October 2009 JMSMA

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October

VOL. L

2009

50 Years of

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No. 10

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Lucius M. Lampton, MD EDITOR D. Stanley Hartness, MD Michael O’Dell, 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 Randy Easterling, MD President Tim J. Alford, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Gary Carr, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: JOURNAL MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, ph.: (601) 853-6733, FAX (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $73.00 per annum; $86.00 per annum for foreign subscriptions; $6.50 per copy, $7.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright© 2009, Mississippi State Medical Association.

Official Publication of the MSMA Since 1959

OCTOBER 2009

VOLUME 50

NUMBER 10

SCIENTIFIC ARTICLES Parental Expectations and Outcomes of Pediatric Cochlear Implantation Elizabeth Piazza, BS; Cherian Kandathil, MBBS and Jeffrey D. Carron, MD, FAAP, FACS

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Mississippi Burnout Part II: Satisfaction, Autonomy and Work/Family Balance Jeralynn S. Cossman, PhD and Debra Street, PhD

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Clinical Problem-solving: A Hole In One Deborah S. O’Bryan, MD

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PRESIDENT’S PAGE We Need to Reform Healthcare Reform Randy Easterling, MD; MSMA President

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SPECIAL ARTICLE More Than Just Drainage Samuel Moak, M1

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EDITORIAL At Last Stanley Hartness, MD

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RELATED ORGANIZATIONS University of Mississippi School of Medicine

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DEPARTMENTS Letters News Numbers Count Images in Mississippi Medicine Placement/Classified

360 364 366 367 354

“MISSISSIPPI SWEET POTATOES” - This photo titled itself without a doubt. The image was captured outside the famous Williams Brothers General Store in Williamsville. This historic Mississippi institution, founded in 1907, retains its old style charm and is an interesting stop for visitors to Philadelphia. Photo and caption by Catherine H. (Cathy) Stroud, MD, a retired internist, avid photographer and community volunteer, who resides in Madison County rearing two teenagers with her husband, Larry. ❒

ABOUT THE COVER:

October

VOL. L

2009

50 Years of

CONTINUOUS PUBLICATION

No. 10

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JOURNAL MSMA, October 2009 — Vol. 50, No. 10

SCIENTIFIC ARTICLES

Parental Expectations and Outcomes of Pediatric Cochlear Implantation Elizabeth Piazza, BS Cherian Kandathil, MBBS Jeffrey D. Carron, MD, FAAP, FACS

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Background: Cochlear implants have been used with increasing frequency over the past twenty years, including very young patients. Objective: To determine if parents are satisfied with their children’s performance after cochlear implantation. Design: Survey mailed to parents of children receiving cochlear implants. Results: 31 questionnaires were returned out of 69 mailed (45 %). The vast majority of responding parents felt that their children benefited substantially from cochlear implant surgery. Conclusion: Cochlear implantation is effective in helping children develop auditory-oral communication skills. Access to auditory/oral communication programs in this state remains an obstacle in postoperative habilitation. BSTRACT

BACKGROUND Sensorineural hearing loss is one of the most common birth defects in the U.S., affecting 1-3 babies per 1000; 95% of these children are born to normal-hearing parents.1 Communication strategies for children include auditory/oral communication, manual communication (sign language), and total communication JOURNAL MSMA, October 2009 — Vol. 50, No. 10

(combination of the two). Studies are showing that major factors in success in achieving auditory/oral communication after implantation include age at implantation, socioeconomic status, comorbid conditions, and participation in postoperative auditory/oral habilitation program.2,3 Studies measuring the communication outcomes for children undergoing cochlear implantation have repeatedly shown tremendous benefit when surgery is combined with aggressive postoperative habilitation therapy;4 most of these studies, however, come from large regional or national referral centers and tend to draw from a more select population of individuals of higher socioeconomic strata. In contrast, the population covered by our program is distinct in that the majority of children are from low-income families and locations that are not in commuting distance to a school that specializes in auditory/oral communication. The goals of this study are to assess the parental expectations and satisfaction with their children’s post-implantation performance.

METHODS This study was approved by the Institutional Research Board at the University of Mississippi Medical Center. Children from English-speaking homes who re331

ceived unilateral or bilateral cochlear implants at the University of Mississippi Medical Center between the years of 2003 and 2006 were identified. Sixty-nine patients met these criteria. Parents of the patients were mailed surveys (see Appendix) concerning the home, school, and socioeconomic environment surrounding the patient. All parents were able to choose not to participate in the study. Thirty-eight of the total 39 questions were in multiple choice format, and all components of the survey were written in English (see Appendix). The purpose of survey items #1 through #11 was to quantify the extent of interaction the patient receives in his home environment. Questions #12 through #22 asked parents to assess their child’s speaking skills and to quantify their degree of satisfaction with their child’s communication, socializing, and scholastic abilities. The goals of items #23 - #30 and #35 - #36 were to describe the patient’s educational environment, including participation in deaf education or other specialized programs, and to reveal parents’ expectations regarding their child’s communication abilities and educational goals. Questions #31 #34 and #37 - #39 depicted socioeconomic factors such as household income, accessibility to deaf schools, and methods of payment for cochlear implant surgery. Data were compiled and tabulated into a Microsoft Excel spread sheet.

FIGURE 1. RESPONSES TO QUESTIONS 16-22, REGARDING PARENTAL SATISFACTION WITH SPEAKING, SPEECH PERCEPTION, HEARING ENVIRONMENTAL SOUNDS, READING, SOCIALIZING/ MAKING FRIENDS, UNDERSTANDING/ HEARING OVER THE TELEPHONE, AND PERFORMANCE IN SCHOOL.

FIGURE 2. CURRENT SCHOOL GRADE OF CHILDREN SINCE

IMPLANTATION.

Kindergarten K indergarten

RESULTS Thirty-one surveys were completed, and parents’ responses to survey items formed the basis of our results. Regarding speech, 23 out of 32 (72%) found the child talking to adults and also found them to talk well enough to be understood (Figure 1). Eighteen (56%) found the child to speak well enough for children their age and other adults to understand them. Sixty-five percent were completely satisfied with their children speaking, and 40% were completely satisfied with their speech perception and ability to read. Thirteen children attend or have attended Magnolia Speech School. Eight others have considered sending their child to a deaf school and only 7 have attended a deaf school than those mentioned above. When asked about the reason if their child has not attended a deaf school or is no longer attending, most of them did not give a reason; 5 of them were asked to have their child attend mainstream school. At the time of the survey, the majority of patients were in preschool (Figure 2), and only 2 were completely mainstreamed (Figure 3). Ten were in full time

deaf school, and 13 were in mainstream school plus special education classes/ therapy for the hearing impaired. Among these 13 students, 59% attended at least 4 hours or greater of special education classes. Among the 32 subjects that took part in the study, it was found that the majority of the subjects belonged to a household with a maximum of 2-3 children (mean 2.7). Fifteen (46%) of the children were reported as receiving individual attention for a period greater than

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FIGURE 3. CURRENT EDUCATION SETTING FOR IMPLANTEES.

FIGURE 4. RESPONSES TO QUESTIONS 2-6, TIME SPENT IN VARIOUS ACTIVITIES BASED ON PAYER STATUS. Q2: TIME SPENT GIVING INDIVIDUAL ATTENTION; Q3: MINUTES SPENT TALKING AND/OR LISTENING INDIVIDUALLY; Q4: TIME SPENT PLAYING WITH OTHER CHILDREN; Q5: TIME SPENT PLAYING ALONE; Q6: TIME SPENT PLAYING WITH FRIENDS.

were somewhat satisfied with their child’s performance in school. Twenty-one subjects had participated in the ‘First Steps’ program, and 8 received services from the SkiHigh Program. Seventy percent of the parents expect their child to communicate normally when they are finished (Figure 5) with their education, and 45% had an education goal of advanced degree beyond college graduate for their child. Most of the cochlear implants were paid for by Medicaid.

three hours each day. Of the total time spent each day giving individual attention, 13 (40%) subjects spent more than three hours talking/ listening to the child (Figure 4). Among the total subjects, 14 (44%) of them spent more than three hours playing with the other children in the household. The amount of playtime outside of school was answered inconsistently and varied substantially. Fortyeight of the children were found to be sharing a bedroom, and among these the majority shared the bedroom with just another person. Eighty percent of the subjects had both the mother and father staying with them in the house. Only 3% had more than 2 adults (other than the parents) live in their household. Eighty percent of the questionnaires were filled out by the primary caretaker of the child. With regard to socialization and making friends, 78% were completely satisfied or somewhat satisfied with their child’s ability to hear environmental sounds. Twenty-five percent were completely satisfied with their child’s understanding/hearing over the telephone. Fifty-five percent were completely satisfied, and 23%

DISCUSSION Congenital hearing loss remains one of the more common birth defects in the United States. Efforts to improve communication outcomes and reduce education and therapy costs for hearing impaired children have brought about universal newborn hearing screening in Mississippi for over a decade, and now nearly all babies in America are screened for hearing loss. The goals of the Joint Commission on Infant Hearing are stated to diagnose hearing loss by three months of age and institute intervention services by six months of age. Initial analysis of the screening efforts in our state demonstrated success in achieving those goals, yet follow-up remains a challenge for children in indigent households. Since the first cochlear implant was done at the University of Mississippi Medical Center in 2003 we have implanted nearly 100 children and over 30 adults. The inception of a university-based implant program has successfully helped open the doors to better auditory-oral communication for a number of children who may not have previously had access to this technology. Our team has expanded selection criteria somewhat to include more children from areas that have limited access to schools for the hearing impaired or therapists skilled in techniques for auditory/oral communication, as even children in less-than-optimal settings can still perform better after implantation than without surgery. The primary barrier to cochlear implantation for indigent children in Mississippi, has been, unfortunately, parental compliance and commitment to postoperative therapy. Despite aggressive parental education and good coverage for cochlear implants through Medicaid, we are faced with parents who habitually no-show for appointments or fail to carry out basic requests to help coordinate care for their children. Indeed, it is stressed to the families of all potential candidates that the surgery does not offer a cure for deafness; rather, it is an enor-

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FIGURE 5. EXPECTED COMMUNICATION ABILITIES FOLLOWING

AURAL HABILITATION PROGRAMS AS REPORTED BY THE CAREGIVER.

mously critical tool to help a person communicate normally with the hearing world without the need for sign language skills or interpreters. The timing of implantation in prelingually deaf patients is particularly important as well, with a large body of evidence showing increasing success with earlier implantation. The Food and Drug Administration at this time has approved cochlear implants as early as twelve months; however, the surgery has been done successfully and safely in younger patients in certain circumstances such as meningitis, where there is a limited window that surgery is technically feasible. Earlier implantation also allows an opportunity for audition to begin before the gap widens progressively between a child’s actual language and the expected language capacity for his or her age. Current thinking is that the plasticity of the developing nervous system to develop brainstem and cortical auditory pathways has a steep slope that levels off with time to where it is virtually flat after six years of age, and that implanting even younger than twelve months may produce better results than at twelve months. Delays in the diagnosis of hearing loss and the implementation of early intervention, hearing aids, and implantation when appropriate remain a substantial barrier to developing oral communication for hearing impaired children in Mississippi. Previous research from our institution has shown the incidence of congenital, permanent sensorineural hearing loss in Mississippi to be approximately 1.3 per 1000 babies.6 With 46,455 births in 2007, the most recent year statistics are available, this translates to approximately 61 hearing-impaired children per year in our state, at least half of which have severe to profound hearing loss. Currently, approximately 20 to 25 children undergo cochlear implantation yearly at the Blair E. Batson Hospital for Children, indicating there are many more Mississippi children who could benefit from this technology.

CONCLUSIONS The initial performance of children receiving cochlear implantation at the University of Mississippi Medical Center is generally in line with parental expectations. Efforts should be made to ensure better follow-up for hearing impaired children in underserved populations, which should, in turn, make more children candidates for implantation, thereby increasing their opportunities for higher education and for a broader spectrum of careers.

