May 2014 JMSMA

May

VOL. LV

2014

No. 5

Old fashioned?

Is the medical journal passĂŠ? Not on your life. Scientific medical publications

continue to be a solid source for up-to-date data to physicians in all specialties.

Your Journal of the Mississippi State Medical Association is alive and kicking with a new editorial advisory board. Drink it in. Drop us a line. Read the JMSMA online and in print. Contact us for information on cost-efficient advertising opportunities.

Karen A. Evers, Managing Editor, 601.853.6733

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

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

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

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

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

Copyright© 2014 Mississippi State Medical Association.

Official Publication of the MSMA Since 1959

MAY 2014

VOLUME 55

NUMBER 5

Scientific Articles Change of Heart: Transplantation in Mississippi

140

Jonah Gunalda, BA; Martin H. McMullan, MD; Marc E. Mitchell, MD; Curtis G. Tribble, MD; Walter H. Merrill, MD

Axillary Lymph Node Treatment in Breast Cancer: An Update

145

Patrick A Williams, MD; Jeanann Suggs, MD; Sophy H. Mangana, MD

Special Insert Legislative Session 2014 Wrap-Up

153

President’s Page Thoughts on Medicaid Expansion

159

James A. Rish, MD; MSMA President

Editorial A Return to the Asclepeia: A Physician’s Enduring Obligation to his or her Patients

161

David P. Smith, MD

Related Organizations Mississippi State Department of Health University of Mississippi Medical Center

148 162

Departments From the Editor: Has Jackson Taken Over our MSMA? MSMA Annual Session Images in Mississippi Medicine: Dr. Lewis New Members Poetry in Medicine: “I Love Nurses”

138 151 158 167 170

About The Cover: Hummingbird in Flight- A majestic hummingbird hovers in mid-air to feed, and one notices the amazing flap of its wings. Hummingbirds drink with their tongue by rapidly lapping nectar. Ornithologists first put forth the theory that hummingbirds took in nectar using capillary action in 1833, and until relatively recently no one questioned it. In a study published in the Proceedings of the National Academy of Sciences [PNAS print May 2, 2011], research shows that it is not capillary action at all, but actually a curling of the tongue to trap liquid. The tips of their forked tongues are lined with hairlike extensions called lamellae.

When inside the flower, the tongue separates and the lamellae extend outward. As the bird pulls its tongue in, the tips come together, closing around the nectar, and the lamellae roll inward. Hummingbirds do not spend all day flying as the energy cost would be prohibitive, spending an average of 1015% of their time feeding. The majority of their activity consists simply of sitting or perching. Because they starve so easily, they are highly attuned to food sources.

Some species, including many found in North America, are territorial and will try to guard food sources (such as a feeder) against other hummingbirds, attempting to ensure a future food supply for itself.

The website hummingbirds.net list, in order of decreasing frequency of sightings, the following species in Mississippi: Ruby-throated, Rufous, Buff-bellied, Black-chinned, White-eared, Calliope, Broad-tailed, Anna’s, and Allen’s. Photo by Ron Cannon, MD, an otolaryngologist/head and neck surgeon who lives in Brandon.

May

VOL. LV

2014

No. 5

May 2014 JOURNAL MSMA 137

From the Editor: Has Jackson Taken Over our MSMA?

S

ince its founding in Jackson in 1856, our MSMA has emphasized its geographic and multispecialty diversity. The annual meetings have purposefully rotated from place to place to trumpet loudly that our Association represented the entire state. Herculean effort has been made by our Nominations Committee to mentor and forward leaders from every specialty and every corner of the state, even utilizing a “tradition” of geographic rotation in the selection of presidential candidates. Fear that a region, city, or oligarchy of leaders would “take control” of our democratic association was always whispered.

To a large extent, these deliberate actions to achieve geographic fairness have been successful. However, the push by some of our leaders and staff to locate our Annual Session permanently in our capital city of Jackson will have unintended detrimental consequences to the tradition of multispecialty camaraderie and state-wide representation of our association.

The statistics from last year’s meeting, as reported at a recent Board of Trustees gathering, found no significant increased turnout among our membership for the meeting, except among Jackson’s Central Medical Society, which doubled its delegates

in attendance, as well as its votes. What seemed also evident was that the number who voted for candidates was higher than those who participated in proceedings.

There are positives of the Jackson meeting: a central location, a technologically capable site, and less travel expense for Lucius M. Lampton, MD staff. But this comes at what cost to our Association? Anyone can manipulate and spin statistics, but members need to focus on percentage of delegate turnout and participation of ALL component societies. Also, members need to review election results to see if Jackson candidates benefited disproportionately compared to those from other areas.

MSMA must be sure all voices are heard and that our rural physicians (and their patients) in every corner of the state are represented. Rural and non-Jackson doctors, heed this call: your voice must be present at the coming 146th Annual Session at Jackson, August 15-16, 2014. The vision and direction of our Association depend on it!

Contact me at lukelampton@cableone.net.

—Lucius M. “Luke” Lampton, MD, Editor

Journal Editorial Advisory Board Myron W. Lockey, MD Chair, JMSMA Editorial Advisory Board Journal MSMA Editor Emeritus, Madison Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson

Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson

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

138 JOURNAL MSMA May 2014

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

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

Jason G. Murphy, MD Surgeon

Surgical Clinic Associates, Jackson

Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson

Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson

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

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

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

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

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

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Reputation Above All Others May 2014 JOURNAL MSMA 139

• Scientific Articles • Change of Heart: Transplantation in Mississippi Jonah Gunalda, BA; Martin H. McMullan, MD; Marc E. Mitchell, MD; Curtis G. Tribble, MD; Walter H. Merrill, MD

A

bstract

Introduction

The first heart On January 23, 1964, transplantation in a Dr. James D. Hardy (Fighuman being was performed ure) and his surgical team on January 23, 1964, in at the University of MissisJackson, Mississippi, by Dr. sippi Medical Center stood James D. Hardy and his team at a crossroads. Rush Boyd, at the University of Missisa patient with impending sippi Medical Center. This cardiac failure, awaited a operation preceded those of new heart. The only human many others who would folheart available for translow Dr. Hardy. Although Dr. plantation was that of an Hardy was eventually given ICU patient who was neudue credit for this unprecrologically unresponsive. edented feat, he was initially Unfortunately, the criticized by the medical concept of “brain death” community and the media was not yet an accepted Figure. James Daniel Hardy, MD because he and his team chose clinical diagnosis in the to transplant a chimpanzee heart into this first patient. This ar1960’s. Hardy, though, was ahead of his own time.1,2,3 A few ticle will retell the story of the first heart transplant in man, weeks prior to this situation, he had purchased four chimpanintroduce the other surgeons also striving to successfully transzees for such an occasion.3 So now, as the situation unfolded plant a heart in a human, identify the racial issues that existed in Jackson, Hardy and his team had to make a choice: either at the time and highlight the debates about morality and ethics discontinue cardiopulmonary bypass and let Boyd die or transthat surrounded many of the issues in transplantation. While plant the chimpanzee heart into Boyd. This dilemma was cerDr. Hardy was not given much credit for his work in heart transtainly not a coin toss. plantation, the time has come to acknowledge him as the first Background surgeon to perform this operation in a human being.

Before a heart could be transplanted in a human, it had to Key words: transplantation, heart be considered an operable organ. Until Blalock’s extracardiac shunt operation in the early 1940’s, the heart was labeled noli me tangere, which translates to “do not touch me.” This phrase Author Affiliations: Fourth year medical student (Mr. Gunalda), Special Advisor to the Vice-Chancellor (Dr. McMullan), Chair, was applied to the “mysterious and sacrosanct” human heart, Department of Surgery (Dr. Mitchell), Professor of Surgery, (Dr. the organ that was believed unapproachable by physicians.4 Tribble) at the University of Mississippi Medical Center, 2500 N. This pervading thought survived as law without question unState Street, Jackson, MS 39216. Professor of Surgery, Vanderbilt University Medical Center (Dr. Merrill). til November 28, 1944. It was then that Dr. Alfred Blalock and his team, assisted by his laboratory technician Mr. Vivien Corresponding Author: Walter H. Merrill, MD; Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232-2102.

Thomas, operated on a baby with tetralogy of Fallot.5 This day marked the beginning of modern-day cardiac surgery.

Reprints will not be available However, it would still be years later before the heart would

140 JOURNAL MSMA May 2014

be completely accepted in its role as a pump and not the soulhousing unit of man. It would take a radical transplantation in order to convince the medical community, and even the world, that the heart had a more concrete physiologic role in the body.

As Dr. Hardy’s story is told over the course of these pages, it is imperative that the reader understands three key points.

First, to credit anyone other than Dr. Hardy with performing the first heart transplantation in man would be erroneous. It was this operation in 1964 – more than three years before Dr. Christiaan Barnard would transplant a heart in Cape Town, South Africa4 – that stands as the prologue to any literature that has been published about the race to transplant the first heart.

Second, the reader should be made aware that Dr. Hardy performed a xenograft transplant using a chimpanzee heart rather than a human heart.3 As will be discussed shortly, perhaps this is one of the contributing factors that caused Dr. Hardy’s name to fade among the other pioneers who performed allograft heart transplants later. Finally, the story would be incomplete if the author did not tell of the commentary and controversy that surrounded this first heart transplant. In Hardy’s own words, “Each job is a portion of the person who did it.”6 And Dr. Hardy was the person who did it – first. He performed the inaugural heart transplantation in man, and his story must be rightly told.

Preparation

The resuscitation of Dr. Hardy’s reputation as being the first to perform heart transplantation in man rests on the fact that he and his team were aptly knowledgeable and prepared for this opportunity. Hardy studied immunosuppression7,8,9 including that of the GI tract, kidneys, and lungs. He talked with other physicians participating in transplant research and became fascinated with Dr. Keith Reemstma’s chimpanzee kidney transplantations at Tulane University. Hardy would later acquire some of Reemstma’s donors for his groundbreaking procedure.10 Hardy’s preparation also included his commitment to developing mechanical support for the failing heart, eventually hiring the famous Dr. Tetsuzo Akutsu to work on artificial heart pumps.11,12 Suffice it to say that Dr. Hardy and his team were well-equipped for the pivotal moment brought about by Rush Boyd and his need for a new heart.

Their efforts were all but incautious, impulsive or insensitive.

