VOL. LIX • NO. 8 • 2019

VOLUME 2019 8 •° 2019 NO. 8 LX • NO. VOLUME LX O

A fabulous gift idea for anyone in medicine!

Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi

D and Karen A. Ever Lucius "Lu ke" M · Lampton, M

Pickup in Ridgeland for $49.95 or $57.95 includes shipping.

Order three or more to receive a discount at: http://tinyurl.com/yb7ab974 “ Images In Mississippi Medicine by Dr. Luke Lampton and Karen Evers is a handsome and impressive book, filled with stories and scenes ranging from primitive operating rooms and rows of hospitalized tornado victims a century ago to the new teaching complex at the University of Mississippi Medical Center with its modern breakthroughs.

The volume is a piece of our history that every Mississippian can appreciate.”

– Curtis Wilkie, journalist, author, and professor at Ole Miss

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Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi; MSMA; Jackson, MS: 2018.

VOL. LX • NO. 8 • AUGUST 2019

SCIENCE OF MEDICINE

EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Philip T. Merideth, MD, JD

THE ASSOCIATION President Michael Mansour, MD

President-Elect J. Clay Hays, Jr., MD

Top 10 Facts You Need To Know about Pharmacogenomics Sidney W. Bondurant, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer W. Mark Horne, MD

PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Richard D. deShazo, MD Sheila Bouldin, MD Wesley Youngblood, M3 and the Editors

Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Executive Director Claude D. Brunson, MD

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 39157. (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.

Top 10 Facts You Need to Know about Screening and Brief Intervention for Alcohol Use Disorders 244 Sara H. Gleason, MD; Julie A. Schumacher, PhD; L. Joy Houston, MD; Mark E. Ladner, MD; Daniel C. Williams, PhD 246

Top 10 Facts You Need to Know about Breast Implants and Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) 249 Pam Brownlee, DO; Ben McIntyre, MD DEPARTMENTS From the Editor – Les Savants Ne Sont Pas Curieux Lucius M. Lampton, MD

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President's Page – A Better Job Michael Mansour, MD

265

Images in Medicine – Tougaloo Hospital 1909 Lucius M. Lampton, MD

267

Poetry and Medicine – Les Savants Ne Sont Pas Curieux Merrill Moore, MD

268

Una Voce – Birthing Babies Dwalia S. South, MD; Joe Johnston, MD

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RELATED ORGANIZATIONS University of Mississippi School of Medicine - Match Day Results

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University Medical Alumni Chapter - Hall of Fame Additions Gary Pettus

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SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available.

Mississippi Department of Health Reportable Disease Statistics Hepatitis A Outbreak

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ADVERTISING RATES: furnished on request. Jill Gordon, MSMA Director of Marketing. Ph. 601-853-6733, ext. 324, Email: JGordon@MSMAonline.com

AMA Dr. Douglas Elected to Council on Medical Education

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POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548.

ABOUT THE COVER

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 © 2019 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

“Idle Time” – Dr. Martin Pomphrey, retired orthopedist of Mayhew, took

this photograph in Milan, Italy while waiting to see The Last Supper mural.

"He was a cute Italian boy sitting on his soccer ball, and I could not resist taking his picture," Dr. Pomphrey remarked. "I had looked forward to taking photos of the work of art but was informed that the rules had changed two weeks before our visit. No photos are allowed anymore." Dr. Pomphrey is an avid photographer who enjoys traveling. He often attends classes sponsored by professionals like Adobe, KelbyOne, David Marx, and Tim Grey. At the time of this writing, the JMSMA contacted him about this cover image. He replied apropos, “We are sitting in the Amsterdam airport waiting on a plane to Prague for a bicycle trip through the Czech Republic, Germany and ending in Vienna. We are on our own in Vienna, and then I join a photo workshop in Salzburg before returning to Prague and home.”

AUGUST • JOURNAL MSMA

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F R O M

T H E

E D I T O R

Les Savants Ne Sont Pas Curieux

W

hat is the worst physician sin?

