July 2010 JMSMA

VOL. LI No. 7

July 2010

Ju

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JUlY 2010 volUMe 51 nUMber 7

Scientific ArticleS

Management of the Substernal Goiter: A team Approach 179

C. Ron Cannon, MD, FACS; Robert Lee, MD, FACS;

and Ralph Didlake MD, FACS

clinical Problem-Solving: now You See it, now You Don’t 183Nahid Islam, MD

PreSiDent’S PAGe

inaugural Address of the 143rd MSMA President 188

Tim J. Alford, MD; MSMA President

eDitoriAl

Awestruck 192

Michael O’Dell, MD; Associate Editor

relAteD orGAnizAtionS

Mississippi State Medical Association 193

information and Quality Healthcare 201

DePArtMentS

images in Mississippi Medicine 200

Poetry in Medicine 202

the Uncommon thread 203

Placement/classified 204

AboUt tHe cover: “StArS AnD StriPeS”- Martin M. Pomphrey, Jr., MD, a semi-retired

orthopaedic surgeon sub-specializing in sports medicine who practiced with

Oktibbeha County Hospital (OCH) Bone and Joint Clinic, created this cover

image from two separate photographs. The pictures were taken on July 4th, 2009 at

Old Waverly Country Club in West Point, where they were offering hot air balloon

rides. The rope tethered balloon did not go up very high. Dr. Pomphrey

superimposed the balloon onto a picture he took of the American flag behind the

bandstand. r

2010July

VOL. LI No. 7

2010July

VOL. LI No. 7

Official Publication

of the MSMA Since 1959

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Copyright© 2010, Mississippi State Medical Association.

Lucius M. Lampton, MDEditor

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PublicAtions coMMittEE

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and the Editors

thE AssociAtion

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Charmain KanoskyExecutive Director

july 2010 jOuRNAl MSMA 177

As a physician, you ask more of an Academic Medical Center.

You ask us to invent new ways to diagnose and treat disease.

To lead the medical research that can give us all better lives.

You ask more of University of Mississippi Health Care.

You ask us to offer the highest level of medical care to our mutual patients, every day.

To push the boundaries of what is possible.

This is University of Mississippi Health Care.Your Academic Medical Center.

Expect more.

Talk doctor-to-doctor at 866.UMC.DOCS or learn more at umhc.com.

An Academic Medical Center Is Not Like

An Ordinary Hospital.

178 jOuRNAl MSMA july 2010

Objectives: Review the diagnosis and management of patients

with substernal goiter. Study Design: Retrospective study of a series

of patients treated for substernal goiter. Methods: Retrospective chart

review of patients with substernal goiter (N = 16). Records were tab-

ulated for demographics, symptoms, physical and CT findings as well

as surgical management and comorbidities. Results: Substernal goi-

ter occurs infrequently. Of the seventeen surgical procedures per-

formed in these sixteen patients, only three required a median

sternotomy. All of the patients had multinodular goiter. There were no

instances of well differentiated thyroid cancer in this series. Co-mor-

bidities were present in each patient. Conclusions: Substernal goiters

are often quite large at the time of diagnosis as they enlarge slowly.

The majority of patients can be managed with a cervical approach.

Technological advancements such as the nerve integrity monitor (NIM-

2; Medtronic Xomed, Jacksonville, Florida) and Harmonic scalpel as

well as team approach to surgery are advantageous for the patient.

KeY WorDS: gOITeR, THyROId glANd, HypOTHyROIdISM,

HypeRTHyROIdISM, SubSTeRNAl,

THyROIdeCTOMy, MulTINOdulAR gOITeR

introDUction

Thyroid disease is becoming much more prevalent. The mani-

festations are protean, one of which is the development of the subster-

nal goiter. This entity was first described by Haller in 1749. The first

resection of a substernal goiter was carried out in 1820 by Klein.1 The

definition of substernal goiter has been variously described as a gland

extending 3 cm below the sternal notch.2,3 Others have described the

substernal goiter as one in which 50% of the thyroid mass lies within

the chest.4,5

The etiology of the substernal goiter is felt to be that of the thy-

roid gland descending into the chest and not that of ectopic tissue. The

thyroid gland descends inferiorly into the chest as this is the path of

least resistance.6 The thyroid gland is bound superiorly by the cricoid

cartilage, posteriorly by the trachea, esophagus and prevertebral fas-

cia, as well as the vertebrae which prevent upward growth of the thy-

roid gland. Other factors which may be related to development of a

substernal goiter are those of gravity, downward traction on the thy-

roid gland when swallowing, as well as the negative intrathoracic pres-

sure generated on respiration.

The substernal thyroid gland enters the superior mediastinum at

the thoracic inlet. It is bounded by the manubrium in front, laterally by

the pleura, posteriorly by the vertebrae, and inferiorly at the level of

the fourth thoracic vertebra.7 (Figure 1) The pathology in this area may

be broadly grouped together by the acronym “Terrible T’s”- namely

that of thyroid disease, thymoma, (terrible) lymphoma and teratoma.

The inferior mediastinum begins at the level of the pericardium is di-

vided into anterior, mid, and posterior compartments.

• SCieNtiFiC ARtiCleS •

Management of the Substernal Goiter:A Team Approach

C. Ron Cannon, MD, FACS; Robert Lee, MD, FACS and Ralph Didlake, MD, FACS

AbStrAct

AUtHor inforMAtion: Dr. cannon specializes in Otolaryngology – head and Neck

Surgery; Primary hospital Affiliation is River Oaks hospital, Flowood, MS, Clinical

Professor in the departments of Otolaryngology, Family Medicine, dentistry, and

diagnostic Studies at the university of Mississippi Medical Center head and Neck

Surgical group. Dr. lee specializes in Cardiovascular - thoracic Surgery; Primary

hospital Affiliation is Central Mississippi Medical Center, jackson, MS. Dr. Didlake

specializes in Vascular Surgery, Primary hospital Affiliation is River Oaks hospital,

Flowood, MS, Professor of Surgery in the department of Surgery at the university of

Mississippi Medical Center. he is also director of the Center for bioethics and Medical

humanities at the university of Mississippi Medical Center.

correSPonDinG AUtHor: C. Ron Cannon, Md, head and Neck Surgical group, 1038

River Oaks drive, Flowood, Mississippi uSA 39236, Office: (601) 932-5244, Fax: (601)

939-0545, email: [email protected]


fiGUre 1: CheSt x-RAy iNdiCAtiNg SubSteRNAl gOiteR. ARROwS

iNdiCAte the tRACheA.


In general thyroid masses are slow growing and may be present

for many years before being noticed. Over this time interval the pa-

tients may have developed comorbidities which enter into decisions re-

garding management. In general the consensus is to operate unless there

are medical contraindications. The surgical approach is generally via a

cervical incision; in cases of a very large mass a thoracic incision may

be needed as well. In terms of medical management, thyroid supple-

ment can temporarily decrease the size of the mass, but carry the at-

tendant risk of atrial fibrillation and osteoporosis.

Although thyroid masses are most commonly benign, cancer

must be considered in the differential diagnosis. Substernal goiters

have a risk of malignancy from 3-21%.8

The purpose of the current study is to evaluate the management

of patients undergoing surgery for substernal thyroid, the patient’s

symptoms, physical findings and radiographic findings. Other areas

of study are those of the pathology, the findings at surgery as well as

the treatment results. emphasis is put on evaluating the patient’s co-

morbidities as well as CT scan as part of the preoperative evaluation

and a collaborative team effort, the use of technology, particularly in

terms of use of the nerve integrity monitor and use of the Harmonic

scalpel.

MetHoDS

A review of 162 thyroidectomies performed by the senior au-

thor was carried out. patient demographics, symptoms, physical find-

ings, radiographic findings, surgical approach (cervical or median

sternotomy), pathology and complications were noted. CT scans were

obtained in each patient at 5 mm intervals from the skull base to the

lung hila using contrast.

reSUltS

Of the 162 thyroidectomies performed in the review period, sub-

sternal goiter was diagnosed in sixteen patients (9.8%). Substernal goi-

ter in this series of patients was defined as extension into the

retrosternal area by physical exam or by CT scan. There were eight

males and eight females who underwent seventeen surgical procedures

(one patient underwent two procedures in a staged fashion). The av-

erage age was 62.5 years with a range of 46-84 years of age. Symptoms

of the neck mass were present in only four patients. Most were un-

aware of any pathology. When questioned more closely regarding com-

pressive symptoms such as dysphagia, only three patients noted

complaints and shortness of breath was noted in only two patients.

None of the patients presented acutely or had stridor – a testament to

the slow growing nature of these substernal goiters.

A complete head and neck exam including laryngoscopy was

carried out. Neck masses were noted on physical exam in ten patients,

the largest measured 10; the smallest measured 2 cm in diameter. One

of the patients had a preoperative vocal cord paralysis which resolved

after surgery. All the patients were euthyroid. Comorbidities were

common and included advanced age, organic heart disease, chronic ob-

structive pulmonary disease, and obesity (see Table I). Radiographic

studies were obtained in each patient. Chest x-ray was the initial study

in four patients (Figure 1). A CT scan was obtained in all patients. CT

scans commonly demonstrated impingement upon the trachea and a

shift of the trachea from the midline. In fact, a shift of the trachea was

present in all but three patients (Figure 2). The largest mass noted by

CT scan measured 17 cm.

The operative technique involved a collar incision in the neck.

The incisions were generally 4 cm or less in size initially, adhering to

a minimally invasive approach.9 The nerve integrity monitor was used

in all cases to ascertain the status of the recurrent laryngeal nerve (Fig-

ure 3). Magnification loupes were used to facilitate dissection in the

patients who underwent a non-paralytic type anesthesia. dissection

was generally by a “top-down” technique. The recurrent laryngeal

fiGUre 2: Ct SCAN ShOwiNg SubSteRNAl gOiteR with tRACheAl

COMPReSSiON

fiGUre 3: NeRVe iNtegRity MONitOR. iN thiS NONiNVASiVe

teChNique the NeRVe MONitOR iS AttAChed tO A SPeCiAl tyPe

eNdOtRACheAl tube AS dePiCted. StiMulAtiON OF the ReCuRReNt

lARyNgeAl NeRVe (RlN) ReSultS iN MOVeMeNt OF the VOCAl CORd

whiCh iS theN deteCted by the NeRVe iNtegRity MONitOR tO

PROVide iNStANt iNFORMAtiON ON the FuNCtiON OF the RlN.

Patients (n=162)Substernal thyroidectomy : 17 surgical procedures in 16 patientsAge 46-84 (Mean 62.5 years) Substernal Thyroidectomy:

Lobectomy 13 (10 on right, 3 on left) Total Thyroidectomy 4

Pathology : Goiter (100%)

tAble i: Study deMOgRAPhiCS


nerve was identified by ligating the superior thyroid vessels. The nerve

was identified as it enters the larynx and dissected inferiorly in a ret-

rograde fashion. The substernal portion of the thyroid gland is elevated

out of the mediastinum using blunt dissection keeping the recurrent la-

ryngeal nerve in sight as the inferior thyroid artery is ligated. The Har-

monic scalpel, which causes hemostasis by friction, was used to ligate

vessels and aid in the dissection. The parathyroid glands were identi-

fied and preserved during the dissection. After the surgical specimen

was removed, the posterior aspect of the gland was closely examined

and if any devitalized parathyroid tissue present, it was implanted into

the sternocleidomastoid muscle (three patients).

