June 2011 JMSMA

June 2011

VOL. LII No. 6

Thomas E. Joiner, MD 2011-2012 MSMA President

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June 2011 JOURNAL MSMA 173

JUNE 2011 VOLUME 52 NUMBER 6

Scientific ArticleSImproving Health Literacy in Our Patients: An Opportunity to ImproveMississippi Health Outcomes 175Deborah S. Minor, PharmD; William J. Lancaster, BS, MD candidate;

Karen W. Freeman, PharmD and Richard D. deShazo, MD

Top 10 Facts You Need to Know About Childhood Hypertension 179Zeb K. Henson, MD

SpeciAl Article The Economic Impact of Office-Based Physicians in Mississippi 182SNR Denton and The Lewin Group, Inc.

preSident’S pAge Inaugural Address of the 144th MSMA President 187Thomas E. Joiner, MD; MSMA President

SpeciAl interviewAn Interview with Thomas E. Joiner, MD2011-2012 MSMA President 190Karen A. Evers, Managing Editor

relAted OrgAnizAtiOnSInformation and Quality Healthcare 200 Medical Assurance Company of Mississippi 201

depArtmentSLetters 195New Members 197The Uncommon Thread 203Placement/Classified 204

AbOut the cOver: thOmAS e. JOiner, md; 2011-12 mSmA preSident – During our MSMA’s 143rd Annual Session, held May 19-22 at the Tupelo BancorpSouth Conference Center, Dr. Tom Joiner of Clinton was installed as the 144th president of the association. Dr. Joiner is board-certified by the American Academy of Family Physicians and is a Past President of the Central Medical Society. He is a former member of the Division of Medicaid’s Review of Medical Necessity and served on the Mississippi Professionals Health Committee. He is in the private practice of family medicine at his clinic on Raymond Road in Jackson, which he opened in 1985. An interview with Dr. Joiner follows in this issue of the JMSMA. r

Journal of the Mississippi state Medical association (issn 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. correspondence: Journal MSMA, Managing editor, Karen a. evers, p.o. Box 2548, ridgeland, Ms 39158-2548, ph.: (601) 853-6733, fax: (601)853-6746, www.MsMaonline.com. suBscription rate: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. advertising rates: furnished on request. cristen hemmins, hemmins hall, inc. advertising, p.o. Box 1112, oxford, Mississippi 38655, ph: (662) 236-1700, fax: (662) 236-7011, email: [email protected] postMaster: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

copyright© 2011 Mississippi state Medical association.

official publication of the MsMa since 1959

Lucius M. Lampton, MDEditor

D. Stanley Hartness, MDMichael O’Dell, MD

AssociAtE Editors

Karen A. EversMAnAging Editor

PublicAtions coMMittEE

Dwalia S. South, MD chair

Philip T. Merideth, MD, JDMartin M. Pomphrey, MD

Leslie E. England, MD, Ex-OfficioMyron W. Lockey, MD, Ex-Officio

and the editors

thE AssociAtion

Thomas E. Joiner, MDpresident

Steven L. Demetropoulos, MDpresident-elect

J. Clay Hays, Jr., MDsecretary-treasurer

Lee Giffin, MD speaker

Geri Lee Weiland, MD vice speaker

Charmain Kanosky executive director

2011June

VOL. LII No. 6

�omas E. Joiner, MD 2011-2012 MSMA President�omas E. Joiner, MD 2011-2012 MSMA President

174 JOURNAL MSMA June 2011

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• Scientific ArticleS •

Improving Health Literacy in Our Patients: An Opportunity to Improve Mississippi

Health Outcomes

Deborah S. Minor, PharmD; William J. Lancaster, BS, MD candidate;Karen W. Freeman, PharmD; Richard D. deShazo, MD

As healthcare providers we are responsible for adminis-tering treatment and relaying relevant health information. How-ever, conveying health information to patients in a manner that is usable and understandable is often as difficult as making a diagnosis. Our patients fill their prescriptions about 50% of the time and take their medicines as prescribed at about this same rate. A major contributing factor is often a basic lack of under-standing of even the need for the medication. Lack of compli-ance to our recommended treatments is a hallmark of low health literacy and associated with poor and disparate health outcomes and increased costs. To positively impact health outcomes we must continually reassess how we communicate.

whAt iS heAlth literAcy?Health literacy is “the degree to which individuals have

the capacity to obtain, process, and understand basic health in-formation and services needed to make appropriate health deci-sions.”1 This includes the ability to understand instructions on a prescription bottle, information on consent forms, educational material in brochures, course of treatment given by healthcare providers, and negotiations in complex health systems.

More than 90 million Americans – nearly half the popula-tion – have difficulty understanding and using health informa-tion.2 Since health literacy is “a stronger predictor of a person’s health than age, income, employment status, education level,

and race,”3 addressing health literacy is a critical public health issue.

Persons with limited health literacy are more likely to forgo important preventative health services and have chronic health conditions. They are less able to manage their illnesses and are more likely to enter the healthcare system later with more critical health issues.4 Individuals with low health literacy are also more likely to report their health as poor and make more treatment or medication errors.5 Higher rates of hospitalization, increased use of costly emergency services, and higher annual healthcare costs are also associated with low health literacy.4

whO hAS lOw heAlth literAcy?Only 12% of U.S. adults have proficient health literacy.6

Groups typically identified as having the lowest health literacy are listed in Table 1.6 In general, a strong correlation exists be-tween health literacy and education level. Those with less than a high school or college degree score consistently lower on health literacy surveys than those with a bachelor’s degree or higher, though only 30% of those with a bachelor’s degree have proficient health literacy.6 In Mississippi where only 18.6% of the population over 25 hold a bachelor’s degree compared to the national average of 25.1%, this disparity is amplified. Mis-sissippi also has the second lowest per capita and family income in the nation, another strong indicator of low health literacy.7

AbStrAct

AuthOr infOrmAtiOn: Dr. Minor, Mr. Lancaster and Dr. deShazo are in the Department of Medicine at the University of Mississippi Medical Center. Dr. Freeman is in the Department of Pharmacy at the University of Mississippi Medical Center.

cOrreSpOnding AuthOr: Deborah S. Minor, PharmD, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216

Table 1: Typical Populations with Low Health Literacy

that health is directly related to academic achievement. With funding and assistance from the Bower foundation, the Mississippi Department of Education created the Office of Healthy Schools and has since encouraged the Coordinated School Health Program (CSHP) developed by the CDC. The CSHP consists of eight components designed to improve child and adolescent health by incorporating fundamental services into the curriculum. A healthy school environment, health services, health education, physical education, psychological and social counseling, nutritional services, opportunities for family involvement, and encouragement for staff health activities comprise the framework for the program.20 By addressing health and health literacy in children, family health can be influenced as well. Many opportunities also exist for partnerships between healthcare providers and educational settings, with the potential to target many of these issues.

Conclusion

The communication gap between patients and healthcare providers is often staggering and influenced by low health literacy. Addressing health literacy and barriers to successful outcomes should continuously be addressed in the delivery of health services. Steps for improving communication are highlighted in Table 4. Though the issues are complex, conscious efforts must be made throughout all encounters and levels of the patient-provider relationship. Programs that advance the health literacy of future generations and increase patient skills across the life span should also be supported at all stages of the educational system.21 We each have the opportunity to positively impact health literacy and make a difference in Mississippi.

Table 1: Typical Populations with Low Health Literacy

Age > 65years Racial and ethnic minorities Non-native English Speakers Low income levels Compromised health status Less than a high school degree or GED

Adapted from reference 6.


hOw dO we ASSeSS heAlth literAcy in Our pAtientS?Most experienced healthcare providers have a general

idea of the health literacy level of their patients. However, in-dividuals with limited health literacy, much like those with low literacy in general, often attempt to hide their difficulties. The Rapid Estimate of Adult Literacy in Medicine (REALM), the Test of Functional Health Literacy in Adults (TOFHLA), and the Newest Vital Sign (NVS) survey are all tools available to assess health literacy. These are used more often in research than in the clinical environment.

In the clinical setting, simple measures such as close at-tention to tip-offs and recognition of groups at risk can help identify limited health literacy. Comments such as “I forgot my glasses,” insistence on consultation with family members, missing appointments, or forgetting to refill prescriptions may indicate low health literacy. Health literacy levels are not uni-formly distributed across healthcare settings and will vary within a setting. All settings have patients at risk. In a setting where patients were largely uninsured and indigent, only 16% of the patients had an adequate (not proficient) health literacy level compared to 51% of patients in another setting within the same institution where most were insured and better educated.8 The methods and best practices discussed below can also help identify and address limited health literacy.

whAt cAn prOviderS dO?Attention to the patient-provider relationship and educa-

tion of medical staff is the most immediate and impactful solu-tion to addressing health literacy. Providers can identify and incorporate simple techniques in their practices that will create an environment of trust and facilitate clear health communica-tion. Some of these techniques are reviewed below.

Identify and Evaluate Sources of InformationThose with low health literacy are more likely to obtain

their health information directly from a provider. In contrast, people with proficient health literacy more frequently obtain information from text-based sources and the internet. How-ever, information from these sources may be misleading and confusing, and 60% of people who search online cannot find the desired medical information. 6,9 Recognition of these dif-ferences and consideration of the individual’s health learning capacity can help identify and resolve confusion. Unfortunate-ly, the disconnect is that approximately 70% of physicians say they provide patients with educational materials and resources, though only 41% of patients identify that they actually receive this assistance.

Most Americans read at the 8th grade level or below while the average reading level needed to comprehend a typi-cal medical pamphlet requires a high school or college degree. For health information to be understandable by the majority of people, it should be written at a 5th grade level or below.10,11 Ed-ucational materials with pictures can also help clarify difficult messages. In a review, health brochures enhanced with pictures

increased both comprehension rates (70% to 90%) and medica-tion adherence (72% to 90%) compared to text alone.12 Many non-profit organizations, such as American Heart Association, offer free printable on-line materials that are easily copied and appropriate for all age and education levels. The Agency for Healthcare Research and Quality also provides a health literacy toolkit for effectively creating and managing specific patient educational materials.11 The use of appropriate educational ma-terials can help improve patient understanding and actually de-crease contact time, especially if support personnel are trained to be a part of these interactions.

Use Lay Health Advisors to Supply InformationLay health advisors and leaders are often dependable

members of a community who are able to identify with a mi-nority or other population because of a shared language and culture.13 Establishing a professional relationship and using these advisors as partners can increase the quantity of global health messages delivered to patients and customize messages to be more culturally acceptable.13 Studies have shown that professionals and lay health leaders working together in part-nerships can lead to positive outcomes in dietary behaviors, blood cholesterol, blood pressure, physical activity, and hemo-globin A1c.13

Use Health Advocates for Resource Services Community health advocates can provide patients with

services that address chronic diseases and problems such as smoking, obesity, kidney disease, alcoholism, and low English proficiency. Providers can supply local resource information to patients efficiently by developing and distributing a standard contact list of available services.11 Access to advocate informa-tion and local social services can be found through agencies such as United Way and the Alliance for Information Referral Systems (AIRS). Websites containing contact information for particular disease services are also usually easily available (i.e., Mississippi ACT Center, American Heart Association, Missis-sippi Kidney Foundation). The Literacy Directory site (www.literacydirectory.org) can be used to find local language and ed-ucational programs. Good resources for medication assistance programs are the SelectCare Benefits Network (www.scbn.org) and RXAssist (www.rxassist.org) websites.