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APPENDIX Questionnaire 1. How many total children (under 18 years of age) live in the household, including the child with the cochlear implant? 1 2 3 4 5 6 7 8 more than 8 2. On average, how much time is spent giving the child with cochlear implant individual attention each day? No time 30 minutes 1 hour 1 hour 30 minutes 2 hours 2 hours 30minutes 3 hours more than 3 hrs 3. Of the time spent in question 2, how many minutes are spent talking and/or listening to the child each day? No time 30 minutes 1 hour 1 hour 30 minutes 2 hours 2 hours 30minutes 3 hours more than 3 hrs 4. How much time does the child spend playing with other children who live at home with them each day? No time 30 minutes 1 hour 1 hour 30 minutes 2 hours 2 hours 30minutes 3 hours more than 3 hrs 5. How much time does the child spend playing alone each day? No time 30 minutes 1 hour 1 hour 30 minutes 2 hours 2 hours 30minutes 3 hours more than 3 hrs 6. How much time does the child spend playing with his or her friends (not including time at school) each day? No time 30 minutes 1 hour 1 hour 30 minutes 2 hours 2 hours 30minutes 3 hours more than 3 hrs 7. Does the child share a bedroom with anyone? Yes No 8. If the answer to question 7 was yes, how many total people sleep in this bedroom? 2 3 4 5 more than 5 9. Are both the mother and the father of the child with the cochlear implant living in the home with the child? Yes No 10. Other than you, how many other adults 18 years old or older live in the home? 0 1 2 3 4 5 more than 5 11. Who takes care of the child with the cochlear inplant most of the time? You the child’s other parent one of your parents one of your relatives other JOURNAL MSMA, October 2009 — Vol. 50, No. 10

12. Does the child with the cochlear implant speak well enough that you can understand them? Yes No 13. Does the child with the cochlear implant speak well enough that others their age can understand them? Yes No 14. Does the child with the cochlear implant speak well enough that adults other than you can understand them? Yes No 15. Does the child with cochlear implant talk to adults? Yes No

For the next few questions, choose a number between 1 and 5 that represents how satisfied you have been with your child’s progress after the cochlear implant in the following areas: Completely satisfied Not satisfied 16. speaking 1 2 3 4 5 17. speech perception 1 2 3 4 5 18. hearing environmental sounds 1 2 3 4 5 19. reading 1 2 3 4 5 20. socializing/ making friends 1 2 3 4 5 21. understanding/ hearing over the telephone 1 2 3 4 5 22. performance in school 1 2 3 4 5 23. What grade is the child currently in? Pre-school Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade or greater 24. What is the education setting for the child: a. Full time deaf school b. Mainstream school plus special education classes and/or therapy for the hearing impaired c. Mainstream school only 25. If you answered b in number 24: How many hours each week does your child attend special education classes? 1 hour 2 hours 3 hours 4 hours 5 hours greater than 5 hours 26. Did/does your child participate in the “First Steps” program? Yes No 27. Did/does your child attend Magnolia? Yes No

28. Did/does your child participate in the “Sky High” program? 29. Have you considered sending your child to a deaf school (where there is an emphasis on teaching the hearing impaired to learn to speak properly or use sign language)? Yes No 30. Is your child now or sometime in the past has your child attended a deaf school other than those programs listed in questions 27-29? Yes No 31. If your child has not attended a deaf school or if your child no longer attends a deaf school, what is the main reason they left? a. You thought deaf school was too expensive b. You thought deaf school was too far away c. You thought mainstream school would be a better environment than deaf school. d. Your child progressed past deaf school and was told to begin attending a mainstream school. e. Other reason not listed here. 32. Out of the following 4 cities, which do you live closest to? a. Memphis, TN b. Jackson, MS c. Hattiesburg, MS d. New Orleans, LA 33. For the city you chose in question 32, how much time would it take to travel to that city from your home? a. 0 – 20 minutes b. 20 - 40 minutes c. 40 minutes – 1 hour d. 1 hour – 1 hour 20 minutes e. 1 hour 20 minutes – 1 hour 40 minutes f. 1 hour 40 minutes – 2 hours g. 2 hours – 2 hours 20 minutes h. 2 hours 20 minutes – 2 hours 40 minutes i. 2 hours 40 minutes – 3 hours j. Greater than 3 hours 34. Would it be possible for you to send your child to the city you listed in question 32 each day to attend a deaf school? Yes No 35. How do you expect your child will be able to communicate when they are finished with their education? a. My child will communicate normally in any situation. b. My child will do partial lip reading and use auditory cues.

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c. My child will sign and use auditory cures. d. My child will use sign language only. 36. What are your education goals for your child with the cochlear implant? a. No set goals b. High school graduate c. High school and junior/community college graduate d. High school and 4-year college graduate e. High school, 4- year college, and advanced degree beyond a college graduate 37. Before taxes, what is your household’s mean yearly income? a. $0-$10,000 b. $10,000-$20,000 c. $20,000-$30,000 d. $30,000-$40,000 e. $40,000-50,000 f. $50,000-$60,000 g. greater than $60,000

38. What is your zip code? _________________ 39. How was the cochlear implant surgery paid for? a. Private insurance b. Medicaid c. CHIPS d. Combination of choice a-c

REFERENCES 1. 2.

3. 4. 5.

6. 7.

Williams PJ. Genetic causes of hearing loss. N Engl J Med. 2000;342:1101-9. Philips B, Corthals P, De Raeve L, D'haenens W, Maes L, Bockstael A, Keppler H, Swinnen F, De Vel E, Vinck B, Dhooge I. Impact of newborn hearing screening: comparing outcomes in pediatric cochlear implant users. Laryngoscope. 2009;119(5):974-9. Geers A, Brenner C. Ear Hear. Background and educational characteristics of prelingually deaf children implanted by five years of age. 2003;24(1 Suppl):2S-14S. Geers AE. Factors influencing spoken language outcomes in children following early cochlear implantation. Adv Otorhinolaryngol. 2006;64:50-65. Joint Committee on Infant Hearing: 2000 Position Statement. Pediatrics. 2000 Oct;106(4):798-817. Connolly JL, Carron JD, Roark SD. Universal newborn hearing screening: are we achieving the JCIH objectives? Laryngoscope. 2005;115:232-236. Miyamoto RT, Hay-McCutcheon MJ, Kirk KI, Houston DM, Bergeson-Dana T. Language skills of profoundly deaf children who received cochlear implants under 12 months of age: a preliminary study. Acta Otolaryngol. 2008;128(4):373-7.

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AUTHOR INFORMATION:

Jeffrey D. Carron, MD, FAAP, FACS is an associate professor of otolaryngology and pediatrics. He is the pediatric cochlear implant center director at the Blair E. Batson Hospital for Children at the University of Mississippi Medical Center.

CORRESPONDING AUTHOR Jeffrey D. Carron, MD, FAAP, FACS Department of Otolaryngology and Communicative Sciences University of Mississippi Medical Center 2500 North State Street Jackson, MS 39216 Phone: 601-984-5456 Fax: 601-815-3062 Email: jcarron@ent.umsmed.edu

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Managing M anaging tthe he R Risks isks

Mississippi Burnout Part II: Satisfaction, Autonomy and Work/Family Balance Jeralynn S. Cossman, PhD Debra Street, PhD

A

Documented Mississippi physician shortages1 make evidence about factors shaping physicians’ career choices especially important if Mississippi policymakers are to devise workable strategies to maximize the physician workforce. Work-life interactions influence physicians’ choices about how they manage their careers and professional burnout is one documented cause of physicians’ decisions to change work hours or to choose early retirement.2 We find that women and mid-career physicians are more likely than men or later career physicians to experience stress and burnout. Additionally, physicians who experience burnout are less likely to report being satisfied with nearly every aspect of their professional life and work-life balance indicating that burnout permeates several dimensions of physicians’ lives. The associations in our findings are suggestive; however, to minimize deleterious effects of burnout on the Mississippi physician workforce, future research should examine the causal factors underlying stress and burnout.

INTRODUCTION Physicians may enjoy the stature and respect accorded their chosen profession, but that does little to inoculate them to challenges of 21st century life—such as how to balance the often competing demands of work and personal life. Work-life balance across the professions has been an active area of research for some time, but the relationships between physicians’ work and family experiences and how that may be associated with professional burnout have not received as much sustained attention.4 Yet “controllable lifestyles” are important for the career choices contemporary physicians make and the professional experiences they encounter.

For example, the capacity to control life and professional circumstances (such as hours worked) is more important to many professionals’ career decisions than pay and prestige.5 More recently, researchers have found that newer cohorts of medical graduates prefer time off and a comfortable lifestyle to toiling more traditionally long hours in the name of medicine.4 This suggests a widening generational distinction between “new model” medicine pursued strictly as a profession and “traditional model” medicine pursued a vocation. Documented Mississippi physician shortages1 make evidence about factors shaping physicians’ career choices especially important if Mississippi policymakers and professional groups are to devise strategies to maximize the physician workforce. Work-life interactions influence physicians’ choices about how they manage their careers and professional burnout is one documented cause of physicians’ decisions to change work hours or to choose early retirement.2 Burnout processes operate throughout physician careers, from early practice experiences to mid-life career re-orientations. For example, doctors who have been in practice for longer than twenty years were trained when there were no limits to hours worked as residents. They subsequently worked long hours in private practice as well,6 often taking call and sometimes even making house calls to home-bound patients.7 Working these types of grueling hours (especially in the absence of compensating factors) can lead to early burnout and increase the potential for early retirement. In contrast, at the beginning of their careers, contemporary cohorts of physicians are trained under new guidelines that limit their work hours as residents. They frequently have innovative working arrangements, like the opportunity to work

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BSTRACT

with hospitalists or in new types of practice arrangements, minimizing the traditional burden of post-clinic work hours.8 Still, more recently trained doctors may experience burnout early in their careers, particularly if their tolerance for work-life imbalance is low. This occurs when physicians attempt, but fail, to balance their professional lives with expectations of the types of personal lives they desire. The focus of this manuscript is the impact of career satisfaction, autonomy and worklife balance—and their association with professional burnout. We use questions from the 2007/08 MSMD survey to assess relationships between burnout and physicians’ work-life balance.

PHYSICIAN BURNOUT Burnout is higher among physicians than among other professionals, plaguing some physicians from the residency phase of their careers.9,10 Physician burnout is an occupational hazard, a syndrome that includes depersonalization (diminished capacity to relate to patients, family, and friends), emotional exhaustion, and a reduced sense of accomplishment.9,11 Stress and burnout present a challenge for maintaining an optimally healthy and effective physician workforce, particularly if the combination of patient needs and insufficient physician supply push some practitioners past reasonable practice limits. Nearly 25% of Mississippi physicians who responded to the 2007/08 MSMD survey reported occasional or persistent burnout, with an additional 55% saying that they experienced stress and lack of energy. Put another way, only 1 in 5 Mississippi physicians seem to practice in their very demanding practices relatively unscathed by the progressive symptoms of professional burnout. Research on the profession links satisfaction and physician autonomy,12,13,14 both implicated in whether or not physicians experience stress or burnout. Career satisfaction reflects both the enjoyment and sense of accomplishment physicians experience in their daily practice of medicine and a holistic perspective on an entire career in their chosen medical specialty. Professional autonomy reflects the capacity for physicians to practice medicine as they prefer,15,16 consistent with medical training and professional ethics, free from third party interference. While individual characteristics and personality traits certainly matter, contextual circumstances also influence physicians’ sense of satisfaction and autonomy, their sense of having work and personal life in balance, and ultimately, the levels of stress they experience in their medical practices. When stress leads to burnout, it creates problems for individual physicians, JOURNAL MSMA, October 2009 — Vol. 50, No. 10

for their patients, and for the physician workforce more generally. At the level of individual physicians, burnout may contribute to lower quality patient care.17 More broadly, burnout may shape size and efficiency of the physician workforce, since stress may push physicians to cut their hours or to leave the profession entirely.18 The evolving delivery of modern health care has challenged physician autonomy as third party actors (such as insurance companies and government agencies) have increased power to intervene in medical decisionmaking.19,20 Such changes in power sharing arrangements associated with medical practice are doubtless stressors for at least some physicians, especially physicians in practice long enough to have experienced less interference in their clinical activities. Medical practice management and workload particulars also shape physician morale and satisfaction21,22 and the sense of fulfillment physicians derive from their work. Physicians who resent third party incursion into their medical practice are at high risk of burnout. So, too, may be physicians who find that recent trends in patient self-advocacy challenge their clinical judgment. Physicians may feel pressures bearing on their traditional professional autonomy both from above and below. Similarly, physicians experiencing greater satisfaction from their medical careers likely have lower levels of stress compared to dissatisfied physicians, who may be at risk for higher levels of stress and burnout. Therefore, a clearer understanding of the relationships among autonomy, satisfaction, work-life balance and burnout is important. If burnout can be avoided, the indirect effects of burnout on physician supply can be reduced, ultimately safeguarding the state’s physician workforce supply and the continuity and quality of patient care.