Four of the patients underwent total thyroidectomies. The re-

mainder underwent lobectomies. There were ten complete lobectomies

performed on the left and three on the right. One patient had a vocal

cord paresis noted by nerve integrity monitor at the time of the initial

surgery, in which a sternotomy was required. This patient later under-

went a completion right thyroidectomy at a later date when the con-

tralateral gland increased in size and the patient developed tracheal

compressive symptoms.

Three patients underwent a median sternotomy as part of the

procedure. In two of these patients, the substernal goiter was on the left

and one on the right side.(Table I) None of these patients underwent a

total thyroidectomy out of concern for development of recurrent la-

ryngeal nerve palsy and also their other comorbid conditions. Of the

median sternotomy patients, one had a temporary vocal cord paralysis

which later resolved.

A multinodular goiter was uniformly found in all patients (Fig-

ure 4). Additionally, one patient was found to have a focus of ectopic

thyroid tissue in her mediastinum. None of the patients had well dif-

ferentiated thyroid cancer. There was no tracheomalacia noted despite

the extrinsic pressure upon the thyroid gland by the enlarged thyroid

gland. All of the patients’ vocal cords were examined postoperatively

in an office setting. One patient has had a persistent paralysis of his

right vocal cord. This is the same patient who had a transient left-sided

vocal cord paralysis after his initial median sternotomy procedure. An-

other patient had a transient left vocal cord paralysis which had re-

solved without incident by six months postoperatively. There was one

patient in the series that had a preoperative left vocal cord paralysis

which resolved after removal of a large goiter stretching the recurrent

laryngeal nerve. There were two patients with transient hypocalcemia

which resolved without the need for long term calcium therapy.

DiScUSSion

Most of the patients in this series were relatively asymptomatic,

indicating slow growth of the substernal goiter and the accommoda-

tion by the body to this gradual enlargement. patients with stridor, dys-

pnea and cough are more likely to have significant tracheal narrowing

by CT scan.10 Symptoms of stridor are generally poorly related to CT

findings. CT findings such as percent of the mass which is substernal,

goiter size at the thoracic inlet, ratio of goiter size to the vertebral body

at the thoracic inlet are not related to clinical symptoms. However,

symptoms of stridor and shortness of breath should be promptly eval-

uated including a laryngeal examination and imaging studies such as a

chest x-ray or CT scan.

A special mention is made of fine needle aspiration. Fine nee-

dle aspiration is considered to be the gold standard in the evaluation of

neck masses and also thyroid nodules. However, FNA was not rou-

tinely performed in patients in this series. The primary reason is that

most of the pathology is in the chest and fine needle aspiration in this

area carries the risk of damage to the major vasculature. The clinical

decision to operate in these cases was made by findings other than that

of fine needle aspiration.

A chest x-ray is a good screening tool in the diagnosis of sub-

sternal goiter. However the CT scan is invaluable in the management

of the substernal goiter. An axial CT scan demonstrates the size, loca-

tion and anatomic peculiarities of each substernal goiter. If contrast is

used, the relation of the thyroid gland to the surrounding vasculature

can be studied. Most goiters are anterior to the center of the trachea, but

can be posterior or complex (both anterior and posterior to the trachea).1

A posterior mass raises the index of suspicion for more difficult dis-

section. Review of the CT scan helps in surgical planning and facilitates

discussion of operative considerations with the patient. Additionally,

newer CT software packages may allow for imaging in the coronal

plane, thus giving further helpful information. CT scan is felt to be

more valuable than MRI in evaluating these patients. Other studies

generally used in evaluation of thyroid nodules such as thyroid scan

and ultrasound are not generally helpful.

Complications of thyroidectomy are well known and include

those of recurrent laryngeal nerve palsy and hypocalcemia.(Table II)

The rates of transient recurrent laryngeal nerve palsy are 3-15%, the

incidence of permanent paralysis is 4-5%.5, 11, 12 In this series, there were

two patients with temporary recurrent laryngeal nerve paralysis (12%)

and one with permanent paralysis (6%). One of the patients had a pre-

operative vocal cord paralysis which resolved postoperatively. The

rates of hypocalcemia range from 3.4 to 38% in patients undergoing

substernal thyroidectomy. permanent rates of hypocalcemia are gen-

erally in the range of 2.6%.5, 11, 12 In this series, there were two patients

with transient hypocalcemia, but none with permanent hypocal-

cemia.(11.7%) There were no differences in complications in patients

fiGUre 4: MultiNOdulAR gOiteR AS SeeN AFteR exCiSiON

RLN Palsy Temporary 12% (2) Permanent 6% (1)Hypocalcemia Temporary 11.7% (2) Permanent 0% (0)

tAble ii: COMPliCAtiONS


with the cervical or sternal splits in the study. This finding is consis-

tent with a study of thirty-five patients with a substernal goiter, of

whom twelve underwent sternotomy.12 There were no cases of wound

infection, hematoma or death. Indications for a sternal split are gener-

ally those of size, cancer, and atypical anatomy, dense scar from pre-

vious surgery or inability to deliver the thyroid gland into the neck.13

Surgeries were carried in combination by Otolaryngologist- Head and

Neck Surgeon (eNT) and cardiothoracic surgeon. The overlap of skill

sets, knowledge of anatomy of different areas and compilation of sur-

gical techniques aid in these difficult surgeries, surgeries which were

carried out in a collegial atmosphere. Newer technology in the form of

use of the nerve integrity monitor and Harmonic scalpel proved to be of

value. For example, after completing a lobectomy if the thresholds using

the nerve integrity monitor are elevated (suggesting damage to the re-

current laryngeal nerve), surgery on the opposite side can be deferred.

every patient in this series had several comorbidities. (Table III)

The most common of these included organic heart disease, diabetes

mellitus and obesity. There was also one patient who had polio in the

distant past. despite these varied and potentially serious medical prob-

lems, there were no deaths in the series, complications from these co-

morbidities, or prolonged hospital stay. It does pose the question of

proceeding with a total thyroidectomy with the advantage of avoiding

further surgery in the future versus performing a lobectomy only and

thus avoiding potential surgical complications and allowing for a

shorter anesthesia time.

Our tendency has been to perform a lobectomy; however, as fur-

ther operative experience is gained there may be a trend to total thy-

roidectomy. Netterville et al have advocated total thyroidectomy with

good results.1 Others have recommended total thyroidectomy, total

lobectomy or subtotal lobectomy, depending on the clinical situation.14

Regardless of the the procedure advocated, the literature suggests sur-

gical excision as the treatment of choice. There have been few com-

plications and a low morbidity rate in this series of patients. Not

surprisingly the rate of complications is higher in patients undergoing

substernal thyroidectomy.15

conclUSion

Substernal goiters are often asymptomatic due to their slow

growth and may be quite large at the time of diagnosis. Of the varied

diagnostic tests, a CT scan is the most valuable as it provides data on

size, location and anatomic vagaries.

patients with substernal goiter commonly have multiple comor-

bid conditions. despite this, surgery is the recommended treatment to

avoid tracheal and vascular compromise as well as to exclude the pos-

sibility of well differentiated thyroid cancer. Surgery can be carried

out with low morbidity and mortality, most commonly via a cervical ap-

proach.

A team approach with the use of advanced technology such as

the nerve integrity monitor and Harmonic scalpel are valuable adjuncts

in the management of patients with substernal goiter.

referenceS

1. Netterville Jl, Coleman SC, Smith JC, et al. Management of substernalgoiter. Laryngoscope. 1998; 108:1011-7.

2. batori M, Chatelou e, Straniero A, et al. Substernal goiter. EUR Rev

Medial Pharmaco Sci. 2005; 9(6):355-9.3. batori M, Chatelou e, Straniero A. Surgical treatment of retrosternal

goiter. EUR Rev Medial Pharmacol Sci. 2007; 11(4):265-8.4. Chow Tl, Chan TT, Suer dT, et al. Surgical management of substernal

goiter: local experience. Hong Kong Medical J. 2005; 11(5):360-5.5. Agha A, glockzin g, ghali N, et al. Surgical treatment of substernal

goiter: An Analysis of 59 patients. Surgery Today. 2008; 38(6):505-1p.6. lahey FA, Suinton MW. Intrathoracic goiter. Surg Gynecol Obstet. 1934;

59:627-37.7. gardner e, gray dJ, O'Rahilly R. Anatomy, 3rd ed. philadelphia, Toronto,

london: W.b. Saunders Company; 1969:297-298.8. Cohen Jp. Substernal goiters and sternotomy. Laryngoscope. 119:683-

688, April 2009.9. Terris dJ, bonnett A, gourin Cg, et al. Minimally invasive thyroidectomy

using the sofferman technique. Laryngoscope. 2005; 115(6):1104-8.10. Mackle T, Meeney J, Tirem C. Tracheoesophageal compression associated

with substernal goiter. Correlation of symptoms with cross sectionalimaging findings. J Laryngo Otol. 2007; 121(4):358-61.

11. ben Nun A, Soudack M. Retrosternal thyroid goiter:15 years experience.ISR Med Assoc J. 2006; 8(2):106-9.

12. Sancho JJ, Kraimps Jl, Sanchez-blanco JM, et al. Increased mortalityand morbidity associated with thyroidectomy for intrathoracic goitersreaching the carina tracheal. Arch Surg. 2006; 141(1):82-5.

13. de perrot M, Fadel e, Mercier O. Surgical management of mediastinalgoiters: when is a sternotomy required? Thoracic Cardiovasc Surg. 2007;55(1):39-43.

14. possetto b, liquori g, Rombola F. Substernal goiter: A diagnostic andtherapeutic problem. (Report of 39 surgically treated cases). Ann Star

Chir. 1999; 70(1):29-35.15. pieracci FM, Fahey TJ. Substernal thyroidectomy is associated with

increased morbidity and mortality as compared with conventional cervicalthyroidectomy. Am J Surg. 205(1):1-7, July 2007.

Cardiovascular * n = 16 Diabetes Mellitus n = 5Obesity n = 4Arthritis n = 4Pulmonary # n = 4Previous neoplasm n = 3Miscellaneous + n = 6* Includes hypertension, coronary artery disease,

hyperlipidemia, organic heart disease, atherosclerosis# Includes COPD, ROAD and pulmonary embolus+ Includes osteoporosis gout, polio, renal disease, hepatitis,

peptic ulcer

tAble iii: CO-MORbid MediCAl CONditiONS

PLEASE TELL OUR

ADVERTISERS THAT YOU

FOUND THEM IN THE

A70-year-old African-American male presented to

the emergency department with chest pain. The

pain was located in the middle of his chest with no

radiation, and the duration of the pain was about 2 days. The pain

was described as an intermittent burning sensation, and each

episode lasted about 5-6 minutes, 2 to 3 times daily. The intensity

was 10/10. He reported shortness of breath and excessive sweating

but could not specify any relieving or aggravating factors. He also

complained of a dry cough and unusually rapid beating of the

heart. He had similar episodes of chest pain last year but those were

not as severe. He had lost about 40 pounds during the previous 8

months. He denied fever, headache, nausea, vomiting, abdominal

pain or hemoptysis.

