September
VOL. LI
2010
No. 9
You Protect and Serve Your Patients, Let Us Do the Same For You!
We Serve Our Customers Above All Else! Our core group of attorneys is highly specialized in the medical malpractice field and has a reputation for providing aggressive defense for our physicians. Advocate, MD is available 24/7 and provides quick response times when you need us most. We take pride in promptly investigating, realistically evaluating, and expeditiously handling all incidents, claims, and lawsuits. It’s your money, your policy, and your decision to fight or settle a case. We provide unrivaled protection so that you can focus on protecting and serving your patients. Medical Defense Coverage is available with separate limits, no deductible or co-insurance provision. Coverage includes: HIPAA/HITECH, Medical Associations, EMTALA/Patient Anti-Dumping, CLIA, ADA, OSHA, Medicare/Medicaid billing and abuse, Professional Licensing Agencies, Subpoenas, Billing Errors, Peer Reviews, Hospitals/Surgical Centers, Stark & Anti-Kickback, Shadow Audits, and RAC Audits.
Protection You Deserve. Call Now!
(800) 686-2734 www.AdvocateMD.com
We offer many types of policies for Mississippi physicians. Please contact us for policy benefits. Medical Defense coverage is offered as a separate endorsement, for details visit www.AdvocateMD.com. Discounts are subject to underwriting approval and some restrictions may apply. For the latest rating information, visit www.ambest.com. All rights reserved. Š 2010 Advocate, MD Insurance of the Southwest Inc.
Lucius M. Lampton, MD EDITOR D. Stanley Hartness, MD Richard D. deShazo, MD ASSOCIATE EDITORS Karen A. Evers MANAGING EDITOR PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors THE ASSOCIATION Tim J. Alford, MD President Thomas E. Joiner, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: JOURNAL MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright© 2010, Mississippi State Medical Association.
Official Publication of the MSMA Since 1959
SEPTEMBER 2010 SCIENTIFIC ARTICLES
VOLUME 51
NUMBER 9
Can the Delta Stop Singing the Blues?
Jessica Harpole Bailey, PhD; Tracilia “Drew” Beacham, RN, MSN; Katie Weeks, MA, CCC-SLP; C. Cory Smith, RN, BSN; Michelle Horn, MD and Vincent E. Herrin, MD
Surgical Management of Eyelid and Periocular Cancers Milam S. Cotten, MD
PRESIDENT’S PAGE
Promise and Hope for Healthy Schools
242 247
253
Tim J. Alford, MD; MSMA President
SPECIAL ARTICLE
Mississippi Women in Medicine Leading the Way
258
Karen A. Evers, Managing Editor
EDITORIAL
Sacred Spaces and Higher Ground
255
Let’s Not Go Down Without A Fight
257
Richard D. deShazo, MD; Associate Editor
Thomas E. Joiner, MD; MSMA President-Elect
RELATED ORGANIZATIONS
Mississippi State Department of Health University of Mississippi Medical Center MSMA Alliance
250 272 275
DEPARTMENTS
Legalease Images in Mississippi Medicine Poetry In Medicine The Uncommon Thread Placement/Classified
273 276 277 278 279
ABOUT THE COVER:
“HOPE PREVAILS”- William F. Pontius, MD took this photograph while visiting with a family member at St. Dominic’s Cancer Center on September 11, 2009. The picture was taken while awaiting the results of the latest CT scan and a consultation with an oncologist. The photo was made from the mezzanine floor as the composition was impressive from this perspective. The flag is flown at half-staff to honor the innocent Americans and people from around the world who lost their lives as a result of the terrorist attacks of September 11, 2001. Dr. Pontius is retired from nine years as a family practitioner and 25 years as a diagnostic radiologist. He resides in Ocean Springs with his wife, Mollie. ❒
September
VOL. LI
2010
No. 9
SEPTEMBER 2010 JOURNAL MSMA
240
An Academic Medical Center Is Not Like An Ordinary Hospital. As a physician, you ask more of an Academic Medical Center. You ask us to invent new ways to diagnose and treat disease. To lead the medical research that can give us all better lives. You ask more of University of Mississippi Health Care. You ask us to offer the highest level of medical care to our mutual patients, every day. To push the boundaries of what is possible. This is University of Mississippi Health Care. Your Academic Medical Center. Expect more.
Talk doctor-to-doctor at 866.UMC.DOCS or learn more at umhc.com.
241
JOURNAL MSMA SEPTEMBER 2010
• SCIENTIFIC ARTICLES •
Can the Delta Stop Singing the Blues?
A
Jessica Harpole Bailey, PhD; Tracilia “Drew” Beacham, RN, MSN; Katie Weeks, MA, CCC-SLP; C. Cory Smith, RN, BSN; Michelle Horn, MD and Vincent Herrin, MD
BSTRACT
This article was written to describe a collaborative effort between the University of Mississippi Medical Center and the Delta Health Alliance to increase primary care providers in the 18 counties designated as the Mississippi Delta. Journals compiled by trainees were analyzed to reveal issues significant to practicing in a rural area from the perspective of medical students and residents who participated in the program. Patient noncompliance, provider sensitivity to cost, continuity of care, and quality of the doctor-patient relationship were all identified as significant issues by the trainees.
KEY WORDS:
INTRODUCTION
PRIMARY CARE PROVIDERS, RURAL HEALTHCARE, MISSISSIPPI DELTA
On the dawn of our nation’s healthcare reform initiative, much discussion has been focused on the predicted shortage of primary care providers. However, in Mississippi, we don’t have to wait for this predicted shortage, as we are already experiencing it. Nowhere is this realization more prevalent than in the Mississippi Delta. Classified as an underserved area, the Delta population suffers from health disparities unequaled in other regions of rural America.¹ The Mississippi Delta is classified as the fourth most rural locality in the United States. All 18 of the designated Delta counties experience poverty rates above the national average, according to the
AUTHOR INFORMATION: Dr. Bailey is the director of educational programs for the School of Medicine at the University of Mississippi Medical Center. She serves as primary investigator for the Delta Health Scholars Program (DHSP) and has had oversight of the DHSP project for the past two years. Mrs. Beacham is an assistant professor and director of multicultural affairs at the University of Mississippi School of Nursing. Her research interests include reducing health disparities by increasing the number of ethnic minority healthcare professionals. Ms. Elkins is an instructor in speech language pathology at the University of Mississippi Medical Center. Mr. Smith is a clinical nurse in the Department of Oral-Maxilofacial Surgery and Pathology. Dr. Horn is the clerkship director for the Department of Medicine and supervises all third and fourth year medical student clinical activities with internal medicine. Dr. Herrin is the program director for the internal medicine residency program. He oversees all clinical rotations for the internal medicine residents. CORRESPONDING AUTHOR: Dr. Jessica Bailey, Director of Educational Programs, School of Medicine – UMMC Graduate Medical Education Office, 2500 North State Street, Jackson, MS 39216. Phone: 601-984-5530, Email: jhbailey@umc.edu.
2004 US Census data.² Delta residents represent a very vulnerable population in the most underserved counties in our nation. Although health status and life expectancy have improved for most US citizens in recent years, this is not true for the Delta, where the burden of chronic disease is exacerbated by the impact of crushing poverty. Access to healthcare for chronic morbidities and access to preventive medicine is quite limited.¹ In order for America to make progress in national health reform, underserved regions like the Mississippi Delta must be addressed. No one will claim that the supply of health professionals in rural areas of our country is sufficient. Research provides evidence that rural areas have fewer primary healthcare providers than the US as a whole.³ Rural practitioners are predominantly primary care providers, a specialty whose supply has been in a steady decline in recent years. To complicate matters even more, 20% of Americans live in rural areas and only 9% of medical doctors choose to practice in rural areas. A 2010 publication by Chen, Fordyce, Andes, and Hart 4 indicates that the University of Mississippi Medical Center is third among the nation’s medical schools producing the highest percentages of graduates practicing in rural areas, coming in just under West Virginia University and the University of Minnesota-Duluth. However, despite continued efforts to increase the number of healthcare providers in rural areas, disparities between supply and demand persist. In most rural areas of the country there are about 170 physicians per 100,000 people. In Mississippi, however, there are only 26.62 primary care physicians per 100,000 people.¹ Fifty-six percent of Mississippi’s physicians are practicing in four urban areas, and the metropolitan area of Jackson is home to 28% of the state’s primary care physicians.6 A collaborative project between the University of Mississippi School of Medicine and the Delta Health Alliance has been initiated to combat the shortage of primary care physicians in the Delta. The program, originally designed by Dr. Rick deShazo of the Department of Medicine at the University of Mississippi Medical Center, is called the Delta Health Scholars Program (DHSP) and is in its second year of operation. This project partners rural primary care healthcare providers with fourth year medical students and residents. The rural providers
SEPTEMBER 2010 JOURNAL MSMA
242
serve as preceptors for a month long clinical rotation to expose the students and residents to life as a primary care provider in a rural health clinic. Delta Health Alliance (DHA) is a tax-exempt, non-profit organization, located in Stoneville, Mississippi, whose mission is to improve the health of the individuals who make the Delta their home. DHA provides funding for the participating preceptors, funding to reimburse trainees for expenses incurred during the rotation, and financial support for administration of the program. Fourth year medical students enroll in a course for a rural clinical experience and receive academic credit for the month they spend with the preceptor. Residents may choose the DHSP experience as a monthly rotation in their annual clinical schedule. Participants in the program are expected to demonstrate an identified interest in practicing medicine in a rural location. The DHSP was created in an attempt to expose future physicians to life in a rural setting and increase awareness of practice opportunities in small community clinics. Design of the program was based upon the premise that these individuals in training need an early exposure to rural medicine practice in order to make well-informed career choices. Naturally, if they attend medical school in a metropolitan area and remain in the same geographic location for clinical training, they will not know what rural practice entails and may not fully realize the positive aspects of a primary care physician’s life-style in a rural community. The program currently has ten primary care clinic locations with Internal Medicine and Family Medicine preceptors who welcome the trainees and are committed to providing a positive learning experience. Additional Family Medicine sites are being added in the fall and there are tentative plans to extend the program beyond internal medicine and family medicine and begin including pediatrics and obstetrics/gynecology preceptors as optional training sites for interested trainees. The quality of the preceptors ensures academic enrichment and outstanding physician role modeling for the trainees. Each trainee’s experience in the program is monitored through an evaluation system with the University of Mississippi School of Medicine. The trainees experience four weeks of the daily schedule of a rural primary care practitioner. A day may begin with treating something as simple as rhinitis in a 3-year-old and progress to treating an 86year-old with uncontrolled diabetes, congestive heart failure, chronic obstructive pulmonary disease, and a skin rash. Trainees are expected to participate in a community service project while on site and are required to keep a journal of their daily activities. The intent of the journal is to capture a glimpse of the trainees’ reflections during this experience. Each trainee was instructed not only to document clinical diagnoses of patients seen but also to record the impact of the patient interaction on their experience in the Delta.
METHODOLOGY
The journals, serving as a main source of data, revealed issues that are important to the practice of medicine in a rural area from the trainee’s perspective. Midway through the second year of the project 24 trainees (18 fourth year medical students and 6 residents) have taken part in this program and have been required to keep a journal of their activities during the experience. The journals have been analyzed using qualitative methodology. Embedded in the journal entries are common themes recorded by the participants.
243
JOURNAL MSMA SEPTEMBER 2010
According to an article published in The Journal of Rural Health, a similar program established in Minnesota recognized that qualitative data was essential to capture the richest descriptions of the Rural Physician Associate Program (RPAP) experience.7 In comparison, the qualitative data gathered from the Delta Health Scholars Program best exemplifies the uniqueness of being a primary care physician in the Delta. Our data collection and analysis process closely followed that employed by the Minnesota RPAP study. We used an interpretive approach to investigate the learners’ perspectives of their rural rotation. Interpretive practice is dependent upon the premise that meaning is constructed through contextually situated events and these events become meaningful through reflection and discourse. Included from the onset, as an integral component of this learning experience, the students and residents were instructed to record daily events and reflect on their interactions with both patients and rural preceptors. This provided our data collection mechanism. Analysis of data began with reading and re-reading of the journal entries, line by line, capturing commonalities among participants’ words and phrases. A constant comparative method of analysis was initiated with the process of open coding. Descriptive themes began to emerge as we first identified and labeled concepts by jotting marginal notes on journal entries. These concepts were then sorted into categories through axial coding. In the final step of analysis we identified patterns in the categorized data and arranged them into explanatory themes. We divided into two sections to perform a test of inter-rater reliability using the initial codes developed and refined during axial coding. After an acceptable level of inter-rater reliability was achieved, we worked together as a team to identify the most representative quotations from the journal entries to best explain the themes that emerged from the data. Thematic findings are described below.
FINDINGS
Continuity of Care Continuity of care emerged as a constant theme by nearly all of the participating trainees. This idea incorporated not only caring for the same patient on multiple visits but also caring for patients across the age continuum – infants to geriatric patients. One student commented, “Rural clinics serve a vital role not only as healthcare providers but also as friends and neighbors.” The importance of continuity of care, particularly in Family Medicine, is valued internationally. A 2009 study by Beaulieu et al. (p. e17) noted family medicine residents viewed their specialty as a “profession of relationships.” 8 Students from UMMC echoed this idea as they described seeing patients for their initial visit and following up with that patient on subsequent visits to see if their treatment plan had worked. It was both rewarding and challenging for students as this aspect of medicine is often absent from their training in an academic healthcare center. Regarding this component of care, one student noted: “It is nice that I have been here for a while, because I am now seeing some patients that I saw earlier in the month. It’s nice to have a little continuity of care. That is something that you don’t get much of in med school. ”
A resident described one day of his rotation as “‘bittersweet.’ We admitted someone to hospice. I didn’t know the patient but Dr. X had been taking care of the patient for 20 plus years. He informed me he definitely had covered end of life issues with her. Her family appeared to be at peace about things.” The opportunity for continuity of care provided by practicing in a rural area was a positive and valued aspect of the rural health rotation noted by almost all trainees and offered a change from the academic world of medicine. Sensitivity to Cost Participating in primary care in a rural area required students not only to select the best treatment plan for the patient but also to consider the cost of that treatment plan. Resources were limited both financially and with regards to availability. As such, students were required to carefully select medications and treatments, tests, and other diagnostic tools. The limited availability of tests was a stark contrast compared to the availability of tests at an academic medical center. One of the trainees describes this below: “It was very interesting participating in a communitybased hospital like this where the resources were much more limited than they are at the large university hospital I am used to. We had to think carefully about the tests that we were ordering due to practical and financial constraints.” Considering financial resources also taught the trainees to ask continuously their patients about medication compliance. One student commented, “We have patients who sometimes cannot afford $4 a month prescriptions.” Learning to consider financial resources encouraged the trainees to carefully consider tests ordered and treatment plans, including access to medications. This will prove to be an ever important skill in caring for their patients and in promoting patient compliance. Noncompliance Noncompliance is defined as the inadvertent or willful failure to adhere to medication regimens, provider instructions, scheduled appointments, or any prescribed course of therapy.9,10 Reasons for noncompliance are multifaceted and are many times inter-related. They include psychological factors, behavioral factors, treatment factors, and healthcare provider-patient interactions. Additionally, consequences of noncompliance can be costly, serious and even fatal. For example, a missed dose of antibiotics could result in the emergence of a more resistant strain of the invading microorganism. Noncompliance with provider orders can also lead to hospitalizations and nursing home admissions.9 Donavan and Blake (1992)10 assert that one-third to one-half of all patients are noncompliant. Heszen-Klemens (1987)11 found noncompliance to be a major source of provider frustration. Frustration resulting from noncompliance was also evident in this study. A fourth year medical student noted in her journal that “approximately twenty percent of the doctor’s patients do not keep their appointments.” While an internal medicine resident was completing his rural rotation, he encountered an “extremely noncompliant” patient diagnosed
with type II diabetes mellitus. He described the patient as having an elevated hemoglobin A1C level (12%), peripheral neuropathy, impending kidney failure, and retinal damage. When the patient was asked why he doesn’t take insulin as prescribed, the patient responded, “I just don’t feel like it.” One of the medical students who participated in the program described his encounter with a noncompliant patient. “I saw a patient this morning that had two chief complaints. One was that he couldn’t see and couldn’t afford glasses. The second complaint was that he wanted a motorized wheelchair because he cannot get around because he gets short of breath. I told him if he didn’t spend $5 per day smoking cigarettes, he could afford glasses and would not need the motorized chair because his breathing would improve. He opted to keep smoking.” Another observation providing an example of the insidious nature of noncompliance is described below: “I saw a patient today who had a lot of classic findings associated with diabetes….was noncompliant with her meds, her blood pressure was through the roof, and she complained of headache, blurry vision, and dizziness. She also has asthma and her breath sounds were audible from across the room. Although she is diabetic, she does not regularly check her blood glucose levels. …..Other signs and symptoms expressed by the patient were those of diabetic neuropathy. She was admitted from the clinic to the hospital. Instead of adhering to her medication and appointment regimens, she will have a ‘tune-up’ for a few days in the hospital.” Doctor-Patient Relationship Another positive theme that emerged from the journals was the feeling of being needed by the community. Lavanchy et al (2004)12 found one determinant of rural physicians’ life and job satisfaction is feeling needed by the community. Berk, Felder, Schur, and Gupta (2009)13 suggest that while there are numerous areas of dissatisfaction associated with rural practice, the quality of doctor-patient relationships is not one of them. In a survey of rural physicians regarding aspects of rural life and practice, 73% indicated they were not satisfied with access to cultural activities, 65% of respondents stated they were dissatisfied with the amount of personal time away from work, 50% were not satisfied with earnings from their practice, but only 14% of physicians indicated dissatisfaction with the quality of doctor-patient relationships. One journal entry revealed the depth of this type of doctor-patient relationship when a student wrote about her preceptor attending a patient’s funeral as a pallbearer. “It is not very often that you see the doctor as the patient’s pallbearer. Dr. X had the death certificate in his pocket when he left the clinic for the funeral.” These relationships were obviously meaningful to students and residents as many of them wrote about this aspect of primary care in a rural clinic setting. One student shared, “Just in my short time in this town, the doctor has seen some of the same patients multiple times. He knows their families. He knows about their jobs. He knows exactly how to talk to them and to motivate them to comply with preventive screenings and medication instructions. Watching him in this role only
SEPTEMBER 2010 JOURNAL MSMA
244
serves to remind me of how much I desire continuity of care in my practice. I want to know the people I am treating.”
