March 2015 JMSMA

March

VOL. LVI

2015

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The Association Claude D. Brunson, MD President Daniel P. Edney, MD President-Elect Michael Mansour, MD Secretary-Treasurer Geri Lee Weiland, MD Speaker Jeffrey A. Morris, MD Vice Speaker Charmain Kanosky Executive Director

I L A SSOC

Official Publication of the MSMA Since 1959

MARCH 2015

VOLUME 56

NUMBER 3

Scientific Articles Incidence of Flap Procedures in the Management of Burn Patients

60

William C. Lineaweaver, MD; Beretta Craft-Coffman, PAC; Tanya M. Oswald, MD

Bedside Gallbladder Ultrasound for the Primary Care Physician

64

Brian J. Tollefson, MD; Nicholas E. Hoda, MD; Graves Fromang, DO; Mary Stone, MD

Top Ten Facts You Should Know about Colorectal Cancer (CRC) in Mississippi

67

Lucius M. Lampton, MD; Mary Currier, MD, MPH; Roy J. Duhé, PhD

President’s Page Measles is Scary

70

Claude D. Brunson, MD; MSMA President

Public Health Report Card

71

Related Organizations UMMC 76 MACM 82

Departments

From the Editor: Treating Patients out of a 2007 Toyota Camry Images in Mississippi Medicine: Natchez Charity Hospital, 1920

58 80

Special Article Spotlight: Physician Leadership Academy Scholars

85

Kara Kimbrough

About The Cover:

Narcissus pseudonarcissus (daffodil) - The Latin name for daffodil is thought inspired by Narcissus, a Greek mythology figure said to have fallen in love with his reflection in a pool of water. The nodding head of the daffodil represents Narcissus bending down and gazing at his reflection.

Southern gardener and author Felder Rushing, who actually started the Master Gardener program in Mississippi, says, “Not all daffodils do equally well in our mild winter and warm, wet springs. Those that are exceptional bloomers multiply by bulb and spread by seed. From early February into March, the flowers of the historic wild daffodils are easy to identify, each having a sizeable yellow trumpet-like corona or cup with six yellow to pale yellow petal-like petals that characteristically sweep forward. The one that typically flowers first, commonly called the Lent lily, is probably the one William Wordsworth wrote about in his ode to nature, in which while he ‘wandered, lonely, as a cloud’ he came across a massive field of golden daffodils, ‘fluttering and dancing in the breeze.’”

Rushing notes, “The other daffodil flowering early are the intensely fragrant and early blooming “paperwhite” Narcissus, with stems topped with clusters of small, usually white flowers. Then bloom the intensely fragrant jonquil with cylindrical tubular clustered little yellow flowers, followed by a cascade of the regular season daffodils.” Narcissus jonquilla are distinguished by dark green, tube-shaped leaves as compared to other types of daffodils which have flat leaves. As Winnie the Pooh author A.A. Milne wrote in his poem “Daffodowndilly,” they whisper, “winter is dead.” Spring has sprung.

Photo by Brett Tisdale, MD, a board certified emergency medicine physician in McComb.

March

VOL. LVI

2015

No. 3

March 2015 JOURNAL MSMA 57

W

From the Editor: Treating Patients out of a 2007 Toyota Camry

hile I am sure there is more to the story (there is always more to the story…), those in private practice can’t help but sympathize with Dr. Carrol Frazier Landrum, the 88-year-old Edwards general practitioner who, after 55 years of work, is now practicing medicine out of his 2007 Toyota Camry. He parks in front of his old office, now an abandoned shopping center next to the Dollar General in this rural Hinds County village, and he awaits his patients. The burden of office overhead won’t allow him to see just two or three patients a day and keep an office open. The State Board of Medical Licensure, he says, has demanded that he shutter his car-based practice and surrender his medical license. His story has drawn international attention, and as of press time, an online petition of support has garnered over 80,000 names from all over the world.

“It’s basically like a house call, except in a parking lot,” Landrum told a reporter as he leaned back on his car. He usually charges $45 for a doctor’s visit, and strangely his $45 dollars may be a higher take home percentage per patient than

his clinic-based peers receive after their overhead is subtracted. In Mississippi, the private practice model of onesies and twosies is on life support, dying under the weight of a thousand requirements and extra duties, deadly in their mass for any business to succeed.

I love the British sitcom Doc Martin, which presents Dr. Martin Ellingham, a brilliant London vascular Lucius M. Lampton, MD surgeon who develops hematophobia and reinvents himself as a GP in a sleepy Cornish village. He sees patients at his house, and his clinic (called “the doctor’s surgery”) has simply a receptionist and him. No other employees! Perhaps Dr. Landrum has a heroic and radical idea: Why should we allow more and more layers to get between the patient and us? Perhaps all that is needed in the end is the patient and the doctor, and maybe a Toyota Camry.

Contact me at lukelampton@cableone.net.

—Lucius M. Lampton, MD, Editor

Journal Editorial Advisory Board Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic

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

Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland

Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson

J. Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo

Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson

Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic

W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel

Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

Ben E. Kitchens, MD Family Physician, Iuka Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

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

Professor of Medicine and Associate Dean for VA William Lineaweaver, MD Education, University of Mississippi School of Medicine, Editor, Annals of Plastic Surgery Associate Chief of Staff for Education and Ethics, Medical Director G.V. Montgomery VA Medical Center, Jackson JMS Burn and Reconstruction Center, Brandon Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

58 JOURNAL MSMA

March 2015

Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist Jackson Health Care-Women, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson

Michael D. Maples, MD Chris E. Wiggins, MD Medical Director Orthopaedic Surgeon Medical Assurance Company of Mississippi, Ridgeland Bienville Orthopaedic Specialists, Pascagoula Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson

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

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

Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

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March 2015 JOURNAL MSMA 59

• Scientific Articles • Incidence of Flap Procedures in the Management of Burn Patients William C. Lineaweaver, MD, FACS; Beretta Craft-Coffman, PAC; Tanya M. Oswald, MD

A

bstract

Increased survival of burn patients presents opportunities for reconstructive strategies to improve outcomes in management of acute and secondary burn injuries.

To assess one such strategy, namely flap reconstruction, we reviewed cases performed during the first 4.5 years of the JMS Burn and Reconstruction Center. We found that flap procedures accounted for 0.8% of acute cases (23 of 2723 procedures) and 33% of secondary cases (260 of 790 procedures).

This initial finding shows that in this practice flap procedures are applied to a small number of acute problems while flap procedures comprise 33% of secondary procedures.

Reconstructive flap surgery plays a measurable role in burn treatment at this center. Further study of outcomes and timing could lead to better understanding of optimal strategies for flap reconstruction in burns.

Keywords: burns, reconstruction, flaps

Both acute and chronic burn injuries, however, can include complex situations not soluble with local wound care and grafts. Skin grafts consist of partial or full thickness harvests of epidermis and dermis and are two-dimensional reconstructive units that derive initial nutrients and eventual vascularity from the beds on which they are placed. Grafts, therefore, cannot survive on avascular beds such as bone, nor can they fill cavities, restore contour, or provide functions such as muscle contraction. 4 Complicated circumstances require different reconstructive strategies. Critical exposed structures, including bones, joints, prostheses, nerves, and vessels, as well as chronic wounds or contractures over areas unfavorable for grafting, can be treated with flap procedures.

Flaps are reconstructive units that contain their own blood supplies and can be placed on avascular beds. Flaps contain larger, more complex tissues than grafts and with correctly mobilized blood supplies can contain skin, subcutaneous tissue, muscle, bone, nerve, and various combinations of these tissues.5 As a first step in defining the role of flap procedures in burn care, we have reviewed the first 4.5 years of the practice at the JMS Burn and Reconstruction Center to determine the frequency of flap procedures within the overall surgical practice of the Center.

Initial treatment of significant burn injuries includes physiological support (especially fluid replacement) and surgical management of the burn wound. The great majority of surgical procedures related to burn wounds consists of debridement or excision followed by skin substitution or autologous skin grafting.1,2 Secondary problems caused by burn injury include chronic wounds and scar contractures. Many of these problems can be adequately treated with excision and skin grafting. 3 Table 1. Acute flap cases Author Affiliations: JMS Burn and Reconstruction Center, Central Mississippi Medical Center, Jackson, MS (Drs. Lineaweaver and Oswald). JMS Burn Center, Augusta, GA (Ms. Craft-Coffman).

Corresponding Author: Dr. Lineaweaver, 1850 Chadwick Drive, Suite 1427; Jackson, MS 39204. Tel: 601) 376-1684 (william.lineaweaver@jmsburncenters.com) Support and conflicts: None. Presented in part at the JMS Mississippi Burn Symposium, Hinds Community College Pearl, MS, October 24, 2012; the Southern Region Burn Conference, Norfolk, Virginia, November 16, 2012; and the JMS Annual Burn Symposium, Chateau Elan, GA, March 4, 2013.

