:30 am 12:00 pm

House of Delegates Installation Luncheon

Sunday, June 10 8:00 am

Past Presidents’ Breakfast

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Credit Card #: Name on Card: Please check the boxes and indicate number of attendees for each event below. Physician Registration (Asterisks indicate family events.)

THURSDAY, JUNE 7

SATURDAY, JUNE 9

FRIDAY, JUNE 8

SUNDAY, JUNE 10

CME Presented by MACM ____ Medical Affairs Forum ____ Welcome Reception ____

Breakfast with Exhibitors ____ House of Delegates ____ Medical Affairs Forum ____ Lunch with Exhibitors ____ President’s Reception* ____ Ice Cream Social* ____

FRIDAY, JUNE 8

Medical Affairs Forum ____ Pres.-Elect Reception ____ Pres.’s Dinner/Dance ____ ($120 per person) Breakfast ____ House of Delegates ____

Alliance Registration

Alliance Board Luncheon (Dutch) ____

SATURDAY, JUNE 9

Alliance House of Delegates ____ Alliance Installation Luncheon ____ ($45 tickets will be sold only on site.)

SUNDAY, JUNE 10

Past Presidents’ Breakfast ____

Mail completed form to

MSMA c/o Becky Wells PO Box 2548, Ridgeland, MS 39158-2548 Questions? BWells@MSMAonline.com or 601-853-6733 March 2012 JOURNAL MSMA 79

• ediTorial • Editor Interview: A Visit with Dr. Fred L. McMillan, President of Mississippi Physicians Care Network Richard D. deShazo, MD; Associate Editor editor: Dr. McMillan, what is the Mississippi Physicians Care Network? dr. mCmillAn: Mississippi Physicians Care Network (MPCN) is a Preferred Provider Organization (PPO). A PPO contracts with providers, which includes physicians, allied health providers, hospitals, ambulatory surgical centers (ASCs) etc., so that an insurance broker or Third Party Administrator (TPA) can offer health coverage at a set price to a group of individuals. MPCN works very hard to obtain the best price for health coverage while at the same time providing proper reimbursement to the providers administering this health coverage. MPCN offers one product, a group of providers that have agreed to provide health care on a fee for service basis at a negotiated price that an insurance broker sells to a group. MPCN has over 3500 Mississippi physicians, a large group of allied health professionals, and essentially all the Mississippi hospitals in our network. editor: Okay, MPCN is a PPO. Why do Mississippi and MSMA need one? Dr. McMillan: The goal of MPCN is to assure that there is a viable alternative in Mississippi to the standard insurance model, an alternative that is responsive to the concerns of the members of the Mississippi State Medical Association (MSMA) about how health care is delivered. This would include physician involvement in determination of what procedures are covered, responsiveness to the level of reimbursement for patient encounters and response to questions of denials and service to the patients and providers that is second to none. These issues have to be addressed in an environment that gives us competiveness with the larger insurance companies in the state. MPCN has insisted on the highest level of service to the individuals utilizing our PPO and to the providers providing the care. MPCN has been fortunate to be associated with brokers and TPAs that share this same goal and have consistently provided this level of service at a cost below the administrative fees generally seen in this market. editor: What role did MSMA play in the formation of MPCN ? dr. mCmillAn: MPCN was organized during a time when the members of MSMA were concerned about the changing environment of the health insurance market, particularly in Mississippi. The leadership of MSMA felt that physicians had the ability and the wherewithal to make a difference in the health insurance market so as to prevent the onerous changes affecting physicians and other providers in other states. editor. How does MPCN interact with MSMA? dr. mCmillAn: MSMA members, by belonging to MSMA, have input into how health care is delivered in Mississippi via the fact that MPCN has over 100,000 covered lives and is able to add new products yearly. MSMA has benefited from MPCN by increasing the membership in MSMA. Physicians see the benefit of belonging to MPCN and therefore MSMA. MSMA has also benefited financially from MPCN. editor: What is MPCN’s biggest challenge? dr. mCmillAn: The biggest challenge to MPCN has been to obtain competitive pricing from the larger providers so as to remain competitive with the large insurance companies. This stiff competition has resulted in numerous fully insured companies (those serving groups) leaving the state. Fortunately, enough of the large provider groups understand what is happening in the neighboring states and see the need for the viability of MPCN. MPCN has been able to meet this competition and thrive because of the excellent staff, savvy brokers and TPAs, and an excellent board of physicians, appointed by the Board of Trustees of MSMA. That Board has kept the company steered in the proper direction. Editor: How can a member of the Assocation learn more? Dr. McMillan: If a physician needs more information regarding MPCN, they can visit our website, www.MPCN-MS.com, or contact me, Fred@FredMcMillanRetinaMD.com. r

80 JOURNAL MSMA

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The Catastrophe of Unwed Motherhood and Teenage Pregnancy: A Physician’s Call to Action Heddy-Dale Matthias, MD, Madison

nwed motherhood at any age is an economic, cultural and medical disaster for the United States,1 but especially for the state of Mississippi. Governor Phil Bryant2 has been the first recent governor to name unwed pregnancy and unwed motherhood as extremely serious problems for our state’s economic progress, and has requested solutions from political, religious, educational, medical and social services professionals. It is refreshing that finally a leader has spoken of the 500-pound gorilla in our room. By ignoring this problem for nearly thirty years, we’ve allowed the beast to homestead in our living room for generations, ransacking and destroying stability, prosperity, and sanity, and holding our families and state hostage. It is well past the time for Mississippi’s physicians, as frontline professionals intimately involved in health care and reproduction, to throw down the gauntlet and lead the charge to expose the medical, psychological, economic, educational, and cultural malevolence caused by unwed motherhood. It is high time for radical change. Unwed motherhood, at any age, is directly related to increasing levels of poverty, substance abuse, sub-par education, prison, unemployment, crime, government dependence, poor medical and psychiatric health of both mothers and their children, physical and psychological abuse, child neglect, STIs (sexually transmitted infections), violence, and generational dysfunction.3 The US has witnessed a fall in the teenage pregnancy rate in the last decade.4 However, older, never-married or presently unwed women now constitute the overwhelming majority of out-of-wedlock births. These births by non-teenage women have helped raise to 41% the total number of out-of-wedlock births in the US, the highest rate to date. Of political and cultural importance, statistics demonstrate that 73% of black, 53% of Hispanic and 29% of white infants are born to unmarried mothers.5 These numbers portend significant political and cultural consequences to the future of the United States. The causes of this tsunami of unwed births are myriad. They include poverty, lack of education, unemployment, government subsidies, feminism, the sexual revolution, and, most importantly, a complete reversal and ambivalence of social attitudes toward unwed motherhood.6 During the last thirty years working women have become less dependent on financial support from men and marriage, while during this same period non-working women have found it easier to receive government assistance for healthcare, housing, and food, thereby making marriage and its resultant economic stability unnecessary for survival. The rules governing these subsidies favor and encourage women with children to remain unmarried, punishing those who do marry with the loss of many, if not most, of these entitlements, especially healthcare for their children. One group of women remains more committed to marriage before childbirth than they did in the past--those earning at least a four-year college degree. Despite early feminism’s push for women to declare their independence from reliance on men, college-educated women, at the end of the 1980s, realized that marriage resulted in superior economic stability for their children, and their “ever-married” incidence increased. Marriage, with its two wage-earning parents, can weather the storms of illness, a recession, and temporary unemployment better than a single-parent family.7 In fact, a recent article in the New York Times has labeled marriage a “luxury good” belonging to the highly educated and economically advantaged.8 As marriage generally confers more economic and psychological stability to its children, these families will turn out better educated and higher-earning children. Married families will beget richer offspring, thereby creating a class more elite than President Obama’s “1%.” A large, comprehensive study of unwed motherhood in highly developed countries demonstrated that, although teens and older women in Sweden and France, for example, have higher access to sex education, medical care, and birth control, their rates of unwed pregnancy are lower than those in the US. The Alan Guttmacher Institute’s crossnational study, “Teenage Sexual and Reproductive Behavior in Developed Countries,” found that “in France and Sweden, there appears to be a strong and universal perception that having a child during adolescence is undesirable (bold-face mine), while in the United States, this attitude is much less strong (sic) and much more variable across groups and areas of the country.” 6 In Sweden, there is no attempt to prohibit adolescents and others from having sex (as if that were possible), but there is pressure to use birth control, prevent STIs and pregnancy, to receive reproductive health care and testing, and to remain monogamous during a relationship. In Sweden and France, having children is considered an adult activity after the completion of advanced education, employment, and a committed relationship. Of note, US teenagers have the highest rates of pregnancy, childbearing, and abortion when compared to the UK, Canada, France, and Sweden, although the levels of sexual activity are the same.6 It is clear that US teenagers have sex with more partners than those in other developed countries, placing them at higher