DISCUSSION
“When I was young, my ambition was to be one of the people who made a difference in this world. My hope is to leave the world a little better for having been there.”14 A well-known Mississippi Deltan by the name of Jim Henson once made this profound statement. Henson’s quote could be claimed by the medical students and residents that participate in the Delta Health Scholars Program. The purpose of the program is for the future doctors of Mississippi to leave this clinical rotation experience in the Delta with a sense of wanting to return to make it a better and healthier place. Now we must ask ourselves why solving the Delta’s access to healthcare is relevant to Mississippi’s healthcare dilemma and, furthermore, America’s healthcare issues. If the state of Mississippi can improve the access to healthcare in one of the nation’s poorest and most underserved regions, we can have a sense of hope for a healthier Mississippi and ultimately a healthier nation. The healthcare needs of the Delta are not simply a matter of correcting a proportionate physician-to-patient-ratio. The needs are deeper than that on the state and national levels. An adequate number of physicians is not only needed for the treatment of disease but to prevent disease. In order to address the healthcare needs of the state, and specifically the Delta, a multi-disciplinary approach is needed, with primary care physicians who are committed to coordinating care for this population. It is common knowledge that Mississippians, and specifically the Delta population, have a high morbidity and mortality associated with preventable diseases, such as, diabetes, heart disease, and obesity. These conditions could potentially be prevented in certain instances or managed more appropriately with regular access to primary care physicians. If we neglect the importance of prevention and wait until the late-onset of symptoms, we have done a disservice to our patient population. Moreover, there is a financial irresponsibility that must be considered by waiting until late stages of an illness to emerge before a patient will seek out a specialist for advanced treatment of the disease process. One resounding theme mentioned throughout the trainees’ journals was the issue of noncompliance. The role of the primary care physician in patient education could have a much needed impact on compliance issues. With an adequate number of primary care physicians in the Delta, more emphasis could be placed on health promotion and wellness as well as improving access to much needed healthcare. The theme of sensitivity to healthcare cost factors was something that even medical students with very minimal experience in the clinical setting noticed in this underserved population. Sensitivity to cost is most appropriate at this time, given the current economical hardships that many patients are facing. In an area where poverty is a commonly shared element of life, trainees had their eyes opened to the reality of patients’ inability to afford medications that could significantly improve their lives. Continuity of care emerged as a theme that trainees experienced and relished. Journal entries reflected excitement as patients were seen repeated times in the clinic during the month-long rotation and even
245
JOURNAL MSMA SEPTEMBER 2010
recognized in social settings in the community. Students were surprised to have the opportunity to see patients more than once and provide follow-up to initial treatment given and to be able to monitor progress. One of the most encouraging themes that the trainees mentioned in their journals was the quality of doctor-patient relationships that they observed between the preceptors and their patient population. The idea of establishing a lasting relationship with patients was one of the biggest rewards that being a primary care physician in a rural community could offer.
CONCLUSION
Finding and executing a solution to the healthcare needs of the Delta will be an arduous task. Even with the rich history and culture of the Mississippi Delta, the residents of the Delta have overcome obstacles in a way like no other. This type of resiliency can be heard in the lyrics and music of the well known Delta Blues. It is suggested that the blues serve as a cathartic response to the hardship of what the Delta residents have faced for years. Mississippians must seek the inspiration from their own region that has birthed and nourished these talented minds of the past and present and use this inspiration to develop and implement creative solutions for Mississippi’s healthcare needs. Moreover, it is important for us as a state to continue to identify barriers that prevent primary care providers from choosing to practice in the Delta and find ways to overcome disincentives. As Mississippians, we are proud of our cultural heritage and the rich historical context that has led to advances in literature, art, music and the practice of medicine. It is important that the blues tradition still be heard from the Delta’s history, but we need to cure the blues associated with inadequate access to healthcare and associated healthcare disparities in the Delta region and our state.
ACKNOWLEDGEMENT
None of this work would have been possible without the tireless efforts of Ms. Becky Yates who has served as education administrator of the DHSP project from its inception. Ms. Yates coordinates all operational activities of the program between UMMC, the rural preceptors, and trainees.
REFERENCES 1.
2.
3. 4.
Mississippi Center for Health Workforce. (2010, January). Listening to Mississippi’s needs: Assessing our health workforce. http://www. nemsahec.msstate.edu/publications/whitepaper/pdf%20of%20complete%20assessment.pdf. Retrieved April 8, 2010. United States Census Bureau. American community survey. Mississippi: Selected economic characteristics:2004. http://fact finder.census.gov/servlet/ADPTable?_bm=y&-context=adp&-qr_name=ACS _2004_EST_G00_DP3&-ds_name=&-tree_id=304&-redoLog=false &-all_geo_types=N&-geo_id= 04000US28&-format=&-_lang=en. Retrieved April 8, 2010. Fordyce M, Chen F, Doescher M, Hart L. 2005 physician supply and distribution in rural areas of the United States. Final Report #116. Seattle, WA: WWAMI Rural Health Research Center, University of Washington; 2007. Chen F, Fordyce M, Andes S, Hart G. Which medical schools produce rural physicians? A 15 year update. Academic Medicine. 2010;85(4):594-598.
5. 6. 7. 8. 9. 10. 11.
12.
13. 14.
American Academy of Rural Physicians (2002).Keeping physicians in rural practice. http://www.aafp.org/online/etc;medialib; aaft_org/documents /about/rhe/keepin-rural.Par.0001.File.tmp/ ruralrr/pdf. Retrieved April 27, 2010. Cossman J, Ritchie J, James W. Mississippi’s physician labor force: A look at primary care physicians.http://www/healthpolicy.msstate. edu/publications/healthmaps/primcarephy.pdf. Retrieved April 29, 2010. Zink T, Halass G, Finstad D, Brooks K. The rural physician associate program: The value of immersion learning for third year medical students. Journal of Rural Health. 2008;24(4):353-359. Beaulieu M, Dory V, Pestiaux D, et al. What does it mean to be a family physician? Exploratory study with family medicine residents from three countries. Canadian Family Physician. 2009; 55:e14-20. Department of Health and Human Services. Medication regimens: Causes of noncompliance; 2005. http://oig.hhs.gov/oei/ reports/oei04-89-89121.pdf. Retrieved April 7, 2010. Donovan J, Blake L. Patient non-compliance: Deviance or reasoned decision-making? Social Science and Medicine. 1992;34(5):507513. Heszens-Klemens I. Patients’ noncompliance and how doctors manage this. Social Science and Medicine. 1987;24(5):409-416. Lavanchy M, Connelly I, Grzybowski S, Michalos A, Berkowitz J, Thommasen H. Determinants of rural physicians’ life and job satisfaction. Social Indicators Research. 2004; 63:93-101. Berk M, Feldman J, Schur C, Gupta J. Satisfaction with practice and decision to relocate: An examination of rural physicians. Bethesda, MD: Rural Health and Policy Centers (Final Report, May 2009). Henson J. It’s not easy being green: And other things to consider. New York, NY: Hyperion; 2005.
TRAGIC BUT IRONIC... Our media focuses so much on homicides (317) in 2008 while 25% more people die from suicides (398).
SUICIDES ARE PREVENTABLE. Let us not lose a single life to suicide.
PSYCAMORE PSYCHIATRIC PROGRAMS Partial Hospital, Intensive Outpatient Therapies
Flowood,MS 601-939-5993
Southaven,MS 662-349-2818
1-877-PSYCH-4-U
Patients are usually scanned in a comfortable seated position watching a 42” plasma screen television throughout the procedure. Conventional lie down MRIs can miss information that is only visible when patients are scanned in an upright position. Our ACR accredited facility offers physicians the choice to scan the patient in their position of pain. Both our technologist and radiologist have over 50 combined years of MRI expertise. We offer same day scheduling, 24 hour reports and transportation in the metro area. Appointments starting at 7 a.m.
MRI’s in flexion and extension positions offer the most accurate diagnosis of herniated disc .
call 504.934.4000 4349 Loveland St. • Metairie, LA 70006
Watch TV during procedure.
SEPTEMBER 2010 JOURNAL MSMA
246
• SCIENTIFIC •
A
Surgical Management of Eyelid and Periocular Cancers Milam S. Cotten, MD BSTRACT
Therapeutic surgical management goals require the achievement of 4 features to cure the patient of eyelid/periocular cancer: 1. complete removal of the cancer; 2. preservation of eyelid function; 3. pain free state after healing; 4. pleasing cosmetic appearance.
KEY WORDS:
INTRODUCTION
EYELID CANCER; EYELID CANCER
TREATMENT OPTIONS OF SURGERY OR
RADIATION; CURE RATE EXPECTATIONS
The principle and concept of evidence based frozen section con1 trol has been published. This article presents a 4 year period of the management of eyelid/periocular cancers that has been successful in the vast majority of such cases using the frozen section control for 30+ years.
RISK FACTORS
Attempts to recognize predisposing causal/protective factors to eyelid/periocular cancers have received worldwide attention including but not limited to duration of exposure to solar radiation, gender, age, race, genetics, and latitudinal locations.
PATIENT HISTORY
bump, or knot located on the eyelid or periocular areas. The patients were aged from 31 to 90 with average age of 66 and did not have a commonality of occupations. Twenty-four patients were referred to me while 11 presented without referral.
NATURAL HISTORY
Untreated basal cell eyelid/periocular cancer usually does not metastasize but can cause extensive anatomical destruction of the superficial and deep tissues interfering with essential functional, protective, and cosmetic attributes. Squamous cell carcinoma of the eyelids and periocular region is a potentially lethal tumor.1 I have not observed a fatal case of eyelid/periocular cancer.
DIAGNOSIS AND MANAGEMENT
Usually an office-based diagnostic biopsy is performed to determine the type of cancer. Identifying the type of cancer assists in planning appropriate treatment options with the patient and family. When appropriate, the patient is presented at a hospital-based tumor conference. This allows the patient and family to consider the best treatment consensus by surgeons, radiologists, oncologists, pathologists, and support personnel. Daily and situational matters considering finances, time, safety, travel, number of procedures or treatments, morbidity, quality of life, and assistance requirements are also very important in the management of cancer.
CANCER LOCATIONS
This retrospective review illustrates the nature of the eyelid/periocular cancers including clinical manifestations, appearance, locations, size, demographics, examinational findings, natural history, tissue diagnosis, expectations, complications, treatment options [surgical or radiation therapy], post-op care, and follow-up exams for evidence of recurrence. Patients usually present with a persistent growth,
This series of 35 Caucasian patients [22 males, 13 females] included locations of the lower eyelid [21], upper eyelid [8], inner canthus, [2] and outer canthus [4]. The size was usually less than 1 cm length of the lid margin cancers and up to 2.5 cm length of the periocular skin cancers.
CORRESPONDING AUTHOR: Milam S. Cotten, MD; Southern Eye Center, 1420 South 28th Avenue, Hattiesburg, MS 39402; Telephone: 601-705-0079 (office), Fax: 601-264-5930, E-mail: milamcotten@comcast.net.
Thirty-four patients [1 patient cancelled surgery] underwent surgical excision of the cancer using frozen section control in the operating room with sedation and local anesthesia. By clinical judgment, the tissue is surgically excised and examined immediately by the pathologist for “tumor-free” margins. Such an exam takes 20-25 minutes dur-
AUTHOR INFORMATION: Milam S. Cotten, MD; University of Mississippi School of Medicine, 1959; Medical officer aboard a nuclear-powered guided missile cruiser; small town general practice; University of Tennessee ophthalmology residency; practiced ophthalmology in Hattiesburg since 1970 at Forrest General Hospital and Wesley Medical Center. His practice is now limited to eyelid/periocular disorders and strabismus surgery.
247
JOURNAL MSMA SEPTEMBER 2010
EXCISIONAL SURGICAL TREATMENT
ing which time the patient and operating room team awaits the results. If margins are clear, the reconstruction phase is performed. If margins are not clear, more tissue is removed before reconstruction is performed.
RECONSTRUCTION AND FOLLOW-UP
Repair of the surgical defect is performed by the appropriate technique: a. pedicle rotational flap [21]; b. full thickness donor skin graft [6]; or c. primary excision of cancer with direct reconstruction [5]. Large benign lesions [2] were excised with direct reconstruction. The usual surgery time was 40-90 minutes. Site is not patched. An antibiotic drop or ointment is used locally 2 times a day until the operative site is healed. Mild analgesics usually control any post-op pain. The patient is Fig 1. Eyelid location of cancers
contacted by telephone the following day and seen 1 week post-op for exam. Sutures are removed at 7 to 14 days. Post-operatively patients are seen at 8 weeks and 1 year.
POST-OP REFLECTIONS
Patients report a pleasing comfort level during surgery with sedation and local anesthesia. Operative complications included 1 same day return to surgery to control bleeding that did not respond to local pressure at home. There were 2 late complications (post-op greater than 1 year) requiring surgery to repair cicatricial ectropions by lid reconstruction with full thickness skin grafts. One case of basal cell carcinoma recurred in this series. Incomplete primary resection of an eyelid skin cancer is the main risk for recurrence.2 At the final post-op visit, the patients stated that they were pleased with their decision for surgical management of their cancer.
MICROSCOPIC TISSUE ANALYSIS
Final diagnoses included 28 basal cell carcinoma; 5 squamous cell carcinoma, and 2 benign lesions [size required operating room]. 32 were surgically cured while 2 were referred for radiation therapy. Successful surgical management of eyelid/ periocular cancers is enhanced by evidence-based frozen section control surgical excision during “real time on the operating table.” The final evidence of excision is confirmed by a permanent paraffin section microscopic tissue exam by the pathologist.
Fig 2. Clinical presentation of cancer
PROFESSIONAL RESOURCES
Fig 3. Frozen section control of excision. Skin margin (black ink) lower left and mucosal margin lower right, showing tumor free margins
It is reassuring that eyelid/periocular cancers can be treated successfully by several modalities. Since my personal experience is confined to the surgical diagnosis and treatment of eyelid/adnexal lesions, it is a particular advantage to have available in our medical community highly credentialed colleagues for the non-surgical treatment of eyelid/periocular cancers when it is in the best interest of the patient. It is imperative that physicians select the matrix of treatment for the patient— rather than subject the treatment to the patient.