Talk Slowly Between 40 and 80% of all information heard in the clini-

cal setting is immediately forgotten while another 50% is re-membered incorrectly.14 Medical terminology often sounds like a foreign language. The “information-giving” period in prac-tice settings is increasingly limited and patients have less time to process complex information.10 Speaking too quickly limits understanding and can prevent the message from registering. Many of us also tend to quickly interrupt patients. If not inter-rupted, in general, patients will speak for less than two minutes and take less time overall. Limiting content to just two or three


essential points prevents information overload and allows pa-tients more opportunity to effectively process and understand the information provided.

Avoid JargonMedical terminology is frequently overused during pa-

tient conversations. The use of jargon is rarely appropriate and creates an obstacle to understanding. Substitution of common words, an example, or visual interpretation greatly facilitates the patient’s understanding and ability to follow instructions. The CDC “Plain Language for Health Communications The-saurus” provides a comprehensive list of medical terms and suggested words for replacement (Table 2, www.plainlanguage.gov).15

Identify Cultural IssuesAn awareness of different cultural beliefs is essential to

establishing trust and clear communication. Unique cultural medical beliefs can conflict with and be a barrier to the adoption of treatment regimens. Every patient should feel comfortable and unashamed in revealing cultural beliefs and differences. Providers must then work with patients to create a treatment plan that can be effectively utilized within their cultural con-text.10 Some examples of cultural differences with typical main-stream Western medicine approaches are identified in Table 3.16 Websites such as ethnomed.org can provide information about cultural beliefs and medical issues.16

Overcome Language DifferencesFor those whose primary language is not English, using

plain language and speaking slowly is not sufficient or effec-tive. All new patients should be asked their preferred language. Utilizing interpreters can improve patient understanding but only if the interpreter is present for the initial delivery of in-

formation.10 The use of trained interpreters is vital because untrained interpreters such as family members and friends can interfere with patient privacy and disrupt familial and cultural hierarchies. Local translators can be found through websites such as proz.com.11 Phone and computer programs are also available that allow simple yes/no questions regarding medical information to be played to patients in their native tongue.17 Such advances in technology may help overcome the growing concern of language differences, but proper training must be obtained to insure correct utilization.

Facilitate Communication and DialogueAssessing patient understanding is paramount to improv-

ing compliance with instructions. An easy process for evalu-ating dialogue is use of the “teach-back” method.11 Ask the patient to repeat in their own words what was discussed and ex-plain how they will follow recommendations and instructions. If they are not clear, then the dialogue and process are repeated. When concluding, ask, “What are your questions?” NOT “Do you have any questions?” An open format provides the patient with a more comfortable atmosphere for expressing concerns and prevents a simple “no” answer, easily stated to avoid em-barrassment. Assessing a patient’s understanding should coin-cide with providing supplemental written materials, circling or highlighting the most important information and having the pa-tient repeat the main points.

The Ask Me 3™ question series developed by the National Patient Safety Foundation is another method for encouraging communication and teaching patients a simple and comfortable way to ask questions. These questions ensure that the most im-portant issues are addressed and encourage communication.18 The three Ask Me 3™ questions are:

1) What is my main problem?

2) What do I need to do?

3) Why is it important for me to do this?

the future Integrate Health Literacy into our Educational System

Health literacy is widely recognized as a critical health problem, but the majority of professional schools do not in-corporate communication training into their curricula.19 The adoption of and requirements for components that address clear communication and cultural competency in healthcare provider training programs are efforts that must be realized. Equipping the next generation of providers with the proper tools is essen-tial for improving health literacy and outcomes.

Efforts to improve health literacy also go beyond the clin-ical setting. In 2007, the Mississippi State Legislature passed the Mississippi Healthy Students Act recognizing that health is directly related to academic achievement. With funding and

Table 3: Cultural Health Beliefs

Table 2

MedicalThesaurus–AvoidMedicalTerminology


Table 3

CulturalHealthbeliefs

Culture MedicalCondition CustomorbeliefLatino Upset stomach Rubbing stomach relieves ailment

Chinese Postpartum Substituting hot beverages and food for cold items (postpartum is a “cold stage”)

Cuban Infection A “lack of balance” or the supernatural contributes to disease susceptibility

Korean Hospitalization A sign of one’s fate and impending death


Table 4

StepsforClearCommunication

1. Slow down and limit content 2. Use “plain language” not jargon 3. Supply text enhanced with pictures 4. Improve cultural competency 5. Provide a social services contact list 6. Use interpreters appropriately 7. Ask Me 3™ 8. Utilize “teach-back” approach

MedicalTerm SuggestedreplacementHypertension High blood pressure

Glucose Sugar Coagulate Clot Adverse Dangerous Chronic Long lasting

Table 2: Medical Thesaurus - Avoid Medical Terminology

Table 2

MedicalThesaurus–AvoidMedicalTerminology


Table 3

CulturalHealthbeliefs

Culture MedicalCondition CustomorbeliefLatino Upset stomach Rubbing stomach relieves ailment

Chinese Postpartum Substituting hot beverages and food for cold items (postpartum is a “cold stage”)

Cuban Infection A “lack of balance” or the supernatural contributes to disease susceptibility

Korean Hospitalization A sign of one’s fate and impending death


Table 4

StepsforClearCommunication

1. Slow down and limit content 2. Use “plain language” not jargon 3. Supply text enhanced with pictures 4. Improve cultural competency 5. Provide a social services contact list 6. Use interpreters appropriately 7. Ask Me 3™ 8. Utilize “teach-back” approach

MedicalTerm SuggestedreplacementHypertension High blood pressure

Glucose Sugar Coagulate Clot Adverse Dangerous Chronic Long lasting


assistance from the Bower Foundation, the Mississippi Depart-ment of Education created the Office of Healthy Schools and has since encouraged the Coordinated School Health Program (CSHP) developed by the CDC. The CSHP consists of eight components designed to improve child and adolescent health by incorporating fundamental services into the curriculum. A healthy school environment, health services, health education, physical education, psychological and social counseling, nutri-tional services, opportunities for family involvement, and en-couragement for staff health activities comprise the framework for the program.20 By addressing health and health literacy in children, family health can be influenced as well. Many oppor-tunities also exist for partnerships between healthcare providers and educational settings with the potential to target many of these issues.

cOncluSiOn

The communication gap between patients and health-care providers is often staggering and influenced by low health literacy. Addressing health literacy and barriers to successful outcomes should continuously be addressed in the delivery of health services. Steps for improving communication are high-lighted in Table 4. Though the issues are complex, conscious efforts must be made throughout all encounters and levels of the patient-provider relationship. Programs that advance the health literacy of future generations and increase patient skills across the life span should also be supported at all stages of the edu-cational system.21 Physicians have the opportunity to positively impact health literacy and make a difference in Mississippi.

referenceS1. Healthy people 2010. 2nd ed. Washington, DC: U.S. Department of

Health and Human Services. http://www.healthypeople.gov/Document/tableofcontents.htm#under.2000. Accessed July 1, 2010.

2. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health literacy: a prescription to end confusion. Institute of Medicine. Washington, DC. National Academies Press; 2004.

3. Health literacy: report of the council on scientific affairs. Ad hoc committee on health literacy for the council on scientific affairs, American Medical Association. JAMA. 1999 Feb 10;281(6):552-7.

4. Quick guide to health literacy. U.S. Department of Health and Human Services. http://www.health.gov/communication/literacy/quickguide. Accessed July 1, 2010.

5. Warner A, Menachemi N, Brooks RG. Health literacy, medication errors, and health outcomes: is there a relationship? Hosp Pharm. 2006;41(6):542-51.

6. Kutner M. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. National Center for Education Statistics (NCES) Home Page, a Part of the U.S. Department of

Education. http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483. Accessed July 1, 2010.

7. Census Bureau Home Page. http://www.census.gov/. Accessed July 1, 2010.

8. Freeman K, Minor D, Guinn A, Replogle W, Hood E. Assessment of health literacy using the Newest Vital Sign. Proceedings of the ASHP 2010 Summer Meeting and Exhibition: An Intensive Educational and Skills-Building Experience for Health-System Pharmacy Leaders, Meeting Abstracts 2010, June:43.

9. Burton N. Usability Testing – WebContent.gov: Better Websites. Better Government. USA.gov: The U.S. Government’s Official Web Portal. http://www.usa.gov/webcontent/usability/testing.shtml. Accessed July 2, 2010.

10. Parker R and Kreps G. Library outreach: overcoming health literacy challenges. J Med Libr Assoc. 2005;93(4):S81-85.

11. DeWalt DA, Callahan LF, Hawk VH et al. Health Literacy Universal Precautions Toolkit. Agency for Healthcare Research and Quality. http://www.nchealthliteracy.org/toolkit/. April 2010. Accessed July 12, 2010.

12. Katz MG, Kripalani S, Weiss BD. Use of pictorial aids in medication instructions: A review of the literature. Am J Health-Syst Pharm. 2006;63:2391-397.

13. Artinian NT, Fletcher GF, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults. A scientific statement from the American Heart Association. Circulation. 2010. http://circ.ahajournals.org/cgi/content/abstract/CIR.0b013e3181e8edf1v1. Accessed July 14, 2010.

14. Kessels R. Patients memory for medical information. J R Soc Med. 2003;96:219-22.

15. Popular Topics: Health Literacy. Plain Language: Improving Communications from the Federal Government to the Public. http://www.plainlanguage.gov/populartopics/health_literacy/index.cfm. Accessed July 12, 2010.

16. EthnoMed. http://ethnomed.org/. Accessed July 12, 2010.17. Medical Spanish (with Audio) by Batoul - IPhone App Review. IPhone/

iPad Medical Apps Review. http://www.imedicalapps.com/2009/09/app-review-medical-spanish-app-adds-audio-in-latest-update-and-were-definitely-smitten/. Accessed July 1, 2010.

18. Ask Me 3™. Clear Health Communication Initiative. Pfizer Inc. 2007. http://www.npsf.org/askm e3/PCHC/. Accessed July 1, 2010.

19. America’s Health Literacy: Why we need accessible health information. An Issue Brief from the U.S. Department of Health and Human Services. 2008.

20. Welcome to the Mississippi Office of Healthy Schools. http://www.healthyschoolsms.org/. Accessed July 14, 2010.

21. Wolf MS, Wilson EA, Rapp DN, et al. Literacy and learning in health care. Pediatrics. 2009;124:S275-281.

Table 4: Steps for Clear Communication1. Slow down and limit content2. Use “plain language,” not jargon3. Supply text enhanced with pictures4. Improve cultural competency5. Provide a social services contact list6. Use interpreters appropriately7. Ask Me 3TM

8. Utliize “teach-back” approach

The Pen is MighterThan the Sword

Express your opinion in the JMSMA through a letter to the editor or guest editorial.

The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers. You can submit your letter via email to KEvers@MSMA online.com or mail to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.