DATA AND METHODS Study design and sample Data for this research are from an omnibus survey of issues important to Mississippi physicians, fielded in 2007/08. The survey covered Hurricane Katrina and malpractice experiences, the use of electronic medical records and series of questions focused on physician satisfaction with their career, family, work-life balance and community. All physicians with a unique email address and, licensed to practice in Mississippi, were invited to participate in the on-line survey. More than 1,000 physicians responded in the first six weeks. In the following months, the researchers worked to boost response rates, targeting under-represented demographic groups (women and minority physicians). The final response 339

The two highest burnout scores (symptoms won’t go away and feeling completely burned out) were combined into a single measure of persistent burnout. Respondents were categorized by four burnout levels, ranging from (1) no burnout to (2) stressed [but no burnout], (3) occasional burnout, or (4) persistent burnout. Race. Race is classified using self-reports from 2007/08 MSMD survey data. Physicians are coded White if they selected that race category on the survey. Physicians are classified as African American if on the survey they selected both Black AND born in the United States. Non-white 2007/08 MSMD respondents who were born outside of the United States and self-identi-

fied as Black, or respondents who indicated another racial category besides White or Black on the survey, were combined and coded as the “Other” race category. Too few physicians in each of the “Other” racial categories preclude analyses on groups beyond the three we identify (White, African American, and Other race). Gender. Each respondent is categorized by gender based on their survey self-identification. If gender was missing in the survey data, it was derived from the Mississippi State Board of Medical Licensure Data administrative data to preserve cases for analysis. Age group. A three-category measure is used to explore generational differences among Mississippi physicians. Physicians under age 40 represent those early in their careers. Physicians from age 40 to 59 represent mid-career professionals. Physicians aged 60 and older have the longest practice experience. We analyzed data from the sample of actively practicing physicians who responded to the questions in the burnout section of the 2007/08 MSMD survey (classified into four distinctive groups based on the four category continuum of burnout responses) alongside items measuring different aspects of physicians’ career satisfaction, autonomy experiences, and work-life balance. Career Satisfaction. For career satisfaction, physicians responded to a series of statements (ranging from strongly disagree to strongly agree) including: I find my present clinical work personally rewarding; In general, practice in my specialty has met my expectations; My specialty no longer has the appeal to me it used to have; My specialty does not provide the security it once did; If I were to choose over again, I would not become a physician; I would recommend medicine to others as a career; My total compensation package is not adequate; and All things considered, I am satisfied with my career as a physician. Answers were scored on a scale from 1 to 5, with items recoded so that five indicates a high level of satisfaction, even if the question was asked in the reverse. Autonomy. The second set of items assesses physicians’ levels of professional autonomy alongside their self-reports about their experiences burnout continuum. The items associated with autonomy (original responses ranged from strongly disagree to strongly agree) are: My practice has adequate resources for me to do my work; I am satisfied with the balance of time I spend on patient care versus administrative tasks; In my practice, it often feels like bureaucrats are second-guessing me; Paperwork required by payers is a burden to me; and, In my opinion, I am expected to take too much call. Items were recoded, as necessary, so that five indicates

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rate was approximately 20% of eligible respondents (N=1,449 physicians licensed to practice in Mississippi). Among respondents, 860 were in active practice in Mississippi at the time of the survey, representing about 20% of active physicians in the state. The 2007/08 MSMD survey data are broadly representative of the physician specialty, practice location, and other demographic characteristics of the physician workforce, determined by comparing MSMD sample characteristics with annual licensure data. Measures Most analyses are based on self-reports from the 2007/08 MSMD. If key demographic data (race, gender, or age) was missing, we backfilled those data from the Mississippi State Board of Medical Licensure administrative dataset to preserve the largest number of cases for analysis and to enhance the representativeness of findings. Dependent variable. We used a validated single measure2,23,24 as the dependent variable, burnout level. Physicians selected the single item most closely representing how they felt:

• I enjoy my work. I do not feel burned out. • Occasionally I am under stress, and I don’t always have as much energy as I once did. But, I don’t feel burned out. • I am definitely burning out and have one or more symptoms of burnout, such as physical or emotional exhaustion. • The symptoms of burnout that I’m experiencing won’t go away. I think about frustrations at work a lot. • I feel completely burned out and often wonder if I can go on. I am at the point where I may need to make some changes or may need to seek some sort of help.

high levels of autonomy and one equals low levels of autonomy. Work-life Balance. The final eight items assess physicians’ family and community life circumstances as those relate to physicians’ work—a set of work-life balance measures. They include: I feel a sense of belonging to the community where I practice; I feel respected by the community where I practice; I do not feel at home in the community where I practice; My family and I are strongly connected to the community where I work; My work schedule leaves me enough time for my family; My spouse/partner supports my career; The interruption of my personal life by work is a real problem; and, Work rarely encroaches on my personal time. Similar to the previous measures of career satisfaction and autonomy, physicians answered each of the work-life balance items on a scale from 1 to 5. Items were recoded so that five indicates a positive orientation or outcome on the measure, even if the item was stated in the reverse. In the following section of the manuscript, a series of figures first depict levels of burnout by the key physician demographic characteristics of race, gender, and age. Following the figures is a series of tables that document the associations between career satisfaction, autonomy, and work-life balance on one hand, and burnout experiences on the other. In the earlier installment of this pair of articles on burnout, we reported three levels of burnout to establish the extent of the Mississippi burnout problem using broad strokes, and for ease of interpretation.25 In contrast, in this article we present a more refined analysis of burnout, using four categories instead of three (ranking from least burned out to most), to support a more nuanced analysis. Findings Variations in levels of stress and burnout by demographic categories are presented in Figures 1-3. Figure 1 shows the distribution of stress and burnout by race. Regardless of race, most physicians report experiencing relatively high levels of stress, but the highest

levels of burnout (occasional and persistent) are less common than high levels of stress. African American physicians are the group most likely to report no stress at all, while physicians of Other races report slightly higher levels of persistent burnout than either White or African American physicians. Only 3% of African American physicians in Mississippi reported persistent burnout, about half the rate as for White and Other race physicians having persistently high levels of burnout.

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Figure 2 shows the distribution of different stress and burnout conditions along the burnout continuum by gender. Note that women report higher rates of stress and persistent burnout (so burned out I need help) than men. These differences are both statistically and substantively significant. Twice as many women physicians as men (9% versus 4%) reported that they experienced persistent burnout symptoms. In fact, 4% of women physicians (compared to none of the men respondents) said they were so burned out that they probably needed help dealing with it. When examining age group differences in stress and burnout (Figure 3), it is clear that mid-career physicians (those 40-59) are the most beleaguered group. At every level of stress and burnout, mid-career physicians report more symptoms and experiences of burnout than physicians who are either younger or older. The intensity of mid-career practice seems to be expressed in the significantly lower percentage of physicians from 40-

59 (70 percent) who said they enjoyed their practices or were only sometimes stressed, compared to 84% of younger, early career physicians (younger than 40) and 80% of older physicians in long-time practice who reported the two less worrisome categories associated with burnout. Occasional and persistent burnout are much higher in the mid-career physicians (40-59 years old) than in older (60+) and younger (up to 40) physicians. The distinctive associations between gender and age and burnout underscore the importance of examining the relationships between career satisfaction, autonomy, and work-life balance. Demographic characteristics are associated in patterned ways with each of those three types of individual physician experiences. For example, women and men in their thirties have career and family experiences that are still formative, at least when compared to mid-career physicians who have been practicing for a decade or more longer (age 40-59). Older physicians (60 and older), in turn, have different family and practice experiences from either of the younger groups, as physicians whose children are mainly grown and who have been in practice long enough to remember practice autonomy before managed care and routine third party interference. Men and women physicians, and physicians from different race/ethnic groups form distinctive patterns of relationships with patients and other professionals, which may bear on their career satisfaction and perceptions of autonomy. Women are normatively expected to assume most of the non-paid caring and kin-keeping activities within families, whether they pursue a profession like medicine or not, creating different sets of social expec-

tations about how to balance work and family life. Therefore, we next examine the relationships between stress/burnout and career satisfaction, autonomy, and work-life balance. Table 1 shows average scores on the career satisfaction items, distinguished by level of burnout. To interpret this table, recall that a five would indicate that all physicians in a particular category who were surveyed strongly agreed with the item presented. The numbers in the tables represent the mean or arithmetic average score for each item (with higher numbers indicating higher levels of satisfaction or positive outcomes associated with the item and lower numbers indicating lower levels of satisfaction or negative outcomes associated with the item) categorized by burnout level. Statistical significance is indicated by asterisks at the end of the item in the left column, and a symbol indicates whether the item was reverse coded (some items were reverse coded; a five always indicates higher levels of satisfaction). Differences across all seven career satisfaction items by burnout level are statistically significant. This means that career satisfaction is directly and significantly correlated to the level of burnout 2007/08 MSMD respondents reported. On average, Mississippi physicians find their clinical work rewarding, but there is a significant difference in how satisfied physicians are when they are not burned out at all (4.4) compared to those who report persistent burnout (3.3). The same pattern holds for the other six items—less satisfaction is associated with more burnout. Burned out physicians are less likely to say their specialization met their expectations, more likely to say their specialty no longer has appeal or provide security, that they would not choose medicine again, recommend a career in medicine to others, and be satisfied with compensation. On the global measure of career satisfaction, physicians with no burnout symptoms report very high levels (4.49) compared to significantly lower levels among those who experience persistent burnout (2.89). Given the body of research that identifies predictable relationships between levels of physician satisfaction and the quality of patient care (among other things), physician burnout can represent a serious problem. We next analyzed the relationship between stress and burnout and

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items that assess aspects of physician autonomy (Table 2). On every measure, lower levels of autonomy for the items that assess that component of medical practice have a statistically significant relationship with burnout. Physicians with negative experiences or outcomes associated with the sufficiency of resources to do their jobs, the balance between patient care and administrative tasks, second-guessing by third parties, the paperwork burden, and the amount of call they are expected to take are more likely to experience occasional and persistent burnout compared to physicians who rate their autonomous capacities in practice more positively. Paperwork and bureaucrats are a particular thorn in the side of the most burned out physicians. Average levels of work-life balance follow predictably similar patterns in terms of their association with burnout. All but one of the work-life balance items in Table 3 has a statistically significant association with levels of burnout. There is a linear, but not statistically significant, relationship between the physician’s re-

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ported connection to the community and burnout level. Otherwise, statistically significant relationships are noted with feeling a sense of belongingness, feeling respected by the community and feeling at home in the community—in every instance, physicians with lower levels of burnout are more satisfied with the community aspect of work-life balance. The measures for the family items in the work-life analysis also differ significantly across levels of burnout. Having more negative (lower) scores on items such as work leaving enough time for family, whether a spouse supports the respondent’s career, whether personal life is interrupted by work is associated with higher levels of stress and burnout.

DISCUSSION AND CONCLUSION With a chronic need for new physicians and the average Mississippi physician approaching his or her mid-fifties,26,27 understanding the relationships between career satisfaction, autonomy, and work-life balance may provide important clues about how processes of stress and burnout that can shorten medical careers can be avoided. Exploring the factors associated with physician burnout is a first step for crafting appropriate policies to maximize physician retention and high quality patient care. Research documents the risk that burnout poses for physicians cutting work hours or leaving the profession/retiring early. These are considerable risks for an underserved state like Mississippi, where high demands on too few physicians grappling with what they regard as unreasonable levels of third party interference in their practices undoubtedly contributes to processes of stress and burnout. Repeated studies have shown that autonomy and career satisfaction are tightly linked, which suggests that addressing physician concerns about clinical control over their practices (including practices and policies to minimize the burden of paperwork and administrative tasks) and minimizing threats to autonomy can be a pathway to higher levels of satisfaction, and by extension, lower levels of burnout. Although supportive commu343

nity and family environments may ameliorate some of career disappointments or threats to autonomy that physicians experience, policies obviously cannot dictate family or community support for physicians who feel like they are highly stressed or under siege. However, innovative policies and practices could help minimize the disruptions to personal/family life that stress practicing physicians, so that doctors have predictable periods off duty when they can focus on their families and non-work pathways to personal fulfillment. A sense of community connection is associated with lower levels of physician burnout. Consequently, a crucial retention strategy may be to devise strategies targeted towards newly recruited physicians (especially those from out of state) to support their continuous integration into the communities they serve. Most challenging, no doubt, will be finding ways to compensate for feelings of occasional or persistent burnout that may influence mid-career physicians to consider limiting their hours of practice or retiring early. After all, most mid-career physicians are likely well-integrated into their communities, having established long-time practices. But a reality is that many of these mid-career practices are located in small town and rural areas in Mississippi, where the sheer volume of need and demands on physician time may be a relatively intractable problem, particularly unless a new supply of medical professionals can alleviate some of the pressures on these mid- to later-career practices. Devising strategies that foster connections to their communities may help early career professionals avoid feelings of burnout, suggesting that nurturing community connections can be an effective recruitment and retention strategy early in a physician’s practice. Strategies that are successful in this regard may also have important indirect effects on later career physicians if they enable recruitment and retention of “new blood” into communities currently served by one or two overworked mid-career physicians. Interested readers can access more findings from the MSMD 2007/08 Mississippi Physician Workforce Survey in a series of four burnout research briefs online at the Northeast Mississippi AHEC website: http://www.nemsahec.msstate.edu/pubs.html.

