September 2014 JMSMA by Journal MSMA

September

VOL. LV

2014

No. 9

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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 Claude D. Brunson, MD President Daniel P. Edney, MD President-Elect Michael Mansour, MD Secretary-Treasurer R. Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. 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. Copyright© 2014 Mississippi State Medical Association.

SEPTEMBER 2014

VOLUME 55

NUMBER 9

Scientific Articles Ultrasound-Guided Fine Needle Aspiration in the Diagnosis of Thyroid Nodules

284

Hoyet A. Hand, MD; C. Ron Cannon, MD

Clinical Problem-Solving: Denial of Scans

287

Saumya Mehta, MD

Top Ten Facts You Need to Know - About Long Term Oxygen Therapy

President’s Page Inaugural Address of the 147th President

298

Claude D. Brunson, MD; MSMA President 2014-15

Related Organizations Mississippi State Department of Health

290

Departments From the Editor: Eliminating the Perverse Incentive 282 MSMA: 146th Annual Session Recap 294 Letters: Adding Value to Membership 305 Poetry and Medicine: “Long Night” 309 Images in Mississippi Medicine: Sure Cure for Small Pox and Scarlet Fever 310 Una Voce: Professional Rasslin’ 311

About The Cover: Wintering White Pelicans at the Ross Barnett Reservoir- Each fall real snowbirds, American White Pelicans, make an annual migration to the warmer southern climates, and the North Shore Causeway of “The Rez” is a favorite spot for many. Because fish are plentiful, they have been migrating here since at least 2002 and usually stay until about May. They are huge birds that can weigh up to 20 pounds with 7-10 foot wingspans. Webbed feet make these pelicans strong swimmers. Unlike Brown Pelicans who dive for their food, White Pelicans swim for their meals. They are distinguished from other birds by a huge pinkish to pale-orange bill and throat pouch used to scoop up fish. Often working in groups, they will circle and entrap their prey. In breeding condition, they have a distinctive knob protruding upward from the upper mandible. The small islands in the main lake and Pelahatchie Bay are favorite spots for them to congregate. Photo by Richard D. deShazo, MD. r September

VOL. LV

Official Publication of the MSMA Since 1959

291

George E. Abraham III, MD; Terry M. Dwyer, MD, PhD; Rajesh Bhagat, MD

2014

No. 9

September 2014 JOURNAL MSMA 281

From the Editor: Eliminating the Perverse Incentive

hysicians and patients have allowed the dread third party payers to turn our medical system’s priorities upside down. The “perverse incentive” of the current system is that payers “reward” physicians and hospitals for providing less medical care and fewer services to the patient. Sadly, it is not the services which are driving up the costs of medical care; rather it’s the tragic invasion of this third party placing layers of costly administrative hurdles to prevent payment or provision of appropriate care. More healthcare employees are shuffling insurance papers than touching patients. Any system focused on preventing hospital readmissions rather than emphasizing access to care is antipatient and will result in the deaths of those most sick and poor. Punishment for necessary care for outliers in our system is against the very spirit of our Hippocratic Oath. Don’t get me wrong: I am in the camp of eradicating unnecessary services; the problem is that the perverse incentive impacts necessary services. Patients who should be hospitalized are sent away from our ERs daily because the federal and private payers won’t reimburse a hospital to care for sick patients who are complicated but don’t fall into their

nonsensical cookbook of admission criteria. Thus you get that Dallas Ebola patient sent away from an ER recently due to “staff miscommunication.” No, it wasn’t that. It was the perverse incentive! If the system needs to keep spending under control, we physicians must tell our payers, at a federal, state, and private Lucius M. Lampton, MD level, how to accomplish it. It is not done through RAC audits, increased bureaucracy, prior authorization, or complicated reimbursement schemes, all of which increase the cost of providing care. It is actually done by achieving the opposite: eliminating those significant administrative costs, which are the expenses not directly related to patient services. The proper incentive for medical care must be the provision of necessary medical services, from prevention to hospitalization, for our patients. The perverse incentive, which is propped up with its unaffordable regulatory encumbrances, must be eliminated. Contact me at LukeLampton@cableone.net. —Lucius M. “Luke” Lampton, MD, Editor

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

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

Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD Radiologist Singing River Radiology Group, Pascagoula

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

Jason G. Murphy, MD Surgeon Surgical Clinic Associates, Jackson

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

Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport William Lineaweaver, MD Editor, Annals of Plastic Surgery Medical Director JMS Burn and Reconstruction Center, Brandon

Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, Michael D. Maples, MD G.V. Montgomery VA Medical Center, Jackson Medical Director Medical Assurance Company of Mississippi, Ridgeland

282 JOURNAL MSMA September 2014

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

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Managing the Risks September 2014 JOURNAL MSMA 283

• Scientific Articles • Ultrasound-Guided Fine Needle Aspiration in the Diagnosis of Thyroid Nodules Hoyet A. Hand, MD and C. Ron Cannon, MD

bstract

A retrospective study of 28 patients who underwent ultrasound-guided fine needle aspiration (FNA) biopsy for thyroid nodular disease was performed to assess the diagnostic accuracy of ultrasound-guided FNA biopsy in detecting malignancy of the thyroid. Sensitivity, specificity, positive predictive value, and negative predicative value were evaluated with respect to final histological surgical pathology. The study’s results substantiate those of previous studies: when there is a negative ultrasound-guided FNA, there is high probability that the patient is free of thyroid malignancy and may be followed clinically without the need for surgery.

Introduction:

The patients diagnosed with malignancy or neoplasms on cytologic results were deemed as positive. The patients classified as negative had benign findings on cytological diagnosis and were followed clinically, none of which subsequently required surgery. Patients found to be positive on cytological diagnosis underwent surgical excision with direct comparison of the final histo-pathological results. The fine needle aspirates were obtained using General Electric Logic 9 ultrasound unit with a 9 megahertz transducer in a hospital setting (Figure). The aspirates were obtained using a longitudinal biopsy method with a 3 cc syringe a 22 gauge needle, and lidocaine for local anesthesia. Figure

Thyroid nodules are very common; by age 60 approximately 50% of people will have a thyroid nodule that is found on physical examination or incidentally by imaging.1 Over 90% of nodules are benign; however, a decision must be made if the nodules can be observed or require surgical intervention.1 The clinical importance of thyroid nodules is the risk of thyroid cancer which occurs in an estimated 5% of all thyroid nodules.1,2,3 The risk of cancer is the same for nodules discovered incidentally and those that are palpated.2 The American Thyroid Association in 2012 recommended that the initial workup of a thyroid nodule include measurement of thyroid stimulating hormone (TSH) and ultrasound exam.1

Method:

This study details a total of 31 nodules in 28 patients, 8 males and 20 females, who were selected for ultrasound-guided FNA. The mean age was 49, with an age range of 24 to 93 years. The range of the nodule size was 0.3 cm to 5.4 cm with an average of 2.6 cm. Author Affiliations: Dr. Hand is a Geriatrics Fellow in the Department of Medicine at University of Mississippi Medical Center (UMMC). Dr. Cannon is a specialist at the Head and Neck Surgerical Clinic in Flowood, Mississippi. Corresponding Author: Hoyet A Hand, MD, Department of Medicine, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS 39216.

284 JOURNAL MSMA September 2014

The results of our study were calculated using standard bio-statistical measurements. Sensitivity (Sn) is the probability of patients with malignant disease having corresponding positive cytological findings or (TP/TP+FN). Specificity (Sp) is the probability that patients without malignant disease have negative corresponding cytology or TN/TN+FP. Positive predictive value (PPV) is the probability that patients with positive cytological findings have malignant disease or (TP/TP+FP), and negative predictive value (NPV) is the probability that patients with negative cytological results are free of malignancy or (TN/TN+FN). 4

Results

Ultrasound-guided FNA biopsy yielded adequate specimens in 84% (26) of nodules. Sixteen percent (5) of the aspirates were non-diagnostic. In this group of non-diagnostic aspirates, 1 patient over 90 years old was managed by clinical observation. The remaining 4 had surgical intervention based on clinical presentation revealing 2 benign follicular adenomas and 2 adenomatous goiters. Of the adequate specimens, cytology results were as follows: 69% (18) were benign and included nodular colloid goiters, colloid cysts, and adenomatous goiters. This group has been closely monitored, and none has required surgery. Twenty seven percent (7) indicated a pathology report of cancer or neoplasm. Four percent (1) had a FNA report of chronic lymphocytic thyroiditis but underwent surgery due to concern for malignancy related to a history of prior neck irradiation. In this particular patient, the post-operative histo-pathology report did agree with the FNA results, but there was also a 1 mm focus of papillary cancer. Histologic examination of the 7 nodules diagnosed with neoplasm or cancer on cytology revealed 4 papillary carcinomas, 1 medullary carcinoma, 1 follicular adenoma, and 1 benign hurthle cell adenoma. The statistical analysis is shown in table 1. Table 1:

Table 1

Hand/Cannon

Discussion

Number of

Sensitivity

Specificity

Positive

Negative

Patients

(Sn) %

(Sp) %

Predictive

Value

(PPV) %

(NPV)%

Fine needle aspiration (FNA) biopsy is an essential diagnostic tool in the management of thyroid nodules and has resulted in a decrease in the number of patients undergoing surgical excision for benign thyroid nodules.3,5,6 Fine needle aspiration of a nodule may be performed by manual palpation or ultrasound guidance. The indications for ultrasound guided needle aspiration include: 1. Non-palpable or difficult to palpate nodules, 2. Nodules that are predominately cystic, inconclusive or non-diagnostic after palpation guided FNA, 3. Nodules less than 1 cm.7 Other reasons for ultrasound guided-FNA include a short thick neck or history of prior neck surgery with the presence of scar tissue. In a review of several studies, ultrasound guided biopsy is shown to be superior to free-handed biopsy in obtaining adequate samples.3,8,9 Several other large similar studies (Table 2) were reviewed to compare the results of the current study. The 18 patients with benign cytologic results were followed clinically, none of which required surgical intervention, revealing a NPV of 95%. This result is consistent with other studies which revealed an average NPV of 95%. In other words, if the ultrasound guided FNA is negative, then there is a high probability the nodule is benign. When a follicular neoplasm or hurthle cell neoplasm is diagnosed on cytology, surgery is required to establish a final

Table 2: 2 Table Number

Specimen

Sensitivity Specificity Positive

Negative

Adequacy

(Sn) %

Predictive

Value

(PPV) %

(NPV) %

(Sp) %

Patients

Hand/ Cannon

Danese9

4697

Can3

184

100

Kim

977

292

Cai

434

Total/Avg.