PHOTOGRAPHIC EXAMPLES
Surgical excisional techniques illustrate the frozen section control (later permanent paraffin sections to verify the complete excision of the cancer) and surgical reconstructive techniques. (Figures 1-8)
ACKNOWLEDGEMENT
For their contributing expertise in the treatment of these cancers, I thank the staff at Southern Eye Center, the hospital-based pathologists, the Departments of Surgery of Forrest General Hospital and Wesley Medical Center, and the medical librarian of Forrest General Hospital.
REFERENCES
1. Cook BE Jr, Bartley GB. Treatment options and future prospects for the management of eyelid malignancies: an evidence-based update. Ophthalmology 2001;108:2088-2098.
2. Nemet AY, Dechel Y, Martin PA, et al. Management of periocular basal and squamous cell carcinoma: a series of 485 cases. Am J Ophthalmol. 2006;142:293-297.
SEPTEMBER 2010 JOURNAL MSMA
248
Fig 4. Reconstruction by pedicle flap
Fig 5. 1 month post op pedicle flap
Fig 6. Reconstruction by full-thickness skin graft using skin from the infraclavicular area as the donor site
Fig 7. Suture graft in position (bottom left)
249
JOURNAL MSMA SEPTEMBER 2010
Fig 8. The infraclavicular area as the donor site (bottom right)
• MSDH • Mississippi Reportable Disease Statistics
June 2010
* Totals include reports from Department of Corrections and those not reported from a specific district NA - Not available (temporarily)
For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com SEPTEMBER 2010 JOURNAL MSMA
250
• MSDH •
MSMA Member Appointed to the Mississippi State Board of Health
T
had F. Waites, MD, of Hattiesburg, has been sworn in as a member of the Mississippi State Board of Health. He was appointed to the Board by Governor Haley Barbour, along with re-appointed member Sammie Ruth Rea, RN, of Jackson. Mississippi State Board of Health Chairman Dr. Luke Lampton looks forward to working with both new members. “Governor Barbour has made two outstanding appointments to the Board. Both recognize the serious problems facing public health in our state and are committed to making a difference. On behalf of our Board, I welcome them with much excitement.” Dr. Waites is a graduate of the University of Mississippi School of Medicine. He completed an internship in the Emory University program at Grady Memorial Hospital in Atlanta, Georgia, and his medicine residency at the University of Colorado. Following a tenure on the medical staff at Ochsner Clinic, he served as Chief Resident and as a fellow in cardiology at Emory University Hospital in Atlanta, Georgia. Waites has been practicing cardiology at the Hattiesburg Clinic in Hattiesburg since 1987. “I am honored to have this opportunity to serve on the State Board of Health. I look forward to using my passion for cardiology to help this Board continue to improve public health in Mississippi,” said Dr. Waites. THAD F. WAITES, MD Dr. Waites presently serves on the American College of Cardiology (ACC) Board of Governors as Governor for the state of Mississippi and as Chairman-Elect of the Board. He has served as President of the Southeast and Mississippi Affiliates of the American Heart Association and was inducted into the Forrest General Hospital Hall of Fame in 2009. Both Dr. Waites’ and Mrs. Rea’s terms will expire on June 30, 2016. ❒
251
JOURNAL MSMA SEPTEMBER 2010
For a bird’s eye view on medicine follow MSMA on
!
Health Department Commends Smokefree Cities
T
he Mississippi State Department of Health (MSDH) recognizes and applauds the following cities for protecting the health of their citizens with the passage of comprehensive smokefree air ordinances:
There’s a lot going on in organized medicine so it’s easy to miss something if you’re on the go. To help you stay in touch no matter where you are, MSMA is now communicating via “Twitter.” In about three minutes, you can set up a free Twitter account for yourself. Simply visit www.twitter. com and submit your name, email address and mobile phone number (optional, standard text messaging rates apply). Once you’re signed up with Twitter, you can add MSMA by going to the following web page http://twitter.com/ MSMA1 and clicking “Follow” next to the MSMA icon.
MSMA1
Aberdeen Amory Bassfield Batesville Belzoni Clinton Collins Corinth Crystal Springs Ecru Flora Greenwood Grenada Hattiesburg Hernando Hollandale Jackson Kosciusko
Laurel Lumberton Madison Mantachie Mayersville Meridian Metcalfe Oxford Petal Pontotoc Prentiss Ridgeland Rolling Fork Starkville Sumrall Tupelo Wesson
“The smokefree policies implemented by these cities will protect citizens from the harmful effects of secondhand smoke. Everyone deserves to breathe smokefree air,” said State Health Officer Dr. Mary Currier. “There is no safe level of exposure to secondhand smoke.” Secondhand smoke causes premature death and disease in children and adults who do not smoke. Even brief exposure to secondhand smoke is harmful. Exposure to secondhand smoke causes respiratory symptoms and slows lung growth in children. Because children breathe faster, they are twice as likely to be affected by secondhand smoke. They are at an increased risk for sudden infant death syndrome, ear problems and more severe asthma. Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes heart disease and lung cancer. Each year, an estimated 550 Mississippians die from exposure to secondhand smoke. ❒
SEPTEMBER 2010 JOURNAL MSMA
252
• PRESIDENT’S PAGE •
Promise and Hope for Healthy Schools
T
he school breakfast program was the last thing on my mind as I joined Mr. Simpson on the track for an early jog the other morning. I consider Mr. Simpson a hero and value his opinion. He is the retired principal of our middle elementary school. We share an appreciation for the sanctuary of the Kosciusko High School track, a secluded place surrounded by old woods and inhabited by families of bluebirds, redheaded woodpeckers, and rabbits. The huge bank of mimosa trees on the backstretch provides built-in aromatherapy in the early summer for those who use this facility. Mr. Simpson is a burly, handsome man with a bottlebrush mustache. He carries his arms like Popeye and has a voice that is pitched such that when he tells a story you think he may break out into song any minute. His marvelous sense of humor is wellTIM J. ALFORD, MD known. On one occasion he placed a bumper sticker on the back of an overly serious fel2010-11 MSMA PRESIDENT low principal’s van that stated, “When this van starts rockin,’ don’t come a knockin!” On this particular morning, Mr. Simpson was poking fun at me because he is now retired. I mused to him that sometimes I feel as though I have been taken to the principal’s office by some of my patients. Usually these are patients we know too well, and they usually have many chronic problems – a recurring cough related to tobacco use or uncontrolled diabetes with the theme of non-compliance or an intractable backache. Often these difficult problems are age-related and/or immune based, but sometimes the problems are self-inflicted and preventable. These patients come in often. There is a shared frustration between doctor and patient with a reckoning that holds the doctor accountable. With all the tricks in the little black bag used, all second opinions exhausted, the sense of futility conjures that helpless feeling of visiting the principal’s office.
The other day on the way around the track with the real principal, I was enlightened. Mr. Simpson is one of those rare educators that demanded the best from his teachers and had each child feeling as though he or she was the most important citizen in Mississippi. He was deployed during Desert Storm, 1990-1991, and upon his return received a welcome home greeting at his school by all the second and third graders waving their little American flags. He hugged each child as he progressed down the breezeway leading to the school. Tears flowed from parents, teachers, and children, and yes – even Mr. Simpson. He stopped to embrace one child in particular whose middle name must have been “trouble” and they BOTH cried like third graders.
My question to Mr. Simpson that morning was how the budget cuts were going to affect our schools. “Well, we are gonna lose our school nurse and special education will be thrown into disarray and these students will have to be mainstreamed. That’s not good. Our teachers will have to manage larger classes and we will lose several teacher aides this year. Next year will be far worse.” I seized the opportunity to ask him about the USDA school breakfast program. This is the one where school districts and independent non-profit schools can choose to take part in cash subsidies for each meal that they serve. The diet must meet dietary guidelines for children so that no more than 30% of an individual’s calories come from fat and 10% from saturated fat. In addition, one quarter of the daily allowance of protein, calcium, iron, vitamin A, and vitamin C should be present in each meal. Sounds good, doesn’t it? Not according to Mr. Simpson. He says, “Okay, you mean the pancake on a stick? We hate it!” This was consistent with the comments one of his third grade teachers made to me earlier in the year as she wished for whole grain cereals and berries for the children in the morning. Instead, the children are given the human equivalent of rocket fuel – pancakes and syrup – and burst forth like a skyrocket only to fizzle out mid-morning. In the meantime, teachers contend with stomachaches and frequent trips to the bathroom. Nevertheless, our school district, like so many others, is addicted to the federal pay of $1.20 per meal and does not want to upset the apple cart because it needs the dollars. Formerly thought to occur only in people over the age of 40 (adult onset diabetes), now one-half of all cases of diabetes mellitus in children are the Type II variety. As blood pressures rise, waistlines expand, and lipid profiles deteriorate, metabolic syndrome is far too commonplace. There is no refuge at home as fast foods, three to four hours of television, and inactivity are now routine. As a consequence, for the first time in the his-
253
JOURNAL MSMA SEPTEMBER 2010
tory of the United States, children will live sicker and die younger than previous generations. Although this grim reality is more apparent among non-Caucasian populations, no ethnicity is exempt.
There are those of us who would like to hide behind the cultural curtain doctrine that says our population is too steeped in its own traditions and habits to change. We are well aware of what is served in most households in Mississippi, if they are lucky enough to get a prepared meal. Most people’s idea of breakfast is a sausage and egg biscuit. Potluck at church dinners offers up a long tradition of heavy casseroles and is seldom seen without a big platter of fried chicken. I have even heard our own office staff bribe a child’s unruly behavior with the reassurance of a trip to McDonald’s.
We claim our children as our most precious resource. We rock them, stroll them, counsel them, console them, bankroll them, and sing them to sleep all in the name of love. If this is so, and knowing what we know of the reality of obesity, then why don’t we behave differently as professionals? There is evidence that physicians are uncomfortable managing obesity and frequently fail to do so. One study found that patients are less likely to receive weight management advice from their primary care physicians than from their spouse, family, or friend. It follows, then, that we physicians avoid engaging a parent about their overweight child.
Not far up the road, Amory Middle School was selected one of the ten healthiest schools nationwide by Health magazine. Amory school administrators successfully challenged the USDA’s breakfast program by offering healthy whole grain cereals and fruit to the children. This menu is reinforced in the classroom by age appropriate curriculum that makes the whole approach lots of fun for the children. The Food Services staff interacts with the children, discusses their food preferences, and encourages healthy choices. There is a school fitness center and a mission to get and keep kids moving. By doing these things and the other elements of the CDC’s eight-component program, within one year Amory Middle School’s reading comprehension scores have soared to a new height. Both Amory and Corinth have fully embraced the 2007 Healthy Schools Law that calls for Health Councils in every school district. These districts have watched Body Mass Index readings in their students stabilize and begin to decrease. Shane McNeill, Director of the Office of Healthy Schools, has many such success stories to share from around Mississippi. He encourages physicians to take the initiative to organize Health Councils within their local school communities. (A word of thanks to the Bower Foundation for assistance in the initial funding of the Office of Healthy Schools) These Councils are comprised of allied health professionals, teachers, parents, ministers and other concerned community volunteers. There is a chef resource that can be called upon by any school district for assistance in improvements to school meal choices. Most districts have abandoned the sweet soda machines, but many still hold onto their deep fat fryers. By the way, our own MSMA Alliance has committed to purchase three industrial grade fruit and vegetable slicing machines to donate to school districts that show a worthy interest in improvements to their menu options. Louise Lampton, Alliance President, will lead Alliance efforts to promote healthy choices amongst students in our schools.
As our children enter school this fall, they will do so with much promise and hope. Unfortunately, we must acknowledge that they are little metabolic syndromes waiting to happen. The Office of Healthy Schools has won the first round fending off the naysayers who continue to preach that you cannot swim against the Southern cultural mainstream.
This time my visit to the principal’s office was not with that nostalgic sense of foreboding but, rather, with a sense of renewal. For even though I have not put my life on the line for our country as Mr. Simpson did, I am sure that we can do a better job of fighting for our children right here at home.
Ask List: • Lead a Health Council in your school district. • Contact your school superintendent or principal concerning compliance with the Healthy Students Act within your school district. • Add BMI to your patients’ vital signs. • Volunteer your time to visit elementary schools and speak to children about healthy habits. • Become a President’s Challenge Program Advocate by promoting and supporting an active lifestyle. Visit http://www.presidentschallenge.org/ to learn more about how you can help promote physical fitness. • Reward your young patients who participate in regular physical activity or exhibit other healthy habits. Consider recognition in your waiting room or another acknowledgement. • Donate to the MSMA Foundation (to help fund MSMA Alliance public health projects that benefit Mississippi children).
References:
Tham M, Young D. The Role of the General Practitioner in Weight Management in Primary Care – a Cross Sectional Study in General Practice. BMC Family Practice 2008. 9:66. Robinson TN. Reduing children’s television viewing to prevent obesity: A randomized controlled trial. JAMA 1999;282(16):1561-1567. Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. J Am Diet Assoc. 205;105(5):743-760. Mississippi Office of Healthy Schools: www.healthyschoolsms.org. 2007 Healthy Students Act Senate Bill 2369 as amended.
SEPTEMBER 2010 JOURNAL MSMA
254
• EDITORIAL •
Sacred Spaces and Higher Ground
O
ver the years, I have received the admonition to “seek higher ground” on many occasions. I found that ambiguous advice until our family lived in New Orleans. We sought higher ground there in the literal sense on a number of occasions. While in New Orleans, I began to understand what my advisors meant. They weren’t talking about keeping my feet dry. They were talking about finding fulfillment in knowing you are doing the best you can in your work and doing it with integrity. The physicians I know who have found higher ground have done so, at least in part, by time regularly spent in “sacred spaces.” I realize this term is even more ambiguous than “higher ground.” Please give me a chance to explain. What are sacred spaces? They are events in life that lift us up from where we are to our highest calling. These spaces are always shared with someone else. They are not quiet times of reflection spent listening to new age music. They include relationships with family, faith partners, and small groups of friends who know our shortcomings but care about us anyway. Not least of these are the relationships we are privileged to have with our patients. Those are among my most valued sacred spaces. Years ago when I was a moonlighting medical student at a private hospital in Birmingham, I crossed paths with an older surgeon. Late one night, he took me aside and began to ramble on about the “magic” he regularly experienced when he was one-on-one with a patient. He told me that he considered each patient interaction a “sacred space,” not just another scheduled encounter. He said that, prior to entering an exam room, he prepared for each interaction by trying to find at least one thing he could say that would “lift the patient up” and “then magic happened.” It might have been as simple as a compliment, a healing touch, or as complex as assurance that the doctor would be there to help even though there was bad news to hear. I thought he was loony until I began to think back to the Sunday afternoons I had spent with my uncle as a boy. My uncle was an elderly general practitioner in a rural area of Jefferson County, Alabama. He worked 24-7. His wife was a regular church-goer; he was not. On Sundays after hospital rounds, he went alone to see those patients who were dying of one disease or another in the mining camps around the area. On occasion, I would ask to go. We would drive up to a modest wooden house on a dirt road in the woods. Family members were usually hanging around in little groups on the porch, in the yard, or in the house. My uncle, whom everyone called “Doctor,” an imposing former full-back with a shock of white hair and an acne-pocked face, would nod to the family and go directly to the patient’s bedroom, sit down at the bedside and “visit.” After a while he would do a brief physical exam and then proceed to give the patient something, a bottle of Gevrabon (80% alcohol with B-complex vitamins), a narcotic if they were in pain or his famous D50-multivitamin IV infusion. Whatever, it always seemed to help. It was a “sacred moment” for the patient, the family, him, and even for me, a pre-teen. It seems that each generation of physicians must rediscover the transformation that comes in sacred spaces. This year, the discovery is highlighted for physicians and the public in Dr. Abraham Verghese’s new novel, Cutting for Stone (Vintage Books, 2010), a title taken from the Hippocratic oath. In this book, since each person deserves to be cared for, the physician is the Samaritan healer and the healing is mutual. I am convinced that the sacred spaces we share with our patients are mutually therapeutic. They provide the emotional energy to stay on higher ground. As we move forward in the evolution of our healthcare system, we must find a way to preserve and improve opportunities for meaningful interactions with patients and families. We may well have to buck the system, make less money, look to other practice models, and do things in very different ways. Assembly line medicine driven primarily by productivity and medicine that treats patients and doctors as commodities, erodes healing relationships and turns our profession into a trade. If we focus on what is best for us in healthcare, we will have achieved tradesman status. There won’t be many sacred spaces or higher ground then. How do we move forward? One place to start is to more fully engage with our colleagues as patient advocates, something we have not done well in the past. Our new MSMA president, Dr. Tim Alford, has good ideas to move us in that direction. He deserves our support… and we need his leadership and passion. He knows how to find higher ground.