60 JOURNAL MSMA

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Year

Total burn admissions

Total acute procedures

Flaps

2010-11

480

454

5

2011-12

663

676

4

2012-13

616

754

2

473

9

2,723

23 (0.8%)

2013-(6 months)

374 2,545

Materials and Methods Since July, 2009, the JMS Burn and Reconstruction Center has been the only inpatient burn unit in Mississippi.6 The unit has emphasized application of comprehensive reconstruction strategies to acute and secondary burn injuries. The patient population of this center can be recognized, therefore, as a representative sample of burn care in the state.

The developing data base for this center was used to quantify the incidence of flap procedures in burn patient management. Flaps were identified as acute procedures if they were performed during a patient’s initial hospitalization. Flap operations performed following a patient’s discharge from initial hospitalization were defined as secondary procedures.

Results Data from 4.5 years of practice were available for analysis. Table 1 shows that during this period these were 2545 acute burn admission that resulted in 2723 acute surgical procedures. 23 (0.8%) of these procedures were flap reconstructions. Table 2 summarizes secondary burn procedures. 790 such cases were performed, and 260 (33%) of these operations were flap reconstructions.

Table 2. Secondary flap procedures Year

Total secondary burn procedures

Flaps

2009-10

104

32

2010-11

144

63

2011-12

168

64

2012-13

248

70

2013-(6 months) Total

1A

126 790

1B

31 260(33%)

Discussion This analysis demonstrates that flap reconstruction is a small percentage of acute burn procedures. Flap reconstructions, however, can be of critical importance for specific problems. Figures 1-3 show cases of flap coverage of a bony prominence, an exposed knee joint, and exposed critical vessels. In such circumstances, flaps can provide the necessary tissue coverage for reconstruction of complex wounds that would not be adequately treated by grafts or wound care. As the illustrations demonstrate, flap selection is based on the magnitude of the defect and indication of optimal tissue for use in the flap reconstruction.

Flap procedures accounted for 33% of total secondary procedures. This experience is consistent with reports describing specific applications of flaps to burn wounds, defects, and deformities from head to toe.7-12 Figures 4-6 illustrate examples of local flaps applied to burn scar contractures. Figure 7 shows a more elaborate microsurgical reconstruction for late complication of a scalp burn. Definitive treatment of the underlying problem in each of these cases required flap reconstruction.

The use of a microsurgical flap shows the advantage of these procedures when no tissue adjacent to the defect is available for flap use. Microsurgical flaps consist of tissue harvested from sites remote from defects, and the vessels critical to flap circulation are connected to vessels at the site of the defect.5 Another category of flap procedure is shown in Figure 8. Flaps can be the basis for staged reconstruction. These flaps can be acute or secondary procedures. The case in Figure 8 illustrates acute microsurgical flap coverage of a severe hand burn. This flap not only preserved wrist function but served as basis for later procedures that provided the patient with functional pinch. This category of flaps is not yet detectable in our database.

This initial analysis shows that flap procedures occur in measurable numbers in comprehensive burn care. Further application and refinement of these procedures can proceed 1C

1D

Fig 1. A. Friction burn, medial mallous; B. Outline of adjacent transposition flap options; C. Flap elevation; D. Flap inset.

2A

2B

2C

2D

Fig 2. A. Full-thickness burn exposing left lateral knee joint; B. Mobilization of lateral gastrocnemius muscle; vessel loop on the peroneal nerve; C. Transposition of flap; D. Healed flap and skin graft at 6 months.

March 2015 JOURNAL MSMA 61

3A

3E

3B

3C

3D.

Fig 3. A. Left groin with exposed femoral vessel stumps; B. Elevation of right rectus myocutaneous flap; C. Transposition of flap to left groin and thigh site; D. Reinforcement of posterior rectus sheath with bovine fetal collagen prior to closure; E. Final inset of flap with split thickness skin grafts.

4A

4B

4C

from further analysis. What are optimal timings for acute and secondary flaps? What outcomes, including salvage Fig 4. A. Dorsal foot scar contracture; B. Release of scar as a “V”; C. Flap inset and and function, can be expected? donor site closure as a “Y”.

While acute care of burn patients has achieved remarkable success in resuscitation, wound coverage, and survival, optimum reconstruction strategies are not clearly defined.3 The advantages of coordinated treatment and flap reconstruction are well established in areas of trauma, surgical infections, and oncology.13-18 Experiences in these areas show that deliberate linkage between treatment of the underlying problem and reconstructive strategy can result in maximum preservation of parts and optimal functional recovery.19 Specific dimensions of burn reconstruction, including transplantation, lasers scar suppression, and peripheral nerve decompression, are being reported as sophisticated advances in burn injury management.

20-22 Flap procedures merit such levels of study that can lead to wider and more specific applications of these operations. Flaps should increasingly be recognized and defined as essential elements of burn surgery.

References 1. Warden GD: Fluid resuscitation and early management. In Herndon D (ed): Total burn care, 3rd ed. Philadelphia, SaundersElsevier, 2007:07-118.

2. Steinstrasser L, Al-benna J: Acute management of burn/electrical injuries. In Neligan P (ed):Plastic Surgery, 3rd ed, vol. 4.

London, Elsevier-Saunders, 2013:393-434.

3. Klein MB: Reconstructive burn surgery In Neligan P (ed): Plastic surgery, 3rd ed, vol 4. London, Elsevier-Saunders, 2013:500510.

4. Scherer-Pietramaggiori S, Pietramaggiori G, Orgill D: Skin graft. In Neligan P (ed): Plastic Surgery, 3rd ed, vol 1. London, Elsevier-Saunders, 2013:319-338.

5. Hallock GG: Classification of flaps. In Wei FC, Mardini S (eds): Flaps and reconstructive surgery. London, SaundersElsevier, 2009:7-16.

6. Farner K., Lineaweaver W.: Efficacy of extrapolation from national burn data for estimating patient volume in a new burn

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March 2015

5A

5B

Fig 5. A. Scar contracture of 3rd and 4th web spaces; B. V-Y flap releases 6A

6B

Fig 6. A. Scar contracture of right ear and neck; B. Rotation flap release of earlobe, multiple z-plasties to neck. unit. Ann Plast Surg. 2012;68:505-507.

7. Rose E: Aesthetic restoration of the severely burned face in burn victims. Plast Reconstr Surg. 1995;96:1573-1585.

8. Xie F, Wang J, Li Q et al: Resurfacing large skin defects of the face and neck with expanded subclavicular flaps. Burns 2012;38:924-930.

9. Grishkevich V: Postburn shoulder medial adduction contracture: Anatomy and treatment with trapeze-flap plasty. Burns 2013;39:341-348.

10. Kreymerman P, Andres L, Lucas H et al: Reconstruction of the burned hand. Plast Recon Surg. 2011; 127: 752-759.

11. Neale H, Smith G, Gregory R et al: Breast reconstruction in the burned adolescent female. Plast Reconstr Surg 1982; 70: 718724.

7A

7B

7C

Fig 7. A. 82-year-old man with a squamous cell carcinoma in a 45-year-old skin graft at the site of a full thickness scalp burn; B. Resection of tumor, skin graft, and underlying skull segment; C. Latissimus dorsi microsurgical flap with skin graft 2 years after reconstruction.

8A. 8A

8B

8D

8C

8F

8E

8A.

Fig 8. A. Combination crush and burn injury; B. Debridement to metacarpals; C. Harvest of latissimus dorsi muscle; D. Muscle and skin graft at 6 months; E. Secondary reconstruction included first web space widening with index metacarpal amputation, full thickness skin graft and two stage flexor tendon reconstruction; F. Thumb in extension; G. Thumb in flexion.

12. Hur G, Rhee B, Ko J et al: Correction of postburn equinus deformity. Ann Plast Surg. 2013; 70: 276-279.

Medley & Brown

13. Celikoz B, Sengezer M, Isik S et al: Subacute reconstruction of lower leg and foot defects due to high velocityhigh energy injuries caused by gunshots, missiles, and land mines. Microsurgery 2005; 25: 3-15.

POINTS OF DISTINCTION

14. Wang T, Elliot R, Low D: Damage control abdomen. Ann Plast Surg. 2013; 70; 324-330.

15. Gayle L, Lineaweaver W, Oliva A et al: Treatment of chronic osteomyelitis of the lower extremities with debridement and mircrovascular muscle transfer. Clin Plast Surg. 1992; 19: 895-907

Focused: A singular long-term, value-driven investment philosophy

16. Lineaweaver W, Hui K, Yin K et al: The role of the plastic surgeon in the management of surgical infection. Plast Reconstr Surg.