6617

Lee

diagnosis.1 The two patients who underwent surgery for neoplasms were found to have a benign histo-pathological diagnosis. This accounts for the 2 false positives and the subsequent lower positive predictive value of 71%. Can et al. identified similar false positives and reported a PPV of 73%.3 The inability to distinctly identify follicular carcinoma or a follicular variant of papillary carcinoma was identified as limitation of fine needle aspiration in the diagnosis of malignant thyroid nodules.11 The other patients who underwent surgery were correctly diagnosed with malignancy, accounting for the 5 true positives. Surgery is also indicated in the presence of other factors: history of radiation therapy to head/neck (in treatment of enlarged thymus as an infant, severe acne, or for malignancy such as Hodgkins Lymphoma), suspicious findings on ultrasound such as micro-calcifications, and size of the nodule greater than 4 cm, in which FNA may not yield an adequate sampling of the entire nodule. It is also to be considered when clinically indicated by a history of familial thyroid cancer. One patient in our study was diagnosed with chronic lymphocytic thyroiditis on cytology report but underwent surgery due to concern for malignancy related to a history of prior neck irradiation. The patient was ultimately found to have a tiny (1 mm) papillary thyroid carcinoma accounting for the only false negative in this series. The results of this study are consistent when compared with other individual studies, as well as when the studies are viewed as a whole. Particularly impressive is the high negative predictive values of 88-100%. Our study is in agreement with a 94% NPV. With an average negative predictive value of 95% as these studies indicate, ultrasound-guided FNA is an important tool in diagnosis and evaluation of the thyroid nodule.

Conclusion:

Ultrasound-guided FNA biopsy of thyroid nodules is a useful diagnostic tool in evaluating the thyroid nodule and should be considered in patients with selected thyroid nodules. With a benign histology reported by ultrasound-guided FNA, there is a high probability that the patientâ&#x20AC;&#x2122;s thyroid is free of malignancy, and the patient may be followed clinically.

September 2014 JOURNAL MSMA 285

References 1. American Thyroid Association, Thyroid Nodules. Available at: www. thyroid.org. June 4, 2012. Accessed February 23, 2013. 2. Steele SR, Martin MJ, Mullenix PS, et al. The significance of incidental thyroid abnormalities identified during carotid duplex ultrasonography. Arch Surg. 2005:140:981-985. 3. Can AS, Peker K. Comparison of palpation-versus ultrasound-guided fineneedle aspiration biopsies in the evaluation of thyroid nodules. BMC Res Notes. 2008;1:1-12. 4. Dawson B, Trapp R, Foltin, J (ed). Basic and Clinical Biostatistics. 4th ed. New York, NY: McGraw Hill Co; 2004:307-309. 5. American Association of Clinical Endocrinologist. Available at: www. aace.com. Accessed April 4, 2013. 6. Cooper DS, Doherty GM, Mandel SJ et al. Management Guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2006;16:109-142. 7. Leenhardt L, Hejblum G, Franc B, et al. Indications and limits of ultrasoundguided cytology in the management of nonpalpable thyroid nodules. J Clin Endocrinol Metab. 1999;84:24-32. 8. Cai XJ, Valiyaparambath N, Nixon P, et al. Ultrasound-guided fine needle aspiration cytology in the diagnosis and management of thyroid nodules. Cytopathol. 2006;17:251-255. 9. Danese D, Sciacchitano S, Farsetti A, et al. Diagnostic accuracy of conventional versus sonography-guided fine-needle aspiration biopsy of thyroid nodules. Thyroid 1998;8:15-19.

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AnnuAl Scientific ASSembly October 30-November 1, 2014

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286 JOURNAL MSMA September 2014

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w Raffle w General Sessions w State and County Project Exhibits w Celebrating its 90th Anniversary

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• Clinical Problem-Solving • Denial of Scans Saumya Mehta, MD

ntroduction

A 54-year-old black male presented to clinic in the summer with a 2 week history of weakness, dizziness, and nausea. He also complained of associated muscle cramps for the past 8 days. The patient required assistance to ambulate short distances because of the severity of his weakness. He reported subjective fevers, which were associated with chills and night sweats. However, he stated he had only a maximum recorded temperature of 100°F. He had vague headaches that were generalized along with associated tinnitus and right ear pain for the past few days. The patient stated that he was healthy prior to his current illness but had similar episodes in the past year. There were no associated cough or cold symptoms. He stated he had been to clinic 7 days earlier and had been prescribed cetirizine/ pseudoephedrine (Zyrtec D) and azithromycin (Z-PAK) for possible upper respiratory tract infection (URTI) but denied improvement. He also went to an emergency room (ED) 3 days earlier with similar complaints, and he still had not improved. The ED physician had ordered an outpatient computed tomography (CT) of his head, chest, and abdomen scheduled for later in the week. In a previously healthy adult male presenting with debilitating generalized weakness with vague symptoms, the list of possibilities is broad. Although he denies cold or cough symptoms, he could have Meniere’s disease or acute sinusitis given his description of intermittent symptoms. Also, URTI alone would not explain his severe weakness and muscle cramps. His chills, nausea, dizziness, and night sweats could be consistent with an infectious process [i.e. gastroenteritis, pneumonia, tuberculosis, encephalitis, leukemia, Human immunodeficiency virus (HIV)], dehydration or migraines. Given the broad range of possibilities, I want to review his medical history and previous functional capacity, which could establish a baseline. I want to obtain his medical records from his ED visit prior to ordering any further investigations. Also, I want to know why the ED considered scanning multiple body parts. The patient could have a suspected infection or possible Corresponding Author: Saumya Mehta, MD, Piedmont Family Practice at Baxter Village, 502 Sixth Baxter Xing, Fort Mill, South Carolina 29708. E-mail: SaumyaMehta10@gmail.com.

mass that would suggest such scans. I also want to review his vital signs and physical exam from previous ED visit to assess the medical attention he needed including possible treatment for dehydration. The patient’s past medical history included recurrent upper respiratory tract infections, with chronic back pain, reflux disease, and a history of leukopenia. He had a previous hospitalization for a syncopal episode exacerbated by acute bacterial sinusitis 1 year earlier. He occasionally took meloxicam (Mobic) as needed for chronic pain but otherwise had no scheduled medications. He was married and had a previous history of smoking for 15 years but quit 10 years ago. He denied alcohol or illicit drug use. He lived in the city, and he had been unemployed for several years. He denied any recent travel or hunting trips. His records from the outside ED visit 3 days earlier showed that due to his weakness the acutely ill patient had been brought to the ED by his grandson. The patient had been afebrile at presentation with stable vital signs. His complaints had been noted as bilateral leg cramps, fever, night sweats, and mild nausea with generalized weakness. He denied headaches and dizziness. The laboratory investigations consisted of complete blood count with differential, complete metabolic panel, urinalysis, 2 blood cultures, creatinine phosphokinase, and HIV antigen antibody combination tests. The results showed a low white count of 2.4 K/uL with mild neutropenia count of 1008/uL, and all remaining results were normal including a negative HIV antibody screen. With exception to generalized weakness with strength 4/5 in all extremities, his remaining exam results including neurological and gait testing were normal. As such, they ordered an outpatient CT of his head, chest, and abdomen for the following week to investigate for malignancy, and he had been instructed to follow up with his primary care provider. Three days later, the patient presented to clinic with continued weakness with nausea, dizziness, poor intake, night sweats, neutropenia, and headache. He had a past finding of leukopenia with neutropenia in his prior hospital visit 1 year ago. He denied alcohol intake, and his normal reticulocyte indexes do not indicate nutritional deficiencies.

September 2014 JOURNAL MSMA 287

From his history, the most likely causes of his neutropenia could be infectious in nature, including viral (Hepatitis B, Epstein-Barr, hepatitis C virus) or bacterial sources.1 However, parasitic and rickettsial infections cannot be excluded. Even though his HIV screen is negative, HIV cannot be completely excluded at this point. His persistent symptoms could be due to a malignancy, such as acute or chronic leukemia, and a bone marrow biopsy is warranted if leukopenia persists. Based upon his presentation, sinusitis is still high on the differential as it may not resolve with a short course of azithromycin. Even though the cause was unknown, his mild neutropenia did not warrant hospitalization. And although he didn’t have photophobia or nuchal rigidity, I am worried about his generalized headache with generalized weakness. I cannot exclude intracranial pathology such as meningitis or encephalitis. His night sweats may be consistent with lymphoma, solid tumors such as prostate cancer, renal cell cancer or germ cell tumors. A thyroid disorder, cancer or infections, such as HIV, tuberculosis, endocarditis, osteomyelitis and pyogenic abscess, may be associated with night sweats. Given the wide variety of differentials, he will need further investigations in the ED setting. To further investigate incidental neutropenia and the possibility of an intracranial infection such as meningitis, a complete blood count and sedimentation rate with inflammatory marker of C reactive protein are ordered. He also needs a scan to investigate for intracranial pathology and, pending the results of the blood tests, a lumbar puncture. The patient was sent to the ED from clinic. He was given ketorolac (Toradol) for his headache. He tolerated an oral challenge test well. A complete blood count with differential showed a white blood count of 4.3 K/uL and monocytes of 14% but otherwise normal differentials. His sedimentation rate and C reactive protein were normal. His urine showed trace ketone and yeast. A CT of the head without contrast showed no acute intracranial pathology or abnormalities. Basic metabolic panel yielded mild hypochloremia and hyponatremia. His chest radiograph showed a patchy infiltrate in the right lung base with mild interstitial prominence in both lungs, which was diagnosed as atypical pneumonia. His cardiac silhouette was within normal limits. Given his symptoms, a West Nile virus immunoglobulin serum test was ordered. The patient stated he felt better in the ED after administration of ketorolac and oral fluids. As such, he was discharged home. When investigating the patient further in the ED, I want to repeat pertinent tests as I am concerned about infection and further causes of neutropenia. Given his history of headache, weakness, nausea, and dizziness, a lumbar puncture could be warranted given the possibility of meningitis. However, now knowing his sedimentation rate, CRP, and white count are normal along with his improving blood pressure and malaise, a lumbar puncture is not clinically necessary at this time. His chest radiograph reveals atypical right pneumonia which could be contributing to his fever and generalized weakness. I question