The Race for Second

The race was underway in the 1960’s to see who would be the first to perform the world’s first heart transplantation. Those competing included Dr. Christiaan Barnard of Cape Town, South Africa; Dr. Norman Shumway at Stanford; Dr. Richard Lower of Richmond, Virginia; and Dr. Adrian Kantrowitz of Brooklyn. The tension was growing tighter by the minute as each approached what seemed like victory. However, Dr. James D. Hardy in Mississippi had performed the first heart transplantation in man more than three years before this quartet would lay claim to the same.

Using a technique that had been previously described

by Dr. Shumway, Dr. Hardy performed the successful transplantation in January of 1964. Though Shumway’s technique is credited, Shumway himself did not perform the first procedure in man. And, yes, Barnard captured the attention of the world when news spread of his heart transplantation in 1967. In fact, Dr. Leonard Bailey claims13 that Barnard “lit the candle” that ignited the heart transplantation inferno.

(It is interesting to note that Dr. Bailey would face similar criticisms as Dr. Hardy when he performed a baboon heart transplant in Baby Fae in October 1984.) But Barnard was not the first, nor did his research in the field of heart transplantation measure up to that of his competitors. Even when Kantrowitz signed his name into the book of heart transplant pioneers, the race had already been won. For some inexplicable reason, medical literature lauds either of these men as being “the first.” However, each of them would have been greatly chagrined to know they were in a race for second place.

Several theories are postulated as to why Dr. Hardy has not been adequately acknowledged for spearheading heart transplantation in man. To some, Dr. Hardy’s preoperative decision to use a chimpanzee heart disqualifies him from the title of first to perform this procedure in man. These individuals would argue that only allograft tissues are morally and ethically acceptable for organ transplantation. However, they may have failed to realize that his choice for xenografting was strictly circumstantial: the patient was rapidly deteriorating, and there was no appropriate human donor at the time. Or perhaps the matter is one of semantics. What exactly is being recognized: the first heart transplantation in man, the first human heart transplantation, the first human-to-human heart transplantation, the first xenograft transplantation, or the first heart transplantation in any species? Probably one of these – “the first human-to-human heart transplantation” – is more recognized than the others. Therefore, it was Dr. Hardy who paved the way for future heart surgeons to perform heart transplantation in man after the procedure on Boyd. The work of Barnard, Kantrowitz, Shumway and Lower was made possible once Hardy showed that the heart could indeed be successfully transplanted into a man and that it would support the human circulation.

Apes and the South

Arguably, one of the more debatable issues regarding this first transplantation was the origin of the graft. Dr. Hardy pointed out that chimpanzees are man’s closest relative, having a 98% DNA match.3 It stood to reason that if a viable human donor were not available to transplant in an emergent situation, chimpanzees were the most acceptable alternative.

Acceptable, that is, unless the stage was set in the South.

The racial upheaval in Mississippi during the 1960’s is not to be understated. For example, in 1963 – before Hardy’s heart transplant procedure – Medgar Evers, an outspoken black Mississippi civil rights activist, was shot at his home and died

May 2014 JOURNAL MSMA 141

in the University of Mississippi emergency department while Hardy was performing the first human to human lung transplant. He was killed at close range by a white supremacist.3 Hardy and his team, Janis Quinn writes, were amply aware of the firestorm they would create by transplanting an ape heart into the empty chest of a white man. She states, “If the idea of heart transplants was alien to people, how would the world react to a chimp heart in a man?”14 This, unfortunately, was the reality Hardy and his team faced. He knew that the media would respond poorly to this controversy, and he was proven right.

So, as Rush Boyd awaited a new heart, his condition continued to deteriorate. The care team had to decide on a definitive plan of action. Transplant? No transplant? Discontinue bypass? Dr. Hardy tells of the dilemma: But at this point, serious constraint developed among the five members of our transplant team. Should the chimp heart be used, even though the patient was at the point of death and supported only with the heart-lung machine? The head injury patient in the ICU continued to exhibit effective heart action. I was well aware, from the “first lung” experience, that the transplantation of a heart would prompt a world-wide sensation; and to use a “monkey” heart would cause even greater criticism.3 They ultimately decided to use the heart of one of four chimpanzees Hardy had purchased from Reemstma at Tulane for such an occasion.10 With regard to informed consent, the only relative of Rush that Hardy’s team was able to speak with was a step-sister. After learning of all the possible options, she consented to the possibility of Rush receiving a heart from a primate.14 With consent obtained, Dr. Hardy could claim that he proceeded as planned without coercing the patient or his family.

Once the transplant was successfully performed, it was only a matter of time before news would spread. The University was not in a position to offer an official report of the procedure, but an insider leaked the story prematurely. When news about the transplant reached public ears, the unthinkable ensued. As Hardy recalls, “Unfortunately, the first release resulted inadvertently in the need to permit another. The initial announcement did not specify that the chimpanzee heart has been used….”2 As Hardy expected, the media propagated this for a while. However, he stood his ground firmly. When a case report was published a few months later, Hardy wrote, “We believed then and we believe at this writing that the insertion of the chimpanzee heart, under the conditions which existed at that moment, was well within the bounds of medical ethics and morality,”2 not to mention the team’s extensive research and preparation that went into this day. Hardy and the team quickly learned that the world did not quite share similar beliefs. And even though the surgery was successful, issues of morality and ethics revolving around the surgery became headline news.

142 JOURNAL MSMA May 2014

Much Ado About Immorality

At the time of the operation, the question posed was this: Is it morally acceptable or ethically sound to remove a person’s heart and replace it with someone (or something) else’s heart? This question was not only considered, but it was a vivid reality for Dr. Hardy that weighed heavily on him. He states that transplantation of the heart would involve basic emotional factors that could be exceeded only by those of the brain.2 In other words, a certain psychological barrier had to be overcome in order to accept the idea of heart transplantation.

Additionally, the elusive element of time was another factor, which only made matters more complex. “In order for a homotransplant to succeed,” Hardy notes,2 “the donor and the recipient must ‘die’ at almost the same time; although this might occur, the chances that both prospective donor and prospective recipient would enter fatal collapse simultaneously were very slim.” Time was of the essence, and the transplant team decided to perform the xenograft transplant. Hardy was convinced that this was an ethical and moral decision. However, the fallout that came afterwards was macabre. Hardy recalls, “The secondary events extended far beyond the operative procedure and greatly exceeded anything that was anticipated by the members of the transplant team. Among these secondary issues was the management of public interest.”2 The public, of course, included the unforgiving extremists of the South, whose imaginations carried them to make unjustified accusations of what was not only a heroic act on Hardy’s part, but a medical masterpiece – surgical installation of a functional heart into a human. Nevertheless, the ballistic criticism muffled Hardy’s heroism. In the years that followed, Barnard and others would receive praise for their seemingly inventive procedure of heart transplantation in man. Hardy was eventually given some acknowledgement for his performance, but initial accolades for the transplant were scant at best.

Closing

The last one hundred years are spangled with many firsts, from technology to political office to pop culture. Among these monumental events is the first heart transplantation in man.

Someone must be credited, and the facts have been obscure as to whom. The heart transplant team in Jackson, Mississippi, accepted the fact that the controversies centered around heart transplantation in man (especially from a primate donor) were unavoidable. Nevertheless, the team was undeterred, and in 1964, after extensive preparation and research, they transplanted a chimpanzee heart into Rush Boyd. Predictably, Dr. Hardy’s successful operation in Jackson was a target for much criticism and debate because of the time and location of the event, as well as the nature of the transplant. Despite the salvo of the media and medical community, Hardy came out on top. He is remembered today as the forerunner of modern heart transplantation, and many would follow his lead in the years that followed.

When Hardy opened this door in 1964, he would join others

in history as a pioneer in his field who challenged traditionally accepted views and turned the unimaginable into reality.

References 1. Aru GM, Call KD, Creswell LL, Turner WW, Jr. James D. Hardy: a pioneer in surgery (1918-2003). J Heart Lung Transplant. 2004;23(11):1307-10.

2. Hardy JD, Chavez CK, Kurrus FD, Nelly WA, Eraslan S, Turner MD, Fabian LW, Labecki TD. Heart transplantation in man: developmental studies and report of a case. JAMA. 1964;188:1132-40.

3. Hardy JD. The Academic Surgeon. Mobile, AL: Magnolia Mansions Press; 2002:286.

4. McRae D. Every second counts: The Race to Transplant the First Human Heart. New York, NY: Berkley Books; 2006:5.

5. Garraty JA, Carnes MC. Eds. American National Biography. Vol. 2. New York, NY: Oxford University Press; 1999:935-6.

6. Hardy JD. Back then – plus ten commandments for graduates with illustrative cases. J Miss State Med Assoc. 1993;34(3):83-5.

7. Alican F, Hardy JD, Cayirli M, Varner JE, Moynihan PC, Turner MD, Anas P. Intestinal transplantation: Laboratory experience and report of a clinical case. Am J Surg. 1971; 121(2):150-9.

8. Kondo Y, Cockrell JV, Kuwahara O, Hardy JD. Histopathology of onestage bilateral lung allografts. Ann Surg. 1974;180(5):753-9.

9. Hardy JD, Timmis HH, Weems WL, Wesson RL, Moore JD, Langford HG. Kidney transplantation in man: analysis of eleven cases. Ann Surg.

1967;165(6):933-46.

10. Cooper DK. A brief history of cross-species organ transplantation. Proc (Bayl Univ Med Cent). 2012;25(1):49-57.

11. Akutsu T, Takagi H, Cheng WF, Hardy JD. Complete ventricular atrialization by an implantable heart support device. J Thorac Cardiovasc Surg. 1968;56(3):421-7.

12. Akutsu T, Takagi H, Cheng W, Hardy JD, Farish CD. Complete atrialization of left ventricle with a new heart assist pump. Trans Am Soc Artif Intern Organs. 1968;14:323-7.

13. Remembering Baby Fae. An interview with Leonard Bailey; by Larry Kidder. http://www.llu.edu/news/babyfae/leonard-1-baileyinterview.page Accessed Nov. 11, 2013 14. Quinn J. Promises Kept: The University of Mississippi Medical Center.

Jackson, MS: University Press of Mississippi;2005:112.