• Scientific •

Top 10 Facts You Need to Know AboutChildhood Hypertension

Zeb K. Henson, MD

The prevalence of hypertension (HTN) and the morbid-ity associated with it in adults has been well documented in the medical literature and main-stream media. The latest re-porting indicates hypertension affects about 50 million adults in the United States.1 It is well known to be a significant, yet treatable, risk factor for ischemic heart disease and other car-diovascular complications in adults. However, HTN is not a condition isolated to the adult population; it is a condition that can begin in childhood and lead to vascular changes in these young patients.2

1. HTN inchildren isbasedonapatient’sage,heightandgender.3

Because of the work and publication of JNC-VII, HTN in adults is well known to be a blood pressure greater than 140/90 mmHg in the general population.4 Howev-er, defining HTN in children is not as simple. In 1996 a NHLBI working group on childhood HTN incorporated height percentages, age and gender in the definition.5 Data are now available online showing blood pressure percentiles for children based on these characteristics at http://www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.pdf. Based on these tables, prehypertension is a blood pressure between the 90th and 95th percentile for a particular patient’s age, height and gender. Stage 1 HTN is a blood pressure between the 95th and 99th per-centile, and stage 2 is a blood pressure greater than the 99th percentile.3

2. The overall prevalence of children with HTN andprehypertensionhasincreasedconsiderablysincethe1980s.6

Population surveys between 1963 and 2002 reveal that the number of children with blood pressure above the 90th percentile has steadily risen since the mid-1980s. HTN prevalence in the studied population rose from 2.7% to 3.7%, and the prevalence of prehypertension rose from 7.7% to 10%.6 Other studies estimate the prevalence of HTN to be as high as 5%.7 Additionally, NHANES data shows that mean systolic blood pressure and diastolic blood pressure have increased by 1.4/3.3 mmHg over about that same time.8 The age group most effected by this rising trend is the 8-12-year-olds.

3. TherisingprevalenceofpediatricHTNmirrorstherisingprevalenceofchildhoodobesity,andobesityisrecognizedasasignificantriskfactorforHTN.8

The number of obese children in the United States has more than tripled in the last 30 years, with rates ap-proaching 20% in 2008.9 The relationship between obe-sity and HTN is profound. A study in Houston, Texas, in 2005 found that among obese adolescents the prevalence of HTN was in excess of 30%, and an obese adolescent was over 4 times more likely to develop HTN.7 These trends have been mirrored in other population studies as well.10,11,12

4. Approximately97%ofchildrenandadolescentshavesodium intake that exceeds the FDA-recommendeddailyintakeof2300mg.13

Increased sodium intake is a known risk factor for HTN. Guidelines now recommend not to exceed 2300mg of so-dium per day. However, according to NHANES data the average adolescent diet exceeds 3700mg and the average diet of the 9-13-year-old exceeds 3200mg of sodium.14 The vast majority of sodium in the typical U.S. diet does not come from salt “added at the table;” it comes from salt added to processed foods and beverages, especially in restaurant foods.

5. White coat hypertension (WCH) may affect morethan40%ofchildrendiagnosedwithhypertension.15

The exact mechanism for WCH in children is poorly un-derstood. Once thought to be secondary only to “nerves”

intrOductiOn

AuthOr infOrmAtiOn: Dr. Henson is board certified in both Internal Medicine and Pediatrics and also has a specialty certification in Hypertension. He is an Assistant Professor in Internal Medicine and an Instructor in Pediatrics at the University of Mississippi Medical Center. Request for reprints may be made to Dr. Henson.

cOrreSpOnding AuthOr: Dr. Zeb Henson, Department of Internal Medicine, Division of General Medicine and Hypertension, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216


related to office visits, it is now apparent that at least some patients with WCH have mild metabolic abnor-malities.16 Prevailing thought is that WCH represents two overlapping populations: one that will ultimately develop essential hypertension and one that will remain normotensive by ambulatory monitoring.

6. About35-45%ofchildrendiagnosedwithhyperten-sionhavetargetorgandamage.17

Various organ systems, including blood vessels, kid-neys, eyes and the brain, may suffer damage from el-evated blood pressure in childhood. However, the organ most commonly affected is the heart.3 Left ventricular hypertrophy (LVH), which is a predictor of cardiovas-cular mortality, is the most common sign of target organ damage in these patients. The changes of LVH may even begin in adolescents with prehypertension.18

7. Onceachildhasbeendiagnosedwithhypertension,initiallaboratorystudiesshouldbefocusedondetect-ing the etiology, other cardiovascular risk factors,andevidenceoftargetorgandamage.3

The 2004 National High Blood Pressure Education Pro-gram Working Group (NHBPEP) recommended specific testing for all children diagnosed with hypertension, with other testing recommended on a case-by-case basis. All children with hypertension should have a complete blood count, electrolyte panel, BUN and creatinine level, urinalysis, fasting glucose and fasting lipid panel. In ad-dition, all of these patients should undergo an echocar-diogram to assess for target organ damage, and a renal ultrasound to assess for evidence of underlying kidney disease.

8. Secondaryhypertensionaccountsforamuchlargerpercentageofpediatricpatientsthanadults,especial-lyprevalentinchildrenundertheageof10years.19

Though proportions vary among centers, renal paren-chymal disease is thought to account for about 75% of secondary hypertension cases and renal vascular disease for another 10%.20 Other causes include coarctation of the aorta, Wilms’ tumor, pheochromocytoma and inher-ited forms of hypertension, such as Liddle syndrome. In general, the younger the child develops hypertension and the greater the degree of the blood pressure elevation, the more likely they are to have secondary hypertension.

9. While lifestyle modifications remain a cornerstoneoftherapyforchildrenwithpersistanthypertension,pharmacologictherapyshouldbeconsideredforcer-tainpatients.3

Lifestyle modifications, including weight loss and so-dium restriction, should be initiated in all children and adolescents with hypertension. Pharmacologic therapy should be initiated for any patient with symptomatic hypertension, end-organ damage, diabetes or hyperten-sion that persists despite lifestyle modifications.3 Un-

like hypertension therapy for adults, few head-to-head trials exist comparing the efficacy of various classes of anti-hypertensive medications. Therefore, the guide-lines recommend single-agent therapy with an ACE-in-hibitor, ARB, Beta-blocker, calcium channel blocker or diuretic.3 Until more data exists, specific classes of anti-hypertensive agents should be tailored to the individual patient.

10. The prevalence and lack of recognition and appro-priatetreatmentofchildhoodHTNhasledtoa“calltoaction”tothepublicandtopolicymakerstopro-moteawareness,prevention,treatmentandresearchtofightthisproblem.20

In addition to the Institute of Medicine’s policy rec-ommendations concerning sodium,13 others have rec-ommended policies specifically directed to childhood HTN.20 These recommendations are made in hopes that the public will be more aware of the problem and es-pecially the effect that lifestyle choices have on blood pressure. These recommendations also hope to stimulate additional research into this problem.

cOncluSiOn

Once thought to be a disease of adults, it is now well-recognized that hypertension and its deleterious effects often begin long before our children reach adulthood. By defining and increasing awareness of the problem, outlining the appro-priate work up, and discussing both pharmacologic and non-pharmacologic treatment options, the medical community in our state and region can work to educate and treat our children appropriately in the hopes of creating a healthier population.

referenceS1. Fields LE, Burt VL, Cutler JA, Hughes J, Roccella EJ, Sorlie P. The

burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension. 2004;44(4):398-404.

2. Berenson GS; Srinivasan SR; Bao W; Newman WP 3rd; Tracy RE; Wattigney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med. 1998 Jun 4;338(23):1650-6.

3. [Guideline] NHLBI. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. Aug 2004;114(2 Suppl 4th Report):555-76.

4. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report.2003 May 21;289(19):2560-71.

5. [Guideline] Task Force. Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: a working group report from the National High Blood Pressure Education Program. National High Blood Pressure Education Program Working Group on Hypertension Control. Pediatrics. Oct 1996;98(4 Pt 1):649-58.

6. Din-Dzietham R, Liu Y, Bielo MV, Shamsa F. High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation. 2007;116(13):1488-96.

7. McNiece KL, Poffenbarger TS, Turner JL, et al. Prevalence of hypertension among adolescents. J Pediatr. 2007;150:640-644.

8. Muntner P, He J, Cutler JA, et al. Trends in blood pressure among children and adolescents. JAMA, 2004;291:2107-2113.

9. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007–2008. JAMA 2010;303(3):242–9.


10. Dasgupta K, O’Loughlin J, Chen S, Karp I, Paradis G, Tremblay J, Hamet P, Pilote L. Emergence of sex differences in prevalence of high systolic blood pressure: analysis of a longitudinal adolescent cohort. Circulation. 2006;114(24):2663-70.

11. Sorof JM, Lai D, Turner J, Poffenbarger T, Portman RJ. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics. 2004;113(3 Pt 1):475-82.

12. Jago R, Harrell JS, McMurray RG, Edelstein S, El Ghormli L, Bassin S. Prevalence of abnormal lipid and blood pressure values among an ethnically diverse population of eighth-grade adolescents and screening implications. Pediatrics. 2006;117(6):2065-73.

13. Institute of Medicine. Dietary reference inkates for water, potassium, sodium chloride, and sulfate. 1st ed. Washington, DC: The National Academic Press; 2004.

14. Sources of Sodium Among the US Population, 2005-06. Risk Factor Monitoring and Methods Branch Website. Applied Research Program. National Cancer Institute. http://riskfactor.cancer.gov/diet/foodsources/sodium/. Updated December 21, 2010.

15. Hornsby JL, Morgan PF, Taylor AT, et al. “White coat” hypertension in children. J Fam Pract 1991;33:617-623.

16. Vaindirlis I, Peppa-Patrikiou M, Dracopoulou M, et al. “White coat hypertension” in adolescents: increase of urinary cortisol and endothelin. J Pediatr 2000: 136:359-364.

17. Sun SS, Grave GD, Siervogel RM, et al. Systolic blood pressure in childhood predicts hypertension and metabolic syndrome later in life. Pediatrics. 2007;119:237-246.

18. Drukteinis JS, Roman MJ, Fabsitz RR, et al. Cardiac and systemic hemodynamic characteristics of hypertension and prehypertension in adolescents and yong adults: the Strong Heart Study. Circulation. 2007;115:221-227.

19. Wyszynska T, Chichocka E, Wieteska-Klimczak A, et al. A single pediatric center experience with 1025 children with hypertension. Acta Paediatr. 1992;81(3):244-6.

20. Falkner B, Lurbe E, Schaefer F. High Blood Pressure in Children: Clinical and Health Policy Implications. J Clin Hypertens. 2010; 12(4); 261-276.

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• SpeciAl Article •

The Economic Impact of Office-Based Physicians in Mississippi

Prepared for: The American Medical AssociationPrepared by: SNR Denton and The Lewin Group, Inc.

executive SummAry

Office-based physicians in Mississippi are a critical component of the healthcare system, fundamentally assuring the health of the community in which they practice. Office-based physicians include both doctors of medicine (MDs) and doctors of osteopathy (DOs) who are primarily engaged in the independent practice of medicine. These practitioners operate private or group practices in offices and clinics and are focused on providing care to their patients.

While physicians are primarily focused on providing care to their patients, they also play a vital role in the state and local economy by creating jobs, purchasing goods and services and supporting state and community public programs through the tax revenues they create.

In these times of rapid change in the health care industry, it is important to understand how changes affect office-based physicians. This report will provide data which can be used by key policymakers, legislators and thought leaders in medicine. It shows how strong physician practices not only ensure the health and well being of communities but also critically support local economies and enable jobs, growth and prosperity.

This report estimates the economic impact of office-based physicians on Mississippi’s economy measured across four variables: output, jobs, wages and benefits, and tax revenue. Economic impact includes both a direct component and an indirect component. The direct impact is the value of output, jobs, wages and benefits, and taxes produced from patient care activities provided in physician offices. The indirect impact includes the output, jobs, wages and benefits, and taxes generated in the industries that are supported by physicians’ offices.