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the need for further imaging studies such as magnetic resonance imaging or electroencephalography (EEG) to detect possible encephalitic changes. However, as they could only reveal supportive but not diagnostic findings of encephalitic changes, I believe it would be more cost effective to see if he will further improve without further imaging. Due to improving leukopenia and results of chest radiograph results, further scanning of the chest and abdomen are not done to investigate for malignancy or infection. I decide he is ready to be discharged home to have supportive care and another course of azithromycin and promethazine (Phenergan) as needed. He is instructed to follow up in clinic in 1 week or to seek medical attention sooner if his symptoms become worse. The patient was seen in clinic by another physician 6 days later. His West Nile serum test result was still pending, and the patient continued to feel general malaise and “not right.” He had been able to tolerate fluids and had mild improvement in his weakness. He was sent home with supportive care and scheduled for outpatient CT scan of chest, abdomen, and pelvis. He was told to follow up in 1 week if symptoms persisted or worsened. His vital signs and physical exam were stable and no laboratory tests were done. Clinically, he appears more acute and his persistent symptoms prompt further investigation. Had I seen him in clinic, I may have repeated a chest radiograph as well as an HIV test and complete blood count. Again, I would have questioned if I should order a magnetic resonance imaging (MRI) of his brain. A CT of abdomen and pelvis would investigate a possible occult malignancy or infection and may have been warranted given his persistent symptoms and history of leukopenia. The patient was found to be positive for West Nile virus 2 days later. He was contacted and seen in the ED the same day for follow up. He stated he still felt ill but his generalized malaise and weakness had improved, and his headache had diminished. He was able to ambulate on his own. His night sweats had resolved, and he stated he felt feverish only occasionally. Follow-up laboratory tests consisted of a urinalysis, complete blood count, and complete metabolic panel. His white count was 2.9 K/uL during the visit with a neutrophil count of 1044/uL. The remaining results were normal. During the follow-up clinic visit 1 week later, he was found to have resolution of symptoms with only mild weakness. No laboratory studies were done. At the time of the patient’s presentation, only 8 cases of West Nile virus had been diagnosed in Mississippi the previous year, 2010. Out of those cases, 3 patients presented with encephalitis. This number increased to 52 reported cases in 2011, out of which 60% presented with encephalitis and 40% as West Nile fever.2 In the initial ED visit, the patient did not show typical signs of encephalitis. When I saw him in clinic, he had more of an encephalitic presentation but this was not confirmed. West Nile presenting as encephalitis has a 12% mortality rate and generalized severe weakness is a risk

factor for poor outcome, both which this patient initially had.2,3 If he had not been clinically stable, a lumbar puncture and MRI of his head would have been warranted as when investigating for encephalitis. The MRI (diffusion-weighted imaging) is preferred to CT in early detection of encephalitis on T2-weighted images. An MRI can also help investigate the differential diagnosis of encephalitis, such as acute disseminated encephalomyelitis, head trauma, intracranial hemorrhage, and tumor.4 Although MRI changes of the head may present in encephalitis, these are additional supportive findings and not diagnostic.3 The MRI changes in West Nile consist of nonspecific increased signal abnormalities. This is because West Nile virus infection, unlike some viral encephalitides, has no definite predilection for specific areas of the brain matter.5 The EEG in West Nile encephalitis shows generalized slow continuous waves more prominent in the temporal or frontal regions.6 After reviewing the case, I would have preferred to have an MRI to further investigate this patient’s case as it may have been more helpful of confirming meningeal involvement.3 However, the diagnostic and prognostic importance of the MRI specifically for West Nile has not been supported by current studies.3

Key Words: Neutropenia, night sweats, West Nile Virus, Encephalitis References 1. Finberg RW TJ. Fever and neutropenia--how to use a new treatment strategy. N Engl J Med. 1999;341(5):362–363. 2. Department MSH. West Nile Virus and Mosquito-Borne Illnesses Mississippi State Department of Health. Available at: http://msdh. ms.gov/msdhsite/_static/14,0,93.html. Accessed February 17, 2013. 3. Zak IT, Altinok D, Merline JR et al. West Nile virus infection. AJNR Am J Roentgenol. 2005;184(3):957–961. 4. Tunkel AR, Glaser CA, Bloch KC et al. The management of encephalitis:clinical practice guidelines by the Infectious Disease Society of America. Clinical Infect Disease. 2008;47(3):303–327. 5. Ali M, Safriel Y, Sohi J et al. West Nile virus infection: MR imaging findings in the nervous system. Am J Neuroradiol. 2005;26(2):289–297. 6. Gandelman-Marton R, Kimiagar I, ItzhakiAet al. Electroencephalography findings in adult patients with West Nile virus associated meningitis and meningoencephalitis. Clin Infect Dis. 2003;37(11):1573–1578.

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September 2014 JOURNAL MSMA 289

• Mississippi State Department of Health •

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• Top Ten Facts You Need to Know • About Long Term Oxygen Therapy George E. Abraham, III, MD; Terry M. Dwyer, MD, PhD; Rajesh Bhagat, MD

ntroduction

Over 12 million Americans are currently diagnosed with chronic obstructive pulmonary disease (COPD),1 and one million Medicare recipients are currently treated with oxygen therapy.2 Yet one study has found that only 32% of COPD patients with baseline hypoxemia have been prescribed this recommended treatment.3 This article discusses the indications, risks, benefits, and practical application of long term oxygen therapy (LTOT). 1. LTOT prolongs life and improves its quality. LTOT can improve 1 and 2 year mortality by half in patients with COPD.4-5 Patients feel better; dyspnea is lessened and endurance improves.6 Additionally, pulmonary artery pressure declines and stabilizes.7 2. Hypoxemic patients need LTOT. Patients with a resting PaO2 ≤ 55 mmHg or oxygen saturation ≤ 88% qualify for LTOT. Additionally, a resting PaO2 ≤ 59% or an oxygen saturation ≤ 89% is an LTOT indication in the setting of lower extremity edema consistent with congestive heart failure, a hematocrit ≥ 55% consistent with secondary polycythemia, or cor pulmonale as evidenced by an echocardiogram or 3mm P wave amplitude in leads II, III, and AVf on an electrocardiogram (P pulmonale). LTOT is also applicable for a PaO2 ≤ 55 mmHg or a saturation ≤ 88% with exertion, though there is less outcome data for this practice. The prescribed flow rate is determined by titration to a saturation > 90%. 3. Patients with isolated nocturnal desaturation may not need LTOT. Patients with daytime hypoxemia should continue LTOT while sleeping. COPD patients with isolated nocturnal oxygen desaturation have an increased Author Information: Dr. Abraham is Assistant Professor of Medicine in the Division of Pulmonary, Critical Care, and Sleep Medicine at the University of Mississippi Medical Center. Dr. Dwyer is Professor Emeritus in the Department of Physiology and Biophysics and the Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine at the University of Mississippi Medical Center. Dr. Bhagat is Associate Professor of Medicine in the Division of Pulmonary, Critical Care, and Sleep Medicine at the University of Mississippi Medical Center and at the G.V. (Sonny) Montgomery VA Medical Center. Corresponding author: George E. Abraham III, MD, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, geabraham@umc.edu.

mortality.8 However, whether there is a beneficial effect of LTOT on either pulmonary hemodynamics or mortality is less clear.9-10 If co-existing obstructive sleep apnea is suspected, polysomnography should be performed. 4. Patients can improve, so they should be re-evaluated for continued supplemental oxygen needs approximately 90 days post hospital discharge if admitted for a newly diagnosed or exacerbation of pulmonary disease. Reassessment follows disease course, ensures proper level of supplementation, and determines if LTOT remains indicated.11 5. Hypercapnia can worsen during oxygen therapy. It has been demonstrated in acutely ill hypercapnic patients that a rise in PaCO2 while on 100% oxygen is due to changes in ventilation, the effect of oxygen on the CO2 dissociation curve of blood “Haldane effect”, and perhaps most importantly worsening in ventilation-perfusion matching.12 Thus, patients with baseline hypercapnia should use the minimum required supplemental oxygen and be monitored during initiation. An acceptable practice in chronic hypercapnic patients would be to check an arterial blood gas after administering supplemental O2 to ensure a near-normal pH is maintained. A study of long term oxygen therapy in patients with chronic hypercapnia reported no withdrawals of therapy due to worsening CO2 retention, supporting its safetly.5 6. Travel at altitude and by air requires special precautions. Airlines should be given advanced knowledge of the patients’ needs and consulted regarding their policies. Patients should carry a letter from their physician describing their need for supplemental oxygen and the prescribed flow rate at altitude. In the United States, patients may be required to use the airline’s equipment. There are multiple portable oxygen concentrators available with Federal Aviation Administration (FAA) approval for in-flight use. When allowed, personal tanks will need to be depressurized, shipped as baggage, and arrangements made for equipment availability at the destination. Patients with a resting PaO2 < 70 mmHg at sea level will require supplemental O2 when traveling by airplane. For patients not on supplemental O2

September 2014 JOURNAL MSMA 291

Table 1: Barometric pressures at varying altitudes.

Table 1: Barometric pressures at varying altitudes. Altitude (ft)

City

0 1,000 2,000 3,000 4,000

Gulfport, MS (20 ft) Atlanta, GA (1,026 ft) Las Vegas, NV (2,030 ft) Kalispell, MT (2,956 ft) Salt Lake City, UT (4,226 ft) Denver, CO (5,280 ft) Cheyenne, WY (6,062 ft) Santa Fe, NM (7,260 ft) Aspen, CO (7,908 ft) Keystone, CO (9,280 ft) Leadville, CO (10,152 ft)

5,000 6,000 7,000 8,000 9,000 10,000

Barometric Pressure (mmHg) 760 733 707 681 656 632 609 586 564 543 523

at ground level, supplemental O2 at 30% (approximately 2.5 L/min) should suffice at altitude. For patients already on LTOT, their requirements while traveling (FiO2(altitude)) can be predicted using the following equation: FiO2(sea level) x Barometric Pressure(sea Barometric Pressure(altitude)

level)

= FiO2(altitude) x

A patient with COPD on home oxygen at 2 L/min will be flying from Gulfport, MS to Denver, CO. Refer to Table 1 for barometric pressures at various altitudes. A general rule of thumb to roughly estimate the FiO2 delivered at a given flow rate (L/min) is: Flow Rate x 4 + 20, in this case 28%. The FAA requires cabin pressurization of 8,000 feet at the maximum operating altitude of an aircraft. Therefore, during flight he will need to increase his oxygen to (0.28)(760)/(564) = 0.38; roughly 4.5 liters/minute. Upon arrival in Denver, he will need to change his oxygen to (0.28)(760)/(632) = 0.34; roughly 3.5 liters/minute.12 Appendix A DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved

OMB No. 0938-0534

CERTIFICATE OF MEDICAL NECESSITY CMS-484 — OXYGEN SECTION A

DME 484.03

Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___

PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or applicable NPI NUMBER/LEGACY NUMBER

(__ __ __) __ __ __ - __ __ __ __ HICN _______________________

(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________

PLACE OF SERVICE______________ NAME and ADDRESS of FACILITY if applicable (see reverse)

SECTION B

HCPCS CODE

__________ __________ __________ __________

PT DOB ____/____/____

Sex ____ (M/F)

PHYSICIAN NAME, ADDRESS, TELEPHONE and applicable NPI NUMBER or UPIN

(__ __ __) __ __ __ - __ __ __ __ UPIN or NPI #_________________

Information in This Section May Not Be Completed by the Supplier of the Items/Supplies.