There are many (the lack of charity, said Sir William Osler) but arrogance is certainly near the top of any list. Our fund of knowledge and experience often leave us the most educated person in any room we are in, but such reality should never leave us without intellectual curiosity or a mind open to new perspectives. Our own gift of profound knowledge makes us Lucius M. Lampton, MD vulnerable to self-deception at times. We Editor think we know it all because usually, we do! We must attempt to avoid the knowit-all attitude of intellectual arrogance in our professional work.

My title (which you will see again in this issue’s poetry section and which I felt worthy of repetition) refers to an oft-quoted aphorism of French novelist Anatole France (1844-1924): “Les savants ne sont pas curieux,” roughly translated “those who know are not curious.” The caveat has been spoken by many a physician, foremost among them the Austrian neurologist Sigmund Freud, whose pioneer work with

psychoanalysis laid the foundation for modern clinical psychiatry. Freud famously used the aphorism to chastise physician critics of his landmark 1899 book “The Interpretation of Dreams” (which introduced his theory of the unconscious), lamenting the medical status quo’s resistance to new ideas. He wrote in its third edition, published nine years after the first: “In most of the publications that have since appeared my work has remained unmentioned and unregarded… a splendid example of the aversion characteristic of scientific men to learning something new. ‘Les savants ne sont pas curieux.’”

What intellectual mindset should a physician strive to attain and maintain? In his essay on chauvinism, Osler described it best: “The open mind, the free spirit of science, the ready acceptance of the best from any and every source, the attitude of rational receptiveness rather than of antagonism to new ideas.” In all our duties, a physician must remain curious and seek the open mind grounded by scientific facts. We don’t know all of the answers, and we never will. We simply must do the best we can with the science available and be ready to journey where modern science takes us. n Contact me at lukelampton@cableone.net.

— Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD

EMERGENCY MEDICINE Philip Levin, MD

INTERNAL MEDICINE/EPIDEMIOLOGY Thomas E. Dobbs, MD

ALLERGY/IMMUNOLOGY Stephen B. LeBlanc, MD Patricia H. Stewart, MD

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer J. Bryan, MD J. Edward Hill, MD Ben Earl Kitchens, MD

MEDICAL STUDENT John F. G. Bobo, M3

GASTROENTEROLOGY James Q. Sones, MD

OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Sheila Bouldin, MD Darden H. North, MD

ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD CARDIOVASCULAR DISEASE Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

242 VOL. 60 • NO. 8 • 2019

GENERAL SURGERY Andrew C. Mallette, MD HEMATOLOGY Carter Milner, MD INFECTIOUS DISEASE Rathel "Skip" Nolen, III, MD INTERNAL MEDICINE Daniel P. Edney, MD Daniel W. Jones, MD Brett C. Lampton, MD

NEPHROLOGY Harvey A. Gersh, MD Sohail Abdul Salim, MD

ORTHOPEDIC SURGERY Chris E. Wiggins, MD OTOLARYNGOLOGY Bradford J. Dye, III, MD PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD PEDIATRICS Michael Artigues, MD Owen B. Evans, MD

PLASTIC SURGERY William C. Lineaweaver, MD Chair, Journal Editorial Advisory Board PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PUBLIC HEALTH Mary Margaret Currier, MD, MPH PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RESIDENT / FELLOW Cesar Cardenas, MD UROLOGY W. Lamar Weems, MD VASCULAR SURGERY Taimur Saleem, MD

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MedicalAssurance Company af Mlssrssrppi

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Cong ratulati ans to this year's awanl reci pientl

Chelsea S. Mockbee, MD Dermatology Past Recipients 1982 .liu::k Fustew., MD -unliology

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2003 KimbedJ W_ Cn:rllll'dl!I"... MD-0phthalinalogr

1986 BolibJ L Gr.dam,. Jr, MD-Medical Oncalngy

2004 ICl!!nbell Liddea_. MD-Family Medicine

1987 Sam Newell... MD- Neumlngy

2005 0.ri51Dph.l!!r M_ Chades,. MD - Pedialric:s.