1999;103:1553-1561

Rational: Thoughtful investment selection

17. Stile F, Sud V, Zhang F et al: Reconstruction of long cervical esophageal defects with the radial forearm flap. J Craniofacial Surg. 2006; 17:382-386.

18. MarrĂŠ D, Buendia J, Hontanilla B: Complications following reconstruction of soft tissue sarcoma: Importance of early participation of the plastic surgeon. Ann Plast Surg. 2012; 69:7378.

19. Lineaweaver, W: Problem analysis in reconstructive surgery, In Wei FC, Mardini S: Flaps and reconstructive surgery. London, Saunders-Elsevier, 2009:3-6

Responsive: Exceptional client service Committed: Our money invested alongside yours Proven: History of investment performance

20. Lineaweaver W: Face transplants and the era of reconstructive transplantation (editorial). Ann Plastic Surg. 2009; 62:225-226.

21. Hultman S, Edkins R, Wu C et al: Prospective, before-after cohort study to assess the efficacy of laser therapy on hypertrophic burn scars. Ann Plast Surg. 2013; 70: 521-526 22. Wu C, Calvert C, Cairns B et al: ;Lower extremity nerve decompression in burn patients. Ann Plast Surg. 2013; 70: 563567.

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March 2015 JOURNAL MSMA 63 M&B MSMA Feb'15.indd 1

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• Scientific Articles •

Bedside Gallbladder Ultrasound for the Primary Care Physician Brian J. Tollefson, MD; Nicholas E. Hoda, MD; Graves Fromang, DO; Mary Stone, MD

This article is the second in a series of articles on the use of bedside ultrasound. Refer to the previous article [Tollefson BJ. The eFAST examination for trauma triage. J Miss Med Assoc.

2014;55(3):72-78] for the introduction of general ultrasound concepts and definitions.1 The focus of this article is the evaluation for gallbladder pathology with bedside ultrasound. Let the JMSMA editors know if you are interested in the following “how to” ultrasound topics in future issues to the Journal MSMA: Abdominal aortic aneurysm, Renal and bladder, Deep venous thrombosis, Cardiac, Ectopic pregnancy, Abscess and foreign body, and Central line placement. —Ed.

I

ntroduction

Abdominal pain, more specifically right upper quadrant (RUQ) pain, is a common presenting complaint in both the clinical setting and emergency department (ED).2 The broad differential diagnosis can be narrowed rather quickly with a focused history and physical examination. When biliary disease remains in the differential, bedside ultrasound can be a very useful tool for the clinician. Bedside ultrasound is a focused clinician-performed and -interpreted examination. It is performed to answer specific questions, such as presence or absence of gallstones, gallbladder wall thickening, and/or sonographic Murphy’s sign.3 Ultrasound is the primary imaging modality for diagnosing biliary pathology.4 The surrounding liver provides an excellent acoustic window for evaluating the fluid-filled gallbladder Author Affiliations: Director of Emergency Ultrasound and Assistant Professor of Emergency Medicine at the University of Mississippi Medical Center in Jackson, Mississippi (Dr. Tollefson).

Second-year resident physician in emergency medicine at the University of Mississippi Medical Center in Jackson, Mississippi (Dr. Hoda). Emergency physician at Martin Health System in Fort Pierce, Florida (Dr. Fromang). Emergency physician at St. Luke’s Health System in Houston, Texas (Dr. Stone).

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

64 JOURNAL MSMA

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and associated biliary structures. Gallstones are easily identified by their brightly hyperechoic surface and posterior acoustic shadow. When used in conjunction with physical exam and laboratory studies, ultrasound can accurately diagnose significant gallbladder pathology.

Given the ease of use and affordability of quality ultrasonography equipment, the bedside ultrasound examination for RUQ pain is a viable option for providers in the ED and primary care settings. With estimations that one in five Americans has gallstones and nearly 30% eventually develop acute cholecystitis, a correct and prompt diagnosis is essential.5 Several studies have concluded that bedside ultrasound performed by emergency medicine physicians compares favorably to formal gallbladder studies.6,7,8 Further, bedside ultrasound has been shown to significantly decrease length of stay, especially after normal business hours.9

Clinical Scenario

Imagine you are a primary care provider in rural Mississippi, and a 40-year-old obese female presents for an unscheduled visit with a chief complaint of intermittent RUQ pain for the past 3 months. The patient states today the pain is more intense and has lasted longer than usual. Her vital signs are as follows: BP 180/90, P 115, and temperature of 100.2oF. As she provides the history of her present illness, you initially consider a diagnosis of symptomatic cholelithiasis for which you would address her pain and arrange for outpatient follow-up with a general surgeon. However, given the acute worsening and fever, you also consider the possibility of acute cholecystitis, which would require urgent surgical intervention.

The physical exam is negative except for RUQ tenderness. Laboratory studies including urinalysis, liver panel, and complete blood count are unremarkable except for mildly elevated leukocyte count.

The patient receives pain medication and IV fluids that provide significant relief. You perform a bedside gallbladder ultrasound that reveals several small stones in the neck of the gallbladder and a positive sonographic Murphy’s sign. In addition,

a small amount of pericholecystic fluid and a thickened gallbladder wall are noted. At this point you diagnose her with acute cholecystitis, initiate IV antibiotics, and arrange transfer to a medical center for immediate surgical consult.

Figure 2. Normal Gallbladder: Longitudinal image of gallbladder (GB) forms an explanation point with main lobar fissure (MLF) between the neck of the GB and the portal vein (PV). The common bile duct (CBD) and Hepatic artery are superficial to the Portal vein forming the Mickey Mouse sign.

Figure 1. Probe Position: Start by placing the probe in the mid-sagittal plane with the probe marker pointed cephalad.

Sweep the probe laterally along the right costal margin until the gallbladder is identified. Once identified, turn the probe on its axis to image the gallbladder in the longitudinal plane.

Procedure for Quality Bedside Gallbladder Ultrasound Exam

Start with the patient in the supine position. Orient the low frequency, curvilinear probe longitudinally (probe marker cephalad) at the patient’s subxiphoid region. Slide probe laterally along the right costal margin until the gallbladder comes into view. After identifying the gallbladder turn the probe on its axis to image the gallbladder in its longitudinal plane (Figure 1). Having the patient take in and hold a deep breath may aid in visualization, as the gallbladder is a mobile structure and can move out of the field of view during respiration. Additionally, the left lateral decubitus position could facilitate gallbladder movement toward the abdominal wall for better visualization if needed.

Visualizing the gallbladder in its long axis demonstrates its relationship with the portal vein and the main lobar fissure, which often resembles an exclamation mark (Figure 2). The portal triad (also seen in Figure 2) consists of the extrahepatic portal vein, common bile duct, and heaptic artery. The structures of the portal triad are often referred to as the Mickey Mouse Sign. The gallbladder must be scanned through its entirety in the longitudinal and transverse planes to identify the neck, body, and fundus looking for signs of pathology.

A gallstone will typically appear hyperechoic (bright) with a posterior acoustic shadow (Figure 3). Another potential finding of cholecystitis is the presence of pericholecystic fluid. Pericho-

Figure 3. Cholecystitis: Longitudinal view of gallbladder (GB) showing a large echogenic gallstone lodged in the GB neck with posterior acoustic shadowing. Also noted is anterior GB wall thickening (5.6mm). To measure the GB wall activate the caliper function on the ultrasound machine and place the cursors across the outer and inner aspects of the anterior GB wall (adjacent to liver).

lecystic fluid appears as an anechoic (black) stripe of variable thickness adjacent to the outer edge of the gallbladder (Figure 4). Measurements to obtain include gallbladder length (normal < 10cm), width (normal < 5cm), anterior wall thickness (normal <3mm), and common bile duct inner wall diameter (normal < 6mm). Measurements are easily obtained by activating the caliper function of the ultrasound machine and placing the two cursors over the ends of the structure of interest.

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Table 1. Potential causes of gallbladder wall thickening.6

Ideally, gallbladder wall thickness, common bile duct diameter, and presence of periDuodenal ulcer cholecystic fluid are determined with the bedside gallbladder Acute pancreatitis exam; however, studies indicate these are not required to make Congestive heart failure a diagnosis of cholecystitis. In the proper clinical scenario, the Carcinomatosis presence of gallstones and sonographic Murphyâ&#x20AC;&#x2122;s sign alone Nephrotic syndrome strongly support the diagnosis of cholecystitis. Gallstones are present in 90-95% of cases of cholecystitis. When gallstones are associated with a positive sonographic Murphyâ&#x20AC;&#x2122;s sign, there is a 92% positive predictive value (PPV) for acute cholecystitis.3,8 Cholecystitis

Figure 4. Acalculus Cholecystitis: Longitudinal view of gallbladder (GB) showing echogenic sludge forming a meniscus. Also noted is pericholecystic fluid adjacent to the thickened anterior GB wall.