He had a past medical history of hypertension (HTN) and

tobacco dependence. He denied any other medical illness includ-

ing diabetes or prior cardiac problems. His medications included

atenolol (Tenormin) 25mg and an angiotensin converting enzyme

inhibitor/hydrochlorothiazide (Zestoretic) 10/12.5 mg for his blood

pressure. He denied any cocaine or other illicit drug use.

based on his age, sudden onset of chest pain, shortness of breath

and diaphoresis, a diagnosis of angina pectoris or myocardial infarction

(MI) should be on the top of the differential diagnoses. patients with

gastrointestinal disorders such as esophageal reflux, esophageal spasm,

esophagitis and peptic ulcer disease may present with chest pain. For

an acute presentation, pancreatitis and cholecystitis are likely. Acute

abdominal pain is a common ed presentation, and related chest pain is

not unusual. patients with pulmonary embolism can present with acute

chest pain and diaphoresis. given his negative chest radiograph and

the absence of fever, pneumonia is unlikely. Other conditions such as

chest wall pain or panic attack should also be in the differential.

We established IV access and gave oxygen by nasal cannula.

On physical examination, his vital signs were within normal limits

except for his heart rate of 58 beats per minute and an elevated

blood pressure of 172/79 mm Hg. Cardiac examination revealed a

regular rate and rhythm and no jugular venous distension. Pul-

monary and abdominal examinations did not show any abnormal-

ity. EKG showed sinus bradycardia, left anterior fascicular block

and ST/T wave abnormality. When compared with previous EKG,

no significant changes were noticed. CBC, serum amylase and li-

pase, and the first set of cardiac enzymes were within normal lim-

its. Chest radiograph showed mildly prominent interstitial

markings in the lower left lung. His blood urea nitrogen (21 mg/dL)

and creatinine (1.6 mg/dL) were elevated.

The initial treatment was a mixture of Maalox, Donnatal,

and Xylocaine (GI cocktail) for presumed esophageal reflux; this

provided no relief. He was also treated with aspirin 325 mg orally,

morphine 2 mg and hydralazine 10 mg intravenously. He became

somewhat drowsy but his pain was not relieved. The addition of

nitroglycerin spray provided much pain relief. We noticed that his

pulse increased to 140 beats per minute each time the pain started

and normalized as the pain was relieved.

The patient has no history of reflux or other gastrointestinal

problems and experiences no symptom relief from the gI cocktail;

therefore, our index of suspicion for reflux is lowered. pancreatitis or

cholecystitis is not apparent, as serum amylase and lipase are within

normal limits, pain is non-radiating and Murphy’s sign is absent. With

costochondritis, point tenderness is common. His normal oxygen sat-

uration, chest radiograph and absence of pain related to breathing did

not indicate pulmonary embolism, pneumonia or pleurisy, although

these possibilities are not excluded. Though the initial cardiac enzymes

and eKg did not differentiate between acute myocardial ischemia and

non-cardiac cause of chest pain, we decided to pursue further investi-

gation for unstable angina.

The cardiology consultant ordered a catheterization that re-

quired administration of eptifibatide (Integrilin); therefore, the pa-

tient was admitted to the Coronary Care Unit. The patient was

given nothing by mouth and was started on a nitroglycerin infu-

• CliNiCAl PRObleM-SOlViNg •

Now You See It, Now You Don’t

Nahid Islam, MD

AUtHor inforMAtion: nahid islam, MD is a third year resident in the department of

Family Medicine at the university of Mississippi Medical Center.

correSPonDinG AUtHor: Nahid islam, Md, 2500 N. State Street, department of Family

Medicine, university of Mississippi Medical Center, jackson, MS 39216; telephone: 601-

984-5826 (office), Fax: 601-984-6889, e-mail: [email protected]

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



sion at 3cc/hr, eptifibatide (Integrilin) per protocol and simvastatin

(Zocor). He was also treated with low molecular weight heparin

(Lovenox) one time only. His lisinopril was held due to his elevated

BUN and creatinine but aspirin and atenolol were continued. An

echocardiogram, basic metabolic panel (BMP), lipid panel and an-

other two sets of cardiac enzymes were scheduled for the next

morning. The repeat cardiac enzymes were normal, and his BMP

was within normal limit except for elevated BUN (28 mg/dL) and

creatinine (1.8 mg/dL). Lipid panel showed a normal triglyceride,

total cholesterol and LDL; his HDL was 30 mg/dL. Echocardio-

gram showed left ventricular hypertrophy with ejection fraction

of 70% and aortic valve sclerosis. As no obvious cause of pain could

be found, the cardiologist recommended cardiac catheterization

and stent placement if indicated. The patient continued to have

chest pain, and on each episode his heart rate increased.

Cardiac catheterization done the following day showed a

critical mid circumflex stenosis, smooth type (70%) within a large

middle left anterior descending artery and concentric 70% steno-

sis within the proximal right coronary artery.

based on these findings, our diagnostic impression is 3 vessel

coronary artery disease (CAd).

The cardiologist prepared to place stents primarily in the

middle left anterior descending (LAD) artery. Before placing the

stents, he performed balloon inflation and repeated flush out. As-

tonishingly, no apparent lesion was detected in the LAD. To ex-

clude Prinzmetal’s angina the cardiologist gave intracoronary

nitroglycerin at a dose of 200 mcg. This resulted in the total disap-

pearance of middle LAD stenosis.

The total disappearance of middle lAd stenosis after giving va-

sodilators such as nitroglycerin is not consistent with 3 vessel CAd.

CAd is characterized by the presence of atherosclerotic plaque in the

coronary arteries that narrows the lumen and impairs the blood flow.

The disappearance of middle lAd stenosis is more consistent with

coronary artery spasm.

Our patient is a 70-year-old male smoker with no history of co-

caine use who presented with chest pain. His eKg on admission did not

show any significant changes in his ST segment. during coronary

catheterization, the middle lAd stenosis seen initially was relieved

with nitroglycerin infusion. This finding confirmed the diagnosis of

coronary artery vasospasm (prinzmetal’s angina). As such, the patient's

presenting complaint of chest pain was likely the cause of vasospasm

as opposed to diffuse coronary artery disease.

beta blockers are used for treatment of HTN, MI, and arrhyth-

mia as well as angina. Selective beta blockers are chosen for their spe-

cific action on the heart. but a beta blocker is contraindicated in

prinzmetal’s angina as it only works on the beta 1 receptor. It can ex-

acerbate coronary vasospasm by exposing the heart to unopposed alpha

stimulation.1 Our patient had been prescribed metoprolol, a nonselec-

tive beta blocker, as a first line treatment for hypertension. He had in-

termittent mild chest pain while taking this medication. He was

switched to atenolol, a selective beta blocker 2 weeks before he started

having severe episodes of chest pain. The use of the selective beta

blocker could have lead to worsening of his chest pain.

Our patient tolerated the coronary angiography well and

was prescribed nitrites, a calcium channel blocker and aspirin per

cardiology recommendation. The following day he did not have

chest pain. He was discharged home with these medications and

follow up appointments with both the primary care physician and

cardiologist were set for 2 weeks. The patient was seen in clinic 2

weeks after discharge. He had 2 more episodes of chest pain, which

were relieved with nitroglycerin spray, and he was feeling much

better.

prinzmetal’s angina, also known as variant angina, was initially

described by dr. Myron prinzmetal.2 It is a spontaneous episode of

chest pain at rest secondary to myocardial ischemia.3 usually it is a

focal coronary artery vasospasm, although diffuse spasm has also been

described.4 The natural history of this disease is not fully understood.3

The prevalence of variant angina is unknown but it appears to be no-

ticeably less common than typical stable angina and unstable angina at

rest.14 Japanese people have higher relative incidence and more diffuse

spasm than others. Men represent 69-91% of reported cases with a

mean age of 51-57 years.13 Cigarette smoking is a common risk fac-

tor.5,6 It may be associated with MI, Raynaud’s phenomenon and mi-

graine or its treatment.7 The autonomic nervous system as well as

endothelial dysfunction play a role in the pathogenesis of prinzmetal’s

angina. Abnormality of normal vasodilator function and hypersensi-

tivity of the coronary arteries to mediators of vasoconstrictors also have

been reported.6

Investigations include eKg, which can show transient ST seg-

ment elevation; exercise tolerance test; coronary angiography, which is

the standard procedure; dobutamine echocardiography, which is more

sensitive and specific than other tests;8 Holter monitor and provocative

test.9

prinzmetal’s Angina is treated by vasodilators such as nitrites,

calcium channel blockers and cholesterol lowering agents such as

statins. percutaneous coronary intervention might be helpful if ob-

structive coronary disease is present.10 Medications contraindicated are

beta blockers, aspirin and sumatriptan. estrogen has beneficial effect on

endothelium but it is not recommended due to the adverse effect it has

on cardiovascular system.11

The prognosis of prinzmetal’s angina is good with more than

95% overall survival at 5 years if no obstructive coronary artery disease

is present. A worse prognosis is associated with concurrent coronary ar-

tery disease and complications of arrhythmia. Calcium channel block-

ers may improve survival and symptoms.12

KeY WorDS: CHeST pAIN, eleCTROCARdIOgRAM,

beTA blOCKeR

referenceS

1. yasue H, Touyama M, Kato H, Tanaka S, Akiyama F. prinzmetal'svariant form of angina as a manifestation of alpha-adrenergic receptor-mediated coronary artery spasm: documentation by coronaryarteriography. Am Heart J. 1976; 91:148-155.

2. prinzmetal M, Kennamer R, Merliss R, Wada T, bor N. Angina pectoris:I- A variant form of angina pectoris; preliminary report. SM J Med.1959;27:375-388.

3. Mishra pK. Variations in presentations and various options in

There’s a lot going on in organized medicine so it’s easy to miss something if you’re on the go. To help you stay in touch no matter where you are, MSMA is now communicating via “Twitter.”In about three minutes, you can set up a free Twitter account for yourself. Simply visit www.twitter.com and submit your name, email address and mobile phone number (optional, standard text messaging rates apply). Once you’re signed up with Twitter, you can add MSMA by going to the following web page http://twitter.com/MSMA1 and clicking “Follow” next to the MSMA icon.MSMA1

For a bird’s eye view on medicine follow MSMA on!

There’s a lot going on in organized medicine so it’s easy to miss something if you’re on the go. To help you stay in touch no matter where you are, MSMA is now communicating via “Twitter.”In about three minutes, you can set up a free Twitter account for yourself. Simply visit www.twitter.com and submit your name, email address and mobile phone number (optional, standard text messaging rates apply). Once you’re signed up with Twitter, you can add MSMA by going to the following web page http://twitter.com/MSMA1 and clicking “Follow” next to the MSMA icon.

MSMA1

For a bird’s eye view on medicine follow MSMA on

!


management of variant angina. Eur J Cardiothorac Surg. 2006;29:748-759.

4. Okumura K, yasue H, Matsuyama K, et al. diffuse disorder of coronaryartery vasomotility in patients with coronary spastic angina.Hyperreactivity to the constrictor effects of acetylcholine and the dilatoreffects of nitroglycerin. J Am Coll Cardiol. 1996;27(1):45-52.

5. Sugiishi M, Tkatsu K. Cigarette smoking is a major risk factor forcoronary spasm. Circulation.1993; 87:76-79.

6. yasue H, Kugiyama K. Coronary spasm: clinical features andpathogenesis. Intern Med. 1997; 36 (11):760-765.

7. Nakamura y, Shinozaki N, Hirasawa M, et al. prevalence of migraineand Raynaud's phenomenon in Japanese patients with vasospasticangina. Jpn Circ J. 2000;64(4):239-242.

8. Kawano H, Fujii H, Motoyama T, Kugiyama K, Ogawa H, yasue H.Myocardial ischemia due to coronary artery spasm during dobutaminestress echocardiography. Am J Cardiol. 2000;85(1):26-30.