255
JOURNAL MSMA SEPTEMBER 2010
—Richard D. deShazo, MD Associate Editor
Medical Medical A Assurance ssurance Company Company of of M Mississippi ississippi An A no outside utside p perspective erspective off MACM aand nd aappreciation ppreciation o MACM
“
My position on the American Board of Family Medicine’s Medicine ’s credentials committee gives me new insight and appreciation for the critical role that MACM plays in the lives of our state physicians. MACM ’s involvement with its insureds — from MACM’s risk management to liability and scope of practice issues — has their best interest, and that of the public they serve, at heart. Particularly at the level of the Risk Management Committee, many of these issues are handled constructively and effectively to improve and ensure quality care for patients, while guiding physicians from potential hazards. In many states, without the commitment of an organization like MACM, physicians and patients are far less protected and similar issues result in adverse actions that often result in licensure and practice restrictions.
“
All insureds of MACM should be grateful for the role MACM and their experts in Risk Management play in keeping us (physicians and patients) safe.
Diane Beebe, MD Family Medicine Jackson, Mississippi
For F or o over ver 330 0y years, ears, M Mississippi ississippi p physicians hysic i ians h have ave looked looke k d tto oM Medical edical A Assurance ssurance C Company ompany o off M Mississippi ississippi for for their their professional professional liability liabilit y needs. needs. Today, Today, MACM MACM is is an an integral integral part part of of the the health health care care community communit y through through its its dedicadedication tion to to risk risk management management services services for for our our insureds. insureds. A dedicated dedicated staě staě and and physician physician involvement involvement at at every every level level guarantees guarantees that that the the interests interests of of our our policyholders policyholders remain remain the the top top priority. priorit y. This, This, combined combined w with ith tthe he m many any y years ears o off lloyalty oyalt y aand nd ssupport upport ffrom rom o our ur iinsureds, nsureds, iiss w what hat allows allows us us to to be be the the carrier carrier of of choice choice in in Mississippi. Mississippi. Please call call on us us to to assist assist with with your your professional professional liability liabilit y needs. needs. Please
11.800.325.417ŘȱȊȱwww.macm.net .800.325.417ŘȱȊȱwww.macm.net
IIn n Partnership Partnership with with Insureds Insureds SEPTEMBER 2010 JOURNAL MSMA
256
• EDITORIAL •
Let’s Not Go Down Without A Fight
T
here is a problem in healthcare and I guess we have been identified as it. It seems healthcare is too costly. It is out of control and this has to be stopped. They say, if the pay for fees and services to doctors is cut, this should solve the problem. After all, the average family practice MD makes over $200,000 a year, according to an internet source called StudentDoc.com. Therein lies the problem. Our reimbursement is becoming more and more dependent on the decisions of parties who have little or nothing to do with the actual delivery of care. As I sit here in my office writing, I’m distracted by a failed air-conditioner that is going to cost $2,000 to fix. My x-ray machine needs a $7,000 repair. I have to cover payroll, monthly expenses and all other costs to run an office; but, this is what “docs” do (or I thought we did). Doctors deliver healthcare and charge enough to live on and take care of their families, just as other business owners do –or did. As friends and fellow physicians have all turned to other financial arrangements to make a living, I have tried to hang on here in my south Jackson clinic I built 13 years ago to better serve patients after I entered private practice in 1985. Perhaps it is my stubborn pride and ego, which have led to the distasteful decisions I am forced to make in the near future. Reimbursement has dwindled to the point I question whether I can afford to continue providing for my patients. I wonder if it pays to practice medicine as I know it. Hospitals can employ “providers” at a loss if their admissions are fed and they have a continuous source of revenue. They can pay their employees $200,000 and support their outpatient facilities with the revenue stream it creates. We dinosaurs, on the other hand, have no way to adjust our fees to cover the costs and expenses of running a primary care stand-alone clinic. If expenses increase from inflation, taxes, maintenance costs or other factors, we are not allowed to adjust accordingly. The “policy makers” know better than we practitioners what we need. After all, we all make $200,000. Why would they want to let us raise our rates to cover expenses? This is the nail in the coffin for us in solo practice. I perceive it as an attack on doctors’ freedom to deliver the care our patients want and deserve and our aspiration to keep the doctor patient relationship as the most important service we can offer. I do not think our patients realize how important this freedom is and will not until a crisis occurs. That is how it sneaks up and becomes acceptable. The “policy makers” are not concerned with this relationship, only that they be perceived as providing the populace with something favorable. They are flooding the country with money for healthcare mandates that have nothing to do with the actual delivery of care. Millions! None of it going toward covering antibiotics for sore throats and infections, surgery, blood pressure control, or chemotherapy for cancer treatment. So, where is the real cost of healthcare? I know that I am preaching to the choir. You and I both know the most efficient way to deliver healthcare is for the doctor actually to see the patient. It is this basic freedom that I am dedicated to fighting for –for myself and my family, you and your family, and our patients. I have told many that we are being shot at from all sides, and I am determined not to go out without a fight! We may not win the war, but we can win some battles! Please let me know how you feel.
—Thomas E. Joiner, MD MSMA President-Elect Jackson
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.
257
JOURNAL MSMA SEPTEMBER 2010
• SPECIAL ARTICLE •
Mississippi Women in Medicine Leading the Way Karen A. Evers, Managing Editor [Each September is designated Women in Medicine Month by the AMA to recognize and celebrate the growing number and influence of women physicians. Here, the JMSMA commemorates the occurrence by highlighting some of Mississippi’s female physicians who are leading the way. Due to time constraints and space limitation, this article is far from inclusive. If you would like to be involved in Women in Medicine Month next year e-mail KEvers@MSMAonline.com and we may feature your story in the JMSMA. To all female doctors: Congratulations, you’ve come a long way, baby!] —ED.
W
Globally, the number of women in medicine has been hat a difference a generation can make. Just a few increasing steadily over the last decade. Today, women comprise decades ago women, like my mother, interested in nearly a third of all U.S. physicians and half of all U.S. medical medicine were encouraged to become a nurse. Even students. Figures from the Mississippi State Board of Medical in today’s liberated society, it’s shocking many women’s magazines st Licensure (MSBML) support this trend showing a steady increase in publish articles on “hot careers for women in the 21 century” listing the number of female licensees over the past several years (Table 1). every health-related job under the sun still failing to mention When asked about the minimal increase, MSBML Director Dr. “physician” as a good career choice. Despite such, Mississippi women H. Vann Craig said, “The main problem I see with the female are choosing medicine as a profession in record numbers. physician is reentry to practice after an absence for family matters Our Mississippi State Medical Association (MSMA) has (birth, parent care, home management). They do not keep their supported a “Women in Medicine” program since the American license active. I personally do not see the $200 renewal fee as a Medical Association (AMA) established it in 1979, when women deterrent to maintaining their license but I guess it is in the global comprised fewer than 12% of all U.S. physicians. Thirty-one years home costs.” ...CONTINUED PAGE 260... later, with women at almost 20% of the physician workforce, female physicians continue to lead the way, creating their own opportunities by founding new programs and focusing on issues that in the past had received little attention. Historically, in the late 1800s the U.S. led the world in training women physicians. However, in 1910 when Abraham Flexner reviewed the medical education system leading to the subsequent closing of almost 50 medical schools, women lost their access to med school acceptance and became scarce in American medical schools. Interestingly, a note scribbled on an AMA meeting program by a MSMA delegate relates there were “more female physicians in 1890 then there were in 1950.” A generation later brought the feminist FIRST WOMEN PRESIDENTS OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION— Women who movement and affirmative action, and once have held the highest office of MSMA president are: Helen R. Turner, MD, PhD (200506) (left), second woman president; Dwalia S. South-Bitter, MD (2006-07) (center), again, women returned to America’s third female president; and Candace Keller, MD, MPH (2000-01) (right), the very first medical school classrooms. woman elected MSMA president.
SEPTEMBER 2010 JOURNAL MSMA
258
r. Nell Ryan was the first woman to graduate from Mississippi’s new four-year School of Medicine. The new medical school enrolled its first students when the University of Mississippi Medical Center opened in 1955. The first class graduated in 1957. A 1950 graduate of Millsaps College, she took her internship in pediatrics at Vanderbilt University Hospital in 1958. She did a rotating internship at the University of Oklahoma Medical Center and completed a pediatrics residency at UMMC in 1960. Dr. Ryan completed a postdoctoral fellowship in pediatric cardiology at Oklahoma in 1961 and a residency in pediatric neurology at the Medical Center in 1977. She joined the Medical Center faculty as an instructor in pediatrics in 1961. In 1964, she became an assistant professor of pediatrics and then became an associate professor of pediatrics in 1969. She also served as an assistant professor of neurology from 1980-1983. While at the Medical Center, Dr. Ryan served as medical director of the Birth Defects Clinic in the Department of Pediatrics from 1961-1983, director of the Pediatric Outpatient Department from 1964-1975 and medical director of the infant care area from 1980-1983. A Vicksburg native, Dr. Ryan left the Medical Center in 1983 to join the faculty at the Louisiana State University Medical Center at Shreveport where she served as associate professor of neurology and associate professor of pediatrics. She was appointed representative for women in medicine to the Association of American Medical Colleges and director of the Neonatal Comprehensive Care Clinic. In 1994, she was named professor emeritus of pediatrics at Louisiana State University Medical Center at Shreveport.
Table I.
259
Dr. Nell Ryan Female Medical Pioneer First woman to graduate from Mississippi’s New Four-Year School of Medicine in 1957
Physicians Licensed by the Mississippi State Board of Medical Licensure
Year 2009
Gender Male Female
In Mississippi 4,498 1,108
Out of State 2,841 556
All Licensees 7,339 1,664
% Women
2008
Male Female
4,461 1,063
2,723 537
7,184 1,600
22.2%
2007
Male Female
4,431 1,016
2,644 522
7,075 1,538
21.7%
2006
Male Female
4,405 981
2,602 482
7,007 1,463
20.8%
2005
Male Female
4,432 989
2,521 423
6,953 1,412
20.3%
2004
Male Female
4,349 956
2,595 449
6,944 1,405
20.2%
2003
Male Female
4,766 999
2,039 354
6,805 1,353
19.8%
2002
Male Female
4,732 951
2,057 347
6,789 1,298
19.1%
22.6%
Source: Mississippi State Board of Medical Licensure Statistical Data website: http://www.msbml.state.ms.us/statisticalreports.htm. Accessed August 2, 2010
JOURNAL MSMA SEPTEMBER 2010
...CONTNUED FROM PAGE 258...
“To help in proving clinical competency, the licensure board will now accept Board recertification in lieu of going to some place like the Center for Personalized Education for Physicians (CPEP) in Denver, Colorado. This is cheaper and gets two birds as it shows their competency and gets them recertified, something most hospitals are requiring for privileges,” Dr. Craig added. While maintaining an active license is one obstacle women face when they take time out for other phases of life like motherhood, there are other significant hurdles female physicians face also. In summary, data from a 2008 survey of members of the AMA Women Physicians Congress revealed the following key findings:
• Achieving a work/life balance is a key issue; women physicians feel it is difficult to maintain obligations with their families as well as patients. • Some women physicians work part-time to help attain this balance. • Popular notions about the frequency of parttime work for women physicians are not supported by the data. In fact, most women physicians do not workpart time, including younger women physicians. • Women may choose lower-paying specialties that more likely accommodate part-time physicians, possibly causing them to sacrifice advancement opportunities in the process; pay disparities result. • Sex discrimination may also account for pay disparities. Women physicians believe they are not paid the same as men, and cite specific examples. • Discrimination is often defined in terms of sexual harassment. Women physicians often do not feel like they get fair treatment and the respect they deserve in terms of equal pay or inappropriate behavior in the workplace.
S
eptember “Women in Medicine” month honors the lives and achievements of female doctors. Here we take a look at a few of our state’s women physicians who have excelled in many diverse medical careers. The JMSMA asked them about overcoming obstacles as a woman doctor… how they have made a difference, work-life balance, words of wisdom from mentors, mentoring roles, and how their careers have evolved. On the next few pages you’ll meet some of Mississippi’s top female physicians, see how vital they are in our health care community and how they help make our state a healthier one.
P
DIANE K. BEEBE, MD CHAIR, DEPARTMENT OF FAMILY MEDICINE, UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
roudest accomplishment as a woman in medicine: Simply being accepted into medical school and becoming a doctor. When I was in high school with aspirations of medical school, colleagues of my dad’s told him, “Good luck to her, but, they really don’t admit women to medical school.” My medical school class had about 10 women out of 150. Leadership: I have been very fortunate to be involved locally, in the state, and nationally. I served on the ACGME Residency Review Committee for Family Medicine for nearly eight years, and was chair of that committee for four. I am still on the RRC-FM appeals board. I served on the AAFP Future of Family Medicine education task force and just completed serving for six years as an academic council member for a national residency leadership development fellowship. I am now on the board of the American Board of Family Medicine and serve as the chair of the communications committee, as well as serving on the credentials and bylaws committees. I’ve been active in our Mississippi Academy of Family Physicians (MAFP) for years as an ex-officio board member and am on the executive committee and board of the Mississippi Physicians Rural Scholars Program. At UMMC, I serve as chair of the Department of Family Medicine and serve on numerous committees. Until recently, I was the only female chair of a department, as was my predecessor. Role models: My role models were both men and women in my profession nationally and locally. These people believed in my skills and me and encouraged me to continue to get involved and apply for various positions. I currently have several close women friends and colleagues nationally in leadership roles who serve as role models and a support system. Mentoring others: Yes, I certainly hope that I mentor others, both men and women, but, specifically, many of the women
SEPTEMBER 2010 JOURNAL MSMA
260
MISSISSIPPI’S FIRST WOMEN AS MEDICAL DOCTORS, 1888-2010 1888
Jones, Verina Morton Harris
1895
Wiss, Rosa Douglas
1890s 1901 1903 1907 1910 1915 1917 1920 1934 1937 1939 1941 1955 1955 1955 1955 1957 1958 1959 1963 1964 1968 1969 1970 1974 1974 1975 1977 261
1978
Fearn, Anne Walter
Jones, May Farinholt Procter, Georgia A.
Bonner, Daisy Estelle Brown Caraway, Margaret Roe Wells, Josie English
Mattingly, Maria Dees
Dean, Sara and Frances Giles Ferebee, Dorothy Boulding Magiera Estelle Antoinette Bass, B. Mary Elizabeth Meloan, Eva Linn
Alexander-Nickens, Myrna Batson, Margaret B.
Gay, Emma von Greyerz Moss, Emma Sadler Ryan, Nell J.
Herrington, Walterine (Bell) Goetz, Catherine
Hawkins, Mary Elizabeth Dowdy, Elizabeth Barnes, Helen B. Mauney, Jessie Blount, June
Blissard, Thomasina
Wells, Peggy Jean Johnson Moy, Ruby
Aseme, Kate N.
Moffitt, Nina G.