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• Scientific •

Axillary Lymph Node Treatment in Breast Cancer: An Update Patrick A Williams, MD; Jeanann Suggs, MD; Sophy H. Mangana, MD

A

bstract

Sentinel lymph node biopsy (SLNbx) is the standard of care for staging of breast cancer. Patients with a negative sentinel lymph node biopsy (SLNbx) do not undergo axillary lymph node dissection (ALND) or regional nodal irradiation (RNI). However, if a patient has a positive sentinel lymph node biopsy (SLNbx), then axillary lymph nodal dissection (ALND) is the standard treatment. Recent studies, notably the Z-0011 and MA-20 trials, have demonstrated that omission of axillary lymph nodal dissection (ALND) did not decrease overall survival. MA20 demonstrated that inclusion of regional nodal irradiation (RNI) in addition to axillary lymph nodal dissection (ALND) did increase survival when compared to axillary lymph nodal dissection (ALND) without regional nodal irradiation (RNI). Ongoing studies are randomizing patients to axillary lymph nodal dissection (ALND) or regional nodal irradiation (RNI) after a positive sentinel lymph node biopsy (SLNbx).

Abbreviations: SLNbx –sentinel lymph node biopsy; ALND –

axillary lymph node dissection; RNI – regional nodal irradiation; ALN – axillary lymph node; BCS – breast conservation surgery; WBI – whole breast irradiation; RT – radiation therapy; RCT – randomized clinical trial; PET – positron emission tomography

path exist. (Figure 1). Evaluation of metastasis to the axillary lymph nodes (ALNs) in breast cancer has been controversial for many years. After BCS and whole breast irradiation (WBI), axillary lymph nodal dissection (ALND) is the more aggressive approach to treating the ALNs when compared with the alternative of regional nodal irradiation (RNI). Whole breast irradiation treats the breast tissue as well as the anatomically low-lying ALNs. Regional nodal irradiation, synonymously known as axillary radiation therapy (RT), may include the supraclavicular lymph nodes, the internal mammary lymph nodes, and the superior ALNs. Chemotherapy treats cancer systemically, thus treating microscopic lymph nodal disease.

The American Society of Clinical Oncology (ASCO) guidelines recommend “routine ALND for patients with a positive SLNbx on the basis of routine histopathologic examination.” However, recent studies have demonstrated an improved outcome with RT over ALND.2,3 Knowing when Figure 1. The lymph node levels and drainage (arrows) of the axilla. These lymph node levels are in respect to the pectoralis minor muscle, which is dissected in this figure. Levels I, II, and III are infero-lateral to, underneath, and supero-medial to the pectoralis minor muscle, respectively.1

Key words: Breast cancer; sentinel lymph node biopsy; axillary lymph nodes; axillary lymph node dissection; whole breast irradiation; regional nodal irradiation Introduction

Lymphatic drainage is typically from the low axilla (level I) to the mid-axilla (level II), to the high axilla (level III) and finally to the supraclavicular nodes, though exceptions to this Author Information: School of Medicine, University of Mississippi Medical Center, Jackson, MS (Dr. Williams). Department of Radiation Oncology, University of Mississippi Medical Center, Jackson, MS (Dr. Suggs, Dr. Mangana).

Corresponding Author: Patrick A Williams, School of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216 Ph.: (662)386-4763 (smangana@umc. edu).

Conflicts of Interest: None

May 2014 JOURNAL MSMA 145

to operate, when to directly radiate, and when to use only chemotherapy and WBI is once again the subject of debate.2 Forty percent of patients with a clinically negative axilla (no palpable nodes and no nodes on imaging) are later found to be pathologically node positive in the axilla as revealed with an ALND.7 The SLNbx is a diagnostic and often therapeutic tool that has been accepted as standard of care. Sentinel lymph node biopsy is 97% sensitive for the presence of axillary breast cancer metastases, has replaced ALND for the clinically negative axilla, and is performed on all breast cancer patients.4-6 The treatment options after BCS or mastectomy and sentinel node biopsy pending receptor studies on the tumor are (Figure 2): 1) ALND +/- chemotherapy, 2) WBI +/- chemotherapy, 3) ALND + WBI +/- chemotherapy, and finally 4) ALND + WBI + regional nodal irradiation (RNI) +/- chemotherapy.

Relevance of Local Recurrence

To justify radiation treatment of the axilla, it must improve overall survival. A meta-analysis in 2005 by the Early Breast Cancer Trialists’ Collaberative Group (EBCTCG) followed over 42,000 patients from 78 randomized clinical trials (RCT’s) who were put into three broad cohorts: 1. RT vs no RT (e.g. mastectomy + ALND +/- WBI) 2. more surgery vs less surgery (e.g. pectoral removal vs not) 3. more surgery with no RT vs less surgery + RT (e.g. mastectomy + ALND vs mastectomy + WBI). In the treatment arms, women with high local recurrence risk disease of >10% had a significant decrease in 5-year local recurrence and in 15-year breast cancer-related mortality.

This is now known in breast oncology as the “4 to 1” ratio. That is, every 4% decrease in 5-year local recurrence translates to about a 1% decrease in 15-year breast cancer-related mortality.8 Figure 2. Various combinations of treatment modalities exist for breast cancer if sentinel lymph node biopsy (SLNbx) is positive after breast conservation surgery (BCS). ALND, axillary lymph node dissection; WBI, whole breast irradiation; RNI, regional nodal irradiation.

WBI!

ALND!

!+SLNBx! after!

BCS! Chemo!

146 JOURNAL MSMA May 2014

RNI!

Axillary Lymph Node Dissection vs Whole Breast Irradiation

In 1985, the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04 study demonstrated no difference in recurrence with ALND vs WBI. This landmark study showed that in patients with clinically node negative disease, radical mastectomy (which includes ALND and hence for these purposes of axillary status can be thought of as ALND) vs total mastectomy + WBI demonstrated no difference in nodal recurrence at 5 years and subsequently at 25 year follow up.7 Axillary lymph node dissection does provide relevant treatment benefit from a staging standpoint.9 However, this staging benefit can likely be obtained through less invasive options such as SLNbx alone,4,10 size of nodal metastasis,11 and lymphovascular invasion.4,10-11 Ultrasound is also an effective tool, but only for excluding nodal involvement in already diagnosed ductal carcinoma. One such study of axillary ultrasound demonstrated low sensitivity but a high specificity of 96% in N2-3 invasive ductal carcinoma nodal metastases.12 Positron emission tomography (PET) has 85% sensitivity and 98.5% specificity (98.4% positive predictive value) in detecting ALN involvement.13

Non-sentinel Axillary Lymph Nodes

The false-negative rate of SLNbx is around 7-9%.6,14 This means that in patients with a negative SLNbx who receive postoperative RT, 7-9% could experience ALN metastases. Nomograms have been developed to accurately predict non-SLN positive lymph nodes.11,15 However, ALN recurrence rates in patients with a negative SLNbx have been observed to be around 0.6%.16 Three possibilities for such low rates have been proposed: 1) the physiology of the breast drains to the consistently predictable SLN, which is removed in SLNbx;5-6 2) systemic therapy; and 3) WBI treatment fields includes the clip left by the surgeon at the time of SLNbx in 78-94% of patients, as demonstrated by retrospective studies that analyzed careful review of the RT fields.17-18

American College of Surgeons Oncology Group Z-0011 Study

One of the most important studies of this subject in recent years is the American College of Surgeons Oncology Group (ACOSOG) Z-0011. This RCT separated 891 patients (closed to poor accrual with a goal of 1900), all with tumor size T1-2 (≤5 cm) and with a positive SLNbx of up to 2 nodes to: BCS, systemic therapy, and WBI, then +/- ALND. The results saw no differences in survival or recurrence after 6 years (Table).2 This study has questioned the need for ALND in women with T1-2 and up to 2 positive lymph nodes, which cover a large percentage of breast cancer patients with the best prognosis.

These results have also questioned the need for RNI, as oncologists have pointed out that RNI was not used at all, yet regional recurrences were still low. Another interesting detail of ACOSOG Z-0011 is that 27% of the patients in the ALND arm

!

were found to have additional positive lymph nodes. We can infer that roughly the same percentage of patients in the other arm, which did not receive ALND, also had additional positive lymph nodes. Yet, ALN recurrences were low in both arms, at 0.5% and 0.9%, respectively. Once again, these results may have occurred because: 1) all received systemic therapy, and 2) all received WBI, the RT fields of which cover level I and II ALNs.

National Cancer Institute of Canada Clinical Trials Group MA-20 study

However, Z-0011 did not cause RNI to fall out of favor.

In 2011, results of the National Cancer Institute of Canada Clinical Trials Group (NCIC-CTG) MA-20 study were released.3 This RCT, which is still not published, randomized 1,832 women to receive BCS, ALND, WBI, and finally +/RNI. Ninety percent of the women were node positive, and 85% had 1-3 positive ALNs. Ninety percent of the women received chemotherapy, consistent with the percentage of women with positive axillary lymph nodes. After only 5 years, women who had received additional RT in the form of regional nodal irradiation experienced statistically significant diseasefree survival and a trend in improved overall survival (Table).

Conclusion

In the ACOSOG Z-0011 study, performing additional nodal treatment via ALND did not benefit survival. In the NCICCTG MA-20 study, performing additional nodal treatment via RNI did benefit survival. In other words, in Z-0011, more is not better, but in MA-20, more is better. Fortunately, future studies examining this issue exist. The European Organisation for Research and Treatment of Cancer (EORTC) 10981-22023 AMAROS trial, an acronym for After Mapping of the Axilla, Radiotherapy or Surgery, is randomizing patients with a positive SLNbx to ALND or RNI.19 In the EORTC trial, the extent of nodal involvement remains unknown in the RNI treatment arm since many occultly node positive patients will not receive subsequent ALND, which runs counter to current ASCO guide-

lines. This makes the trial a combination of the conflicting results of Z-0011 and MA-20 and may provide more insight into treatment of the ALNs in breast cancer. Regardless, the prudent oncologist will continue to use the ever changing and best evidence in every case to select the most appropriate management to deliver the best possible individualized care for the patient.

References 1. Netter FH. Atlas of Human Anatomy. 4th ed, Philadelphia, PA: Saunders Elsevier; 2006:184.

2. Giuliano AE, McCall L, Beitsch P, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: the American college of surgeons oncology group Z0011 randomized trial. Ann Surg. 2010;252:426-432.

3. Whelan TJ, Olivotto I, Ackerman JW, et al. NCIC-CTG MA.20: An intergroup trial of regional nodal irradiation in early breast cancer. J Clin Oncol.

2011;29: (suppl; abstr LBA1003).

4. Krag DN, Anderson SJ, Julian TB, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph- node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010;11: 927-933.