March 2012 JOURNAL MSMA 81

• gUesT ediTorial • risk of STIs, pregnancy, and abortion. United States teenagers are less likely to use long-acting methods of birth control, such as IUDs and hormonal implants, than their European counterparts.6 They are also much less likely to take advantage of health clinics for reproductive counseling, SDI testing/prevention, and pregnancy avoidance as European girls do because access to these clinics is difficult. Although some states prohibit it, Mississippi law allows prescribing birth control to girls less than 18 without parental permission. If a teenage girl is motivated and knowledgeable, she may, often with great effort, get herself with regularity to a public health clinic in Mississippi that can counsel and provide her with birth contraception, although the logistics of transportation to a distant clinic during clinic hours (school hours) may prove problematic, decreasing the likelihood of its use. Some states locate these clinics in middle and high schools in order to provide easy access to male and female teenagers. The clinics provide childhood healthcare for routine illnesses such as colds, fevers, and asthma, and they also provide adolescent health care, including reproductive services. A plethora of studies of school-based clinics throughout the US have repeatedly shown that school-based and school-linked clinics do not increase the proportion of teens who are sexually experienced.9,10 In other words, access to reproductive clinics does not increase the sexual of activity of teenagers. Their activity is high and remains that way, leading to unplanned, unwed pregnancies, STIs, and increasing abortions for teen girls. Mississippi faces two major problems in this regard, and although they appear to be the same problem with the same solutions, they are quite different. The first problem is accidental pregnancy in teenagers and its attendant exposure to STIs. Sadly, experts agree that adult (parental) supervision, moral teachings, and religious acculturation do not prevent teenage sexual activity. Abstinence teaching alone fails to decrease sexual activity, unplanned pregnancies, or abortions. Easy (school) access to birth control lowers the rate of pregnancy, abortion, and STIs.10 Therefore, if prevention of teenage pregnancy is of paramount importance for the emotional, psychological, and physical health of our adolescents, teenage sexual education and contraception (for both sexes) are mandatory. The Society for Adolescent Medicine supports confidential and easy access to birth control for adolescents.11 Groups adamant against comprehensive schoolbased adolescent sexual education (biological, psychological, moral, economic, and cultural,) easy access to birth control, and STI prevention are a major impediment to lowering teen pregnancy. JNLMSMed-BW1 The second problem is that of unwed pregnancy and motherhood of non-teenage women, and it has no easy solutions.

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1076 HIGHLAND COLONY CONCOURSE 600, SUITE 100 RIDGELAND, MS 39157

(601) 856-7200 www.cctb.com

Unwed motherhood is now the norm, and it is either glorified by celebrities or considered “standard operating procedure” for black and Hispanic women with white women gaining speed. If US culture has lost shame and disapproval of unwed pregnancy, how can this thirty-year trend be reversed? There are many who believe that a paradigm shift in marriage has occurred, both in the US and other Westernized countries, and that return to our previous two-parent family tradition is impossible. If the trend is non-reversible in the US, which it appears to be, then disparity between the rich and the highly educated will continue to grow. If Americans desire that outcome, they will do nothing to find solutions to the problem. If the US wishes to stop the erosion of the belief that having a baby without benefit of marriage is advantageous for a woman, then we physicians must take radical steps. To start, we must convince young women that having a baby without marriage will prevent them from fulfilling many, if not most, of their dreams. We must convince them that they will live a life of economic insecurity, un(der)-employment, poor(er) health, less education, more violence and substance abuse, and that they will bestow these bedevilments upon their children. We physicians must convince girls and women that they must not settle for less, and that accidental or purposeful unwed motherhood is a disaster they can choose, or avoid. Cultural, religious, educational, medical, political, and educational leaders must convince women that purposeful unwed motherhood is an economic, personal, health, and cultural disaster. By idly standing by for three decades, by remaining silent from our clinics as single motherhood became the norm, we gave overwhelming (tacit) approval to women to believe that unwed motherhood was synonymous with emancipation, with empowerment, with equality, when it has led to poverty, instability, and economic slavery.12,13 Perhaps it is too late to reverse the shift, and Western culture is destined to become female-centered and socialist (governmentdependent) with serial, unwed relationships as the norm. It is inevitable that other cultures with more stable familial and reproductive strategies will find they have an economic advantage over single-parent Western arrangements. Only then will Western political, religious, and cultural institutions understand the gravity of the loss of the stable two-parent family to our civilization. Society has conferred on physicians the privilege of “doctoring.” Our goals are to improve our patients’ lives, if possible. If we agree that unwed motherhood has a profoundly deleterious effect on the health of our patients,14 we are required to do everything within our power to help women avoid this tragic outcome. We must stand front and center and speak loudly, plainly, and without guise. It is, after all, our duty as physicians to enhance the health of our patients. referenCeS: 1. Kearney MS, Levine PB. Income Inequality and Early Non-Marital Childbearing: An Economic Exploration of the “Culture of Despair” (June 2011). NBER Working Paper Series, Vol. w17157:1-60. 2. Governor Phil Bryant. State of the State Address. January 24, 2012. 3. McLanahan S. ed. Children in Fragile Families. In: England P, Carlson M, eds. Changing Families in an Unequal Society. Palo Alto, CA: Stanford University Press. The Future of Children. 2010; 20(2):3-229.

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

Klein JD, Committee on Adolescence. Adolescent pregnancy: Current trends and issues. Pediatrics 2005;116(1):281-286.

Centers for Disease Control. Changing Patterns of Nonmarital Childbearing in the United States. NCHS Data Brief. May 2009;18:1-8.

Darroch JE, Frost JJ, Singh S, and the Study Team. Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made? Alan Guttmacher Institute; 2001; Occasional Report. No. 3:3-122.

McLanahan S, Percheski C. Family Structure and the Reproduction of Inequalities. Annu Rev Soc. 2008; 34(8):257-276.

DeParle J, Tavernise S. For Women Under 30, Most Births Occur Outside Marriage. New York Times. February 17, 2012.

Kirby D. The impact of schools and school programs upon adolescent sexual behavior. J Sex Res. 2002;39(1):27-33.

10. Ricketts S, Guernsey B. School-based health centers and the decline in Black teen fertility during the 1990’s in Denver, Colorado. Am J Public Health. 2006;96(9):1588-1592. 11. Society for Adolescent Medicine. Confidential health care for adolescents: Position paper. J Adolesc Health. 2004;35:1-8. 12. Fothergill K, Feijoo A. Family planning services at school-based health centers: Findings from a national survey. J Adolesc Health. 2000;27(3):66–169. 13. Sawhill I, Thomas A, Monea E. An ounce of prevention: Policy prescriptions to reduce the prevalence of fragile families. The Future of Children. Fall 2010;20(2):133-155. 14. Williams K, Sassler S, Frech A, Addo F, Cooksey E. Nonmarital Childbearing, Union History, and Women’s Health at Midlife. Am Sociol Review. 2011;76(3):465.

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• gUesT ediTorial •

Electronic Medical Records and the End of Value: Physicians, Nurses, and Scribes Carl R. (Kel) Feind, MD, FACC; McComb

lectronic medical records (EMR) are being implemented across the country and here in Mississippi in order to satisfy mandates from the federal government (CMS). Unlike other changes in the practice and tempo of medical delivery, the way these mandates have been interpreted will fundamentally disrupt the practice of medicine as most of us know it.

“Phil, can I ask you a question?” “Sure, Kel.” “Phil, how many patients do you see in clinic in a day?” “15.”