REFERENCES 1.

2.

Butts CC, Cossman JS, Welford E. Where’s the Primary Care? A Spatial Analysis of Mississippi Generalists. http://nemsahec.msstate.edu/publications/healthmaps/generalist.pdf. 2008. Rohland BM, Kruse GR, Rohrer JE. Validation of a singleitem measure of burnout against the Maslach Burnout Inventory among physicians. Stress and Health. 2004; 20(2):75-79.

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12. 13. 14. 15. 16. 17. 18.

19. 20.

21. 22.

Crompton R. Gender and Work. In: Davis K, Evans MS, Lorber J, eds. Handbook of Gender and Women’s Studies. Thousand Oaks, CA: Sage Publications; 2006. Keeton KF, Fenner DE, Johnson TRB, Hayward RA. Predictors of Physician Career Satisfaction, Work–Life Balance, and Burnout. Obstet Gynecol. 2007; 109(4):949-955. Schwartz RW, Jarecky RK, Strodel WE, et al. Controllable lifestyle: a new factor in career choice by medical students. Acad Med. 1989;64:606-9. Schroeder SA. How Many Hours Is Enough? An Old Profession Meets a New Generation. Ann Intern Med. 2004:140(10): 838-839. Watson DE, Slade S, Buske L, Tepper J. Intergenerational differences in workloads among primary care physicians: A ten-year, population-based study. Health Affairs. 2006; 25(6):1620-8. Pham HH, Dever KJ, Kuo S, Berenson R. Healthcare market trends and the evolution of hospitalist use androles. J Gen Intern Med. 2005;20(2):101-107. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358-367. Eckleberry-Hunt J, Lick D, Boura J, et al. AcadMed. 2009;84(2)269-77. Spickard A, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA. 2002; 288:1447-1450 Schneider CE. The Practice of Autonomy: Patients, Doctors, and Medical Decisions. New York NY: Oxford University Press; 1998. Konrad TR, Williams ES, Linzer M, et al. Measuring physician job satisfaction in a changing workplace and a challenging environment. Med Care. 1999;27:1174-82. Landon BE, Reschovsky J, Blumenthal D. Changes in career satisfaction among primary care and specialist physicians, 1997-2001. JAMA. 2003;2389:442-9. Warren MG, Weitz R, Kulis S. Physician satisfaction in a changing health care environment: the impact of challenges to professional autonomy, authority, and dominance. J Health Soc Behav. 1998; 39(4):356-367. Mello MM, Studdert DM, DesRoches CM, et al. Caring for patients in a malpractice crisis: physician satisfaction and quality of care. Health Aff. 2004;23(4)42-53. Freeborn D. Satisfaction, commitment, and psychological well-being among HMO physicians. West J Med. 2001; 174(1):13–18. Steiger B. Doctors Say Morale is Hurting. Physician Exec. 2006;32(6). Light D, Levine S. The changing character of the medical profession: a theoretical overview. Millbank Q. 1988; 66(suppl 2):10-32. Williams ES, Konrad TR, Linzer M, et al. Physician, practice, and patient characteristics related to primary care physician physical and mental health: Results from the Physician Worklife Study. Health Serv Res. 2002;37(1):121-43. Huby G, Gerry M, McKinstry B, et al. Morale among general practitioners: qualitative study exploring relations between partnership arrangements, personal style, and workload. BMJ. 2002;325(7356):140. Jensen PM, Trollope-Kumar K, Waters H, Everson J. Build-

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23. 24. 25. 26. 27.

ing physician resilience. Can Fam Physician. 2008; 54:722729. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory, 3rd ed. In: Zalaquett Cp, Wood RJ, eds. Evaluating Stress: A book of resources. Scarecrow Education; 1997:191-218. Cossman, JS and D Street. Families, Communities and Physician Burnout. http://www.nemsahec.msstate.edu/publications/policybriefs/Family%20Community%20and%20B urnout--FINAL.pdf. 2009. Cossman JS. Mississippi’s Physician Labor Force: Current Status and Future Concerns. Jackson MS: Mississippi Health Policy Research Center Policy Paper. http://www.healthpolicy.msstate.edu/publications/laborforcereport.pdf. 2003. Street B, Cossman JS, Smith S, Butts CC. Mississippi Physicians: Characteristics and experiences of physicians in an underserved state. http://www.nemsahec.msstate.edu/publications/Physicians%20Practicing%20in%20Rural%20and %20Underserved%20Areas%20(3).pdf. 2009.

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AUTHOR INFORMATION:

Jeralynn S. Cossman, PhD, Clinton Wallace Dean’s Eminent Scholar and associate professor of sociology at Mississippi State University in Starkville, is the director of the Mississippi Center for Health Workforce.

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Phone: 662-325-7880 Fax: 662-325-4564 Email: Lynne.Cossman@msstate.edu

Support for this research is from the Mississippi State Medical Association, the Mississippi Academy of Family Physicians, the American Academy of Family Physicians, the Social Science Research Center at Mississippi State University and the Mississippi Center for Health Workforce at the Northeast Mississippi Area Health Education Center. We appreciate helpful comments from Sarah Smith and Katherine Harney.

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CLINICAL PROBLEM-SOLVING Presented and edited by the Department of Family Medicine University of Mississippi Medical Center Diane K. Beebe, MD, Chair

A Hole In One Deborah S. O’Bryan, MD

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41-year-old African American woman presented to the emergency department (ED) with a chief complaint of generalized weakness of 2 days duration. She had nausea and vomiting twice and diarrhea 3 or 4 times on the day of presentation and a history of abdominal pain with nausea, vomiting and diarrhea for 4 to 5 days. She had a history of an abdominal mass for several months but really noticed her abdomen getting bigger over the past few days. She denied any sick contacts. She denied any exacerbating or alleviating factors. She had a history of heavy menses for a couple of years. Her last menstrual period was 3 weeks before her presentation and lasted for 2 weeks. From the initial history, our differential diagnosis for the acute nausea, vomiting, and diarrhea includes viral, bacterial, and parasitic gastroenteritis. With her history of nausea, vomiting and diarrhea, it is likely that she is dehydrated. This severity of vomiting and diarrhea could also result in some electrolyte imbalances such as hypokalemia that would make her feel weak. Other causes of generalized weakness include hypoglycemia, hypotension, thyroid disease, medications, infection, malignancy and neurological disorders. Her prolonged

heavy menses could cause anemia and fatigue. With her history of a mass in her abdomen and heavy menses, could she have uterine fibroids or ovarian cysts? Could a malignancy explain the gastroenterological and the gynecological symptoms as well as the weakness? More information about the past medical history is needed. Her past medical history included hypertension and anemia, both diagnosed a month before presentation to the ED. At that time, a computed tomography (CT) scan was ordered because of her abdominal mass, but she never presented for the test. Until then, the patient had not seen a physician in years. Her medications included hydrochlorothiazide 25mg daily, naproxen (Naprosyn) 500mg twice daily as needed for dysmenorrhea and hydroxyzine (Atarax, Vistaril) 25mg as needed for anxiety. She had been taking these medications for a month. Her family history was positive for hypertension, heart disease, diabetes and kidney disease, and negative for cancer. Her mother died 3 months prior to the patient’s presentation to the ED, and the patient had been depressed as a result. She had never used tobacco, alcohol and illicit drugs. She had never been married, and she lived with her father. She had never had sexual intercourse and had never had a pelvic

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examination. She had no history of pelvic or abdominal surgery. From the past medical history, our differential diagnosis of weakness now also includes hypotension, anemia and depression. Additionally, she has been vomiting all oral intake, including medication; therefore, her blood pressure may be elevated from lack of medication, or it may be abnormally low from hypovolemia. Further, a diuretic can contribute to electrolyte imbalance. A month ago, she was diagnosed with anemia, which can cause fatigue. Depression and grief as experienced by our patient can also cause tiredness, fatigue or lack of energy. We need to perform a physical examination and proceed with laboratory analysis. Physical examination revealed a 41-year-old African American woman who was well developed, in no acute distress but appeared ill with generalized weakness. She was lying supine on the stretcher. Her vital signs were temperature of 97ÂşF, pulse of 101 beats per minute, respiratory rate of 18 breaths per minute, blood pressure of 88/50 mm Hg (104/59 mm Hg after a fluid bolus) and oxygen saturation of 96% while breathing room air. Head, ears, eyes, nose and throat examination revealed pale conjunctivae and dry mucous membranes. Cardiovascular examination revealed a prominent point of maximal impulse with regular rate and rhythm and no jugular venous distention. On abdominal examination, bowel sounds were decreased, the abdomen was distended and diffusely tender without rebound or guarding, and there was tympany over the upper abdomen. There was a firm, well circumscribed pelvic/abdominal mass that extended above the umbilicus. Skin examination revealed no rashes but palms were pale. Neurological and psychiatric examinations were normal. Since an electrolyte abnormality, such as hyponatremia or hypokalemia, or other derangements, such as hypoglycemia or anemia, could contribute to symptoms of weakness, fatigue or hypotension, I would like to obtain a metabolic profile and complete blood count. Because renal impairment could alter electrolytes, I would want to see her BUN and creatinine values. Laboratory results included a complete blood count with a white count of 59.2 K/uL, hemoglobin of 5.1 g/dL, hematocrit of 16.9% and platelets of 799 K/uL. Urinalysis was abnormal with 1+ protein, 1+ blood, 3+ leukocyte esterase, 30-49 white blood cells/hpf and 4+ bacteria/hpf. Chemistries revealed a sodium of 127 meq/l, chloride of 90 meq/l, bicarb of

11 meq/l, blood urea nitrogen (BUN) of 111 mg/dl, creatinine of 4.8 mg/dl, glomerular filtration rate of 13.31 mL/min/1.73m2, albumin of 3.1 g/dl and alkaline phosphatase of 170 U/L. Now we can see that our patient is very sick. Her weakness is the result of many different problems. Her tachycardia, dry mucous membranes, sodium and chloride indicate that she is dehydrated. Her BUN would probably be even higher except that she is malnourished as is evidenced by her low albumin. Infection is another cause of generalized weakness; she does have evidence of a urinary tract infection. But it also appears that she could have septic shock, as evidenced by her high white count, low blood pressure, tachycardia, metabolic acidosis, anion gap of 26 and renal failure. She may have acute pre-renal failure from hypoperfusion of her kidneys, chronic kidney disease or a combination. She has a profound chronic anemia. We know that it is chronic because she has a history of anemia but also because her vital signs are relatively stable. But what is causing the anemia? We know that she has had menorrhagia, and she also has renal failure. Perhaps she has a combination of excess loss and decreased production of red blood cells. So what is causing the pelvic mass and the heavy menstrual bleeding? The differential diagnosis includes uterine leiomyomas, an endometrial polyp or other mass including cancer, adenomyosis, dysfunctional uterine bleeding, endometriosis, ovarian tumors and cervical lesions including cancer.1 Cervical cancer is less likely considering her stated history of no sexual activity. Endometriosis or polyps would not be expected to cause such a large abdominal mass. Uterine adenoma, endometrial carcinoma and ovarian cancer are also considerations. Leiomyoma is more likely considering the frequency in African American women of this age and her history of menorrhagia.2 Next we need radiographs and a CT of the abdomen for further evaluation. Radiological evaluation included chest and abdominal radiographs. The chest radiograph revealed bilateral atelectasis, with no cardiomegaly, pleural effusions or infiltrates. The abdominal radiographs revealed air-fluid levels in the large bowel and the stomach, with possible free air under the right diaphragm. A CT of the abdomen and pelvis without contrast revealed a large amount of free fluid and free air. The scan also revealed a large uterus with multiple leiomyomata. Because of the free air in the abdomen, we know that our patient has a perforated viscous. She has an

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acute abdomen and needs emergent exploratory laparotomy. We do not know if the perforation is in the stomach or intestine, and we do not know what caused the perforation. Because of her severe anemia, she was immediately transfused with packed red blood cells and taken to the operating room where 2 liters of purulent matter was drained from her peritoneal cavity. She was found to have a 1 centimeter perforation in the left colon at the splenic flexure. Left hemicolectomy with end colostomy, appendectomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. The entire hysterectomy specimen, including uterus, cervix, fibroids, bilateral tube and ovary, weighed 2805 grams. The surgeon reported that the cause of the perforation was the large uterine leiomyoma obstructing the large intestine. In reviewing the English literature, we find very few case reports of intestinal obstruction and no reports of ruptured intestines in conjunction with uterine leiomyoma. Our search found only 7 patients with small bowel obstruction as a result of uterine leiomyomas,3-5 and only 1 report of large bowel obstruction due to a uterine leiomyoma.6 There was 1 report of small bowel obstruction in a twin pregnancy due to a large pedunculated uterine fibroid.7 The patient did well after surgery. When she was discharged from the hospital 10 days later, her kidney function was normal, her electrolytes had normalized and her hemoglobin and hematocrit were stable. Three and a half months later she had gained weight, her blood count was normal and she underwent a colostomy closure. Although intestinal obstruction and perforation are rarely the result of uterine fibroids, this complication should always be in the differential diagnosis of abdominal pain in women with large uterine fibroids as in our patient.

