September 2012 JMSMA by Journal MSMA

September

VOL. LIII

2012

No. 9

BEACON Imagine the possibilities. You’ve heard of the Beacon Grant.

It’s a $14.7 million grant to the Delta Health Alliance (DHA) from the Office of the National Coordinator for Health Information Technology with goals of building and strengthening Mississippi’s Health IT infrastructure, testing healthcare innovations and improving healthcare efficiency.

What can the Grant do for my practice and my patients?

DHA has established the BLUES (Better Living Utilizing Electronic Systems) Beacon Community to work with physicians and other healthcare providers across the Delta region. Your Delta BLUES Beacon is testing innovations with over 35 Delta providers, including Clinical Decision Support, Diabetic Retinopathy Screening, Medication Therapy Management, Care Transitions and Health Information Exchange.

Imagine the possibilities!

The Delta BLUES Beacon Program is available to physicians in ten counties across the Mississippi Delta area until March 2013. How can the BLUES Beacon guide you?

Learn more:

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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 Steven L. Thomas Demetropoulos, E. Joiner, MD President Steven L. Demetropoulos, James A. Rish, 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 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

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VOLUME 53

NUMBER 9

Scientific Articles Does One Medical School’s Admission Policy Help a Rural State “Grow Their Own” Physicians?

284

Philip B. Mason, PhD and Jeralynn S. Cossman, PhD

Top 10 Facts You Should Know about Headaches

293

Richard D. deShazo, MD and Allyn Bond, MD

Just Off the Press- Info You Want to Know: Probiotics– Are They Beneficial?

295

Lucy Cadwallader, PharmD and Richard L. Ogletree, Jr., PharmD

President’s Page Tort Reform

297

Steven L. Demetropoulos, MD, MSMA President

Special Articles MRPSP Scholars- Embracing the Vision for a Healthier Mississippi

299

Karen A. Evers, Managaing Editor

Do the Supreme Court Elections Really Matter?

302

401(k) Changes Will Help Physicians Better Understand Their Practice Retirement Plans

305

Robert M. Jones, J.D.; Legal Counsel, MACM

R H. Larry Fortenberry, CPA, CLU, ChFC, Executive Planning Group, PA

Related Organizations Mississippi State Department of Health

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Departments From the Editor Poetry in Medicine Physician’s Bookshelf Information for Authors Uncommon Thread

282 308 309 311 313

Asclepiad John M. McRae, MD

316

About The Cover:

Oil painting by John F. Jackson, MD, “Dunn’s Falls, located in Enterprise, Lauderdale Co., MS” — As indicated on an historic land marker, Irish immigrant John Cooper Dunn resettled in this area and surveyed the land on the Chunky River near Meridian. The river’s clay bluffs provided material used in a ceramic factory that supplied the family’s livelihood. Later Dunn diverted the river and created a 65-foot waterfall which he used as a source of power for a gristmill and cotton mill. During the Civil War, his factories were confiscated by the Confederacy where he manufactured blankets, knives, hats, and clothing for the war. At war’s end, the mill struggled but survived until Dunn’s death in 1904. Dr. Jackson taught medical genetics and internal medicine for 30 years at the University of Mississippi Medical Center before he retired in 1992 as chairman of the Department of Preventive Medicine. r September

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SEPTEMBER 2012

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VOL. LIII

Official Publication of the MSMA Since 1959

2012

No. 9

SEPTEMBER 2012 JOURNAL MSMA 281

From the Editor

residential politics may dominate many physician conversations this fall, but that election is NOT the most important one for Mississippi physicians on November 6. Rather, the often-overlooked state Supreme Court races are easily the most critical elections this fall for state physicians. Why? Tort reform hangs in the balance. Pundits currently predict tort reform is just one vote away from being overturned by a closely divided state Supreme Court. Mississippi’s physicians must make their voices heard in the following three Supreme Court races to secure tort reform: In the northern District 3, the Mississippi Medical Political Action Committee (MMPAC) has endorsed Oxford defense attorney Josiah Coleman over Flip Phillips, a former president of the Trial Lawyers Association. The grandson of the late (and great) Governor J. P. Coleman, Josiah has significant medical connections. His maternal grandfather was a Jackson physician (Dr. Robert McLean), and he has two physician brothers. His grandfather Coleman was a great friend to medicine, protecting the University Medical School in its infancy. (He appointed friend Dr. Verner Holmes to the then College Board and supported it through its first trials as Governor, even getting his gall bladder taken out at UMC! As well, J. P. brilliantly maneuvered the V. A. Hospital’s creation next to the University in Jackson, despite heavy legislative opposition.) Despite my enthusiasm for his grandfather,

Josiah’s intellect and integrity alone merit every physician’s support. In District 1, MMPAC has endorsed current Chief Justice Bill Waller, a fair and honorable justice, who is the father of a Mississippi physician. Waller has earned pro-business endorsements for his impartial rulings. His wisdom and leadership are desperately needed on the court. He faces a tough race against a Lucius M. Lampton, MD legislator who is also a trial lawyer. Physicians Editor must get Waller reelected. Finally, in District 2, Justice Mike Randolph has been endorsed by MMPAC. Although he doesn’t have a strong opponent, physicians should support and vote for Judge Randolph. What can you as a Mississippi physician do? First, make a financial contribution to our MMPAC (visit www.MMPAConline. com for more information). Second, reach out and give to candidates Coleman, Waller, and Randolph (especially Coleman and Waller, who face tough trial lawyer opposition!). Even if you don’t live in their districts, call your friends in north and central Mississippi and tell them of the importance of these races. Physicians must stand tall this fall to maintain our tort reform progress! Contact me at LukeLampton@cableone.net. —Lucius M. Lampton, MD, Editor

Journal Editorial Advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD, FAAP, FACS Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH Health Officer, District VII/VIII Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for V A Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist The Street Clinic, Vicksburg

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

282 JOURNAL MSMA SEPTEMBER 2012

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

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Representing Physicians SEPTEMBER 2012 JOURNAL MSMA 283

• Scientific Articles • Does One Medical School’s Admission Policy Help a Rural State “Grow Their Own” Physicians?

Philip B. Mason, PhD and Jeralynn S. Cossman, PhD

bstract

Context: The University of Mississippi Medical Center (UMC) has been the only medical school in the state since its inception in 1955 (until the 2008 establishment of the William Carey College of Osteopathic Medicine, yet to graduate its first class). Recruiting out-of-state physicians is difficult in Mississippi,1 and stakeholders frequently talk of “growing our own” physicians, especially challenging with a single public medical school. Purpose: This study investigates: (1) the proportion of a recent (1990-1999) cohort of UMC graduates practicing in Mississippi, (2) the proportion of all practicing Mississippi physicians who are UMC grads, (3) whether UMC graduates are more likely to practice in rural, small towns, or geographically isolated areas than other physicians, and (4) whether UMC graduates are more likely to recommend Mississippi as a practice location to new medical school graduates. Methods: Using Mississippi Board of Medical Licensure data (2009) and Mississippi Medical Doctors survey data (2007-2008), we employ GIS, logistic regression, and multinomial logistic regression models. We also use qualitative methods to examine interviews from purposefully sampled minority and/or female Mississippi physicians from the Mississippi Medical Doctors survey. Findings: Approximately 56% of UMC 1990-1999 cohort grads are practicing in Mississippi. Moreover, UMC graduates—of any year—constitute about 58% of Mississippi’s practicing physicians. UMC graduates are not more likely Author Information: Department of Sociology, University of South Carolina Aiken, Aiken, South Carolina (Dr. Mason). Social Science Research Center, Mississippi State University, Mississippi State, Mississippi (Dr. Cossman). Corresponding Author: Philip B. Mason, PhD, Assistant Professor, Department of Sociology, University of South Carolina Aiken, 471 University Pkwy., Aiken, South Carolina 29801; Phone: 803-6413213; Fax: 803-641-3461 (PhilipM@USCA.edu).

284 JOURNAL MSMA SEPTEMBER 2012

to practice in rural, small towns, or geographically isolated areas in Mississippi than physicians who graduated elsewhere. Controlling for other factors, UMC grads are not more likely to recommend practicing in Mississippi than physicians trained elsewhere. Conclusion: Health educators and policy makers should consider broadening UMC’s enrollment policies, and greater emphasis should be placed on recruiting physicians. Key Words: Rural physician recruitment; medical school admissions; minority physician recruitment; female physician recruitment; rural health policy

Background Mississippi’s cultural and political environment may discourage physician recruitment, encourage early physician retirement, and exacerbate physician shortages.1 There are two physicians to every 1,000 Mississippi residents compared to the national of average of 3 physicians per US resident. Additionally, the existing supply of physicians is not evenly distributed across the state. More than half of physicians live in 1 of 4 urban areas, although more than half of Mississippi’s residents live in rural areas.1 Despite Mississippi’s concentration of African Americans (37.2% of the population),2 the percentage of black physicians fails to reflect the state’s demographics.1 Mississippi’s physician workforce also does not reflect national trends associated with gender; the state has about half (12-13%) as many female physicians than the national average (25%).1 In short, Mississippi exemplifies a critical need for more physicians, especially physicians who are women and/or who have minority racial and ethnic backgrounds, particularly because patients report feeling more comfortable with a physician who is similar to them.3 UMC is the only public medical school in the state and Mississippi is one of the most rural states in the nation with about half of new practicing physicians coming from UMC’s