Summary

Modern ultrasound machines are relatively inexpensive to own and simple to operate. Basic ultrasound exams can be easily learned and mastered. As with any clinical exam skill, practice makes perfect. Providers interested in learning ultrasound should seek hands-on guidance from an expert in the field.

There are several quality hands-on ultrasound courses (http:// emergencyultrasound.com/) as well as free online videos (http:// emergencyultrasoundteaching.com/index.html).

The emergency ultrasound team at UMMC will be offering a hands-on ultrasound training course in the spring of 2015.

Please contact Dr Brian Tollefson for specific dates and times of the course (btollefson@umc.edu).

References

Figure 5. Cholecystitis: longitudinal view of gallbladder (GB) with multiple gallstones and associated posterior acoustic shadowing. Note the dilated common bile duct (CBD). The CBD diameter is determined by using the caliper function to measure between its inner walls.

After evaluating the gallbladder (GB) in the longitudinal plane, rotate the probe counterclockwise to visualize it in the transverse plane. Color Doppler can be used to differentiate the common bile duct from adjacent blood vessels (blood vessel lumen fills with color due to blood flow while the common bile duct lumen will remain anechoic). Measuring the GB wall in the transverse plane lessens tangential slicing artifact compared to longitudinal imaging. Tangential slicing overestimates GB wall thickness by imaging through the wall off center. Aside from cholecystitis there are other causes of gallbladder wall thickening to consider (Table 1).6

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1.

Tollefson B. The eFAST examination for trauma triage. J Miss Med Assoc. 2014; 55(3):72-8.

2.

Jang T. Bedside ultrasonography for gallbladder disease. Medscape. Retrieved 7/10/2014 from http://emedicine.medscape.com/article/104439overview.

3.

Gaspari R, Dickman E, Blehar D. Learning curve of bedside ultrasound of the gallbladder. J Emerg Med. 2009;37:51-56.

4.

Weiss CA III, Lakshman TV, Schwartz RW. Current diagnosis and treatment of cholecystitis. Curr Surg. 2002:59;51-54.

5.

Singer AJ, McCracken G, Henry MC, et al. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med. 1996;28:267-272.

6.

Scruggs W, Fox J, Potts B, et al. Accuracy of ED bedside ultrasound for identification of gallstones: Retrospective analysis of 575 studies. West J Emerg Med. 2008;9:1-5.

7.

Summers SM, Scruggs W, Menchine MD, et al. A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis. Ann Emerg Med. 2010;56:114-122.

8.

Miller AH, Pepe PE, Brockman CR, et al. ED ultrasound in hepatobiliary disease. J Emerg Med. 2006;30;69-74.

9.

Blaivas M, Harwood RA, Lambert MJ. Decreasing length of stay with emergency ultrasound examination of the gallbladder. AcadEmerg Med. 1999;6:1020-1023.

• Top 10 Facts You Need to Know • About Colorectal Cancer (CRC) in Mississippi Lucius M. Lampton, MD; Mary Currier, MD, MPH; Roy J. Duhé, PhD

A

mong cancers that impact both women and men, colorectal cancer (CRC) is the second leading cause of cancer-related death in this country and the third most common cancer in men and in women. Every year, almost 140,000 Americans are diagnosed with colorectal cancer, and more than 50,000 die from it, with largely equal percentages by sex.1 Despite these dismal statistics, this disease is highly preventable, with the key simply regular screening, beginning at age 50 and continuing until age 75. Regular and appropriate screening not only detects but also prevents the development of cancer by the removal of pre-cancerous polyps. Physicians of every specialty can play a significant role in decreasing CRC in Mississippi and our nation by encouraging the regular and appropriate screenings of our patients. March is National Colon Cancer Awareness Month, and the “Top Ten” things Mississippi physicians should know about CRC seem timely and highly relevant: 1. CRC is a major medical problem in Mississippi. Mississippi has the highest CRC mortality rate in the United States, according to the CDC’s SEER database (http:// apps.nccd.cdc.gov/uscs/cancersrankedbystate.aspx), and this statistic has not changed for several years. Furthermore, there are significant disparities between geographic regions in the state, with Public Health District 3 having the worst CRC incidence rates and mortality rates of all 9 Public Health Districts. In general, regional variations in the availability of colorectal cancer screening resources appear to influence regional screening rates. CRC outcomes of incidence and mortality are significantly worse for Mississippians of African ancestry versus those of European ancestry, which is largely a reflection of the differences in screening rates between these two groups (Faruque, Zhang, et. al., manuscript submitted for publication).

Author Affiliations: Dr. Lampton, JMSMA Editor, is a Clinical Associate Professor of Family Medicine at Tulane School of Medicine practicing at Magnolia Clinic in Magnolia; Dr. Currier is State Health Officer of Mississippi; and Dr. Duhé is Professor of Pharmacology and Toxicology, Professor of Radiation Oncology, and Associate Director for Cancer Education at UMMC. Corresponding Author: Roy J. Duhé, PhD, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216. (rduhe@ umc.edu)

2. Everyone should begin regular CRC screening by age 50, but some need to begin screening earlier. The U. S. Preventive Services Task Force, the American Cancer Society, and the U.S. Multi-Society Task Force2 all agree that every person should begin routine screening for colorectal cancer at age 50.3 All agencies recommend the use of colonoscopy (every 10 years, if no polyps are found) or Fecal Immunohistochemical Test (FIT, annually if no positive results are found), but some agencies recommend the use of other screens which are not unanimously recommended.

The initiation of screening at an earlier age is encouraged for individuals who have familial circumstances which predispose them to CRC, such as familial adenomatous polyposis (FAP), Lynch Syndrome, MYH-Associated Polyposis (MAP), or first-degree family members who have been diagnosed with CRC. 3. People are more likely to be screened for CRC if their physician advises them to do so. The leading reason reported by most people who have been screened for colorectal cancer is that their primary care physician personally recommended that they get screened.4 Conversely, the leading reason cited by screening-eligible people who have not been screened is that they were not advised by their physician to be screened,5 that they were unaware that they should have been screened, or some other variant of this response. When it comes to CRC screening, ignorance is not bliss. As well, it is clear that Mississippi physicians play the key role in increasing screening and decreasing CRC death for the state’s citizens.

4. Colonoscopy/polypectomy is proven to reduce CRC incidence and mortality. In 1993 the landmark National Polyp Study provided the first major clinical evidence that colonoscopy, coupled with the concurrent removal of adenomatous polyps, dramatically reduced the incidence of colorectal cancer in an initial cohort of 1418 individuals.6 In 2012 the results of a long-term follow-up study of the NPS cohort were released, and it was revealed that the use of colonoscopy/polypectomy resulted in 53% reduction in colorectal cancer mortality rates compared to the control cohort.7 To date, the removal of pre-cancerous polyps in

March 2015 JOURNAL MSMA 67

average-risk individuals is the single most effective behavior to reduce CRC incidence and mortality known to science.

5. The accuracy of colonoscopies is improved by the experience of the endoscopist. Several parameters affect the accuracy of detecting polyps, especially small polyps or sessile polyps. Quality control parameters such as the adequacy of bowel preparation, whether the cecum is reached, and the colonoscope withdrawal rate can affect whether small polyps and carcinomas are detected or overlooked. But the most important parameter of all is the experience of the endoscopist. Because of the great number of colonoscopies required during their residency, numerous studies have documented that gastroenterologists are more accurate in detecting polyps and carcinomas than non-gastroenterologists.8,9 For increased accuracy in diagnosis, there is no substitute for training and experience.

6. Capsule endoscopy is FDA approved for incomplete colonoscopies but not as a screen for CRC. The use of capsule endoscopy (a.k.a., Colon Capsule Imaging System) might conceivably increase the availability of colonoscopies in rural parts of Mississippi which currently lack convenient access to gastroenterology clinics.

Patients swallow the capsules, and endoscopic data are collected by the telemetry jackets worn by the patients as the capsule passes through the GI tract. A head-to-head clinical trial compared the results of back-to-back capsule endoscopy followed by conventional colonoscopy in the same patient, and this study demonstrated that capsule endoscopy was less accurate in detecting smaller polyps than conventional colonoscopy..10 This was the deciding factor in the FDAâ&#x20AC;&#x2122;s decision not to approve the new technology for routine CRC screening. However, the use of a Colon Capsule Imaging System was approved for use by the FDA under circumstances where an incomplete (i.e., the cecum was not reached) colonoscopy was performed (http://www.accessdata.fda.gov/cdrh_docs/pdf12/ k123666.pdf).