5. Posther KE, McCall LM, Blumencranz PW, et al. Sentinel node skills verification and surgeon performance: Data from a multi-center clinical trial for early-stage breast cancer. Ann Surg. 2005;242:593–599.

6. Kim T, Giuliano AE, Lyman GH. Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: a metaanalysis. Cancer. 2006; 106:4-16.

7. Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twentyfive year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Eng J Med. 2002;347:567-575.

8.

Clarke M, Collins R, Darby S, et al. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005;366:2087-2106.

9. Andersson Y, Frisell J, Sylvan M, et al. Breast cancer survival in relation to the metastatic tumor burden in axillary lymph nodes. J Clin Oncol.

2010;28:2868-2873.

10. Kell MR, Burke JP, Barry M, et al. Outcome of axillary staging in early breast cancer: a meta-analysis. Breast Cancer Res Treat. 2010;120:441-447.

11. Van Zee KJ, Manasseh DM, Bevilacqua JL, et al. A nomogram for predicting the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy. Ann Surg Oncol. 2003;10:1140–1151.

12. Neal CH, Daly CP, Nees AV, et al. Can preoperative axillary US help exclude N2 and N3 metastatic breast cancer? Radiology. 2010;257:335-341.

13. Gil-Rendo A, Zornoza G, García-Velloso MJ, et al. Fluorodeoxyglucose positron emission tomography with sentinel lymph node biopsy for evaluation of axillary involvement in breast cancer. Br J Surg. 2006;93:707-712.

14. Lyman GH, Giuliano AE, Somerfield MR, et al.

American society of clini cal oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol. 2005;23:7703-7720.

Table. A comparison of the results of the Z-00112 study and the MA-203 study, which demonstrate no benefit with axillary lymph node dissection (ALND) in the Z-0011 study (left), and demonstrate significant benefit with regional nodal irradiation (RNI) in the MA-20 study (right). NS, non-significant.

15. Gur AS, Unal B, Johnson R, et al. Predictive probability of four different breast cancer nomograms for nonsentinel axillary lymph node metastasis in positive sentinel node biopsy. J Am Coll Surg. 2009;208:229–235.

16. Swenson KK, Mahipal A, Nissen MJ, et al. Axillary disease recurrence after sentinel lymph node dissection for breast carcinoma. Cancer. 2005;104:1834-1839.

17. Rabinovitch R, Ballonoff A, Newman F, Finlayson C. Evaluation of breast sentinel lymph node coverage by standard radiation therapy fields. Int J Radiat Oncol Biol Phys. 2008;70:1468-1471.

18. Chung MA, DiPetrillo T, Hernandez S, Masko G, Wazer D, Cady B. Treatment of the axilla by tangential breast radiotherapy in women with invasive breast cancer. Am J Surg. 2002;184:401-402.

19. EORTC 10981-22023 AMAROS trial: http://research.nki.nl/amaros/start.htm.

May 2014 JOURNAL MSMA 147

• Mississippi State Department of Health •

148 JOURNAL MSMA May 2014

MSDH: 2012 Annual Summary of Selected Reportable Diseases What follows is an excerpt of the 2012 Annual Summary of Selected Reportable Diseases, highlighting a few reportable diseases of significance in Mississippi. The full summary may be accessed on the Mississippi State Department of Health website at 2012 Annual Summary. Submitted

by State Epidemiologist Thomas Dobbs, MD, MPH and Deputy State Epidemiologist Paul Byers, MD

HIV/STD/Hepatitis HIV: New diagnoses of HIV in Mississippi remained relatively stable in 2012, with 547 new diagnoses compared with 573 in 2011. African Americans represented a disproportionate share of new infection (78% vs. 20% being Caucasian). The 20-24 year old age group reported the highest number of new diagnoses (though new diagnoses were identified in all age ranges 10-14 and above). Sexual transmission continued as the most likely risk factor, with 51% reporting themselves as MSM (men who have sex with men). In 2011, of the 50 states and the District of Columbia, Mississippi ranked 7th for the highest number of new HIV diagnoses.

STD: Mississippi had the highest rates of Chlamydia and Gonorrhea in the U.S. in 2012 (with 23,082 and 6,877 cases respectively). African Americans were disproportionately affected, accounting for 82% of all Chlamydia cases and 90% of Gonorrhea cases. Young adults, 15 – 24, accounted for the majority of infections.

Hepatitis: Mississippi had eleven cases of Hepatitis A reported in 2012, four more than 2011, but still below the national rate.

There were 78 cases of acute Hepatitis B reported, 20 more than were reported in 2011, with a median age of 35.5 years. MSDH continues efforts to prevent Hepatitis B transmission to newborns by ensuring immunoprophylaxis of newborns and vaccinations of close family contacts of Hepatitis B surface antigen (HBsAg) positive mothers. MSDH followed 100 HBsAg pregnancies in 2012 with no documented transmission events to newborns.

Tuberculosis Mississippi continued to document a steady decline in the TB case rate for 2012, with 81 cases compared to 91 in 2011.

Mississippi has had a case rate below the national average since 2011. Sixty percent of cases were diagnosed in African Americans and six percent of TB cases were coinfected with HIV (a decline from 15% in 2009). The over 65 age group had the highest rate of TB. MSDH continues special TB control initiatives including expanded testing in the homeless population and the accelerated 3 month, once weekly directly observed treatment of Latent TB with isoniazid and rifapentine (3HP).

West Nile Virus In 2012 Mississippi recorded the highest annual number of cases of West Nile Virus (WNV) infection since the disease was first reported in the state in 2002. Of the 247 cases reported, 103 (42%) were classified as WNV fever and 144 (58%) were classified as neuroinvasive disease, with five deaths attributable to WNV. There were 5,674 cases nationwide in 2012. On a per population basis, Mississippi ranked second in the nation with a case rate of 8.5 per 100,000, led only by South Dakota with a rate of 24.3 per 100,000. The highest case rate was observed in those > 65 years of age. In response to the increased WNV activity, MSDH initiated multiple interventions including enhanced mosquito surveillance, extensive public health messaging and strengthened cooperation with local mosquito control agencies.

Vaccine Preventable Diseases Pertussis: The number of pertussis cases reported annually has increased over the last several years in both the US and Mississippi and several outbreaks of pertussis have been reported in many US states, especially among under immunized populations. Pertussiss immunity wanes 5-10 years after the booster vaccine, leaving adolescents and adults more vulnerable to infection. Children <1 year of age are typically at highest risk for complications and deaths as a result of infection. In 2012 there were 77 reported cases of pertussis in Mississippi, compared to 49 in 2011. Fifty-one percent of the cases were among children <1 year of age; one death was reported in a two month old infant. In an effort to reduce the disease burden among adolescents who can serve as a source of infection in infants, Mississippi instituted a Tdap vaccine requirement beginning in the 2012-1013 school year for all students entering the 7th grade.

Haemophilus influenzae, type b (Hib): Once the most common cause of bacterial meningitis in children <5 years of age, the number of reported cases of Hib has dropped to fewer than 5 cases per year after the institution of the complete vaccine series in 1991. In 2012 there were no reported cases of Hib, compared to 3 in 2011.

Meningococcal Disease: The annual number of cases has decreased over the last several years, from 20-24 cases per year in the early 2000â&#x20AC;&#x2122;s to five less per year by 2010. In 2012 there were five reported cases of invasive meningococcal disease compared to four in 2011. The median age for the cases was 24 months; nationally the highest incidence is in infants <1 year of age.

Routine vaccination with is recommended for all children at 11-12 years of age.

Measles: There have been no reported cases of measles in Mississippi since an outbreak at a Mississippi university in 1992.

In 2000, endemic measles transmission in the US was interrupted as a result of widespread vaccination. However imported cases, particularly from Europe where vaccination rates have decreased, have led to outbreaks in US communities among unvaccinated individuals. Continued high vaccine rates in Mississippi are important to provide appropriate population immunity and reduce the risk of widespread transmission form imported cases.

Influenza: The 2012-2013 influenza season was moderately severe when compared to the previous season, with higher rates of outpatient visits due to influenza-like illnesses, more reported deaths due to pneumonia and influenza, and higher rates

May 2014 JOURNAL MSMA 149

•

MSDH •

of hospitalizations, particularly among ≥65 year olds. There was one reported pediatric influenza-associated death in Mississippi in a 5-year-old. The predominant influenza strain causing illness in the 2012-2013 season was influenza A H3N2. Mid-season estimates conducted by CDC showed that, when stratified for age group and virus type, there was markedly reduced vaccine effectiveness against influenza A H3N2 among ≥65 year olds. Also of note for the 2012-2013 season were 33 influenzaassociated outbreaks in long-term care (LTC) facilities, compared to only two reported outbreaks in LTC facilities in the 20112012 season.

Enteric Diseases Among the most commonly reported enteric diseases in the state each year are Salmonella, Shigella, Vibrio and E. coli O157 and related shiga-toxin producing E. coli (STEC). Most occur as individually reported cases; however either person to person or foodborne transmission may lead to localized or larger outbreaks.

Salmonella: In 2012, 1,248 cases of Salmonella were reported, less than the 1,440 cases in 2011, but consistent with current trends. The highest incidence was in children <5 years of age. No Mississippi outbreaks were identified; however several multistate Salmonella outbreaks occurred of which many cases were in Mississippi residents. The most notable multistate outbreaks were associated with contaminated cantaloupes with 261 cases in 24 states (seven cases in Mississippi residents) and exposure to turtles sold as pets with 473 cases in 43 states (four in Mississippi).

Shigella: There were 285 cases of Shigella in 2012, consistent with the previous year. Shigella infections are most common in children, with 74% of the reported cases occurring in children <10 years of age. There were no reported outbreaks of Shigella in 2012.

STEC: E. coli O157 and related STEC organisms cause a severe gastroenteritis and can lead to the development of hemolytic-uremic syndrome (HUS). In 2012, there were 15 E. coli O157 infections (with four who developed HUS), 15 other STEC infections and one other instance of post-diarrheal HUS reported in Mississippi with a median age of 10 years. There was one reported outbreak of STEC in 2012, resulting in six cases in an extended family group.

Vibrio: Vibrio infections are not transmitted person to person but are the result of exposure to raw, undercooked or contaminated fish and shellfish (e.g. raw oysters) or wound exposure to seawater. There were 16 reported cases in 2012, slightly higher than the 13 reported in 2011. Vibrio infections can lead to severe sepsis and deaths, mainly among individuals with chronic liver disease, alcoholism or immunosuppression. In 2012, there were two reported deaths, both occurring in individuals less than 50 years of age with underlying alcoholism.