Phil is an old friend and electrophysiologist in Indiana. I called him after a recent meeting here about the implementation of an EMR in McComb, Mississippi. After Phil and I parted ways some years ago his clinic sold itself to Clarion Health System in Indianapolis. They built a new hospital and clinic that was advertised as “paperless.” Phil has been practicing in the EMR environment for about 4 years now. Their system is one of several on the market; it is robust and in compliance with the most recent requirements from CMS. When I worked there, before the EMR, there were six cardiologists and two surgeons. Each of us worked closely with a nurse and saw twenty-five to thirty patients a day. If a patient needed a test, the nurses ordered it and explained it to the patient. If someone needed an admission, we dictated an admission note, but otherwise the charting was SOAP notes written in longhand in a paper chart. It seemed to work pretty well. The patients were seen in a timely fashion; they were satisfied and well cared for and the doctors. Nurses and staff were busy but not overextended. We had the time and support to think about our patients and how best to meet their needs. Fast forward four years: With the new EMR, it takes Phil 20 minutes to see a patient that used to take him 10. There is not more face-to-face time between Phil and his patients; there is less. Instead of spending his time talking to patients, understanding their concerns, examining them, and imparting learned advice and counsel, Phil spends most of his time entering data in a computer. His administration insists on it. They have fired all the nurses. There is now one medical assistant for two doctors. They room a patient, take vital signs and leave. If the patient needs a refill, Phil has to enter it in the computer. If they need a test, Phil has to schedule it in the computer. It takes a few minutes to do an exam and twice as long to enter it in to the computer. He has tried to streamline it, but he has failed. Phil’s efforts to increase the number of patients he can see in a day have become impossible. He can no longer dictate. He is not allowed verbally to direct anyone to enter anything for him. If he sees more than 15 patients, he is working at home late into the evening. I didn’t ask how long it takes to get an appointment, but we both know the answer to that. Certainly Phil seems less satisfied in his practice. Like all specialists, he used to help out his patients with routine care like refilling medications or listening to their problems and making referrals to other doctors. But there isn’t time for that anymore. He used to pride himself on the quality of his records. Now his once fluid prose has become staccato and nearly meaningless. And crucially, the time he spent with patients imparting value has become vanishingly small. There is only so much time available. The time spent entering data is stolen from the time spent thinking about the patient and their unique clinical circumstance. In our practice in McComb, we have four cardiologists, one surgeon, and one nurse practitioner. We see roughly 300 patients a week in clinic. In order to see all the patients in the hospital and emergency room, we can spend only two days a week in the clinic. If we see 15 patients per day in the clinic, there will be over 100 patients per week that aren’t seen. How is that going to work and who is that good for? There certainly isn’t a gaggle of cardiologists and practitioners out there who we can hire to see all these patients. We certainly can’t expect the emergency rooms to absorb them, and there aren’t a bunch of family practice doctors waiting to see patients with heart failure and malignant vascular disease. According to the Board of Health, Mississippi already has one of the lowest ratios of providers to patients in the country; we should be trying to increase the number of patients we see, not lower it. What is going on?

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“Glen, can I ask you how many patients you see in a day?” “Sure, most days I see 12, sometimes I see 14.” Glen works in the VA clinic in McComb where he is a primary care doctor. It usually takes him 10 to 15 minutes to review the computer records before he ever lays a stethoscope on a patient’s chest. After he spends a few minutes with the patient, it takes him another 10 to 15 minutes to complete the computer work. He puts in an eight hour day just seeing patients in the clinic. He does not go to the hospital and takes no emergency calls day or night. And his productivity is typical. Is this the future for the rest of us? Are we all going to be working in a virtual VA clinic system? As a business model, the two systems could not be more different. I can understand why the VA wants Glen to see only 12 patients a day. He is paid a salary, and every patient he sees is a risk to the system. He may find a lump that needs a biopsy or hear a murmur that needs an echocardiogram. In order to stay within their budget, the VA needs to limit these services, and the easiest way to do so is to limit the number of patients that go through the system. In private practice, the business model is just the opposite. We have been encouraged to see as many patients as possible. Fortunately (or unfortunately), for patients in an underserved area, it makes sense for the limited number of practitioners to see as many patients as possible. The irony is this: in every other business, computers have increased efficiency. However, in the way these new EMR systems are being installed, they will decrease efficiency, sometimes dramatically. The danger is that demand for medical services is only going to increase in the next few years as the population ages and the Affordable Care Act (ACA) brings more people into the health insurance system. In order to accommodate this increase in demand, health systems will have to increase efficiency, not become more inefficient. Doctors and providers will have to be empowered to see more patients, not fewer. Furthermore, my value to patients is not as a data entry clerk. My value as a physician is the knowledge that I bring to bear on their cardiovascular problems. It is the product of years of training and the honing of a unique set of skills. In order to serve the patients, I need time to explore their issues deeply. That is what they expect and what we should strive to give them. I am certainly not opposed to legible medical records. They serve many purposes. What is frightening for the practice of medicine in this country is the ascendancy of the record over the encounter that it reflects. If there was ever an example of putting the cart before the horse, this is it.

A different model DiD your last meeting leave you feeling a taD

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We’re right in the middle of the midsouth and tupelo is the headquarters of the north mississippi medical Center, the largest non-metropolitan hospital in the united states, and is a winner of the prestigious malcolm Baldrige national Quality award! And we promise you won’t feel out of place here! For information about setting up your next meeting, give Linda Elliff a call at 800-533-0611.

I would like to propose a different model. We can have both excellence in clinical medicine and excellence in record keeping. It will take a reinterpretation of regulations and a recognition that doctors in clinic act as team leaders. They must supervise nurses, medical assistants, and scribes. Doctors will spend their time examining patients, thinking about the problems and proposing a plan of treatment. Nurses will teach and help take and organize patient’s history and concerns. And scribes will faithfully record each encounter into an EMR. This is the only way we can continue to meet the patient’s expectation of receiving value for their time and money. And it is the only way we can meet the increased demand for medical services in the coming years. It will take our physician leaders to bring these concerns to the leadership at CMS. Let us direct them now. Nothing is more important. r

he comments expressed in this Journal are those of the indicated author. Comments and opinions are not expressions of the views or official policies of the Mississippi State Medical Association. We encourage our membership to submit comments for publication regarding any opinion expressed or information contained in the Journal. mail to Managing Editor, Karen Evers: KEvers@MSMAonline.com or mail to: Editor Lucius Lampton, MD, 111 Magnolia St., Magnolia, MS 39652-2825. We encourage your comments.

March 2012 JOURNAL MSMA 85

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Physicians Should See Their Own Consults on the First Visit

ear JMSMA Editor,

Historically physician-to-physician referrals or consults were exactly that. It is our belief that this fact is implied when a physician’s office accepts a referral and makes an appointment with the doctor on a given day and at a given time. At our last meeting, the Mississippi Academy of Family Physicians (MAFP) board discussed the increasing number of physicians using physician extenders, especially subspecialists, as the initial and often, only contact with their new patients. This practice seems to be occurring not only with patients who self refer, but also with patients who are physician referred. This process concerns the MAFP Board,

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and from experiences of the Board, we feel this to be a less than ideal practice. The MAFP Board acknowledges that there are many practice changes ahead of us, and the need to use mid-levels is definitely a part of the ever-changing face of the delivery of medical care. We also understand that we cannot require anyone to alter their practice process, but we do expect and encourage proper etiquette among physicians. I find it a little ironic that MSMA is pushing legislation that basically demands that anyone in the medical field identify themselves and clarify their training background to patients with whom they have a clinical relationship. MAFP feels strongly that when a physician refers a patient to a specialist that the patient be seen by the specialist on the initial visit. Understandably, specialists may use mid-levels in multiple venues, even to include much of the initial work-up, but we request there be clear and definable presence and input documented from the specialist if this process is used. It would be our request that any physician whose normal practice is to have mid-levels as the only contact on the referral visit take the initiative to inform the referring physician so that the physician and patient could jointly make an informed decision as whether to proceed with said referral or not. We value and trust our specialist’s evaluation and recommendations. Therefore, we believe our patient’s care is jeopardized when the above practice occurs. As referring physicians, we (and our patients) expect a referred patient to be seen by a physician specialist during their initial evaluation. When this is not the customary process of the physician’s practice, their practice referral and work up process should be clearly stated and disseminated to the referring physicians. We hope the specialists in Mississippi believe as we do that continuity of care between physicians creates a confidence in patients and that this is something that seems to be more in question lately. Thank you for allowing us to use this format to address this important health care issue. Sincerely, William B. Jones, MD MAFP President, Greenwood