KEY WORDS:

REFERENCES 1.

2. 3. 4.

5.

6. 7.

Bukulmez O, Doody KJ. Clinical features of myomas. Obstet Gynecol Clin North Am. 2006;33(1):69-84. Ryan GL, Syrop CH, Van Voorhis BJ. Role, epidemiology, and natural history of benign uterine mass lesions. Clin Obstet Gynecol, 2005;48(2):312-324. Fontana R, Kamel PL. Small bowel obstruction associated with a leiomyomatous uterus. A case report and review of the literature. J Clin Gastroenterol.1990;12(6):690-692. Johnson HR, Miller JM. Intestinal obstruction caused by a uterine leiomyoma. South Med J. 1980;73(6):831. Jacobs LB, Bhagavan BS. Intraluminal obstruction of distal ileum caused by a uterine leimyoma. Mod Pathol. 1993;6(2):229-231. Chaparala RP, Fawole AS, Ambrose NS, Chapman AM. Large bowel obstruction due to a benign uterine leiomyoma. Gut. 2004;53(3):386, 430. Macdonald DJ, Popli K, Byrne D, Hanretty K. Small bowel obstruction in a twin pregnancy due to fibroid degeneration. Scott Med J. 2004;49(4):159-160.

AUTHOR INFORMATION:

Deborah S. O’Bryan, MD was a resident in the Department of Family Medicine at the University of Mississippi Medical Center in Jackson.

CORRESPONDING AUTHOR: Deborah S. O’Bryan, M.D. 2500 North State Street Department of Family Medicine University of Mississippi Medical Center Jackson, MS 39216 Phone: 601-815-5700 Fax: 601-815-5796 Email: debo3@bellsouth.net

LEIOMYOMA, UTERINE, INTESTINAL

OBSTRUCTION, PERFORATION

Clinical Problem-solving is a monthly feature of the Journal of the Mississippi State Medical Association. Clinical Problem-solving manuscripts are case-based and portray the sequential process of clinical decision-making when the physician is faced with a diagnostic dilemma. Cases may be unusual presentations of common diseases or common presentations of unusual diseases. Patient problems must be based on actual patients from your practice, not contrived patients, and the problem must be solvable. Cases with interesting and educational differential diagnoses are most appropriate. Patient information is presented in segments (indicated in boldface type in the manuscript). The clinician then shares with the reader (regular type) how the new information is synthesized and the rationale for critical decisions. The decision making process continues as new information emerges until there is resolution of the problem. Authors from all medical and surgical specialties are encouraged to submit manuscripts for consideration in this monthly feature. Manuscripts and requests for Instructions to Authors should be addressed to Dr. Replogle at Department of Family Medicine, 2500 N. State St., Jackson, MS 39216.

Review Committee: Chris R. Arthur, PhD; Diane K. Beebe, MD; Judy Gearhart, MD; Shannon D. Pittman, MD; William H. Replogle, PhD

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PRESIDENT ’S PAGE

WE NEED TO REFORM HEALTHCARE REFORM

Y

ou have to hand it to President Obama, Nancy Pelosi, and the merry men and women in the United States Congress. An “A” for effort is in

order. Since his June 15, 2009 appearance before the AMA House of Delegates in Chicago, the President and his Randy Easterling, MD Democratic sidekicks in the congress have executed a “full2009-10 MSMA President court press” in the gymnasium of public opinion. While he is touted to be quite an accomplished basketball player, it appears more and more as if this south paw from Chicago has grossly underestimated his opponent (the American public) and may well have dropped the ball. The Democratic healthcare reform initiative now has a name and a face; it is called H.R. 3200. While the 1000-page dissertation contains a smattering of tempting chocolates, hidden deep within this buffet of Democratic hogwash one can smell the decaying odor of a rotten fish called “public option.” The last several weeks have been fascinating, entertaining, and eye-opening. Reality TV has nothing on this seemingly endless number of town hall meetings that have sprung up in almost every community and hamlet in America. Much like fire ant beds in Mississippi, once a United States congressman and/or senator stamps out his most recent encounter with the public, another one equally as vicious springs up somewhere else in his or her own backyard. There appears to be no effective pesticide found that will eradicate the roar of public opinion concerning the issue of the government-run insurance program. Mr. President, what about “WE DON’T WANT A PUBLIC OPTION” do you not understand! While most Americans appear to recognize a need to make changes in the manner in which we receive, pay for, and disseminate the best health care in the world, an overwhelming number of citizens have serious concerns that yet another “government program” will not only add to an already insurmountable federal deficit, but result in an intolerable bureaucratic rationing of health care. Mississippi physicians, in large measure, share this same concern. If I may be so bold, allow me to clarify what I think is the essence of our endeavor to rebuild the healthcare system in America. I will hit only the high points. • Expand coverage and/or equal access to quality care for all Americans. This is certainly a noble goal, but practically impossible to achieve. Even under the president’s proposal, the Democratic program would cover at best only 97% of U.S. citizens.

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• Bring the escalating cost of health care under control. Again, this is another stellar objective that will be very difficult to accomplish. Granted, I am only a family doctor in rural Mississippi, but I cannot wrap my overworked and underpaid arms around how dumping an additional $1.8 trillion into the federal sinkhole will result in more cost-effective care. • Portability, allow U.S. citizens to purchase their own health insurance policies across state lines. The more expansion of an already proven free market system would in and of itself stimulate competition and drive prices down. • Do away with preexisting conditions. This may well be the most difficult goal to accomplish.

I would suggest to you that health care is tremendously personal to us all. The restructuring of how, when, under what circumstances, and what quality of health care we receive should deserve, no demand, a debate that is fact-based and void of political partisanism. If we really want to accomplish the lofty goal of providing quality, affordable health care to all Americans, let us put aside our political ideologies, and solve the damn problem! Allow me to make a few simple suggestions. First, strengthen the existing federal programs such Medicare and Medicaid. This could be done simply by doing away with the present SGR and pay us physicians a fair reimbursement for caring for the elderly and the disadvantaged. This in and of itself would expand access and improve quality of care. Second, pass federal tort reform legislation with teeth. This would, from day one, save the system approximately $125 billion a year. Physicians would no longer feel the burden to practice “defensive medicine.” Such legislation would also expand coverage in that it would unleash the already proven benevolent nature of the physicians and allow us all to care for more of the underprivileged. Tort reform in our own state of Mississippi has proven without a doubt to expand coverage, improve care, and slow down the rising cost of health care. Third, place into effect significant tax incentives for low-to-moderate income households to purchase their own insurance policies on the free market. This would encourage the 14-million uninsured that make up the “bullet-proof” generation (age 18 to 35) to purchase health insurance. Fourth, give tax incentives to businesses, large and small, to continue to provide employer-based policies at an affordable rate to their employees. Last, the albatross of preexisting conditions is formidable. However, if all insurance carriers were required by law to co-op together and create pools of policyholders with preexisting conditions, it would seem to me this would dilute the burden on any one company and might well create a vehicle where those individuals could be covered. This pool would, by definition, be at a higher risk, therefore more expensive. However, tax incentives to these companies would allow them to provide the care at a more affordable rate. Simply put, as a primary care physician, if I send nine well-insured patients to my local cardiologist, I fully expect him or her to see the 10th referral, even if they are uninsured or underinsured. If the present free market system allows insurance companies to make hundreds of millions of dollars a year in profits, pooling together to cover those with the preexisting conditions would be of little financial concern to the giants of capitalism. It has been said “there is no limit to what can be accomplished when no one cares who gets the credit.” With our health and the health of our friends and loved ones at stake, would it be too much to ask our President and our Congress to tear down the walls of partisan politics and simply work together to bring about a greater good for all Americans? We all deserve, and yes the taxpayers should expect, more out of our elected officials. The task is difficult, but not impossible. The rewards for succeeding are great, but the penalty for failure is much greater. Perhaps, we need to reform healthcare reform. Your partner in making Mississippi healthier,

Randy Easterling, MD President, Mississippi State Medical Association 352

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UMC SCHOOL OF MEDICINE

A New Year at the Medical School

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he beginning of each new academic year provides the 2009 WHITE COAT CEREMONY— opportunity to pause and reflect for a moment on the The White Coat Ceremony is held changes which have occurred over the last academic during orientation week and celebrates year and to look forward to the challenges of the upcoming year. the addition of the new medical There is much hustle and bustle on campus with one class of students to the larger family of students just having graduated (with many of then moving up to be medicine. The ceremony for the new interns here at the medical center), one new class entering, and students follows a guest speaker and two classes moving up to the next level. All the students are excited dinner. During the ritual, the students for some reason and their excitement and enthusiasm are and faculty read “A Covenant for contagious. Of all the qualities of academic medicine that drive Medical Education” which defines the some of us to choose this career path, none is more compelling to student-teacher relationship. The me than the freshness of the passion and the enthusiasm for students receive a Gold Foundation medicine found in our students and residents. Humanism in Medicine pin and sign Our student body is made up of young men and women who the student code of conduct, are are intelligent and also quite accomplished. As undergraduate “coated” with their short white coats, students, they excel in their coursework while very often and finally read the Oath of simultaneously managing a full plate of other as activities. They Hippocrates. Additionally, a copy of participate in research projects, make impressive contributions in “On Doctoring,” a medical anthology community service work, and are usually leaders on their edited by native Mississippian Dr. John undergraduate campuses. Stone, is given to every first-year Earlier this decade, the AAMC released its “Statement on the medical student in the country through Physician Workforce” which recommended medical schools a grant from the Robert Wood Johnson increase enrollment by thirty percent over the 2002 level. This Foundation. Photos by Jay Ferchaud, recommendation was based on a number of workforce and UMMC Public Affairs photographer. population studies conducted since 2000 which predict a physician shortage in the United States. In reports on physician per capita data, MS ranks at the bottom or near the bottom for physicians per capita in almost all rankings. It should be noted, however, that this medical school does a better job than most other medical schools in retaining graduates to practice in the same state. It is our vision to continue our efforts to increase our medical school class size so that we may better meet the needs of all Mississippians. This fall, 120 new first year medical students arrived on campus. The medical school curriculum is a perpetual work in progress in an effort to stay abreast of current education models, accreditation requirements, as well as new medical discoveries. The preclinical curriculum underwent a review and restructure several years ago with a goal toward a THE SCHOOL OF MEDICINE CLASS OF 2013 more integrated curriculum and increased JOURNAL MSMA, October 2009 — Vol. 50, No. 10

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opportunity for interactive learning. Now, when feasible, topics are aligned in time across courses. For example, while the student learns gross muscle structure in gross anatomy, they also learn the histological FIRST YEAR MEDICAL STUDENT, MEGHAN ALFORD, READING “A structure and biochemical COVENANT FOR MEDICAL mechanism of muscle EDUCATION” function. The course directors have worked together to provide increased integration of material for our students. In the clinical years, students today gain much of their experience in the new University Hospital. A graduate of this medical school from more than ten years ago might require a guided tour of the medical center to navigate from one hospital to another. The school and the medical center have grown in many ways. Current medical students have never known our campus without the DR. LORETTA JACKSON WILLIAMS, Batson Children’s ASSOCIATE DEAN FOR ACADEMIC Hospital, the Wiser AFFAIRS, PINNING FIRST YEAR Women’s and Infants MEDICAL STUDENT JAMES LEIGH Hospital or the Conerly GRIFFITH, JR. Critical Care tower. Looking to the challenges of the upcoming year, we acknowledge the transition of Dr. Dan Jones to the Chancellor position at the University of Mississippi. We are exceedingly proud of the work he has done and delighted his leadership abilities have been recognized in such a powerful manner. We look forward to identifying our next leader as someone with the vision to continue to raise expectations to promote excellence and transparency in all aspects of our mission as well as the discipline to drive us forward to meet the healthcare and education needs of the people of Mississippi. For our students, we will work hard to ensure that the momentum gained in both the growth of the class size and the expectations of increased levels of performance of the medical students is not compromised, but indeed continues to move forward. It is a great time to be a part of the medical center family. —LouAnn Woodward, MD Interim Dean, School of Medicine 354

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JOURNAL MSMA, October 2009 — Vol. 50, No. 10

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SPECIAL ARTICLE

More Than Just Drainage Samuel Moak, M1

I

Samuel Moak, M1

Since I have come to UMC, I have seen patients in consultation intermittently from Dr. Joe Moak in Brookhaven. I didn’t really know who he was when I first started receiving these consults, but I did note the patients were exceptionally well worked up and loved their doctor. More often than not, he had already figured out what was wrong with them and just wanted some support on an unusual diagnosis or syndrome. I talked to him by phone from time to time and saw him in Sam’s Discount Store where I learned the story of the Moak-Massengill Clinic in Brookhaven. It is a primary care clinic where two general internist brothers work together to provide care to a community which needs many more primary care physicians than are available. I learned more when Joe volunteered to teach in our resident clinic, something I really appreciated him doing. Joe and Ed Moak have been practicing together for 27 years NTRODUCTION

and are still going at it. On one of these occasions, Dr. Joe mentioned that his son had been acutely ill while a pre-med student at Vanderbilt and how grateful they were that he had survived the illness. Having a son of my own who was also pre-med, that story obviously got my attention. Several years later, I got a note from Samuel Moak looking for a summer job. At first, I did not know which Moak was his dad but figured out he had to be pretty bright, so I offered him a position working on several projects. He was a hard worker, and I knew he had the right stuff to become a fine physician. During the time we worked together, I found out he was Joe’s son and the one who had been so sick. We talked about this and he told me the impact that illness had on his family and himself. I encouraged him to write that down. The essay published in this month’s MSMA Journal is the result. From time to time, all of us become discouraged about the future of medicine and the future of health care. Coming in contact with physicians to be, like Sam Moak, should give us some level of assurance that all the tumult around us will work out because folks like Sam will be involved in the process. Sam started medical school at Tulane this fall.