1988 Marc Al"hn,. MD-0rthapilll!dic Smgl!!ry

2006 Mnt Runlll!!ls., MD-GastmenteralD!IJ'

1989 W_ Richanl Rmihill!j. MD-0b-Gyn

2007 David L Spencer. Jr, MD- UralD!IJ'

1990 Cltarles G. Pig.m. MD -GI!~ Smgl!!rJ

2008 Liliim Ja, HCN&ton,. MD - Psychiatr,

1991 L Glenn Hl!!rringtan. MD-0phthalinalogr

2009 Slane Michael Sims. MD -0b-Gyn

1992 Man: G_ Hilll!!il'nann., MD-G1!!11aa.l SullJay

2010 Lee MullilJ., MD-Neun:6,gy

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2011 Leslie~ MD-0b-Gyn

1994 Michael R. McM..Lan., MD-Canlinlagy

2012 O1riS1:11ph1!11 M. Bean,. MD - Urology

1995 Daml!il.11.. llenmn... MD- Paliatrics

2013 Victa. Copi!andr MD- Ophthalmnlagy

1996 Jeffrl!J D. Nabl'n,. MD-0rthapedic SullJl!l'J"

2014 O.ristina. G_ . . . . . MD- llmiology

1997 Scott E. l-liurison., MD-Omlaryngnlagy

2015 Ja111es A. Moss., .k:.... MD- Orthopaedic Sla"!Jl!!rr

1998 David Stuart Eml!ll'!illn., MD-Family Medicine

2016 Rishi A. Ray. MD-General Surgery

1999 Timll'lhJ IL Mma,. MD -Gelll!!liill Smger,

2017 Michael T_ Cm;ulich... MD- DermalDID!IJ'

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,..,_.man H_ Will~ MD-HematalogylDncology (800) 325-41

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Top 10 Facts You Should Know about Screening and Brief Intervention for Alcohol Use Disorders SARA H. GLEASON, MD; JULIE A. SCHUMACHER, PHD; L. JOY HOUSTON, MD; MARK E. LADNER, MD; DANIEL C. WILLIAMS, PHD

Introduction Alcohol consumption is a significant and preventable contributor to the global burden of disease and injury.1 All physicians can acquire the skills to relieve the impact of this epidemic. An educational grant from the Substance Abuse Mental Health Services Administration (SAMHSA) to the University of Mississippi Medical Center (UMMC) is helping provide training on alcohol screening, brief intervention, and referral to treatment (SBIRT) to the medical students and residents who will be the future leaders of our state’s healthcare.

Established guidelines for “at risk” drinking may be lower than you think.

Although physicians may be most familiar with the concepts of “alcohol abuse” or “alcohol dependence,” the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) adopts the term “alcohol use disorder” (AUD) to describe a spectrum of disease.2 The National Institute on Alcohol Abuse and Alcoholism (NIAAA) provides guidelines for drinking associated with low risk for developing an AUD.3 For women, this is no more than three drinks in a single day and no more than seven drinks per week. For men, this is no more than four drinks on any single day or 14 drinks per week. The Department of Health and Human Services and the U.S. Department of Agriculture define “moderate drinking” as up to 1 drink per day for women and two drinks per day for men.4 One standard drink is equivalent to 12 ounces of beer, 1.5 ounces of 80-proof spirits, or 5 ounces of wine.

Alcohol consumption has been linked to numerous adverse health outcomes.

Even moderate alcohol consumption has been linked to increased risk for certain cancers, and there is no amount of alcohol considered safe for pregnant women. As consumption becomes heavy, risks increase for dementia, polyneuropathy, amenorrhea, pancreatitis, esophageal and rectal cancers, osteoporosis and cirrhosis.8 Injuries are the leading cause of alcohol-attributable deaths worldwide.1

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Binge drinking is a particular hazard for the future of our state’s young people.