EST. LENGTH OF NEED (# OF MONTHS): ______ 1–99 (99=LIFETIME) ANSWERS

DIAGNOSIS CODES (ICD-9): ______ ______ ______ ______

9. Equipment for oxygen therapy must be cared for properly. Oxygen cylinders are heavy and can rupture catastrophically when they fall. Cylinders must be secure when stored and transported. Liquid oxygen, which exists below −182.96° C, can be a source of tissue damage if direct skin contact is made. Finally, patients with concentrators should be on the electric company’s priority list, as they will need service outages reversed as quickly as possible.14 10. Fire is a serious risk. Oxygen facilitates combustion, so the oxygen cylinders should certainly not be stored next to open flames, heaters, or stoves. Additionally, patients must certainly not smoke while using supplemental oxygen since the smoldering cigarette can ignite and spread flames to the tubing, clothes, and bedding. The inhaled smoke can also flash back, resulting in burns to airway epithelia and skin.15

ANSWER QUESTIONS 1–9. (Circle Y for Yes, N for No, or D for Does Not Apply, unless otherwise noted.)

2. Was the test in Question 1 performed (1) with the patient in a chronic stable state as an outpatient, (2) within two days prior to discharge from an inpatient facility to home, or (3) under other circumstances?

3. Circle the one number for the condition of the test in Question 1: (1) At Rest; (2) During Exercise; (3) During Sleep

4. If you are ordering portable oxygen, is the patient mobile within the home? If you are not ordering portable oxygen, circle D.

______________LPM

5. Enter the highest oxygen flow rate ordered for this patient in liters per minute. If less than 1 LPM, enter a “X”.

a)_________mm Hg b)_____________% c)____/____/____

6. If greater than 4 LPM is prescribed, enter results of most recent test taken on 4 LPM. This may be an (a) arterial blood gas PO2 and/or (b) oxygen saturation test with patient in a chronic stable state. Enter date of test (c).

ANSWER QUESTIONS 7-9 ONLY IF PO2 = 56–59 OR OXYGEN SATURATION = 89 IN QUESTION 1 Y

7. Does the patient have dependent edema due to congestive heart failure?

8. Does the patient have cor pulmonale or pulmonary hypertension documented by P pulmonale on an EKG or by an echocardiogram, gated blood pool scan or direct pulmonary artery pressure measurement?

9. Does the patient have a hematocrit greater than 56%?

NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print): NAME: ____________________________________________ TITLE: ____________________________ EMPLOYER: ______________________________

Narrative Description of Equipment and Cost

(1) Narrative description of all items, accessories and options ordered; (2) Supplier’s charge and (3) Medicare Fee Schedule Allowance for each item, accessory and option. (See instructions on back.)

SECTION D

8. Oxygen sources are available in 3 forms: liquid oxygen flasks, gas cylinders, and oxygen concentrators. Liquid oxygen is expensive but it is portable and can provide the longest use time per unit weight at a standard flow rate. Concentrators are low cost and provide oxygen indefinitely but require electricity, either directly or to recharge batteries. Gas cylinders can be cumbersome; however, they do not require electricity and are less expensive than liquid oxygen systems. More recently, specially designed home concentrators have been used to fill portable gas cylinders, obviating the need for home deliveries. Ideally, portable equipment should deliver 2 L/min for over 4 hours and weight under 10 lbs.

1. Enter the result of most recent test taken on or before the certification date listed in Section A. Enter (a) arterial blood gas PO2 and/or (b) oxygen saturation test; (c) date of test.

a)_________mm Hg b)_____________% c)____/____/____

SECTION C

7. Documentation requirements for Medicare are exacting but not onerous. The medical record should include the diagnosis responsible for chronic hypoxemia, the saturation or PaO2 demonstrating need, the corrected saturation or PaO2, the flow rate, the frequency of use, and the duration of need. A certificate of medical necessity (Appendix A: http://cms.hhs.gov/Medicare/CMS-Forms/ CMS-Forms/Downloads/CMS484.pdf) must be sent to the durable medical equipment supplier.

Physician Attestation and Signature/Date

I certify that I am the treating physician identified in Section A of this form. I have received Sections A, B and C of the Certificate of Medical Necessity (including charges for items ordered). Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity information in Section B is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability. PHYSICIAN’S SIGNATURE ______________________________________________________________________ DATE _____/_____/_____

Signature and Date Stamps Are Not Acceptable. Form CMS-484 (09/05)

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References 1. COPD, Learn More Breath Better, NHLBI, NIH. http://www.nhlbi. nih.gov/health/public/lung/copd/index.htm Last Accessed December 9, 2013. 2. Stoller JK, Panos RJ, Krachman S, et al. Oxygen therapy for patients with COPD: current evidence and the long-term oxygen treatment trial. Chest 2010;138:179-87. 3. Mularski RA, Asch SM, Shrank WH, et al. The quality of obstructive lung disease care for adults in the United States as measured by adherence to recommended processes. Chest 2006;130:1844-50. 4. Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease. Ann Intern Med 1980;93:391-98.

5. Medical Research Council Working Party. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet 1981;1:681-86. 6. Criner GJ and Celli BR. Ventilatory muscle recruitment in exercise with O2 in obstructed patients with mild hypoxemia. J Appl Physiol. 1987 Jul;63:195-200. 7. Zieliński J, Tobiasz M, Hawryłkiewicz I, et al. Effects of long-term oxygen therapy on pulmonary hemodynamics in COPD patients: a 6-year prospective study. Chest. 1998;113:65-70.

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8. Fletcher EC, Donner CF, Midgren B, et al. Survival in COPD patients with a daytime PaO2 > 60 mm Hg with and without nocturnal oxyhemoglobin desaturation. Chest 1992;101:649-55.

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9. Chaouat A, Weitzenblum E, Kessler R, et al. A randomized trial of nocturnal oxygen therapy in chronic obstructive pulmonary disease patients. Eur Respir J 1999;14:1002-8. 10. Fletcher EC, Luckett RA, Goodnight-White S, et al. A double-blind trial of nocturnal supplemental oxygen for sleep desaturation in patients with chronic obstructive pulmonary disease and a daytime PaO2 above 60 mm Hg. Am Rev Respir Dis 1992;145:1070-76.

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11. Conference Consensus Report. New problems in supply, reimbursement, and certification of medical necessity for long-term oxygen therapy. Am Rev Respir Dis 1990;142:721-724. 12. Aubier M, Murciano D, Milic-Emili J, et al. Effects of the administration of O2 on ventilation and blood gases in patients with chronic obstructive pulmonary disease during acute respiratory failure. Am Rev Respir Dis 1980;122:747-54.

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13. Gong H Jr. Air travel and oxygen therapy in cardiopulmonary patients. Chest 1992;101:1104-13. 14. American Thoracic Society / European Respiratory Society Task Force. Standards for the Diagnosis and Management of Patients with COPD [Internet]. Version 1.2. New York: American Thoracic Society; 2004 [updated 2005 September 8]. Available from: http://www.thoracic.org/go/ copd. Last Accessed December 9, 2013. 15. Litt EJ, Ziesche R, Happak W, et al. Burning HOT: revisiting guidelines associated with home oxygen therapy. Int J Burn Trauma 2012;2:167-70.

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September 2014 JOURNAL MSMA 293

• MSMA •

146th Annual Session Recap Dr. James A. Rish Receives MSMA’s James Grant Thompson Memorial Pin — During MSMA’s 146th Annual Session

business meeting James A. Rish of Tupelo received the James Grant Thompson memorial past- president’s pin, given to acknowledge completion of his term as 2013-14 MSMA president. Claude Brunson, MD of Jackson, Senior Advisor to the Vice Chancellor for External Affairs and Professor of Anesthesiology at UMMC, was installed as 2014-15 president of the association. Dan Edney, MD of Vicksburg is presidentelect.

Actions Taken by the MSMA House of Delegates

he Mississippi State Medical Association House of Delegates met August 15-16 at the Norman C. Nelson Student Union on the University of Mississippi Medical Center (UMMC) Campus in Jackson. Actions taken on appropriate resolutions are listed below:

LEGISLATIVE INITIATIVES

• Pursue “Any Willing Provider” legislation. • Pursue legislation that requires all health insurers and their designated review entities to employ a standardized web-based, • • • • • •

electronic review prior authorization request system with the ability to utilize a HIPAA 278 transaction format that facilitates a response within two business days for non-emergency services to the requesting physician Ask Mississippi Insurance Commissioner promulgate rules mandating that health insurers utilize a standardized web-based, electronic review prior authorization request system and promote automated processes as much as possible to expedite patient care decisions and reduce the amount of paper and number of forms necessary for manual processing. Include legislation prohibiting texting while driving by all drivers in its legislative priorities for 2015. Support medical staff bylaws that are independent from hospital bylaws and free from unjustifiable hospital interference and governance. Support physician-run integrated care models that benefit patient care by physicians in all specialties. Dissolve the MississippiCAN program, revoke the current managed care vendor contracts, and ensure Medicaid directly reimburses physicians on a fee-for-service basis for all Medicaid patients. Establish procedures and define interventional management of chronic pain disorders as the practice of medicine.

294 JOURNAL MSMA September 2014

• Seek licensure regulations requiring physicians performing spinal injections for back/neck pain to obtain fluoroscopy training and training in radiation safety.

• Seek state legislation requiring insurance companies that provide drug coverage to Mississippi insureds continuously update • • •

online drug formularies for each insured’s plan that interface with all EMRs and provide online prior authorization forms directly linked to those drugs searched. Require all healthcare plans to cover non-implantable insulin delivery devices at the same tier as vial and syringe insulin. Explore alternate sources of GME funding at both the university and community level including the “all payers pay solution” particularly exploring use of Medicaid funding. Work with MAFP to create an Office of Health Secretary.

COMMUNICATIONS • Task force to implement and publicize POST. • Promote health literacy in the Journal of MSMA and online. • Endorse creation of the Mississippi Rapid Response Medical Brigade and assist the Rapid Response Medical Brigade to enlist volunteer physicians by publicizing opportunities to volunteer.

ADMINISTRATIVE • Create a Council on Accreditation to share duties of Council on Medical Education. • Plan annual session 2015-2017 in Jackson and examine all factors of other locations for 2018 and beyond. • Council on Ethical and Judicial Affairs study and issue an official opinion on appropriate principles to govern MSMA campaigns.

• Secretary to chair committee to analyze membership statistics and issue report of likely impact. REFERRED TO BOARD OF TRUSTEES • Whether/how to oppose efforts to mandate MOC as a condition of licensure, participation, etc. • Consider policy regarding use of scribes, model language physicians may include in contracts that includes use of scribes to • •

ensure proper documentation of clinical services into any EMR/HER. Consider model medical staff bylaws addressing oversight of transfer policies involving hospitalists and whether to distribute model language to the chiefs of medical staff in Mississippi hospitals. Consider seeking a physician-developed Medicaid managed care model like Community Care North Carolina and work with the primary care community to end MississippiCAN as the only managed care option for Mississippi Medicaid.