I

Richard D. deShazo, MD Billy S. Guyton Distinguished Professor Chair, Department of Medicine

grew up with the romance of medicine. My father and uncle have practiced, lived and shared internal medicine in our hometown of Brookhaven for over twenty-five years. The better portion of my life has in some way been spent in the halls of their clinic, engaged in all manner of activities from doodling on dry erase boards to filing charts. When a friend fell ill or someone was injured on the football field, Dad and Uncle Ed were always there with a smile and assorted medical gear. They carried the day and became my heroes, along with other physicians. Although I have heard complaints that doctors are unsympathetic towards patients, I grew up discounting such talk as the grousing of a few malcontents. Others may have opined that doctors were arrogant and they could not relate to the experience of the patient; I always felt that was far from the truth. We knew that good doctors like Dad and Uncle Ed

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understood what the patient was going through, because we had seen how they treated those who came through their doors. Yet that same arrogance which we eschewed as a fault of others, in reality comprised our own mask of blindness which insulated us from a whole other side of medicine, the world of medicine received rather than the world of medicine administered. Like the blind man in the ancient fable who claimed that an elephant was shaped like a snake after only feeling its trunk, we too existed in a realm of confident ignorance, oblivious to the realities that lay before us. My adolescence sparked a yearning to begin the journey of becoming a physician, using the footsteps of my father and uncle as guideposts to my quest. High school and college were viewed as stepping stones into that profession, and by the time my college years were half finished, my perspective had been enriched by study, volunteering and shadowing. I was pre-med all the way and on the fast track to the big leagues. I had it figured out. When I woke up one morning in March of my junior year with a sore throat, I shined my flashlight on the back of my throat, saw a few white bumps, and dismissed my symptoms as mere mucus or at worst streptococcus. Not a big deal. I’d had strep before. By noon, a blanket of fatigue settled upon my shoulders, and my throat felt as if I had tried to swallow a small window pane only to have it shatter in my pharynx. Putting the pieces together in my mind, I figured that I had to have mono. The hunch was soon confirmed by a positive spot test at the student health center. For anyone exposed to large amounts of medical science for any amount of time, a weird, precarious balance inevitably develops between apathy and paranoia regarding one’s own health. When I called my dad, all I could do was grumble about missing at least a week of school. We weighed the options of coming home or waiting it out at Vanderbilt, and I retired to my bed and a diet of mostly liquids. Comfort did not quickly follow. People get mono every day, I was told. That may be true, but everyone also seems to have a mono story, and none of them is good. The typical mono war story describes a distant relative having mono for a period of time equal to a Presidential election campaign. As I lay in bed with little to do but experience my increasingly uncomfortable symptoms, I gained a newfound respect for the substance of these tales and realized that it was going to be difficult to try to get back to speed without help. The same day that I had my spot test, Dad was teaching first-year residents six hours away in Jackson, MS. I called him that Tuesday, and we talked for a while. He sounded calm on the phone, but something was different in his voice . He drove up that evening, and I shuffled out to meet him outside the dorm. He had on his poker face, a thin smile with hands behind the back, but I could tell his concern. I stayed in the hotel room with him that night but the pain that came from swallowing barely allowed me to doze. So he took me home. Once home, my face and neck swelled to linebacker size from lymphadenopathy, and I found that I could barely climb out of bed. Then Friday came. I awakened to choking that would not cease. Dad had left early that morning to check on a patient, and Mom was home in the next room answering emails. She responded to my frantic cry for help by briskly guiding me out of bed and hurrying me to the car. As fate would have it, Uncle Ed was passing near our house on his morning walk. He quickly instructed us to meet him at the hospital. During the shaky blur of the car ride to the ER, I heard the static muffle of my dad’s voice over my mom’s cell. Upon arrival, I was admitted to the hospital under the signature of my uncle. Things went well at first, and the choking stopped. The admission chest x-ray was normal, and the lab was compatible with mononucleosis. My uncle ordered an Epstein-Barr virus titer and suggested, all things considered, it would probably be best if I stayed overnight for observation. Things didn’t seem so bad. Antha, my dad’s office manager, even visited us and brought me a big cup of sweet tea. Later that evening and throughout the night, the staff noticed my difficulty in breathing. In the fetal hours of the morning, a second chest x-ray showed several small infiltrates mustering in the bottom corner of my right lung. The decision was made to transfer me from our small town in south Mississippi to one of the major medical centers in Jackson. As Dad rode with me in the ambulance, I began to have pleurisy while the morning sun flashed weakly through the passing rows of pine. Arriving at the medical center, another x-ray was taken. Dad later told me the reading went through him like a cold blade. “I looked at the x-rays, and it was like a textbook. Diffuse bilateral pneumonia.” I was started on a heavy course of antibiotics and moved to the ICU. By evening I had been placed on oxygen. Nothing could be cultured from my blood samples. It was anybody’s guess as to whether it was viral or bacterial. A CT scan taken after what would have been dinner time revealed numerous abscesses in the liver. Only a few hours later, these impersonal opacities became more than just images when my skin and eyes grew jaundiced. The results of the EBV titer drawn in Brookhaven arrived. My dad now recalls the number he saw on the printout as seeming to burn a hole in his eye. It was the highest titer that he or Uncle Ed had ever seen or heard of in either of their careers. The night wore on, and I continued to worsen while Mom and Dad held vigil at various points between my bed and

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the ICU waiting room. Mom led them in prayer each hour, and Dad kept anxious track of my lab numbers but was determined to let the doctors do their job without interference. As my values declined, his poker face crumbled. “You were going into ARDS and DIC from sepsis, and your platelet count just started plummeting.” My mom remembers my pulmonologist walking back to see them in one of those tiny family conference rooms. They asked him how things stood, and he grimly shook his head. “You need to be prepared for anything.” They said whatever could be said after such a statement, and then he left to check on something. Soon after that they had a conversation about placing me on a ventilator, but decided that I might be able to handle a bi-pap machine. For my part, the whole experience felt literally like a dream, more specifically, a nightmare. I remember the ICU nurse coming in, pushing a slug of morphine and then wrapping the positive pressure mask around my face. For the next thirty-six hours, my breath, indeed the whole of my life, was measured by the sterile gasps of this ghoulish device, gasps which were as constant as the silence of everyone else holding theirs. My dad and I have since talked of this dark time, and he says it took him to a place he had never been in medicine. “One thing I’ve learned is that no matter how much you know or how much experience you’ve had, you can always be tested. Especially if you are a generalist. Things can happen real quick, and you can get in over your head. I had never been as scared on a hospital floor until that night.” It took a long time to culture the germ infecting my lungs and liver. In the meantime, Dad enlisted the help of some of his colleagues to research what was going on with me. He says he remembers huddling in the ICU lobby with my mom when he suddenly recalled hearing about a case similar to mine at an ACP chapter meeting down in New Orleans several years before when I was in junior high. It had been a meeting that we had attended together, at a time when I was just becoming interested in medicine. The case presented that day had described the successful treatment of a gramnegative rod infection in an immuno-compromised patient which had started in the mouth, invaded the surrounding throat tissue and then migrated to the chest, eventually causing sepsis. Reasoning that a therapeutic edge might be garnered from the natural history of cases similar to mine, Dad set about calling friends and colleagues in the medical field for any sort of information they might have about cases with characteristics roughly matching mine. A few hours after these frantic appeals, my dad’s colleague, a pathologist at Brookhaven, found a case report which correlated with my case to a strikingly eerie degree. The report was from the previous year and detailed the treatment of a college student suffering from intense hepatic and pulmonary infections secondary to mononucleosis. The next day, a medical school professor at Vanderbilt whom I had shadowed the previous year contacted Dad with information that cases such as mine stretched back for decades in the literature, and for the most part seemed to be complications of something called Lemierre’s syndrome— the classic presentation of which is defined as sepsis stemming from an initial internal jugular phlebitis. This combined information was forwarded to my physicians just as my blood cultures came back positive for Fusobacterium bacillus, a gram negative anaerobic rod associated with dental disease and known to be both notoriously difficult to culture and slow to grow. The mechanism for its entry into my blood stream remains undetermined, but the overriding theory is that my tonsils initially harbored it and then released it into my blood stream upon becoming intensely inflamed by the Epstein-Barr infection. Continued bi-pap treatment as well as a narrowed spectrum of antibiotics tailored to fight a germ like Fusobacterium did the trick, and I was out of the hospital in eleven days. During one of my last nights there, Dad and I were alone in my room on the regular floor. It was a clear night outside the window, and through it we had a clear view of our state capitol, outlined and illuminated against the night sky. I was eating dinner. It took me a long time because I still couldn’t breathe so well, and my appetite wasn’t much better. Dad was flipping through channels, only stopping to watch something for a few minutes before moving on to the next. “How’s that…um…what is that? A steak?” he asked, gesturing to my plate. “It’s something, I’ll say that. What did you have to eat?” “Mom brought me a sandwich.” “Lucky.” “We’ll bring you one if you want.” “That’s OK. This stuff is better than what I had in the ICU.” “Well, son, whatever they bring you doesn’t really matter. What matters is that you’re here to eat it.” He paused and looked away. “You made it.” I looked at him then and remembered something else he had said the day before about how you never know what can happen in medicine. Whenever you think you’re on top, something comes along to knock you off. It strikes me that in medicine and in any field of life our ability to function effectively is often at odds with our own arrogance.