March 2012 JOURNAL MSMA 87

• special arTicle • G. H. Tichenor, MD, and His Antiseptic Solution: The Mississippi Years - Part 1 of 2 Michael C. Trotter, MD, FACS

ntroduction

George Humphrey Tichenor has been called “the South’s most famous doctor,” 1 “the best known Southern surgeon,” 1,2, “ the greatest Southern surgeon,”2 “one of the most famous medicine men in American history,”3,4 and “one of the most prominent and popular physicians and surgeons in the South.” 5 He is also recognized as a famous persona of Amite County and Liberty, Mississippi,6,7,8 and Madison County and Canton, Mississippi.7,8,9 He was a remarkable multi-faceted individual who, among other things, was a soldier, physician, and innovator. The story of his life and accomplishments contribute to the medical history of the Confederacy and post-Civil War South as well as leave a legacy of a successful business model with a consistent, effective product that has withstood the test of time. early years George Humphrey Tichenor was born April 17, 1837, in Ohio County in western Kentucky to Rolla and Elizabeth Humphrey Tichenor, both natives of Kentucky. His father was a merchant and steamboat owner, and this influence instilled an interest in boats, rivers, and river travel. His early education was in public schools in Rumsey, Kentucky.10,11 At age 13, his mother died, and his father remarried within the year. He and his younger brother Thomas J., age 11, ran away from home. His stepmother had five children from a previous marriage, and the boys felt unwanted in the new home situation. This marriage ended a year later, and his father died two years afterwards.2 The two boys, ages 17 and 15, were left without their natural parents. Young Tichenor developed an interest in chemistry and pursued its private study after leaving school. By 1859, at age 22, he had moved to Franklin, Tennessee, and was involved in manufacturing explosive guncotton.4,10,11,12,13,14 At the outbreak of the Civil War, the business was commissioned by the Confederate government to manufacture gunpowder.10,11,12,14 Additionally, in 1860, Tichenor was in business in Nashville as “Prof. G.H. Tichenor, operator in oriental and positive pictures, instruction given in the art on the most reasonable terms” (Figure 1).15,16,17 The 1860 Census has Tichenor, age 24, listed as living in Davidson County, Tennessee.18

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Figure 1. Early efforts in the photography business. tHe civil war His experience as a Confederate soldier and his post-war Confederate veterans’ activities demonstrate the significant impact his Confederate military service made upon his personal and professional life. Fortunately, Tichenor kept a diary (two volumes) during his military service which is located in the George H. Tichenor Collection in Hill Memorial Library (Special Collections) at Louisiana State University.19 From this diary much insight can be gained into the experiences that would profoundly impact his future life. In the preface he writes “The intention of my notes is to facilitate my memory in years to come.” In May 1861, at age 24, he volunteered in the Williamson County “Dare Devils” (the Light Dragoons, Williamson County Cavalry) for a period of 12 months. In the diary, he created a roster of the unit, listing each individual for a total count of 77. He noted their “position in private life” which listed 10 doctors and one druggist. His profession was listed as “Artist.” This company was one of five composing the First (McNairy’s) Cavalry Battalion of the Provisional Army of Tennessee. They mustered into Confederate service at Knoxville, Tennessee, and became combatants by engaging in skirmishes throughout south central and southeast Kentucky by the end of 1861. They proceeded into middle Tennessee, in early 1862 and by March were in Iuka, Mississippi. There they served as scouts and pickets at Eastport, Mississippi, during the build-up and troop movement preceding the Battle of Shiloh on April 6-7, 1862. Afterwards he commented, on April 9, “Our men are in good spirits and feel confident as to the final result.” They moved on to Burnsville, Mississippi and

then Jacinto, Mississippi, where he describes waiting for engagements (that never occurred) and noted the paucity of “provisions for man and horse.” On May 29, they moved to Booneville, Mississippi where they were involved in a significant confrontation and were able to liberate about 3000 Confederate POWs. On June 13, 1862, McNairy’s Battalion was consolidated as the Second Regiment (Barteau’s) Cavalry, also known as the 22nd Tennessee Cavalry. On August 22, 1862, they joined Armstrong’s Cavalry Brigade and proceeded across the Tallahatchee River into west Tennessee. They were engaged at the Battle of Britton’s Lane on September 1, 1862, and then returned to Mississippi via LaGrange, Tennessee. They were engaged at the Battle of Iuka following which Tichenor was dispatched with a train of wagons to Baldwyn, Mississippi. During the Battle of Corinth on October 3-4, 1862, they attacked Federal supply wagon trains in the region around Corinth. On October 9, he decided to examine his arms as he recalled having had “too bad carteradges” in their last engagement. While cleaning the pistol, it accidentally discharged, wounding him in the left arm between the wrist and the elbow. He states “my arm was torn very near to pieces.” Once treated on the scene, he was advised to “get to some place whare I could be comfortably situated.” He secured railroad passage and traveled to West Point, Mississippi, and then hired a private buggy to Palo Alto, Mississippi, where he remained until January 31, 1863. During this time he was near the residence of Mr. Benjamin Bugg and cared for by Drs. D. B. Hill and G. M. Gordon. He was treated without amputation. No diary entries are recorded for the remainder of October 1862 through January 1863. On February 4, 1863, he received orders from Richmond to be detailed as recruiting officer for the Second Tennessee Cavalry at the rank of captain. He was ordered to middle Tennessee where he was to endeavor to obtain recruits by offering inducements to volunteer. If that was unsuccessful, he was authorized to conscript. Recruiting was difficult only because the men could not furnish themselves with horses. He then proceeded to north Alabama and then to Verona, Mississippi, on April 23, 1863. At that point the diary ends. There is a paucity of detail relating to his evolution as a physician. In fact, medical related information from the diary is minimal. He sustained a significant accidental gunshot wound of the left arm requiring an extended recovery period. His war record is noteworthy in that he participated in a total of 24 engagements including support and rear guard deployment at the Battle of Shiloh and direct engagement at the Battle of Britton’s Lane, Battle of Iuka, and Battle of Second Corinth. An examination of his military service record is enlightening. Besides the personal diary, the “Certificate to be Given at the Time of Discharge” is revealing (Figure 2). He describes his physical

characteristics, lists his enrollment profession as “Artist,” and gives a final statement detailing his cause of discharge as “gunn shot wound of left fore arm uper third -fracturing radius & splintering portion of ulner Re’cd on 9th October 1862.” His discharge date was June 7, 1863.

Figure 2. “Discharge summary” from the Confederate army.

tHe legend The ‘Legend’ connected to his military service has been consistent over the years.4,10,11,12,13,14,20,21,22,23,24 Pinpointing its exact origin has been somewhat elusive. Reportedly, he spent two years studying during his time of active service and applied to take the Medical Board Appointment Examination. He was found qualified and appointed as Acting Assistant Surgeon, Confederate States Army. His interest was in the concoction of an antiseptic liquid which would facilitate wound healing. He sustained a leg wound in a battle near Memphis during November, 1863. By the time he arrived at a hospital, he had developed infection and gangrene. Amputation was advised, and he refused. With the aid of friends, he was smuggled out of the hospital and proceeded to the safety of a private residence. There he was able to treat himself with his antiseptic solution and accomplished healing the leg and avoiding amputation. He has been credited in popular writing with the introduction of the use of antiseptic to the Confederate States Army. The diary does not give