JOURNAL MSMA SEPTEMBER 2010
First Black Female Physician in Mississippi
Holly Springs Native Founded First Co-Ed Medical School in China First Female Licensed to Practice Medicine in Mississippi
First Female Member of the Mississippi State Medical Association First Black Female Physician in Vicksburg
First Black Female from Mississippi to Earn M.D. First Graduate from a Mississippi Medical School First Woman to Teach at Meharry Med. College
First Woman Accepted to School of Medicine UMMC
First Female Graduates 2-Year Medical School Ole Miss First Director Mississippi Health Project
First Female Psychiatrist to Practice in Mississippi
First Female Officer of the Southern Medical Association First Woman Physician Health Officer in Mississippi First Black Female Cardiologist in Mississippi
First Female Faculty Dept. of Pediatrics UMMC
First Woman Member, Mississippi State Medical Association 50-Year-Club First Female President American Society of Clinical Pathology
First Female Medical Student and Graduate, School of Medicine UMMC First Female Medical Student Recipient of Leathers Medal UMMC First Female Faculty Dept. of Pathology UMMC First Woman Resident Ob/Gyn UMMC
First Female Faculty UMMC Dept. of Anesthesiolgy First Black Female Obstetrician in Mississippi
Blue Mountain College First Alumna of the Year First Female Faculty Dept. Radiology UMMC First Female Psychoanalyst in Mississippi
First Black Female Graduate School of Medicine UMMC First Female Asian Graduate School of Medicine UMMC First Black Female Surgeon in Mississippi
Founder of the Caduceus Club (Mississippi Professionals Health Program)
1979
Spruill Davidson, Faye
1983
Eakins, Maxine
1982 1985 1986 1986 1987 1992 1993 1993 1993 1995 1996 1997 2001 2002 2003 2004 2005 2005 2005 2006 2007
Tolbert, Virginia Stansel
First Female Urologist Dept. of Surgery UMMC First Black Female Neurosurgeon
Graeber, Angela Dickson
First Female Recipient Waller S. Leathers Award
Phillips, D. Melessa
First Female Dept. Chair (Family Medicine) UMMC
Fredricks, Ruth K.
First Female Neuro-Oncologist in Mississippi
Manley, Audrey Forbes
First Black Female Appt. Asst. Sec. Pub. Heal. Ser.
Pullen, Jeanette
First Female Recient Barnard/Guyton Dist. Prof.
Currier, Mary
First Female State Epidemiologist for Mississippi
Tatum, Nancy O’Neal
Established UMMC Formal Ethics Program
Lockard, Blanche
Gibson-McKee, Lisa Tijuana
First Woman Faculty Dept. Ob/Gyn UMMC
First Black Female Resident Dept. Ob/Gyn UMMC
Travelstead, Meredith Montgomery
First Female Recipient of the Carl G. Evers, MD Award
Coney, Ponjola
First Female Grad. Dean of School of Medicine UMMC
Keller, Candace E. Turner, Helen
Malpass, Aimee Sparkman Bush, Freda McKissic Douglas, Sharon
Poe, Katrina Nichelle Chaney, Geraldine
First Female President of the Mississippi State Medical Association First Female Associate Vice Chancellor Academic Affairs UMMC First Female Recipient of the Wallace Conerly, MD Award First Female Chair of Central Medical Society
First Mississippi Female on AMA Council on Ethical And Judicial Affairs 2005 Country Doctor of the Year Award
First Black Female President, Jackson Medical Society
South Bitter, Dwalia
First Grandmother, Third Female President of the MSMA
Woodward, LouAnn
First Female Interim Dean, School of Medicine UMMC
Currier, Mary
2010
Bush, Freda McKissic
2010
Schlessinger, Shirley D.
2010
First Woman Elected to Mississippi State Medical Association Board
Hyde-Rowan, Maxine
2009 2009
Mississippi’s First Medical Examiner
Woodward, LouAnn
First Female State Health Officer for Mississippi
First Mississippi Female Chair, Federation of State Medical Boards
Vice Dean, Associate Vice Chancellor Health Affairs, School of Medicine UMMC First Female (interim) Chair, Dept. of Medicine UMMC
Acknowledgement: Special thanks to the Rowland Medical Library, University of Mississippi Medical Center, for access to and use of their "Mississippi Women archive and history collection “Mississippi Women in in the the Health Health Professions, Professions, 1888-1977" 1888-1977” developed developed by by David David Juergens Juergens and and Virginia Virginia Hughson. Hughson. "firsts" for for women women in in health health professions professions from from Mississippi Mississippi beginning beginning in in the the 19th 19th century It is a challenging endeavor to identify the numerous “firsts’ centuryto to present. While Mr. Juergens is an extraordinary archivist and librarian, we do not claim complete accuracy for this listing compiled from the aforementioned exhibit and other sources. For the purpose of this JMSMA feature, only a limited number of medical doctors are included from "firsts" among the list of health professionals. If you know of other “firsts” among Mississippi Mississippi women women in in medicine medicine contact contact Head Head of of Collection Collection Development Development and and Juergens: (601)981-1830, DJuergens@umc.edu, or Karen Evers: KEvers@MSMAonline.com. (601)853-6733, KEvers@MSMAonline.com. Archives Manager David Juergans:
SEPTEMBER 2010 JOURNAL MSMA
262
DIANE K. BEEBE, MD CONTINUED...
participants in our national fellowship program for program directors have become mentees. We actually talk openly during the fellowship about roles in medicine and personal and professional balance – for all, not just the women. In addition, my Mississippi Rural Physicians Scholar mentee is a young woman, now in medical school. I hope that over the years I have also mentored young faculty, many of them women. Balancing professional and family responsibilities: Clearly, this balance is important for both men and women, and I believe men are becoming more sensitive to the challenges that women, particularly with children, face in the workplace. There are still barriers for child care for working mothers, more of an expectation that the mother stay home to care for sick children but with no differential of time to do this. The responsibilities are not just related to children. The role of caring for elderly parents is an issue as well, since much of that responsibility as well traditionally falls to the daughters and wives. Even without young children or elder parents, it is challenging to keep up a home, with all of the cooking, shopping, and cleaning responsibilities, while working fulltime. In addition to the daily responsibilities, things like gift shopping, party organizing, holiday decorating, card and letter writing, and so much more, falls, at least in my household, to the woman of the house. After hour work commitments increase this challenge with less time to accomplish the personal responsibilities, or just to spend time with spouse and children. Overcoming these challenges is all about setting priorities, being able to multi-task and being extremely organized. It’s also about having a spouse who understands and helps tremendously. You have to block time out to do the things that are important in your life and you have to make time for vacations and time together as a family. Thoughts about childbearing/rearing issues in training and practice: In training, there are time issues related to childbearing such as the maximum time allowed away from the training program. At least our Board of Family Medicine is generous with exceptions when pregnancy and childcare issues affect this. Hopefully most training programs and employers are becoming more equal to provide paternal time for leave and childcare as well. I think our younger generation of physicians, both male and female, are more interested in balance with their careers and their families. We see this in the job opportunities they seek. Many of our male residents have wives who are also professionals, so the non-professional responsibilities are shared. Much of this is also supported by increasingly stringent duty hours during training. Preparing for more women in the profession: It’s happening now. I think we have to be realistic in looking at the workforce. As above, expectations are changing among many of those entering medical school and practice. I think we have to realize that many of our new generation of doctors are not going to practice like many of those who came before us, or even like us. We have to be more flexible with hours so that parents can attend school programs and recitals and appreciate the value of part-time positions. We need to use more effectively our colleagues in nursing, pharmacy,
263
JOURNAL MSMA SEPTEMBER 2010
psychology and other professions to render care to our patients that the physician does not absolutely have to render, thus utilizing the physician’s time with their patients fully. This is, by the way, part of the concept of the Medical Home as well to utilize more teamwork in patient care.
P
SISTER ANNE BROOKS, DO (right) with Dr. Narayan Bhetwal, MD, (left) who joined her at the TUTWILER CLINIC in 2007. roudest accomplishment as a woman in medicine: To have graduated from Michigan State University College of Osteopathic Medicine at the age of 44 . Leadership: 1987- Hosted and testified before the U.S. House of Representatives Select Committee on Hunger and Infant Mortality; 1989- Testimony presented at the Lower Mississippi Delta Commission; 1996-Testified before the Mississippi Senate and House HMO Oversight Committee; 2000-2002 first female Chief of Staff Northwest Mississippi Regional Medical Center; 2003- Participated at the Health Care Policy Round Table (Wye River Health Foundation); 2005- Panelist at the AMA Foundation "Pride in the Profession" Award ; 2008-current Member of the Advisory Board of William Carey University College of Osteopathic Medicine in Hattiesburg. Mentor: John Upledger, DO challenged me by giving me power over my health and insisting that I could become a physician Mentoring others: As instructor/ preceptor at the Tutwiler Clinic for student physicians and nurse practitioners on family practice/rural practice rotations for the past 27 years. Balancing professional and family responsibilities: At Michigan State University College of Osteopathic medicine there was a spiral curriculum, allowing students to take time off for several months or (even a year) to handle family matters or more intensive instruction if they wished and then plug back into the curriculum where they left off. Changes needed to attract more women to the profession? Flexible hours, particularly call schedules. An admirable woman in medicine: Mel Bouldin, MD, a delightful woman dedicated to good health, constantly inspiring, teaching, collaborating, challenging her colleagues to jump into the fray and help people become more healthy!
JENNIFER BRYAN, MD FAMILY MEDICINE PHYSICIAN UNIVERSITY PHYSICIANS, GRANTS FERRY CLINIC FLOWOOD
P
roudest accomplishment as a woman in medicine: Returning to my home of Rankin County to provide medical care in a typical family medicine clinic. Leadership: Currently Central Medical Society (CMS) President-elect, previously CMS secretary and Rankin County Vice-President, served on a local hospital’s medical executive committee as secretary, also served as chair of ethics committee, chair of pharmacy and therapeutics committee, and chair of MR/UR committee. Role model: My uncle, Dr. Tom Joiner, who is also a family physician and president-elect of MSMA. He has encouraged me to remain active in both the field of family medicine and medicine in general including MSMA and Central Medical Society. I have had many other mentors along the way. Mentoring others: I have had many female medical students rotate through my clinic as 3rd year medical students. Preparing for more women in the profession: Great strides have been made towards overcoming obstacles for women in medicine. An admirable woman in medicine: Dr. Helen Turner because she is an excellent physician and past-president of MSMA. She is a great leader and well-respected physician and gives all female Mississippi physicians someone to look up to. Additional comments: Women in medicine have come a long way since the early days. There may be some discrepancies between men and women, however, I feel the gap is closing. I have felt supported in my decision to balance my career with family life, and I have not felt any hindrance to being involved in professional medical organizations or medicine in general.
FREDA MCKISSIC BUSH, MD OBSTETRICIANGYNECOLOGIST, PRIVATE PRACTICE, EAST LAKELAND OB-GYN ASSOCIATES, JACKSON
P
roudest accomplishment as a woman in medicine: Co-authoring the book, Hooked, New Science on How Casual Sex is Affecting Our Children with Dr. Joe McIlhaney, Founder of the Medical Institute for Sexual Health. I have been working for years in my practice and in the culture to influence strategically young women to raise the standard of their sexual behavior. This book brought the science into the discussion in a practical way that would inform and empower them to do just that. No longer was the discussion just on the physical effect of sex like sexually transmitted infections and unplanned pregnancy but on the larger more pervasive impact on the emotions and the effect on the brain chemistry which drives the thinking and thus the behavior. Women listen to women. As a woman in medicine, I was proud to use be able to use the science in a practical way to help women and thus families and the larger community. Leadership: April 2010, I was installed as the chair of the Federation of State Medical Boards of the United States. This was the second time a Mississippian has held this honor. The first was Dr R. N. Whitfield in 1948. I served for 12 years on the Mississippi State Board of Medical Licensure (MSBML) and did a two-year stint as president and as chair of the Joint Practice Committee between the MSBML and the Mississippi Board of Nursing. In 1995, I was elected as the first female and first African American to serve as President of Central Medical Society. I saw these leadership opportunities as preparation for the national positions. Role models: My principle role model is my mother. She pursued her dream of becoming a teacher by going to school through the years and graduated from college two weeks before the birth of the 9th child. When I began medical school, it was with three children and had a fourth while in med school. I was confident I could do it because my mother did. Beverly McMillan, MD, FACOG was a mentor for me as well as my senior partner in practice. Dr. McMillan, founder of the first abortion clinic in Mississippi,who as a Christian has become a strong Pro-Life advocate. She demonstrated how you could have principles of conviction that may not be popular or politically correct and still have a successful practice. Mentoring others: This past school year, I served as a mentor for an M3 through a mentoring program with the UMMC
SEPTEMBER 2010 JOURNAL MSMA
264
Multicultural Affairs Division. There were many hours of shadowing and discussion about studying, career choices, and attention to family matters. For several years, I have served as the coordinator for the Department of Family Practice residents rotating through my practice. This has afforded me the opportunity to spend quality time with the women as they have spent time with us. Some of those relationships continue today. Through the years, I have spent time with young women on the telephone, emailing and at dinner not in any official capacity but who just wanted to seek my opinion or advice. Balancing professional and family responsibilities: Balancing professional and family responsibilities was and is a challenge. My mantra is to provide quality and quantity time to my family. When I am present with my family, I try to be totally present and give them my undivided attention. My husband and I got an understanding of what would be required to be successful in marriage and in medicine and periodically would sit and talk with the children about “why mama is not home a lot of time.” We planned a 24-hour schedule for me and posted it on the refrigerator, changing it as needed. If a sacrifice is to be made, we share as much as possible but knowing I would be the one ultimately to do so. At the end of my career and my life, it is family that will matter most to me. I consider it more important to invest in the lives of my children. Therefore, when I was pursuing my education and later in practice, I limited external community and professional activities until the children were older. When I could, I took the children with me to the hospital, office and to various meetings. Thoughts about childbearing/rearing issues in training and practices: I viewed childbearing as one of my primary privileges as a woman. I was also to “live my life.” Even though I viewed my career in medicine as a privilege, I did not see the two privileges in competition but complementary-- Not “either or” but “both and.” Therefore, my husband and I sought to develop a good support system through family and friends and nurtured relationship with a good housekeeper/babysitter. For about eight years when I began in private practice, my husband served as the primary parent in the home allowing me to establish myself in practice. Gender-related organizational barriers: These were faced through women’s networking groups that were official in some organizations, unofficial in others. Women helping women with “best practices” and working through the system in other areas helped overcome obstacles. Preparing for more women in the profession: First, I would like women to recognize they are not men. The differences are natural and not less than. They do not have to act like men to be professionals. The profession needs to acknowledge also, there are gender differences in thinking and problem solving and the differences are okay. Flexible work schedules and “shared” positions are arrangements I have heard work well for women, especially with small children. Admirable women in medicine: I admire several women in particular. Regina Benjamin, MD, MBA is the new Surgeon General of the United States. However, more than that, she was the only
265
JOURNAL MSMA SEPTEMBER 2010
family doctor in a small shrimping town in AL for years. Nancy Dickey, MD was the first woman president of the AMA; Helen Barnes, MD, FACOG was the first in a number of areas as an African-American and as a woman. Additional comments: I have been married to Lee Bush for 41 years. We have four children and seven grandchildren. He has been my friend and biggest supporter. I also consider my career in medicine a calling from God who has guided me from the beginning. In addition to Lee, my faith in God has sustained me.
MARY CURRIER, MD, MPH STATE HEALTH OFFICER MISSISSIPPI STATE DEPARTMENT OF HEALTH
P
roudest accomplishment as a woman in medicine: I think my proudest accomplishment is having both a service career that I love, doing something I think is useful and of benefit to the public, and having a family that is so wonderful. That balance has been difficult and has required thought and dedication from the whole family. I don’t think the kids (now perfectly spectacular adults, not that I’m biased or anything), have suffered from the example I’ve set, and my relationship with my husband [Dr. Currier is married to pediatric ophthalmologist Dr. Robert A. Mallette. —ED.] is better for my having a purpose in the outside world. Leadership: I was the State Epidemiologist with the Mississippi State Department of Health (MSDH) for many years (about 13), coordinating activities around disease surveillance and response. For example, disease surveillance allows us to recognize foodborne outbreaks, to investigate the cause, interrupt transmission, and prevent future transmission. I’m now the State Health Officer with MSDH and oversee all health department activities, as well as relating to outside entities such as the Legislature. It is certainly a challenge but also such a great opportunity to have an effect on health in the state. Role models: Well, of course, my parents. My Dad was the Chairman of the Department of Neurology for many years, and my Mom taught English before I was born. Both made it easy for me to believe I could do whatever I wanted, and medicine was such an important part of my growing up years, I suppose it was inevitable. The first time I really thought about epidemiology was when our family went to Ireland for 6 months in 1972, and Dad interviewed twins discordant for multiple sclerosis, then created on graph paper (!) lovely charts and figures comparing the risk factors between twins. These graphs were all over our dining room for the time we were there, and they fascinated me. My parents always believed in me and encouraged me and loved that I was interested in epidemiology, public health, and prevention.