graduating classes. With 62% of Mississippi counties being classified as a Health Professional Shortage Areas (HPSAs),we speculate that UMC’s atypical admission technique will capture applicants who come from rural Mississippi and return to practice medicine in their rural town and thereby “grow their own” physicians. Being raised in a rural area is the best predictor of developing a rural medical practice.4 Researchers hypothesize that a rural upbringing or a rural experience increases the likelihood of practicing medicine in a rural location through four primary means: familiarity, sense of place, community involvement, and self-actualization.4 Familiarity with a location provides a sense of trust and comfort.4 A sense of place is developed with a personal connection to the environment which results in feeling rooted to the locale.4 A sense of community provides a feeling of connection to the people, relationships, and social milieu; the social makeup of a rural community provides an opportunity for one to develop meaningful relationships with their patients and staff through everyday interactions.4 Finally, some physicians find rural environments help them achieve self-actualization;4 they view the challenges associated with rural practice as a source of growth and enjoyment, knowing they are making a difference where they live and work. Although familiarity, sense of place, sense of community and self-actualization draw physicians to practice in rural areas, rural physician recruitment is difficult. Research has shown rural upbringing is an important predictor, but the majority of rural physicians were not raised in rural areas.5, 6 Rural physicians typically have experienced rural America through their education or some other life experiences, rather than being born in rural locations.4 By logical extension, the greatest predictor of practicing medicine in Mississippi should be whether one was raised in this largely rural state. However, just like those who choose to practice in rural areas were not necessarily raised in a rural locale, UMC’s practice of admitting only legal Mississippi residents may be limiting exposure to the state. If so, this tradition may need to be amended to expose more students to Mississippi’s medical school who may ultimately decide to practice permanently in the state. Researchers predict that in the near future, rural areas are expected to experience decreased physician supply relative to population.7 Because the Patient Protection and Affordable Care Act will increase access to health insurance for many Americans, likely increasing healthcare visits, scientists must seriously address possible factors contributing to Mississippi’s already undersized physician workforce. Since it takes a decade or more to train a physician, enrollment adjustments must be made well in advance of critical shortages.8 Mississippi already feels the pressures of a physician shortage, necessitating the examination of what we refer to as the “grow your own” policy of UMC admissions. The wineglass model is a theoretical model which illustrates physicians’ locational histories.9 Areas of initial recruit-

ment are symbolized as the base of a wineglass, the medical school program is represented as the stem, and practice location is conceptualized as the bowl.9 The wineglass model allows researchers to acknowledge variations through time and space with the ability to visualize the geographic area of initial recruitment and its relationship with ultimate practice location (the bowl). In practice, the wineglass model has shown that initially smaller bases produce smaller bowls. Ten years following graduation, however, physicians’ migration patterns widen and attachments to the school’s region substantially weaken, resulting in a much wider bowl.9 We speculate that UMC’s tradition of exclusively accepting Mississippi residents is used in hopes that its restrictive applicant pool results in graduates who are more attached to Mississippi and will be less likely to practice in other states, resulting in a smaller bowl. Hypotheses Based on our reading of the literature, we have developed four hypotheses. 1. More UMC students from the 1990s practice in Mississippi than in any other state. 2. More Mississippi physicians graduated from UMC than from other medical schools. 3. UMC graduates are more likely to practice in rural areas or small towns than physicians who attended medical school elsewhere. 4. UMC graduates are more likely to recommend practicing medicine in Mississippi to medical school students than physicians who attended medical school elsewhere.

Methods

Sources of Quantitative Data Data for this study come from multiple sources. To examine what proportion of Mississippi’s physicians were “home grown” and UMC-trained, we use licensure data collected by the Mississippi State Board of Medical Licensure (MSBML). These data contain location of primary practice, specialization, activity status, alma mater, age, race/ethnicity, and sex of every physician who is licensed to practice in the state. We study the UMC graduate cohort of the 1990s to allow graduates time to complete residency requirements—which may have temporarily taken them out of the state—and set up their first practice (or take their first post-residency position). The UMC graduate cohort of the 1990s was first examined by using a list of graduates provided by UMC. Combining this list with MSBML license renewal data, we identified physicians who were actively licensed in the state of Mississippi even if their primary practice was located outside of the state boundaries (see Table 1). This method resulted in a match with 71% of graduates. For those who were not licensed in the state, we used internet sources (viz. google.com; drscore.com; vitals. com, etc.), information provided by UMC’s Alumni Associa-

SEPTEMBER 2012 JOURNAL MSMA 285

tion, and the Official ABMS Directory of Board Certified Medical Specialists. These supplementary resources enabled us to correctly identify a total of 337 graduates not licensed in Mississippi and examine what proportion of UMC graduates are likely practicing outside of the state; we are unable to state with certainty their activity status. What we do know is that they are not licensed to practice in Mississippi and they are licensed to practice elsewhere; we cannot ascertain whether they are actually seeing patients elsewhere. Ultimately, we successfully identified locations for 99% of the 1990-99 UMC cohort graduates using the MSBML data and other resources (see Table 1). The MSMD survey (Mississippi Medical Doctors) was conducted in late 2007 and early 2008, yielding responses from 1,418 physicians. Additional outreach was focused on physicians from minority groups and physicians who worked in rural or underserved areas. An examination of response rates by gender and race indicates the analytic sample is demographically comparable to the population of Mississippi physicians, establishing confidence in generalizability. More details of survey design, data collection and representativeness are presented by Street et. al.10 Two survey questions were used to create our dependent variables. The first survey question was “Please describe the dominant patient population you served in your primary practice setting (check all that apply).” Possible answers included “inner city,” “urban/suburban,” “small town,” “rural,” “geographically isolated/remote,” and “other.” We dichotomized this variable by combining those who practiced in a rural, small town, or geographically isolated area into one category, making the referent group those who did not practice in a rural, small town, or geographically isolated area. To create the second dependent variable of the likelihood of recommending Mississippi as a place to practice to recent medical school graduates, we used the survey question “How likely would you be to recommend to someone graduating from medical school that they practice in Mississippi?” with possible responses of “very likely” (=reference), “somewhat likely,” “not very likely,” and “I would not recommend.” We trichotomized this variable by combining the response categories of “not very likely” and “I would not recommend” into one category. Source of Qualitative Data The final source of data comes from the spring/summer (2007) data collection effort which purposefully sampled minority physicians or physicians whose practices were rural or served traditionally underserved (poor/minority) patient populations in Mississippi. Interviews were performed with 57 physicians to gain a more clear understanding about what social factors prove to act as incentives and challenges of practicing medicine in Mississippi as a minority. To preserve the integrity of the data, interviews were recorded and later transcribed (one participant asked to not be recorded and only notes were taken). We systematically analyzed the interview transcriptions for patterns and themes.

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Table 1: Descriptives of 1990-99 UMC Graduates Table 1: Descriptives of 1990-99 UMC Graduates Percentage Population Percentage 99.2% Population Successfully Identified 920 Successfully Identified 99.2% 920 Identification Source Identification Source 1 583 MSBML 2009 71.1% 583 MSBML 220091 71.1% Other 36.4% 337 2 Other 36.4% 337 518 Actively Practicing in MS 518 Actively Practicing in MS 55.9%55.9% 3 3 Practice Type Practice Type 248 Primary Practice Physician 248 Primary Practice Physician 26.8%26.8% 270 Specialist 270 Specialist 29.1%29.1%

927 n n 927 Notes: 1. Mississippi State Board of Medical Licensure. 2. Internet Notes: 1. Mississippi State Board of Medical Licensure. 2. Internet sources (eg(eg drscore.com; vitals.com; google.com), Official ABMSABMS sources drscore.com; vitals.com; google.com), Official Directory of Board Certified Medical Specialists - 2004- ,2004 University of Directory of Board Certified Medical Specialists , University of Mississippi Medical Center's Alumni Association. 3. We3.are only Mississippi Medical Center's Alumni Association. We areable onlytoable to report practice typetype withwith certainty among thosethose who are licensed with with report practice certainty among who are licensed MSMBL. MSMBL.

Table 2: Characteristics of Practicing Physicians in Mississippi (2009; Table 2: Characteristics of Practicing Physicians in Mississippi (2009; Listwise Deleted) Listwise Deleted) Percentage/Mean Population/SE Percentage/Mean Population/SE Sex Sex Male 79.5% 361 Male 361 Female 20.5%79.5% 93 Female 93 Age in Years 51.020.5% 0.5 1 in Years Age 51.0 0.5 Race 90.1% 409 Race1White Black 5.7%90.1% 26 White 409 Other 4.2% 5.7% 19 Black 26 Married Other 86.8% 4.2% 394 19 Attended High School in MS 58.4% 265 Married 86.8% 394 Attended College in MS 55.1% 250 Attended High School in MS 58.4% 265 Medical School Attended College in MS 55.1% 250 UMC Graduate 52.9% 240 Medical School Internship in MS 39.4% 179 UMCinGraduate 240 Began Practice MS 43.4%52.9% 197 Internship in MS 179 Moved Practice to MS 24.2%39.4% 110 BeganType Practice in MS 43.4% 197 Practice Moved Practice to MS 110 Specialist 49.1%24.2% 223 Practice TypeCare Physician (PCP) Primary 50.9% 231 Practice in Specialist a Small Town 68.7%49.1% 312 223 Salary $231,893.77 50.9% $5,922.18 Primary Care Physician (PCP) 231 Student Loan $43,299.20 68.7% $2,497.85 Practice in Debt a Small Town 312 n Salary 454 $231,893.77 $5,922.18 OnlyLoan one respondent was Hispanic. 1 Note: Student Debt $43,299.20 $2,497.85

n 1

454 Note: Only one respondent was Hispanic.

Quantitative Results About 56% of University of Mississippi Medical Center graduates are actively practicing in the state of Mississippi. Because we used various internet sources to verify location of out-of-state physicians, the validity of locations for out-of-state physicians has not been confirmed. Based on the distribution of data as illustrated in Map 1, UMC 1990s graduates tend to be located in the Southeast United States; UMC graduates who are primary care physicians tend to be near Mississippi. Therefore, we fail to reject our first hypothesis that the proportion of 1990s UMC graduates who practice in Mississippi is greater than those who do not. Map 2 depicts the spatial distribution of 1990s UMC graduates practicing in Mississippi in 2009. Counties with higher numbers of primary care physicians also tend to have more specialists. These counties are generally more populated and are not designated HPSAs. In other words, most UMC graduates from the 1990s who practiced in Mississippi in 2009 were not in health professional shortage areas. In Map 3, we

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show the distribution pattern of all actively practicing physicians in Mississippi by practice type, HPSA typology, and proportion of UMC graduates. The pattern of distribution of 1990s UMC graduates (Map 2) is generalizable to Mississippi physicians broadly (Map 3). That is, UMC graduates are apt to practice where physicians tend to practice; they are not more likely to practice in rural areas or HPSAs, although they are a majority (57.6%) of the healthcare workforce (see Table 2). Using MSBML renewal data, we present similar descriptive statistics for all physicians practicing in the state (see Table 2). The percentage