7. FIT screens are more effective than some older FOBT screens. There are multiple ways to screen your patients for CRC if, for a variety of reasons, colonoscopy is not readily available to or chosen by all patients. For such individuals, annual testing to detect the presence of blood in the stool may be a preferred alternative to endoscopic screening. It is important to remember that not all such tests are equivalent, so you should recommend the most reliable and accurate tests for your patients. Certain older tests are no longer recommended. Newer Fecal Immunohistochemical Tests (FIT) have improved accuracy and lower false positive rates than older tests.11 In addition, the

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use of specific antibodies means fewer dietary restrictions for the pre-test patient, and it is also easier for the patient to collect the stool sample, which results in better consumer acceptance and higher compliance rates. All positive results from fecal occult blood tests must be confirmed via colonoscopy as part of the recommended screening protocol. In addition to the FIT, much excitement has surrounded the U. S. Food and Drug Administrationâ&#x20AC;&#x2122;s recent approval of Cologuard, a stool-based colorectal screening test that detects the presence of hemoglobin and DNA mutations that may indicate the presence of cancer or precursors to cancer. As with FIT, patients with positive test results are advised to undergo a diagnostic colonoscopy.

Although stool DNA testing is not currently recommended as a method to screen for cancer by the USPSTF, CMS has proposed national coverage for the test. It is clear that evolving science may offer physicians additional safe alternatives for CRC detection.12 8. CRC screening reduces overall health care costs. The introduction of biological agents such as cetuximab and bevacizumab has substantially increased the life expectancy of patients with advanced CRC, but this comes at a great monetary cost. Thus, treatment costs for CRC are second only to those for breast cancer.13 Numerous studies have shown that population-wide CRC screening saves money for the entire health care system because it greatly reduces the total treatment costs for CRC.14 However, we will not be able to realize the full benefit of this cost savings until we maximize CRC screening compliance.

9. CRC screening is a wellness benefit under all ACAcovered health plans. Out-of-pocket costs for colonoscopy have been a significant barrier for many Mississippians. In order to meet the standards of the Affordable Care Act, health insurance plans must offer CRC screening as a wellness benefit to eligible plan members. To reduce outof-pocket expenses for your patients, remember to enter the correct billing code for polypectomies performed during screening colonoscopies upon polyp discovery.

10. Some CRC subtypes are more aggressive than others.

One of the most exciting advances in basic colorectal cancer research has been the discovery that colorectal cancers with different clinical outcomes can be distinguished at the molecular level. Gene expression profiles and monoclonal antibody arrays have revealed at least three distinguishable subtypes; minor differences arose when two different research consortiums used two different analytical methodologies.15,16 Both groups reached a consensus that some subtypes (CCS-1 or goblet-like CRCs) have extremely good outcomes with surgery alone;17 this is the ideal clinical scenario. However, other subtypes (CCS-3 or stem-like CRCs) result in very poor survival rates with

surgery alone. The latter subtype may be responsible for many of the deaths which occur despite screening and early detection. If such is the case, this creates a very strong rationale for continued basic and translational research to devise new clinical tools to recognize the distinct subtypes and to change the current treatment paradigm for early-stage CRC. One final caveat: Despite our zeal for physicians to maximize the screening of appropriate patients, overscreening can exact a toll in morbidity, mortality, and system-cost in inappropriate patients, especially among our geriatric population.

Studies have indicated that more intensive colonoscopy screening by both interval (three to five years instead of ten) and age (at age 85 to 95 years instead of 75) resulted in a net loss of quality-adjusted life years. Age, limited life-expectancy, and comorbid illness should be taken into consideration by physicians before advising surveillance colonoscopy in elderly and chronically ill patients. Be sure the risk of the screening for these patients provides a net benefit. 18

References 1.

U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2011 Incidence and Mortality Web-based Report.

Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2014.

2.

Short MW, Layton MC, Teer BN, Domagalski JE. Colorectal cancer screening and surveillance. Am Fam Physician.

2015;91:93-100.

3.

Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 2008;134:1570-1595.

4.

Modiri A, Makipour K, Gomez J, Friedenberg F. Predictors of colorectal cancer testing using the California Health Inventory Survey. World J Gastrointest Endosc. 2013;19:1247-1255.

5.

Wee CC, McCarthy EP, Phillips RS. Factors associated with colon cancer screening: the role of patient factors and physician counseling. Preventive Medicine 2005;41:23-29.

6.

Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med.1993;329:1977-1981.

7.

Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med.2012;366:687-696.

8.

Hassan C, Rex DK, Zullo A, Cooper GS. Loss of efficacy and cost-effectiveness when screening colonoscopy is performed by nongastroenterologists. Cancer 2012;118:4404-4411.

9.

Grimminger PP, Holscher AH. Quality of colonoscopy by gastroenterology and surgical trainees. Endoscopy 2012;44:716; author reply.

10. Van Gossum A, Munoz-Navas M, Fernandez-Urien I, et al.

Capsule endoscopy versus colonoscopy for the detection of polyps and cancer. N Engl J Med.2009;361:264-270.

11. Young GP, Symonds EL, Allison JE, et al. Advances in Fecal Occult Blood Tests: The FIT Revolution. Digestive diseases and sciences 2015. 60:609-622.

12. U. S. Food and Drug Administration News Release. FDA approves first non-invasive DNA screening test for colorectal cancer: Collaboration with CMS contributed to proposed Medicare coverage. August 11, 2014.

13. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst 2011;103:117-128.

14. Lansdorp-Vogelaar I, van Ballegooijen M, Zauber AG, Habbema JD, Kuipers EJ. Effect of rising chemotherapy costs on the cost savings of colorectal cancer screening. J Natl Cancer Inst 2009;101:1412-1422.

15. Sadanandam A, Lyssiotis CA, Homicsko K, et al. A colorectal cancer classification system that associates cellular phenotype and responses to therapy. Nat Med. 2013;19:619-625.

16. De Sousa EMF, Wang X, Jansen M, et al. Poor-prognosis colon cancer is defined by a molecularly distinct subtype and develops from serrated precursor lesions. Nat Med. 2013;19:614-618.

17. Sadanandam A, Wang X, de Sousa EMF, et al. Reconciliation of classification systems defining molecular subtypes of colorectal cancer: interrelationships and clinical implications. Cell Cycle 2014;13:353-357.

18. Siwek, J. “Screening and Surveillance for Colorectal Cancer: Avoiding the Pitfalls of Overscreening.” Am Fam Physician.

2015;91:82-84.

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• President’s Page •

Measles is scary.

M

easles is scary. That’s what MSMA’s 2015 Public Health Report Card poster in this issue of the Journal says. Measles once killed 450 children each year and disabled many more. But, measles is preventable when children are properly immunized. We physicians know this.

Claude D. Brunson, MD 2014-15 MSMA President

Yet, uncannily the 2015 Mississippi Legislature came very close to overlooking the science, ignoring the advice of every physician in the state and allowing misguided parents to refuse measles and other vaccinations for their school-aged children. Physicians I consulted were as baffled as I am why the Legislature would even consider letting kids go without vaccines.

But when it comes to parents and children, legislators can be real softies.

In the last year, anti-vaxxers have pummeled state lawmakers seeking weaker state law that makes it easier to opt out of mandatory vaccines for all children entering kindergarten. That did not work in Mississippi this year when physician groups joined with the State Health Department, the Public Health Association, and others to stop the Mississippi Legislature from lowering vaccination standards. Mississippi remains the state with perhaps the toughest immunization law and the best rates of compliance.

That’s right. Mississippi is Number One in the nation having the highest vaccination rates for children entering school. That’s a real feather in Mississippi’s cap, and I applaud the work of the State Health Officer Dr. Mary Currier, State Epidemiologist Dr. Thomas Dobbs, and the Health Department staff.

Measles was virtually eliminated in the United States 14 years ago by use of the MMR vaccine, but the Legislature is ever sympathetic to parents who somehow got the notion that vaccines cause autism (they don’t). It further amazes when the same parents who trust physicians to treat just about every other condition their children face listen to a blogger or believe a neighbor rather than the pediatrician.

Fueled by a growing anti-vaccine movement and misinformation, measles is making a comeback in the US spreading like the contagious disease that it is. Last year 189 measles cases were reported in the US. In the first 60 days of 2015 physicians reported 115 cases. If that trend continued, we would be looking at nearly 700 cases this year in the US. Luckily, Mississippi seems to have avoided the outbreak. That is likely because there weren’t any Mississippians who traveled to Disney World the particular week of the outbreak there. We rely on herd immunity but that only protects the population when nearly the whole herd is immunized. Immunity breaks down and everyone is more vulnerable when more children are allowed to forego the protection of vaccines.

USA Today reported that a 2008 measles outbreak in San Diego “showed how many can be put at risk by the selfish decisions of a few.” That outbreak started with one intentionally unvaccinated 7-year-old and spread to 11 other children who also were not vaccinated. “In less than a week, the infected youngsters exposed more than 800 other people to the disease at school, at a clinic, a swimming class, a grocery store and on a flight to Hawaii,” the media reported.