The report drills down to examine the economic impact across eleven medical specialties and within the metropolitan statistical areas (MSAs) in Mississippi. Finally, this report provides a snapshot of the economic impact of office-based physicians compared to other select industries in Mississippi.

The economic impact of office-based physicians varies across states and depends on the number of physicians in each state as well as the characteristics of the state’s economy. There were 638,661 office-based physicians practicing within the fifty states and the District of Columbia as of October 2010. (Note: This count is based on AMA Masterfile data, October 2010, for physicians in the 50 states and the District of Columbia. The Masterfile identifies 599,334 physicians as office-based and an additional 71,670 as having an unknown type of professional activity. To avoid undercounting the number of office-based physicians, we imputed the office-based status for physicians with an unknown professional activity. Through this methodology an additional 39,327 physicians were identified as office-based, yielding a total number of 638,661. For further detail on methods, see Appendix A in the full report.) Of these, 4,256 physicians practiced in the State of Mississippi.

Total Output: In Mississippi, office-based physicians created a total of $5.0 billion in direct and indirect economic output (i.e., sales revenues) in 2009.

Jobs: Physician offices employ support staff and often work with non-physician providers, increasing the total number of employees in the industry to well above the count of physicians alone. In 2009, Mississippi’s office-based physicians supported 24,217 jobs, the total of direct and indirect positions. On average each office-based physician supported 5.7 jobs, including his own.

Wages and Benefits: Office-based physicians significantly contribute to wages and other benefits in their communities. In


Mississippi, physician offices contributed $3 billion in direct and indirect wages and benefits for all employees in 2009; on average, each physician supported $695,233 in total wages and benefits. (For ease of reading, “wages and benefits” is used to mean salaries and wages plus other forms of compensation paid to employees, e.g., benefits, for the remainder of this report. Values include wages and benefits to all support staff, non-physician practitioners and physicians.) Tax Revenues: The revenues and earnings generated by physicians’ offices contribute to state and local taxes, which in turn

support public works and community development. In Mississippi, physician offices supported $192 million in local and state tax revenues in the year 2009.

ecOnOmic impAct AnAlySeS Economic impact analyses (EIAs) track the reach of revenues generated by an activity as they flow through the local

economy, tracking jobs created, spending that supports local business, and new tax revenues. EIA’s include both direct and indirect benefits. Direct benefits, in the context of the office-based physician “industry,” take the form of: 1) revenues generated in the course of the practice of medicine (i.e., the value of output); 2) the wages and benefits that go to physicians and practice employees who are hired to support the delivery of care; 3) the number of jobs created in the office-based physician industry; and 4) the taxes that are paid by physician offices and their owners and employees.

Economic activities and businesses that are supported by the physician’s practice outside of their own industry represent the indirect benefits of the physician office. These business-to-business effects include the supplies and equipment purchased by the physician, practice administrative services, cleaning and property maintenance services and clinical and laboratory services that support physician operations.

Additional indirect benefits (sometimes called induced effects, induced effects are included as a portion of “indirect” effects in this report for ease of reading) arise when the employees of physician practices and employees of vendors, in turn, spend their earnings to support local businesses which pay their employees and pay taxes, and so on (see Figure 1). With each cycle of spending there is some “leakage”, i.e., some spending goes outside the community and, as a result, generates no additional local value.

The indirect and direct effects make up the “multiplier” that drives an economic impact analysis. Simply put, the total impact in a community is a multiple of the economic benefit that is generated directly from the practice of medicine. In the current context, the multiplier reflects the number of times that each dollar generated in the practice of medicine circulates through the local economy supporting local jobs and spending.

There is a separate multiplier for three types of direct benefits mentioned above: output, jobs, and wages and benefits. An output multiplier is used to compute the total value (i.e., direct and indirect) of output created by an industry. This value indicates the total economic output generated in an economy for every $1 million in direct output. A job multiplier computes the total number of full-time equivalent jobs supported for every $1 million in direct output created by an industry. The multiplier for wages and benefits is based on direct wages and benefits. For every $1 million in direct employee compensation the multiplier indicates the total value of supported wages and benefits.

Multipliers are specific to geographic areas and to particular industries, and their values can vary widely. A multiplier of 1.0 would indicate that the total economic value of the industry is the same as the direct economic value, i.e. a dollar of revenue in the industry immediately leaves the community so that there is no cycling through the community for additional economic benefit. A multiplier will take on a value greater than 1.0 when a dollar earned by a business, e.g., a physician practice, is spent in the community supporting jobs and other local businesses which in turn pay their employees who, in turn, buy more goods and services in the local community.

Multipliers are lower when business revenues are spent (leak) outside the community or are spent on goods or services that support fewer local jobs. Multipliers for small community areas will be smaller than for larger areas or a state because establishments in smaller areas often must look outside of their immediate communities to find inputs. It is often said that “health care is local.” Indeed health care multipliers tend to be higher than those for many other industries precisely because physicians and their office staffs tend to live in the community, and their services support the local community.

An output multiplier is the number of dollars of total economic activity created by one dollar of new business revenue in a community.

INDIRECT EFFECTS

retail payrolls

DIRECT EFFECTS

Physician Office Revenues

Purchased goods & services



payroll retail payrolls

retail purchases

payrollretail

payrollretail

purchases

Purchased goods & services payroll

retail payrolls

retail purchases

INDIRECT EFFECTS

retail payrolls

retail payrolls

DIRECT EFFECTS

retail purchases

Physician Office Payroll

retail purchases

retail purchases

Physician Office Payroll

Physician Office Revenues


retail payrolls

retail purchases


payroll retail payrolls

retail purchases


retail payroll

retail purchases


Figure 1: Economic Multipliers


dAtA SOurceS

Three primary data sources were used to evaluate the economic impact of physician offices: the AMA Masterfile, MGMA Cost Survey, and IMPLAN. IMPLAN’s economic impact multipliers were combined with MGMA’s per-physician revenue and costs data and the Masterfile’s number of physicians to estimate values for the direct, indirect and total economic impact of the office-based physician industry. For specific methods used, see Appendix A in the full report.

ecOnOmic impAct fOr miSSiSSippi

This report estimates the direct, indirect and total impact of office-based physicians on the following four measures of economic activity: output (i.e., total sales revenues), jobs, wages and benefits (i.e., employee compensation), and tax revenues generated on the local and state levels. The direct and indirect economic benefits for each measure sum to the total benefit.

Output

The direct output of an industry is defined as the total sales revenue produced by that industry in any given year. For office-based physicians, such “output” can be thought of as the total value of care (e.g., patient visits) provided plus the value of any other services provided by the physicians office (e.g., revenue from renting additional office space, parking fees). This value includes both medical and non-medical revenues generated by office-based physician practices.

The output multiplier for office-based physicians in Mississippi is 1.58, meaning an additional $0.58 of indirect output is generated in the State over and above each dollar of direct output created in the practice of medicine. Indirect output captures the value of revenues generated by other businesses as a result of the office-based physician industry, e.g., the sale of equipment to the offices or the sale of laboratory services related to a physician visit.

The “total output” of office-based physicians sums the direct and indirect output generated by the industry. In Mississippi, office-based physicians generated $5.0 billion in total output. Total output is presented by physician specialty in Appendix B in the full report.

JObS

Employment is a second means of evaluating an industry’s economic value. A total of 4,256 office-based physicians (MDs and DOs) were practicing in Mississippi as of October 2010. The number of jobs directly created by physician offices in the State was 21,969 employees, including self-employed positions. (The direct employment figure includes physicians as well as non-physician staff, including administrative and non-physician provider personnel.) This is the direct employment impact of the office-based physician industry.

Physician offices employ support staff and often work with non-physician providers, increasing the total number of employees in the industry to well above the count of physicians alone. The employment multiplier in Mississippi is 1.71, meaning that each million dollars of office-based physician output generated an additional 0.71 full time jobs in the economy outside the office-based physician industry. In other words, 0.71 additional jobs, above and beyond the clinical and administrative personnel that work inside the physician practices, were supported for each one million dollars of revenue generated by a physician office business.

The total number of jobs supported by the office-based physician industry in Mississippi was 24,217; the average office-based physician supported 5.7 jobs in the economy, including his own. For detail by specialty, see Appendix B of the full report.

wAgeS And benefitS

Employee compensation, i.e., the wages and benefits that are paid to local residents, is also an important measure of an industry’s value to the local economy. The value of direct wages and benefits in Mississippi includes compensation and benefits paid to physicians, non-physician staff, practice owners, and any other staff on payroll. This direct amount of wages and benefits totaled to $2.3 billion in the State in 2009.

The payroll multiplier in Mississippi is 1.31, meaning that an additional $0.31 in wages and benefits was generated for every dollar of direct employee compensation within the industry. Including the indirect wages and benefits supported by the industry, the total amount of wages and benefits in Mississippi was $3 billion, an average of $695,233 per physician. For detail by specialty see Appendix B of the full report.

tAxeS

Physicians’ offices also generate tax revenues at the local and state levels. The industry also generates federal tax revenue,

Table 1: Total Output, Jobs, and Wages & Benefits Supported by the Office-based Physician Industry in Mississippi, 2009


but the federal level is beyond the scope of this report. The total tax contribution is computed by summing taxation on employee income, proprietor income, indirect business interactions, households, and corporations. Tax revenues are included from physician offices (direct) and from other affected industries (indirect); i.e., these are the “total” tax revenues supported by the industry.

The state and local taxes incorporated in this study include:

Social Security taxes: the state portions of Social Security taxes, both the employee and employer paid portions;

Personal taxes: state and local income taxes, gift and estate taxes, motor vehicles taxes/fees, fishing/hunting and other license fees, property taxes, personal property taxes, and other fines/fees or donations;

Business taxes: corporate profits and dividends taxes; and

Indirect business taxes: property taxes, sales taxes, motor vehicle licensing, severance taxes, non-tax payments (e.g., rents and royalties, special assessments, fines, settlements and donations), and other taxes (including business licenses, documentary and stamp taxes).

In the State of Mississippi, the aggregate local and state taxes generated by office-based physician offices in 2009 totaled $192 million.

impActS by metrOpOlitAn StAtiSticAl AreA

Economic impact analyses can also be performed for smaller areas and economic regions, such as a metropolitan statistical area (MSA). MSAs are defined as cities and their adjoining counties where the population of the city exceeds 50,000 or the population of the area exceeds 100,000. These urban areas are important as economic centers. Table 2 presents the total output, jobs, wages & benefits, and tax revenue for all MSAs within Mississippi, including any MSAs that cross borders of neighboring states.

AcknOwledgement: Reprinted with permission by the American Medical Association.

Full report with appendixes on the Impacts by Metropolitan Statistical Area, Methodological Overview, Total Economic Impact by Specialty Category and Specific Specialties and Comparison Industry Analysis available on the Mississippi State Medical Association website: http://www.msmaonline.com/Docs/PressRoom/economy%20study.pdf.

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Let’sWorkTogethertoMakeitHappen

Thank you for your confidence in me. I pledge as your President to work to my utmost to stand for Mississippi medicine in this year and in the years to come. It is a responsibility I could never have accepted if I thought I was standing alone. But I feel blessed because I know you all will be standing beside me, and I thank you.

I am also blessed with many of my family and friends who honor me by joining in our celebration this evening. First and foremost, allow me to introduce my wife and partner Debbie, who brought into my life love, three children and never a dull moment... and now, certifiably, the two most wonderful grandchildren ever born.