March 2012 JOURNAL MSMA 89

information regarding the ‘Legend.’ The actual Battle of Memphis was a naval battle on June 6, 1862 and resulted in Union occupation of the city. However there were land skirmishes throughout the region during this time period, and his unit had been in that region and actively engaged. There is no mention of a leg wound, gangrene, or possible amputation in his diary. Certainly an event of this magnitude would have been recorded. However the arm gunshot fracture likely would have met criteria for amputation. There were also no diary entries during his recovery period, and he received documented medical care. His arm healed with the treatment plan that was utilized. In 1997 the Confederate Service Record of George Humphrey Tichenor at the Tennessee State Library and Archives in Nashville was reviewed. There was no mention of his being an Acting Assistant Surgeon in their records (letter from Archivist Ann Bomar to Mr. Joe W. Moore of Slidell, Louisiana, June 12, 1997). In January 2009, a search of all relevant records of Confederate medical personnel at the National Archives in Washington, D.C. was undertaken with regard to the Confederate medical service of George Humphrey Tichenor. There was no reference to him as an Acting Assistant Surgeon or in any other medical capacity (letter from Archivist DeAnne Blanton to the author, Jan. 5, 2009). post civil war years Much of the popular history written about Tichenor has been based on oral histories, and some of this information may not be historically accurate. For example, on the website for the Amite County and Liberty Mississippi Bicentennial,25 the following is noted referring to “Some Interesting Facts about Liberty and Amite County:” Dr. G.H. Tichenor invented his famous antiseptic in Liberty prior to the Civil War. This invention is credited with saving the lives of many Confederate soldiers who were wounded in the war. It has been said that he refused to use his product on the Union army. It is not known if he invented his antiseptic in Liberty as there is no written documentation of this. The claim that his antiseptic saved many Confederate soldiers’ lives is undocumented in historical and medical records. There is also no documentation that he somehow kept his product from the Union army. However, much is known about his life during the post-war years. canton, mississippi Madison County, Mississippi Circuit Court records reveal that he married

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Margaret Ann Drane on November 12, 1863, in Canton. There is a letter from her father, Rev. Thomas Jefferson Drane, in these records granting “Capt. Tichenor” permission to marry his daughter.26 He was 26, and she was 17. Rev. Drane had moved from Barren County, Kentucky with his family in the 1850’s to Memphis. He was a preacher at First Baptist Church in Memphis from 1857 to 1862. The family evacuated to Canton, Mississippi when Memphis fell,27 and Margaret was reported to have been involved in nursing at local hospitals.14 Additionally, Margaret was sent back to Memphis to care for a sick sister. In doing so she smuggled letters in her petticoats and pistols in her armpits.27 The records of the Canton Lodge #28 F & AM, Canton, Mississippi, from 1864-1869 confirm Tichenor’s presence there as well as that of his father-in-law.28,29 The 1870 Lodge records are consistent with their departure.29 It appears that G.H. Tichenor had a good and close relationship with his father-in-law. During this time he may have begun his practice of medicine.30 A search of the Index of Land Deeds, 1826-1872, Madison County, Mississippi, revealed that G.H. and M.A. Tichenor bought, sold, and leased property and took out a loan with their property as security.31 In the post-war South, there was an increase in patent applications. This was felt to be the result of a new labor system and the restoration of peace.32 On December 26, 1868, G. H. Tichenor of Canton, Mississippi, submitted Letters Patent and an accompanying diagram for an inhaler.33 The inhaler received Patent No. 87,603 on March 9, 1869 (Figure 3).32, 33 There is no mention of M.D. or Dr. associated with his name in these documents. The patent was listed in Scientific

Figure 3. Patented inhaler and description.

Figure 4. First medical publication.

American in the section titled “Official List of Patents Issued by the U.S. Patent Office for the week ending March 9, 1869.”34 An article titled “Treatment of Disease by Inhalation” about his patented inhaler was published in June 1869 (Figure 4).35 This may well have been his first medical publication and lists his address as 363 Broadway, New York. In this article both M.D. and Dr. are associated with his name. This is one of the earliest times that the title and degree are seen listed with his name. In March, 2009, a search was made of the records of the Mississippi State Board of Medical Licensure in Jackson. There is no record of G.H. Tichenor having a medical license from the MSBML (letter from MSBML Bureau Director Rhonda Freeman to the author, August, 2009). However, formal licensing to regulate the practice of medicine in Mississippi was not approved by the legislature until Feb. 28, 1882.36 Two letters to the “Mississippi Historical Reference Library” in February and March 1977 from Edwin B. Tichenor (Tichenor’s grandson) provide insight. He noted that his grandfather had been an amateur photographer before the war and a professional photographer afterwards. He also noted that Tichenor was a talented artist, painting in oils. He stated that after the Civil War, G.H. and Margaret Tichenor briefly lived in New York City37 and that he had a photography studio in Canton.38 Tichenor was interested in the Cartes-de-visite type of photography. An example of his work resides in the William C. Darrah Collection of Cartes-de-visite, 1860-1900, in the Special Collections Library at Pennsylvania State University Libraries.39 His official title, “G.H. Tichenor, Photographer, Canton, Mississippi” is on the back (Figure 5). Prior to leaving Canton, he sold the “entire stock and apparatus” of his “photograph gallery” to Mr. W. H. Williams who received the endorsement of the local newspaper.40 Two children, Rolla Absolum, and Sallie Eola, were born in Canton in 1864 and 1867, respectively.13 In summary, Tichenor received a medical discharge from the Confederate army in 1863, married and lived in Canton, Mississippi, from 1863-1868, and was involved in the photography business and perhaps some type of medical practice while inventing and publishing. Next Month: Part 2- The “Dr.” in Dr. Tichenor. references 1. Stoney, WS. John L. Ochsner, M.D. In: Pioneers of Cardiac Surgery. Nashville: Vanderbilt University Press; 2008:401.

Figure 5. Cartes-de-visite photography. (Image contained in the William C. Darrah Cartes-de- 2. Ochsner, JL. The Greatest Southern Surgeon. Presentation given at Field Memorivisite Collection. Courtesy of Historical Collections and Labor Archives, Special Collections al Hospital Annual Lecture Series. Gloster, Library, The Pennsylvania State University, University Park, PA. Reproduced with permission.) Mississippi. 1990.

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3. Lockhart, JM. Dr. George Humphrey Tichenor: Pointe Coupee medicine man. Currents from The Riverside Reader. Aug. 18, 1997:1,6

32. Inventions in Southern States. In: Annual Report of the Commissioner of Patents for the Year 1869. Vol. I. Washington: Government Printing Office; 1871:5.

Lockhart, JM. From soldier to medicine man. The story of Dr. George H. Tichenor. The Riverside Reader. March 21, 2005:1,6.

Distinguished Confederates. Dixieland. June, 1905:15.

Some Interesting Facts about Liberty and Amite County. Amite County and Liberty, Mississippi Website. http://www.amitecounty200.com. Accessed July 21, 2009.

Trotter, MC. George Humphrey Tichenor - Soldier, Surgeon, and Innovator. Presentation given at the Fifteenth Annual Conference on Civil War Medicine. Frederick, Maryland. October 14, 2007.

36. Thompson, RH; Dillard, GG; Campbell, RB: The Annotated Code of the General Statute Laws of the State of Mississippi. Nashville: Marshall & Bruce, Law Publishers; 1892:441-442.

Trotter, MC. George Humphrey Tichenor - Soldier, Physician, and Innovator. Presentation at the Amite County and Liberty, Mississippi Bicentennial. Liberty, Mississippi. May 1, 2009.

37. Tichenor, EB. Letter to the Mississippi Historical Reference Library. March 23, 1977. Subject File, Mississippi Department of Archives and History, Jackson, MS.

FAQ. Canton Convention Center & Visitors Bureau Website. http://can tontourism.com. Accessed July 21, 2009.

38. Tichenor, EB. Letter to the Mississippi Historical Reference Library. Feb. 28, 1977. Subject File, Mississippi Department of Archives and History, Jackson, MS.