This all stems back to a 1998 study in a British medical journal that linked the MMR vaccine to autism. That study has been thoroughly debunked. Yet, it has sparked fear in worried parents who now 17-years later seem fearful of all childhood vaccines.

The message here is that physicians know medicine. Legislators do not. So, it’s up to us to educate our lawmakers and to become their resource on medical issues. Put the “Measles is scary” poster in your office or waiting room; talk with legislators about bad science. Offer to supply lawmakers with the facts they need to make good decisions because immunizations save lives.but only if they are required.

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and preventable.

Measles is scary...

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Vaccine-preventable diseases are still out there.

Learn how to protect your family at: www.CDCgov/vaccines/parents/

SAVE LIVES. IMMUNIZE.

Fellow Mississippians: of the 2015 Public Health Report We are proud to report in this edition on in school entry immunization Card that Mississippi is #1 in the nati rates.

n ranking, Mississippi is still last But despite our enviable immunizatio number of deadly diseases and or near the bottom in defeating a debilitating medical conditions. om of these lists, Mississippi To help move Mississippi off the bott the Commission on Health State Medical Association has formed leaders to help achieve health Equity to bring together committed equity for all Mississippians. physicians will be asked to use As the Commission moves forward, health and well-being of the their training and skills to influence ity in the delivery and access of Mississippi citizens and promote equ ippian will have access to and care. It is our hope that every Mississ ary care teams to manage their availability of caring, well-trained prim health and medical care. ons on access to care; utilization The Commission has started discussi acy and education, especially in barriers to accessing care; health liter ine the cost of care and lack of school-aged children. We will exam of our population. The adequate coverage for a significant part some of the troubling health ge chan Commissionâ&#x20AC;&#x2122;s ultimate goal is to statistics listed on the right. rselves on the various health crises To all Mississippians: Educate you rt card. Do your part by eating and solutions highlighted in this repo recommended health screenings. healthier, staying active and getting te a healthier future for all Working together, we can crea Mississippians.

According to these national rankings, thereâ&#x20AC;&#x2122;s still work to be done. Mississippi ranks: #1 in heart disease death rate Tied for #1 in obesity (with W.V.) #1 in low birthweight babies #2 in cancer deaths #3 in most teen births #3 in diabetes #3 in deaths from stroke #7 in HIV rate

er,

Yours in Making Mississippi Healthi

MD

MSMA President Claude Brunson,

, MD, MPH

State Health Officer Mary Currier

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brought to you by The 2015 Public Health Report Card is and Mississippi State Mississippi State Medical Association rs for Disease Control and Cente es: Sourc .

Health of tment Depar Health Statistics; United Prevention (CDC)-National Center for Rankings; MSDH STD/HIV Health Foundation, American Health Office.

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March 2015 JOURNAL MSMA 75

• University of Mississippi Medical Center •

Join the 70x2020 Initiative to Prevent and Eradicate Colorectal Cancer

Dr. Roy Duhé, associate director for cancer education at the Cancer Institute at the University of Mississippi Medical Center, leads a cheer proclaiming a goal of 70 percent of Mississippians get screened for colorectal cancer by the year 2020 during a press conference at the state Capitol on March 9. Aimed to lower Mississippi’s last-place ranking in colorectal cancer morbidity rates, the event also featured speakers, from left, Dr. Sam Pace, state Insurance Commissioner Mike Chaney, State Health Officer Dr. Mary Currier, Gov. Phil Bryant, and Marsha Thompson, widow of the late Dr. Ed Thompson who lost his life to the disease.

A

fter getting the all-clear on a colonoscopy performed in 2000 when he was 50, retired Tupelo gastroenterologist Dr. Sam Pace got an ironic shock on a follow-up screening in 2011: He had colon cancer.

“For my entire life, I’ve been on the business end of a colonoscope, doing screening colonoscopies. I’ve performed about 20,000 over 34 years,” said Pace, who was 61 when diagnosed, was experiencing no symptoms, and had no family history of colon cancer. “But I was practicing what I preached, and it was time to have the next screening. I wouldn’t be standing here today if I hadn’t had that screening.”

“I am not cured. I’m in remission,” said Pace, former president of the Mississippi Gastrointestinal Society and Mississippi’s governor for the American College of Gastroenterology. “And if I hadn’t caught it so early, I wouldn’t even be in remission.”

Pace is among Mississippians from every part of the state who are encouraging family and friends to be screened for colorectal cancer, which is most treatable when discovered early. Mississippi has the highest colorectal cancer death rate in the United States, and colorectal cancer is also the second leading cause of cancer death in Mississippi.

“Our ultimate goal is to save lives and spare them the physical, mental and financial cost of treating colon cancer,” said Dr. Srinivasan Vijayakumar, director of the University of Mississippi Medical Center Cancer Institute and chairman and professor in the Department of Radiation Oncology. “Every death from cancer is one too many.”

As the nation observes Colorectal Cancer Awareness Month, a number of leaders in the cancer-fighting community gathered March 9 at the Mississippi Capitol to champion the 70x2020 Colorectal Cancer Screening Initiative. That program has a goal of ensuring at least 70 percent of Mississippians are up to date with recommended screening by the year 2020. It’s recommended that the first screen for colon cancer occur at age 50, with a second screen 10 years later. If there’s a family history of colon cancer, a screen every five years is recommended. The screening is recommended for African Americans at age 45.

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“

Screening is so important, because it can lead to the prevention or early treatment of colorectal cancer.

During the screening process, precancerous lesions can be located and removed,” said State Health Officer Dr. Mary Currier.

“This is one of those screenings that should not be put off. With screening, you can avoid colorectal cancer altogether.”

“There are simple and affordable tests available, and if you’re 50 or older, you should be screened,” said Dr. Roy Duhé, associate director for cancer education at the Cancer Institute and an organizer of the 70x2020 effort. Many private insurance companies offer coverage; ask your insurance company how much you should expect to pay. Medicare covers a number of colorectal cancer screenings for “I am not cured. I’m in remission,” said those 50 and over.

Dr. Sam Pace, former president of the The American Cancer Society estimates that in 2015, 1,460 Mississippi Gastrointestinal Society and Mississippians will be newly diagnosed with colon cancer and 640 Mississippi’s governor for the American will die of it. Compare that to ACS estimates of 40,730 Mississippians College of Gastroenterology. “And if I being newly diagnosed with breast cancer and 410 dying of it, or of hadn’t caught it so early, I wouldn’t even be in remission.”

2,150 men being newly diagnosed with prostate cancer and 300 dying of it.

An estimated 58 percent of Mississippians who are eligible for a colorectal cancer screening get one.

“How great it would be, and how many colon cancers would we prevent, if that number were approaching 80 or 90 percent,” Pace said. “That’s what the 70x2020 initiative is all about.”

“Early detection of cancer can save your life,” said Mississippi Gov. Phil Bryant. “I thank UMMC, the Mississippi State Department of Health, and leaders in the health care community for helping spread the word and for encouraging Mississippians to be screened for cancer.”

The 70x2020 Initiative is aligned with the National Colorectal Cancer Roundtable, a coalition of public, private, and voluntary organizations working to State Health Officer Dr. Mary Currier speaks about the importance lower colorectal of preventative screening procedures for colorectal cancer in deaths. The residents aged 50 or older during a press conference at the Roundtable has a state Capitol. Aimed to lower Mississippi’s last-place ranking in goal of seeing 80 colorectal cancer morbidity rates, the event also featured speakers, percent of eligible from left, MSMA President Dr. Claude Brunson, senior advisor to U.S. residents the University of Mississippi Medical Center’s vice chancellor on screened by 2018. external affairs, state Insurance Commissioner Mike Chaney, and Gov. Phil Bryant.

March 2015 JOURNAL MSMA 77

• MSMA •

MSMA Engages Medical Students in Advocacy, STAT J. Conner Reeves, MSMA General Counsel

MSMA STAT Program MSMA has launched a new program to encourage medical students to participate in advocacy activities. It’s called the STAT Program, short for Student Advocacy Training. Not only will students gain valuable experience, they also will be recognized at annual session. “Active students are likely to stay involved,” said MSMA President Dr. Claude Brunson, “It starts with advocacy when MSMA introduces active students to organized medicine and shows them how to influence public policy.”

Activities throughout the year give students a variety of opportunities during their time in medical school. Each activity engages the student and supplements his clinical training when actively supporting patients and the practice of medicine. MSMA staff work directly with the students at events and through activities to ensure they have a positive, educational experience.

How it Works

Jamie Stanford, UMMC M3 with Representative Bobby Howell, MSMA identifies at least twelve activities each year in which STAT students may participate. The student selects any six activities to complete while in medical Chairman of Medicaid Committee school and MSMA staff coordinates their participation. MSMA keeps a record of completed activities to eliminate paperwork for the students! This year MSMA will even give retroactive credit for activities completed in earlier years of medical school. Once the student completes six activities, he or she is deemed an MSMA STAT Scholar and is recognized for STAT endeavors in the Journal MSMA and at MSMA Annual Session.