Talk about blessed, we are so pleased my mother Mary Dennis Grisham and Debbie’s mother Thelma Davidson could be with us tonight. Also joining us are my older brother Charlie, younger brother Dennis, his wife Marsha and their daughter Jennifer Bryan, with her husband Tim and their children Kylie and Kolby. Additionally, Debbie’s three brothers, Ronnie, his wife Leanne and their daughter Amanda as are David and his wife Laurie, and Noel and his wife Laura. Also present are our three children… Jared, his wife Bonnie and their daughters Cameron and Bailey Kate, two perfect grandchildren. Melissa and her fiancé Lucas Sandroni, and Carrie and her friend David are here.

Last, but far from least, my three office staff who have been with me for the last 15 to 25 years: Sue Carter, Debbie Jacobson, and Delois Lewis. They let me pretend I run my practice, but I know better. I thank them for all they do for me and for medicine.

I knew as early as elementary school I wanted to be a doctor. I don’t know why; I just knew. I never wanted to be anything else, and there’s not a day in my life that I have regretted that decision. I love my patients; I love my practice. But, regrettably, I do not love what I see happening to my profession.

It saddens me to see the most pristine parts of our profession – the sanctity of the patient-physician relationship and our ability to choose how we practice medicine …it saddens me to see them under attack by government, third party payers/insurers, and other health professionals.

When I am asked that age-old question, “Would you want your son or daughter to be a doctor?” I pause. I find myself not actively discouraging them but not actually encouraging them to enter medicine. That is not good; that is tragic.

• preSident’S pAge •

Inaugural Addressof the 144th

MSMA President

thomAS e. Joiner, md2011-12 mSmA preSident

[In lieu of the regular “President’s Page” feature, it is customary for the JMSMA to reprint the inaugural address of the incoming president for the initial column. What follows is an edited version of the official inaugural address given by Thomas E. Joiner, MD; MSMA President 2011-12.] —Ed.


The ability to choose to hang out a solo practice shingle in your hometown, to join a small specialty group, or to move north and practice along side the many multitudes at Mayo’s or Cleveland Clinic ought to be your choice. That choice ought to always be available to our generation, the next generation and the next after.

I have been in the private practice of medicine for over 25 years, and I can honestly say that I do not think that there is anything else I would have wanted with my life. I enjoy patient care. I enjoy the science of medicine. I enjoy the good-will that exists between me and my patient. And I know you feel the same.

Nothing gives me more pleasure than when a patient of mine is happy with my care and adds a tip to a bill … you know, in the form of an apple pie, a jar of Muscadine jelly, a mess of collard greens. In some ways, that type of green is more valued to me than money. That type of green and good will is under threat of extinction.

And the predator is our own government, aided last year – confoundedly – by our own professional association, the American Medical Association (AMA). Dr. Cecil Wilson, current AMA President (in audience), and I have talked, and he knows I mean no disrespect. I’ve been an AMA member since my first year of practice, and I will continue to be a member.

But our AMA let us down last year. Our AMA fell short in its leadership responsibilities and left many physicians and physician organizations frustrated and angry… frustrated at what many of us view as a sellout, a buckling under to the Administration and Congressional pressures and angry at AMA leadership who answered that it was a failure to communicate.

Rank and file physicians in Mississippi and many other heartland states view this as a failure of not communicating to our President and our lawmakers, not informing them that there is a line in the sand that must be drawn, must not be crossed and must never be erased…if we are to preserve what makes American medicine the gold standard for the world.

Now, I sympathize with the AMA leaders who met with the Administration and members of Congress. Working with those politicians must have felt like drinking from a fire hose —lots of splatter and splash and very little satisfaction. But we must send our leaders back; we must keep trying.

Tomorrow in our House, delegates will vote on Resolution 3, calling for legislation that makes the purchase of health insurance a matter of personal responsibility, not a government mandate. And we are not alone.

Kansas and Georgia medical societies have passed a similar resolution. Other states are considering adding their voice. On the national level, Georgia Representative and physician Dr. Tom Price has introduced federal legislation for the right to privately contract. If we don’t stand up and push back from onerous legislation and mandates, medicine as we know it today will go the way of that old Model T we saw at the car museum last night, a relic consigned to museums and memory.

We must continue and escalate the fight to protect a physician’s right to take care of patients without interference from government, payers, and other health professionals. We must not allow ourselves to be pushed to the margins of our patients’ lives. We’ve already fended off one chilling potential consequence of government interference.

Remember last year, the government recommended that women not have mammograms until a later age than has long been the standard for care? If this recommendation had been put in place, there are members of my family circle who would not be here tonight. We would have mourned our personal loss while the government bean-counters would have pointed proudly to an improved bottom line, profiting at the expense of patients.

I don’t want to contemplate what further pain and suffering those guys could dream up in the name of efficiency and accountability, but I do want for medicine—for my professional organization – to stand up and to halt this erosion, this death by a thousand cuts to American medicine.

So… how do we go about righting the wrongs in last year’s passage of the Affordable Health Care Act?

My first thought was of Jimmy Stewart and that wonderful movie, “Mr. Smith Goes to Washington,” where one man – alone – took on the entire Washington establishment and won. It’s a great movie but it’s no documentary. It’s fiction. You and I know that’s not how things get done.


Our most effective tool is not one person alone but many — joined together — as one large, loud, effective organization. Physicians, physician organizations … all joining together in common cause led by spokespersons who truly represent and reflect our interest: the AMA and the MSMA.

Look how effective Mississippi physicians were when we pulled together through MSMA to pass tort reform. Physician leaders like Dr. John Cook and Dr. Pat Barrett teaming with professional staff like Bill Roberts, Charmain Kanosky, Linda McMullen, now Neely Carlton and Chris Espy hit a home run for Mississippi medicine. What they did could serve as a model for other states in need of liability relief.

Or look how successful we were when all of medicine pulled together to correct the egregious error by government for Medicare reimbursement. MSMA — again with strong leadership by folks like Dr. Tim Alford, Dr. Hugh Gamble and Dr. Ed Hill— led the effort coordinated by the AMA and members of our Federation – to return to physicians’ pockets the monies that were rightly ours.

It is amazing what can be done when we all pull on the same oar, at the same time. Despite our unhappiness with the AMA, I firmly believe it is our strongest instrument for voicing American medicine’s values.

When ABC, CBS, NBC,and FOX ask what the doctors think, they do not ask me. They do not ask Charmain. They ask the AMA. That is why I feel comfortable sharing our concerns with Dr. Wilson among us today.

For we are family, all part of a big medical family, and family doesn’t walk away from differences. They sit down and talk and work them out. We can do it. I am firmly wedded to the concept that physicians ought to belong to the AMA and support the AMA. But they must know that their voice is being heard and their opinions respected.

Let’s work together to make that happen. I know we can do it.

This is America. Anything is possible.

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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. Profile name: MSMA1


• SpeciAl Article •

An Interview with Thomas E. Joiner, MD2011-2012 MSMA President

Karen A. Evers, Managing Editor

[Each June the JMSMA interviews the incoming president. Here we go behind the scenes. Due to space limitations, the answered questions do the speaking for this interview.] —Ed.

fAmily lifeI was born in Crawfordsville, Arkansas,

but grew up in Greenwood. I was the fourth of four children, three boys and one sister. I went to high school there (1973) and then Mississippi Delta Junior College, then Ole Miss, and the University of Mississippi School of Medicine. Our family was very close. If there was one thing we all knew it was that we were going to go as far in school as possible.

My oldest brother Charlie received a degree in accounting and became a CPA. He is now in Scottsdale, Arizona. Dennis received a degree in accounting and law

and is now the Federal Public Defender in Jackson. My sister Mary earned her degree in math, working in Oakridge, Tennessee, and now the University of Tennessee.

My parents stressed hard work and discipline with minimal free time. I think that this paid off for all of us. We were taught that no one owed us anything and that if we wanted something in life we had to work for it ourselves. I always knew what I had to do to achieve my goals and my family held me to it. I think that this is the key to raising a successful family, but I see less and less of it each generation.

medicAl SchOOlMedicine, it seems, was the only thing I was interested

in from the start. The only problem with the medical school years is that I knew of nothing that went on outside of it.

Dr. Joiner (front) with his wife Debbie, (l. to r) and her children Melissa, Jared and Kerri Harper. Dr. Joiner says his most favorite thing to enjoy is an “eclipse,” which occurs when Jared, his stepson married to Bonnie, and Lucas, Melissa’s boyfriend, both have the same time off work and can come over to grill steaks together.

Dr. Joiner married the former Deborah Hinote, whom he lovingly calls “Deb,” in 2002


Nowadays, when we play trivia games items from those years are a weak point. But overall, it was a rich experience that I would not change for anything.

The toughest time, I guess, was the old days when there were no hour restrictions concerning call for students and residents. Those long nights at the V.A. were “killers” but prepared us for what was ahead. I finished my family medicine residency in 1985 and have been in private practice in South Jackson since that time.

prActice Of medicineMy proudest accomplishment has been a

successful Family Practice and the respect of my peers. I became active in organized medicine from the start, through Central Medical Society, the American Academy of Family Physicians and Mississippi Academy of Family Physicians. I was chief of staff at Methodist in 1995 and became president of Central in 1999. I feel we have helped protect the practice of medicine and the doctor-patient relationship during those years, for example, through tort reform.

It is this that I enjoy the most about medicine. I think that being able to practice the art as well as the science and see patients benefit is what I enjoy most. The things I least like about it are government and third party intervention, the attack on the practice of medicine by others, the loss in independence and the ability to make a living at something I love.

preSidentiAl plAtfOrm

My presidential platform is “Back to Basics”: the protection of the doctor-patient relationship and the profession from outside scope attacks. I think this is what is in jeopardy, and we need to turn our efforts to preserving the quality of medical care that our patients and families deserve.

Proud parents: the late Mr. Charles L. and Mrs. Mary D. Grisham Joiner

Dr. Joiner is the youngest of four children. His siblings are brothers Charles L. Jr., S. Dennis, and Mary Maude.

Tom Joiner and his first big fish, a grinnell

Tom in his younger years

Dr. Joiner standing in Central Park by the bronze statute of Balto. The sculpture is dedicated to the sled dogs that led several dogsled teams through a snowstorm in the winter of 1925 in order to deliver medicines that would stop a diphtheria epidemic in Nome, Alaska, which is now the course of the Iditarod.

Dr. Joiner by his plane. He no longer has the plane but he maintains his pilot’s license.


At a glance…Dr. Tom Joiner

Most likely to see me: At Home Depot and Lowes, in the garden section looking for peppers and tomatoes. Doing yard work and gardening.

Weekends: Swimming with my granddaughters, Horseracing (Hot Springs and New Orleans), Family time.

Teams I follow: Ole Miss. St Louis Cards.

Music: Alison Krauss, Emmylou Harris, Country (Old, not new) (Real old).

Movies: Old black-and-white Bogart, Gable, Rita Hayworth; Newer, Clint Eastwood.

Books: I read a lot (a whole lot), mostly history, spy, Cold War, and I read some Greg Iles from the last annual meeting in Natchez, Strange Mind.

I am passionate about: Horseracing. I used to love NASCAR, (and still do) but it has become too sterile.

Perfect meal: Something with tomatoes, fried okra, onions, plus or minus meat. I love veggies!

Perfect day: Two days at the Breeders’ Cup at Churchill Downs with Deb.

Favorite color: Red.

Cologne: What I get for Christmas.

Text, email or cell phone: Cell, I like to talk to people the old fashioned way.