10. Fortier, A. Tichenor, Dr. G. H. In: Louisiana (Vol. 3); Comprising Sketch es of Parishes, Towns, Events, Institutions, and Persons, Arranged in Cyclopedic Form. Madison, WI: Century Historical Assn; 1914:430-431. 11. Rhodes, J. Dr. Tichenor: His trademark was his name. Baton Rouge Morning Advocate. January 5, 1953:9. 12. Espenan, G. Dr. Tichenor: physician who healed himself. Dixie, New Orleans Times-Picayune. October 13, 1974:9. 13. Tichenor, HA. Tichenor Families in America. Napton, MO. Privately printed; 1988:303. 14. Denny, LC. Antiseptic pioneer: Dr. George H. Tichenor. The Journal of Civil War Medicine. 1999; 3:41-43. 15. Craig, JS. Craig’s Daguerreian Registry, Revised Edition, Vol. 1. Torrington, CT: John S. Craig; 2003:373. 16. Craig, JS. Craig’s Daguerreian Registry, Revised Edition, Vol. 2. Torrington, CT: John S. Craig; 2003:717. 17. Nashville City and Business Directory for 1860-61, Volume V. Nashville: L. P. Williams & Co; 1860:183. 18. 1860 Census. United States Census Bureau. 19. George H. Tichenor Diaries. Mss. 580, 893, Louisiana and Lower Mississippi Valley Collections, LSU Libraries, Baton Rouge, LA. 20. History. The Dr. G.H. Tichenor Antiseptic Co. Website. http://www. drtichenor.com. Accessed Jan. 2, 2010. 21. Gueymard, E. Antiseptic inventor lived here. Baton Rouge State-Times. December 4, 1973. 22. Amoss, J. Dr. Tichenor’s: The long march from the civil war to civil rights. Lagniappe, New Orleans States-Item. May 10, 1975:3. 23. Trowbridge, D. Dr. G. H. Tichenor Antiseptic Co. New Orleans City Life. March, 2004:39-44. 24. Gordon, O J. Selected History of Amite County, Mississippi. Liberty, MS: Amite County Historical and Genealogical Society; 2006:46-47, 436-439. 25. Amite County Facts. Amite County and Liberty, Mississippi Website. http://www.amitecounty200.com. Accessed Jan. 2, 2010.

33. Patents Search. United States Patent and Trademark Office Website. http://www.uspto.gov. Accessed Jan. 2, 2010. 34. Official list of patents. Scientific American, New Series. 1869; 20:205. 35. Tichenor, GH. Treatment of disease by inhalation. Scientific American, New Series. 1869;20:403.

39. William C. Darrah Collection of Cartes-de-visites, 1860-1900. Special Collections Library, Pennsylvania State University Libraries. 40. Untitled article, col. 1 & 3. The Canton Mail. Jan. 23, 1869:3.

autHor information: Michael C. Trotter, MD, FACS Delta Regional Cardiovascular & Thoracic Surgery 1693 South Colorado Street Greenville, MS 38703 phone: (662) 347-9588, fax: (662) 335-6705 mdatrotter@gmail.com

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26. Marriage Records Book H, Marriage License and Certificate of Marriage, G. H. Tichenor and Margaret Drane. Canton, MS: Madison County; 1863:74. 27. Untitled article, col. 1-2. New Orleans Times-Democrat. June 24, 1906:6. 28. Lincoln and Madison County Masonic Lodge histories with other selected information on Mississippi Lodges. Canton # 28 F. & A.M. – Canton. Members: 1850-1869. Selected Mississippi information Website. http:// www.icrr.net/canton.htm. Accessed Jan, 2, 2010. 29. Lincoln and Madison County Masonic Lodge histories with other selected information on Mississippi Lodges. Canton # 28 F. & A.M. – Canton. Members: 1870-1889. Selected Mississippi information Website. http:// www.icrr.net/canton.htm. Accessed Jan. 2, 2010. 30. Lacey, J. History Bits About Canton and Madison County, Mississippi. Canton, MS: Canton-Madison County Historical Society; 1999:165. 31. Index of Land Deeds, Book Q. Canton, MS: Madison County; 18261872:523, 526, 541.

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DISABILITY DETERMINATION SERVICES

• INSTRUCTIONS FOR AUTHORS • The Journal of the Mississippi State Medical Association (JMSMA) welcomes material for publication submitted in accordance with the following guidelines. Address all correspondence to the Editor, Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS, 391582548. Contact Karen Evers, managing editor, with any questions concerning these guidelines: (601)853-6733, ext. 323. STYLE: Articles should be consistent with JAMA/ JMSMA style. Please refer to explanations in the AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford University Press; 2007. JAMA and JMSMA style differs from APA style. JAMA: http://jama.ama-assn.org/misc/ifora.dtl Quick reference quide:http://www.docstyles.com/amastat.htm Any manuscript that does not conform to the AMA Manual of Style, 10th edition will be returned for revision. MANUSCRIPTS should be of an appropriate length due to the policy of the Journal to feature concise but complete articles. (Some subjects may necessitate exception to this policy and will be reviewed and published at the Editor’s discretion.) The language and vocabulary of the manuscript should be understandable and not beyond the comprehension of the general readership of the Journal. The Journal attempts to avoid the use of medical jargon and abbreviations. All abbreviations, especially of laboratory and diagnostic procedures, must be identified in the text. Manuscripts must be typed, double-spaced with adequate margins. (This applies to all manuscript elements including text, references, legends, footnotes, etc.) The original and one duplicate hard copy should be submitted. In addition, the Journal also requires manuscripts in the form stated above be supplied in Windows OS-compatible digital format. You may email digital files as attachments to KEvers@MSMAonline.com or supply them on a portable memory storage medium. All graphic images should be included as individual separate files in TIFF, PDF or EPS format. Please identify the word processing program used and the file name. Pages should be numbered. An accompanying cover letter should designate one author as correspondent and include his/her address and telephone number. Manuscripts are received with the explicit understanding that they have not been previously published and are not under consideration by any other publication. Manuscripts are subject to editorial revisions as deemed necessary by the editors and to such modifications as to bring them into conformity with Journal style. The authors clearly bear the full responsibility for all statements made and the veracity of the work reported therein. REVIEWING PROCESS: Each manuscript is received by the managing editor, and reviewed by the Editor and/or Associate Editor and/or other members of the MSMA Committee on Publications and its review board. The acceptability of a manuscript is determined by such factors as the quality of the manuscript, perceived interest to Journal readers, and usefulness or importance to physicians. Authors are notified upon the acceptance or rejection of their manuscript. Accepted

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manuscripts become the property of the Journal and may not be published elsewhere, in part or in whole, without permission from the Journal MSMA. TITLE PAGE should carry [1] the title of the manuscript, which should be concise but informative; [2] full name of each author, with highest academic degree(s), listed in descending order of magnitude of contribution (only the names of those who have contributed materially to the preparation of the manuscript should be included); [3] a one- to two-sentence biographical description for each author which should include specialty, practice location, academic appointments, primary hospital affiliation, or other credits; [4] name and address of author to whom requests for reprints should be addressed, or a statement that reprints will not be available. ABSTRACT, if included, should be on the second page and consist of no more than 150 words. It is designed to acquaint the potential reader with the essence of the text and should be factual and informative rather than descriptive. The abstract should be intelligible when divorced from the article, devoid of undefined abbreviations. The abstract should contain: [1] a brief statement of the manuscript’s purpose; [2] the approach used; [3] the material studied; [4] the results obtained. Emphasize new and important aspects of the study or observations. The abstract may be graphically boxed and printed as part of the published manuscript. KEY WORDS should follow the abstract and be identified as such. Provide three to five key words or short phrases that will assist indexers in cross indexing your article. Use terms from the Medical Subject Heading list from Index Medicus when possible. Available at: http://www.nlm.nih.gov/mesh/authors. html. SUBHEADS are strongly encouraged. They should provide guidance for the reader and serve to break the typographic monotony of the text. The format is flexible but subheads ordinarily include: Methods and Materials, Case Reports, Symptoms, Examination, Treatment and Technique, Results, Discussion, and Summary. REFERENCES must be double spaced on a separate sheet of paper and limited to a reasonable number. They will be critically examined at the time of review and must be kept to a minimum. You may find it helpful to use the PubMed Single Citation Matcher available online at: http://www.ncbi.nlm.nih. gov/ entrez/query/static/citmatch.html to find PubMed citations. All references must be cited in the text and the list should be arranged in order of citation, not alphabetically. Reference numbers should appear in superscript at the end of a sentence outside the period unless the text cited is in the middle of the sentence in which case the numeral should appear in superscript at the right end of the word or the phrase being cited. No parenthesis or brackets should surround the reference numbers. Personal communications and unpublished data should not be included in references, but should be incorporated in the text.