MSMA Election Results

he 146th Annual Session of the MSMA House of Delegates adjourned Saturday, August 16. During the meeting, physicians elected officers, trustees, and council members to open positions for terms beginning in 2014. Claude Brunson, MD, of Jackson was named MSMA President after serving as President-Elect for one year and on the Board of Trustees since 2008. Dr. Brunson is Senior Advisor to the Vice Chancellor for External Affairs and Professor of Anesthesiology at UMMC. Elected President-Elect was Dan Edney, MD, of Vicksburg. Dr. Edney, an internal medicine physician, is a member of the Board of Trustees and has served as Speaker and Vice-Speaker of the House of Delegates. MSMA members elected the following physicians to serve on the Board:

• • • • • • •

Lee Voulters, MD, of Pass Christian – Board of Trustees, Chair, District 8 Bill Grantham, MD, of Madison, – Board of Trustees Vice-Chair, District 4 J. Clay Hays, Jr., MD, of Jackson – Board of Trustees, Secretary, District 4 Mark Horne, MD, of Laurel – Board of Trustees, District 6 Joe Austin, MD, of Vicksburg – Board of Trustees Member, District 7 Jane Beebe Jones, MD, of Hollandale – Resident Representative to the Board of Trustees Jordan Ingram, of Jackson – Medical Student Representative to the Board of Trustees

September 2014 JOURNAL MSMA 295

MSMA Board of Trustees — (l. to r. standing) Medical Student Representative Jordan Ingram, Jackson; Mark Horne, MD, Laurel; Secretary J. Clay Hays, Jr., MD, Jackson; Resident Representative Jane Beebe Jones, MD, Hollandale; Joe Austin, MD, Vicksburg; Chair Lee Voulters, MD, Pass Christian; Steven Brandon, MD, Starkville; Bill Grantham, MD, Madison; Carlton Gordon, II, MD, Belzoni; Speaker Geri Lee Weiland, MD, Vicksburg; Brett Lampton, MD, Oxford; and Dwight Keady, MD, Meridian; (seated) Secretary-Treasurer Michael Mansour, MD, Greenville; President Claude Brunson, MD, Jackson; Past President James A. Rish, MD, Tupelo; and Dan Edney, MD, Vicksburg.

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296 JOURNAL MSMA September 2014

SMA members also elected the following physicians to these respective offices:

• SPEAKER OF THE HOUSE 2014-2017 – Geri Weiland, MD

• VICE SPEAKER 2014-2017 – Jeffrey Morris, MD

• EDITOR, JOURNAL 2014-2017 – Luke Lampton, MD

• ASSOCIATE EDITOR, JOURNAL 2014-2016 – Stanley Hartness, MD

• COUNCIL ON BUDGET & FINANCE

(AT LARGE) 2014 -2017 – Rod Givens, MD

• COUNCIL ON CONSTITUTION & BYLAWS

(AT LARGE) 2014-2017 – Mary Armstrong, MD

• COUNCIL ON LEGISLATION, DIST. 6 2014-2017 – William Waller, MD

• COUNCIL ON LEGISLATION, DIST. 7 2014-2017 – Ann Rea, MD

... Annual Session continued p. 304

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Monster of a Good Time! September 2014 JOURNAL MSMA 297

• President’s Page • Inaugural Address of the 147th President Claude D. Brunson, MD

r. (Jim) Rish, thank you for that kind introduction. And thank you for your exceptional leadership as President of our Mississippi State Medical Association over the last year. Your leadership and friendship have meant so much to me, not just this past year but during your tenure in leadership in the Association. Chairman (Lee) Voulters, thank you for your leadership of the Association’s Board of Trustees over the past year and we look forward to your capable leadership in the years to come.

Claude D. Brunson, MD 2014-15 MSMA President

What a high honor and distinct privilege it is for me to serve as the 147th President of the Mississippi State Medical Association. I have been informed that this is an historic inaugural event; apparently, I am the first bald anesthesiologist you ever elected. And, speaking to my specialty as an anesthesiologist, I will try not to practice that art tonight.

Let me take a few minutes to recognize some of the people who have meant so much to me during my life and career. This will not be an all-inclusive list for the sake of time so if I do not call your name aloud, it is not because you are not and have not been important in my life; you have and I know you know that. First, to my lovely daughter Christin, thank you for participating in the swearing-in ceremony with me. Christin is a fairly newly minted attorney; she received her law degree last year from Ole Miss and just finished a health law fellowship at the University of Houston Law School at the end of May. She has been gainfully employed for the past 2 months and 2 weeks, but who’s counting. Thanks also to her “friend” Mr. Marcus Williams for being here with us. Marcus just graduated from Ole Miss Law this year and holds the distinction of being the first African-American to be President of the Ole Miss Law student body. Christin’s sisters, Chelsea and Claudia, could not be here tonight as they are on duty helping their mother with the Mississippi Sickle Cell Foundation Annual Fundraiser being held just down the street at the Jackson Country Club. So, my daughters had to split their duties this evening. However, they are committed to take their dad for a celebration in the next few days. My sister Patsy is here with us tonight from Atlanta, GA. She has her son and my nephew Adrian with her and his lovely wife Bridgett. Thank you for being here to celebrate this evening with us. My mother could not be with us tonight as she is dealing with a progressive medical illness but I can feel her presence and her smiling approval of her youngest son’s achievement. A person who I dearly wish could have been here is my grandmother who meant so much to me and who was always confident that I and my brothers and sister would achieve wonderful things. She listened incessantly to my early stories about wanting to be a doctor and so lovingly encouraged it. I know she is smiling in heaven. Thank you to my lovely lady Felicia for being here and for being my sounding board for a lot of the issues I have had to deal with over the past months. I have leaned on her for support and caused her many headaches along this journey and she has been graceful along the way the entire time. Joining her is her brother and sister in law and my friends Mr. and Mrs. Brian and Tiace Anderson. Thank you for being here. Also, here with us tonight is a very dear friend, Mr. John Harvey. Thank you, John, for being here. As I look back over my career and what has prepared and led me down the road to professional and organized medicine leadership, I can’t help but reflect on the very beginnings of mentorship. It began with the grooming in management from Dr. Mahesh Mehta as we endeavored to reengineer clinical services in the operating rooms at UMMC. That taught me to think through issues to find workable solutions and consensus, not an easily achieved task in a world of surgeons. Dr. Mehta you have no idea how much that mentoring has helped me in navigating this world of organized medicine. It continued with my being appointed to the Pharmacy and Therapeutics Committee by then Chief of Staff, Dr. Andrew Parent. That was my first real foray into what I would consider organized medicine. I was so excited to be participating at this level of medical decision-making

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that was not direct patient care but that would affect patient care and patient care providers. I was immersed in this amazement and excitement for about two weeks when Dr. Parent appointed me chair of the committee when the then chairman left the Medical Center for other opportunities. Amazement and excitement quickly gave way to terror, as I had no idea about how to lead a committee. But as I came to find out and which has been true my entire career, there are always those around who will help you and want to see you succeed. Let me also recognize Dr. Helen Turner who has been nothing but supportive to me in both my academic and organized medicine careers. It is as though she mapped out how my career should progress and gently reminded along the way that I needed to stay on task and get on with it. Thank you, Dr. Turner. I cannot adequately express my appreciation for what you have done for me and what you mean to me. And in a similar scenario to my Dr. Parent experience, my dear friend Dr. Eric Lindstrom, who upon my election to the Council on Legislation congratulated me and promptly appointed me chair of the Committee. He must have spoken to Dr. Parent about tactics.

Dr. Brunson thanks his daughter Christin for assisting with the swearing-in ceremony. Christin received her law degree last year from Ole Miss and finished a health law fellowship at the University of Houston Law School. She is now a staff attorney in the Mississippi Division of Medicaid.

Thank you to my colleagues from the Office of the Vice Chancellor who are here and especially to Dr. Keeton, my boss, who has led the Medical Center in a phenomenal fashion during his tenure. As you know, he has announced his retirement. He will leave big shoes to fill. Thank you, Dr. Keeton, for your leadership and friendship. And, special thanks to the Chancellor of the University of Mississippi, Dr. Dan Jones, for attending tonight. Dr. Jones’s visionary leadership of our flagship University has been nothing short of remarkable and courageous.

We also have with us two remarkable young people who work directly with me in my office, Mrs. Felicia Estes Caples and her husband Mr. Michael Caples and Mr. Michael Jones. Felicia is my Executive Assistant and manages my life in superb fashion when I do as she tells me and Michael is the Deputy Director of the Myrlie Evers-Williams Institute for Health Disparities and Director of Healthy Linkages, which is a collaboration between the MSDOH, UMMC and the FQHCs in the state. Thank you both for being here with us tonight. And let me not forget to mention the phenomenal staff at the MSMA offices who are very capably led by Mrs. Charmain Kanosky. They make the work we all do on behalf of Mississippi physicians and patients achievable. Finally, I would like to call out the name of someone who has endured my constant inquiries, asking about how to do this or do that, to help me understand the process for advancement in the medical association, walking me through the leadership process in Central Medical Society and getting me beefed up to take on the challenge of advancement in MSMA. And she never wavered or tired of me from the questioning or needing help with this or that. She has always been there for me, gently nudging and coaxing me along, Mrs. Becky Wells. Thank you so much, Becky. Now, let me address a couple of key things that I think we need to concern ourselves about in the next months and years. The first is our mental health system. Well, let me restate that, our lack of a mental health system. Now I won’t go into much detail this evening about this save to say that the system is defined by dysfunction, consent decrees and disservice to Mississippians who need a more readily accessible, comprehensive and cost effective mental health system. In 2010, the Joint Committee on Performance Evaluation and Expenditure (PEER) issued a report on Planning for the Delivery of Mental Health Services in Mississippi. The report criticized the Board of Mental Health for not focusing on strategic planning, for allowing community based programs to fall behind and for not planning for reallocation of resources to meet emerging needs. In response to that report, the Joint Legislative Study Committee on Mental Health was formed and hearings were held. Although initially there was some progress made, it was insufficient and now stalled. Our Mississippi Psychiatric Association has made gallant efforts to get a better plan in place and momentum restarted. Their efforts have fallen on deaf ears. MSMA continues to hear from Mississippi physicians pleading for help with this intolerable situation for their patients and patients’ families. The MSMA must act with our Psychiatric Association, physicians and all other stakeholders to make a difference in this issue. The Mississippi Psychiatric Association has repeatedly advocated for: • Putting physicians back in full charge of medical necessity determinations and certifying medical necessity