9. previtali M, Ardissino d, bargeris p, et al. Hyperventilation andergonovine tests in prinzmetal’s variant angina pectoris in men. Am J

Cardiology. 1989;63:17-20.10. Corcos T, david pR, bourassa Mg, et al. percutaneous transluminal

coronary angioplasty for the treatment of variant angina. J Am Coll

Cardiol. 1985;5(5):1046-1054.11. Rossouw Je, Anderson gl, prentice Rl, et al. Risks and benefits of the

estrogen plus progestin in healthy postmenopausal women: principalresults From the Women’s Health Initiative randomized controlled trial.JAMA. 2002;288:321-333.

12. yasue H, Takizawa d, Nagoa M, et al. long term prognosis of patientswith variant angina and influetial factors. Circulation. 1988;78:1-9.

13. Mesari A, Severi S, Nes Md, et al. “Variant” angina: one aspect of acontinuous spectrum of vasospastic myocardial ischemia. pathogeneticmechanisms, estimated incidence and clinical and coronaryarteriographic findings in 138 patients. Am J Cardiol. 1978;42(6):1019-1035.

14. Mayer S. Hillis ld. prinzmetal’s variant angina. Clin Cardiol.1998;21(4):243-246.

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• PReSideNt’S PAge •

Inaugural Addressof the 143rd

MSMA President

It is a singular honor to speak to you this evening as the newly installed

president of the Mississippi State Medical Association. Our Association is

engaged on so many fronts but this evening I shall limit my comments to

three areas: children’s education, the Medical Home, and physician workforce.

before I get too far into this I want to thank Mary Al, my wife, senior editor,

and best friend for her understanding and support over the past 30 years. Mary Al

inherited her mother and father’s intellect, but more than that their strong sense of

service. If Mary Cobb had not been a public health nurse, I believe that she would

have been a nun. She is the best Catholic I know! but Alton won out and Mary Al is appropriately named for both. you know of so many of

Alton’s accomplishments, but you may not know that he is soon to be a great-grandfather. I apologize to Timothy, leah, and John paul for

getting short-changed by their father because of the competing forces of a busy medical practice.

It goes without saying that dr. Randy easterling has worked tirelessly in his role as president this year. A special thanks to Janie, his

devoted wife and Matt and Megan. Also, thank you to Charmain and her executive Staff for going above and beyond to work for the betterment

of this organization. Thanks to Sondra pinson and the Alliance for all of their work this past year including the “did you Know- go”

campaign. I look forward to working with louise lampton as the Alliance takes their Healthy Food for Children Campaign to the next level.

Also, thanks to Steve demotropolis, Chairman of the MSMA board, who helped the board work through its share of challenges. your board of

Trustees is now ready to help this organization move our state off the bottom with regard to Mississippi’s overall health status.

Tonight I hope you will think along with me as I talk about a strategy to begin this “lift-off.” Some have called for an action plan but

action plans leave room to fail so I prefer to consider a “do-list.” This list is short but doable. First, be more actively involved in the

comprehensive school education curriculum. Second, encourage implementation of county pilot programs for the patient centered medical

home. Third, assist uMC with continued efforts to enhance the statewide physician workforce as expeditiously as possible.

before I share details of these three items, let me digress for a moment to my early memories from childhood and MSMA. I think it will

help for you to understand why I am moved in such a direction.

My first act as a member of the Mississippi State Medical Association was to deliver the invocation at a winter meeting some 25 years

ago at the Holiday Inn in downtown Jackson. Shortly after the prayer an 18-foot tall partition door came off its hinges falling like a great oak

tree and striking dr. John Fair lucas’ late wife, Sethelle, on the head. John Fair held pressure as dr. Richard Miller arranged for one of his

house staff to sew her up. As she was coming to, Sethelle looked up at me and said, “Timmy, that was one hell of a prayer!” Her affectionate

use of “Timmy” gave our history away as we both shared the hometown of greenwood, Mississippi. greenwood was considered more of a

town than a village but in terms of the proverb, Sethelle lucas had helped raise me. Her husband, dr. John Fair lucas, is one of many

remarkable physicians living in greenwood, immersing himself in a community during a most combustible time in Mississippi history – the

fifties and sixties. Another notable greenwood physician was dr. Reed Carroll who had completed his surgical residency at Johns Hopkins. A

Renaissance man, dr. Carroll was also a finalist for the National Forestry Award and graduated a whole army of eagle Scouts into our midst in

tiM J. AlforD, MD

2010-11 MSMA PreSiDent


greenwood. His wife, evelyn, a former Ob nurse at Hopkins, with her steely, soft voice, had a calming effect on the many children who

frequented their household on River Road in greenwood – myself included.

When I was around two years old dr. Howard Nelson, also of greenwood, was elected president of the Mississippi State Medical

Association. This was in 1957-58. later on in the 1960’s I recall riding with my dad, dr. John Alford, to make a special delivery to the Nelson

Home. dad brought a load of cow fertilizer from his farm in Carroll County to be used in Howard and elma Nelson’s immaculate flowerbeds.

dad and dr. Nelson stood across a split rail fence from one another and argued. I remember it as if it were yesterday. dr. Nelson always

animated his words – sharp, terse and humorous. Their discussion must have been along political lines. The reason I know this is that one was a

democrat, the other a Republican and there was a load of manure involved.

It was during this time that greenwood, Mississippi, and the American Medical Association confronted the issue of racism. In the book,

The Good Doctors, John dittmer speaks of the AMA’s refusal to deal with racial and religious discrimination. The Massachusetts Medical

Society had submitted a resolution at the annual meeting to banish or eliminate any medical society that excluded physicians on racial or

religious grounds. The AMA leadership held fast to its position of “no action necessary” because in the words of the AMA president, “We

cannot find a single society where discrimination exists.”

It was Mississippi’s MSMA president, dr. Howard Nelson, who rose to sway and stir the audience by stating that Mississippi’s two-man

delegation supported the anti-discrimination resolution presented by Massachusetts. Following a round of applause, the House of delegates

overrode the reference committee and took the first official steps toward ending discrimination. A two-man delegation from all places –

Mississippi – in the midst of the civil rights strife of the 1960’s provided leadership within the country’s leading medical organization.

These were turbulent times growing up in the Mississippi delta. As the courts moved to enforce Brown v Board of Education, massive

white flight ensued within the greenwood public schools – and in public schools throughout Mississippi. My parents made certain that my

brother peter and I did not fly anywhere and dr. Carroll’s family did as well. We stayed grounded in the public schools and this stand brought

much ridicule from the local citizens’ council. My mother wrote a piece in the greenwood Commonwealth in support of public education.

Afterwards our phone would ring every fifteen minutes after bedtime. These frightening, harassing phone calls ceased when dad spoke with the

head of the Citizens Council who also happened to be his patient!

you must be wondering why I present these stories of my formative years in greenwood. Several significant life lessons are derived

from this reflection and sometimes the future is forged by the lessons of our past. First, it does not really matter with which political party we

are affiliated. We should acknowledge the bad and seek the good in both even if we find ourselves dealing with a pile of manure from time to

time. Secondly, a two-man delegation has proven to be effective in doing the right thing. This is important because our own MSMA delegation

is about to go from 7 members to two as a result of the recent house action to de-unify. Thirdly, like dr. Carroll, we must exemplify positive

involvement in our communities even if we don’t produce an eagle Scout. Our influence and example are far-reaching. perhaps the most

important lesson learned is that mothers often speak softly but mean what they say. I can still hear my own mother reminding me almost daily,

“Timmy, be ye kind one to another.” Timothy, leah, and John paul, our children, heard the New Revised Standard Version each and every day

as they departed for school, as Mary Al’s admonition was “be kind to others.”

These lessons derived from my home front are what inspire me to lead this Association at this time and from which I derive my

commitment to health education, the Medical Home, and our medical teaching programs.

My entry into organized medicine began twenty-five years ago as a member of the young physicians Section of the AMA during its

formative time. I apprenticed with an AMA delegation then that saw dr. Sidney graves as Chairman – also known as “The godfather.” Other

notable members of the delegation included doctors elmer Nix, lamar Weems, Mal Morgan, Carl evers, Jimmy Waites, bill gates, ed Hill and

Alton Cobb. Since dr. lamar Weems had given me a 79 as a final grade on my urology exam in medical school, I took pleasure in observing

The godfather put lamar in his place more than once.

This distinguished delegation and those that came fore and aft contributed to the betterment of health in the united States and Mississippi.

For more than 160 years the AMA work has remained focused on its founding principles of the advancement of science, ethics, and the public’s

health. Without the influence and leadership of the AMA, we might still see the health landscape ravaged by such threats to the public health as

small pox, polio, and tuberculosis. Without the AMA’s leadership, would we have legal limits for driving under the influence of alcohol?

Would we have seatbelt restraint laws or airplanes that are not smoke filled? Absent the AMA’s leadership, would the tobacco industry have

open access into the minds of young children with a modern version of the Marlboro Man?



To de-unify from the very organization that gave us life saddens me. For decades AMA members have found the wisdom and courage to

work through their differences for the greater good in health care. I recognize that many in this association do not share this historical

perspective. However, as population dynamics play even more into the public health equation, it is naïve to assume that a strong national

organization will not become more relevant.

Over the past year dr. Randy easterling has provided MSMA a steady hand through very turbulent waters. I believe that dr. easterling

encouraged the House of delegates to make the right call under the circumstances. As a result, our MSMA membership has increased in

contrast to many other states. This is in large part due to the efforts of doctors Claude brunson and James Keeton at uMC and dr. Fred

McMillan with the Mississippi physicians Care Network (MpCN) who worked tirelessly along with Charmain to deliver the uMC faculty into

the ranks of our membership- some 400 members - pushing our total membership to over 3,850. I trust we will remember dr. easterling’s

consistent message during those days – we must keep a strong state medical organization, which is essential to the health of our patients. It must

be said that every MSMA board member has maintained AMA membership because of the reality that this organization remains the strongest

collective voice for medicine in our country.

We do have our problems, though and according to our own public Health Report Card, more than our fair share! We are first in the

nation in adult obesity and our patients are the least physically active in the country; second in the nation in heart disease mortality, diabetes, and

hypertension; highest in the nation in traffic fatalities; and ¼ of our children have not been sufficiently immunized.

I am sure that you have heard variations on this list ad nauseum. We are very good at documenting our failures but two years in a row of

publicity from these statistics begs for a plan of action. So once again, here is my suggested “to-do” list:

1) Further enhance comprehensive health education for all of our children.

2) embrace the new model of care, the patient Centered Medical Home.

3) Assist our medical center in meeting our physician workforce needs statewide.

Remembering one former AMA president’s refrain that “knowledge doesn’t change behavior, good habits do” we should recognize that

the Office of Healthy Schools is implementing the Comprehensive School Health education Curriculum – the same one that dr. ed Hill spoke

of ten years ago. The Amory School district among other districts, reports marked improvement in reading comprehension and state test scores

with the implementation of fully unadulterated comprehensive school health curriculum. So, early education improves public health and in turn

good public health improves a child’s capacity to learn. dr. Hill’s vision is literally bearing fruit as real fruits and vegetables are presented on

school lunch trays so that kids will really eat them. Sugar beverages have been eliminated and physical activity and education is more

coordinated and organized, not just a coach twirling his whistle in study hall. As a part of this plan there are health councils in each school

district looking for direction from local physicians. This comprehensive curriculum addresses each one of the indicators I cited earlier – obesity,

physical activity, and safety and we should do all that we can to support this initiative. This is where the Alliance will play a key role by helping

school food service staffs revolutionize food quality and presentation.