Binge drinking is associated with an increased risk of accidents and injuries. NIAAA defines binge drinking as a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL, which typically occurs after 4 drinks for women and 5 drinks for men in about 2 hours.3 Estimates for Mississippi indicate that in 2013-2014, 5.8% of Mississippians age 12 and older met criteria for past-year AUD; 12% of youth age 12-20 (approximately 45,000 Mississippians) engaged in binge drinking in the past 30 days; and 6.8% of adults age 21 and older (approximately 135,0000 Mississippians) engaged in binge drinking on 5 or more days in the past 30 days.5 The prevalence of alcohol use disorders is on the rise, and most patients do not get treatment.

Shocking new epidemiological data indicate that the prevalence of past-year AUD in adults 18 and over in the United States increased by 49.4% over the 11 years from 2001-2002 to 2012-2013.6 Importantly, 95.4% of Mississippians identified as having an AUD in 2013-2014 did not receive treatment.5 Lack of recognition that alcohol use is a problem and a lack of understanding of the potential benefits of treatment are key barriers to treatment seeking.7 Lack of available, affordable treatment may also play a role for many patients.

Most patients are comfortable talking about alcohol use and expect physicians to ask.

Although many physicians may be concerned that their patients will be offended by alcohol screening, when patients were asked for their opinions about self-report and biomarker alcohol screening, the clear majority indicated this as an important and acceptable part of routine medical care. In fact, most patients believed their physician should screen for alcohol problems and provide advice on drinking.11

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Alcohol Do you drink alcoho\?

□ Yes

D

No

There are brief, validated tools to screen for harmful alcohol use and alcohol use disorders.

Evidence-based care can start with one simple question: “How many times in the past year have you had five (men) or four (women and patients over age 65) drinks or more in a day?9 If the answer is more than once,’ additional screening should be performed, using a tool, such as the Alcohol Use Disorders Identification Test, Adapted for Use in the United States (USAUDIT), which is available in 10- and 3-item formats.10 Well-implemented feedback and brief interventions by physicians of any specialty are efficacious in reducing alcohol consumption.

Brief interventions, implemented according to established guidelines, are an evidence-based approach to reducing harmful alcohol use. A brief intervention typically includes feedback, motivational enhancement strategies, and education.10 A synthesis of findings from 56 randomized controlled trials of brief interventions in primary care found consistent evidence that brief intervention is effective for addressing at-risk and harmful drinking in primary care.12 Most patients with alcohol problems do not need specialty care.

In a typical healthcare setting, almost 80% of patients abstain from alcohol or drink within low-risk guidelines.13 Even when a problem with alcohol is identified, approximately 16% of patients will be appropriate for physician-delivered brief intervention and will not require referral to brief or intensive treatment.10, 13 FDA-approved medications for alcohol use disorders are effective though underutilized.

As an adjunct to behavioral interventions, acamprosate and oral naltrexone (both of which are FDA-approved for alcohol use disorders) significantly improve outcomes for patients with alcohol use disorders.

Disulfiram and injectable naltrexone have limited evidence to support their efficacy.14 Screening and brief intervention for alcohol are reimbursable by some insurers.

Although Medicaid does not currently reimburse for screening and brief intervention in the state of Mississippi, Medicare does provide coverage if these services are conducted according to established guidelines. There are also CPT codes that may be covered by private insurers.15

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Conclusions Alcohol is a significant and seemingly increasing risk to the health of our population. Many of the available tools to prevent and mitigate these health impacts, such as universal screening, brief intervention, and pharmacotherapy are underutilized. Links to freely available screening tools, training, and information are available through the UMMC Department of Psychiatry and Human Behavior website: www.umc.edu/sbirt. n References 1.

Rehm J, Mathers C, Popova S, et al. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet.

2009;373:2223-2233.

2.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington DC: 2013.

3.

National Institute on Alcohol Abuse and Alcoholism (NIAAA). Rethinking Drinking: Alcohol and Your Health. Pub. No. 10–3770. Rockville, MD: NIAAA; 2010.

4.

U.S. Department of Health and Human Services and U.S. Department of Agriculture. Appendix 9. Alcohol. Dietary Guidelines for Americans 2015-2020. https://health.gov/dietaryguidelines/2015/guidelines/appendix-9/. Accessed December 6, 2017.

5.

Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: Mississippi, 2015. HHS Publication No. SMA–16–Baro–2015–MS. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015.