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â&#x20AC;˘ M aking qualifications for the DMH executive director in accordance with national standards and best practices for the position; other administrators should be physicians and/or persons trained in healthcare administration â&#x20AC;˘ T he Board of Mental Health should be reconstituted in similar fashion as was done with the Board of Health with the majority of members and the Chairman being a physician trained and experienced in the delivery of quality mental health services. We must stand with our colleagues to make a difference in this issue. The second topic I want to touch on is the changing nature of our healthcare delivery system. Not since the advent of Medicaid and Medicare have we seen such a tectonic shift in the structure of healthcare delivery as we have seen since the passage of the Affordable Care Act. Healthcare delivery financing in the United States was on its way to insolvency, access to healthcare was worsening and outcomes not improving. Healthcare expenditure per capita has increased every year since 1960 when spending was $147 per citizen to 2010 when expenditures were $8,042 per citizen. Yet, a recent Institute of Medicine report ranked the U.S. 17th out 17 peer nations in life expectancy. Presidents dating back to the Teddy Roosevelt administration have struggled with trying to find a solution to the healthcare debacle. In 2010, the current administration got passed and signed into law the Patient Protection and Affordable Care Act. You are very much aware Dr. Brunson is congratulated on of the firestorm that has ensued since that time, from Supreme Court rulings his inauguration by Dr. Dan Jones, to 50 plus votes to repeal the law in the U. S. Congress, a rocky roll out Chancellor of the University of of the health insurance exchanges to dividing up the states into Medicaid Mississippi. expansion vs non-expansion states. And caught in the middle of all of this are physicians and their patients. This Act not only divided people based on their political views but also divided physicians, mostly along the lines of primary care vs other specialists. We have seen this in our own state and among our own MSMA members. As Chair of your Board of Trustees in 2012, I think I set a record of special call Board meetings to review and discuss this Associationâ&#x20AC;&#x2122;s public stance on Medicaid expansion. And those were difficult discussions and decisions that the Board wrestled with to try and get it right for the entirety of the house of medicine. And I believe that we did and we continue to have it right. This Association has always advocated for Mississippians to have access to healthcare and we have always stated that the best way for that to happen is to have access to health insurance. Now there are multiple avenues to attaining this insurance coverage that have been debated and advocated by politicians and healthcare economists alike. We simply encourage our political leadership to find a path to get to coverage and therefore enhanced access to healthcare. While this new law should have sparked constructive debate and tweaking or revisions to a law of this magnitude to improve it or overhaul it, that previously normal process did not occur. The current political environment has not leant itself to the time tested and proven tradition of debate and compromise in the legislative process. The expected constructive deliberations that have followed other major pieces of legislation simply have not occurred. What it has left us with is a great deal of uncertainty as to what the final healthcare delivery system will actually consist of. This uncertainty has led to a number of ill-conceived responses to the access problem. For example, the lack of primary care physicians that exists and is projected to worsen as more Americans enter the healthcare system has led to our political leaders and states devising alternative, unproven models of care. These non-traditional models consist of varying levels of healthcare providers being deployed to provide more complex levels of medical care, even though these new providers may not be adequately trained to take on these new roles and maintain quality at the level that the American people enjoy and expect. For instance, in the state of Missouri, as a response to its stated primary care physician shortage and the increasing number of medical school graduates who cannot find a residency program (because as you know those slots did not increase), the state has legislatively created a new category of physicians, the Assistant Physician. This Assistant Physician would work under a fully trained and credentialed physician but nonetheless would begin clinical practice after medical school graduation. Now, we all know that medical school is a rigorous curriculum but only provides you the requisite knowledge to begin to learn and understand the complexities of clinical medicine and practice. You gain that clinical knowledge and experience in residency training. But Missouri legislators obviously believe they know better about training

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physicians than our collective professional experience in training the nation’s physicians. America’s physicians are trained to a high standard in a reliably reproducible fashion such to maintain quality and safety for the American people. Even against the overwhelming disapproval of the American Medical Association about this new politician-created physician, the Missouri Governor signed this into law. As one author expressed it in Forbes magazine, “If you live in Missouri, you are entitled to no such professional reassurance about the person you call doctor.” The author goes on to correctly state that it is not fair to these aspiring young physicians to put them in a position to do harm, and it’s certainly not fair to their patients. But this is not likely the only place or type of innovative approach we will see our political and some healthcare leaders try in an effort to increase the numbers of advanced healthcare providers. In the area of telemedicine, which Mississippi is a national leader in, a state where we have good telemedicine rules and regulations and that will facilitate improved access to care to Mississippians, we now find national companies who see the huge amount of money to be made in telehealth contacting Mississippi physicians to sign them up as telehealth physicians for telephone only consultations. Again, this does not meet state standards and we believe does not provide the same level of quality, care and safety as streaming audio-visual assessments. We also see a number of new training programs springing up or being planned across the state that leave us wondering about the quality of the formal training plan. Don’t get me wrong, I agree we need to expand residency training slots, but those positions need to be in a single pathway accredited program that maintains the same high standards as existing training programs in this state and across the nation. Anything less raises the specter of returning to a pre-Flexner era where the quality of medical training was demonstrated to be inconsistent, substandard in many instances, and virtually non-existent in some programs. This is a disservice to those residents and to our citizens. So what is the solution to all of this upheaval and experimentation in our new and ever changing healthcare delivery world? It’s you. It’s all of us who practice quality medicine and care about our patients and the healthcare they receive. I believe the new model of practice, particularly in the primary care specialties, must encompass a medical care team approach with a physician at the head of a team of multidisciplinary providers who manage the entire spectrum of a patient’s health. Some might call this a version of population health management. Others may envision it as under another name or program. But the main point is that a process somewhat similar to this likely is a path forward, one that maintains quality and safety while improving our citizens’ health and also managing costs. Physicians must be actively engaged in helping to craft solutions to the healthcare delivery problem. The physician is the ultimate patient advocate and must be a part of the ultimate solution to this healthcare issue. To get the MSMA engaged on this task, I call for the establishment of a Presidential Commission on Health Equity. This commission will be made up of healthcare experts from across disciplines and across the state. They will be charged to study the issue of Mississippi’s poor health grades, access and provider issues and anything else that impacts the access to quality healthcare and an overall improvement in our citizens’ health. They will be asked to report back with a blueprint that we can use to begin the work of improving the health of Mississippians. I call on the Board of Trustees to allocate the needed funds for this commission to do its work so that the Association can take its rightful place with presenting to our state’s leaders and stakeholders the path forward to finally make progress on this vexing issue. Now, we can’t solve this problem overnight, but we will never solve it if we don’t have a plan and we don’t start somewhere. And I strongly believe that it is our charge to lead this effort and help direct our policy makers, physicians and other healthcare stakeholders to an effective solution for this for the sake of our patients and citizens. I have asked former President of the American Medical Association and MSMA, Dr. Edward Hill to lead this effort and he has kindly agreed to do so. As you know, Dr. Hill has been a passionate advocate of implementing practical solutions to improve the health of Mississippians and health status of our state. Thank you, Dr. Hill, for agreeing to take on this challenge. Finally, as I lightheartedly mentioned earlier, this is an historic inauguration. This inauguration takes place in the 50th year anniversary of Freedom Summer when the civil rights movement was in full force and our society was deeply divided along racial lines. It was a time when African Americans could not become members of the MSMA. A time when hospitals were segregated, if in fact they even allowed black patients to be admitted; and if they did, black physicians often had to transfer their patients to their white colleagues. It was a time when I could not be addressing you in this manner or even listening to the address. But here I stand tonight addressing you as your 147th President. And I submit to you that the importance of this achievement is not defined by my standing here, but by your sitting there. Because it is you collectively who made this moment possible. It was interesting the apparent news-worthiness of your electing me your president-elect. From local to national news, reporters wanted to know how this moment became possible. In fact, it was a national reporter who asked me what my thoughts were about the significance of the fact that I would be installed the President of the Mississippi State Medical Association almost exactly 50 years since my predecessor was adamantly denied membership as a black physician when he asked the new president to be admitted. What I told that reporter is that the remarkable thing about my election was that it was unremarkable. I have had a chance to reflect back on my career in medicine and in the MSMA during this period of remembrance of the Civil Rights Movement. And I reflected fondly on a meeting of the BOT where we were discussing the lack of diversity on the Board. One of my good friends and colleagues

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stated rather matter-of-factly that we had to do better to try and bring some diversity to the Board. He went on to comment that we were a “Board of white guys” to which another member quickly retorted, “What about Claude?” I responded that I blend in easily so it was an easily understandable oversight. But the great thing about that is my colleague did not see color but saw Claude. Isn’t that where we have all been trying to get to? Now, I do not make light of the times in our Association when all physicians were not welcome to join our ranks, nor the fact that we still have more work to do in this area. But I do celebrate that we have made significant progress in this regard and that we continue to take on this issue head on. Our JMSMA published a series of fascinating and illuminating articles and editorials by our Associate Editor Dr. Rick deShazo and Editor Dr. Luke Lampton chronicling the history of Civil Rights issues in medicine in Mississippi. Dr. Rick deShazo in partnership with the William Winter Institute on Racial Reconciliation held the first Marston Symposium on Race and Health: Fifty Years after Freedom Summer Can Physicians Heal Themselves. This turned out to be a very well-attended event, emceed by our own Dr. Ed Hill, and led to some powerful and wonderful discussions among the attendees. Our own HOD last year directed the BOT to explore ways to increase a more diverse membership. The BOT subsequently appointed an Ad Hoc Committee on Diversity which met and had stimulating and meaningful discussions. Out of those discussions came some good recommendations that our BOT will take under consideration for further actions. One of the more obvious recommendations was that we, as many organizations have already done, develop a statement on diversity. Also, it was apparent that there was lingering hurt from the past in how this Association treated their black physician colleagues and our relative silence on the issue since then. We were reminded that even the AMA published an apology in 2008 after reviewing that organization’s role in discriminatory practices against African American physicians and their patients. But no such comments from our own MSMA regarding our history. So now I stand in a similar place as my newly installed President colleague 50 years ago with a similar but opposite and unequivocal statement that yes indeed we do want you to be a member of the Mississippi State Medical Association. And whatever role this Association had in the past of fostering racial inequity, whether it was by engaging in actions that promoted racial inequity or by inaction in not supporting racial equity, we are sorry and regret those actions. Dr. Martin Luther King, Jr. said that “The ultimate tragedy is not the oppression and cruelty by the bad people but the silence over that by the good people.” We are a different organization now and we want to be as strong as we can to achieve the goals and missions of MSMA and to do that we need all of Mississippi physicians to participate. I want us to celebrate those heroes, black, white and others, who stood on the right side of history for our citizens and especially for medicine. Some of those heroes are here with us tonight. Dr. Helen Barnes is here. Dr. Barnes is one of the first African American female physicians to practice medicine in Mississippi. Thank you, Dr. Barnes, for your steadfastness and stamina in those early years to make sure that any Mississippian, especially women, in need of healthcare had a welcoming place to seek that care. I also want to recognize one other such hero here publically, Dr. Robert Smith. Dr. Smith is one of those genteel souls who is humble and non-aggrandizing but who was a tremendous leader in the Movement 50 years ago and since. He has been a consistent mentor, advocator and supporter of mine since I’ve been in MS. And he has been the consummate role model. He has been an activist in equity in healthcare since his early years as a physician, being a leader and founder in the Medical Committee for Human Rights, to picketing the AMA in Atlantic City, New Jersey, in 1963 to lobby for admittance of black physicians to AMA membership, to being a co-founder in the creation of neighborhood health centers which became the Federally Qualified Health Center program (the first of which was established in Mound Bayou, Mississippi). Dr. Smith, thank you for the contributions you have made to our profession, communities, our state and our nation. Now I say to us all, let us commit our lives to doing as meaningful work as Dr. Smith and those heroes that I speak of. Our profession and how we practice it will continue to evolve. Americans will live longer and with more illnesses, consume more medical services and demand a high quality, financially efficient system. And that is what we also want. But we cannot attain the high quality, reasonable cost healthcare system that the nation desires if we are not leading the change. Your participation in crafting the solution is not only necessary but required. Please allow me to join you in modeling the best healthcare system possible for our patients, practices, state and country. The future is ours to create. Thank you for your attention and for the awesome but humbling privilege to serve as your President. May God continue to bless you and bless our Mississippi State Medical Association.