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of 1990s UMC graduates who practice in Mississippi (56%) (see Table 1) closely approximates the proportion of UMC graduates of any single year (58%) (see Table 2). This is a critical finding as it provides evidence that the 1990s UMC cohort we tracked is likely representative of UMC alum more broadly which suggests UMC graduates do, in fact, constitute a greater proportion of Mississippi’s healthcare workforce than those who attended graduate school outside of the state, a trend that is likely to continue. Table 3: Odds Ratios of Mississippi Physicians Practicing in Smalltown Model 1 Model 2 OR OR Predictor SE SE UMC Graduate (non as ref.) 1.003 0.203 0.671 0.225 Attended High School in MS 0.840 0.276 Attended College in MS 1.669 0.561 Internship in MS 1.037 0.290 Began Practice in MS 0.956 0.267 Moved Practice to MS 1.021 0.334 Primary Care Physician 2.444 *** 0.557 Age 1.001 0.012 Sex (female as ref.) 1.394 0.390 Race (non‐white as ref.) 0.843 0.310 Married (not married as ref.) 0.996 0.315 Salary 1.000 ** 0.000 Student Loan Debt 1.000 0.000 ‐282.072 ‐270.383 Log Likelihood 2

Model χ df n *p <0.05 **p <0.01 ***p <0.001

0.00 1 454

23.38* 13 454

There are two other findings that are noteworthy from our descriptive analysis of all actively practicing Mississippi physicians. About 20% of Mississippi’s physicians are women and about 20% of physicians are non-white (see Table 2). Only 39.4% of Mississippi’s female physicians (Pearson Chi-square =4.379; P > .05) and 12.1% of the state’s physicians who have a minority racial status are UMC alum (Pearson Chi-square =446.287; P > .001) (analyses available upon request). Mississippi is clearly not “growing their own” female and racial minority physicians. We performed logistic regression to test our third hypothesis that UMC graduates have a greater likelihood of practicing in rural areas, small towns, or geographically isolated areas (see Table 3). Results from Models 1 and 2 indicate that UMC graduates do not have significantly different odds of practicing in rural, small towns, or geographically isolated areas in Mississippi than physicians from other medical schools. The only statistically significant finding of our analysis is that primary care physicians are 2.4 times (P<.001) more likely to practice in small town areas than specialists, all else being equal. These empirical results lead us to reject our third null hypothesis. Table 4 shows the likelihood of recommending Mississippi as a destination state for new medical school graduates to practice. For both models, the category of “not very likely or would not” recommend Mississippi is the referent. The results in Model 1 show that Mississippi physicians who are UMC graduates are 180% (P>.01) more likely to be “very likely” to recommend Mississippi than are physicians who

Table 4: Multinomial Logit Odds Ratios of Mississippian Physicians Who Would Recommend Practicing in Mississippi (2007) Model 1 Model 2 Not Very Likely or Somewhat Very Not Very Likely or Somewhat Very Would Not Recommend Likely Likely Would Not Recommend Likely Likely SE SE SE SE SE SE OR OR OR OR OR OR (ref.) (ref.) UMC Graduate (non as ref.) 1.89 0.34 2.80 ** 0.33 1.13 0.53 1.51 0.52 Attended High School in MS 0.54 0.53 0.64 0.52 (ref.) Attended College in MS 2.09 0.57 1.14 0.55 (ref.) (ref.) Internship in MS 0.95 0.48 1.70 0.46 (ref.) Began Practice in MS 1.10 0.48 1.80 0.47 (ref.) Moved Practice to MS 0.77 0.49 0.57 0.49 2 (ref.) Primary Care Physician 1.75 0.37 2.96 ** 0.36 (ref.) Practice in Small Town 0.55 0.39 0.50 0.39 (ref.) Age 0.97 0.02 1.00 0.02 (ref.) Sex (female as ref.) 0.80 0.45 0.70 0.44 (ref.) Race (non‐white as ref.) 2.66 * 0.48 3.44 ** 0.48 (ref.) Married (not married as ref.) 1.37 0.46 1.32 0.45 (ref.) Salary 1.00 0.00 1.00 * 0.00 (ref.) Student Loan Debt 1.00 0.00 1.00 0.00 ‐422.82 ‐400.20 Log Likelihood 11.72** 56.95 Model χ2 2 28 df 454 454 n *P<0.05 **P<0.01 SEPTEMBER 2012 JOURNAL MSMA 289 ***P<0.001

graduated medical school elsewhere. After adding statistical controls to Model 2, the odds of UMC grads practicing in Mississippi recommending Mississippi as a practice location are not significantly different from non-UMC graduates. Results from Model 2 show that whites are significantly more likely to be “somewhat likely” (2.66; P<.05) and “very likely” (3.44; P<.01) to recommend practicing in Mississippi to new medical school graduates compared to non-whites and specialists, all else being equal. Lastly, the findings in full model indicate that primary care physicians have 2.96 (P<.01) higher odds of being “very likely” to recommend Mississippi than do specialists who also practice in the state net of statistical controls. Qualitative Results Although the qualitative data (2007) analyzed in this study were not gathered specifically to understand where UMC graduates practice medicine, a thorough analysis reveals distinct racial and gender patterns about the social climate experienced by female and minority physicians who practice in the state. We speculate that the uninviting attitude towards female and minority physicians might discourage UMC graduates from practicing in the state or encourage potential minority and female students to train elsewhere. In this section, we briefly discuss some of the racial and gender barriers respondents experienced. Our in-depth minority physician interviews (2007) are congruent with the literature and provide additional support for the main findings in this study, primarily that most minority and female physicians in Mississippi are trained outside of the state and that Mississippi is a difficult place to recruit new physicians. Mississippi has long been associated with racism and conservative gender roles. Thus, we were particularly interested in how race and gender provided both opportunities and barriers to minority and female physicians in Mississippi. In general, black respondents experienced barriers throughout their career—by patients and colleagues (to a lesser extent)— that called to question their credibility as a physician. However, older physicians reported less racial discrimination and less overt discrimination than in the past; most black female physicians reported being regularly confused as a nurse or a food/janitorial service worker (less frequently reported among white female physicians) thereby suggesting an overall belief that physicians are not black. In short, the racial environment does not encourage minorities to practice medicine in Mississippi and may implicitly discourage minorities from attending UMC or practicing in the state after they have graduated. Regardless of racial identity, nearly all female physician respondents said that they experienced an initiation process by colleagues that forced them to prove their abilities as a physician. Interestingly, many female physicians also reported their position, in an ironic way, that their colleagues (and patients) felt that they had to prove themselves as physicians before

290 JOURNAL MSMA SEPTEMBER 2012

they would be taken seriously, but then they were also quickly helped and treated with chivalry. Despite improvements in gender discrimination, one of the greatest reported barriers associated with being a female physician is the difficulty in balancing occupational and familial roles. In fact, female physicians frequently cited they felt some judgment about how they juggled these roles, while these feelings were not expressed by male physicians. We suspect that the strong gender roles and negative attitudes about female physicians indirectly discourage women from attending UMC or practicing elsewhere after they graduate. We also suspect that as gender attitudes about female physicians continue to change, more female physicians will practice in Mississippi—including UMC graduates.

Discussion and Conclusion We investigate whether the practice of Mississippi’s single public medical school admitting only state residents was beneficial in helping this rural state “grow their own” physicians. While the majority of Mississippi’s physician workforce is constituted of UMC graduates, a substantial minority are not. If Mississippi needs to train their own physicians, class size must be increased. Between 1990 and 2000, UMC graduated half (3.2 per 100,000 population) the new physicians than the United States (6.4) on a per capita basis.11 However, one minority physician we interviewed acknowledged that UMC’s class size, albeit relatively small, is at its threshold and admitting more students is problematic due to lab capacities and classrooms not being large enough to accommodate more students. If UMC maintains the in-state-resident-only admissions approach, it is imperative that the classes reflect the gender and racial diversity of the state. Efforts will also need to be made to retain female and minority medical students at the same rate as white male medical students—our data do not allow us to investigate whether this is occurring. The medical student population can be diversified in a number of ways. First, UMC could accept out-of-state applicants who have ties to Mississippi. For example, Louisiana State University School of Medicine accepts out-of-state applicants whose parents are alumni.12 In efforts to broaden their applicant pool, UMC could accept applicants whose parents are alumni of any Mississippi university. Second, UMC could increase their applicant pool by including students from contiguous states (e.g., University of Missouri School of Medicine at Columbia 13) or states within the region (e.g., Pacific Northwest University of Health Sciences, College of Osteopathic Medicine 14). Using the MSBML data, we can see that most Mississippi physicians who were not trained at UMC were trained at Louisiana State University School of Medicine (at New Orleans and at Shreveport), the University of Tennessee Health Science Center, and Tulane University School of Medicine; therefore, recruitment from those schools for students to return to Mississippi for residency and practice might be fruitful. Third, like the University of Nevada School of Medicine, 15 UMC could accept applicants

from states which do not have medical schools (i.e., Alaska, Idaho, Montana, Wyoming). And UMC could make exceptions for out-of-state minority applicants (e.g., The University of North Dakota School of Medicine and Health Sciences16). Finally, using programs and policies to promote socioeconomic diversity does not translate into a diverse racial workforce; instead it is recommended that educators preferentially seek minority applicants17 whether they live in Mississippi or not. Mississippi physicians who are UMC graduates are not any more likely to work in rural areas, small towns or geographically isolated areas than physicians who attended medical school elsewhere, all else being equal. Thus, like other states with large proportions of rural HPSAs, Mississippi may benefit by focusing its attention on creating recruitment programs which entice out-of-state physicians to work in this rural state, and in particular, in its HPSAs.18 Since retention in HPSAs is no different from retention in other areas,18 the struggle is largely with recruitment. Strong stigmas are associated with Mississippi and persist even among other Southerners which make Mississippi’s recruiting experience challenging. One black female physician said it best: “Alabamians don’t go to Mississippi. We go through Mississippi on our way to New Orleans; we don’t go to Mississippi” (emphasis in original interview). Many minority physicians who relocated to the state explained in their interviews that Mississippi needs to get potential candidates and their spouses to experience Mississippi before serious recruitment will occur. Recruitment can only occur after candidates and their families are aware of the advantages a practice in Mississippi has to offer. In fact, half of the minority physicians interviewed said that they chose to practice in the state because they had family in Mississippi or in neighboring states. Summarizing one black female physician’s remarks colloquially, this pattern may suggest that the best way to get physicians to practice in the state is to get them to marry a Mississippian because they are already aware of the state’s advantages. Mississippi’s physician recruiters could also focus their attention on encouraging medical school graduates to fill residency positions in Mississippi. Previous research indicates that the importance of medical school location is less important than the location of one’s residency training.19, 20 Many students leave the state where they attend medical school for residency training, including those who attend school in the state in which they lived previously.21 This is of particular interest because many who leave do so despite the fact that there is usually a surplus of residency positions available compared to the number of medical school graduates.21 Others have found that state residents were more likely to continue graduate medical education in the area compared to out-of-state students, particularly for women.22 New graduates might be more willing to consider Mississippi as a residency location for a finite period of time, knowing they could choose to leave after residency.