I believe the second component of my “to do” list will be revealed with the new model of care now surfacing on Mississippi’s health

horizon called the patient Centered Medical Home. Medical Home legislation House bill 1192 was delivered quietly and without fanfare by

MSMA and will empower the establishment of medical homes throughout the State through public/private collaboration with the State

department of Health. dr. Currier at the Health department has already initiated a work group in this regard. This physician driven model has

proven successful in several states including North and South Carolina, both of which have similar demographics to Mississippi. It is obvious

that it is in the best interest of Mississippi for all citizens to receive their health care in the most cost effective way and for each patient to have a

medical home.

you will be hearing more about the medical home concept, but in the meantime please know that the American College of physicians, the

American Academy of pediatrics, the American Osteopathic Association, and the American Academy of Family physicians have agreed upon

joint principles of care that are common to the medical home model. lest I watch all of your eyes glaze over as I recite these principles, I will

spare you at this time and I ask you for a moment to think of your own homes. Can we all agree that home is where we learn good habits? At

least for me, home was where I learned to eat fresh fruits and vegetables. Home is a place to seek refuge where you are accepted, broke or

broken. If you don’t come home, someone comes to find you! Home is where relationships begin. In the patient Centered Medical Home, the

doctor-patient relationship is the main commodity. If this sounds too lofty and undoable, consider this. Corporations such as IbM have seized

upon this concept and help constitute a 500-member primary care collaborative of employers, insurers and other consumers of health care. In

these transformed practices healing has begun in a fragmented and fractured system. ladies and gentlemen, “this is a big deal.”


For too long we have been bogged down in the intractable question, “Is health care a right or a privilege?” A more relevant question may

be “Is it in the best interest of communities for every individual to have a personal relationship with a primary care physician?”

The final item on the to-do list is enhanced communication with our medical center so that the health workforce needs are of the highest

priority. A larger, stronger, better-trained physician workforce is needed even if that includes decentralizing training to other parts of the state.

dr. Richard Roberts, former AAFp president and president-elect of the World Organization of Family doctors, has long held that the

Mississippi delta cries out for a community based family medicine residency program. Also, rural tracks for such training could be part of the

solution.

The Rural Scholars program, a collaborative effort between MAFp and MSMA, is providing a solution to one of the great deterrents to

medical student specialty choice – tuition! Janie guice continues to lead this program on a most successful path and thanks to her leadership

and the support of MAFp and MSMA, the fund was not only reappropriated by the legislature but also significantly increased in this session.

Thirty scholarships at $30,000 per student per year go a long way toward addressing the crisis of primary care access in our State. Our job will

be to assure the next level of funding for this essential program.

In closing tonight, I would like to share some words from dr. Howard Nelson of greenwood. In addressing the MSMA House of

delegates as Vice-Speaker, dr. Nelson said, “We are challenged to make our best even better, our vision keener, our policies more penetrating

and farther reaching. Shall we say that we are unique among people in the burdens we bear? Hardly so, for we are caught up in a time which

defies definition, frustrates logic, and casts aside the new for the newer, even before it becomes the familiar.”

It is my hope that we can move beyond mere recitation of our plight and laying blame. While our problems are not unique, solutions are

at hand but action is required. We are privileged to follow in the footsteps of so many quiet but courageous physicians who sought the best for

their patients and their communities. let us remain committed to their legacy of healing.

l.V. Hull, folk artist, philosopher, and one of my patients, died last spring. Frequently she would come to the office with a basket full of

art ranging from painted Clorox bottles to shoes to pieces of lumber. She would share with patients and office staff alike and her artwork still

decorates our office. I believe l.V. gave generously to all of us in our office because she knew this was a place where she could receive comfort

and rest although she was not always completely satisfied with her medical home! In one of her last visits she presented me with a plaque –

words colorfully painted on an old board that stated, “To dr. Alford, thank you for being a verb!” What I think l.V. meant is that nouns are just

things and verbs show action – they are doers. If l.V. were alive today I would commission her to create a similar piece for all of us, “MSMA,

be a Verb for your patients!”

let us get on with the “do” list. Thank you for affording me the privilege of being your president.

Tim J. Alford, MD

President, Mississippi State Medical Association

Benefit PlansCompliance ProgramsFraud & Abuse/StarkLabor & EmploymentMalpractice DefenseMedicare Law & RegulationCONSTARK

HIPAAMedical StaffTaxationWorkers’ CompensationGovernment RelationsMergers, Acquisitions

& Joint Ventures

JACKSON OFFICE401 East Capitol St., Suite 600, Jackson, MS 39201

Post O�ce Box 651, Jackson, MS 39205-0651PH. 601.968.5500 FAX 601.968.5593

GULF COAST OFFICE 2781 C.T. Switzer, Sr. Drive, Suite 307

Biloxi, MS 39531 PH. 228.385.9390 FAX 228.385.9394

HATTIESBURG OFFICE 601 Adeline St., Hattiesburg, MS 39401

P.O. Box 990, Hattiesburg, MS 39403-0990 PH. 601.582.5551 FAX 601.582.5556

www.wisecarter.com

• editORiAl •

Awestruck

Iam in awe of the national anthem. I am a patriot, having served my country for

over two decades in the Navy Reserve and retiring as a Navy Captain (O-6).

My patriotism, however, is not what provokes my feelings of awe regarding

the “Star Spangled banner.” To explain my feeling of awe, consider as an example the

singing of the national anthem at a Royals game. I am awestruck by 30,000 plus people

doing the same thing, at the same time, for a common purpose.

Over eight years ago, I joined North Mississippi Health Services (NMHS). Much

of my attraction to NMHS was the sense of common purpose regarding the

organization’s commitment to serving the people of the region. The sense of serving

neighbors and family is emotionally palpable at NMHS. being at NMHS has been

rewarding and fulfilling in this regard. Six-thousand five-hundred people work together

successfully to better the health of people in the region. I am awestruck again.

Tupelo, Mississippi is a community that understands “better Together.” Having

enjoyed living in various areas of our country, it is natural for me to compare

communities. I place Tupelo well in the lead in community unity and purposefulness. The

sense of togetherness, shared destiny, and commitment, so apparent in Tupelo, have

provided me many moments of pleasure. I am awestruck again.

Various medical leaders conspired in developing Mississippi’s Rural physicians

Scholarship program, created by the legislature in 2007. Members of the legislature,

university of Mississippi Medical Center, and medical leaders found common ground,

helping rural students and rural communities satisfy needs for development of physicians

to serve rural patients. Janie guice and members of the committee that lead this program

now have dozens of interested students and scholars working towards returning as

physicians to their rural communities. The legislature has recognized the value of this

effort and provided funding even in tough times. This experience for me may go beyond

being awestruck. It seems work of the divine to me!

Mississippi can accomplish most anything when leaders work together in this state,

in my opinion. Mississippians working together bear no likeness to the mindless partisan

counterproductive belligerence that is poisoning much of the rest of the country. good

work and service require respect for others and a commitment to working together, attributes that I have seen so many times in Mississippians.

Clearly, I have deep affection for Mississippi and Mississippians. Many of you know I am leaving though, having accepted the position of

Chair of the department of Family and Community Medicine at university of Missouri at Kansas City. I admire yogi berra’s Zen-like knack for

holding two opposing concepts together in one statement. So here is my yogi-ism on leaving for Kansas City: “If I were not so happy, I would

be sad.” leaving behind Mississippi would have been very difficult for me but for returning home to Kansas City and to a position I have long

wished to serve. My affection for Mississippi is unabated.

I have been inspired by living in Mississippi, made stronger, and I hope I have become wiser through my experiences here. I leave with

this wish and hope for my fellow physicians in Mississippi. May you increase your joy through working together, bringing forth countless

inspired works of service for Mississippians. I will be awestruck by you once again.

—Michael O’Dell, MD

Associate Editor

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

you can submit your letter via email to [email protected] or mail to the Journal office at MSMA headquarters: p.O. box 2548,Ridgeland, MS 39158-2548.

we CONgRAtulAte JMSMA ASSOCiAte editOR

Dr. MicHAel o’Dell ON the biRth OF hiS FiRSt

gRANdSON, ANd wiSh hiM well AS he RetuRNS tO

hiS Old StOMPiNg gROuNdS hAViNg ACCePted the

POSitiON OF ChAiR OF the dePARtMeNt OF FAMily

ANd COMMuNity MediCiNe At uNiVeRSity OF

MiSSOuRi At KANSAS City. dR. O’dell ObtAiNed

hiS MediCAl degRee FROM the uNiVeRSity OF

KANSAS SChOOl OF MediCiNe. he beCAMe A PROud

gRANdFAtheR with the biRth OF gRANdSON,

AubRey. AubRey wAS bORN juNe 27 tO hiS

dAughteR Kelly ANd heR huSbANd eRiC whO liVe

iN hOuStON, texAS. MSMA PReSideNt dR. tiM

AlFORd APPOiNted dR. RiCK deShAzO tO Fill dR.

Odell’S POSitiON AS ASSOCiAte editOR FOR the

JOURNAL OF THE MISSISSIPPI STATE MEDICAL

ASSOCIATION, eFFeCtiVe AuguSt 1, 2010.


• MSMA •


Richard D. deShazo, MDAppointed JMSMAAssociate Editor

MSMA president dr. Tim Alford has appointed dr. Richard d. deShazo to fill

the unexpired term of dr. Michael O’dell as associate editor of the Journal of the

Mississippi State Medical Association.

“There is no one more capable of bringing good science to the MSMA journal

than Rick. Moreover, he understands our unique Southern culture and where and how

we can apply that science smartly,” dr. Alford said.

Added Journal editor dr. luke lampton: “Rick is one of the brightest minds

in Mississippi medicine. He’s a practicing academic physician who has an extensive

background in medical journalism, serving in editorial positions at various medical

publications across the country. He is currently associate editor of both the American

Journal of Medicine and the Southern Medical Journal. besides his editorial

expertise, he’s also a skilled and cognitive writer. I admire very much his outstanding

public radio program Southern Remedy. He understands the positive influence this

journal can have on our profession and our state’s public health. Rick can help us take

the Journal to a higher level.”

dr. deShazo, Md is billy S. guyton distinguished professor, professor of

Medicine and pediatrics in the department of Medicine at the university of Mississippi Medical Center. He also has an active medical practice

as a clinical immunologist and cares for patients with allergic and rheumatic disorders.

dr. deShazo, a graduate of birmingham-Southern College in birmingham, Alabama, received the Md degree from the university of

Alabama at birmingham. He completed an internship in pediatrics at the Children’s Hospital of the university of Alabama at birmingham,

residency in internal medicine and fellowship in adult and pediatric allergy/immunology at the Walter Reed Army Medical Center and a research

fellowship at the Walter Reed Army Institute of Research in Washington, d.C. He served as the uS Army’s only clinical immunologist for four

years after his training and was a guest scientist at the National Institutes of Health during that period. He is board certified in the medical

specialties of internal medicine, allergy-immunology, rheumatology and geriatrics. before becoming Chair at the university of Mississippi, he

served on the faculties of the uniformed Services university of the Health Services, the university of Colorado School of Medicine, Tulane

university and was Chair of Medicine at the university of South Alabama.

dr. deShazo has served as a board member of the American board of Allergy and Immunology, the American board of Internal Medicine,

the American board of Medical Specialists and the Association of professors of Medicine. He is past president of the Association of professors

of Medicine and the Southern Society for Clinical Investigation. He has served on the Council of Academic Specialists of the American

Association of Medical Colleges for over 10 years. He is the author or co-author of more than 200 scientific publications in the areas of clinical

immunology and has served on the editorial boards of four scientific journals, several NIH study sections and a Federal drug Agency (FdA)

Advisory panel. In addition to his two associate journal editorships, he serves on the editorial board on the American Journal of the Medical

Sciences and the Annals of Allergy. He has served on the boards of the Alabama Quality Assurance Foundation, Information for Quality Health,

and the Mississippi physicians Care Network.