For questions or further information call the Mississippi State Department of Health Office of Epidemiology at 601-576-7725.

PHYSICIANS NEEDED Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, Neurologists, Psychiatrists, etc. interested in performing consultative evaluations according to Social Security guidelines.

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Contact us at: Mary Jane Williams 601-853-5556 or Gwendolyn Williams 601- 853-5449

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Step up to the mic for medicine.

MSMA 146th Annual Session Business Meeting August 15-16 Jackson

AGENDA Friday, August 15

9:00 am Board of Trustees Meeting 11:30am Physicians for Smoke-Free Air Special Guest Secretary of State Delbert Hosemann 1:00-2:00pm House of Delegates 1:00 pm Alliance Board Orientation 2:00-5:00pm Reference Committee Hearings 7:00 pm Official Inauguration of Claude Brunson, MD

Saturday, August 16 8:00 am Board of Trustees Meeting 10:00 am Excellence in Medicine Awards 10:45 am Candidate Speeches 11:45 am Lunch Caucuses Boxed Lunch Provided 1:00 pm House of Delegates 4:00 pm Board of Trustees Meeting 6:30 pm UMMC Alumni Dinner Jackson Country Club May 2014 JOURNAL MSMA 151

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152 JOURNAL MSMA May 2014

6/20/13 3:38 PM

2014

This is an interactive PDF outlining MSMA action on 2014 legislation.

Scan the QR codes to view MSMA action on each bill throughout its life at the Capitol.

“It is certainly reassuring to know as a physician and as a neurologist especially, that extra precautions have been mandated by law to protect our young athletes.

Concussions are a serious issue and it is gratifying to see Mississippi finally recognize the need for legislation such as this – as the rest of the country has.” –Dr. Lee Voulters

Following direction from the House of Delegates, MSMA strongly advocated for Return to Play legislation to be passed protecting the student athletes of MS.

MSMA organized a press conference featuring Return to Play the first week of session.

Governor Phil Bryant signs HB 48, making Return to Play the first bill to be signed into law in 2014.

Senator Brice Wiggins and House Public Health Chairman Sam Mims champion the bill in Clarion-Ledger article.

Following the direction of the House of Delegates, MSMA lobbied at the Capitol for POST legislation to be passed in MS.

MSMA President Dr. Jim Rish’s primary agenda item for his presidential term was to see POST legislation passed in MS.

The governor signed POST legislation into law. Scan the code to view the bill.

“The national POLST Paradigm Program is an approach to end-of-life planning based on discussions between patients, families and medical providers. The POLST Paradigm is designed to ensure that seriously ill patients can choose the treatments they want and that their wishes are honored by medical providers.” –Dr. Jim Rish Dr. Sharon Douglass meets with legislators to emphasize the importance of POST legislation in Mississippi.

MSMA lobbied to pass Any Willing Provider legislation, preventing discrimination against physicians to be included in insurance networks.

MSMA sent many calls to action to its membership.

Scan to view.

Governor Bryant met with MSMA leadership and staff following the House discussion on Any Willing Provider and agreed to call a special Executive Committee to study the issue of Any Willing Provider to report back at the beginning of 2015 legislative session.

MSMA stood strong on its stance to support the current 45% cap on Medicaid managed care when HB 1275 called for an increase to 70%.

MSMA called on its members to strongly advocate to their legislators maintaining the 45% cap. Click to view video message from Dr. Rish calling for action.

Scan to view explanation of why raising the allowable percentage to 70% was really a move to 100% managed care.

“Physicians adamantly oppose increasing the managed care population. We cannot condone the wedge these companies put between the physician and his patient.” —Dr. Jim Rish Scan to view letter sent to Speaker Gunn from Dr. Jim Rish.

Following the announcement of a new BCBS policy which mandated that prescriptions written by an out of network physician would no longer be covered, MSMA pursued two pieces of legislation to stop this harmful policy with H.B. 546 & H.B. 548.

(From left) Dr. Claude Brunson, Speaker of the House Philip Gunn, and MSMA President Jim Rish met to discuss limiting MississippiCAN at the Capitol.

To bring the issues surrounding this policy to light, Dr. Rish submitted an Editorial to local papers, emphasizing the importance of prescription drug coverage for patients in MS.

A letter was sent to the President of BCBS, calling for them to rescind their policy to not cover prescriptions written by an out of network physician.

Due to the legislative efforts of MSMA, BCBS rescinds policy denying prescription coverage for out of network physicians.

Drs. Easterling & Rish spoke to the media, stressing the importance of prescription drug coverage.

Click the photo to view the video story.

“Imagine paying health insurance premiums for years but now you are being told your coverage will not include prescribed medications on which you have come to rely.” —Dr. Jim Rish

In supporting efforts to make Mississippians healthier, MSMA worked closely with health organizations to pass HB 1328, creating the Small Business & Grocer Investment Act. Scan to view the 2014 Public Health Report Card.

Each year, MSMA is instrumental in supporting funding for the Rural Physician Scholarship Program. This legislative session, the Program was funded in the amount of $1.5 million.

This legislative session, MSMA was able to defeat a number of scope of practice bills that would have hindered the practice of medicine. Two of those bills “got legs” this session but MSMA was able to kill both in the committee process. SB 2748: Aimed at deleting the requirement that APRNs must practice within collaborative relationships with physicians. SB 2391: Aimed at removing physician referrals for acupuncturists

SB 2331: Mandating when health insurance policies must include coverage for mental illness HB 547: Requiring insurance companies to honor assignment of benefits for a year or until insurer revokes SB 2860: $1.5 Million for the Office of Physician Workforce SB 2218: Simplification of the School Asthma Plan

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Contact: Phyllis Williams Director of Practice Strategies Mississippi State Medical Assoc.

601-853-6733 Ex. 322 PWilliams@MSMAonline.com FAX: 601.853.6746

A minimum of 5 people are required in order to host a class on a particular date. Additionally, the class is limited to 24 people on each class date. Should a class be cancelled because 5 people have not registered, you will be offered alternative class dates from which to choose.

May 2014 JOURNAL MSMA 155

• Images in Mississippi Medicine •

D

R. W. H. H. LEWIS OF FAYETTE (1866-1936)—

Born June 1, 1866, William Henry Harrison Lewis, MD, was reared at Woodville. He was the son of Fletcher D. Lewis, a Confederate veteran who had served with Stonewall Jackson and later became a large Wilkinson County planter of 3500 acres, and Mary E. Harris Lewis.

William H. H. graduated from the Tulane University Medical School in 1889. He then practiced in Tensas Parish, Louisiana before moving to Natchez. He moved to Fayette in 1858, where he would practice for the next 37 years. Not only was he a respected general physician with a large practice, he also served as Jefferson County’s Health Officer for more than two decades. He was a longtime member of the Homochitto Valley Medical Society of the MSMA, which included Adams, Amite, Franklin, Jefferson, and Wilkinson Counties. He was widely admired for his service to his community, serving as President of the Jefferson County Agricultural High School at Union Church, as a Mason, and as trustee of Fayette Methodist Church. Dr. Lewis married Miss Mamie Z. Geoghegan in 1890, and this happy union would result in two sons, two daughters, and five grandchildren.

The Editor of the “Fayette Chronicle” wrote in 1936: “During these nearly thirty-seven years, since his coming to Fayette, Dr. Lewis has been the personal and considerate friend of the writer. He had ministered to us in illness and pain, advised with us and was apparently always interested in our wellbeing. In his passing we sustain a very personal loss…

As a physician, Dr. Lewis had opportunity to do much good. His unquestioned skill and his unhurried patience in attending and ministering to the sick made his practice of a noble profession highly successful.” He died in Fayette of pneumonia on January 6, 1936 (for obituary see the “Fayette Chronicle,” January 10, 1936). This photo courtesy of his grandson Norman B. Gillis, Jr. of McComb, who is pictured with him above as a child. 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

156 JOURNAL MSMA May 2014

• President’s Page • Thoughts on Medicaid Expansion

M

James A. Rish, MD 2013-14 MSMA President

SMA has just wrapped up an interesting legislative session, which I think was very successful. We had some key wins with the passage of the Youth Sports Concussion law and POST legislation. We defeated the usual efforts including scope of practice expansions. I was somewhat disappointed that we didn’t get Any Willing Provider passed and that children were added into Medicaid Managed Care (although this addition was supported by the pediatric society). What was not widely publicized this session was the expansion of Medicaid eligibility to 138% of the Federal Poverty Level (previously the FPL varied based on the age and/or need of the beneficiary).

Medicaid expansion of any kind leads to a spirited debate. There are honorable, well meaning physicians supporting both sides of most every Medicaid argument. Nonetheless, we all can agree that expanding insurance coverage for all citizens, particularly the working poor, is a laudable goal. Your MSMA has been and will remain committed to continuous improvements in health care delivery within the Medicaid program. We want the Medicaid program to be one in which our physician members are eager to participate. We have worked tirelessly in that regard.

MSMA did secure a couple of wins this session. First, Medicaid is authorized to maintain payments at 100% of Medicare for primary care physicians performing certain primary care evaluation and management and vaccine administration services as initially provided under the Affordable Care Act. Second, MSMA insisted on removing language that would have allowed Medicaid to extrapolate the amount of restitution from claims found to be fraudulent. The proposed language was too vague and did not conform to Medicare rules, which limits the use of extrapolation in Medicare audits.

MSMA was also successful in designating a new position (with funding) for a full time medical director. This eliminates an earlier Division of Medicaid concern of a potential ethical dilemma about there being a part time medical director who could be conflicted by virtue of seeing Medicaid patients within his/her own practice setting. We will continue to pursue the hiring of a medical director for the for the Medicaid program. Stay tuned!

MSMA successfully convinced the Division of Medicaid of the need for a standardized prior authorization process.

Recently, the Division of Medicaid signed new managed care contracts with a July 1, 2014, effective date that require the vendors to use a standardized web-based, electronic review prior authorization request system. Each vendor is required to create a “smart” electronic authorization request form so that a decision tree can immediately generate an approval. In addition, the new contracts require that the physician requesting a prior authorization be notified of a decision within three working days of the initial request.

An expedited review must be made within 24 hours after receipt of an expedited authorization request when a delay in the decision could seriously jeopardize the patient’s life or health.