Dr. Tom Brooks, professor and chairman emeritus of the Department of Preventive Medicine at UMMC, played a huge part in my career. I loved his preventive medicine course in medical school, and he worked with us at MSDH for many years as the editor of the Mississippi Morbidity Report. His wisdom and advice helped me see the possibilities in my life and work. Dr. Ed Thompson also encouraged me and provided support for the epidemiologic activities that we undertook for so many years. He was so knowledgeable and so solid; he always “had our backs.” Without him and his belief in me, I would not be doing what I am today. Mentoring others: I spent time working with the Education program within the Department of Medicine at UMMC and had an opportunity to get to know several female medical students during that time. This was not a formal program, but I tried to be available to talk about whatever they wanted. At MSDH, we’ve also had medical students, both female and male, for summer work or a rotation, whom I have taken time to get to know and hope to have been a positive example. Balancing professional and family responsibilities: Certainly, there are obstacles wherever you go that make it difficult to balance a family and a career. I think those can be overcome through careful thought, understanding marital relationships, and a system that is supportive. Something that would have been very useful and would have decreased the stress level in our family would have been childcare that was close and dependable and connected to my or my husband’s work. If residency programs would/could support mothers (and fathers) by providing healthy and happy day childcare onsite, I think it would benefit the parents and the program. Thoughts about childbearing/rearing issues in training and practices: With great difficulty and much family discussion! My husband and I talked about everything relating to our career choices. We also took turns in our training, which made for interesting jobs between training opportunities! It is just not easy, but it is so worth it. Preparing for more women in the profession: I used to think that we (humans) were blank slates at birth, but my children taught me different. You just can’t get around the genetics of being male or female, and moms are women. I think that the business of medicine will have to become more flexible and more accommodating to alternative schedules for moms and to less formal office atmospheres as children become more common in the workplace. I think it will take open minds as we think of new ways to accommodate moms. I also think it will make us more empathetic to our patients and their needs as we increase our own flexibility. Admirable women in medicine: I think of Helen Turner, MD, PhD, Associate Vice Chancellor for Academic Affairs at UMMC, who is truly an example of someone who has achieved with her equanimity and femininity intact. I also think of Helen Barnes, MD, who is a female African American obstetrician and taught at UMMC, who led the way. Additional comments: I know I’m lucky. I’m grateful for all the opportunities I’ve had and for all the folks in my life who’ve put up with me. I hope they continue to do so.
CAROLYN F. GERALD, MD EMERGENCY MEDICINE PHYSICIAN HATTIESBURG
P
roudest accomplishment as a woman in medicine: Being the first woman in my family to graduate from medical school and having my sweet, wonderful mother be there to see it and enjoy it. Role models: Dr. Mary Clarr, a pioneer woman pediatrician in Hattiesburg. While I admired her from afar, I also got a wonderful handwritten note from her once. Mentors are not gender specific, there were also men doctors at medical school and elsewhere who were influential. Mentoring others: Yes, with the pediatric medical students and loved it. Balancing professional and family responsibilities: Yes, there have certainly been times when I felt torn between family and career desires. Unfortunately, your family definitely suffers. Gender-bias in the workforce: Not much. You can overcome these. Thoughts about childbearing/rearing issues in training and practices: Marry a wonderful husband like mine. I would never be here without him. An admirable woman in medicine: Dr. Nancy Tatum – a kind and wonderful family practitioner who unfortunately died and left us early. Dr. Tatum once said a lot of us “never forget the divine privilege God has granted us in the opportunity to care for our patients.” (A great teacher and lecturer.) She was a wonderful friend. Dr. Tatum is also remembered as a pioneer in treating HIV/AIDS patients in the Hattiesburg area when others were so fearful. Additional comments: Things I tell young people in pre-med – women or men: 1. Be persistent in striving for your dreams. One turn down by an admission committee is not the end unless you decide it is. Apply again, but improve your application and skills. Apply more than one place. Take that MCAT over! 2. The one person who will keep you from becoming a doctor for sure is yourself. If you believe it’s “no use” and you can’t do it – you are right. If you know you can and you keep trying – you’re right! You just have to convince others. 3. Sir Oliver Wendell Holmes (Dr. Holmes) said, “To save life on occasion - to relieve suffering often – to comfort always.”
SEPTEMBER 2010 JOURNAL MSMA
266
P
CAMILLE J. JEFFCOAT, MD ANESTHESIOLOGIST JACKSON
roudest accomplishment as a woman in medicine: I had no idea that I wanted to go to medical school when I finished college. After a year of working, I decided that I really would love to be a doctor. Since I lacked some of the pre-requisites, I had to go back to school and take 16 hours of chemistry and 8 hours of physics, while continuing to work fulltime. My medical school class consisted of 20 women and around 100 men initially. On graduation day, I was one of only 10 women in my class that had completed the four years of medical school. Today I have the privilege of practicing medicine... this is my proudest accomplishment. Leadership: While I have been a doctor, I have been president of my group, Anesthesia Consultants, a member of the Medical Executive Committees at River Oaks Hospital and Surgicare of Jackson, a member of the MMPAC Board, and chair of one of the Claims Committees at MACM. Presently, I serve on the Board of MACM, Board of Preferred Health Services, and the Mississippi Professional Health Program Committee. Role models: I guess if I had to say that I had a mentor in my early anesthesia days, it would be Dr. Marion Parker. Dr. Parker was an anesthesiologist in my group who was devoted to pediatric anesthesia. He practiced in the days before there was the drug, Versed, which today is given to sedate children pre-operatively. He knew how to talk to children and their parents and put them at ease. He showed me how to hold a baby in my arms while slowly putting him to sleep. He taught me how to start an I.V. on a seven-pound infant while still holding a mask on his face. I learned so much from Dr. Parker about pediatric anesthesia. I will be eternally grateful to him. Mentoring others: I have mentored several women who have wanted to become anesthesiologists. Some have been in high school, others in college or medical school. It thrills me to see their enthusiasm, and I try to teach them a little about being a woman in medicine and how great the specialty of anesthesia is for a woman. Balancing work/life: I personally think that women make great doctors. Therefore, I am glad that there are more women graduating from medical school. Gender-bias in the profession: I have not seen any genderbias in anesthesia nor income inequalities. In my group, you ‘eat what you kill’, so to speak; therefore, my income is based on how much I am willing to work. Admirable women in medicine: When I think of women in medicine, I think of Dr. Helen Barnes and Dr. Gerry Ann Houston. Both have given so much of their lives to their particular specialties. I admire both of them and am proud to have known them.
267
JOURNAL MSMA SEPTEMBER 2010
D. MELESSA PHILLIPS, MD RETIRED PAST CHAIR, DEPARTMENT OF FAMILY MEDICINE, UNIVERSITY OF MISSISSIPPI SCHOOL OF MEDICINE JACKSON
P
roudest accomplishment as a woman in medicine: My proudest accomplishment as a woman in medicine was being named the first woman Chair of a clinical department (Family Medicine) at UMMC in 1987. I was humbled to be recognized in 2008 by UMMC as a Local Legend in the Changing Face of Medicine National Library of Medicine program [See p. 270-71]. Leadership: I was fortunate enough to serve as the chair of the Department of Family Medicine for 19 years until my retirement from UMMC in 2006. I was also fortunate to be chosen for leadership positions over the years in the national Society of Teachers of Family Medicine organization. In 1990, I was named one of 50 Kellogg Fellows by the Kellogg National Fellowship Program and in 1999 received the American Academy of Family Physicians Thomas Johnson Award for Career Contributions to Family Medicine. Role models: I was one of eight women in a medical school class of 164 at Tulane Medical School from 1969-73. There were only a very few women on the faculty then –the most memorable being Dr. Hannah Woody, a pediatrician. I can’t say that she gave us any encouragement outside of expecting all of us, men and women, to do our job on the pediatric service. When I came to UMMC in 1973 to enter the Family Medicine residency, I was the only woman resident in the program, and there were no women faculty. By 2006, half of the departmental faculty was women. Mentoring others: I hope that I served as a mentor to women medical students during my years at UMMC. I know that I talked to hundreds of them about medicine in general and career choices in particular. Gender differences and the complexity of balancing professional and family responsibilities: Although there are now more women medical students, residents, faculty members, and deans at American medical schools and more women in the national physician workforce, men still dominate medicine in positions of power. CEOs and CMOs of managed care organizations, third party insurance companies, medical licensure boards, hospital staffs, national specialty and practice organizations, state and local medical societies, and the editorships of major medical journals are still almost exclusively male. Strong stereotypes, borne out by multiple studies, exist that women cannot manage family and a career or leadership positions in medicine simultaneously –women with children have less successful academic progress than their male colleagues. Women are still paid less in private practice for the same work as men, even when adjustments are made for years of training
and hours worked. I don’t believe that these issues are exclusively “women’s issues” but societal issues. Gender equality is still characteristic of our culture – men’s careers in all areas are more highly valued than women’s. Thoughts about childbearing/rearing issues in training and practices: I greatly admire the women physicians I know who juggle childcare responsibilities and practice. While women always have had and always will have primary responsibility for raising children, medicine and parenthood are not incompatible. It’s the hardest job in the world, and most woman doctors I know make concessions to their careers in order to care for their families. Preparing for more women in the profession: The infrastructure of academic, research, and private practice medicine needs to change in order to create a woman physician friendly atmosphere. The “male model” fulltime-dedicated first to careerexample will not work for tomorrow’s male or female doctors. When I think of women in medicine: I think of my eight women colleagues in medical school. We were a tight knit group because we really only had each other to depend on to understand our “women’s issues”–there simply were no women faculty members and very few women residents for us to talk to.
DEANNA I. PRICE, MD, FAAP (DEEDEE) PEDIATRICIAN EAST MISSISSIPPI
P
roudest accomplishment as a woman in medicine: Being able to raise two wonderful girls while working full time in a job that I love. My life is full of children –both others’ as patients and mine. Leadership: I have chaired the Women’s Caucus, MSMA Young Physicians Section (YPS), and the Rules and Regulations Committee. I have served on Reference Committees and represented Mississippi at AMA annual and interim meetings. I have served on the Medicaid Committee. I have been an invited guest to the Board of Trustees meetings for several years. I have also served as the Mississippi Chapter of the American Academy of Pediatrics as vice-president. Locally, I have been on every committee in our hospital, including the Medical Administrative Committee, and served as the chair of pediatrics for several years.
Role models: Dr. Helen Turner at UMMC was always involved in organized medicine. I enjoyed getting to know her at meetings on and off-campus. She also had an important family life and reassured me I could have both a good job as a physician and be successful as a mother. I really appreciated Dr. Sharon Douglas sharing her home with a small group of females for a Bible study while I was at UMMC. We learned a lot from each other during that time and it was nice to see a female physician on “the other side.” I have met many wonderful female physicians at the MSMA Annual Session through the years, two of whom are Dr. Dwaila South and Dr. Mary Gayle Armstrong. Missing the convention for the past two years due to family commitments was hard because I enjoy talking with these women, and this is the main time that I see them face-to-face. I have e-mailed Mary Gayle several times about different issues and am glad that I met her through MSMA. I would encourage everyone to attend the Annual Session and the YPS CME. They are both great avenues to meet wonderful physicians from across the state. The Women’s Caucus at the Annual Session is especially fun and a good way to meet other female physicians. Mentoring others: I have had several medical students do pediatric rotations with me. I try to discuss “life” with these students, as well as teaching them the fundamentals of pediatrics. Gender differences in the profession: In the health system in which I am employed, I feel the income is equal between men and women based on our specialties. However, I also feel that I have had some resistance being “heard” by administrators when I personally or our pediatrics department has a hospital/health system problem. Sometimes, I have to get my Dad (also a pediatrician in my group) to call and help plead our case, which is ridiculous. Being confrontational and demanding is not in my nature. I don’t know of many females whose nature it is. I do believe that this is a factor sometimes in not being taken seriously by our hospital administration. I am learning to be a little more aggressive without being rude, and as the saying goes, “The squeaky wheel gets the grease.” Persistence definitely pays off. On gender equality with patients: I am still called a nurse, or “Miss Price” very frequently by parents, grandparents, and patients. I have never heard this mistake made with my male partners. Gender-bias in the profession: When I was put on bed rest at 28 weeks with my second daughter, I knew that it caused a strain on my partners and I felt really guilty about that. I tried every way that I could think of to work part-time to “make up” for it but kept contracting and finally had to sit strictly in bed, which is totally against my nature. Looking back, I was probably depressed during that time, but I made it through with a healthy baby! I did, because of guilt, rush back to work when she was 5-weeks-old and managed somehow to nurse her for the first year of her life. Again, I had a supportive husband who could sometimes bring her to me at the office or come by and pick up pumped milk. Those were very tiring days but we made it through as a team. I can see how childbearing/rearing could scare many females from working fulltime, especially if their husbands work full-time. There are many days when I still feel inadequate (and tired!).
SEPTEMBER 2010 JOURNAL MSMA
268
DEANNA PRICE, MD CONTINUED...
When my partner had a baby and took eight weeks off, it was stressful for the rest of us, especially since I had two young children at that time. However, having been through that myself, I encouraged her to take as long as she needed and tried not to complain! We have given our male partners two weeks of “paternity leave” when their wives have had children. I think this is important to them, especially if their wives have had C-sections. I’m sure that we would have agreed to more if they had requested it. We try to be very family-oriented at our clinic. Of course, my dad, being older, is not eligible for paternity leave, so we give him every Friday off. He’s happy with that. Overall, within our clinic, I don’t think we have gender-related issues between our physicians. Balancing professional and family responsibilities: I think that balancing family responsibilities well would be impossible without a supportive spouse. I am blessed with Chris. He even stayed home for several months with each of our daughters after birth. Now that they are older, it is nice to be able to “Tag Team” them. Extended family is also important. We love having both sets of grandparents here in Meridian! A New England Journal of Medicine study concludes that it is possible for women to combine motherhood with a fulfilling career in academic medicine, but it is difficult, and most such women believe that motherhood slows the progress of their careers (N Engl J Med. 1989;321:1511–7). Thoughts about childbearing/rearing issues in training and practices: I am not employed in academic medicine, so I cannot comment directly to that study. However, I would have liked to do a fellowship in pediatric emergency medicine because that is the area I most enjoy. If I had completed that training, I most likely would have been tied to a medical center. However, three more years of living in poverty and stress was not conducive to my plans to have a family before I was considered to be “advanced maternal age.” I delayed having my first child until I was 28 because of medical school/residency. My husband and I had been married six years at that time. So, I guess being a female did keep me from ever entering the academic world. Preparing for more women in the profession: I read that many practices across the country are using job-sharing as a way to accommodate females. I don’t think anyone can adequately prepare for what life will be like after residency, but rotations through clinics where job sharing, maternity and paternity leave, and other accommodations are used as well as just talking to physicians who have “been there” would be helpful. When I think of women in medicine: I think of my friends/mentors from UMMC and my female partner because it is a small group from which I gain a great deal of support. I don’t personally know many other “women in medicine.” Even though there are several other female physicians in Meridian, I guess our individual schedules have kept us from being better acquainted, which is a shame because we could all probably learn from/support each other. ❒
269
JOURNAL MSMA SEPTEMBER 2010
Women in Leadership at the University of Mississippi Medical Center School of Medicine by Richard D. deShazo, MD; JMSMA Associate Editor
Shirley Schlessinger, MD
Interim Chair of the Department of Medicine University of Mississippi School of Medicine
S
ince the University of Mississippi School of Medicine was founded on the Oxford campus, Mississippi women have continued to grow in their leadership roles. We all know these individuals as recently represented by Dr. Helen Turner, MD, PhD, associate vice chancellor for academic affairs and MSMA past-president, and LouAnn Woodward, MD, vice dean of the School of Medicine and associate vice chancellor for health affairs. Most recently, Shirley Schlessinger, MD, associate dean for graduate medical education who also serves as medical director for the Mississippi Organ Recovery Agency (MORA), has become the interim chair of the Department of Medicine, the first woman in the school’s history to serve in that role. Now that the medical school class is about half and half male and female, it is encouraging to see the
growth of women in leadership roles in our medical school where role modeling is so important to long term career choices and practice styles. Dr. Schlessinger joins Dr. Diane Beebe, MD, chair of the Department of Family Medicine, and her predecessor Dr. Lessa Phillips, as the third female chair among the primary care departments. Dr. Schlessinger brings the very best in professionalism, clinical skills, and leadership to this role. She established the renal transplantation program at University Medical Center and is a passionate advocate for individuals with chronic disease. However, she is an equally passionate advocate for the selection of medical students and house staff who are empathetic, caring, principled, and altruistic individuals open to meeting the needs of the communities from which they come. Since she now chairs the largest department in the medical center, it is comforting to know that a woman of her integrity has assumed this important role. It will be good for Mississippi. ❒
Mississippi Women Physicians Recognized as "Local Legends"
A
scholarly history and archive collection “Mississippi Women in the Health Professions, 1888-1977” in the University of Mississippi School of Medicine Rowland Medical Library is dedicated to the state’s women health professionals. The following Mississippi women physicians are recognized as local legends: • Dr. Helen Barnes, of Jackson, earned the MD in 1958 at Howard University in Washington, D.C., and completed residency training in obstetrics and gynecology at Kings County Hospital in Brooklyn, N.Y. Her commitment to improving health care for the economically disadvantaged and for women was the hallmark of her career. She was on the faculty of the University of Mississippi Medical Center from 1969-2003. • Dr. Lessa Phillips, of Madison, the first female chair of a department in the School of Medicine at UMMC, earned the MD in 1973 at Tulane University School of Medicine and completed an internal medicine internship and family medicine residency at UMMC, where she led the Department of Family Medicine from 1987-2006. • Dr. Jeanette Pullen, of Jackson, professor emeritus in the Department of Pediatrics at UMMC, earned the MD at Tulane in 1961 and completed pediatric residency training in the Tulane Department of Pediatrics at Charity Hospital in New Orleans. She later completed a postdoctoral fellowship in pediatric hematology-oncology at the University of Tennessee Health Sciences Center. She joined the UMMC faculty in 1969 and was instrumental in the creation of Mississippi’s Children’s Cancer Clinic. • Dr. Nell Ryan, of Vicksburg, the first woman to graduate from Mississippi’s new four-year School of Medicine in 1957, completed an internship in pediatrics at Vanderbilt University Hospital in Nashville, a pediatrics residency at the Medical Center, a postdoctoral fellowship in pediatric cardiology in Oklahoma and a residency in pediatric neurology at the UMMC, where she served in leadership roles during her time on the faculty from 1961-1983. She then served on the faculty at Louisiana State University, where she was named professor emeritus of pediatrics at LSU at Shreveport. • Dr. Helen Turner, of Jackson, associate vice chancellor for academic affairs and senior associate dean for academic affairs at UMMC, is professor of medicine and on staff at the Department of Veterans Affairs Medical Center. She was the second faculty member at UMMC to be named president of the Mississippi State Medical Association. She earned the PhD in microbiology at UMMC in 1975 and the MD in 1979. She took her internship and residency in internal medicine and a fellowship in infectious diseases at UMMC.