Once physicians and their spouses experience the benefits that Mississippi has to offer during residency, they may be more inclined to stay and practice. Our qualitative data hint that the Mississippi experience will be most beneficial in retaining residents and transforming them into long-term physicians in rural areas as they become a key fixture in the community. Based on the findings from our in-depth interviews, we specifically suggest that, as Mississippi increases its recruiting efforts for residency positions, recruiters emphasize that many residency/ clinical positions are located in more rural areas among a critically vulnerable population. Emphasizing Mississippi’s rurality and vulnerability will prove successful for three reasons. First, although many Southerners view Mississippi through stereotypes, descriptions of the rural environment and population will sound similar to their home environments which will make physicians more likely to consider filling residency positions in Mississippi. Second, respondents noted that doing a residency with a vulnerable population provided experiences practicing on a wide variety of illnesses and in a wide variety of circumstances which quickly built an important repertoire of skills. Third, because Mississippi’s population is so vulnerable, physicians can see their services as important, providing much needed care and creating self-actualization. We are unable to explore how many resident positions are left unfilled each year, what proportion of residents are UMC graduates, and whether they have a rural background with the data we currently have. Future research should investigate how residency training affects location of physician practice in Mississippi. It is noteworthy that having attended high school and college in Mississippi were not significant predictors in our regression models. These findings suggest that among those who choose to practice in Mississippi, there is little difference between those who grew up in Mississippi and those who did not. However, future research should more closely examine the characteristics of UMC graduates who leave and compare them to UMC graduates who choose to practice in Mississippi. Existing data do not allow us to even reliably report racial or sex characteristics for UMC graduates who have chosen to leave the state. This type of study will better enable healthcare professionals to know how to recruit and retain physicians to this rural state.

References 1. 2. 3. 4.

Cossman JS. Mississippi’s physician labor force: current status and future concerns. J Miss State Med Assoc. 2004;45(1):8-31. US Census Bureau. State and County QuickFacts. Washington, DC: US Census Bureau; 2010. Available at: http://quickfacts. census.gov/qfd/states/28000.html. Accessed July 23, 2010. Ferguson WJ, Candib LM. Culture, language, and the doctorpatient relationship. Fam Med. 2002;34(5):353-361. Hancock C, Steinbach A, Nesbitt TS, Adler SR, Auerswald CL. Why doctors choose small towns: a developmental model of rural physician recruitment and retention. Soc Sci Med. 2009;69:1368-1376. Owen JA, Hayden GF, Bowman RC. Influence of places of

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6. 7. 8. 9. 10.

11.

12.

13.

14.

15.

16.

17. 18. 19. 20. 21. 22.

birth, medical education, and residency training on the eventual practice locations of family physicians: recent experience in Virginia. Southern Med J. 2005;98:674-675. Pathman DE, Konrad TR, Agnew CA. Studying the retention of rural physicians. J Rural Health. 1994;10(3):183-192. Ricketts TC, Randolph R. Urban-rural flows of physicians. J Rural Health. 2007;23(4):271-285. Iglehart JK. Grassroots activism and the pursuit of an expanded physician supply. N Eng J Med. 2008;358(16):1741-1749. Baer LD, Gesler WM, Konrad TR. The wineglass model: tracking the locational histories of health professionals. Soc Sci Med. 2000;50(3):317-329. Street D, Cossman JS, Butts CC, Smith SH. Mississippi Physicians: Characteristics and Experiences of Physicians in an Underserved State. Starkville, MS: Mississippi Center for Health Workforce; 2009. National Center for Health Workforce Analysis. State Health Workforce Profiles: Highlights from the 2000 Profiles. Albany, NY: HRSA Bureau of Health Professions National Center for Health Workforce Analysis, Center for Health Workforce Studies, State University of New York at Albany 2004. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/profiles/ . Accessed March 15, 2011. Office of Admissions. Criteria Used in Selecting Applicants. New Orleans, LA: Louisiana State University School of Medicine at New Orleans 2010. Available at: http://www.medschool. lsuhsc.edu/admissions/Criteria.aspx. Accessed March 17, 2011. University of Missouri School of Medicine. Requirements for Admission. Columbia, MO: University of Missouri School of Medicine; 2010. Available at: http://som.missouri.edu/requirements.shtml. Accessed March 17, 2011. Pacific Northwest University of Health Sciences. Admissions. Olympia, WA: Pacific Northwest University of Health Sciences; 2010. Available at: http://www.pnwu.org/admissions. Accessed March 17, 2011. University of Nevada School of Medicine. Propspective Applicants. Las Vegas, NV: University of Nevada School of Medicine; 2009. Available at: http://www.medicine.nevada.edu/dept/ asa/prospective_applicants/adm_residency.htm. Accessed March 17, 2011. Office of Student Affairs Admissions and Financial Aid. Guide for Prospective Medical Students. Grand Forks, ND: University of North Dakota School of Medicine and Health Sciences; 2008. Available at: http://www.med.und.edu/studentaffairs/prospectivemsguide.html#resreq. Accessed March 17, 2011. Saha S, Shipman SA. Race-neutral versus race-conscious workforce policy to improve access to care. Health Aff. 2008;27(1):234-245. Pathman DE, Konrad TR, Dann R, Koch G. Retention of primary care physicians in rural health professional shortage areas. Am J Public Health. 2004;94(10):1723-1729. Gessert C, Blossom J, Sommers P, Canfield MD, Jones C. Family physicians for underserved areas: the role of residency training. West J Med. 1989;150(2):226-230. Stefanu C, Pate ML, Chapman JS. Hospitals and medical schools as factors in the selection of location practice. Acad Med. 1979;54(5):379-383. Barzansky B, Etzel SI. Educational programs in US medical schools, 2004-2005. J Am Med Assoc. 2005;294(9):1068-1074. Cooksey JA, Harman CP. Dissecting the medical training-topractice continuum: factors associated with choosing in-state graduate medical education. Acad Med. 1999;74(10):S114-S117.

William C. Lineaweaver, MD

Tanya Oswald, MD

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292 JOURNAL MSMA SEPTEMBER 2012 ROC Microvascular Hand Surgery JMSMA Ad 6-12.indd 1

6/8/12 11:19 AM

• Top 10 Facts You Should Know •

About Headaches Richard D. deShazo, MD, Allyn Bond, MD

1. What are the most common types? Ninety percent of headaches are tension, cluster, or migraine which accounts for up to 45% in some studies.1 2.

Terms out of vogue. The term “vascular headache” to describe migraine and cluster headache and the terms “psychogenic headache” and “muscle contraction headache” to describe tension headache are discouraged as they do not necessarily denote the pathophysiology of these syndromes.2

3. Alarm signs. Alarm signs indicating the necessity for more extensive evaluation and observation of headaches include sudden onset, severe headache reaching maximal intensity within seconds to minutes after onset, new visual or other neurologic findings, cranial bruits, trauma, headaches associated with headache in other family members (carbon monoxide), those with onset during exercise, those with radiation of headache pain to shoulders or arms (spinal cord space occupying lesions), headaches associated with acute febrile illnesses or occurring in cancer or HIV patients, new onset headache in the elderly (temporal arteritis headache), and acute headaches during pregnancy (cerebral venous thrombosis) or intercourse. Indications for lumbar puncture to measure CSF pressure and cervicospinal fluid analysis include suspicion of subarachnoid hemorrhage with a normal uncontrasted head computed tomography or central nervous system infection or inflammation.3 4. What features distinguish cluster headaches? Cluster headaches are always unilateral and distinguished by their rapid onset, origin around the eye or temple, excruciating severity, short duration (30-180 minutes), ipsilateral red eye, rhinorrhea, nasal stuffiness, focal neurologic symptoms, patient activity (movement), and sensitivity to alcohol. In the “episodic form” they occur 1-8 times a day for weeks followed by a remission. They respond best to oxygen inhalation and subcutaneous sumatriptan. Once they start, preventative therapy with verapamil should be started. A chronic form occurs without sustained remissions.2

5. What are sinus headaches? There is no consensus on the definition of sinus headaches. Moreover, most “sinus headaches” are actually migraine headaches.4,5 6. What is chronic daily headache syndrome? Chronic daily headache is a headache that is present for more than 15 days a month for 3 months without evidence of organic pathophysiology. It includes chronic (transformed) migraine, chronic tension, medication overuse (rebound) headache, hemicrania continua, and the NSAID responsive headaches including primary cough headache, idiopathic stabbing headaches, and new daily persistent headache. “Medication overuse headache” is the most common form from chronic overuse of opiates and butalbital containing medications as well as aspirin/ acetaminophen/caffeine preparations. It can also occur with triptan use.6 7. What are trigeminal headaches? The trigeminal autonomic headache group includes “cluster headaches”, “paradoxical hemicranias,” “short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT)” and “short lasting unilateral neuralgiform headaches with cranial autonomic symptoms.” They are characterized by unilateral trigeminal distribution pain that occurs in association with ipsilateral cranial autonomic features.6 8. Are headaches associated with brain tumors? Headaches occur in 50% of patients with brain tumors and resemble tension headaches about 75% of the time. Tumor associated headaches are suggested by nausea, vomiting, worsening with position changes or coughing, and different from previous headache patterns.7 9. What is the best acute treatment of an intractable headache? A recommended treatment regimen for severe undifferentiated headache after negative evaluation for an underlying disease includes a dopamine agonist and an NSAID. The medications used most often are 30 mg of ketorolac intravenously (IV), 0.1 mg/kg chlorpromazine IV, with pretreatment with 12.5 mg of Benadryl or

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1 mg benzatropine to prevent akathisia. Treatment options for failure to respond to this regimen include dihydroergotamine 1 mg IV, sumatriptin, olanzapine, metoclopropamide, and dropesridal. Opiates are reserved for patients with contraindications to NSAIDs or dihydroergotamine.8 10. Headache fallacies. Headache fallacies include “antibiotics need not be given prior to lumbar puncture or other evaluation of patients with possible meningitis,” “lumbar puncture is not required in patients suspected of subarachnoid hemorrhage who have normal head CTs,” and “clearing of blood in CSF collection tubes is a reliable way of excluding subarachnoid bleeding.” Although concerns have been raised about the induction of serotonin syndrome with serotonin reuptake inhibitors (SSRI) in patients who require triptan treatment for headaches, the risk of the combination SSRI and SNRI with tryptase medication seems low to non-existent.9

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Resources for Patients Website resources for patients with headaches include those from the American Committee for Headache Education (www.achenet.org), the American Headache Society (www. achenet.org), the American Headache Society (www. americanheadachesociety.org), and the National Headache Foundation (www.headaches.org).