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“You never know what little bit of information can come in handy. I don’t care how unimportant it seems. Even then, sometimes you almost have to get lucky.” By this time in my recovery he had already told me about his recollection of the case in New Orleans. “You don’t remember this, but we almost didn’t go to that lecture. It was either that or go shopping with the girls, and I think you were the one who passed on that. Just goes to show. Little things make the difference. You have got to be alert when it comes to the practice of medicine.” There was mostly silence as I finished eating. He settled on one channel, and we both half watched the Wheel of Fortune spin for a while giving thousands to one and nothing to another. “You know,” I said, turning my gaze from the TV, “it doesn’t hurt to swallow anymore.” “Yeah, you’re about through with the mono, I think.” Then I asked him a question. “Hey, Dad, what made you want to come up and get me at Vanderbilt?” He paused for a moment then shook his head. “I don’t know. I just kind of felt like I needed to. And over the phone…well, I could tell from the way you sounded that it was a little more than just drainage.” That moment, I think it might have been the first time during that whole ordeal that I remember us laughing. Though at the time there were still two more years of striving to get into medical school ahead, I now reflect on this moment with the clarity of hindsight and see it to be emblematic of my spiritual and emotional arrival to a place where I finally understand what it means to be a physician. The science, the technology, the money--they mean nothing if the patient does not come first. During my eleven days in the hospital, my family and I went through a private, quiet hell. Our hell was the same hell that millions across the world go through every day when illness strikes. And, like the rich man begging Elijah for a drop of water to land on his tongue, we cried out for support, not to ease parched throats, but to soothe our distressed souls. In medical crisis, empathy becomes the highest currency even though it’s free. When my dad and I were laughing over that sandwich together, we might as well have been laughing at the fact that things seemed so different; suddenly everything was something to be happy about. Indeed, some of his long-time patients have commented to me that something changed in him after my ordeal. They say he no longer simply knows what they are going through--he understands. Still, my family and I are romantics when it comes to medicine, but we are romantics who understand that the romance comes not from achieving clinical success against disease but from giving something of ourselves to the patient. We understand this because our blindness was washed away, taken by a tempest and replaced by the lens of clear sight. ❑

—Samuel Moak, M1, Tulane School of Medicine

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LETTERS ED Utilization by Medicaid Beneficiaries

C

Dear JMSMA Editor:

rudden and colleagues are to be commended for their critical and detailed evaluation of emergency department utilization by Medicaid beneficiaries (July 2009 Journal MSMA, Emergency Room Demographics - Diagnoses, and Frequency of Use among Mississippi Medicaid Beneficiaries).1 I’m sure it comes as no surprise to those who treat patients in our state’s emergency departments that Mississippi Medicaid patients are four times more likely to use the ER than patients with private insurance.2 Also striking was their graphical depiction of ER utilization by county (Map 1).3 While the authors did not comment extensively on this phenomenon, it appears that ED use is substantially greater among Medicaid recipients in areas with tertiary hospitals (Rankin, Washington, Jackson counties), especially when viewed in comparison with the relative lower density of Medicaid beneficiaries within the county. North Mississippi (especially Lee, Lafayette, and DeSoto counties) seems to be the exception, with the reasons for this being somewhat of a conundrum. Why, for example, do the Mississippi Gulf Coast counties (George, Hancock, Harrison, Jackson) have relatively low percentages of population eligible for Medicaid, but are among the highest percentages in those accessing the ER one or more times per year? This is presumed to be “pre-Katrina” data, for the most part, so the devastation of private medical practices from the storm would not reasonably explain this disparity. However, the primary purpose of this editorial is to point out one particularly egregious but (hopefully) 1.

2. 3. 4. 5.

6. 7.

unintentional error on the part of the authors, and that is the assumption that treating patients in a hospital emergency department may be as cost efficient as providing care in the ambulatory clinic setting such as a doctor’s office. This erroneous belief appears to be primarily based on the assertions by Robert Williams in his 1996 article.4 What many, including the authors, do not appreciate, is that Dr. Williams’ article is fatally flawed due to his inherent financial bias, and should not be relied upon in evaluating true costs associated with ED versus office treatment. Williams was a national president of the American College of Emergency Physicians (A.C.E.P.) in the early 1990’s, a time when organized emergency medicine was intensely lobbying Congress to be included as a location for “primary care,” and thereby eligible for additional financial reimbursement for non-emergent patients seen in the ED. ACEP’s Board of Directors has historically been comprised of the major emergency department contract holders, thus, this was directly a “pocketbook issue” for those who generated large incomes from the employment of other ER physicians (i.e., “scrubs”) who actually saw and treated the nearly 100 million ER patients annually.5 In fact, Dr. Williams is presently Chairman of the Board, and a co-founder of Emergency Consultants, Inc., or ECI, which contracted for emergency room coverage with large numbers of hospitals across the United States.6 ECI, like most all other ER “contract management groups” employs the ER physicians directly (who are paid hourly), with the contract holder gleaning the income from direct patient care, thus, the more patients seen, the more money made by the contract holder.7

Crudden A, Cossman J, et al., Emergency room demographics- diagnosis, and frequency of use among Mississippi Medicaid beneficiaries. J Miss Med Assoc. 2009;50(7):219-223. Id. Id. Williams, RM. The costs of visits to emergency departments. New Eng J of Med. 1996;334(10):642-646. Anyone, Anything, Anytime: A History of Emergency Medicine. Brian J. Zink. Elsevier Health Sciences (2005) p. 248-250. (many of the “founders” of ACEP were owners, executive directors, or had financial interest in these large ER contract groups. Dr. Karl Mangold, who created Mangold Group, later known as Fischer Mangold, the largest emergency department staffing company in the U.S., is described by Zink as a “wheeler dealer” in obtaining emergency department “franchises” with his Group. Leonard Riggs, who formed the mega-entity EmCare, Inc., and other physicians who founded/owned contract management companies [CMC’s] such as Spectrum, Emergency Physicians’ Medical Group, and Coastal Emergency Care, who at one time boasted of holding over 400 hospital ER contracts nationally.) http://www.eci-med.com/about/executive-team.html Zink.

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None of these are required (or needed) by a local clinic or physician’s office, even if open for extended hours. Additionally, and perhaps more importantly than all of the above, the authors, Dr. Williams, as well as

President Obama, fail to appreciate that the same individual who presents to her doctor’s office as a wellknown patient of that primary care physician, will likely not engender the “million dollar workup” that the same patient will certainly receive when she comes to the ED and indicates she is a bit “out of breath.” For what selfrespecting ER physician, attempting to avoid the pitfalls of a missed MI or, God forbid, acute pulmonary embolus, could simply examine, reassure, and then discharge the slightly anxious lady from church who got a little excited during the pastor’s sermon? Rather, in the ER that patient will be immediately subjected to a: stat EKG, IV access (18 gauge at least!), binasal cannula oxygen, ABG’s, cardiac isoenzymes (CPK, CKMB, and troponin), CBC (with differential), betablockers, continuous pulse oximetry, ER telemetry monitoring, blood cultures (2 sets!), CMP, Urinalysis, stat portable CXR, ACE-inhibitors, Q 3 minute vitals, Urine tox screen, BNP, D-dimer, aspirin, venous dopplers, digoxin level, nitroglycerin, 2D bedside cardiac echo, and the inevitable spiral CT chest for PE protocol that it now seems every patient with a complaint between the bridge of the nose and the umbilicus now absolutely must have before discharge (or admission) from the ED. And 2 weeks later, when she comes back to the ER again with the same complaint, receive the entire workup again from start to finish, this time of course by a different emergency physician. Thus, it begs the question, as we are now engaged in a contentious national debate over access to care and the cost of providing this care, how does extending Medicaid benefits to even MORE patients result in LOWER healthcare costs? The answer, which the President does not want to believe, or perhaps doesn’t want the rest of us to know, is that it does not and cannot, at least under the present scheme. When a patient with private insurance visits the ER, it is understood the patient will likely be responsible for a co-payment, and meeting a sizeable deductible, and therein is the disincentive to utilize the ED as an expensive means of doctor’s office visit. Alternatively, when the Medicaid patient presents to the ER, the cost is zero to the patient, but as we all know, it is certainly not “free.”10 Emergency Department care is generally expensive care, and it doesn’t matter if you have Medicaid, Medicare, private insurance or no coverage at all. ER’s deliver high quality care, but it cannot be as cost effective as a physician’s office or clinic for low level complaints like

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Williams’ argument is amusing from an intellectual standpoint, as he attempted to make the case that treating a patient with a non-urgent medical problem such as a “cold” or URI was just as cost-effective in the ER as it was for the same patient to be treated in a local doctor’s office. This article was initially the premise of Williams’ doctoral thesis in health administration, and it was eventually submitted for publication. It remains the sole foundation for ACEP’s current Policy statement that it is “costeffective” to provide non-urgent, primary care in our nation’s emergency departments,8 though paradoxically ACEP simultaneously decries via its own website the pressures of “ED overcrowding” and claims (correctly in this instance) that overcrowding presents a threat “to patient safety and access to emergency care for everyone.”9 Unfortunately, this argument does not pass the “straight face” test, as it appears to ignore the tremendous costs of:

1) maintaining large numbers of highly trained staff (multiple physicians, mid-level providers, nurses, respiratory therapists, x-ray technicians, lab technicians, CT technicians, ultrasound technicians, orderlies, clerical staff, social workers, medical records staff, security guards, etc.) that the average small to medium size ER is required to have available twenty four hours a day, seven days a week. 2) maintaining a large physical plant with electricity, oxygen, suction lines, generators, x-ray equipment, computers, etc., as well as the staff to repair these items when they break down. 3) maintaining supplies and stocks of splints, bandages, crutches, IV’s and fluids, as well as a whole pharmacy of medications (many of which have limited shelf life). 4) maintaining blood banks & clinical laboratories to perform an extensive array of diagnostic evaluations, all required to be JCAHO compliant. 5) maintaining current and available surgical and obstetrical crews, on-call physicians in all available specialities, and keeping ED areas free (but staffed and ready) in the event of medium to major trauma arriving instantly via ambulance.

8. 9. 10.

http://www.acep.org/pressroom.aspx?LinkIdentifier=id&id =25902&fid=3496&Mo=No http://www.acep.org/pressroom.aspx?LinkIdentifier=id&id =25906&fid=3496&Mo=No http://www.medicaid.ms.gov/Manuals/Section%203%20-%20Beneficiary%20Information/Section%203.08%20%20Beneficiary%20Cost%20Sharing.pdf (The Mississippi Division of Medicaid applies a beneficiary “co-pay” in the amount of $3 for certain medical services, but this co-pay can be waived in the event the beneficiary asserts he/she cannot afford the co-pay, and is also not required in instances of “emergency services,” and it does not apply to pregnant women, infants, or children under the age of 18.)

respiratory infections, earaches, colds, rashes, sprains, conjunctivitis, sinusitis, and contusions. Crudden and colleagues did not evaluate the hospital admission rate among those Medicaid beneficiaries seeking care in the ED, which may be helpful in correlating the level of acuity of these ER visits, but the authors did provide data which supports that a huge percentage of presentations were non-urgent and/or non-life/limbthreatening, e.g., 8.6% were dermatologic ailments, 21% respiratory (of which only one in 20 of these were “pneumonia”), and 6.5% of all visits were for ear infections.11 These findings are strongly reinforced by official reports from the Centers for Disease Control. In the most recent report from August 2008, the CDC confirmed Medicaid/SCHIP patients have an ED use of 82 visits per 100 patients, where private insurance patients present to the ER at a rate of only 21 per 100.12 At time of triage, only 5% of patients were deemed by skilled ED staff to have a need to be seen “immediately.”13 If need for admission can be inferred as an indicator of urgency of care, note that only 12.8% were admitted to the hospital, and only 1.9% were admitted to the ICU.14 Finally, our authors suggest in their last paragraph that patients with “transportation difficulties” or other factors may make the emergency department “an appropriate health care choice.”15 Lack of available transportation is never a sufficient reason to access the hospital’s emergency department (over an office setting), as the sole underlying premise is the problem is by definition non-urgent and could be treated in a clinic or physician’s office. ED folklore is rife with incidences of patients who summon an ambulance because they “didn’t have a ride;” in fact, hardly anyone who works in an emergency department has not experienced this phenomenon firsthand. Unfortunately, this scenario is expensive, wasteful, and potentially hazardous to others who may have a real emergency for which an ambulance is temporarily unavailable. Further, Division of Medicaid Policy § 53.22 expressly excludes services which are solely for the “convenience of the beneficiary” (or physician) as not medically necessary,16 and Policy § 8.02 prohibits ambulance utilization unless the patient is transported to

the nearest hospital, AND other means of transport are contraindicated based on the patient’s condition, AND the “emergency is sudden and of such severity that absence of immediate medical care could reasonably result in permanently placing the patient’s health in jeopardy.”17 Fortunately, there are mechanisms which may be effective in lowering health care costs for the Medicaid population. Greater responsibility by the beneficiary is imperative, but having an identified, available primary care physician (or, in appropriate cases, a supervised nurse practitioner) is the most effective means of reducing unnecessary ER utilization while still maintaining quality care. Managed care applications for Medicaid populations have experienced varying success in other states, and may soon be implemented in Mississippi.18 Direct incentives to beneficiaries, while a novel concept, may also be effective. The “medical home” model espoused by numerous medical groups is likely to be the best choice. Extending Medicaid coverage to those who cannot afford medical insurance is a laudable goal, but it incurs additional costs through federal taxation or other means of revenue generation and requires “matching funds” to be appropriated simultaneously at the state level. However, simply expanding the availability of Medicaid will increase health care costs, not lower them. Utilization of our state’s already over-burdened emergency departments as “24 hour Medicaid clinics” is not cost effective and cannot be sustainable.

—Joseph Blackston, MD, JD Jackson

The comments expressed in this Journal are those of the indicated author. Letters and opinions are not expressions of the views or official policies of the Mississippi State Medical Association. We invite the membership to submit comments for publication regarding any opinion expressed or information contained in the Journal. Send to: Lucius Lampton, MD, Editor, P.O. Box 2548, Ridgeland, MS 39158-2548 or email KEvers@MSMAonline.com. We encourage your comments.