SEPTEMBER 2010 JOURNAL MSMA
270
Local Legends Recognized in "Changing the Face of Medicine" Exhibit
MISSISSIPPI WOMEN PHYSICIANS RECOGNIZED AS LOCAL LEGENDS — The contributions of women to the profession of medicine served as the backdrop for the grand opening of the National Library of Medicine’s traveling exhibit “Changing the Face of Medicine: Celebrating America’s Women Physicians.” Mississippi’s five “local legends” were the luminaries of the program held March 6, 2008, at the Jackson Medical Mall. The exhibition included a special display of “first” women physicians in Mississippi, part of the archive and history collection “Mississippi Women in the Health Professions, 18881977,” developed by David Juergens and Virginia Hughson with the University of Mississippi School of Medicine Rowland Medical Library. The “Mississippi Women in the Health Professions, 1888-1977” collection contains information on about 350 of the state’s female health professionals. The criteria for the collection include women who were either born in Mississippi or spent much of their professional career in our state. Two large displays highlighted 50 women of the 64 first physicians from this collection. The following Mississippi local legends’ names were added to a national list of women physicians: Dr. Tenley Albright, second from left, general surgeon and director of Collaborative Initiatives at MIT, stands with the ‘Mississippi Legends - Women in Medicine” recipients including, from left, Dr. Helen Barnes of Jackson, professor emeritus of obstetrics and gynecology, Dr. Nell Ryan of Vicksburg, first female graduate of the School of Medicine, Dr. Helen Turner of Jackson, associate vice chancellor for academic affairs, and Dr. Jeanette Pullen of Jackson, professor emeritus of pediatrics. Dr. Lessa Phillips of Madison,(not pictured) the fifth honoree, was unable to attend.
271
JOURNAL MSMA SEPTEMBER 2010
• UMMC •
Jackson Heart Study to Mark 10th Anniversary with Conference
T
o celebrate the Jackson Heart Study’s 10th anniversary, organizers plan a scientific conference that will both mark progress in understanding disease disparities among African-Americans and help shape the study in the coming years. The conference, September 23 and 24 to be held at the Jackson Convention Complex, will include speakers from Harvard University, Johns Hopkins University, the National Institutes of Health, Duke University and other prominent research institutions. The Jackson Heart Study (JHS) is a population study by three longstanding Jackson institutions – The University of Mississippi Medical Center, Jackson State DR. HERMAN A. TAYLOR, JR., MD, MPH, FACC, FAHA SHIRLEY PROFESSOR FOR THE STUDY OF HEALTH DISPARITIES University and Tougaloo College – to characterize risks for cardiovascular disease PRINCIPAL INVESTIGATOR, JACKSON HEART STUDY in African-Americans. It is funded by the National Heart, Lung and Blood Institute UNIVERSITY OF MISSISSIPPI MEDICAL CENTER and the National Center on Minority Health and Health Disparities. Through numerous medical tests, scans, exams and interviews, JHS has followed 5,300 African-Americans in Jackson. It also analyzes lifestyle factors such as diet and community and church involvement. The study has served as a springboard for community health outreach and given training opportunities to dozens of undergraduate students interested in science, medical and public-health careers. In the mid 1990s African-Americans suffered cardiovascular disease at astounding rates. For example, 40-year-old black women had a likelihood of dying of cardiovascular disease four and a half times higher than the national average. “You had these obscenely skewed statistics that needed investigation,â€? JHS Principal Investigator Dr. Herman Taylor said. “In the late 1990s African Americans represented, unfortunately, a worst-case scenario for cardiovascular disease.â€? Through its first decade the study amassed an impressive collection of achievements including doubling the number of publications every year for the last three years. This year also marked the founding of a support group for the study, Friends of the Jackson Heart Study. Organized under President Rita Wray, the non-profit group is raising private funds. “Through Friends of the Jackson Heart Study, we provide material support, such as books, supplies and equipment, for student researchers, travel expenses for young faculty dedicated to the JHS mission, community outreach and coverage of other related costs,â€? t $PNQSFIFOTJWF .BOBHFNFOU Wray said. For more information on giving to the Friends group, contact t $PNQSFIFOTJWF $POTVMUJOH the UMMC Office of Development staff, at (601) 984-2300 or t #JMMJOH "DDPVOUT 3FDFJWBCMF .BOBHFNFOU http://giveto.umc.edu. t $PEJOH %PDVNFOUBUJPO The anniversary also includes a pre-conference symposium for t 1SBDUJDF "TTFTTNFOUT 3FWFOVF &OIBODFNFOU junior investigators using JHS data scheduled for September 22 and a t 1SPĂśUBCJMJUZ *NQSPWFNFOU gala reception at the Jackson Medical Mall on September 24. t 1SBDUJDF 4UBSU VQT A complete Jackson Heart Study 10th Anniversary Conference t 1FSTPOOFM .BOBHFNFOU schedule is available on the study’s website, www.jsums.edu/jhs.
We specialize in the business of healthcare
PLEASE TELL OUR ADVERTISERS THAT YOU /PSUI 4UBUF 4USFFU 4VJUF +BDLTPO .4 5FMFQIPOF 8"54 XXX NQTCJMMJOH DPN
FOUND THEM IN THE
SEPTEMBER 2010 JOURNAL MSMA
272
• LEGALEASE •
W
Talking to Lawyers about Patients: When is it really Okay? Stephanie M. Rippee, Esq.
hen facing a malpractice claim, a physician knows to hire a lawyer and then not talk to anyone about the patient’s care except as specifically instructed by his or her lawyer. Nevertheless, how do you handle the situation when malpractice is not the issue, but a lawyer wants to discuss a patient’s care with you? Take, for example, a pharmaceutical product liability case. You prescribed a drug to your patient, and your patient believes he was injured by that drug and sues the manufacturer. You get a call from the manufacturer’s lawyer, and she wants to talk with you about your patient. Assuming Mississippi law and rules govern the situation, can you talk to her alone without the patient and/or his lawyer being present? The answer is generally no. Have you ever wondered why? Below is a series of questions and answers to help you understand why and to help you properly deal with such requests.
Q: What exactly is the physician-patient privilege and what does it cover?
A: In a lawsuit, “discovery” is the term for allowing lawyers to learn about the facts of a case. This includes learning facts about the plaintiff’s medical condition. Discovery is allowed only of relevant, non-privileged information. Certain medical information shared between a physician and a patient is deemed to be “privileged.” Privileged information, even if relevant, is not discoverable. Based on privilege, a patient can refuse to disclose and prevent others (i.e., his physicians) from disclosing: 1) knowledge derived by the treater by virtue of his professional relationship with the patient; and 2) confidential communications made for the purpose of diagnosis or treatment of his physical, mental, or emotional condition. Knowledge derived by the treater has been held to include even such things as test names, not to mention results. A “confidential communication” is any communication that was not intended to be disclosed to a third person except to facilitate treatment. The privilege applies to communications with licensed physicians treating physical, mental, or emotional conditions, as well as licensed or certified psychologists. There is also authority to argue that the privilege applies to communications with osteopaths, dentists, hospital personnel, nurses, pharmacists, podiatrists, optometrists, and chiropractors. The privilege arguably also applies to communications with any person a patient reasonably believes to be such a treater even if that person actually is not a treater. The privilege does not apply to communications with licensed social workers.
273
JOURNAL MSMA SEPTEMBER 2010
Q: Whose privilege is it and who can waive it?
A: The privilege belongs to the patient. It can be claimed by a living patient, by a living patient’s guardian or conservator, or by the personal representative of a deceased patient. A treater may assert the privilege but only on behalf of the patient. Except as noted below, because the privilege belongs to the patient, only the patient can waive it to allow disclosure.
Q: Are there any instances when no privilege exists or when the privilege is deemed to be waived?
A: Yes. Examples are: 1) commitment proceedings; 2) courtordered physical or mental examinations; 3) medical malpractice lawsuits; and 4) the release of medical information needed to comply with certain public health regulations (e.g., reporting of communicable diseases). Before making any disclosures, a physician should ask a lawyer if the situation permits disclosure without the patient’s permission.
Q: What actions by a patient can waive the privilege?
A: A patient waives the privilege when he places any aspect of his physical, mental or emotional condition at issue (such as by filing a lawsuit against the manufacturer and requesting damages). Waiver of the privilege, however, is limited and conditional in both personal injury actions and medical malpractice actions. The party is deemed to have waived the privilege only to the extent he places his condition at issue. Only information relevant to that specific condition is now made discoverable by the waiver. Any aspect of the patient’s condition that is not placed at issue in his pleadings remains privileged. Statements about non-medical issues, (e.g., the cause of an accident) also remain privileged.
Q: What is an “ex parte” communication?
A: Ex parte is lawyer talk for speaking with one side only (e.g., just the manufacturer without the patient/plaintiff present). This is what is generally not allowed.
Q: If the privilege is waived by the filing of a lawsuit, why can’t I talk ex parte to the lawyer who wants to talk to me?
A: The Mississippi Supreme Court has reasoned that since the patient is the holder of the privilege and gets to decide when to waive
it, allowing a physician to speak ex parte with opposing counsel places the physician, rather than the patient, in control of determining what information is or is not privileged and thus, is or is not able to be disclosed. To protect the patient’s privilege, the Court has held it necessary for a patient to be given notice of any ex parte contacts with his physicians and the right to prevent them. The Court has further held that the medical information gathered by ex parte contact will not be admissible at trial. If the information obtained is inadmissible, it is effectively useless to the party who obtained it.
Q: Can a patient authorize his physician to have ex parte communications with an attorney?
A: Yes, so it never hurts to ask. But practically speaking, a patient’s lawyer (that is who you will have to ask) has no incentive to say yes and likely never will. This is why the opposing party’s lawyer generally asks to take your deposition instead of asking just to talk to you alone. A deposition is a proceeding where both sides are present and allowed to ask you questions under oath. A court reporter is present to swear you in as a witness and to record your answers word for word. Busy treaters are often reluctant to give depositions because they can be inconvenient. But generally, the attorney who needs to learn the details of your treatment of the patient cannot learn that information any other way. A physician’s testimony can often be instrumental in getting rid of a weak or frivolous claim. Thus, the attorney asking to depose you should try to accommodate your schedule if possible.
Q: If I agree to allow an attorney to depose me, why am I still served with a subpoena commanding me to appear? A: This is a legal step designed to protect both you and the opposing party. If you appear for a deposition because you were subpoenaed, you do not seem to your patient to be voluntarily cooperating with the opposing party. In addition, if for some reason you elect not to appear, the opposing party cannot be sanctioned (i.e., required to pay the other side’s costs associated with coming to the deposition). Understand that you must comply with a subpoena or you can be held in contempt of court. For further information on the issues discussed, please contact Stephanie M. Rippee, Shareholder at Baker, Donelson, Bearman, Caldwell & Berkowitz at 601-351-8943 or srippee@bakerdonelson.com. ❒ This article is written for a non-lawyer audience and is designed to provide general information on the issues addressed as governed by Mississippi law and the applicable state court rules. Thus, the legal citations that support the information provided have been omitted. For a more in depth legal analysis of the issues discussed, including an analysis of the somewhat conflicting rules and statutes that govern these issues, please see the related legal article written by the author entitled "Don’t Ask The Doctor: The Prohibition on Ex Parte Communications with Non-Party Treating Physicians." This article can be found at http://www.bakerdonelson.com/stephanie-m-rippee/.
CLINIC LIQUIDATION•EVERYTHING MUST GO! If you are looking for any of the following items, you can find it at A.H. Salon & Clinic, Inc. All are in excellent condition. Only used once, some are practically new! Owner still has receipts and operation manuals:
• Autoclave Sterilizer (Valued at $3000)
• Urinalysis Machine (Valued at $500)
• 12-Lead EKG Machine (Valued at $2400)
• Dual-Head Teaching Microscope (Valued at $1500) • Video Colposcope (Valued at $9000)
• Weighing Scale (Valued at $500)
• Pediatric Examination and Weighing Station: all-in-one (Valued at $3000) • Rosie Electronic Vital Signs Monitor w/ supplies (Valued at $3700) • General Medical Supplies (to include OB instruments and much, much more)
Liquidating all medical-related assets to make room. If interested, please correspond via email: ahsalonclinic@hotmail.com.