Claude D. Brunson, MD 147th President Mississippi State Medical Association

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COUNCIL ON LEGISLATION, DIST. 8 2014-2017 – David Sawyer, MD COUNCIL ON LEGISLATION, RESIDENT 2014-2015 – Julia Thompson COUNCIL ON LEGISLATION, STUDENT 2014-2015 – Logan Rush COUNCIL ON MEDICAL EDUCATION, DIST. 1 2014-2017 – Katherine Patterson, MD COUNCIL ON MEDICAL EDUCATION, DIST. 3 2014-2017 – Murray Estess, Jr. COUNCIL ON MEDICAL SERVICE, DIST. 1 2014-2017 – Abhash Thakur, MD COUNCIL ON MEDICAL SERVICE, DIST. 2 2014-2017 – Bill Mayo, MD COUNCIL ON MEDICAL SERVICE, DIST. 3 2014-2017 – Laura Gray, MD COUNCIL ON MEDICAL SERVICE, RESIDENT 2014-2015 –Tal Hendrix, MD COUNCIL ON MEDICAL SERVICE, STUDENT 2014-2015 – Emily Brandon COUNCIL ON PUBLIC INFORAMTION, DIST. 4 2014-2017 – Chris Boston, MD COUNCIL ON PUBLIC INFORAMTION, DIST. 5 2014-2017 – Dewitt Crawford, MD COUNCIL ON PUBLIC INFORAMTION, DIST. 6 2014-2017 –Stephen Beam, MD

In Memorium The MSMAHouse of Delegates paused for a moment of silence to acknowledge Resolution 1 that mourns the passing of these esteemed colleagues (30 members to date of resolution): Joel L. Alvis, MD of Black Mountain, NC Claude L. Austin, MD of Hattiesburg Donald R. Berry, MD of Picayune Bernard H. Booth, III, MD of Madison David B. Ellis, MD of New Albany Richard J. Field Jr., MD of Centreville Richard C. Fleming Jr., MD of Meridian James R. Gleaves, MD of Meridian Larry J. Hammett, MD of Hattiesburg Elmer J. Harris, MD of Huntsville, AL Garland H. Holloman, Jr., MD of Jackson T. T. Lewis, MD of Charleston Clifford Neal Lowe, MD of Picayune Ben F. Martin, III, MD of Holly Springs William C. Mayfield, Jr., MD of Jackson C. Brent Meador, MD of Jackson James E. McAfee, MD of Columbus Bernard S. Patrick, MD of Jackson John M. Patterson, MD of Dothan, AL John Sanders, MD of Tupelo William H. Spragins, MD of Hollandale Joe W. Terry, Jr., MD of Canton James L. Thornton, MD of New Albany Martins Ugwu-Dike, MD of Columbia G. Dan Van Cleve, MD of Jackson Thomas L. Vinson, MD of Columbus Bill M. Wansley, MD of Biloxi Earl E. Whitwell, MD of Tupelo John D. Wofford, MD of Jackson Harvey B. Wright Sr., MD of Laurel

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May 1, 1923 to March 30, 2013 January 4, 1919 to February 20, 2014 December 13, 1922 to January 17, 2014 March 11, 1938 to January 8, 2014 March 29, 1920 to July 22, 2014 September 6, 1926 to July 22, 2014 September 28, 1934 to November 11, 2013 June 30, 1944 to July 20, 2013 September 18, 1937 to August 4, 2013 September 27, 1916 to June 23, 2014 April 17, 1943 to February 7, 2014 January 28, 1920 to January 6, 2014 July 12, 1969 to February 15, 2014 March 25, 1938 to February 24, 2014 June 27, 1945 to July 6, 2014 October 23, 1950 to September 6, 2013 July 7, 1935 to October 3, 2013 February 16, 1927 to September 23, 2013 December 16, 1925 to August 20, 2013 October 8, 1945 to September 28, 2012 November 20, 1945 to December 12, 2013 October 31, 1931 to April 4, 2014 August 4, 1935 to January 12, 2014 November 25, 1963 to April 10, 2014 February 9, 1962 to October 3, 2013 September 1, 1949 to September 29, 2013 July 12, 1934 to December 11, 2013 July 12, 1943 to November 8, 2013 August 9, 1927 to February 4, 2014 May 23, 1936 to June 2, 2014 r

• Letters • Adding Value to Membership Dear JMSMA Editor:

hrough this letter to the editor, I am writing to share with you and other MSMA colleagues a recent conversation I had with a distinguished member of the Louisiana State Medical Society.

On the evening of August 5, 2014, I received a phone call from Dr. Keith DeSonier, past president of the Louisiana State Medical Society. Dr. DeSonier has also served on the Louisiana State Medical Society Board of Trustees, Council on Legislation, and I believe is presently chair of their Political Action Committee. He is also a delegate to the American Medical Association from Louisiana. Dr. DeSonier related to me that membership in the Louisiana State Medical Society has been decreasing over the past several years and he had been charged with the task of engineering a plan to stop, and if possible, reverse the trend. I would point out that declining membership has be fallen a number of state medical associations across the country. In fact, declining interest and membership has led a number of state medical associations to cease having an annual meeting – or at least consider that possibility. Dr. DeSonier related that his investigation into declining membership led him to isolate those states who have, in fact, maintained a membership or even increased their number of members. He then opined that the Mississippi State Medical Association numbers were impressive and stands out among other states across the country. He had a simple query, how do we do it? I reminded him that I in no way represent the Mississippi State Medical Association and will be more than happy to give him the names of those in leadership positions and staff that may well give specifics as to his question. However, as a former president and active member of the association, I would be more than happy to share my impressions. I said, quite simply, that we at MSMA place a priority on membership. Not only do we value membership, but we encourage engagement of our physicians in our state medical association. Through the hard work and determination of our Board of Trustees, members, and staff, MSMA has successfully “added value” to membership for the physicians in Mississippi. As an association, we played a central role in the 2002 and 2004 Tort Reforms, supported our physicians and their practices after the 2005 hurricane Katrina catastrophe, and our political action committee (MMPAC) was a driving force in electing 7 of the 8 statewide elected officials who are all patient and physician friendly. In addition, our political action committee was a key component in electing a patient and physician friendly House of Representatives for the first time in 137 years. Our Council on Legislation and lobbyists continue, year after year, to be the most respected and listened to contingency at the Capitol. MSMA has, time and time again, fought off challenges to our tort reform legislation, scope of practice encroachments, and battles with third party payers. I further commented that our for-profit subsidiary MPCN was instrumental in capturing a 100% membership of the physician faculty at our only academic health center in Mississippi (a feat which, by the way, is virtually unheard of anywhere else in the country). As he listened with great interest, Dr. DeSonier’s response was to the point. He said, “Well, it sounds as though you docs in Mississippi are heading in the right direction.” I told him that I felt sure that our leadership and staff would be more than happy to share further details of our success. In closing, I feel it important to share this conversation. While there appears to be among us a vocal minority who take delight in criticizing and detracting from MSMA’s success, I think it important for all MSMA members to be aware that other states are both watching our accomplishments and take notice that MSMA stands out as a positive example. Kudos for a job well done to MSMA, the Board of Trustees, our executive director, and staff. It would serve us all well to “keep our eyes on the ball” and continue to serve our patients and physician members. There is so much more than joins us than that which divides us. We have so much more in common that we do in difference. Again, I think every Mississippi physician for their devotion to better health care for all patients, and I encourage us collectively to work toward more positive and productive endeavors. Yours truly, Randy Easterling, MD; MSMA Past President, Vicksburg

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• Letters • [As the Chair of the Board of Health and the Editor of the Journal MSMA, it pleases me to see our Mississippi State Medical Association working closely with the Department of Health to protect our strong immunization laws for the state. This is an important public health issue for all of our patients. Below you will find a letter sent (dated September 5, 2014 with the fact sheet September shown on p. 307) to5,all2014 Mississippi legislators from MSMA and other medical specialty groups and health organizations urging full support of immunization. Share these facts with your own legislators] —Ed.

To: Mississippi Legislators From: Concerned Health Advocacy Associations September 5, 2014

You may have seen a disturbing video sent recently to legislators filled with untruths about immunizations. The under-signed health care associations want you to have accurate data and statistics. We know that To: Mississippi Legislators strong From: immunization laws are important to keep our children healthy. Concerned Health Advocacy Associations

Protect children - don’tvideo allow Mississippi to filled become the next Youour may have seen a disturbing sent recently to legislators with untruths about California. immunizations. The under-signed health care associations want you to have accurate data and statistics. We know that

Immunizations protect our children from todeadly diseases still occur in the U.S. including whooping strong immunization laws are important keep our children that healthy. cough. Also known as pertussis, whooping cough is a highly contagious respiratory infection that can result Protect our children - don’t Mississippi nextmakes California. in death. Its nickname is derived from allow the whooping soundtoanbecome infected the patient when gasping for breath Immunizations following a series of our painful coughs. the proper immunizations and whooping young children protect children from Without deadly diseases that still occur in the newborns U.S. including becomecough. the most likely as age group whooping to contract whooping cough. For decades, toxicthat disease has been Also known pertussis, cough is a highly contagious respiratorythis infection can result in death. Its nickname derived from whooping sound an infected patient makes when gasping for the successfully contained fromis becoming an the epidemic through protective immunizations. Unfortunately, following a series of painful coughs. Without theand proper immunizations newborns and young of children trend tobreath forfeit lifesaving immunizations for newborns children has allowed an awakening the disease become the most likely age group to contract whooping cough. For decades, this toxic disease has been cough in the U.S. with an increase in cases sited. Just this year, the state of California declared a whooping successfully contained from becoming an epidemic through protective immunizations. Unfortunately, the epidemic. Worth noting, the county in California with the greatest number of cases is also the county that had trend to forfeit lifesaving immunizations for newborns and children has allowed an awakening of the disease an overwhelmingly percentage of sited. newborns who were immunizations based on their in the U.S. withlarge an increase in cases Just this year, the denied state of necessary California declared a whooping cough parents’epidemic. misguided choice tothe notcounty vaccinate. Worth noting, in California with the greatest number of cases is also the county that had an overwhelmingly large percentage of newborns who were denied necessary immunizations based on their