We also worked diligently this year to lessen your workload by reducing the number of prior authorizations you must do.

Now one single preferred prescription drug will be consistent for all Medicaid fee-for-service; both managed care vendors will also use that same preferred drug list beginning July 1, 2014. Through the CAP (Claims Advocacy for Physicians) Committee MSMA continuously seeks to reduce the burdensome prior authorization process so we can all get back to caring for our patients.

May 2014 JOURNAL MSMA 157

The administrative burdens alienate physicians and serve to reduce participation in the program, particularly the participation of sub-specialists.

We’ve not made much progress in getting Medicaid to develop integrated care models like the Patient Centered Medical Home, but it’s not for lack of trying. We’ve had many discussions and made many requests to do so. The Medicaid Director has steadfastly refused to develop these types of programs and seems to rely exclusively on the MississippiCAN program. We do know that both Medicaid managed care vendors are developing an integrated care model, and MSMA wants to be a part of these discussions to ensure critical elements of the model are included in the design of the program. Medicaid, however, doesn’t often seek advice.

These and many other aspects of Medicaid are routinely discussed by the Board of Trustees. The Mississippi Medicaid program faces many multi-faceted and complex care issues. The more I learn the more I realize that the real question of whether to expand Medicaid is only one part of a much bigger picture.

Much goes into passing bills into law. From writing press releases to lobbying at the Capitol, MSMA staff and physicians work together to champion medicine each year. MSMA has prepared an interactive document for your viewing to illustrate action on each one of MSMA’s major legislative items this year. Turn the page to access this document and follow the designated links to view news stories, handouts, letters, and other materials used to advocate for our MSMA physicians at the Capitol. Check out the legislative session 2014 wrap-up on the center pages of this issue.

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158 JOURNAL MSMA May 2014

• Editorial • A Return to the Asclepeia: A Physician’s Enduring Obligation to his or her Patients David P. Smith, MD, Summit

T

he straining loads being placed upon the backs of physicians are immense these days. We are being squeezed by hospital administrators, insurance companies, patients, and, for those in the shrinking numbers of private practitioners, add in all of those overhead costs that are onerous. It would be easy if we could just take care of the patient the way we were trained, and everyone else would help us to accomplish that worthy goal. However, the reality is that we have a multitude of non-health professionals who believe they know what patients need, constantly not just suggesting to us what we should do but outright now dictating how it should be done. I do not need to list the multitude of ways that this is occurring. All of us are very familiar with these stresses from the impossible task of pleasing everyone at once, although I think most of us do attempt to do so, especially for those of us who view ourselves as more than just “providers.”

There are huge financial pressures upon our hospitals now, and physicians are being asked to be increasingly efficient to the point that the only person who could do it any better is God Himself. Governmental programs are notorious for onesize-fits-all approaches which do not allow for the individual variation in patient care that individuals who are all made a little differently should be allowed to have provided for them. Not everyone, especially the very elderly, can be discharged safely from a hospital at the prescribed number of days, assuming they even “qualify” for admission past observation.

We have to remember why we decided to practice medicine in the first place and do what is right for the patient whether others, who do not do what we do, understand or not. Of course, we should try to help administrators and bureaucrats to understand why another day is really needed before someone can go home, but in the end we have to do, and should only do, what we truly know is right for the patient. A good question to ask yourself might be what would you do if this patient were your parent, or maybe even better, what would you do for yourself?

In the waiting room of my clinic, I have hanging the framed copy of the Hippocratic Oath which was given to me by MBMC upon graduation from my family medicine residency at UMC. This oath calls us to a higher calling in the practice of our profession which cannot be allowed to transform us into cook-book technicians. Looking back in history around the time of Hippocrates, we also find another symbol that is commonly used today – the rod of Asclepius. Asclepius (or Asclepios) was the Greek god associated with healing and medicine. During that time, there were places which were called Asclepions which were built for people to visit who were ill. While at these temples, which were run by priests, patients could bathe, meditate, and were encouraged to get plenty of rest and sleep. While sleeping, it was thought that Asclepius and his two daughters, Hygeia and Panacea, would visit which would cure everything. The priest would dress as Asclepius while the Therapeutae entourage would make their rounds in the evenings to care for the patients.

For those who used the asclepeia, an offering, which for the poor was not much while for the rich a more generous contribution, would be expected. It is interesting that many of the poor would bring a rooster, which was thought to ward off evil spirits, and sacrifice it to Asclepios hoping for a cure while in the temple. In the early days of medical practice in this country, it was widely practiced that those seeking treatment from a physician would bring a chicken for payment. Observing the way our country is heading presently, those days may not be completely in the past.

While we have greatly advanced modern hospitals, in many ways we still can find similarities to those asclepeia of thousands of years ago. Let’s keep the modern advancements we have made, but let us also keep in mind the art of the practice of medicine which requires us to do what is right for the proper treatment of the patient first and put what is right for the finances farther down on our list of priorities. If we do not do what is right for the patient first, we may find ourselves like Asclepius, who is said in mythology to have been killed by a thunderbolt from Zeus because Asclepius accepted gold for raising Hippolytus from the dead. If we get our eyes focused on the gold instead of on the patient’s best interests, everyone loses. None of us are gods, but patients do generally look to us to have a higher standard for how we lead our lives and practice our profession. Luke 14:11 reads, “For everyone who exalts himself will be humbled, and he who humbles himself will be exalted.” We have a responsibility to stand up for our patients first, and then all of the rest will fall into its proper place. r

May 2014 JOURNAL MSMA 159

• UMMC • UMMC Med Students Learn their Future on Residency Match Day

D

uring the annual rite of passage called Match Day medical students at the University of Mississippi Medical Center discovered where they will spend the next three to seven years of their lives in residency training, The 128 fourth-year students on UMMC’s Match Day list were among the thousands of students across the country who participated simultaneously in the National Resident Matching Program.

Most of the 900 chairs in a Jackson Marriott Hotel event room were filled by students, their family and friends and others gathered to learn where members of the 2014 medical school class will train for their 23 different specialties, such as pediatrics, emergency medicine, surgery, psychiatry, and family medicine.

“It reminds me of Christmas,” said Terica Jackson of Jayess, who drew a coterie of 10 relatives, including her husband Jason Jackson, to downtown Jackson for her big day.

“I set two alarm clocks to make sure I woke up in time this morning,” Terica Jackson said before the announcements were made. “It’s like Santa Claus is coming, and you don’t want to miss it.”

More than a third of the class, or 49, will remain at UMMC for their residencies, including Jackson, as she learned later.

Others are headed to institutions as far away as Oregon and California.

Some of those facilities are the University of California, San Francisco; the University of Kentucky Medical Center in Lexington; the University of Virginia, Charlottesville; and Oregon Health & Science University, Portland.

Those leaving the state were urged to return to Mississippi by two of UMMC’s leaders – Dr. James Keeton, vice chancellor for health affairs and dean of the School of Medicine; and Dr. LouAnn Woodward, associate vice chancellor for health affairs and vice dean of the medical school. UMMC is their med school alma mater.

“We need you,” Keeton said. “If you leave, come back and help us do something about the health care of Mississippi.”

Dr. Woodward described the Match Day process as an “exhausting” series of applications, travels, interviews, and more that led up to the moment when each student walked to the stage and opened a white envelope for the big reveal in front of their supporters.

Quoting a previous med school graduate, Dr. Woodward described the day as a “combination of the Academy Awards and the NFL Draft for nerds.”

“We’re happy,” Dr. Woodward said. “It’s a good day to be nerds.”

One of the day’s bonuses was the awarding of a doctor’s black bag stuffed with a $5 bill by each student who walked to the podium. Traditionally, it goes to the last student called, who in this case was Vicky Phillips of Vicksburg; she’s bound for Vanderbilt University Medical Center in Nashville, where she will do her residency in pediatrics. Asked what plans she had for the several hundred dollars spilling out of the bag, Phillips said, “Relocation expenses.”

—Gary Pettus, UMC Public Affairs Colette Jackson receives her match envelope from Dr. LouAnn Woodward, right, associate vice chancellor for health affairs and vice dean of the School of Medicine. Colette would announce her preliminary match with Baylor University Medical Center followed by a residency in ophthalmology at University of Texas Southwestern.

160 JOURNAL MSMA May 2014

University of Mississippi School of Medicine 2014 Match Results Leonard Addae - Internal Medicine

Morehouse School of Medicine, Atlanta, GA

Jahnavi Chatterjee - Pediatrics

University of Mississippi Medical Center, Jackson

Audie Aderholt, III - Internal Medicine

University of Arkansas, Little Rock, AR

Ed Chinchar - Medicine-Prelim/Radiation Oncology

University of Mississippi Medical Center, Jackson

Anna Allred - Dermatology

University of Mississippi Medical Center, Jackson

Jeb Clark - Internal Medicine

University of Mississippi Medical Center, Jackson

Leah Anderson - Family Medicine

Tallahassee Memorial Healthcare, FL

Jared Cobb - Pathology

Oregon Health & Science University, Portland, OR

Chad Armstrong - Internal Medicine

Vanderbilt University Medical Center, Nashville, TN

Allison Cruse - Medicine Preliminary

University of Virginia, Charlottesville, VA

Terry Bang - Pediatrics

University of Mississippi Medical Center, Jackson

Kendrick Currie - Family Medicine

Floyd Medical Center, Rome, GA

Kevin Batte - Internal Medicine

Medical University of South Carolina, Charleston, SC

Bradley Deere - Internal Medicine

Tulane Univ. School of Medicine, New Orleans, LA

Lindsey Berg - Family Medicine

Self Regional Healthcare, Greenwood, SC

Andrew Diaz - Family Medicine

John Peter Smith Hospital, Fort Worth, TX

Jake Bishop - Pediatrics/Psychiatry/Child Psych

University of Kentucky Medical Center, Lexington, KY

Joan Dickerson - Pediatrics

VA Commonwealth Univ. Health System, Richmond

Kory Blackwell - Family Medicine

Forrest General Hospital - Hattiesburg

Jay Dolia - Medicine Preliminary

University of Mississippi Medical Center, Jackson

Aaron Blakeney - Internal Medicine

University of Virginia, Charlottesville, VA

Savannah Duckworth - Internal Medicine

University of Mississippi Medical Center, Jackson

Marketta Blue - Family Medicine

University of Mississippi Medical Center, Jackson

Clayton Dugan - Pediatrics

Univ. of Alabama Medical Center, Birmingham, AL

Jon Buchanan - Family Medicine

University of Mississippi Medical Center, Jackson

Sarah Duhon - Ophthalmology

Univ. of Tennessee College of Medicine, Memphis, TN

Luke Campbell - Family Medicine

North Mississippi Medical Center, Tupelo

Miles Dunbar - Medicine Preliminary

Mount Auburn Hospital, Cambridge, MA

Radiology-Diagnostic

Nassau Univ. Medical Center - East Meadow, NY

Nicole Carden - Pediatrics

University of Mississippi Medical Center, Jackson Marla Chapman - Medicine/Pediatrics