References 1.

Bigal ME, Bordini CA, Speciali JG. Etiology and distribution of headache in two Brazilian primary care units Headache 2000;40:241.

Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders. 2nd edition, Cephalagia 1991; 11:1.

Edmeads J. Emergency management of headache. Headache 1988; 28:675.

Schreiber CP, Hutchinson S, Webster CJ, et al. Prevalence of migraine in patients with a history of self-reported or physician-diagnosed “sinus headaches.” Arch Intern Med 2004;164:1769.

Levine HL, Setzen M, Cady RK, et al. An otolaryngology, neurology, allergy, and primary care consensus on diagnosis and treatment of sinus headaches. Otolaryngoly Head Neck Surg. 2006;134:516.

Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders: 2nd Edition Cephalagia 2004;24 Suppl 1:9.

Forsyth PA, Posner JB. Headaches in patients with brain tumors: a study of 111 patients. Neurology 1993;43:1678.

Torelli P, Campana V, Cervellin G, Manzoni GC. Management of primary headaches in adult Emergency Departments: a literature review, the Parma Ed experience and a therapy flow chart proposal. Neurol Sci. 2010;31:545.

Wenzel RG, Tepper S, Korab WE, Freitag F. Serotonin syndrome risks when combining SSRI/SNRI drugs and triptans: Is the FDA’s alert warranted? Ann Pharmacother 2008;42:1692.

Acknowledgement: The author appreciates the assistance of Ms. Leigh Wright and Mrs. Monica Watkins in the preparation of this paper.

294 JOURNAL MSMA SEPTEMBER 2012

BRANDON BYRAM CANTON CLINTON JACKSON LAUREL MADISON PEARL RICHLAND RIDGELAND

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www.meamedicalclinics.com DiD your last meeting leave you feeling a taD

“ECTOPIC” If so, you should consider having your next meeting in Tupelo!

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

â&#x20AC;˘ Just off the Press - Info You Want to Know â&#x20AC;˘

Probiotics- Are They Beneficial? Lucy Cadwallader, PharmD and Richard L. Ogletree, Jr., PharmD

Background: Diarrhea occurs in as many as 30% of patients using antibiotics. Probiotics assist in restoring gut flora during or after antibiotic treatment through a variety of mechanisms, including receptor competition, inhibition of the adherence of pathogens to mucosa, and stimulation of immunity. In recent years there has been interest in determining the efficacy of probiotics in treating and preventing GI disorders, including antibiotic associated diarrhea. Article: Hempel S, Newberry S, Maher A, et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea (AAD): a systematic review and meta-analysis. JAMA. 2012 May; 37(18):1959-69. Objective: To evaluate the available evidence on probiotics and symbiotic interventions including the genera Lactobacillus, Bifidobacterium, Saccharomyces, Streptococus, Enterococus, and Bacillus, alone or in combination for the prevention or treatment of antibiotic-associated diarrhea (AAD). The primary outcome was the number of participants with diarrhea in the treatment groups. Design: Systematic review and meta-analysis Methods: 12 databases (DARE, Cochrane Library, CENTRAL, PubMed, EMBASE, CINAHL, AMED, MANTIS, TOXLINE, ToxFILE, NTIS, AGRICOLA) were searched from inception to February 2012. The search was not restricted to individual probiotic genera or to any clinical indications or outcomes. Two independent reviewers assessed publications and extracted trial details. Results: 2426 publications were screened for inclusion in the review, with 82 randomized controlled trials (RCTs) meeting criteria. Of the 82 RCTs, 63 reported the number of patients with diarrhea as well as the number of participants in each treatment group. There was a statistically significant association of probiotic use with reduction in AAD (RR 0.58; 95% CI, 0.5-0.68; p<0.001, i2 54%; number needed to treat, 13; 95% CI 10.3-19.1). The majority of patients used Lactobacillus-based interventions alone or in combination with other genera; however, strains were poorly documented. Conclusion: Pooled evidence suggests that probiotics are associated with a lower incidence of AAD. More evidence is needed to determine which genus is most efficacious and for which patient population receiving which antibiotic.

Table 1. Overall Efficacy of Probiotic Use

Genus Blend Enterococcus Lactobacillus Saccharomyces Overall random effects

Relative Risk 0.66 0.51 0.64 0.48 0.58

Confidence Interval (0.49-0.88) (0.38-0.68) (0.47-0.86) (0.35-0.65) (0.50-0.68)

Table adapted from: Hempel S, Newberry S, Maher A, et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea (AAD): a systematic review and meta-analysis. JAMA. 2012 May; 37(18):1959-69.

Reviewer comments: Probiotics seem to have some utility in the prevention of antibiotic associated diarrhea. Based on the above data, treating 13 patients with probiotics would prevent one case of AAD. Currently, the data do not point us to the particular type of patient nor the antibiotic exposure that may benefit most from the use of probiotics. However, the information currently available makes it seem to be an option worth exploring. r

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• MSDH • Mississippi Reportable Disease Statistics

July 2012 Figures for the current month are provisional

Totals include reports from the Department of Corrections and those not reported from a specific District. For the most current MMR ﬁgures, visit the Mississippi State Department of Health website: www.HealthyMS.com.

296 JOURNAL MSMA SEPTEMBER 2012

• President’s Page •

Tort Reform

e have some very important elections coming up in November. Of course we think about our national races, but the one that directly affects Mississippi physicians will be the election for the State Supreme Court judges in your respective districts. In 2002 we were at the very height of the tort crisis in our state. Physicians were leaving the state. Doctors could not get insurance to practice. Rates had increased dramatically, and it was really a low point for the medical profession. Since that time we enacted legislative tort reform in 2002 and then again in 2004. This was coupled with traditional tort reform and electing fair-minded judges to the state Supreme Court. They have had a much more balanced approach to medical Steven L. Demetropoulos, MD malpractice cases, and consequently our tort environment has improved 2012-13 MSMA President dramatically in the state. Since that time rates at Medical Assurance Company of Mississippi have fallen significantly. They have opened up the company to offer new policies for physicians entering the State. We have stemmed the tide of physicians leaving the State and now have physicians coming back into the State to practice. But all this can be overturned within one or two election cycles. So it is critical that we remain vigilant on the judicial tort scene. Any change of Supreme Court judges resulting in a net loss of conservative, fair-minded judges and we will find ourselves again in a position where the tort scene can dramatically change for us. So what can we do as physicians?

1. First we need to know who the Supreme Court Justice is that is supported by our Mississippi State Medical PAC in our district. We can support that person financially.

2. We need to make sure that we get our families and friends and people that we have influence with to vote for that person and to get out to the polls and support them.

3. We can support these candidates in our offices and let our patients know that the positive environment that we are

experiencing in Mississippi is directly related to having conservative, fair-minded judges on the Supreme Court bench and that their access to care is directly related to that as well.

ust what the doctor ordered CITRUS SALAD

The next recipe that I have for you is another salad. This salad is a citrus salad. You use navel oranges cut up in chunks. Mix that with avocado that is also in chunks. Add some fresh mint, which goes really good with citrus. Then place that over two dollops of soft goat cheese. A brand that I like to use is Laura Chenel’s Chevre and by dollops I mean two small slices on a salad plate. Then ladle the citrus and the avocado over it and drizzle that with your balsamic vinegar, olive oil and a little salt and pepper for taste. In the wintertime you could substitute the navel orange with blood oranges which make a particularly pretty salad. Then when strawberries come in season, you could replace the citrus with strawberries and avocado over the goat cheese. Again the dressing stays the same and is very simple, but the citrus and/or the strawberries with the avocado make a great salad that’s very well received. If you don’t have any fresh mint, you could use cilantro in place of it. Next month we will move on to another course. Bon appetit!

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O’Brien & Family Law Group

James

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

Tell Congress to support Medicare choice Urge your lawmakers to support the Medicare Patient Empowerment Act (H.R. 1700/S.1042). This legislation would allow patients to use their Medicare coverage to help cover the cost of seeing any physician, even those who do not accept Medicare.

TAKE ACTION n Visit ama-assn.org/go/privatecontracting to access resources for physicians and patients, and to get involved in grassroots activities. n Sign our online petition at MyMedicare-MyChoice.org and encourage your patients to do so, too.