6.

Grant BF, Chou SP, Saha TD, et al. Prevalence of 12-month alcohol use, high-risk drinking, and DSM-IV alcohol use disorder in the United States, 2001-2002 to 2012-2013. JAMA Psychiatry. 2017;74:911-923.

7.

Mojtabai R, Crum RM. Perceived unmet need for alcohol and drug use treatments and future use of services: Results from a longitudinal study. Drug Alcohol Depend.

2013;127: 59-64.

8.

Grønbæk, M. The positive and negative health effects of alcohol- and the public health implications. J Intern Med. 2009;265:407–420.

9.

Smith, PC, Schmidt, SM, Allensworth-Davies, D, et al. Primary care validation of a single-question alcohol screening test. J Gen Intern Med. 2009;24:783−788.

10. Babor TF, Higgins-Biddle JC, Saunders JB. USAUDIT: The Alcohol Use Disorders Identification Test, Adapted for Use in the United States: A Guide for Primary Care Practitioners. Rockville, MD: Substance Abuse Mental Health Services Administration; 2016.

11. Miller PM, Thomas SE, Mallin R. Patient attitudes towards self-report and biomarker alcohol screening by primary care physicians. Alcohol Alcoholism. 2006;41:306-310.

12. O’Donnell A, Anderson P, Newbury-Birch D, et al. The impact of brief alcohol interventions in primary healthcare: A systematic review of reviews. Alcohol Alcoholism. 2014;49:66-78.

13. Madras BK, Wilson MC, Avula D, et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and six months. Drug Alcohol Depend. 2009;99:280-295.

14. Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings. A systematic review and meta-analysis. JAMA. 2014;311:1889-1900.

15. Substance Abuse Mental Health Services Administration. Reimbursement for SBIRT. https://www.integration.samhsa.gov/sbirt/Reimbursement_for_SBIRT. pdf. Accessed December 6, 2017.

Author Information Author Information: From the Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson. Psychiatrist, Associate Professor and Vice Chair for Faculty Development (Gleason). Psychologist, Professor and Vice Chair for Education (Schumacher). Psychiatrist, Associate Professor and Residency Training Director (Houston). Psychiatrist, Professor, Division Director of Adult Psychiatry and Director of Outpatient Psychiatry (Ladner). Psychologist, Associate Professor and Director of Psychology (Williams). Conflicts of Interest: None Corresponding Author: Sara H. Gleason, MD, Associate Professor and Vice Chair for Faculty Development, Department of Psychiatry and Human Behavior, 2500 North State Street, Jackson, Mississippi 39216-4505 (shgleason@umc.edu).

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Top 10 Facts You Need To Know About Pharmacogenomics SIDNEY W. BONDURANT, MD Introduction Pharmacogenetics is a new and rapidly expanding technology that holds the promise of more accurate and safer prescribing of medications based on knowledge of how an individual’s genetic makeup can affect drug metabolism.

What is Pharmacogenomics?

According to the NIH: “Pharmacogenomics (sometimes called pharmacogenetics) is a field of research that studies how a person’s genes affect how he or she responds to medications.”¹ What is personalized medicine? Is it different from pharmacogenomics?

Personalized medicine is using information specific to a patient to tailor his/her healthcare. Pharmacogenomics can be used as part of a personalized medicine approach.² Personalized medicine has a long and evolving history. For many years doctors have determined a patient’s ABO and Rh blood types before ordering a transfusion. This is an example of personalized medicine. Recent advances in pharmacogenomics have shown that there are variants in the Cytochrome P450 2D6 (CYP2D6) gene that affect how the inactive compound codeine is metabolized to the active compound morphine in the human body. In about 1 to 2% of patients, the drug is ultra-metabolized, and the patient is at risk of respiratory depression, somnolence and other adverse effects. In about 5 to 10% of patients, the codeine is under-metabolized, and the patient gets little to no pain relief. Personalized medicine is when a physician identifies the effect a gene has on a particular drug’s metabolism and adjusts his treatment of the patient to account for that effect.³ Many commonly used drugs are affected by several different genes.