University of South Carolina, Greenville, SC

Andrew Dunn - Pathology

University of Arkansas, Little Rock, AR

May 2014 JOURNAL MSMA 161

â&#x20AC;˘

UMMC â&#x20AC;˘

David Finney - Family Medicine

Anderson Area Medical Center, Anderson, SC

Nancy Harrison - Internal Medicine

University of Mississippi Medical Center, Jackson

Francie Finney - Family Medicine

Anderson Area Medical Center, Anderson, SC

Drew Hayslett - Pediatrics

University of Mississippi Medical Center, Jackson

Matthew Fort - Otolaryngology

Univ. of Alabama Medical Center, Birmingham, AL

George Henry, Jr. - Internal Medicine

VA Commonwealth Univ. Health System, Richmond, VA

Andrew Fredericks - Emergency Medicine

Univ. of Texas Southwestern Medical, Dallas, TX

Eric Holland - Internal Medicine

University of Virginia, Charlottesville, Virginia

Will Fuller - Internal Medicine

Univ. of Kentucky Medical Center, Lexington, KY

Laura House - Otolaryngology

University of Mississippi Medical Center, Jackson

Rob Gathings, III - Transitional Joel Howard - Pediatrics

Baptist Health System, Birmingham, AL

Emory University School of Medicine, Atlanta, GA

Dermatology Mitchell Hudson, Jr. - Internal Medicine

Medical Univ. of South Carolina, Charleston, SC

LSU Health Sciences Center, Shreveport, LA Sam Gay - Anesthesiology

VA Commonwealth Univ. Health System, Richmond, VA Ben Illich - Emergency Medicine

University of Mississippi Medical Center, Jackson Don Gibson, Jr. - Family Medicine

Palmetto Health Richland, Columbia, SC Colette Jackson - Medicine Preliminary

Baylor University Medical Center, Dallas, TX Daniel Gilmer, Radiology-Diagnostic

Ophthalmology

University of Mississippi Medical Center, Jackson

University of Texas Southwestern, Dallas, TX Curtis Glidewell - Family Medicine

Floyd Medical Center, Rome, GA

Terica Jackson - Internal Medicine

University of Mississippi Medical Center, Jackson

Clara Gomez-Sanchez, Plastic Surgery

Univ. of California San Francisco, San Francisco, CA

Michael Jennings - Urology

University of Tennessee at Knoxville, Knoxville, TN

Andrew Gowdey - Urology

Univ. of Tennessee College of Medicine, Memphis, TN

Lindsay Jerome - Obstetrics / Gynecology

University of Mississippi Medical Center, Jackson

Caleb Graham - Medicine/Primary

Univ. of Colorado School of Medicine, Aurora, CO

Brett Jeter - Internal Medicine

University of Mississippi Medical Center, Jackson

Sarah Graham - Emergency Medicine

Univ. of FL COM Shands Hospital, Gainesville, FL

Ashley Johnson - Obstetrics / Gynecology

University of Mississippi Medical Center, Jackson

Jonah Gunalda - Emergency Medicine

Wake Forest Baptist Med. Center, Winston-Salem, NC

Andy Jones - Internal Medicine

Univ. of Alabama Medical Center, Birmingham, AL

Brannon Harrison - General Surgery

University of Mississippi Medical Center, Jackson

Brannan Jones, Jr. - Medicine-Pediatrics

University of Mississippi Medical Center, Jackson

162 JOURNAL MSMA May 2014

Marilyn Kelleher - Urology

Univ. of Kentucky Medical Center, Lexington, KY

Maureen Offiah - Dermatology

University of Mississippi Medical Center, Jackson

Daniel Kennedy - Radiology-Diagnostic

University of Mississippi Medical Center, Jackson

Osa Ogiamien - Anesthesiology

Jackson Memorial Hospital, Miami, FL

Carson Kisner - Radiology-Diagnostic

LSU Health Sciences Center, Shreveport, LA

Matthew Oglesbee - Internal Medicine

LSU School of Medicine, New Orleans, LA

Thompson Liddell - Internal Medicine

University of Mississippi Medical Center, Jackson

Oche Okeke - Medicine-Pediatrics

Tulane Univ. School of Medicine, New Orleans, LA

Joe Lightsey - Internal Medicine

Medical Univ. of South Carolina, Charleston, SC

Chase Osbon - Family Medicine

Ventura County Medical Center, Ventura, CA

Carlisle Livingston - Medicine-Pediatrics

University of Mississippi Medical Center, Jackson

Ben Pace - Ophthalmology

University of Mississippi Medical Center, Jackson

Erin Livingston - Pediatrics

University of Mississippi Medical Center, Jackson

Corey Parish - Ophthalmology

University of Mississippi Medical Center, Jackson

Wyatt Lydolph - Anesthesiology

University of Mississippi Medical Center, Jackson

Adam Parker - Radiology-Diagnostic

University of Mississippi Medical Center, Jackson

Jeff Mahony - Radiology-Diagnostic

University of Tennessee at Knoxville, Knoxville, TN

Ryan Paulk - Medicine-Pediatrics

University of South Carolina, Greenville, SC

Kristina Makey - Obstetrics / Gynecology

University of Mississippi Medical Center, Jackson

Patrick Peavy - Orthopedic Surgery

University of Mississippi Medical Center, Jackson

David Marbury - Pathology

Univ. of Colorado School of Medicine, Aurora, CO

Chris Penton - Radiology-Diagnostic

Baylor University Medical Center, Dallas, Texas

Denise McDuffey - Internal Medicine

University of Mississippi Medical Center, Jackson

Mary Anne Perez - Pediatrics

University of Mississippi Medical Center, Jackson

John Randall Moore - Urology

Mayo Clinic, Jacksonville, FL

Brandon Phillips - Medicine Preliminary

University of Mississippi Medical Center, Jackson

Radiology-Diagnostic

Univ. of Alabama Medical Center, Birmingham, AL

Jack Murray - Internal Medicine

West Virginia University SOM, Morgantown, WV Jack Neill, Jr. - General Surgery

University of Mississippi Medical Center, Jackson Dan Nguyen - Emergency Medicine

St. Vincent Mercy Medical Center, Toledo, OH Will Nichols - Internal Medicine

University of Mississippi Medical Center, Jackson Chandler Nicholson - Internal Medicine