298 JOURNAL MSMA SEPTEMBER 2012

• Special Article •

MRPSP Scholars- Embracing the Vision for a Healthier Mississippi

Top left to right: MRPSP Pediatric first year resident and former MRPSP scholar John Russell McPherson, MD of Inverness pins M3 Jonathan Buchanan of Carthage. Students were all smiles with their oversized checks. Chair of the Department of Family Medicine at the University of Mississippi Medical Center Diane Beebe, MD, visits with AMA & MSMA Past President J. Edward Hill, MD. Janie Guice, MRPSP Executive Director, shares a laugh with Randy Easterling, MD. Sen. Hob Bryan (D-MS 7th District) Public Health and Welfare, Vice Chair, visits with MRPSP Scholar Leah Anderson of Tremont.

friends and families witnessed the presentation of oversized $30,000 checks to the medical hey used to call them country scholars. MRPSP lapel pins doctors; now they call them were presented to the M3 class rural physicians. In 2007, the by MRPSP Chairman John Mississippi Legislature authorized the Russell McPherson, PG-1 in pediatrics. Mississippi Rural Physicians Scholarship Program (MRPSP), MRPSP Executive Director Janie Guice remarked, “In creating a unique longitudinal program that identifies rural less than five years, the poorest state in the nation in the middle college students who aspire to return to their roots to practice of a recession is awarding over a million and a half dollars to medicine. The Mississippi State Medical Association (MSMA) encourage preventive medicine and nurture future rural physicians was instrumental in establishing the MRPSP to help alleviate from college through residency training. Maintaining a high Mississippi’s access to care problem by increasing the number level of awareness and involvement in Mississippi’s rural health of primary care physicians in our state to help reduce healthcare care is a constant in every phase of MRPSP training. Channeling costs, improve life expectancy, and save lives. students into five primary care specialties (Family Medicine, With continued strong legislative support in 2012, MRPSP Obstetrics and Gynecology, Pediatrics, Medical Pediatrics or awarded $1.5 million in state funded scholarships. In an evening ceremony held in Mississippi’s Old Capitol Legislative Chamber, General Internal Medicine) will target the current physician shortage.” 54 medical students received $30,000 each for their studies in Turn the page to see the 2012-2013 MRPSP composite. For medical school through the combined resources of the Mississippi more information on the MRPSP, contact: Janie Guice, MRPSP Legislature, the Medical Assurance Company of Mississippi, Executive Director, (601) 815-9022, jguice@umc.edu. the Selby and Richard McRae Foundation, and the Madison —Karen A. Evers, Managing Editor Charitable Foundation for a total of $1,620,000.00. A crowd of

SEPTEMBER 2012 JOURNAL MSMA 299

Photo courtesy of UMMC Biomedical Illustration Services

300 JOURNAL MSMA SEPTEMBER 2012

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SEPTEMBER 2012 JOURNAL MSMA 301

• Special Article •

Do the Supreme Court Elections Really Matter?

A History Lesson

As we approach the November elections, it may be helpful to review our Robert M. Jones, J.D. history in Mississippi with respect to medical liability. Prior to the 1980’s, it was not Legal Counsel common for physicians or health care providers to be sued for medical negligence. Medical Assurance In the early 1990’s, the number of claims and lawsuits brought against physicians Company of Mississippi and other healthcare providers increased dramatically. At the same time, a more “plaintiff-friendly” Mississippi Supreme Court was elected. Over the next ten years, it was difficult for physicians and hospitals to get relief from adverse trial court rulings and excessive jury verdicts. As a result, premiums paid by physicians for malpractice insurance skyrocketed, it was difficult to recruit new physicians to come to Mississippi, and physicians began to practice defensive medicine. In short order, parts of Mississippi were referred to as a “Judicial Hellholes,” and our state became known as the “lawsuit capital of the world.” This crisis is reflected by Chart A, which shows the increase in the number of lawsuits filed against physicians insured by Medical Assurance Company of Mississippi from 1986 to 2002:

Chart A – Lawsuits filed against MACM insureds (does not includes mass tort)

Suits Filed 1986 ‐ 2010 630

355 218 167173 159 132 129109135

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

238257 215214202229227 159163172 131152 123 107

As a result of the dramatic increase in the number of medical malpractice claims and the rulings of the Mississippi Supreme Court, a physician insured by Medical Assurance Company of Mississippi saw his malpractice insurance premium more than double from 2000 to 2004.

YEARS 1989 – 20022012 302 JOURNAL MSMA SEPTEMBER 2003 – 2008 2009 - 2012

FOR DEFENDANT 41 76 24

FOR PLAINTIFF 71 23 23

More significant, however, was the impact that the medical 355 liability crisis had on patients’ access to care. Access to health care in Mississippi was in serious jeopardy because physicians were leaving the state, and it was nearly impossible to recruit new 630 physicians, due partly to the decreased availability and excessive cost of professional liability insurance. It got so bad at one point 238257 229227 that Medical Assurance Company of Mississippi had to place a moratorium on insuring new physicians. 218 215214202 173 a cap on noneconomic 172 167 159 159163 Fortunately, the Mississippi Legislature responded by passing tort reforms. The reforms included 132 131152 129109135 123 107 damages, a limit 82 on the venue in which physicians may be sued, pre-suit notice of claim, and the requirement that plaintiffs consult with a medical expert prior to filing suit. At the same time as the passage of tort reforms, the public elected a fair and balanced Supreme Court, which has correctly and impartially355 interpreted and applied our tort reform statutes.

Suits Filed 1986 ‐ 2010

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

From 1989 to the present, the Mississippi Supreme Court handed down many medical liability decisions involving 238257During the218 229227 physicians, hospitals, nurses, and other healthcare providers. medical liability crisis from 1989 to 2002, the Supreme 215214 202 Court was decidedly pro-plaintiff; however, since then, the more balanced Court in Chart B: 172 167173 163 159 is reflected 159 132 131152 129109135 107123 82

Chart B - Medical Liability Decisions of the Mississippi Supreme Court FOR DEFENDANT 41 76 24

FOR PLAINTIFF 71 23 23

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

YEARS 1989 – 2002 2003 – 2008 2009 - 2012

Medical Assurance Company of Mississippi insures approximately 75% of physicians in private practice in Mississippi. YEARS FOR DEFENDANT FOR PLAINTIFF As a result of the passage of tort reform and the presence of a fair and balanced Supreme Court, the number of lawsuits against 1989has– decreased 2002 as reflected in Chart 41 71 insured by Medical Assurance Mississippi physicians A. As reflected in Chart C, physicians 2003 – 2008 76 23 Company of Mississippi have experienced a significant reduction of insurance premiums:

2009 - 2012

Chart C Medical Assurance Company of Mississippi Effects of Tort Reforms on Premiums

Note: graph demonstrates the annual premium changes for a physician who paid $4,000.00 in 1999.

The professional liability insurance market has stabilized, it is easier to recruit physicians to Mississippi, and physicians do not have to practice medicine under constant threat of being sued. So, where do we go from here? What does the future hold for Mississippi healthcare providers and those who depend upon their care? Can we ever have another medical liability crisis?

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• Special Article • Important Questions Still Remain

There remain many important medical liability questions to be decided by the Mississippi Supreme Court. Most significant is the fact that the Supreme Court has not decided if our cap on noneconomic damages in medical liability cases is constitutional. Even though the Court has already interpreted many aspects of tort reform, there are other issues that the Court will be called upon to review in the coming years.

Warning – A Different Court May Result in a Different Outcome

On July 31, 2012, the Missouri Supreme Court declared that state’s cap on noneconomic damages to be unconstitutional. By a 4-3 vote, the Court overruled a 1992 decision that had upheld the same cap. Thus, to the surprise of many, the Missouri Supreme Court reversed 20 years of precedent. Why? Because the make-up of that court changed! In 2010, the Georgia Supreme Court similarly declared that state’s cap on noneconomic damages in medical liability cases to be unconstitutional. Fortunately, more than twice as many state appellate courts have upheld caps on damages than have struck them down. It does matter who sits on your Supreme Court.

So, What Do You Do Now?

For several years, we have enjoyed a fair and balanced Supreme Court that has corrected judicial error and runaway jury verdicts. In this November’s election, the stability of Mississippi’s civil justice system is at risk. Two of our balanced justices are opposed, and a court vacancy opens the door for a new member on the Court. I concur with the advice of Dr. Demetropoulos: educate yourself about those who are running for the three contested positions, educate others about the best persons for the job, and support those candidates. r JNLMSMed-BW2

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304 JOURNAL MSMA SEPTEMBER 2012

• Special Article • 401(k) Changes Will Help Physicians Better Understand Their Practice Retirement Plans

H. Larry Fortenberry, CPA, CLU, ChFC Executive Planning Group, PA

New 401(k) Legislation Can Bring New Responsibilities and Potential Liabilities for Fiduciaries New Department of Labor fee disclosure regulations are a mixed blessing for 401(k) plan sponsors. On the one hand, the new rules give plan sponsors the legal right to a full disclosure of expenses levied by service providers, thereby ensuring that they will have adequate information to act prudently on behalf of plan participants. On the other hand, the regulations have increased the responsibility of plan sponsors by further raising the bar of what it means to be a responsible fiduciary.

Understanding the Significance of 401(k) Plan Fees As a 401(k) plan sponsor, it is your fiduciary responsibility to negotiate a plan that most effectively balances expense with value on behalf of plan participants. Though the best options won’t always be the least expensive, in the world of retirement plans finding seemingly small cost savings can have a large impact on the ability of participants to successfully prepare for their financial futures. Plan fees are a crucial component of this cost analysis. Just how important are they? According to estimates provided by The Vanguard Group, reducing annual fees by just 0.5% can increase a retiree’s nest egg by 10% over a 30-year career! Many plan sponsors have found it difficult to meet their fiduciary responsibilities from within the current regulatory framework which allows sufficient leeway for service providers to hide certain fees, making it difficult for fiduciaries to conduct a true cost analysis and meaningfully compare alternatives. New Department of Labor fee disclosure regulations aim to close this information gap at both the plan sponsor and participant levels. Effective July 1, 2012 rule 408(b)(2) required service providers to disclose to plan fiduciaries a detailed account of all direct and indirect compensation received for services rendered. Under rule 404(a)(5), plan sponsors had until August 30, 2012, or 60 days after plan year, for plan years starting November 2011 to disclose these fees to plan participants.

Can You Pass the 401(k) Quiz? A 2010 survey conducted by the AARP revealed that seven in ten 401(k) participants are unaware that they pay fees for their retirement plans.

Are you prepared? Test yourself by answering these important questions: ·

Who are my plan’s service providers? Do service agreements include detailed descriptions of services provided and associated costs?

How many service providers assume fiduciary responsibilities? What is my exposure to liability?

How will my fiduciary responsibilities increase under the new regulations?

What review process do I have in place for monitoring service providers?

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• Special Article • ·

Do I have a record-keeping system in place?

Do I understand all of the fees associated with my plan?