Students May Choose from these STAT Activities • Visit the State Capitol with MSMA staff during the legislative session and work with the Doctor of the Day. • Attend a local medical society meeting.

• Attend a meeting of the Mississippi Board of Medical Licensure.

• Join an MSMA legislative update conference call.

• Participate in a grassroots effort by writing a letter to a legislator.

• Contribute to or write an article for the Journal MSMA. • Attend the MSMA Annual Session (each attendance counts individually).

• Volunteer at an MSMA Foundation event.

• Participate in an AMA/MSMA recruitment event or AMA meeting.

• Attend at least one meeting of the AMA Medical Student Section (MSS).

• Attend a meeting of the MSMA Council on Medical Service.

• Volunteer in an event sponsored by the Mississippi Medical Political Action Committee (MMPAC).

• Participate in an activity with the Medical Assurance Company of Mississippi.

78 JOURNAL MSMA

March 2015

MSMA STAT SCHOLAR

Passionate about physician advocacy?

Participate in the MSMA STAT Program to get involved with your MSMA!

To get started, contact Conner Reeves at MSMA 601-853-6733 or CReeves@MSMAonline.com

Annual Session

1/30/15 11:23 AM

of the MSMA

House of Delegates August 14 &15 Hilton Jackson

1001 E. County Line Rd.

Reservations: (601) 957-2800 Mention MSMA or use group code (MSM) PPI S T

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March 2015 JOURNAL MSMA 79

• Images in Misssissippi Medicine •

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ATCHEZ CHARITY HOSPITAL IN 1911—Perhaps the most historic hospital in state history, the Natchez Charity Hospital followed an earlier “Natchez Hospital” created by the Mississippi Territorial Legislature on January 18, 1805, as the territory’s first charity hospital. Soon after statehood (in May 1818), Governor David Holmes addressed the governors of other states and told them that their states should contribute to this hospital’s operation since it chiefly cared for out of state strangers (the boatmen of the river). Help from federal sources eventually arrived, with federal dollars erecting this Greek Revival structure, see above, between 1849-1852 as the 100-bed U. S. Marine Hospital of Natchez. It was one of seven hospitals authorized by Congress in 1837 to be built in ports along the Mississippi and Ohio Rivers. The structure, designed by architect Charles A. Fuller, possessed four stories and a basement, and its octagonal cupola commanded majestic views of the Mississippi River. (Credit also has been given to Robert Mills, long US architect for public works, who appears to have designed the “prototype” for marine hospitals.) The facility functioned as a marine hospital until the outbreak of the Civil War. In 1876, it was sold to the American Home Baptist Missionary Society, which created the Natchez Seminary there, dedicated to the training of black teachers and ministers. By 1883, the school moved to Jackson to become the predecessor of Jackson State University. The city of Natchez purchased the structure in 1884, making it the Natchez Hospital, and by 1920, it would be called officially the Natchez Charity Hospital. It became an important state school for nurse training, and the Mississippi Nurses Association was founded here in 1911. The old hospital, located at 801 Maple Street, was situated on a bluff overlooking the Mississippi on the north side of Natchez on what is now Cemetery Road. Standing just south of the cemetery, Natchezians would joke that when you died at the hospital, your body was just rolled down the hill in a gurney to be buried in the cemetery. This historic structure burned on August 5, 1984. Only one antebellum U. S. Marine Hospital structure survives, in Louisville, Kentucky, on a bluff above the Ohio River. It is nearly identical to this historic lost structure once on the bluff in Natchez. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal.

— Lucius M. “Luke” Lampton, MD; JMSMA Editor 80 JOURNAL MSMA

March 2015

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• Medical Assurance Company of Mississippi •

MACM Announces Stephanie C. Edgar, JD as Legal Counsel

Stephanie C. Edgar, JD

T

he Board of Directors of Medical Assurance Company of Mississippi is pleased to announce Stephanie C. Edgar, JD has joined the Company as Legal Counsel and will represent MACM in corporate, insurance and related issues.

Before coming to MACM, Ms. Edgar was in private practice for 11 years and concentrated her practice primarily in the area of medical malpractice defense. She has represented individual physicians and medical groups with respect to general healthcare, corporate, contracting, compliance, and business law matters. Ms. Edgar received her Bachelor of Arts from the University of Southern Mississippi in 2001 and her Juris Doctor from the University of Mississippi in 2004.

Ms. Edgar is a member of the Mississippi Bar, American Health Lawyers Association, American Association of Corporate Counsel, and Defense Research Institute. She holds the AV Preeminent® Peer Review Rating from Martindale-Hubbell, its highest rating for ethical standards and legal ability.

Ms. Edgar was also recognized in 2014 by MidSouth Super Lawyers as a “Rising Star” in the area of healthcare law.

Committed to Excellence.

“As we celebrate our 35th Anniversary, we are committed to continuing the level of care you’ve come to expect from MEA.”

“Stephanie brings to MACM a wealth of experience that will only help us continue to provide reliable and accessible coverage to Mississippi physicians,” Robert M. Jones, MACM CEO, said.

“We are extremely fortunate to have someone of her caliber in this position and look forward to working with her for many years.”

Founded in 1976, Medical Assurance Company of Mississippi is an organization of physicians dedicated to providing sound, stable insurance products and quality related services to physicians and other health care providers practicing in the state of Mississippi. r

82 JOURNAL MSMA

March 2015

William Howard, MD Chairman of the Board Partner since 1984

Contact us today for information on how you could become part of MEA’s winning team.

Stephanie Holt 601-898-7567

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The University of Mississippi Medical Center Hospitalist Division is seeking a BC/ BE Hospitalist.

Faculty candidates should submit a CV via fax Journal ofEOE, theM/F/D/V. Mississippi State to 601-984-5608.

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March 2015

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SPOTLIGHT:

Physician Leadership AcademyByScholars Kara Kimbrough 1

First in a series of features on the inaugural class of MSMA’s Physician Leadership Academy scholars.

Fourth-grade goal set the course for Mark Horne, MD’s future

E

arly on, Mark Horne knew he wanted to be a doctor.

“It was a profession that interested me from about the fourth grade,” Dr. Horne recalled recently from his office in Laurel. The internal medicine physician singled out his mother, a nurse; his father, an Army medic and a great-uncle, a respected Laurel physician, who modeled professionalism and piqued his interest in a medical career.

“It was something I innately felt I could do back then and it was a feeling that guided my decisions from then on,” said Dr. Horne. “Seeing family members who gave back to others through their work in the medical field was inspiring.”

Watching the 1970’s television show “Emergency” also proved inspirational as he considered a medical career.

“I was fascinated by the show and wanted to be Dr. Brackett and paramedic Gage, two of the main characters,” Dr. Horne said. “Everything about becoming a physician, including mastering math and science classes to get into medical school, was emotionally and intellectually challenging.”

After graduating from high school, Dr. Horne attended nearby Jones County Junior College on an ACT scholarship. His knack for expertly mapping out his college and future career path began to pay dividends in the form of jobs that offered insight into all aspects of hospital work. “As a full-time college student, I attended classes during the day and worked nights and weekends at South Central Regional Medical Center as an orderly,” said Dr. Horne. “I did everything from bathing patients to cleaning bed pans.”

At the age of 19, he moved to the ambulance service.

Still juggling a full load of academic classes, he took EMT courses at night. This training, along with the all-night shifts on the ambulance team, prepared him for the rigors of medical school and residency.

“The goal of becoming a doctor was behind every decision I made,” he said. “I knew everything I was doing would provide useful in my career and ultimately it would pay off.”

He applied to Mississippi College and began working on an honors project. Working as an assistant in MC’s lab opened the door to a position in UMMC’s microbiology department. At UMMC he made valuable contacts and gained experience that further solidified his career path.

Choosing internal medicine was an easy decision after realizing the specialty would provide the opportunity for his two main interests: problem-solving and personal interactions with adult patients.

“I enjoy getting to know patients and having them get to know me,” said Dr. Horne, now medical director of Jefferson Medical Associates. “I give them my best medical advice and they can choose to follow it or not; they’re adults and can make their own decisions. I like the communication and clear lines of respect that exist between adult patients and me.”

Family life is important and once he leaves the office, he is able to focus fully on his family, which includes wife Danita and their three children. Oldest son Kiser, now 16, has expressed an interest in following his dad into the medical school.

“He was around 12 years old when he first mentioned it; just a little older than I was when I first decided I wanted to be a physician,” said Dr. Horne. “He’s very technicallyoriented and it appears he’s maintaining an interest in medicine.”