University of Mississippi Medical Center, Jackson

Vicky Phillips - Pediatrics

Vanderbilt Univ. Medical Center, Nashville, TN Jon Rayburn - Anesthesiology

Ochsner Clinic Foundation- New Orleans, LA Rachel Riley, Obstetrics / Gynecology

University of Mississippi Medical Center, Jackson Julie Rivero - Family Medicine

University of Mississippi Medical Center, Jackson

May 2014 JOURNAL MSMA 163

â&#x20AC;˘

UMMC â&#x20AC;˘

Josh Roark - Internal Medicine

Univ. of North Carolina Hospitals, Chapel Hill, NC

Willie Thompson, Jr. - Psychiatry

East Tennessee State University, Johnson City, TN

Taylor Sawyer - Emergency Medicine

Palmetto Health Richland, Columbia, SC

Ron Tullos - Neurological Surgery

University of Oklahoma COM, Oklahoma City, OK

Travis Scharr - Radiology-Diagnostic

Unive. of Tennessee College of Medicine, Memphis

Clark Walker - Orthopedic Surgery

University of South Carolina, Greenville, SC

Darren Scoggin - Pediatrics

University of Mississippi Medical Center, Jackson

Micah Walker - Family Medicine

University of Mississippi Medical Center, Jackson

Cameron Sherrill - Surgery- Preliminary

University of Mississippi Medical Center, Jackson

Courtney Jo Weaver - Family Medicine

Univ. of Alabama SOM-Tuscaloosa, Tuscaloosa, AL

Tess Sison - Internal Medicine

University of Texas Medical School, Houston, TX

Adrienne Webb - Medicine-Pediatrics

University of Mississippi Medical Center, Jackson

Erin Smith - Otolaryngology

University of Mississippi Medical Center, Jackson

Ashley Wells - Pediatrics

Medical Univ. of South Carolina, Charleston, SC

Justin Smith - Family Medicine

Floyd Medical Center, Rome, GA

Lindsey Westbrook - Pathology

Univ.of Colorado School of Medicine, Aurora, CO

Ryan Speights - Internal Medicine

University of Mississippi Medical Center, Jackson

Jeremy White - Internal Medicine

Univ. of Alabama Medical Center, Birmingham, AL

David Steele - Internal Medicine

Univ. of North Carolina Hospitals, Chapel Hill, NC

Christian Widdows - Emergency Medicine

University of Mississippi Medical Center, Jackson

Kevin Stevens - Emergency Medicine

Univ. of Tenn. College of Medicine, Chattanooga, TN

Ashley Winford - Pediatrics

University of Arkansas, Little Rock, AR

Jonathan Strong - Radiology-Diagnostic

Baptist Health System, Birmingham, AL

Thomas Wood - Orthopedic Surgery

San Antonio Military Medical Center, San Antonio, TX

Cody Stroupe - Internal Medicine

University of Tennessee at Knoxville, Knoxville, TN

Crystal Wright - Pediatrics

University of Mississippi Medical Center, Jackson

Lekha Sunkara - Internal Medicine

Tulane Univ. School of Medicine, New Orleans, LA

Virginia Wright - Internal Medicine

University of Mississippi Medical Center, Jackson

Charlotte Taylor - Radiology-Diagnostic

University of Mississippi Medical Center, Jackson

Eric Yates - Emergency Medicine

Univ. of Alabama Medical Center, Birmingham, AL

Doug Thaggard - Internal Medicine

University of Virginia, Charlottesville, Virginia

164 JOURNAL MSMA May 2014

• New Members • AGANS, STEPHEN CARL, Gulfport Specialty: Emergency Medicine

COLLIER, CHARLENE H., Jackson Specialty: Obstetrics & Gynecology

ANDERSON, MARK D., Jackson Specialty: Neurology

COMBEST, FELTON EUGENE, Corinth Specialty: Emergency Medicine

ASHRAF, MUFEED A., Jackson Specialty: Nephrology

COSGROVE, MICHAEL, Ocean Springs Specialty: Anesthesiology

BALDER, DONALD ALLEN, Gulfport Specialty: General Surgery

CROTHERS, ANDREW, Southaven Specialty: Ophthalmology

BARKER, JEAN MARIE, Greenville Specialty: Family Medicine

CUSHING, CAROLYN, Jackson Specialty: General Surgery

BATLIVALA, SAROSH, Jackson Specialty: Pediatrics

DIMITRI, ELIZABETH, Slidell, LA Specialty: General Practice

BATSON, SHUNTAYE D., Jackson Specialty: Trauma Surgery

DODGE-KHATAMI, ALI, Jackson Specialty: Cardiothoracic Surgery

BEAUCHAMPS, LAURA S., Jackson Specialty: Internal Medicine

DUNN, JACK, Natchez Specialty: Anesthesiology

BENTLEY, MATTHEW B., Brandon Specialty: Internal Medicine

EID, ISSAM N., Jackson Specialty: Otolaryngology

BERG, KATHLEEN J., Jackson Specialty: Pediatrics

EL FEGHALY, RANA E., Jackson Specialty: Pediatrics

BLACK, WILLIAM H., Jackson Specialty: Dermatology

FREEMAN, CARRIE L., Jackson Specialty: Pediatric Critical Care Medicine

BONDI, STEVEN A., Jackson Specialty: Pediatric Critical Care Medicine

FRIEL, MICHAEL, Jackson Specialty: Plastic Surgery

BREWER, JUSTIN M., Tupelo Specialty: Maternal & Fetal Medicine

GALARZA, IVONNE E., Jackson Specialty: Pediatrics

BRODELL, LINDA P., Jackson Specialty: Ophthalmology

GREEN, ERICK, Jackson Specialty: Family Medicine

CARPENTER, JULIE JACKSON, Southaven Specialty: Family Medicine

GRENIER, MICHELLE A., Jackson Specialty: Pediatrics

COLLIER, ANDERSON B., Jackson Specialty: Pediatrics

GUPTA, NITIN K., Jackson Specialty: Gastroenterology

May 2014 JOURNAL MSMA 165

GUPTA, ASHISH, McComb Specialty: Pediatrics

KUMAR, HAMIT, Laurel Specialty: Internal Medicine

HADIDI, FASEEH, Clarksdale Specialty: Neurology

LAGE, JANICE M., Jackson Specialty: Chemical Pathology

HALL, MICHAEL E., Jackson Specialty: Cardiovascular Disease

LANEY, CHARLES, Oxford Specialty: Cardiovascular Disease

HALL, MELANIE K., Hattiesburg Specialty: Family Medicine

LEVINE, DAVID, Tutwiler Specialty: Family Medicine

HARDEN, BAHATI S., Greenwood Specialty: Family Medicine

LILLEY, JESSICA, Jackson Specialty: Pediatrics

HELMS, STEPHEN E., Jackson Specialty: Dermatology

LITTLE, WILLIAM C., Jackson Specialty: Internal Medicine

HIGHTOWER, OLIVIA, Gulfport Specialty: Internal Medicine

MALTBY, KAREN, Tupelo Specialty: Allergy Immunology

HUDGENS, JOSPEH L., Jackson Specialty: Obstetrics & Gynecology

MAPOSA, DOUGLAS, Jackson Specialty: Anesthesiology

IYER, SIVA S., Jackson Specialty: Ophthalmology

MCKEE, MILLISSA A., Jackson Specialty: Pediatric Surgery

JACKSON, LANA L., Jackson Specialty: Otolaryngology

MCKINNEY, SHAWN A., Jackson Specialty: General Surgery

JAIN, PANKAJ, Jackson Specialty: Anesthesiology

MCKINNEY, GERALD, Jackson Specialty: General Surgery

KARAM, SIMON, Jackson Specialty: Pediatrics

MELGAR, MIGUEL A., Gulfport Specialty: Neurosurgery

KELLUM, R. BRADLEY, Flowood Specialty: Orthopedic Surgery

MILES, DEREK, Cleveland Specialty: Urology

KELLY, NICHOLAS A., Meridian Specialty: Pediatrics

MOHAMAD, ALMOIS, Jackson Specialty: Cardiovascular Disease

KIM, WOO S., Laurel Specialty: Internal Medicine

MONGA, DIVYA, Jackson Specialty: Nephrology

KIRK, BRIANNA, Jackson Specialty: Pediatrics

MOORE, PAUL H., Jackson Specialty: Obstetrics & Gynecology

KITZMAN, GEOFFREY A., Jackson Specialty: Internal Medicine

MULLINS, ROBERT, Jackson Specialty: General Surgery

KOKOCKI, STANLEY P., Jackson Specialty: Cardiovascular Surgery

NEWLON, HEATHER, McComb Specialty: Dermatology

166 JOURNAL MSMA May 2014

QAISI, MOHAMMED K., Jackson Specialty: Oral & Maxillofacial Surgery

TRIMM, KRISTI, Jackson Specialty: Family Medicine

RASMUSSEN, SARA K., Jackson Specialty: Pediatric Surgery

VARNER, LOUIS M., Gulfport Specialty: Hospitalist

REED, RITA, Meridian Specialty: Family Medicine

WATKINS, WILLIAM, Jackson Specialty: Ophthalmology

ROBERTSON, CHARLES M., Jackson Specialty: Anesthesiology

WEST, BOBBIE BRITT, Pearl Specialty: Emergency Medicine

ROBERTSON, THERESA ELIZABETH, Jackson Specialty: Trauma Surgery

WOOTEN, DARWIN BESHAN, Corinth Specialty: Ophthalmology

SAUNDERS, BARBARA S., Brandon Specialty: Pediatrics

WYATT-ASHMEAD, JOSEPHINE, Jackson Specialty: Clinical Pathology

SCHARR, NERMA, Jackson Specialty: Anesthesiology

YOUNGBLOOD, SLOAN C., Jackson Specialty: Anesthesiology

SEIGERMAN, JEDD, Biloxi Specialty: Nephrology SHIPLEY, SONYA, Jackson Specialty: Family Medicine SIMEONE, ALAN A., Jackson Specialty: Cardiovascular Surgery SMITH, DANIEL H., Starkville Specialty: General Surgery SMITHERMAN, JEREMY D., Starkville Specialty: Anesthesiology SNELL, MILDRED, Batesville Specialty: Family Medicine

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SOUZA, FREDERICO, Jackson Specialty: Radiology SULLIVAN, ELIZABETH, Hattiesburg Specialty: Neurology TIPNIS, NEELESH A., Jackson Specialty: Pediatrics TIPNIS, SAJANI M., Jackson Specialty: Pediatrics

1600 North State Street Suite 400 Jackson, MS 39202 Telephone: 601.944.1717 WATS: 1.800.355.4231 www.mpsbilling.com May 2014 JOURNAL MSMA 167

• Poetry and Medicine • [This month, we print a poem from Dr. Woody D. Davis, an ophthalmologist of Meridian. He writes, “This is National Nurses Week. I love nurses. In fact I married one! My grandmother prayed her up. I’ve been blessed to work with some of the most remarkable nurses who’ve made my work rewarding and fun. I’m so thankful for them. It makes me wax poetic just thinking about it...So in their honor, with apologies to Sir Walter...”

His reference and inspiration are to a famous passage from Sir Walter Scott’s “The Lay of the Last Minstrel.” Its Canto VI begins “Breathes there the man with soul so dead, who never to himself hath said, This is my own, my native land!...” Physicians need to appreciate and acknowledge the contributions of nurses in our practice of medicine. They are essential, our closest partner, in the delivery of quality and compassionate healthcare. The great Osler agreed with Dr. Davis, stating, “The trained nurse has become one of the great blessings of humanity, taking a place beside the physician and the priest, and not inferior to either in her mission.” Dr. Charles Mayo added that the “trained nurse has given nursing…the divine touch.” Note they say with intent “trained” nurses, emphasizing the importance of skilled hygiene and education in nursing. Thank God for our trained, skilled, and compassionate nurses, who make us better physicians!!! Any physician is invited to submit poems for publication in the JMSMA, attention: Dr. Lampton or email me at lukelampton@cableone.net]—Ed.

I Love Nurses Breathes there the doctor, with soul so dead, Who never to himself hath said, This is my nurse, my faithful nurse Whose heart hath ne’er within him burn’d, As to work his footsteps he hath turn’d, From wandering in a hospital hall!

If such there breathe, go, mark him well; For him no Minstrel raptures swell; High though his titles, proud his name, Boundless his wealth as wish can claim; Despite those titles, power, and pelf, The wretch, concentred all in self, Living, shall forfeit fair renown, And, doubly dying, shall go down To the vile dust, from whence he sprung, Unwept, unhonour’d, and unsung.

God bless all the nurses in our lives.

168 JOURNAL MSMA May 2014

—Woody Davis, MD, Meridian

Excellence in Medicine Awards Nomination Form Each year, MSMA presents two deserving members of the medical community with awards â&#x20AC;&#x201C; the MSMA Excellence in Wellness Promotion Award and the MSMA Community Service Award. Please complete the form with your nomination for one or both of these award recipients. Mail to the attention of Hannah Duchesne at PO Box 2548 Ridgeland, MS 39157, fax to 601-856-6746, call 601-572-5474 for additional information or email at HDuchesne@MSMAonline.com.

Nominee Information Name: Address:

First

Last

State

Zip Code

Street Address

City/State: Telephone:

Middle Initial

City

Birth date: Medical School:

Daytime Phone

Place of Birth:

(mm/dd/yyyy)

City and State

Graduated:

Medical Specialty:

Board Certification(s): E-mail address: Nominee is an MSMA Member:

Yes

No

Submitted By: E-mail Address:

Name (and contact information) of person submitting the nomination E-mail address of person submitting the nomination May 2014 JOURNAL MSMA 169

Supporting Information 1. Principal Professional Membership and Faculty Appointments (List position held and dates.)

2. Principal Honors:

3. Sponsorâ&#x20AC;&#x2122;s Narrative Statement

4. Endorsement I (not required)

5. Endorsement II (not required)

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

170 JOURNAL MSMA May 2014

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