Pets: Prince, 10-year-old Lab that is the most, gentle dog around children. Great disposition.

Grew up: In Greenwood. Lived in Jackson/Clinton since 1978.

MSMA Member: Since 1985.

Aside from his wife, the love of Dr. Joiner’s life is his granddaughter Cameryn (born to Jared and Bonnie Harper) whom he affectionately calls “Camster” and “Camster the Bamster.”

Dr. and Mrs. Joiner at a rainy Kentucky Derby 2010

Dr. Joiner poses with his granddaughter Cameryn by his backyard pool on a snow day last year.


Tom Joiner and I are both from Greenwood. Our friendship goes back to our childhood. He was a heckuva good trumpet player, and we used to battle for chair position in an above average high school band at Greenwood High. I look forward to hearing Tom sound the trumpet for MSMA. —Tim Alford, MD; Kosciusko

Dr. Joiner has served as a part-time clinical faculty in our department for years. He was always one of the most highly regarded teachers by the residents, particularly for his ability to give them a glimpse of “the real world” of practice. He continues to serve as a favorite medical student preceptor for which we are eternally grateful. Along with his trueness to the Hippocratic oath in patient care, Tom holds dear to the pledge “to gladly share such knowledge as is mine with those who are to follow.” —Diane Beebe, MD, Professor and Chair, University of Mississippi Medical Center, Department of Family Medicine, Jackson

With great pleasure, I salute my friend Tom Joiner upon his inauguration as the 144th president of MSMA. Notwithstanding my own involvement in MSMA in a fairly serious and consistent fashion over the last 7 years, Tom was but an “acquaintance” until about two years ago--when the vicissitudes of policy and politics within MSMA and the AMA regarding an expanded role for the federal government in health care delivery thrust the two of us together as staunch allies. As a result, Tom Joiner’s friendship is one of the greater blessings to accrue to me within the last 25 months.

Particularly as a physician, Tom is one of the most humble and meek (Biblical sense, from the Beatitudes) MDs, I believe, I’ve ever known. He is “salt-of-the-earth” and “down-to-earth.” While his achievements tend to command a certain amount of limelight directed his way, Tom Joiner eschews the kind of attention that seems to illuminate the messenger, more than the message. Yet he acquits himself admirably when it falls his lot to make the case to the public or to his peers for our patients and for the profession.

The model of “servant-leadership” is easily associated with Tom Joiner. He leads by example, and it emerges quite naturally. Crucial, I believe, to his secret as a leader is that his authority comes from

his authenticity. He is the “real deal” and “walks the walk.” He doesn’t wield power. Instead , he exercises the influence of a well-considered argument--developed from a wealth of information from multiple reliable sources which has been analyzed and collated deftly with clean logic; and then delivered cogently. (Just because I do not practice it does not mean that I can NOT appreciate brevity!)

Congratulations, Tom! Here’s a wish that you have an eventful year at the helm--but not “too eventful” (or tumultuous)! —Kenn Beeman, MD; Tupelo

Tom is quite a successful duck hunter and a good friend in the blind. —Bill Burke, MD; Madison

I have always found Tom to be very approachable, easy to talk to and providing excellent care in a compassionate way. —Ron Cannon, MD; Flowood

Tom is just a great human being! His dedication of time and energy to the MSMA and the Mississippi Professionals Health Program (MPHP) is a powerful demonstration of his character. We are grateful for him.—Scott L. Hambleton, MD; Madison Medical Director, Mississippi Professionals Health Program

We at the MPHP have enjoyed and appreciated Dr. Joiner’s participation and interest in this vital service of MSMA. —Ken Lippincott, MD; Tupelo, Chair, Mississippi Professionals Health Committee

During our first year in medical school at UMC, way before the days of laptops or Microsoft Word, Tom and I opted to handle the printing and distribution of the class notes. This kept us from having to take several turns at recording lectures by cassette, transcribing, and typing our share of class notes for the rest of the class. I’m sure that this early experience in medical administration (picking up bundles of notes from the printing office in the basement and sliding them into our classmates’ cubicles arranged alphabetically) will serve Tom well as he leads us as MSMA president. Congratulations to a sincere individual. The Class of 1982 is proud! —Darden North, MD; Jackson

“What they say about him...”


Medical Assurance Company of Mississippi

“

“Clay Hays, MD

Cardiologist and MSMA Representative to the MACM Board Jackson, Mississippi

Having a chance to serve as the Mississippi State Medical Association liaison to the MACM Board of Directors has given me a unique opportunity to see how the Company works for physicians. I have been impressed by the financial stability of the Company and the strong management team. This gives me great confidence that MACM will be around for years to come.

I also like the fact that MACM is not a static company. Constant ongoing review and benchmarking with national standards keeps MACM in the upper echelon of malpractice insurance companies.

Furthermore, excellent management of resources has kept my premium low and has provided a refund during the past several years. As a result of all these things, MACM has been a good choice for me and my practice—and I know this now from a new perspective.

For over 30 years, Mississippi physicians have looked to Medical Assurance Company of Mississippi for their pro-fessional liability needs. Today, MACM is an integral part of the health care community, working with other organi-zations that have the best interest of Mississippi’s physi-cians in mind.

A dedicated staff and physician involvement at every level guarantees that the interests of our policyholders remain the top priority. This, combined with the many years of loyalty and support from our insureds, is what allows us to be the carrier of choice in Mississippi.

Please call on us to assist with your professional liability needs.

1.800.325.4172 • www.macm.net

New perspective brings increased confidence


• letterS •More on Doctors’ Naps

Dear JMSMA Editor,

Regarding your introduction to Dr. McEachin’s poem (McEachin JD, Lampton L. [Poetry in Medicine] How to Check a Chest. J Miss State Med Assoc. 2011;52(4):125) about the story of the great Rudolph Matas (1860-1957) of Tulane who also fell asleep while auscultating heart sounds in the middle of rounds….Whether true or not, this story is told about my anesthesiologist father, Ansel M. Caine, Sr., MD of New Orleans:

During WW I, Dad did not see military service due to a complication of typhoid fever. Doctors in civilian practice were few and overworked. Supposedly, Dad took the silk handkerchief out of his coat outside left chest pocket and draped it on a lady patient’s chest to auscultate her heart. When he laid his ear on her breast, he went sound asleep!

Dr. Matas and “Big Ansel” worked together for several decades. Dad recounted that there he was, with rudimentary equipment (using a blacksmith foot-pumped bellows to blow air over sulphuric ether), doing his best to keep a patient both anesthetized and alive and, thus, anxious to get the surgery completed. Dr. Matas, scrubbed and gloved, would turn to the gallery of visiting surgeons from around the globe and proceed to lecture for a while, Dad shifting from cheek to cheek in frustration.

Dad graduated from Tulane Medical School in 1907. It was Dr. Matas who, in 1909, suggested to Dad at the end of his 2-year internship at Touro Infirmary, “Ansel, why don’t you go into anesthesia?” And he did until he retired at age 75. Dad went to join my predeceased Mother, Pearl, in Heaven in 1961.

I practiced until I was 83. I graduated from Tulane on 10/14/1944, retiring 10/14/2004 - 60 years.

—Curtis Caine, MD Brandon

Dear Editor,

For whatever reasons the U.S. is loathed by other countries and their leaders. It only follows that many statistics that make the U.S. look bad are not only created but promoted with great glee and fanfare by U.S. bashers. Medical statistics are no exception.

Unfortunately we doctors accept these stats as truth and become surrogate agents, demonizing our own medical systems.

I am from one of those countries that often loathes the U.S. medical system. I have tried mightily since coming from Canada to warn my U.S. colleagues that much medical data is false and misleading, but I often feel like reporter Phil Connors in Ground Hog Day. I hear these false stats again and again especially by doctors who should know better.

For instance, Tim Alford, our past president, tells us that “according to the World Bank, the U.S. has the highest infant

Ground Hog Day (again)

Rudolph Matas, MD


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mortality rate among 33 other advanced countries”(April, 2001). Well, not exactly. I think Tim means not the World Bank but rather the Organisation for Economic Co-operation and Development (OECD) which now has 34 countries (Turkey recently added).

The OECD average infant mortality rate is 4.6 deaths/1000 live births in 2008. The U.S. rate is 6.7. But the comparison is not valid for several reasons:

1) The U.S. alone amongst the 34 countries counts missed abortions and still births which accounts for about 20% of the total figure.

2) Although we do not have the highest teen pregnancy rate, we have by far the highest minority rate (black & Hispanics). These young mothers have a 50% increased rate of hypertension or diabetes, and therefore their pregnancies are 50% more morbid. Most OECD countries are monoethnic (Scandinavia, Japan, Europe, etc.) with very tiny minorities.

3) We count anchor babies whose mothers received little or no care before they crossed our porous border sometimes just to have babies. No other OECD country has such a border. Actually many OECD countries are islands with no borders.

Apples and oranges can be compared, but the comparison is not valid. So when these differences are considered, the U.S. infant mortality rate is well below the OECD average. So Dr. Alford helped me out. Do not simply accept medical data designed to demonize the U.S. Stop my Ground Hog Day.

Let’s remember the wise warning of Disraeli more than 100 years ago- there are three kinds of lies: lies, damned lies, and statistics.

—Calvin S. Ennis, MD Moss Point


• new memberS •AFriDi, SHAbiNA NAz, Hatties-burg; Specialty: Internal Medicine.

ATkiNSON,SuSANrOSe, Laurel; Specialty: Pediatrics.

AuLTMAN, TriCiA kuNOviCH, Biloxi; Specialty: Internal Medicine.

bADve,SeeMAANiL, Escatawpa; Specialty: Internal Medicine.

bAHNMiLLer,JODy, Long Beach; Specialty: Family Medicine.

beHM,TrACyLyNN, Tupelo; Spe-cialty: Obstetrics & Gynecology.

beHNiAye, HOSSeiN, Brooklyn; Specialty: Family Medicine.

beNNeTT, FreeMAN THOMAS, Newton; Specialty: Internal Medicine.

bHATT,DiNeSHkuMAr, Hatties-burg; Specialty: Cardiovascular Dis-ease.

bibb, kiMberLy LekeSHiAANDerSON, Ridgeland; Specialty: Family Medicine.

bOyeTTe, SCOTT TrACy, Hat-tiesburg; Specialty: Radiology.

briDgeWATer,JOvieNAeDgAr, Southaven; Specialty: Anesthesiology.

brierTy, rOberT eMMeTT, Bay St Louis; Specialty: Anatomic Pa-thology.

brOADriCk, gAry, Kosciusko; Specialty: Emergency Medicine.

brOOMe,DAviDvAN, Greenville; Specialty: Anesthesiology.

bruCe, ANDreA MAureeN, Collins; Specialty: Family Medicine.

buCkLe,rApHAeLAuguSTiNe, Amory; Specialty: Pediatrics.

burLeSON, WiLLiAM DAviD, Hattiesburg; Specialty: Radiation On-cology.

burrOW, JAMey WALCOTT, Jackson; Specialty: Orthopaedic Sur-gery.

CAMerO, FrANCiSCO, Gulfport; Specialty: Family Medicine.

CArNey,LeeANTHONy, Laurel; Specialty: Obstetrics & Gynecology.

CArrOLL, WiLLiAM STeveN, Tupelo; Specialty: Internal Medicine.

CArTer,ANDreAM., Hattiesburg; Specialty: Obstetrics & Gynecology.

CArTer,JOHNgArDere,Biloxi; Specialty: Anesthesiology.