References must conform to proper style to be eligible for review. Contact managing editor Karen Evers for an easy-to-follow guide with examples of how to use JMSMA/ JAMA reference citation format. The following form should be followed: Journals: [1] Author(s). Use the surname followed by initial without punctuation. The names of all authors should be given unless there are more than three, in which case the names of the first three authors are used, followed by “et al.” [2] Title of article. Capitalize only the first letter of the first word. [3] Name of Journal. Abbreviate and italicize, according to the listing in the current Index Medicus available online at http://www.nlm.nih.gov/bsd/aim.html. [4] Year of publication; [5] Volume number: Do not include issue number or month except in the case of a supplement or when pagination is not consecutive throughout the volume. [6] Inclusive page numbers. Do not omit digits. Do not include spaces between digits of the year, volume and page numbers. Example: Bora LI, Dannem FJ, Stanford W, et al. A guideline for blood use during surgery. Am J Clin Pathol. 1979;71:680-692.

Books: [1] Author(s). Use the surname followed by initials without punctuation. The names of all authors should be given unless there are more than three, in which case the names of the first three authors are used followed by “et al.” [2] Title. Italicize title and capitalize the first and last word and each word that is not an article, preposition, or conjunction, of less than four letters. [3] Edition number, [4] Editor’s name. [5] Place of publication, [6] Publisher, [7] Year, [8] Inclusive page numbers. Do not omit digits. Example: DeGole EL, Spann E, Hurst RA Jr, et al. Bedside Examination, in Cardiovascular Medicine, ed 2, Smith JT (ed). New York, NY: McGraw Hill Co; 1986:23-27.

FIGURES require high resolution digital scans to be provided. Printed copies should also be submitted in duplicate in an envelope (paper clips should not be used on illustrations since the indentation they make may show on reproduction). Legends should be typed, double-spaced on a separate sheet of paper. Photographic material should be high-contrast glossy prints. Patients must be unrecognizable in photographs unless specific written consent has been obtained, in which case a copy of the authorization should accompany the manuscript. All illustrations should be referred to in the body of the text. Omit illustrations which do not increase understanding of text. Illustrations must be limited to a reasonable number. (Four illustrations should be adequate for a manuscript of 4 to 5 typed pages.) The following information should be typed on a label and affixed to the back of each illustration: figure number, title of manuscript, name of senior author, and arrow indicating top. TABLES should be self-explanatory and should supplement, not duplicate, the text. The brief descriptive title, usually written as a phrase rather than a sentence, appears above to distinguish the table from other data displays in the article. Data should be aligned horizontally not to exceed 6.5". Tables should be numbered and supplied on individual pages separate from manuscript body text

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with placement indicated within. See Section 4 of the "AMA Manual of Style" for specific Figure and Table components and proper presentation of data. ACKNOWLEDGMENTS are the author’s prerogative; however, acknowledgment of technicians and other remunerated personnel for carrying out routine operations or of resident physicians who merely care for patients as part of their hospital duties is discouraged. More acceptable acknowledgements include those of intellectual or professional participation. The recognition of assistance should be stated as simply as possible, without effusiveness or superlatives. SUBMISSIONS TO JMSMA SCIENTIFIC SERIES Top 10 Facts You Need to Know Series The purpose of this series of articles is to provide referenced information on clinical management of medical conditions in a concise fashion. The submissions should be directed toward practitioners who do not have specialty training on the specific topic as a matter of general information. The author of the best submission for each year will receive a prize. Guidelines: 1) Articles should consist of 10 numbered paragraphs. Each of the paragraphs will begin with a fact that physicians need to know and a brief explanation of why. Facts will be referenced for each of the 10 points. 2) Suggested organization of manuscript is Introduction, Point 1, Point 2, etc., Conclusion, and References. 3) Articles will be about 3 pages (about 700 words) in length written at a level that can be easily understood by a practicing physician of any specialty. 4) A reference supporting the fact offered should be provided for each of the 10 points. Citations should not be review articles. 5) If there are specialty society guidelines in the area being discussed, the essential features of the recommendations should be included in the official guidelines cited in the references. UpToDate Series The purpose of this series of articles is to provide brief reviews on topics of general interest to the practicing physicians of Mississippi in areas where recent developments in diagnosis or treatment have occurred. Guidelines: 1) Articles should be practical and useful to physicians in office or hospital practice. 2) Suggested organization of manuscripts is Introduction, Diagnosis, Recent developments, Conclusion, and References. 3) Articles will be about 6 pages (1500 words) or so in length written at a level that can be easily understood by a practicing physician of any specialty. 4) Only include those references useful to physicians who desire further information in the area. Five to eight references that will be useful to those who desire further information should be included. 5) Figures are great as are “callouts,” i.e., boxes with key points to remember emphasizing the “take home” messages. 6) If there are specialty society guidelines on the topic, the essential features of the recommendations should be summarized in the text and the official guidelines should be cited in the references. GALLEY PROOF - The principal author will receive a PDF via email to review. It is the author's responsibility to proof and approve it. Corrections should be clearly marked and returned promptly. If you desire reprints, inquire about prices to order. ❒

In honor of National Doctorsâ&#x20AC;&#x2122; Day March 30th Katherine Carmichael Peggy Crawford Bev Crossen Amy Gammel Shoba Gaymes Danita Horne Louise Lampton Nancy Lindstrom Pat Lobrano Brinda ManiSundaram Eileene McRae Karen Morris Sondra Pinson Merrell Rogers S SI

PPI S T

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The MSMA Alliance Board acknowledges

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Donna Witty

The Physicians Who Care for Mississippi A

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Inaction vs IN ACTION We understand the difference The Litigation Center of the American Medical Association and the State Medical Societies fights to protect doctors and uphold the highest standards of patient care. In courtrooms across America, we are achieving legal victories that preserve the rights of physicians, promote public health and protect the integrity of the profession. Whether we are challenging managed care organizationsâ&#x20AC;&#x2122; payment practices or preserving the autonomy of the hospital medical staff, one thing remains constant: The Litigation Center is an active force fighting for physiciansâ&#x20AC;&#x2122; rights. Learn more on how The Litigation Center can help you:

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• UncoMMoM Thread • Supralumenal Neutrinos and “The God Particle” – A CERN Update