He received a Special Service Award from the American Academy of Allergy, Asthma and Immunology in 1993 for his work as editor of

the Primer of Allergy and Immunology and a second Special Service Medal for overall contributions to the specialty in 2006. He was named a

distinguished Fellow of the American College of Allergy, Asthma, and Immunology in 2006. Other awards include the u.S. Army Meritorious

Service Award, the Hoff Medal of the Walter Reed Army Institute of Research, the Mayor’s Award for Special Service from the City of New

Orleans, the bernard berman and Harold Nelson lectureships from the American College of Allergy, Asthma and Immunology, the dr. Robert

d. and Alma W. Moreton Original Research Award of the Southern Medical Association and the Founders’ Medal of the Southern Society for

Clinical Investigation. He was elected a distinguished Alumnus of birmingham-Southern College, has been consistently listed in best doctors,

and is listed in Marquis’ Who’s Who in American Medicine, Who’s Who in the united States and Who’s Who in the World.

dr. deShazo has been active in a number of community, civic and religious groups working toward racial reconciliation and has served as

an elder in the presbyterian Church and a steward in the Methodist Church. He and his wife, gloria, have three children and four grandchildren.

The deShazo’s enjoy singing in their church choir, gardening, boating, and spending time with friends and family.

ricHArD D. DeSHAzo, MD

• MSMA •


thRee yeARS OF the ASSOCiAtiON’S PReSideNCy ARe RePReSeNted, FROM LEFT, Dr. rAnDY eASterlinG OF ViCKSbuRg, iMMediAte PASt

PReSideNt, 2009-10; Newly iNAuguRAted PReSideNt Dr. tiMotHY J. AlforD OF KOSCiuSKO, 2010-11; ANd Dr. tHoMAS e. Joiner OF jACKSON,

PReSideNt-eleCt, 2011-12.

MSMA Election Results Announced

during the 142nd Annual Session of the House of delegates, held in Natchez, June 3-6, our MSMA inaugurated its president and

chose its president-elect and other leadership for the 2010-2011 term. dr. Tim J. Alford, who served as president-elect over the

past year, was inaugurated as president, and dr. Thomas e. Joiner was elected to serve as president-elect and will represent

MSMA as president in 2011-2012. dr. J. Clay Hays, Jr. of Jackson won a second term as secretary of the association.

during the inauguration ceremony, president dr. Alford, a Kosciusko native, acknowledged Mississippi’s health issues, including obesity,

heart disease, and diabetes, and encouraged MSMA members to be proactive for the sake of patients. “It is my hope that we can move beyond

mere recitation of our plight and laying blame. While our problems are not unique, solutions are at hand but action is required,” he said. dr.

Alford’s goals for his tenure include enhancing comprehensive health education for children, establishing public/private collaborative patient

medical homes throughout the state, and improving and enlarging the physician workforce through better communication with our state medical

center. He is a member of the American Academy of Family physicians, where he served as chairman of the Commission on legislation for two

years, the Mississippi Academy of Family physicians, and the American Medical Association (AMA). employed by premier Medical

Management of the Kosciusko Medical Clinic, he is past chairman of the pharmacy Review board of Mississippi division of Medicaid, a

former member of the Mississippi Trauma Advisory Council, and a former member of the Mississippi Foundation for Medical Care. He is a

graduate of Millsaps College and the university of Mississippi School of Medicine.

MSMA president-elect dr. Joiner practices family and industrial medicine in the Jackson area. Originally from greenwood, dr. Joiner

completed both undergraduate and medical degrees from the university of Mississippi. He serves the medical community through involvement

with the Central Medical Society, the American Medical Society, the Mississippi Academy of Family physicians, the American Academy of

Family physicians, and the Southern Medical Association. dr. Joiner is a former MSMA board of Trustees member, former member of the

division of Medicaid’s Review of Medical Necessity, and past-president of the Central Medical Society. He served as chief resident at

university of Mississippi Medical Center and as chief of staff at Central Mississippi Medical Center.

MSMA members also elected the following physicians:

• James A. Rish, Md, Tupelo – Chair of the board of Trustees

• daniel p. edney, Md, Vicksburg – Vice-Chair of the board of Trustees

• Claude brunson, Md, Jackson – Secretary of the board of Trustees

• bradford J. dye III, Md, Oxford – Trustee, dist. 2, 2010 -2013

• William M. grantham, Md, Clinton – Trustee, dist. 4, 2010-2013

• dwight S. Keady, Jr., Md, Meridian – Trustee, dist. 5, 2010-2013

• patrick brent Smith, Md, Jackson – Resident Representative to the board of Trustees


• Sam Holdiness, brandon – Medical Student Representative to the board of Trustees

• J. Clay Hays, Jr., Md, Jackson – AMA delegate, 2010-2012

• James A. Rish, Md, Tupelo – AMA delegate, 2010-2012

• Mary gayle Armstrong, Md, Madison – Alternate AMA delegate, 2010-2012

• Claude brunson, Md, Jackson – Alternate AMA delegate, 2010-2012

The result of other races follows:

• Stanley Hartness, Md, Kosciusko - Associate editor, JOURNAL MSMA, 2010 – 2012

• Marty Tucker, Md, Jackson – Council on budget & Finance, 2010-2013

• Jennifer J. bryan, Md, brandon – Council on budget & Finance, 2010-2013

• edwin d. Meeks II, Md, Columbus – Council on Constitution & bylaws, 2010 -2013

• Michael Mansour, Md, greenville – Council on legislation, dist. 1, 2010-2013

• brett lampton, Md, Oxford – Council on legislation, dist. 2, 2010-2013

• laura A. gray, Md, Tupelo – Council on legislation, dist. 3, 2010-2013

• landon e. Argo, Md, Jackson – Council on legislation, Resident, 2010-2011

• Tal Hendrix, Jackson –Council on legislation, Student, 2010-2011

• Tom Carter, Md, Kosciusko – Council on Medical education, dist. 2, 2010-2013

• Shirley d. Schlessinger, Md, Jackson – Council on Medical education, dist. 4, 2010-2013

• John d. Voss, Md, Meridian – Council on Medical education, dist. 5, 2010-2013

• John Wilkaitis, Md, Jackson – Council on Medical Service, dist. 4, 2010-2013

• dwight S. Keady, Jr., Md, Meridian – Council on Medical Service, dist. 5, 2010-2013

• Jason d. Stacy, Md, Jackson – Council on Medical Service, Resident, 2010-2011

• Andrew Weeks, Jackson – Council on Medical Service, Student, 2010-2011

• Scott e. Nelson, Md, Cleveland – Council on public Information, dist. 1, 2010-2013

• June A. powell, Md, Walnut – Council on public Information, dist. 2, 2010-2013

• C. Kenneth lippincott, Md, Tupelo – Council on public Information, dist. 3, 2010-2013

MSMA Awards: Community Service, Leadership,and Wellness Promotion Project Honored

The Mississippi State Medical Association (MSMA) honored two physicians

and a wellness promotion project during the ceremony for the 2010

excellence in Medicine Awards. Recipients and respective honors include:

• Dr. Jennifer D. Gholson – Dr. James C. Waites Leadership Award

• Dr. Ralph L. Brock – MSMA Community Service Award

• “Fit 4 Change” Fitness Challenge by Victory Sports Foundation – MSMA

Award for Excellence in Wellness Promotion

The dr. James C. Waites leadership Award honors one physician under the age of

50 who is an outstanding leader in organized medicine and community affairs. dr.

gholson, a Summit native, has served in leadership positions with MSMA, the

Mississippi Academy of Family physicians, the American Medical Association, the

Medicaid pharmacy and Therapeutics Committee, and the Mississippi department of

Health. Named as a “Top 40 under 40” business leader by the Mississippi Business

Journal, she has practiced in Tylertown and Magnolia and currently is employed by

peak Healthcare in Summit.

dr. brock, a family physician in McComb, was presented with the MSMA

Community Service Award, which recognizes participation in civic activities for the

betterment of the community. He designated the Rotary Club as the recipient of the

$500 contribution to a community organization. The award is designed to provide

recognition to members of the association who are actively engaged in the practice of

medicine and for the many and varied services above and beyond the call of duty which

they render to their respective communities. dr. brock serves the McComb community

in many organizations including the Rotary Club, polio plus program, pike County Arts

Council, Southwest Mississippi genealogy Society, pike-Amite-Walthall library

System, McComb public Schools Infirmary Foundation, Southwest Mississippi

Community College, McComb Chamber of Commerce, and McComb parents league.

2010 Dr. JAMeS c. WAiteS leADerSHiP AWArD

reciPient Jennifer D. GHolSon— the AwARd wAS

iNStituted iN 2001 tO ReCOgNize the MANy

CONtRibutiONS OF dR. wAiteS, tO hiS COMMuNity

ANd tO ORgANized MediCiNe. eACh yeAR the bOARd

OF tRuSteeS SeleCtS ONe PhySiCiAN uNdeR the Age

OF 50 whO iS AN OutStANdiNg leAdeR iN ORgANized

MediCiNe ANd COMMuNity AFFAiRS.


The Victory Sports Foundation, a non-

profit organization promoting amateur sports

and fitness in Mississippi, and athletic trainer

paul lacoste hosted the “Fit 4 Change”

project during the 2010 legislative session.

This 11-week fitness challenge was designed

to help participants, which consisted of four

teams of state legislators, governor’s office

employees, and civilians, make personal

lifestyle changes in the areas of diet, exercise,

and healthy living. Many of the co-sponsors

had an active role in the flow of the program.

However, MSMA Alliance past president

Angela ladner (Mark ladner, Md) and

lacoste were primary planners who

coordinated the program and worked together

to see it succeed. The team captains also

played a high profile role for their team

members by communicating program

instruction and encouraging them to work

hard to attain their personal goals. Notably

State Sen. Terry burton (R-Newton), Chair of

the Mississippi Senate public Health and

Welfare Committee, and State Rep. Steve

Holland (d-plantersville), Chair of the

Mississippi House public Health and Welfare

Committee, led the bipartisan effort to get the

leaders of the Mississippi state legislature

moving and fit.

The success of the program, with a total

weight loss of 1,401 pounds by 105

participants, led “Fit 4 Change” to be named

winner of the MSMA Award for excellence in

Wellness promotion. MSMA coMMUnitY Service AWArD — MSMA PASt PReSideNt dR. RAlPh l. bROCK (L.) wAS

PReSeNted the 2010 MSMA COMMuNity SeRViCe AwARd by ChAiR OF the COuNCil ON PubliC

iNFORMAtiON dR. hugh A. gAMble, ii (R.).

JAMeS GrAnt tHoMPSon MeMoriAl PASt-PreSiDent’S Pin —

2010-11 MSMA PReSideNt dR. tiM j. AlFORd (R.) PiNS the

jAMeS gRANt thOMPSON MeMORiAl PASt-PReSideNt’S PiN ON

MSMA iMMediAte PASt PReSideNt dR. RANdy eASteRliNg

(L.).