CHAMberS, ArTHur LLOyD, Tupelo; Specialty: Emergency Medi-cine.

CHApMAN,STeveNFreDriCk, Greenville; Specialty: Cardiovascular Surgery.

CHerNeCky,riCHArDeDWArD, Ocean Springs; Specialty: Gastroenter-ology.

CHOWDHAry,SuSHMA, Hernan-do; Specialty: Internal Medicine.

CLeMeNT, keviN bryAN, Hat-tiesburg; Specialty: Sports Medicine (Ortho. Surg).

COLeMAN, JAMeS p., Meridian; Specialty: Radiology.

COrDeLL,WeST, Tupelo; Special-ty: Anesthesiology.

COSTeLLO,MeLiSSAW., Mobile; Specialty: Emergency Medicine.

CrOWDer, JASON brADLey, Gulfport; Specialty: Diagnostic Radi-ology.

DArgQuiNONeS,ruTHg., Nat-chez; Specialty: Family Medicine.

De ASiS, berNArD guevArA, Laurel; Specialty: Pediatrics.

DeNiSON, DANieL Dru, Merid-ian; Specialty: General Surgery.

DeNNy,JAMeSb., Biloxi; Special-ty: Psychiatry.

DOWNS,DANieLMArk, Corinth; Specialty: Orthopaedic Surgery.

DuNbAr, MArviN, Laurel; Spe-cialty: Emergency Medicine.

DuNCAN, uLriC D., Southaven; Specialty: Gastroenterology.

DupONT, JOANNA THereSe, Ocean Springs; Specialty: Pediatrics.

eCHOLS-WiLLiAMS,QueNyATTA, Hattiesburg; Specialty: Internal Medi-cine.

egger, eDWiN grOver, Ru-leville; Specialty: Ophthalmology.

erbOWOr-beCkSeN, JAMeS, Vicksburg; Specialty: Internal Medi-cine.

FiSHer, eDWArD HerberT, Clarksdale; Specialty: Orthopaedic Surgery.

FLeMMiNg, DAviD THOMAS, Pearl; Specialty: Internal Medicine.

FOre, DANieL beNJAMiN, Southaven; Specialty: General Surgery.

FOrT, CHriS, Jackson; Specialty: Family Medicine.

FuSSeLL, STepHANie, Gulfport; Specialty: Medical Oncology.

gAuTier, keNNeTH bryAN, Senatobia; Specialty: Pediatrics.


grAverSeN, JeNS FrANCiS, Laurel; Specialty: Urology.

greeN, MiCHAeL rAyMOND, Brandon; Specialty: Allergy & Immu-nology, Pediatrics.

greeNe, MiCHAeL LeWiS, Madison; Specialty: Family Medicine.

grigOryev, LeONiD MArk, Jackson; Specialty: Physicial Medicine & Rehabilitation.

guevArrA,viCTOriACApuyAN, Choctaw; Specialty: Family Medicine.

HAMADeH, FerAS, Vicksburg; Specialty: Pulmonary Disease.

HAMMOND,rOSALiND, Jackson; Specialty: Internal Medicine.

HArper, JuLie g., Oxford; Spe-cialty: Obstetrics & Gynecology.

HeNCerOTH, WiLLiAM, Green-ville; Specialty: Orthopaedic Surgery.

HiNeS,breNDAp., Flowood; Spe-cialty: Family Medicine.

HirSHMAN, bruCe, Flowood; Specialty: Pain Medicine.

HugHeS,MiCHeLeH., Gulfport; Specialty: Dermatology.

HugHeS,rALpHCONDON, Me-ridian; Specialty: Anatomic/Clinical Pathology.

HuNT, MATTHeW J., Flowood; Specialty: General Surgery.

HuNTer,JOSepHSAMueL, Ox-ford; Specialty: Family Medicine.

iSOM,ADOLpH, Brandon; Special-ty: Internal Medicine.

JeTT, pAMeLALOuiSe, Jackson; Specialty: Blood Bank/Tranfusion Medicine.

JONeS,ALySON ireNe, Jackson; Specialty: Physicial Medicine & Reha-bilitation.

JuSTiCe, CLAreNCe ALLeN, Tupelo; Specialty: Gastroenterology.

kAMALApur, viDyA, Natchez; Specialty: Anesthesiology.

kASApiS, CHriSTuS, McComb; Specialty: Cardiovascular Disease.

keiTH,CArMeNNiCOLe, Tupe-lo; Specialty: Anesthesiology.

keLLy,MArkALAN, Laurel; Spe-cialty: Emergency Medicine.

kerby,ANDreW LiNN, Corinth; Specialty: Nephrology.

kiNDSvATer,STeveMiCHAeL, Gulfport; Specialty: Cardiovascular Disease.

kiTTreLL,JiMMyLAMAr, Pic-ayune; Specialty: Internal Medicine.

kLeiN, MArk NiLS ANDerS, Flowood; Specialty: Nephrology.

kLeMiS, JAMeS eDWArD, Southaven; Specialty: Cardiovascular Disease.

kOSkO, JOHN H., Hattiesburg; Specialty: Orthopaedic Surgery.

LADerer, kAy e., Jackson; Spe-cialty: Obstetrics & Gynecology.

LAMberT, buFOrD L., Tupelo; Specialty: Emergency Medicine.

LAprAD,DebrAL., Ocean Springs; Specialty: Ophthalmology.

LArOCHeLLe,MiCHAeLDAviD, Laurel; Specialty: Emergency Medi-cine.

LAWreNCe, WiLLiAM keiTH, Oxford; Specialty: Vascular & Inter-ventional Radiology.

LeWiS, eriC, Tupelo; Specialty: General Surgery.

LOWe, CLiFFOrD NeAL, Pica-yune; Specialty: Family Medicine.

MCALpiN, brODie WAyNe, Corinth; Specialty: Pulmonary Dis-ease.

MCCLuNey, riCHArDA., Tupe-lo; Specialty: Anesthesiology.

MCCOy, DeNNiS DeWAyNe, Southaven; Specialty: Anesthesiology.

MiCHAeL,DANieLWAyNe, Lau-rel; Specialty: Orthopaedic Surgery.

MiHALkO, MArC JeFFrey, Southaven; Specialty: Orthopaedic Surgery.

MiTiAS,HANNAM., New Albany; Specialty: Orthopaedic Surgery.

MObLey,rOberTLeWiS, Jack-son; Specialty: Pediatrics.

MOCk,gregOrypAuL, Colum-bus; Specialty: Nephrology.

MONAgHAN, MiCAH T., Tupelo; Specialty: Radiation Oncology.

MOrriS,TrOyD., Southaven; Spe-cialty: Family Medicine.

MOrriSON, MiCHAeL burCH, Oxford; Specialty: Anesthesiology.

MOSS, MAry LiNDA Lipe, Flo-wood; Specialty: Diagnostic Radiol-ogy.

NeLSON, HuNTer beN, Clarks-dale; Specialty: Diagnostic Radiology.

NieLSeN,JANeTM., Jackson; Spe-cialty: Family Medicine.

NiOLeT, pAuL DAviD, Ocean Springs; Specialty: Allergy & Immu-nology.

NuNeNMACHer,STepHeNJOSepH, Ocean Springs; Specialty: Internal Medicine.

OrOzCO,LyNNeA., Morton; Spe-cialty: Family Medicine.

OWeNS,WiLLiAMeArL, Corinth; Specialty: Neurology.


OzuA,eDWiNiyere, Clarksdale; Specialty: Internal Medicine.

pAbbATHi, SAbiTHA r., Green-ville; Specialty: Internal Medicine.

pArker,gerALDLeSLie, Amo-ry; Specialty: Family Medicine.

pATeL,vipiNS., Flowood; Special-ty: Vascular & Interventional Radiol-ogy.

peArSON,riCHArD, Amory; Spe-cialty: Urology.

pHiLLipS, JOSHuA FrANkLiN, Jackson; Specialty: Allergy & Immu-nology.

piTTMAN,TrACybLAir, Ocean Springs; Specialty: Nephrology.

prATer,ALLieLee, New Albany; Specialty: Internal Medicine.

prATT, HeiDi DAWN, Water Val-ley; Specialty: Family Medicine.

priOr, DONALD STeWArT, Greenville; Specialty: Diagnostic Ra-diology.

reeD, SANDrA JOANN, South-aven; Specialty: Anesthesiology.

riCHArDSON,SAMueLMiLTON, Jackson; Specialty: Emergency Medi-cine.

riMMer, rONALD ANDreW, Brandon; Specialty: Pediatrics.

rOSS, DiANe eLLeN, Gulfport; Specialty: Neurology.

SALLOuM, eLLiS, Hattiesburg; Specialty: General Surgery, Vascular Surgery.

SAMSON,STuArT, Laurel; Special-ty: Psychiatry.

SANDiFer,vANeSSAL., Jackson; Specialty: Endocrinology.

SiMON, ureLAiNe r., Meridian; Specialty: Obstetrics & Gynecology.

SivAprAkASApiLLAi,brAHMeSHS., Meridian; Specialty: Cardiovascu-lar Disease.

SivAprAkASApiLLAi,NirMALAM., Meridian; Specialty: Internal Med-icine.

SOOD, HArpreeT, Collins; Spe-cialty: Family Medicine.

STeveNS, DANieL, Mendenhall; Specialty: Family Medicine.

SuLLivAN,DAviDWAyNe, South-aven; Specialty: Hematology/Oncol-ogy.

SuTTON, JAMeS DAviD, Ocean Springs; Specialty: Ophthalmology.

SzATkOWSki, Arie, Southaven; Specialty: Cardiovascular Disease.

TADLOCk, rACHeL FrANCeS, Biloxi; Specialty: Internal Medicine.

TANNer, erikA L., Vicksburg; Specialty: Obstetrics & Gynecology.

TANNer, LANASHA CONiCe, McComb; Specialty: Obstetrics & Gy-necology.

TAyLOr, kATHryN L., Brandon; Specialty: Family Medicine.

THOrDerSON,NeLSWALLACe, Tupelo; Specialty: Orthopaedic Sur-gery.

TrAiNA, JeFFrey, Natchez; Spe-cialty: Orthopaedic Surgery.

TruSSeLL,briANS., Hattiesburg; Specialty: Physicial Medicine & Reha-bilitation.

TuLi,rAJeSH, Gulfport; Specialty: Radiology.

Turk,LeeHArriS, Natchez; Spe-cialty: Internal Medicine.

vANOSTeN,geOrgekArL,Tupelo; Specialty: Orthopaedic Surgery.

vOWeLL,CHriSTy, Eupora; Spe-cialty: Family Medicine.

WAHL,geOrgiAM., Hattiesburg; Specialty: General Surgery.

WALDrOp,OLivergrey, Jack-son; Specialty: Family Medicine.

WALLACe, DerriCk, Jackson; Specialty: Otolaryngology.

WeekS,DAviDCHAMp, Gulfport; Specialty: Urology.

WeiSSer, LyDiA eLLiS, Whit-field; Specialty: Psychiatry.

WeLCH,WiLLiAMperry, Jack-son; Specialty: Anesthesiology.

WHiTeHurST, ANNe brOWN, Jackson; Specialty: Infectious Disease.

WiLLbrANDT,bArryWiLLiAM, Gulfport; Specialty: Urgent Care.

WiLLiAMS, erNeST QuALLS, Oxford; Specialty: Gastroenterology.

WOO,WAyNe, Flowood; Specialty: Endocrinology, Diabetes & Metabo-lism.