ost of you who have peeked in over the last few years know that I’ve been a follower of the goings on over on the French-Swiss border at the CERN facility from way before they threw the first switch. That hasn’t changed. The first year over there has been a doozy. First, back in September we had what appears to be the first thing ever identified that r. SCott AnderSon, md travels faster than the speed of light, more specifically, supralumenal neutrinos. Now they aren’t a lot faster than light, but they were faster nonetheless. The first reaction was “impossible!” So they repeated the experiment twenty-five times, and guess what? It was still faster. That means that neutrinos don’t listen to Einstein. Well, there are ways that Einsteinian Laws of Special Relativity may still apply, but we’ll talk about that in a minute. We should have had a clue that this was a possibility. The initial indications that this could be the case were originally noticed in 1987. When the 1987 Supernova SN1987A was first observed, neutrino waves from the massive explosion across the galaxy in a section called the Tarantula Nebula arrived on earth three hours before the first photons arrived. It was impossible for that to have happened, so it was postulated that a light cloud or the excessive gravity of the process somehow slowed the light down and it just arrived here a little late. I’ll spare you the math, but the main problem with the findings at CERN is that their neutrinos were a good deal faster that that. If the neutrinos from the 1987 Supernova which was 168,000 light years away from earth were as fast as the CERN neutrinos they would have gotten here a whole three years before the first light evidence arrived. So there is a reasonable chance we either just missed the initial pulse of the fastest neutrinos or simply had no context to apply at the time. Calm down! Slow your breathing down a little bit. I don’t want anyone hyperventilating on me. And no, I’m not sure what the practical applications of this discovery are either, but there seems to be the obvious boon to communications. The neutrinos at CERN were being shot 120km through solid rock. See, neutrinos are unaffected by the density of the medium they travel through, so even being shot through solid rock they’re faster than light. I can see directional communication relays that, rather than bouncing signals off satellites to compensate for the curvature of the surface of the earth, are able to shoot “line of sight” straight through the earth, faster than electromagnetic communication allows. The second big announcement, made recently, shows evidence of the existence of the Higgs boson. Postulated since the 1960s as necessary for the unified theory of particle physics, the Higgs has been called “the God Particle,” as it is considered the determinate of all other particulate behaviors. Most importantly, it is the Higgs that confers mass to all other objects. Now, nobody has a little Higgs pinging around in a baby food jar or anything. But by smashing tiny objects together at the highest speeds attainable on earth, we see a shadow. A small blip in the 124-125geV range, the area that the Higgs was postulated to be hiding. That’s about 130 times bigger than a proton. How could we have missed something that big? We don’t know. One theory I read suggested that the Higgs in its resting state exists in a dimension outside the three that we as humans are capable of perceiving and we can see the Higgs only in its excited state before it decays and falls back into the unidentifiable dimension. Speaking of extradimensionality, about that supralumenal neutrino thing, well. One of the explanations of how, it can achieve supralumenal speeds without violating Einstein’s laws of special relativity is that it may make a dimensional transition, that is kind of like a fish jumping out of water and coming back in on a shorter path somehow, due to curvature or wave like attributes of the unknown dimension. Lots of fun stuff to think about. Do your best, Scott P.S. I’ll stick on a borrowed explanation of how the Higgs may confer mass. It’s brilliant and I wish I had thought of it. We have to think of the individual Higgs particles as existing in a Higgs field. Think of the Higgs field as a Hollywood party, and all of the Higgs particles are arranged at the party having drinks, eating canapés, and chatting. When a particle enters the field, it’s like a superstar actress coming through the crowd. The people nearest the door she comes in turn to look at her, then gather around her. As she moves through the party, she attracts the people closest to her and releases those she is moving away from, and they return to whatever it was they were doing before she walked by. The star, by gathering a fawning crowd around her has gained momentum, an indication of mass. She’s harder to slow down than she would be without the crowd but, once stopped is harder to get going again because of the number of interactions occurring. r

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• Una Voce • [The following column by Dr. South is directed at our patients, containing advice each of us wishes our patients would follow to enable and maximize their encounters with us. The Journal encourages our physician-readers to distribute copies of this column to their patients.] —Ed.

How to Be a Better Patient

Dwalia S. South, MD

hen you go to the doctor’s office for a visit these days, do you come away feeling like a calf just herded through the slaughter house chutes? Don’t feel alone. Physicians these days are equally frustrated by their new role as medical cowhands armed with computerized cattle prods directing the flow of hapless patients from one holding pen to the next. In today’s changing medical climate, office visits are constrained into rushed 10-15 minute blocks of time for each patient. The difficulty and dissatisfaction can be made worse if your doctor is straining to master his new electronic medical records system during your brief visit. But the most unproductive thing of all is when the patient arrives for this race against the doctor’s clock scared and totally unprepared. You can do something about this by becoming a “better patient.”

Do Your Homework before Your Office Visit

Make yourself a personal health notebook. Someday all this information might be found on a computer chip on your wrist bracelet, but right now, health information gathering is piece-meal and very unscientific. Write down your past health history as best you can. Particularly important are visits to other healthcare providers. Someone is always going to ask you to list your prior surgeries and for a list of your meds (including vitamins and over the counter meds) and your allergies. Better yet, bring all your meds to EACH office visit. Playing guessing games about your prescriptions is a dangerous practice as well as a waste of precious face time with the doctor. Make a written problem list about your concerns for your appointment with the doctor prioritizing those you feel most urgent for that day’s visit. Bring a log of your blood pressure or blood sugar readings if known. If you are going for lab work, remember to fast that morning. Take your regular medications that day so your treatment can be accurately assessed. Don’t wait until you have been out of your meds for two weeks before going to get your blood pressure checked!

What to Take With You to Your Appointment

Bring your current insurance information. Bring the health notes you have so masterfully constructed. Bring all of your meds including over the counter ones. Bring a relaxing book. (You know there will be a wait, right?) Express your biggest concern at the beginning of the visit, not as your doctor is making his exit. Bring an open mind and total honesty to your doctor visit. Don’t be embarrassed, he’s heard it all before! Do not downplay or over dramatize your problems. Bring ONE trusted person with you if desired. Two heads are better than one when you are stressed by the concerns of your illness. Have them help you by taking notes on the doctor’s answers to your question list and treatment directions. Patients don’t hear 50% of what has been said in a typical office visit. DO NOT bring children to baby-sit. If you simply can’t live without your cell phone, TURN IT OFF in the exam room. And please refrain from posting on Face-Book in the middle of your pap smear.

What to Take When You Leave the Appointment

Ask for any available patient handouts, credible web sites, get your prescriptions for meds, diet, and exercise and make sure you understand what your treatment plan is in layman’s terms BEFORE you leave. Leave knowing what you can expect in the days ahead. If needed, get a follow-up appointment card. Leave with the understanding that while your primary care doctor is your healthcare partner, your good health is ultimately your own responsibility.

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• asclepiad •

r. leonard (len) Brandon, (seated) a pillar of the Starkville medical community, was born in Greenville to parents living on the family farm in Arcola, Mississippi. At age 12, his family moved to Jackson where he matured. After a tour of duty with the armed services, he returned to Jackson and graduated from Millsaps in 1948. He attended Columbia University Medical School in New York City. While there, he had the good fortune to meet Rae Carmichael, a young nurse from Toronto, Canada. Dr. Brandon married the love of his life in 1950 at the Church of the Transfiguration, also known as the Episcopal “Little Church around the Corner” located at 29th Street and 5th Avenue in New York City. After finishing medical school, Dr. Brandon spent a year in Hartford, Connecticut, as an intern. Interns there received no salary. The scheduled second year of his postgraduate training promised a whopping $25 a month. With a young child in the family, financial considerations led the Brandons to Nashville, Tennessee where Len took a second year of training in the Vanderbilt system. Dr. Brandon received financial assistance to attend medical school with the understanding that he would return to Mississippi and serve a community of less than 5,000 people. A map search revealed that Starkville was about 4,900. Therefore, in 1954 Dr. and Mrs. Brandon brought their young family to Starkville where he began solo practice as a family physician. The Brandons raised a family of four in Starkville. Their youngest son, steven Brandon, Md, (standing) later joined his father in the Family Clinic. Steven’s daughter, Emily, is currently a student at University Medical Center in Jackson and will soon be the third generation of Brandons practicing medicine. Serving one’s community as a solo practitioner is very demanding and not for the faint hearted. Yet Dr. Brandon found time to play tennis, golf, and even take family camping trips. Dr. Brandon was also active in the local Episcopal Church and Lions Club. He gave back to organized medicine by serving two terms on the board of trustees of the Mississippi State Medical Association. He also served as president of the Academy of Family Physicians. In 2004 he was named Mississippi’s Family Physician of the Year. When asked if he had any regrets, Dr. Brandon answered, “None.” As a young boy, he shared a bed with his brother who had a seizure disorder. Dr. Brandon well remembers his startled and helpless feelings when his brother would awaken him, seizing beside him in bed. “I think that made me interested in doing something about it. From then on, I never wanted to be anything but a doctor.” I asked Dr. Brandon to recall some of his memorable moments in medicine. He chose two. He remembers making a house call to one of the tenants on Warren Oakley’s farm in Oktoc, Mississippi. In order to reach the house he had to ride behind Mr. Oakley on a tractor. “I was hanging on for dear life.” Then there was a patient of his with acute appendicitis. The town surgeon was away for the weekend, and the patient refused to travel a few miles to West Point to see the neighboring surgeon. She insisted that Dr. Brandon take care of her. Dr. Brandon had assisted Dr. Strange on hundreds of appendectomies over the years. He recruited another family doctor to provide anesthesia, and the patient and doctors did fine. Those were the good ole days, some would say the golden days, of medicine in this country. Dr. Len Brandon was a big part of it in the Starkville area. — Martin Pomphrey, MD

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