Icome before you this Friday morning overcome by a virtual plethora of emotion. It is a spirit

of thanksgiving in my heart that I ask for a few moments of your time, and I can assure that I

am learning day by day that brevity is a treasured commodity.

While I feel no obligation to thank neither this House nor the 3,800 members of the Mississippi

State Medical Association who sent you here today, I am compelled to do so by an overwhelming sense

of gratitude and respect for each of you and for those whom you represent.

I will begin by simply saying thank you. Thank you for honoring me and my family far more than

we ever earned. you allowing me to serve as your president this past year has been the event of a

lifetime. Rest assured, these past twelve months will never be forgotten.

I shall long remember and never forget the component societies, each one with their own unique

places and personalities. your warmth and hospitality have forever been imprinted in my heart. After

all, who could ever forget the Meridian meeting? We were in the largest room in the historic

Weidmann’s restaurant, standing room only. It was weeks after the AMA had come out in public support

of HR3200 and you could cut the tension with a knife. As president of the Mississippi State Medical

Association and also an AMA delegate, it took very little intelligence and/or imagination on my part to

arrive at the conclusion that someone might not leave that room in one piece. Since Steve and Charmain

were both younger and faster than I, it was blatantly obvious for whom they were sharpening the

guillotine. Maybe it was just my imagination, or perhaps that flood of catecholamines surging through

my body, but I swear to this day that prior to my introduction, the inviting aroma of steaks on the grill

waffling from the kitchen was overcome by the smell of hot tar.

After a brief and polite introduction, the president of the Component Society reached under the podium as I approached and said “Here I

think you may need this.” He then gave me a football helmet. It was a great ice breaker, we had a good time, great food, and an excellent

discussion.

each meeting was unique, a reflection of your personalities but more so your communities. Who could ever forget that quaint little

restaurant off of town square in Kosciusko? good, down home cooking, and Stanley Hartness boot-legging wine through the back door. Then

there was McComb, good crowd, warm reception, good food, this meeting was held in a bar. I am not sure to this day if anyone heard or cared

what I had to say, but we all had a good time that night.

Sometimes getting to the meetings was more exciting than the meetings themselves. Having Neely Carlton as your driver is an

experience in and of itself. I mean, with Steve and Charmain, it had been a particularly long day and a long trip to the component’s society, I

had no reservations about taking a short nap on the way home. Not so with counselor Carlton. Riding with Neely was akin to say, riding shot

gun with a Kamikaze pilot. I will never forget the trip to pascagoula. We met at the parking lot of Kroger grocery store in Richland, just south

of Jackson. I swear we were pulling into the restaurant parking lot 1½ hours later. One thing was for sure with Neely, the only thing more

exciting than the drive was the conversation. The constant conversation.

Well, long story short, we made it. The year has come rapidly to an end. If I were to sum it up in descriptive prose, I would say it has

been a year of dialogue. A year of debate. A year of definition. A year of coming to grips with who we are as physicians and persona. A year

of serious reflection on the role we play individually as an association with the American Medical Association, and in the grand scheme of how

we fit into the all familiar “Health System Reform.”

It has been a year that has brought out the best in most of us and the worst in a few of us.

Make no mistake about it, regardless of the emotion, the rancor, the accomplishments, and the failures, I am convinced that we are better

for the experience. Our association is strong, our relationships healthier, our staff more committed, and most important of all our patients better

served.

While this body’s decision in October of last year to deunify from the AMA has resulted in a precipitous drop in AMA membership by

Mississippi physicians (over 3,000), I am proud to stand before you and report that the Mississippi State Medical Association’s membership will

have increased by the end of this year by close to an estimated 500. These numbers speak, not so much, in my opinion, to our disapproval of the

AMA, but more so to the affection, respect, and love, that we all have for the Mississippi State Medical Association. I have said it from the

Coast to Corinth, from Vicksburg to Meridian, and I will repeat it time and time again. do what you will with the AMA, that is a personal

decision. I for one plan to stay with the AMA as does your entire board of Trustees. but for god’s sake, don’t leave the Mississippi State

Medical Association.

We have accomplished much in the past few years: Tort Reform bills in 2002 and 2004 (the 2004 bill being known as landmark

legislation and the most significant tort reform since MICRA in California 30 years ago), fully funding Medicaid, scope of practice issues, rural

scholars program, tobacco tax, reshaping the Mississippi State board of Health, putting in statutes that the Chair of the Mississippi State board

of Health must be a physician, a yearly report card on the state of health that has become the benchmark by which we fight obesity,

hypertension, coronary artery disease, stroke, etc., electing friendly judges to the Mississippi Supreme Court, increasing the medical class from

100 to 120 to hopefully 150, maintaining a well respected voice in the Mississippi legislature, a pAC second to none, a journal published

monthly that is second to none, and most recently, Senate bill 2127, the Fair and equitable Claims process Act. This bill is one of the few

pieces of legislation to ever pass both bodies of the Mississippi legislature without a single dissenting vote, and due to the imagination, hard

Address of the MSMA President 2009-2010S. Randy Easterling, MD

rAnDY eASterlinG, MD

2009-10 MSMA PreSiDent


work, and determination of Charmain Kanosky, dr. Fred McMillin, dr. Claude brunson, dr. Jimmy Keeton, for the first time in the history of

our organization, every physician faculty member at the university of Mississippi Medical Center will be a member of the Mississippi State

Medical Association.

These things did not happen by accident. It takes untold hours of hard work, planning, scheming, and a staff with a single minded

determination unmatched anywhere in this country.

One evening while we were at the Capitol during the 2004 tort battle (It was one of those late night marathons. everyone was exhausted,

tired, hungry, and emotions frayed.), I asked Charmain, “Why do you do this?” After all, I know that you are a great lobbyist and you could

make a lot more money working for someone else. Her answer has stayed with me until this day.

Simply put she said, “I like coming to work every day, going to the Capitol, wearing a white hat. I like working for the good guys who

always take the high road.”

I have learned through the years that being right is often not enough to win, but is a hell of a lot better than being on the winning side of

the wrong issue.

While our accomplishments have been many, make no mistake about it, our work is far from done.

In the words of the poet, Robert Frost, “I have promises to keep and miles to go before I sleep and miles to go before I sleep.”

Allow me to call your attention to a few issues: upcoming elections, especially the Mississippi Supreme Court. It would serve us well as

a constant reminder that this very minute as we are having this meeting, the trial lawyers are planning to dismantle our caps on non economic

damages.

Limas v Double Quick is a premises liability case that will be heard by the Mississippi Supreme Court in the next month. We must be

ever diligent, failure to do so will surely result in our being thrust back into a judicial hell hole that will be even hotter than before. It has

already happened in Illinois and georgia, and other cases are pending all over the country.

To be very frank with you, I have little patience and/or affection for those of us who in the doctor’s lounges all over this state and country,

day in and day out, continue to bitch, moan, and complain about the state of affairs in medicine, but do absolutely nothing to better the course.

If you are not comfortable going to the Capitol, talking to officials, being in press conferences, that is okay. I understand, there are

enough of us who can carry that torch. but all of us can do a very few simple things.

1. Come to your component society and be supportive.

2. give support both money and otherwise, to local, state, and federal elected officials who are patient and medicine friendly. (If you

don’t know who they are call the office and we can tell you.)

3. Continue to support the Mississippi State Medical Association every way possible.

4. last but not least, give to our pAC. everyone can at least write a check.

I was talking not long ago with one of our physician members who is a highly compensated medical subspecialist. He was rejoicing the

fact that our 2004 tort reform bill was saving him over $20,000 a year in malpractice premiums. Our response, well I am sure you will be

equally as pleased to donate at least $1,000 to our pAC. He looked at me as if I was crazy. give money to politicians, are you kidding? Well,

no I am not kidding. Whether we like it or not, agree or disagree, money is a mother’s milk of politics. As crazy as it may seem, politicians be

it at the state level or the national level, define what we do, how we do it, what we get paid to do, and how we care for our patients every single

minute of every day. I wish it weren’t so, but it is.

The passage of HR3590, the patient protection Affordable Act, signed in by president Obama on March 23rd of this year, is our most

prime example.

In one of our Capitol Club luncheons at the AMA one and a half years ago, Stu Rosenburg was the guest speaker. dr. Rosenburg is a

nationally known political analyst, editor of the Rosenburg Report, and a weekly commentator on Fox, NbC, CbS, AbC, etc. during the

question and answer session after his speech, a physician member from California asked, “What is the single most effective tool we can use to

get our message across in Washington?” Without reservation, he said, “Join and support your pAC.”

Well, enough of my ranting.

I want to say a few thank yous. First, dr. Jim Rohack, thank you for coming again. you were in Oxford last year. As tough as this last

year has been for me and our Mississippi State Medical Association, I cannot begin to imagine what you and other AMA leadership have been

through this last year.

I want all of you to know, regardless of how you feel about the American Medical Association and her position on issues, especially

Health System Reform, the AMA has been responsive to Mississippi this past year.

1. Cecil Wilson, president-elect of AMA, came to Jackson in August and spent several hours in a townhall type meeting.

2. dr. Rohack came to the Hattiesburg Clinic in late October or early November to discuss issues with the Hattiesburg Clinic.

3. As an association, you need to hear that in the mist of all this debate and dialogue, while Mississippi physicians may not see eye to

eye with the AMA leadership, the AMA continues to support our efforts to be informed and engaged. Thank you Jim. Thank you for

what you have done and continue to do. To our staff, your patience, your kindness, your support, your advice, your willingness to

always go the extra mile, I salute you all.

4. To Charmain, Neely, Steve, Karen, and the rest of you all who make the train run on time, I will never, ever forget you and what you

have come to mean to me. you are simply the best.

5. To Janie, what can I say that I have not already said time and time again? you have been patient beyond reason, understanding

beyond what could be expected, and loving beyond my wildest dreams. As exciting and fulfilling as most of this year was, the

highlight of everyday was, always hands down, coming home to you. I love you.


There are many who have asked, what are you going to do after this is over? Well, several things.

1. Sleep for about a week.

2. Janie and I are going to europe for about 10 days.

3. I have purchased a thesaurus and I am going to spend several months trying to figure out what the hell all those e-mails Kenn beemon

sent me meant.

The work of your association is far from done. The Mississippi State Medical Association is much bigger than any one person or groups

of persons. Our mission should always transcend personality and ideology. Our ultimate goal, always, without question is to serve our patients.

In a few short hours the mantle of leadership will be passed to dr. Tim Alford. Without question, you will give him the same level of support

and encouragement that you have given presidents before him. you will do so not so much because he is president, but because he has earned it.

As a father, husband, and physician, Tim is thoughtful, caring, and dedicated. He will serve our association and our patients well.

As I move on to other opportunities and challenges that lie before me, whatever they may be, please hear from this day forward, from me

personally, the distance from Oxford to Natchez will never again be measured in miles or time traveled. Minutes and miles will never ever be

adequate to describe this journey. Oxford to Natchez will forever more be a collage of emotion and memory. A snap shot in time, when you and

I joined hands, tethered not by background or belief, income or interest, personality or politics, but held together by that internal flame that

drives us all to care for our patients. because you see, the lot that you and I have chosen as Mississippi physicians is unique. Our challenges

are different and more difficult than others, but by the same token, our opportunities are unlimited.