BEST OFFERS WILL BE ACCEPTED
SEPTEMBER 2010 JOURNAL MSMA
274
• ALLIANCE SPOTLIGHT •
Past President’s Spotlight Danita Horne, 2004-05, Laurel
DISCO FEVER— SABINE, MARK, KISER, DANITA AND FLETCHER IN COSTUME. FAR RIGHT: DR. & MRS. MARK W. HORNE
W
here did you grow up? I grew up in a very small town (about 5,000 people) called Gate City, Virginia. I am an only child of only children, so I have no aunts, uncles or first cousins. My dad used to say we could have a family reunion in a closet. Gate City is right at the state line of Tennessee, so many people think I am from Tennessee. We had to travel five miles to go out of state when going to the mall, movie, hospital and almost any restaurant. I did attend college at the University of Tennessee where I became happily anonymous among 25,000 students! How did you meet your physician spouse? I met Mark at Erlanger Medical Center in Chattanooga, Tennessee. He was a resident at the time and I was selling pharmaceuticals with Merck. He deployed to Desert Storm 6 months before he completed his Internal Medicine residency and while he was gone I left Merck and became the Infection Control Coordinator at Erlanger. When he returned, we started dating and became engaged within a year. We married on the beaches of Seaside, Florida, (we were engaged there too) on October 17, 1992. As they say, the rest is history. What are the names and ages of your children? We have boy-girl twins, Kiser and Sabine, who are 11. They were born December 3, 1998. Then, as a surprise, we had Fletcher on March 1, 2005. He is five. How do you spend your free time? My first response is “What free time?” The license plate on my car says NVRHOME (never home) and that is fairly accurate. I wake up most mornings before sunrise and work out. I do a little of everything – weight training, cardio machines and I love to run, when I am not injured. I enjoy reading, traveling and do lots of volunteer and church work in Laurel. I also scrapbook and get great pleasure watching my children look through all their scrapbooks and talk about their favorite memories. How did you come to join the Alliance? I distinctly remember receiving a couple of cards in the mail from the Jones County Medical Alliance members, after Mark and I were engaged, and before I moved to Laurel. After I moved, I received a phone call and was personally invited to a meeting. I think one of the members even picked me up and took me to the meeting. I immediately felt welcome. What is your favorite Alliance memory? I recall being asked by some JCMA members who were serving on the state level and were active nationally to write a Health Alliance Project (HAP) entry for our Women’s Life Conference held annually in Laurel. I read the directions for applying,
275
JOURNAL MSMA SEPTEMBER 2010
wrote up the project, and we won! I was invited to present the project (this was the first year they had award winners do this) in Chicago at the AMAA Annual Meeting. At this point, I don’t think I had even attended a state meeting, much less a national meeting. I recall going to Chicago, walking into the lobby of the Drake and thinking “Wow, this is quite a place.” After checking in, I walked around and explored the hotel. I saw a sign that said “Gold Coast Room” and I recognized that as the room I was to speak in the next day. When I opened the door, I was blown away by the magnificence of the room. I still am! They had it set up for the event the next day, so I walked up on stage and looked out over the room. Public speaking has never bothered me, but the grandeur of the room left me speechless. Being in there alone was a special moment, and of the dozens of times I have walked into that room, I still recall that magical first time. Needless to say, I left Chicago being quite impressed with the Alliance. What are the highlights of your presidential year? There are two: 1) Finding out in October that I was 17 weeks pregnant! I had delayed accepting the presidency position until my twins were in first grade, going to school all day, and fairly independent. Shock doesn’t even do it justice when I realized that not only was I going to have a baby sometime between the winter board meeting and our state convention, but I had managed to get pregnant the month I took office! Some people ask me how a doctor and a nurse could not figure out I was pregnant ’til half way through the pregnancy…well, we needed lots of help to get pregnant the first time and were told it wouldn’t be possible again. As they say, the rest is history, 2) The second highlight of my tenure was being able, as an Alliance, to give Barbara Shelton a diamond cross necklace. I usually wore cross necklaces, and she always commented on them. When the money was approved, I immediately knew what would be the perfect gift. Every time I see her with it on, it still brings back thoughts of a memorable year. Do you have any advice for fellow physician spouses? Stick together and nurture our friendships. Nobody else understands the trials, tribulations, joys and frustrations of being married to a physician. I am always proud of my husband and what he does but I am often frustrated because while he is “practicing,” I am often a single parent, attending events solo, and spending weekends wishing we could do something other than listen to the phone and beeper sing. However, I wouldn’t have it any other way. Only my physician spouse friends understand and appreciate this crazy lifestyle. ❒
• IMAGES IN MISSISSIPPI MEDICINE •
JACKSON SANATORIUM, 1902-1916 —These two old postcards are of the important Jackson Sanatorium which was a large private hospital established in Jackson by Dr. Julius Crisler in 1902. Located in the capital city on West Street just behind the current downtown main office of Trustmark Bank, the hospital operated from 1902 to 1916, with many Jackson doctors caring for patients there. Dorland’s Medical Dictionary defines "sanatorium" (also “sanitarium”), derived from the Latin “sanitas” (which means health), as an “institution for treatment of sick persons, especially a private hospital for convalescents or patients with chronic diseases or mental disorders.” Dr. Crisler, a prominent Jackson physician, delivered my father-in-law Louis Lyell on September 15, 1925, at his parents’ house on Bellevue. Family tradition notes that the day was one of the hottest ever in mid September, 104 degrees, and Dr. Crisler performed admirably despite the heat! After the Sanatorium closed, the West Street site was used by the YWCA, and later the Catholic Rectory was built there in 1922. Also after it closed, the Jackson Infirmary on the corner of President and Amite Streets became the major Jackson hospital for a period. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please contact the Journal or me at lukelampton@cableone.net. —Lucius Lampton, MD, Editor
SEPTEMBER 2010 JOURNAL MSMA
276
• POETRY IN MEDICINE •
[This month, we print a poem by John D. McEachin, MD, a Meridian pediatrician. This poem, written recently, represents “a faithful account”of events surrounding the surgical removal of a basal cell skin cancer from his wife’s nose. Dr. McEachin explains: “The results of the procedure, itself, were aesthetically excellent and without complication. Nevertheless, there are lessons to be learned from the total experience, many of which can perhaps remind us of our need to be on guard for style and substance in the delivery of principled and considerate care to our patients.” The prolific Dr. McEachin holds a special place at the Journal as our unofficial poet laureate. For more of Dr. McEachin’s poetry, see past JMSMAs and look for more in coming months. Any physician is invited to submit poems for publication in the Journal, attention: Dr. Lampton or email him at lukelampton@cableone.net.] —ED.
“Just a Little Xylocaine” My wife was referred for a procedure called Mohs To treat cancer on the tip of her nose. A specialist was called in a city one state away; This would be surgery in the office —same day! Delighted with the prospect of a neat little trip, We soon discovered we were in for a flip! On providing a medical history to the new Doc’s aide, Came a terse response, “Hospital surgery, I’m afraid!” Xylocaine allergy, confirmed with positive skin test, Too risky— hospital setting would be best. (If Marcaine could be used, office would be fine. Marcaine was acceptable —wouldn’t change her mind!) Four times I gave the Xylocaine info for tagging her chart; Aides all recorded it —they did their part. Wife was “screened” by an M.D. for routine physical; Brevity was the game, and indeed a bit quizzical. Seems the Doc had for his exam table no clean sheet, Worse, the used pillow case was stained, and sticky sweet! Ordered to leave our motel next A.M. at sunrise, We were to encounter yet another little surprise. Seems scheduled for 9:30 means “all patients for that day;” But 1:30 after lunch was when things really got under way. The Derm specialist dropped by to greet my wife and me; He was in quite a hurry, a brief visitor was he! A Plastic associate checked the nasal lesion, too To assess the kind of graft he would plan to do. Then came the male nurse for an I.V. insertion; He kindly invited me to render tactful observation. A filled syringe was ready and he was set to begin, When my curiosity dared me ask, “What fluid is that within?” His casual answer brought blood to my face!
277
JOURNAL MSMA SEPTEMBER 2010
Remember the reason we were here in the first place? Didn’t take long, you knew without a quiver; Xylocaine, for S.Q. prick was the item they planned to deliver. I calmly reminded the nice young man, “Glance at her chart if you think you can!” Once that was ironed out and all seemed straight, Mohs surgery proceeded with the Derm and Plastic mate. The work completed about 4:30, same day, We got Rx for pain and got back on the highway. Follow-up appointment was set for noon, seven days hence; Surely a more normal visit! I should have had better sense! Well, back to the big city for post-op evaluation, Hoping, anyway to avoid further aggravation. Assistant came in quietly, took the dressing off the face; Nurse then removed sutures at a steady pace. A third attendant now entered, camera in hand; The sequential activity was surreal, part of a plan so grand. We waited for the Derm or Plastic man to come assess; Perhaps to peek, opine, advise, or simply bless! Sitting there several more minutes expecting this type of event, The ambient office quietude should have given us a hint. Finally, in came another aide, appearing somewhat bemused. “I thought you’d gone!” Again were we shocked, confused! Won’t the Derm or Plastic man surprise us and appear? “Nope! Return to your local Doc in three months or next year.” Thus ended a saga of blunders –attention, concern, and welfare; We had visited a “mill” which only postured “care.” As a physician, myself, I have taken this encounter to heart— I hope all this was aberrant misadventure, not the state of our art!
— John D. McEachin, MD Meridian
• THE UNCOMMON THREAD •
Boils and Goiters
R. Scott Anderson, MD
H
owdy boils and goiters. Wait a minute. That’s wrong. Oh, I know why. I guess I’m thinking about what it was like to practice in what the press likes to call “third world” countries. I don’t really know what “third world” means. Mostly I guess they’re financial deprivation zones. The people don’t have squat, and one of the things that they have the least of is access to medical care.
You start to understand that when you wake up at first light in some collection of tin and plywood shacks in the middle of a desert or some jungle clearing and find a line of people a half-mile long waiting to see you. And you’re deployed on what’s supposed to be a covert operation, but they heard a doctor was there, so they came with the small hope that you would take the time to look at them, or their children, or their mother. That’s why terrorists in conflict areas frequently kill medical aid workers. Nothing’s more valuable to any local population than the care of them and their families. Mothers will walk miles carrying their children just for a bit of your time and a few antibiotics to treat a rampant impetigo. You should do it sometime. If you don’t believe me, ask folks like Danny Edney who went down to help the folks in Haiti…not once but twice. I would have gone, but my linear accelerator wouldn’t fit in my suitcase. It’s always easy to find reasons not to do the right thing. The truth is that radiation treatments aren’t what’s needed anyway. Their needs are much more basic: a sharp blade to lance a boil so a father can work to feed his family, some iodine to abate a goiter that’s grown so large it’s compressing the airway of young woman being carried on a stretcher by her neighbors. Okay, okay! You’ve rambled enough. Now get to the point. The point is…well, that is the point! There really are areas of such medical deprivation that it is simply unimaginable, and Mississippi could end up being one of them. Our state was economically deprived before the economy took a big downturn. Now even fifty out of fifty in the USA isn’t southern Honduras or the middle of the Sahara, but it isn’t all that great either. We have a whole lot of patients that are dependent on public assistance to have any real access to the medical care they need. Our governors have used a lot of different methods to try and improve that access, but it has always been a difficult problem to address in the face of limited resources. Of course, we have federal programs that help, but they remain significantly flawed as well. I started thinking about all of this when I was asked if we as a state medical association should sign on to a letter pushing for expansion of the rights of physicians to contract privately. The more I thought about it, the more problems I had with it. I’m all for making money, but if the recent banking and real estate collapses showed us anything, it’s that rampant greed and lack of regulation are generally not a good thing for anyone in the long run. What happens to the poor folks in Mississippi if the access to health care that they are currently being provided goes away? That’s exactly what happens if the right to contract privately is unregulated. Let’s be perfectly honest. The right to contract privately is about the ability to ask for more. Not just to ask for more, but to demand more from those who would receive the care. What we’re asking for is the ability to agree to accept this patient because he can pay more and reject that patient because he can’t. “Cherry-picking,” in other words. The right to contract privately is meaningless in the context of private insurance. You’re able to do that already. It’s meaningless in the context of the uninsured, as they are being gouged into insolvency by the requirements of the federal bureaucracy which allows them no power in limiting what they’re charged for the care they receive. So they’re charged four or eight times as much as the insured for, at best, the same level of health care.
SEPTEMBER 2010 JOURNAL MSMA
278
The right to contract privately is aimed only at patients covered by publically provided health care insurance, Medicare and possibly Medicaid. The Balance Budget Act of 1997 already gives Medicare patients and their physicians the right to contract privately for health care services outside of the Medicare system. Physicians who want to opt out of Medicare participation to contract privately with their patients are already allowed to do so. They just can’t do it on a case-by-case or patient-by-patient basis. This is done to prevent the “cherry-picking” problem we already mentioned. I know, I know. None of us would ever do that, but somebody would. It happens in every market of every state every day with uninsured patient population. That’s why you have to choose if you’re in or you’re out for a two-year period. We don’t have to provide care for any group of patients at all. There’s no requirement to provide that care. It’s all a matter of choice. But is it? Let me ask you, “What am I supposed to do about cancer patients who aren’t able to pay for any extra out-of-pocket expenses?” Boot ‘em out the door of the cancer center? Sure, I might be allowed to do it legally. But the whole idea of it kind of reminds me of Lou Reed’s suggestion in his song “Dirty Boulevard”: “Give me your hungry, your tired, your poor. I’ll piss on ’em” That’s what the statue of bigotry says. “Your poor huddled masses, let’s club ‘em to death And get it over with.” Of course, he meant it only as social satire. We’re talking about doing it for real. What happened to “Whatever houses I may visit, I will come for the benefit of the sick”? I have bunches of patients who can’t afford anything—not food, not medicine, not gas, not Boost or Sustacal—nothing. That’s why we started the Cancer Patient’s Benevolence Fund so we can give them some of that stuff. Cancer patients aren’t the only ones though. You all have them, the same kinds of patients, in your own practices. We need to think about them before we, as a state medical association, go off signing letters in magazines supporting the right to contract privately. What we should be about is our patients, and a lot of our patients don’t have the resources that you and I do—and they never will. Doing things that will further deny them access to the care that they need is unconscionable. We need to aggressively push the state and federal governments to provide fair reimbursement for the services we provide and not place that burden on those who can least afford it.
•
PLACEMENT/CLASSIFIED
•
Locum Tenens Pathologist Needed
Surgical Pathologist with Mississippi license needed to fill in at small practice in North Miss. Proficient in GI biopsies, routine surgicals and non-gyn cytology. Oxford Pathology, Inc. E-mail: 1210lcb@bellsouth.net
PHYSICIANS NEEDED
Physicians (specialists such as cardiologists, ophthalmologists, pediatricians, orthopedists, neurologists, etc.) interested in performing consultative evaluations (according to Social Security guidelines) should contact the Medical Relations Office. Toll Free 1-800-962-2230 Jackson 601-853-5487 Leola Meyer (Ext. 5487)
DISABILITY DETERMINATION SERVICES
1-800-962-2230
If you use a knife to take money from someone against his will, it’s criminal. If you use a knife for the good of a person and are fairly paid for it, it’s noble. We should embrace nobility in all that we do. You’re welcome to believe what you want about all of this. Just make sure you think about it some before you’re too sure about what you believe.
—R. Scott Anderson, MD Meridian
R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian and past vice chair of the MSMA Board of Trustees. Additionally, he is an accomplished oil-painter and dabbles in the motion-picture industry as a screen-writer, helping form P-32, an entertainment funding entity.
279
JOURNAL MSMA SEPTEMBER 2010
using technology to get you the right protection, right away! Shave three to four weeks off the old way of doing business Call1-888-285-9477 or visit MSMAqui MSMAquicklife.com Group can give you straight answers you need to make informed decisions. If you prefer person personal nal service, Larry Fortenberry Forten and The Executive Planning Life IInsurance. Quickly.
and your loved ones. right decisions for yourself information you need to make the We provide the important through the application process. objectives and then guide you questions about your specific Apply on online. We ask the right competitively priced policies. life insurance quotes for Online. Fast. It’s easy to get free Executive Planning Group. and offered by MSMA and The rated life insurance companies insurance quotes all from highlyselection of personalized life Quick Life offers an excellent
is the answer. Life Insurance. Quickly.
insurance protection for your family - fast. Sometimes you need to get quality life
Faster is better.
Faster is better.
Sometimes you need to get quality life insurance protection for your family - fast. Life Insurance. Quickly.
is the answer. Quick Life offers an excellent selection of personalized life insurance quotes all from highlyrated life insurance companies and offered by MSMA and The Executive Planning Group. Online. Fast. It’s easy to get free life insurance quotes for competitively priced policies. Apply on online. We ask the right questions about your specific objectives and then guide you through the application process. We provide the important information you need to make the right decisions for yourself and your loved ones. Life IInsurance. Quickly.
If you prefer person personal nal service, Larry Fortenberry Forten and The Executive Planning Group can give you straight answers you need to make informed decisions. Call1-888-285-9477 or visit MSMAqui MSMAquicklife.com
Shave three to four weeks off the old way of doing business using technology to get you the right protection, right away!