The FDA has listed over two hundred drugs that have known issues related to specific genes. Some, such as the frequently prescribed clopidogrel, have “black box” warnings about genetic risks associated with the drug. The list of drugs shows many that are used commonly by multiple different medical specialties. Some of the issues are relatively minor while a few have “black box” warnings. Most show guidance on drug-drug interactions and dosage adjustments needed in the presence of genetic variations.⁴ Many physicians see more need to perform pharmacogenomic testing.

According to the FDA: “Healthcare providers can use pharmacogenomic information to help decide the most appropriate treatment for each individual. Choosing a drug that is more likely to work, avoiding drugs that might have side effects, adjusting the dose of

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a drug, or determining if closer monitoring is needed are just some of the things that physicians can utilize from pharmacogenomics.”⁵ Collecting the test is simple; performing it is complex.

The tests can be done on almost any type of human tissue, but most labs only need a cotton swab taken from the buccal mucosa.

The swabs are then sent to the lab for the sophisticated analysis work required. Turnaround time for results is generally just a few days. Your reference lab usually supplies the kit necessary for collection. The genes tested and the information generated varies significantly between different labs. You will have to know that the data you will need will be available from the lab. Some labs have developed reports that show the gene variations from a patient with an emphasis on different areas of interest (cardiology, psychiatry, pain management, etc.) and guide drug selection, warnings of interactions, and side effect risk probabilities.

Others give very basic reports showing the gene variations with references to reports that describe the clinical importance of the variation.⁶ Medicare and private insurance do cover pharmacogenomic testing, but the details are complicated.

In Mississippi, the Medicare Administrative Contractor (MAC), Novitas Solutions, covers four genes for testing but only for specific medical indications. Recent recommendations from CMS to increase the number of genes will likely lead to changes in this number.

The location of the testing lab determines which MAC rules apply for Medicare coverage, not the location of the requesting healthcare provider. Private insurance coverage varies widely.7,⁸ Direct to consumer pharmacogenomics is now being offered by pharmacies and through the internet. However, what the patient does with that information is yet to be determined.

The FDA approved one company to market a pharmacogenomic testing kit covering 33 variants of multiple genes. The kit is approved for informational purposes only, and the purchaser is advised that repeat pharmacogenomic testing in a health care provider setting is needed along with consultation with a health care provider before any action based on the findings should be considered.⁹

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Pharmacogenomics is cost-effective.

Several studies have shown it to be cost-effective. One recent study of patients with mood or anxiety disorder diagnoses had 2,745 control patients and 817 patients who had pharmacogenomic testing. The 6-month study showed there were 40% fewer all-cause emergency room visits and 58% fewer all-cause hospitalizations in the tested group. The p values were highly statistically significant, being p < 0.0001 for both criteria. The average dollar amount saved per patient in the six-month trial was $1,948.00 in the tested group.10-11 The patient population group that is growing the most is the group that will benefit the most from pharmacogenomic testing.

What patient population group would benefit the most from pharmacogenomic testing? The value of pharmacogenomics is most significant in the elderly and adults who are most at risk from adverse drug events (ADE). These patients are often “polypharmacy patients” and have comorbidities that place them at risk for an ADE. Since pharmacogenomic testing is essentially “one and done,” the prescriber can utilize the gene/drug interaction information in making decisions about continuing medication, changing to a new medication, or adding another medication to a patient treatment plan for however long he is seeing the patient. ¹²

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utility for those tests. The committee stated that as more clinical trials are conducted, the recommendations will likely change.13,14,15 n References 1.

National Institute of General Medical Sciences. Science Education, Pharmacogenomics https://www.nigms.nih.gov/education/pages/factsheetpharmacogenomics.aspx. Accessed November 3, 2018.

2. PharmGKB FAQs https://www.pharmgkb.org/page/faqs#what-is-personalizedmedicine-is-it-different-from-pharmacogenomics. Accessed on November 3, 2018.

3. Dean L., Codeine Therapy and CYP2D6 Genotype. March 16, 2017. https://www. ncbi.nlm.nih.gov/books/NBK100662/. Accessed November 3, 2018.