Are any conflicts of interest present? Which transactions are legally prohibited?

How has my plan performed in relation to market benchmarks? Are investments diversified?

Do participants make their own investment decisions? Have they been given sufficient information to do so?

What is my communication plan for disclosing information to eligible plan participants and beneficiaries?

Are You Compliant? The ‘Prudent Man’ Standard Here is a frightening statistic: over 73 percent of plans audited by the Department of Labor in FY 2010 had compliance deficiencies that resulted in fines, penalties, and other corrective actions. As a 401(k) plan sponsor, it is your fiduciary duty to ensure that your plan meets ERISA-required standards of due diligence. With new fee disclosure regulations that took effect July 1, 2012, plan sponsors will come under increased scrutiny. We believe now, more than ever, it is vital to ensure that you have adequate processes and procedures in place to meet your fiduciary obligations. ERISA compliance requires that a plan and its assets be managed according to the ‘prudent man’ standard which generally requires plan sponsors to act as discerning consumers on behalf of plan participants. Selecting service providers through a documented process of due diligence, periodically monitoring and evaluating their services, and tracking fee disclosure compliance are necessary steps to mitigate legal risk and ensure that your 401(k) plan allows employees to efficiently and effectively prepare for retirement. Many plan sponsors are discovering that the new regulations actually require them to meet a ‘prudent expert’ standard in order to satisfy their fiduciary responsibilities. Indeed, the level of technical expertise required to achieve ERISA compliance can be overwhelming. Are you prepared to meet your fiduciary responsibility of due diligence? Now is the time to start asking the tough questions: ·

Did I compare a number of service providers before making a meaningful selection? Was this process documented? Can I justify my selection?

Do I have a process in place for monitoring and periodically evaluating service providers? Is this process delegated to a committee? If so, are committee members educated on their roles and do they meet regularly?

What system will I use to track the receipt of fee disclosures from service providers? Have I established a standardized process for determining that these disclosures are complete?

Do I have an established procedure for processing participant complaints?

Am I prepared to meet my fiduciary responsibilities, or do I need the assistance of a professional advisor?

Partnering with an independent financial consultant can help you to manage these complex and time-consuming roles. Our advisors bring over 25 years of experience in ERISA compliance and can assist you in understanding the full extent of your plan’s expenses, assessing whether fees are reasonable and appropriate in relation to provided services, and developing a communication plan to disclose fees to participants while mitigating the effect of sticker shock. r

For more information contact: H. Larry Fortenberry, CPA, CLU, ChFC, President, Executive Planning Group, PA (601) 982-3000 1640 Lelia Drive, Suite 220, PO Box 16566, Jackson, MS 39216 Securities offered through ValMark Securities, Inc. Member FINRA, SIPC Investment Advisory Services offered through ValMark Advisers, Inc., A SEC Registered Investment Advisor 130 Springside Drive, Suite 300 Akron, OH 44333-2431 • 1-800-765-5201 Executive Planning Group is a separate entity from ValMark Securities Inc. & ValMark Advisers Inc.

306 JOURNAL MSMA SEPTEMBER 2012

We specialize in the business of healthcare

CALLING ALL Mississippi Physician-Photographers to enter the 2013

COVER PHOTO CONTEST

oad your camera or grab your digital. Shoot landscapes, people, animals, or anything else you can capture on film. Photos of subjects indicative of Mississippi will be given the highest consideration. Photos of original artwork are also acceptable. The Committee on Publications will judge the entries on the merits of quality, composition, originality, and appropriateness to the JMSMA.

• • • • • • • •

Comprehensive Management Comprehensive Consulting Billing & Accounts Receivable Management Coding & Documentation Practice Assessments & Revenue Enhancement Profitability Improvement Practice Start-ups Personnel Management

Specifications: Color slides, digital files & photos. A hard copy print is required for judging. Size: Vertical format 5 x 7” or 8 x 10”

Deadline: November 28, 2012 Mail to P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to headquarters 408 W. Parkway Place, Ridgeland, MS 39157 For more info contact: Karen Evers, Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com

1600 North State Street Suite 400 Jackson, MS 39202 Telephone: 601.944.1717 WATS: 1.800.355.4231 www.mpsbilling.com

www.bcbsms.com

Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company, is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

SEPTEMBER 2012 JOURNAL MSMA 307

• Poetry • Land etters Medicine • • [This month, we print a poem by William “Bill” Lineaweaver, MD, a Brandon plastic surgeon and burn specialist. He’s medical director of the JMS Burn and Reconstruction Center in Brandon, the state’s only inpatient burn service. He is also the editor of the Annals of Plastic Surgery. Bill comments: “Sometimes an apparently illogical connection to an image can illuminate an experience. The child Vardaman makes such a connection in Faulkner’s ‘As I Lay Dying.’ In the painful course of experiencing the death and decay of his mother, he associates the unimaginable concept of her mortality with a large catfish he recently caught and cleaned. His thoughts culminate in the startling chapter consisting only of the sentence, ‘My mother is a fish.’ Using the image of the dead fish, Vardaman constructs an understanding of the death of his mother. When I walked into the room to find my patient and his wife, I thought that they looked like a boat. The association was nonsensical, but when I worked back from it, I found that the image gave me a way to explain to myself what these two people were going through. The husband, my patient, had other things on his mind besides my thought processes. The title of the poem highlights the image by connecting to the adjective ‘scaphoid.’ The poem has been a pleasure to write and revise. It has also given me a chance to know something of these two people and their loving family.” Any physician is invited to submit poems for publication in the Journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.] —Lucius Lampton, MD, Editor

Boatlike

he is like the ghost Of a beautiful woman. She lies, almost weightless, Forgetfully breathing; Her white hair framing, Her white skin draping The elegant bones of her face, Her nose of delicate china. I am looking for my patient. He has taken his neck With my flap to sit By the bed of his wife On this last dark morning Of their sixty two married years. When I find them together They make a scaphoid curve, She the prow with white foam Crowning the wave of her pillow, He the declined stern, steady At the dark end of their wake. He says, “Good morning,” I say, “Don’t let me bother you now.” He says, “Come on and change this dressing, I want to go home.” —William “Bill” Lineaweaver, MD Brandon 308 JOURNAL MSMA SEPTEMBER 2012

• Physician’s Bookshelf •

The Immortal Life of Henrietta Lacks: Evolving Medical Ethics in a Constantly Changing World Reviewed by Whitney Sherman, M3, Tulane University School of Medicine

The Immortal Life of Henrietta Lacks By Rebecca Skloot. 369 pages. Crown Publishers, 2010. $26. Available in hardback, paperback, and kindle.

Henrietta and David Lacks, circa 1945

edicine, ethics, and the art of putting together a motherless daughter’s broken heart are central to The Immortal Life of Henrietta Lacks. The story has been told and retold in medical circles: HeLa cells are a line of cells that are now produced in large quantities and sold to labs the world over to be used in research. They have made multi-millionaires out of those who cultured and sold them; meanwhile, the source’s children, poor and uneducated, were completely unaware of the fact that they exist for many years. The children weren’t informed, and it is posited that neither was the patient, Ms. Henrietta Lacks. Should her descendants have rights to the cells? To the hefty capital gained from them? Are the cells themselves physical property, or are they intellectual property, because they would be useless without the manipulations that allowed them to be valuable? Part history book, part expository journalism, in The Immortal Life of Henrietta

Lacks, author Rebecca Skloot tells a very human side to a story of modern science, evolving medical ethics, and unforeseen technological advances. Henrietta Lacks was a black cancer patient in 1950’s Baltimore, a time and place where segregation was the norm. That norm, now plainly a virulent form of racism, led to segregated hospital wards and medical experimenting on poor black patients without consent. The book’s author, Skloot, meticulously details as much as she can about Henrietta’s medical treatment in her final days, being sure, of course, to include as much as she could surmise about any relating of information and consent, or lack thereof, that may have taken place. Henrietta’s treating physician biopsied the cancer cells and gave them to Dr. George Gey who was on the hunt for “immortal cells,” or those that surpassed the normal shelf-life of several days, as had been his experience. A technician in Dr. Gey’s lab cultured these cells as she had

SEPTEMBER 2012 JOURNAL MSMA 309

every other strain, but eureka! These kept living… they kept dividing. Consequently, the cells became newsworthy: they were touted as the fountain of youth, the cure for all ailments. The cells were popularized in science, medicine, and mainstream media but never with any mention of the original patient. Henrietta succumbed to a particularly aggressive strain of cervical cancer at the tender age of 31, leaving behind a husband, five children, and her legacy: HeLa cells. Twenty years later, in 1973, Henrietta’s children find out by sheer coincidence via casual conversation with a friend of a friend who had done research with the cells. Poor, largely uneducated, and with multiple ailments, the children seem not to know what this means. They struggle to understand that these cells are an extension of their mother--- living and reproducing--- yet she is not still alive. Deborah, the only living daughter, struggles with the idea that her mother may be feeling the pain of the experiments. “When she found out scientists had been using HeLa cells to study viruses like AIDS and Ebola, Deborah imagined her mother eternally suffering the symptoms of each disease: bone crushing pain, bleeding eyes, suffocation.” She agonizes over the idea that someone is making a pretty penny off selling these cells in bulk without the family’s consent. In contrast, however, to her brothers’ more litigious endeavors, Deborah is more focused on the idea that she was left motherless; while her mother’s cells are still living, she has yet to see them: that strangers have more of a relationship with her mother than she does. She grapples with this abstract concept of life after death and yearns to connect with a mother she never knew. Skloot covers many of the notable ways in which HeLa cells have contributed to science, taking care to make it both accessible for the non-scientists as well as engaging for those in the field. She explains that HeLa cells have contributed so much to the field of medicine, including the Salk polio vaccine, which needed a high volume of sturdy cells to be made in mass quantities, as well as FISH and karyotyping. It was discovered that HeLa cells were so sturdy that they were contaminating other cell cultures and outliving them, eventually replacing them in culture. In a turn of what seems to be poetic justice, it was found that millions of dollars’ worth of research had to be abandoned because it was done on the wrong cell types. Although the actions of each person involved in the chain, from biopsy to mass production to executing experiments, may reside in an ethical grey area, the legal issues do not. Informed consent was not the law when the biopsy was taken. Even if it had been, precedent was set by a ruling in the 1980’s that once a patient’s cells have been removed from his body, they are no longer his property; one doesn’t have rights to them. Though the case cited involved a different patient with a different disease in a different

310 JOURNAL MSMA SEPTEMBER 2012

state, the issue was the same. That ruling established that human tissue used in medical experiments is intellectual property more than anything because it is what is done with them, more than their intrinsic properties, Rebecca Skloot that makes them valuable: “The Supreme Court of California ruled… in what became the definitive statement on the issue: When tissues are removed from your body, with or without your consent, any claim you may have had to owning them vanishes. …They had been transformed into an invention and were now the product of [the doctor’s] human ingenuity and inventive effort.” However, the Lacks family believes they deserve restitutions. Do they? I’ll let you decide that for yourself. r

Pen > Sword

xpress 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 clarify ambiguities, to protect our letterwriters. You can submit your letter via email to: KEvers@MSMA online.com or mail it to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.