The numbers don’t lie—children parents’ misguided choice to not vaccinate. live longer today because of immunizations. In 1900, thenumbers U.S. faceddon’t 165 infant deaths per live everylonger 1,000 babies In 2010, this number dropped to 6 The lie—children today born. because of immunizations. deaths per 1,000 babies born. The numbers don’t lie: the U.S. is a safer place today for newborns and In 1900, the U.S. faced 165 infant deaths per every 1,000 babies born. In 2010, this number dropped to 6 children because immunizations protect our children from deaths per 1,000 babies born. The numbers don’t lie: the U.S. is a safer place today for newborns and BEFORE AFTER deadly children diseases.because immunizations protect our children from IMMUNIZATION IMMUNIZATION BEFORE AFTER diseases. are withheld the annual morbidity Smallpox IMMUNIZATION When deadly immunizations  29,005IMMUNIZATION 0 rates from diseases frightening. A comparison Whencommon immunizations areare withheld the annual morbidity Smallpox  29,005 0 Diphtheria 21,053  0 rates provides from common diseases are frightening. A comparison of statistics clear data supporting immunizations. Diphtheria

21,053 

Polio  16,316 0 Currently, Mississippi leads the country in immunization Polio  16,316 0 Currently, Mississippi leads the country in immunization rates. Mississippi’s strong school entry law protects Measles 530,217 rates. Mississippi’s strong school entry law protects Measles  220 220 530,217 immunized children as well as as others immunized children as well othersaround around them them who who Rubella can’t becan’t immunized like like newborn infants, those be immunized newborn infants, thosewith with special special Rubella 47,745  0 0 47,745 medicalmedical conditions, and and seniors for conditions, seniorsat at higher higher risk risk for complications. Any Any alteration to current immunization couldcause cause fatal, unwanted consequences. complications. alteration to current immunization standards standards could fatal, unwanted consequences. asktoyou to stand the health care communityand and maintain school entry immunization law. law. We askWe you stand withwith the health care community maintaina astrong strong school entry immunization of statistics provides clear data supporting immunizations.

All depend on you. Allchildren children depend on you.

306 JOURNAL MSMA September 2014

FACT: Immunizations Protect our Children

JUST THE FACTS

Keep Mississippi Immunization Laws Strong

• For U.S. children born between 1994 and 2013, immunizations will prevent over 300 million illnesses, 21 million hospitalizations and 732,000 deaths. • Mississippi children continue to die unnecessarily. Two Mississippi children died from vaccine preventable whooping cough in 2008 and 2012. • Reducing Mississippi’s immunization rates would lead to more unnecessary illness and deaths.

FACT: Immunizations are Effective, Safe and Cost Effective • According to a recent study in the July issue of Pediatrics, routine childhood immunizations are safe, and serious adverse reactions are “extremely rare.” • Numerous studies – including one involving more than 500,000 children – have demonstrated conclusively that the MMR (measles, mumps and rubella) vaccine is not linked to autism. • Every dollar spent on immunizations saves $5 in direct medical costs and $11 in total expenses.

FACT: Mississippi is a Leader in Protecting its Children • Mississippi is one of 32 states that does not permit philosophical exemptions for children attending school or day care. • The Mississippi Supreme Court deemed religious exemptions unconstitutional in 1979. However, Mississippi does allow exemptions for children who have a have a medical reason for not receiving a vaccine. • Due to deadly outbreaks of measles and pertussis (whooping cough), several states are now following Mississippi’s lead and tightening their exemption laws.

FACT: Deadly Diseases Still Threaten Children • Internationally, vaccine preventable illnesses kill millions annually. • In 2014, the U.S. has seen a > 600% increase in measles cases linked to travelers from abroad. Under-immunized communities account for 89% of measles cases in eighteen national outbreaks. • Strong immunization policies are protecting Mississippi residents from outbreaks of measles and other vaccine preventable diseases that other states have experienced. September 2014 JOURNAL MSMA 307

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• Poetry and Medicine •

his month, we print a poem from Jim Brown, MD, of Starkville. Dr. Brown has practiced comprehensive ophthalmology in Starkville since 2002. After completing medical school at UMMC, he went on to an internship in Internal Medicine at Wake Forest University. He returned to UMMC to complete his ophthalmology residency. He is actively involved in the Golden Triangle community and has recently finished a term as Chief of Staff at Oktibbeha County Hospital. He writes: “I have enjoyed reading the MSMA Journal under your leadership. I intermittently note poetry in the back of the Journal and thought I would go out on a limb and submit one of my own...‘Long night’ is an attempt to explore the ill-defined space of the grieving spectrum, somewhere between bargaining/depression and acceptance. It is the space where the inevitability of loss clashes one last time with the last strands of hope, two equally strong forces. The real pain of the loss is likely coupled in that last dance with bargaining. The problems ‘minimized’ early on come back to haunt the situation at the end, but there is still possibility if it is dealt with. In what seems like the last long night there is intense pain, there is a reliving of how the ending could be made different, and there is hope that it could be made ‘right.’ The long night is a metaphor for a painful situation that, though bleak, could still turn.” Most Mississippi physicians, especially those facing similar struggles daily in our state’s hospitals, will appreciate this metaphor and poem. Look for more of his poems in coming journals. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.] —Ed.

“Long Night” The night is long Light will come they say But I do not see it Longing for a whipping post Longing for a death camp Longing to trade the pain of the reality I feel for something else Longing and wishing for a different beginning or ending Minimization is plaguing me like a slowly expanding abscess Until it can be ignored no more Until it has to be drained or comes forth on its own Are you septic now? Total organ failure? Or can a long night in the ICU make it right again?

— Jim Brown, MD; Starkville

September 2014 JOURNAL MSMA 309

• Images in Mississippi Medicine • [Dr. W. W. McBride, a general practitioner in Ethel, Mississippi, located in Attala County until the late 1950’s or early ‘60’s, was well over 90 years old when he retired. Although I never met him personally, I was able to acquire several of his well-worn medical texts at the time of his estate sale. Found among the pages of one of the books was an intriguing “recipe” in Dr. McBride’s own handwriting (note the rusted straight pin still in the paper).] —D. Stanley Hartness, MD; Jackson Associate Editor, Journal MSMA

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310 JOURNAL MSMA September 2014

• Una Voce • Professional Rasslin’ “I’ve got to tell you I’ve been racking my brain, Hoping to find the way out. I’ve had enough of this continual rain; Changes are coming, no doubt. It’s been a too long time with no peace of mind, And I’m ready for the times to get better.” —Allen Reynolds

any of us have written at length about the daily frustrations of modern medical practice. Although there are larger cataclysms looming, one of the chief thorns in our side continues to be the inexorable transition of documentation and communication within our profession to the dreaded EMR. It is a runaway train, unstoppable and accelerating. As with the weather, we all gripe about the digitization of our world of work, speculate endlessly upon it. So far, we remain powerless to change it. All we can do is rant and rave it seems. I am tired of grumbling my way through every day; it gains me nothing. Dwalia S. South, MD

Last week while I was frenetically trying to reboot my laptop for the third time in an hour, a patient said to me, “You know, you must have the most wonderful job in the world, you get paid good money to play on the computer and laugh and talk with folks all day long.” In hindsight, she was correct in her assessment, but at that moment, I was not in the mood to agree with her. I popped back… “Girl, you don’t know what my job really is. I get to listen to dozens of people moan and complain all day long. I beg patients to do what they need to do to be healthier, but they simply do not do it. People just want me to throw pills at them!” Later I regretted having said those words and questioned myself if I was in an early stage of ‘professional burnout.’ Those of us who are technically classed Baby Boomer docs are rapidly becoming the geriatric generation of physicians. We find ourselves standing precariously perched in two different worlds. We should realize that the electronic evolution of healthcare is a mere distraction for us as elderdocs; the younger physicians seem to embrace what we disdain. There are far worse things beyond our profession’s control happening in American healthcare…far bigger windmills at which to tilt. At the recent annual session of your Mississippi State Medical Association the membership has again reasserted through the voice of the House of Delegates that it does not want the print Journal MSMA to cease to exist while we expand our horizons into a ‘doctor friendly’ on-line presence. I must say your Committee on Publications has been forced to expend excessively much energy to accomplish this goal over the past couple of years…time and effort that should have been spent on those far more important issues. We sincerely hope that the recent bouts of ‘professional rasslin’ are behind us. “Mutatis… Mutandis.” For now, to meet the needs of our membership we shall continue to stand firmly with our feet in both the print and digital world. To avoid the fate of dinosauric extinction, we must evolve and adapt while keeping what is good and necessary to our publication. Your editors are actively implementing a carefully crafted “5-year strategic plan” for the Journal MSMA to

September 2014 JOURNAL MSMA 311

accomplish this goal. We ask for your patience, but more than that, we ask for your insights and participation in the form of ideas, opinions, and editorials from all our readers. Feel free to drop us a line through our managing editor Karen Evers: KEvers@MSMAonline.com. We want to hear from you. Every physician has wonderful stories to tell and wisdom to share. We sincerely want to hear from you. We want to expand our base of contributing writers and introduce new bloodlines into the fold. For example, write and tell us how you are handling the new regulations for controlled medications and pain management, how your practice is dealing with the Affordable Care Act (or not), or how you have transitioned your clinic into a ‘cash-based’ practice. The mission of your Journal MSMA is to be the “voice, the face, and the spirit of Mississippi medicine.” We have put our plan in writing; now is the time to put it in action.

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PARTICIPATE IN MSMA’S DOCTOR OF THE DAY PROGRAM

Every year, MSMA staffs the Capitol Medical Unit during the legislative session with a full time nurse and a volunteer physician each day. The Doctor of the Day program runs from January through March and allows MSMA members to participate in the legislative process by being front and center at the state capitol. Doctors of the Day are only asked to provide minimal health care services to legislators and capitol staff. Doctors of the Day volunteer for half days on Monday and Friday while Tuesday, Wednesday, and Thursday are full day commitments. As Doctor of the Day, you will be introduced in the House and Senate chambers by your local legislators and thanked for your service. This is a perfect opportunity to not only “give back,” but have valuable personal time with your legislator and voice support for pro-medicine policies. To participate in MSMA’s Doctor of the Day program, please contact Blake Bell at BBell@MSMAonline.com.