Dr. Horne continues to strive to improve his skills to further enhance his career and practice. Enrolling in March 2015 JOURNAL MSMA 85

MSMA’s first Physician Leadership Academy was a natural step for someone who has set goals his entire career.

“I love what I do and it’s a wonderful life, but being a physician comes with a lot of responsibilities,” said Dr. Horne. “Particularly in the rapidly-changing world of medicine, there’s a need for physicians to see further down the road, set goals to help facilitate growth and obtain the leadership skills to help obtain them.”

As a leader in his practice, hospital, community, church and since August, on MSMA’s Board of Trustees, he’s seen the need to negotiate and size up others’ personalities and leadership skills.

“I’m very outcomes-driven, so I want to set the right goals and then set an effective course of action to get there,” said Dr. Horne. “These were my primary goals in joining the Physician Leadership Academy. So far, it has provided many of the tools to help me reach my ultimate goal of becoming a more effective leader.”

‘Status quo’ not an option for Robin Schwartz, MD

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obin Schwartz looks puzzled when asked to explain how she effectively manages a busy life as a hospital anesthesiologist; medical director of Laurel Surgery and Endoscopy Center; mother of two daughters and a wife to husband Chris, also a physician. Oh, and there was the 21-month period when “full-time Physician Executive MBA student” joined the list.

When pressed, Dr. Schwartz credits her profession for sharpening her multi-tasking skills.

“As an anesthesiologist, there are a whole bunch of tasks that must get fully completed with each case,” she said.

“I have about 5-10 minutes to gain a rapport with the patient before surgery. The things I do before and during surgery allow the surgeon to do his or her job. When I leave the OR, everything is taken care of for the day. Then I move on to other aspects of my life.”

Choosing anesthesiology as a specialty is one of many good decisions, starting with a high school goal to work toward a medical degree. An affinity for math and science 86 JOURNAL MSMA March 2015

courses at McComb High School continued when she entered the University of Southern Mississippi.

At USM, she met her future husband Chris, who shared her goal of going to medical school. After graduation, they married and moved to Jackson to attend University of Mississippi School of Medicine.

Being able to share the experience with her husband was a plus. She also enjoyed forming relationships with other students and in the final two years, the clinical aspects of medical school, Dr. Schwartz said.

Her decisive nature helped guide her to anesthesiology from an initial decision to specialize in internal medicine.

After completing an internship in internal medicine at University of South Alabama Medical Center in Mobile, she stayed there to complete an anesthesiology residency.

Even the one-year detour from her ultimate goal is viewed as a good decision by Dr. Schwartz.

“I realized the field was not for me, but everything in my career has prepared me for the place I’m at today,” she said.

Stints at anesthesiology groups in Jackson and Hattiesburg led the way for her current positions at Laurel’s South Central Regional Medical Center and Laurel Surgery and Endoscopy Center.

With a secure career and busy life raising two

daughters, a Millsaps College student preparing to follow her parents into medicine and a high school junior considering a legal career, there wouldn’t appear to be time for additional education. But settling for the easy route has never been an option.

“I’ve always been interested in the business side of medicine,” she said. “After researching many different programs, Auburn’s MBA Physician Executive program with an emphasis in healthcare was the best fit for me.

The curriculum allows for a combination of online and on-site classes, which I really enjoyed.”

Completing the MBA program in May 2014 gave Dr. Schwartz extra assurance she’ll be prepared for the challenges ahead. Finance, accounting and management classes were beneficial, but no more meaningful than relationships formed with fellow physicians. Traveling to Washington to witness the legislative process firsthand, then to Berlin and Copenhagen to view alternate healthcare systems with other physicians was also a valuable side benefit of the experience, she said.

“We all had busy medical practices and family and we figured it out,” Dr. Schwartz said. “It’s a matter of priority and deciding the best way to get everything done.”

Obtaining the MBA and a prestigious Certified Physician Executive award from the American Society of Physician Leaders should appease most physicians’ desire to excel in their field.

However, when the opportunity to join MSMA’s Physician Leadership Academy appeared last year, Dr. Schwartz was quick to apply.

“I’m convinced medicine is going to be vastly different in the future,” said Dr. Schwartz. “As physicians, we need to be able to show we provide value to our hospital systems along with quality care to every patient.

We are moving more toward payment for quality care and value instead of simply fee for service. I want to do everything possible to make sure I am able to do that.”

Already, the Physician Leadership Academy has offered valuable lessons on how to excel in a changing medical field.

“Everything you do to advance your skills is important, whether it’s improving public speaking skills or learning how to negotiate,” Dr. Schwartz said. “It’s always been important that I’m a good physician. Now, being a good leader is on the list. The Physician Leadership Academy is helping me achieve this important goal.”

William Waller, MD, bypassed political dynasty for medicine

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illiam Waller III, MD, still remembers the day he told his family he was applying to medical school. Expectations were high, at least in his mind, that he’d follow his grandfather, former Gov. William “Bill” Waller, Sr. and his father, William Waller, Jr., Chief Justice of the Mississippi Supreme Court, into the legal field. For starters, he bore their name, a formidable one in Mississippi’s legal and political field. And, he’d always felt it was something the two men he admired the most would want him to do. Nothing could have been further from the truth.

“I always felt my father and grandfather would be upset if I didn’t enter the legal field,” Dr. Waller said, speaking from his Hattiesburg dermatology clinic. “Actually, their reaction was quite the opposite. Both of my parents and my grandparents were very supportive of my decision from the beginning. They felt the medical profession was a noble calling.”

Growing up in Jackson within walking distance of Jackson Academy, the opportunity to enroll in advanced math and science high school classes was seized by Dr. Waller. Once he delved into an A&P class, his future in the medical field was sealed.

Enrolling at Mississippi College as a biological science major meant studying often trumped regular college activities.

However, politics had influenced him more than he realized.

He was elected MC’s student body president and served as band leader of the college show choir.

The extracurricular activities, intertwined with intense hours of studying, meant he “rarely experienced downtime,” he said. It was a lesson in multi-tasking that proved useful when he was accepted to University of Mississippi School of Medicine.

Rigorous high school and college courses had left him well-prepared for medical school classes. But it wasn’t until his third year that he began to enjoy the process and find his niche in the medical field, Dr. Waller said.

“I enjoyed seeing patients and found it to be very gratifying,” said Dr. Waller. “I became interested in dermatology because of the visual aspect and opportunity to perform a variety of procedures. However, UMC didn’t have a dermatology residency program at that time, so my exposure was somewhat limited.”

March 2015 JOURNAL MSMA 87

He briefly considered otolaryngology as a specialty; however, he decided to seek a rotation in dermatology before making a final decision. An away rotation at Tulane University during his fourth year of medical school was cancelled due to Hurricane Katrina. His calling into dermatology was solidified after he completed the rotation at Emory University.

After medical school, Dr. Waller completed an internship in internal medicine at St. Mary’s Medical Center in San Francisco, a residency in dermatology at Tulane University and a clinical research fellowship in dermatology, also at Tulane University.

When choosing an area in which to practice, once again he broke from tradition and chose Hattiesburg instead of Jackson, where his large family still resides. The opportunity and support offered by Hattiesburg Clinic to build a new practice, Dermatology-South, reinforced his decision to move to Hattiesburg. Like previous decisions that deviated from the norm, it’s one he hasn’t regretted.

“I’ve enjoyed being in Hattiesburg and developing relationships in the South Mississippi area,” said Dr. Waller. “The complexity and variety of skin conditions is both the most rewarding and the most challenging aspect of my practice. One minute I can be freezing a wart on a 2–year-old, and in the next room, I’m telling an older patient they have melanoma. My patients range in age from a week old to 104. Treating patients of all ages and performing a mixture of surgical and medical treatments makes each day interesting.”

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March 2015

Public speaking has never been a problem for Dr. Waller. He serves as clinical professor at Tulane and lectures to community groups in the Hattiesburg area. It’s not a stretch to think he inherited a public speaking gene from his father and grandfather.

Despite his experience, the session on media training during MSMA’s Physician Leadership Academy proved fortuitous, Dr. Waller said.

“The mock interviews we underwent just prior to a Capitol press conference at which I spoke on the dangers of tanning beds were very helpful,” he said. “I was wellprepared, organized my thoughts and remembered to keep it positive.”

Like his father and grandfather, Dr. Waller believes in giving back to his vocation. Years ago, he served on the MSMA Board of Trustees and as an AMA medical student representative. Now that he’s back in Mississippi, he is an active member of MSMA. In addition to joining the Physician Leadership Academy, he currently serves on the Council on Legislation.

“Once I got reestablished in Mississippi, I wanted to reconnect with others in my field,” said Dr. Waller.

“MSMA was the best way to do it.”

If you are interested in applying to the 2015-16 Physician Leadership Academy class, contact Phyllis Williams at 601-853-6733.

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