WrigHT, JOHN eDWArD, Nat-chez; Specialty: Urology.

zeiDMAN, gLeNN e., McComb; Specialty: Family Medicine.


• iQh •

Medicare Beneficiary Protection, Prevention and Patient Safety

IQH and its provider partners have achieved the quality improvement goals that have been the focus for the past three years in the themes of Medicare Beneficiary Protection, Prevention and Patient Safety. IQH serves as one of 41 contractors participating in the Centers for Medicare & Medicaid Services (CMS) quality improvement program. The

current efforts in the Ninth Scope of Work began in 2008 when IQH received the three-year contract from CMS. Participation from partners in the themes has been enthusiastic, showing dedication to working for the improvement in the

effectiveness, efficiency and services delivered to our Medicare beneficiaries in the state.Summarizing the themes: Beneficiary Protection: IQH staff reviews quality of care concerns made by Medicare beneficiaries through case review, discharge appeals and complaint processes. The Beneficiary Protection team has met or exceeded CMS goals in all five measures associated with review timeliness, customer satisfaction and assistance to providers in improving system-wide quality improvement activities.

Prevention: Seventeen physician practices working with IQH have begun using their electronic health records (EHRs) to improve their patient population prevention quality measures for breast and colorectal cancer screening as well as influenza and pneumonia vaccinations. With IQH assistance, the participating practices exceeded all CMS goals for measurable improvement.

Reducing Disparities in Diabetes Care: IQH was awarded a special Prevention Disparities project to provide diabetes self-management education to underserved Medicare beneficiaries. The Mississippi Health First project is a collaboration with federal and non-federal partners to provide diabetes self-management education. IQH is working with 72 primary care physicians and has provided education to nearly 1000 Mississippians.

pAtient SAfety

Surgical Care Improvement Project (SCIP): IQH worked with hospitals committed to improving inpatient surgical safety and heart failure treatment, and through the work with the hospitals, they met or exceeded all CMS goals for measurable improvement.

Calhoun County Health Services in Calhoun City has been recognized for outstanding performance in achieving and maintaining 100% in all clinical core measures, which are indicators of care quality. The core measures include quality standards for AMI, heart failure and pneumonia.

Bolivar Medical Center in Cleveland is recognized for outstanding performance in achieving and maintaining for five quarters 100% in all its clinical core measures.

Garden Park Hospital in Gulfport is recognized for outstanding performance in achieving and maintaining 100% in all its SCIP and clinical core measures.

MRSA in Hospitals: CMS-selected hospitals in Mississippi are now successfully transmitting infection data to CDC’s National Health Safety Network database as outlined in the CMS Scope of Work goals. IQH worked closely with the hospitals in efforts to reduce rates of healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) infections, providing support, tools and resources.

continued on Page 201


“Fatigue makes cowards of us all” is a quote famously attributed to Vince Lombardi but was certainly understood by Caesar and indeed cavemen. Thankfully Congress, in its infinite

wisdom, experience and forethought, has sought to save poor physicians-in-training from fatigue and cowardice by limiting their work hours. Behind the guise of protecting patients from tired house staff, Congress has further restricted work hours. This looks good on paper (and in the newspaper), but was any thought given to the poor patients in Boondocks, Miss., area code 911, who will subsequently be cared for by a doctor who was never trained to make the correct and hard decision at 2:30 a.m. despite overwhelming fatigue. The doctor, with guidance and back up from a training institution, could learn to fight through the fatigue and, in fact, ignore the fatigue in order to do the right thing for the patient.

If the present manpower and work restrictions persist, I can foresee this scenario in the aforementioned Boondocks, Miss., at 2:30 a.m.: “not enough sleep; call me day after tomorrow.” Medical and surgical emergencies do not have that luxury. By limiting access to care, health care would be less expensive.

Ruptured abdominal aneurysms cost less if they don’t make it to the OR.Training and, indeed, selection of people to serve in our armed forces is based on ability to withstand physical, mental and

emotional stress. Why should medicine be different? Some highly specialized forces are selected almost exclusively on their ability to withstand fatigue. SEALS seek out the point at which you will quit; SEALS don’t want someone covering their back that is going to quit.

I think that our collective risks are being increased by Congress’ actions. A guilt-ridden editor from the New York Times is primarily responsible for Congress intervention and concern for house staff work hours. Neither Congress nor the New York Times has experience in the training of physicians. If the goal is good patient care in this country, then restricting house staffs work further is not consistent with that goal.

• mAcm •Maples’ Musings: Fatigue, Cowards and Help

from the Government

michAel d. mApleS, mdmedicAl director

medicAl ASSurAnce compAny of miSSiSSippi

Pressure Ulcers in Nursing Homes: IQH worked with 21 nursing homes in Mississippi to reduce pressure ulcer rates. These nursing homes achieved a 30.5% improvement rate, which exceeded the quality improvement goals of the Scope of Work. IQH also worked intensively with rural nursing homes and was able to reduce significantly the rate of non-Caucasian pressure ulcers. Physical Restraints in Nursing Homes: Twenty-six nursing homes in Mississippi worked toward significantly reducing physical restraint usage, exceeding targeted improvements and achieving a 34% improvement. The following nursing homes are recognized for outstanding performance in being restraint free: Choctaw County Nursing Center in Ackerman, Ashland Health & Rehabilitation in Ashland, Shady Lawn Health & Rehabilitation in Vicksburg, Jones County Rest Home in Ellisville, and Comfort Care of Laurel.

Drug Safety: IQH has worked closely with prescribers across the state to reduce the number of potentially inappropriate medications (PIMs) prescribed to Mississippi’s Medicare population and to reduce the number of prescriptions that could lead to drug-to-drug interactions (DDIs). IQH exceeded the performance goal with a 3.8% statewide reduction in PIMs and a 1% statewide reduction in DDIs. For Mississippi to be ranked one of the highest in the nation for both PIMs and DDIs, these reductions are significant. —James S. McIlwain, MD, President

IQH continued from Page 200


for the first-ever

BIGBANGSKEET SHOOT AND POLITICAL LUNCHEON

Four-Man Team Skeet Shoot Competition with Fellow Physicians

Lunch with Candidates for Elected Office

$300 per shooter (includes course fees, breakfast, and lunch)

Limited Space Available! RSVP BY JUNE [email protected] or 601-853-6733, Ext. 324

JOIN MMPAC Saturday, August 27

Providence Hill Farm Jackson, MS

Proceeds benefit the Mississippi Medical Political Action Committee.


• the uncommon threAd •

r. ScOtt AnderSOn, md

“This electronic conundrums got a hold of me too, I’ve got the EMR pneumonia in the IT flu.”

With all respect to Johnny Rivers, I have taken the liberty of appropriating his lyrics in the context of the current headache that we are facing in the medical community. EMR is something that we are supposed to become efficient at in the coming years. All of us will be expected to make the transition or face significant reimbursement penalties. The problem is we don’t really hang out a good model for EMR implementation. Which leaves us unfortunately with what I think of when these letters are put together: eternal masochistic redundancy. We all seem to be stuck in the same place. We’ve been working diligently to put electronic medical records into clinical use, and most of us have gotten enough penetration into our clinics to qualify as implementing the technology. The problem is, most of us have not been able to complete the process, which is to render our offices completely paperless. Computers are great at compiling data. The problem is, a lot of times that data isn’t easily retrievable in any sort of convenient fashion. Right now my own office have gotten to that point where we are dependent on both electronic records and paper records. What that means is that I now have to do all the work I always did but I have to do it twice wants to enter into the electronic record and I to sit down with my control in pan and stick it into the paper record or dictate then review and sign it. It wouldn’t be so bad if it was only the consults that I had to do this with. Unfortunately it’s everything that comes into the record so every pathology report, every laboratory value, and every pathology report are reviewed and verified twice, once in each location. You quickly reach the point that you become overwhelmed with the amount were the trailing to put into trying to go ahead and get your electronic medical records implement. At first, I thought I was just an idiot and everybody else was doing a much better job of this than I was. However, everywhere I’ve looked everyone is facing the same dilemma. Clinicians and healthcare managers everyone were stymied by the final hurdle of moving to paperless medical records.

The delays are multi-factorial. There is extreme expense associated with the implementation of electronic medical records. Someone, that’s expected. We all know that new technology cost money. But most of us don’t expect, is that having electronic medical records is actually more expensive on a day-to-day basis in paper chart maintenance cost. We all think we were going to be able to reduce our operational costs by switching the medical records will be less people there have to did the patient less people would have to pull records less people have to chase around afterwards to make sure we sign those medical records. However those savings are more than offset by the fact that we now have to have an IT department or if we have an IT department that the implementation of electronic medical records will result in our doubling the size of that department.

I took the time to sit down with some of my colleagues have moved to electronic medical records and names them if this technology has allow them to spend more time with their patients. The answer, almost universally, was no. Now, this really surprised me. A lot of them are actually spending more time taking their word back to their offices to try to get their charting done rather than being able to get it accomplished in the room while they are still with the patient. Now I don’t know about you, but pretty much, I didn’t knows punched out clinical records that get generated automatically with each patient contact. They don’t really convey much at all. They are repetitive, and of me actually, look like the position is not really taken the time to change anything but they said the last time they saw the patient. It’s like we all forgot what documentation was all about in the first place. We’re supposed to be telling each other what’s going on with this person. Not just generating a stupid piece of paper so we can charge people. Now, I’m fine with charging people. But I don’t think the computer-generated mishmash of gibberish that we end

EternalMasochisticRedundancy

[The grammatical errors in this article are intentional to illustrate the inaccuracies that occur when voice recognition software is utilized instead of the writer’s authenticity.] —Ed.


• plAcement/clASSified •

PHYSICIANS NEEDEDPhysicians (specialists such as cardiologists,ophthalmologists, pediatricians,orthopedists, neurologists, etc.) interested inperforming consultative evaluations(according to Social Security guidelines)should contact the Medical Relations Office.

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up with actually helps anything at all. This

I guess the biggest problem, is a user-interface. Ever since I was in medical school, I’ve loved big old fountain pens. I like the way they feel, I like the way they write, and I like the way they look in my charts. The computer generated sheets that print out just don’t do it for me. I’m trying, but it’s hard to change a lifetime’s habits. But, I’m trying right now. I’m using one of the new Dragon speech recognition tools as I write this. It’s not really the same as writing with a yellow legal pad and a fountain pen like I used to, but I don’t really well see it as being much worse than typing things into my laptop computer. I guess even old dogs can learn a new trick every once in a while.

I guess you’ll get used to seeing me in this new location. Let us know what you think about the concept of the uncommon thread. I hope you continue to enjoy it, but if you think that it and Una Voce are redundant, let us know and we can make some adjustments.

Well, I’ve enjoyed talking to you, see you next month.

—R. Scott Anderson, MD

PHYSICIANS NEEDEDMedPlan works with hospitals and

healthcare systems in Mississippi andthroughout the Southeast to identify qualifiedphysicians of all specialties. We are retained bythe healthcare systems and hospitals, so we areable to save you time as we provide informationconcerning multiple opportunities, withoutcharging fees. Many of the positions have verycompetitive compensation packages and, insome cases, school loan repayment. Allinquiries are kept confidential.

If you would like more information, pleasecontact us at [email protected] or 205.870-7068.

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.

Save the date:

144th MSMAAnnual Session

Grand Hotel Marriott Resort,Golf Club & SpaPoint Clear, Alabama

June7-10,2012

What’s Your Specialty?

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Documents

June 2011 JMSMA