Come Monday morning, when you and I go to work, we will get up earlier than most, stay up later than most. We will work harder than

most and get paid less than most. We will hold more hands than most and mean more to others than most. Our patients will be sicker than most

and will require more attention than most. They will be poorer than most and have less access to quality care than most. Our patients will be

fatter than most and exercise less than most. They will have higher rates of hypertension, diabetes, and coronary artery disease than most.

What they will have, however, is a gift of divine proportion. They will have you as their doctor.

May god bless you all and god bless the Mississippi State Medical Association.

S. Randy Easterling, MD

President 2009-2010


• iMAgeS iN MiSSiSSiPPi MediCiNe •

THE TABORIAN HOSPITAL, MOUND BAYOU— This photo is of the Taborian Hospital in Mound Bayou. It is the front

of a postcard dated July 14, 1946 and the back of the cards reads: “The Taborian Hospital, Mound Bayou, Mississippi.

Seventy-five beds; all modern equipment; built at a cost of $100,000; is sponsored by the Knights and Daughters of Tabor,

leading Negro Fraternal Order of Mississippi. $100,000.00 Hospital Expansion Campaign in Progress.” The one-story

Taborian Hospital was opened on February 1, 1942 with forty-two beds by the Knights and Daughters of Tabor and

situated in the historic “all-black” town of Mound Bayou. Dr. W. L. Smith of Clarksdale and Dr. Phillip M. George of

Mound Bayou were the original directors of the hospital, assisted by Dr. Theodore Howard as surgeon-in-chief. From 1947

to 1974, Meharry Medical College sent residents and interns as part of their training to the hospital. This was one of the

earliest rural training programs established at any American medical school. Meharry also trained many of the hospital

workers and technicians. The Taborian holds historic importance as one of the two most successful black fraternal

hospitals in Mississippi. The other, also located in the Delta but established earlier in 1928, was the Afro-American Sons

and Daughters Hospital in Yazoo City. Anyone with additional information on The Taborian Hospital is asked to contact

Dr. Lampton. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians,

please contact the Journal or me at [email protected].

—Lucius Lampton, MD, Editor

• i q h •Dr. Frothingham Named Recipient

of the A. A. Derrick Physician Quality Award

dr. Rodney Frothingham of Ruleville has been

named the recipient of the A. A. derrick

physician Quality Award given by Information

& Quality Healthcare (IQH). The award was announced at the

39th Annual Meeting of the Medicare quality improvement

organization. dr. Frothingham was recognized for giving

outstanding support to quality improvement, becoming the 19th

recipient of the award that was established to honor the late dr.

Arthur Aaron derrick Jr. of durant. dr. Frothingham’s name

has been placed with the other physicians who are listed on the

permanent derrick Award plaque on display at IQH.

The award is traditionally made at the IQH Annual

Meeting, held in conjunction with the Mississippi State

Medical Association Annual Session. dr. James S. McIlwain,

president, announced the award and also named the newly

elected board members, John dawson of Kosciusko, dr.

Thomas Skelton of Jackson, and dr. Frank Wade Jr. of Magee.

He recognized outgoing board members, dr. Frothingham and

dr. peggy davis of Jackson.

In announcing the award, dr. McIlwain said, “dr. Frothingham’s support is demonstrated as we look back on the past six

years he has served on the IQH board of directors. He was very much involved in the Circle of Champions effort that featured

hospital quality improvement staff nominating physicians who showed an interest in and participated in quality improvement

efforts within their hospitals. dr. Frothingham received enthusiastic nominations in the endeavor to familiarize physicians with

techniques for bringing meaningful change with a minimum of time and effort. His participation has been valuable in the various

aspects of the quality improvement program. We at IQH are very appreciative of the time he has given to the mission of

supporting quality medicine.”

dr. Frothingham is currently serving on the consulting staff with North Sunflower Medical Center. Formerly the chief

medical officer at delta Regional Medical Center from 2003 to 2007, dr. Frothingham was chief administrative officer of the

West Campus of delta Regional Medical Center, 2007-08, and active staff 1974-2008. He served as medical director of the Acute

Rehabilitation Center from 2000 to 2008. His practice affiliations have included the Neurosurgical Associates, p. A., in

greenville, SC, and the greenville Neurosurgical Clinic in greenville, MS.

The recipient of numerous recognition awards, dr. Frothingham was named “doctor of the year” by the Mississippi

Society of Medical Assistants and was elected to membership in the Sigma Xi scientific research society. He is chairman of the

Ruleville Methodist Church Council and is also a certified lay speaker. Among his military achievements, he has served as

commanding officer, 134th Combat Support Hospital, 2nd detachment at Camp McCain. He is a recipient of the u. S. Army

legion of Merit and the Mississippi Magnolia Cross. dr. Frothingham has also served on numerous medical and community

service advisory committees.

In accepting the award, dr. Frothingham said, “I am very pleased and humbled to have been recognized in such a way as to

receive the Arthur A. derrick Memorial Award. It is always a pleasure to serve IQH and the advancement of healthcare in

Mississippi.”

dr. Frothingham, a native of Rolling Fork, received a degree in chemistry from Mississippi College and pursued graduate

studies in biological chemistry prior to earning his M. d. degree from the university of Mississippi Medical Center (uMMC).

His surgical internship was completed at duke university Medical Center and his residency in neurological surgery at uMMC.

The late dr. derrick, a founder of IQH, was active with the State Medical Association, serving as president and chairman of

the board as well as chairman of the IQH board. After dr. derrick died in an automobile accident in March 1993, the tradition of

recognizing a physician who has been outstanding in the support of quality medicine was begun in his honor each year.


Dr. roDneY frotHinGHAM (R.) OF RuleVille ReCeiVeS

CONgRAtulAtiONS FROM Dr. JAMeS S. McilWAin, iQH PreSiDent (l.)

FOR beiNg NAMed the ReCiPieNt OF the A. A. deRRiCK PhySiCiAN

quAlity AwARd. dR. FROthiNghAM’S NAMe hAS beeN PlACed with

the OtheR PhySiCiANS whO ARe liSted ON the PeRMANeNt

deRRiCK AwARd PlAque ON diSPlAy At iqh.

• POetRy iN MediCiNe •

[This month, we print a poem by John D. McEachin, MD, a Meridian pediatrician. This poem, written recently, was inspired by

one of his friends who witnessed this event in the late 1940s. Dr. McEachin writes the editor that he is in charge of the choir

music and program at Spring Hill Church, outside Grenada, each third Sunday in May. This church was attended by his

ancestors. He adds: “It opens one day a year. We have upgraded ‘Dinner on the Grounds’ with PORTA-POTTIES in recent years!

Ha!” For more of Dr. McEachin’s poetry, see past JMSMAs and look for more in coming months. Any physician is invited to

submit poems for publication in the journal, attention: Dr. Lampton or email him at [email protected].] —ED.

The Macon Post-season Glee ClubWhen football season was finished,Macon boys looked for things to do.What better choice than glee Club;

pretty girls were there to woo.

glee Clubs hit the roadTo sing in towns nearby;

district Festivals were special,More pretty girls! Oh my!

The boys could get by it seems,When they “auditioned” at home base;

but when they went to district,Muted notes prevailed to save face!

guest choral conductors—big ShotsWere prone to challenge voices;

yes! One after the other, andThen, some shocking choices.

One fateful day in louisville,A conductor went down the line,Asking each young man in order,“Section? Sing a note! Whine!”

Some of the boys knew just enoughTo respond with the parts they sang—

“Tenor! bass! bass! Tenor!”With assurance, replies rang.

Then came the last, a gangly ladFrantic, voice cracking and hoarse,

eyes glancing down at the music he held,“Sir, I sing MIXed CHORuS!”

— John D. McEachin, MD

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• the uNCOMMON thReAd •

CreativeWriting


Igot thrown for a loop the other day. One of the girls in the Tumor Registry sent a copy of the JOURNAL version of “Squirrel Story”

to the inspector from the American College of Surgeons that was coming to do our cancer center certification. She had great

intentions. She wanted to show him how well rounded we were. I understand that and I’m happy for it. That’s not what threw me.

What did was what the inspector said the morning he showed up.

He was from pennsylvania, and I guess there they don’t put goofballs writing about squirrels in their medical journals. What he said that

startled me was that it was amazing they included something like this in a state medical journal at all, but he could understand it because

Mississippi had such a rich tradition of good creative writing.

That was just the thing to send me into a full-fledged neurotic meltdown.

At my age, I’ve spent most of my life trying to figure out what good writing is supposed to be. I’ve spent a lot of time studying it and

reading authors that are recognized as being good writers. I’m starting to get a fair idea of what people say really great writing is supposed to

change to look like and how great writers are supposed to write. unfortunately, I’ve also come to the unavoidable conclusion that I’m not one

of them.

lord knows, I’ve tried to be a better writer, but all of that thrashing about trying to say things in as convoluted and descriptive a manner

as possible is exhausting. Not only that, after all that work, I don’t even like to read it.

I know, I know. you’re supposed to grow and develop as you keep on, but every time I try, it doesn’t sound like me anymore. It sounds

like me being an idiot is all. The other problem is, it’s as boring as hell.

I tried reading some Hemingway again, to give me an idea of where I should go. everybody knows that he’s a great writer, and it’s been

years since I’ve tried to read any of his short stories. Not because I have anything against him, but he is dead, and he hasn’t been coming out

with very many new books lately, at least not since his demise anyway. If I remember right from college, from the book on ernest …what made

Hemingway revolutionary was a return to the use of short direct sentence structure. problem is, where the sentences are going is anything but.

Why can’t we just have people with names in the stories who were just doing something, without their past crowding them around to the

point you can’t tell what they were doing in the first place? Over time it’s gotten worse.

lord knows, I’m not picking on anyone, but since then, modern short story writers can’t seem to tell a story. They get so tied up with

descriptions and feelings that they forget to tell the story. It’s kind of like a flash of lightning at night. And while that sort of thing can be

intriguing, to me it’s never quite enough. I like to have some idea of what it is that I’m seeing. Maybe I lack imagination, but the flavor of the

story comes from a little bit of chewing, not simply the quick swallow. Some of it comes from knowing where the proper starting point is, and

r. Scott Anderson, MD

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going on until you reach the stopping point. every author is gonna

come up with a different starting point and stopping point. That’s

okay, as long as you get enough in it to make the reader say, “I like

that,” and not “What the hell was that?”

There is a natural pressure here to want to try and become a

better writer. It’s the expectation of the place. Mississippi has a rich

tradition of storytelling. you can say anything you want about the

relative merits and literary skills of our writers, but by gosh, they’ve

always known how to tell a story.

Something about that makes it hard to be a writer who just so

happens to be in Mississippi. There’s a lot to live up to. even saying

the name Faulkner is enough to make anything I write seem

worthless by comparison. When you throw in names like eudora

Welty, Willie Morris, ellen gilchrist, and modern writers like

grisham and Iles, this can turn into an absolute creative paralysis. It

was scary enough for me that I wrote both of my first two novels

based in someplace other than Mississippi, just to keep from having

to face it.

I think from now on, especially in this little column, I’m just

going to have to give up on trying to be some kind of a “Mississippi

writer” and just keep on telling some little stories. Who knows?

Some of them may even end up being true.

See ya next time,

Scott

R. Scott Anderson, MD, a radiation oncologist, is

medical director of the Anderson Regional Cancer

Center in Meridian and past vice chair of the MSMA

Board of Trustees. Additionally, he is an accomplished

oil-painter and dabbles in the motion-picture industry

as a screen-writer, helping form P-32, an

entertainment funding entity.

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July 2010 JMSMA