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

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

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

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

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

312 JOURNAL MSMA SEPTEMBER 2012

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

• Uncommon • Una Voce Thread • • Stars

R. Scott Anderson, MD Chair, Journal Editorial Advisory Board

try never to be serious any more than is necessary, especially when writing is concerned. There’s a simple reason for that. For the most part, unless it directly pertains to you and you have some specific interest in whatever it is that’s being written about, it’s boring and tedious as hell. Oh, stop now… come on back here…I didn’t say I was going to be boring and tedious. (If I were, I sure as heck wouldn’t give you advanced notice of the fact.) The truth is most writers who are being boring or tedious usually don’t realize it in the first place. They think you’re going to love whatever junk it is they’re writing about, because they’re so damned passionate about it.

What I want to write about is stars, not the ones up in the sky at night, more like the ones you read about in People magazine or who happen to show up unexpectedly on Oprah (yeah right, she didn’t know a thing about it). I went out to Hollywood and made a movie once; no, I really did. I should have probably set the money on fire; at least that would have produced heat. I guess I was concerned about global warming. I did learn a lot of good stuff by doing it though. Number one: never believe what people tell you about yourself to your face. We were making a movie about a con-man environmental activist…and we were going to have to try to sell the thing as an independent film in Hollywood or New York. We might as well have made a movie where Jesus was gay and tried to sell it to the Vatican. No, we would have had better luck with that one. The Pope and the Cardinals may have hated it, but the film festival folks would have been all over it. Actually they would have loved that one over here…we would have been invited to Sundance ten seconds after the Pope denounced us. Did anybody out in California say, “Hey, that might be a stupid idea,” while we were making it? Nope. They told us what geniuses we were, how cutting edge and forceful. Then they got all of our money. After that, they didn’t say anything at all, because they wouldn’t take our calls. So, you have to have some ideas about how things really are. The second big thing I learned was that every supporting actor thinks he or she should be the star. Everybody wants to be the star, even the person who snaps the clapper. The truth is they aren’t. Most of them never will be. Some of you may think that’s sad, but it isn’t. There has to be supporting actors for a movie to work. Even Brad Pitt droning on is going to get monotonous after a while. You have to have something to work against or for or something. The third thing I learned was how to tell when you’re not the star. And, I’m not the star. I’d hate it. I’m not that guy. I’m not Brad Pitt or George Clooney. I’m more like Wilford Brimley, but I’m okay being like old Wilford, riding the chuck wagon or running the livery stable…whatever. Nevertheless, I’m not afraid to tell you what I think. As a doctor, I don’t believe in politicians. They’re just like actors or producers. They have professional staff members whose whole job is to tell them how smart they are, what a good job they’re doing, and how they are the mainstay of the party. That’s a big part of the problem. Neither party is smart enough or honest enough to give up on the political posturing and actually do what needs to be done to fix health care in the near future. We have to look past the politicians. If you don’t believe me, look at how much the Super Committee got accomplished. Not a damned thing. With politicians, we get a pile of paper that doesn’t really accomplish much of anything but provides targets for accusation and pontification. They all believe what the paid hacks around them tell them about how wonderful they are, and every one of them thinks he’s the star. I talked to somebody the other day that said they wanted to get rid of all the politicians in D.C. and elect some new guys. People who would represent the way we should think. I told him he was making a mistake. He answered, “We can do whatever we want.” Well, you can set the front of your pants on fire too, if you want to. That doesn’t mean it’s a good idea. “Different

SEPTEMBER 2012 JOURNAL MSMA 313

politicians” is a temporary solution that sways back and forth with the current election cycle. What we need is a non-partisan coalition with an appointed administrator similar to the Federal Reserve Board. The Fed isn’t a branch of the government; it represents the interests of the major banking institutions. If we set up a Medical Administrative Board with equal representation of all the players in the health care arena, outside the influence of partisan politic, and gave them binding authority to make decisions, we could finally come up with a coherent health care agenda. We need to tell them they’re not supposed to be the stars but that we can’t make the movie without them, and let’s see what they come up with. It couldn’t be worse than pointing fingers and doing nothing. Just a thought, Scott

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When your medical office is short-staffed, you get frustrated. When you get frustrated, you dread going to work and you start playing hooky. When you start playing hooky, the bills pile up. When the bills pile up, Mama ain’t happy.

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Thank you for your interest in the JOURNAL MSMA. Your ad is typeset for a 8 line b/w ad at the rate of $4.00 per line ($32.00) plus an additional typesetting charge of $25 for a rate of PHYSICIANS NEEDED $57.00 for the May insertion; $44.00 thereafter. Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, Neurologists, Psychiatrists, etc. interested in performing consultative evaluations according to Social Security guidelines. This ad will run in the May 2012 issue thereafter until you notify us to OR and discontinue the ad. Please proof, sign off,disability fax backclaims (FAXat601-853-6746) or Physicians to review Social Security the call if you have questions, 601-853Mississippi Department of Rehabilitation Services (MDRS) in Madison MS. 6733, extension 323. You will also Contact us need at: to include your full billing information to mail an invoice with a Leola Meyer 601-853-5487 copy of the magazine featuring your Toll Free 1-800-962-2230 5487) ad. (Ext. All cancellations must be received or in writing by the first of the month for Jo Ann Summers 601the853-5599 following month’s issue.

DISABILITY DETERMINATION SERVICES Many thanks, 1-800-962-2230 314 JOURNAL MSMA SEPTEMBER 2012

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• Asclepiad •

Murrell McRae, II of Hattiesburg– Born in Memphis, Tennessee to Mildred and John Murrell McRae, John McRae was reared in Lexington, Mississippi, and in Cuba. His father graduated with a degree in sugar chemistry and that led him to Cuba where he was the manager of a large sugar mill, Punta Allegra. His mother was a graduate of Mississippi State College for Women (now Mississippi University for Women) and homeschooled him until age 13. At that time, he returned to Lexington and lived with his grandmother to continue education through high school. John has one sibling, a sister, Sibyl Child, who lives in Jackson. His wife, Eileene, is a past president of the MSMA Alliance. He has three children: the late John M. McRae, III, Lisa McRae of Boston, Massachusetts; Katie Crenshaw of York, Pennsylvania; and two stepsons: Travis Bedwell of Charlotte, North Carolina and Matthew Bedwell of Starkville. They also have 13 grandchildren. Dr. McRae received his M.D. from Harvard. His first practice was in Greenville, Mississippi, where he stayed for three years before being recruited to practice in Laurel. Reflecting on his younger life in medicine, he says, “I enjoyed being a general surgeon and was grateful to have a busy practice for many years. During my residency (the days before Medicare and Medicaid), we had patients sent in to us from all over the state. This gave us a tremendous opportunity to operate day and night, and I loved it! After twenty-five years, my surgical practice ended because of my alcoholism. Just when I thought I was doomed after losing my practice, the God of my understanding led me to a wonderful new career in medicine. I got sober and then began to study to sit for the boards in addiction medicine. My career in addiction medicine was a real joy for me, especially when I had the opportunity to offer hope to another physician during his/her treatment.” Dr. McRae is currently a Diplomate of the American Society of Addiction Medicine and is Board-Certified. His addiction medicine career started at Caduceus Out-Patient Addiction Center (COPAC) in Jackson. He then became medical director at Pine Grove Behavioral Health and Addiction Services in Hattiesburg for ten years and finished his career as a consultant to Cumberland Heights in Nashville, Tennessee. He says, “I finally retired at age 81.” When asked about bright moments in medicine or MSMA memories he says, “Being elected as President of the Medical Alumni Association was an honor. I have attended MSMA Annual Session for decades and have always enjoyed that. When my children were young, that used to be family vacations.” Acceptance to Harvard Medical School for his third and fourth years after being selected by Dr. Arthur Guyton is another honor he mentions. “Harvard accepted anybody chosen by Dr. Guyton,” he said. He also fondly recalls playing in full football uniform in one of the last “Murder-Bowl” games held at VaughtHemingway Stadium. “I played one halfback and Elmer Nix, MD, played the other one, and we beat the law school 16 to 0,” he says. “Another highlight was being elected cheerleader at Ole Miss in 1950 with my dear friend, Henry Paris,” he adds. “Last but not least, my greatest highlight was when I married my wife, Eileene.” Among mentors, he mentions the late James D. Hardy, MD, Chief of Surgery. “He was much more than his title implies,” he says. “Dr. Hardy was a mentor who was always available, instructive, and helpful. There are others like Dr. Al Meena, Dr. Buddy Griffin, and Dr. Heber Ethridge. In the field of addiction medicine, the late Dr. Conway Hunter of Sea Island, Georgia, was a wonderful mentor.” In closing words to fellow physicians, he offers, “Always lead from your heart by being kind, understanding, and humble. Make yourself available to those in need. Be a member of your local society and your state organizations.” Now that he is retired, Dr. McRae enjoys golf, reading, children and grandchildren at the beach, and tending his yard. He adds, “Because of Eileene’s involvement in the MSMA Alliance, we have made and maintain friendships across the country. She loves the Alliance and the family of medicine. Eileene’s love and concern for children living with parental addiction has also kept her involved as the Alliance chair of the MPHP Committee for twenty years.” —Karen A. Evers, JMSMA Managing Editor ohn

316 JOURNAL MSMA SEPTEMBER 2012

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