11. Crudden, et. al. 12. Pitts SR, Niska RW, et al., National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary. Number 7, August 6, 2008, National Health Statistics Reports, Centers for Disease Control and Prevention, Department of Health and Human Services. (These bi-annual reports on Emergency Department utilization were previously referred to as the “Advance Data” but now are deemed under the purview of the National Health Statistics Reports.) 13. Id. 14. Id. 15. Crudden, et al. 16. http://www.medicaid.ms.gov/Manuals/Section%2053%20-%20General%20Medical%20Policy/Section%2053.22%20%20Medically%20Necessary.pdf 17. http://www.medicaid.ms.gov/Manuals/Section%208%20-%20Ambulance/Section%208.02%20-%20Definitions.pdf 18. http://www.medicaid.ms.gov/Documents/MS%20 Coordinated%20Care%20Program%20Proposal%20Summary%20Rev01282009.pdf (The MississippiCAN Program enrolls “target populations” of Medicaid beneficiaries in a managed care model.)

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EDITORIAL

I

At Last

didn’t realize that it would be this difficult.

Come December 31 (I’ve checked ... it’s on a Thursday), I plan to retire after 40 years of practice. On top of my game, hopefully. And, as if that isn’t enough, Beth and I will be relocating to Jackson. Our daughters insisted that we make the move while the choice was still ours. The fact that our four adorable grandchildren will be within a stone’s throw had no bearing on our decision.

Where did these 40 years ... this lifetime ... go? When we arrived in Kosciusko, our now 40-year-old daughter was a mere 4-month-old babe-in-arms. After everyone got past the “Oh, I remember when you were about this high (hand extended at about 3 feet) at your dad’s grocery store” or “I remember when you were drum major of the band,” my practice settled in for the long haul. Kosciusko and I seem to have developed into a mutual admiration society.

The memories of joyous deliveries are indelible. The Lord’s mercy for terminally-ill patients has been appreciated. The scars of malpractice suits have faded.

Beth has been the consummate physician’s wife: loving, supportive, involved, and noncontroversial. Our children both received excellent educations in the Kosciusko public schools and seem to be “reasonably” welladjusted adults.

Now that the word is on the street, patients are approaching me with the obvious (and not so obvious) questions and comments: “We’re praying that your house won’t sell.” “What will you do with all those pigs?” “Who do you want me to change to?” “I don’t know what me and my family will do when you leave.” I’m hoping that it will work sort of like a junior high romance. After the gut-wrenching breakup, there’ll be a new love interest by the next week, and I’ll be just a figment of their imagination. Insight into this retirement thing was provided by, of all things, a recent television program about Steve McNair, “The Death of a Titan.” One of his former teammates, also retired, reminded the host, “When the new season rolls around, do you know what it feels like not to be gettin’ in shape, learnin’ the plays, and dressin’ out?” Hopefully, I have enough interests to keep me mentally and physically engaged in this afterlife.

Sentiments on a “Happy Retirement” card seem to say it all: Look back with pride on all you’ve accomplished, look forward with excitement to all of the adventures ahead, and just enjoy yourself—you’ve earned it. Wishing you all the life-is-good moments you deserve, —Stanley Hartness, MD Associate Editor

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NEWS

Former AMA Trustee Dr. Benjamin Nominated to be Surgeon General

Obama also picks former Human Genome Project chief Dr. Collins to be NIH director

W

Doug Trapp, AMNews

ashington - President Obama’s choices to be the nation’s top physician and top scientist are both hands-on practitioners with extensive leadership

experience. On July 13, Obama announced that he was nominating Regina M. Benjamin, MD, a family physician from southern Alabama, to be surgeon general. Dr. Benjamin, 52, became the first woman and first African-American president of the Medical Assn. of the State of WITH HER NOMINATION BY PRESIDENT OBAMA, DR. Alabama in 2002. She also completed a term in June as chair of the REGINA BENJAMIN SAYS SHE WILL EDUCATE PEOPLE ON AMA Council on Ethical and Judicial Affairs and served on the AMA HEALTH SYSTEM REFORM. “I WANT TO ENSURE THAT NO Board of Trustees from 1995 to 1998, becoming the first physician ONE – NO ONE – FALLS THROUGH THE CRACKS AS WE IMPROVE OUR HEALTH CARE SYSTEM.” under 40 to serve on the board in a non-resident role. On July 8, Obama nominated Francis S. Collins, MD, PhD, as director of the National Institutes of Health. Dr. Collins, 59, led the Human Genome Project – an effort to sequence and map human genes, that concluded in 2003. He left his position as director of the NIH’s National Human Genome Research Institute in 2008 after 15 years but maintains a lab at the NIH’s Bethesda, Maryland, campus. Both nominees must first be confirmed by the Senate. AMA President J. James Rohack, MD, said Dr. Benjamin has an impressive list of accomplishments, including receiving a MacArthur Fellowship in 2008, commonly known as the “genius grant.” But awards are not her main focus, he said. “Dr. Benjamin’s most important qualification for surgeon general is her deep commitment to her patients.” Dr. Benjamin said in the White House Rose Garden announcement that the deaths of close relatives from preventable diseases drove her to focus on public health. “My father died with diabetes and hypertension. My older brother, and only sibling, died at age 44 of HIV-related illness. My mother died of lung cancer, because as a young girl, she wanted to smoke just like her twin brother could.” Dr. Collins’ colleagues said he is a natural choice to head the primary federal agency for funding and conducting medical research because of his thoughtfulness, willingness to listen and experience as a spokesman for the genome mapping effort. “He’s a forceful personality,” said Tom Murray, PhD, head of the Hastings Center, an independent bioethics research institute. “He wants to hear from people who don’t agree with him.” If confirmed, Dr. Benjamin would be the nation’s lead public health educator. Fellow physicians see the role as a good fit. Besides experience with family illnesses, Dr. Benjamin said she also was influenced by her medical school training under David Satcher, MD, PhD, who later became surgeon general, and others who focused on public health issues in underserved areas. Jorge Alsip, MD, the Alabama medical society’s president, said Dr. Benjamin has seen how much patients in poor and rural areas appreciate her help. “That can’t help but affect you and make you want to do something for these people,” said Dr. Alsip, an emergency physician who has known Dr. Benjamin for more than 15 years.

PATIENTS BEFORE PROFITS

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Dr. Alsip also said Dr. Benjamin is tenacious. “If Regina’s in a fight, don’t ever bet against her.” She rebuilt her clinic in Bayou La Batre, Ala., twice after hurricanes destroyed it and is rebuilding it a third time after a fire. Obama said his surgeon general pick has personally witnessed how the U.S. health system is broken. “She’s seen an increasing number of patients who’ve had health insurance their entire lives suddenly lose it because they lost their jobs or because it’s simply become too expensive.” Dr. Benjamin lamented the difficulty some doctors face in caring for patients, regardless of ability to pay. “It shouldn’t be this expensive for Americans to get health care in this country,” she said. Obama said Dr. Benjamin has forgone a salary when her clinic faced financial hardship. Jeff Terry, MD, chair of the AMA’s Alabama delegation and a urologist, said Dr. Benjamin has proven herself through work in organized medicine and elsewhere. The two co-founded the young physicians section of the state medical society nearly two decades ago. Since then, she has held leadership positions in physician organizations and other groups. Dr. Benjamin is also probably more politically liberal than many physicians on Alabama’s Gulf Coast, Dr. Terry said. “Maybe President Obama saw a little of that in her.” Obama lauded Dr. Collins’ experience in the July 8 announcement. “Dr. Collins is one of the top scientists in the world, and his groundbreaking work has changed the very ways we consider our health and examine disease.” Dr. Collins’ laboratory discovered several important genes, including those responsible for cystic fibrosis and Huntington’s disease. Acquaintances and colleagues predicted that Dr. Collins would do a good job representing NIH in front of lawmakers and others. He is a very approachable person who doesn’t rely on jargon to communicate, said Sean B. Tipton, spokesman for the American Society of Reproductive Medicine. “He has an ability to interact with the public and with policymakers and the press that I think will serve him very well as an NIH director.” The Hastings Center’s Murray said that if Dr. Collins ever made a mistake, it may be that he was a bit overly enthusiastic when describing the potential for breakthroughs when he was leading the Human Genome Project. Still, “I can’t fault the scientist who really believes in their work for being enthusiastic as they talk to Congress,” Murray said. Dr. Collins has garnered attention by professing that his belief in God can coexist with his pursuit of science. He’s written books on the topic, including the 2007 best-seller The Language of God: A Scientist Presents Evidence for Belief. He is also founder and president of the BioLogos Foundation, whose purpose is to find compatibility between the scientific and religious searches for truth. In an interview with the spiritual Web site Beliefnet in 2007, Dr. Collins said Christians who reject scientific evolutionary theory are also rejecting humans’ ability to understand, a God-given skill. But there are limits to the questions science can answer, such as why we are here or what happens after death, he said. William Hurlbut, MD, a consulting professor of neuroscience at Stanford University and a former member of President George W. Bush’s Council on Bioethics, said the idea that science and religion can’t coexist is ridiculous. “A person with Francis’ background is a very wise choice” for NIH chief, he said.

BOTH SCIENTIFIC AND RELIGIOUS

AND THE NOMINEES ARE ... REGINA M. BENJAMIN, MD

FRANCIS S. COLLINS, MD, PHD

Hometown: Daphne, Ala. Education: BS, Xavier University, New Orleans (1979); MD, Morehouse School of Medicine/University of AlabamaBirmingham (1984); MBA, Tulane University (1991) Professional experience: Family physician, private practice (1984-present), founder and CEO of the Bayou La Batre (Ala.) Rural Health Clinic (1990); member, American Medical Association Board of Trustees (1995-98); president, Medical Society of the State of Alabama (2002); chair, Federation of State Medical Boards (2008) Hobbies: Hiking, singing in church choir Of note: Was the first African-American female member of the AMA Board of Trustees (1995)

Hometown: Staunton, Va. Education: BS, University of Virginia (1970); PhD, Yale University (1974); MD, University of North Carolina (1977) Professional experience: Postdoctoral fellow in human genetics and pediatrics, Yale Medical School (1981-84); assistant professor, professor of internal medicine and human genetics, University of Michigan (1984-1993); director, National Human Genome Research Institute, National Institutes of Health (1993-2008) Hobbies: Playing guitar, riding motorcycles Family: Married to Diane; two children: Margaret and Elizabeth

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This article is reprinted with permission from American Medical News, July 27, 2009.

NUMBERS COUNT

How Does Health Care Correlate to America’s Budget?

H

ealth care reform is sure to be at the forefront of the federal agenda for some time to come. It may be interesting to look at just how American health care relates to the country’s budget. The following statistics were provided by Congressman Roger Wicker’s office and originated from the U.S. House of Representatives Budget Committee, the Congressional Budget Office and The Heritage Foundation. • The total U.S. health care spending each year is $2.1 Trillion.

• 16% of the U.S. gross domestic product (GDP) is annually spent on health care.

• The U.S. spends twice as much per capita on health care as other industrialized nations. • 50-cents of every health care dollar spent in the U.S. are spent by the government. • 18% of the federal budget is spent on health care programs. • 20% of the federal budget is spent on national defense.

• Medicare and Medicaid are expected to grow by more than 7% each year for the next five years.

• The U.S. economy is expected to growth less than 3% per year for the next five years. • $34 Trillion is the amount of Medicare’s unfunded obligations for the next 75 years.

William Gunther, Director of the Bureau of Business and Economic Research at the University of Southern Mississippi, was quoted by the Clarion Ledger as estimating that more than 500,000 residents of Mississippi are not covered by a health plan. That’s more than 18% of the state population or almost one-infive Mississippians. He had more statistics: • In 1980, Americans spent about 10 % of their budgets on medical care.

• In 2007, Americans spent more than 17% of their budget on medical care while spending 13% on food, 15% on housing and less than 3% on education. ❑

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IMAGES IN MISSISSIPPI MEDICINE

AMERICAN MEDICAL ASSOCIATION (AMA) ANNUAL MEETING, JUNE 1990 — Jean Hill of Tupelo was president of the AMA Alliance (then Auxiliary) in 1989-90. Here she presents a check for a million dollars on behalf of the Auxiliary to benefit the AMA Foundation. The amount given was actually a million dollars and 25 cents, which Mrs. Hill gave as a quarter in coin to mark the first time the Auxiliary had given more than a million dollars. The AMA Auxiliary name was later changed to the AMA Alliance to encourage more male members to join. Following in Jean’s footsteps, Dr. J. Edward Hill went on to become president of the AMA, 2005-06.

The Pen is Mightier than the Sword

Express your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers.

You can submit your letter via email to KEvers@MSMAonline.com or mail to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.

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