4. Table of Pharmacogenomic Biomarkers in Drug Labeling, August 3, 2018. https:// www.fda.gov/Drugs/ScienceResearch/ucm572698.htm. Accessed November 3, 2018.

5. Pharmacogenomics: Overview of the Genomics and Targeted Therapy Group, March 30, 2018. https://www.fda.gov/Drugs/ScienceResearch/ucm572617.htm.

Accessed November 3, 2018.

6. GeneTrait™ Laboratories, PGX Information For Providers https://www.genetrait. com/learn-more/pgx-information-for-providers/. Accessed November 3, 2018.

7. Map of Pharmacogenetic Test Reimbursement According to MAC. Revision March 8, 2018. https://ignite-genomics.org/mac-reimbursement-map/. Accessed November 3, 2018.

8.

Lu C, Loomer S, Ceccarelli R, et al. Insurance coverage policies for pharmacogenomics and multi-gene testing for cancer. J Pers Med. 2018; May 16;8(2). pii: E19. doi: 10.3390/jpm8020019. https://www.fda.gov/NewsEvents/ Newsroom/PressAnnouncements/ucm624753.htm. Accessed November 3, 2018.

9. U.S. Food and Drug Administration, News & Events, FDA Newsroom, Press Announcements. October 13, 2018. FDA authorizes first direct-to-consumer test for detecting genetic variants that may be associated with medication metabolism. https://www.fda.gov/news-events/press-announcements/fda-authorizes-firstdirect-consumer-test-detecting-genetic-variants-may-be-associated-medication Accessed September 9, 2019.

10. Verbelen M, Weale M, Lewis C. Cost-effectiveness of pharmacogenetic-guided treatment: are we there yet? Pharmacogenomics J. 2017;17:395-402.

The relationship of pharmacogenomics to the “standard of care” is still undetermined.

“Standard of Care” is a legal concept. In Hall v. Hilbun (1978) the Mississippi Supreme Court said, “[G]iven the circumstances of each patient, each physician has a duty to use his or her knowledge and therewith treat through maximum reasonable medical recovery, each patient, with such reasonable diligence, skill, competence and prudence as are practiced by minimally competent physicians in the same specialty or general field of practice throughout the United States, who have available to them the same general facilities, services, equipment and options." The clinical use of pharmacogenomics is still a controversial topic. Some experts say it is not reasonable to adopt pharmacogenomics into general clinical practice while others say failure to use pharmacogenomics in some specific areas violates the “standard of care.” A recent report by a committee in the Veterans Health Administration (VHA) evaluated 30 gene-drug pairs for consideration of use in the VHA. Four were strongly recommended for use, and 12 were recommended for use. Fourteen were not recommended for use, although one of the not recommended tests involved an FDA “black box” warning of a drug/gene interaction. Of the tests not recommended for routine use in the VHA, the reason for not recommending was primarily a lack of documentation of clinical

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11. Perlis R, Mehta R, Edwards A, et al. Pharmacogenetic testing among patients with mood and anxiety disorders is associated with decreased utilization and costs: A propensity-matched score study. Depress Anxiety. 2018 Oct; 35(10):446-452.

12. Rule D, Hachad H. Pharmacogenomics: A pre-emptive tool for effective medication management. October 24, 2018. http://www.medicaleconomics.com/business/ pharmacogenomics-pre-emptive-tool-effective-medication-management.

Accessed November 3, 2018.

13. Ventola CL. Pharmacogenomics in clinical practice: reality and expectations. P T. 2011;36(7):412–450. PMID: 21931473.

14. Ducharme J. TIME Health, Genetics. 23andMe Can Now Tell You How You May Respond to Some Drugs. But Experts Are Wary. November 1, 2018. http://time. com/5441955/23andme-pharmacogenetics/?utm_source=emailshare&utm_ medium=email&utm_campaign=email-share-article&utm_content=20181102.

Accessed November 3, 2018.

15. Vassy J, Stone A, Callaghan J, et al. Pharmacogenetic testing in the Veterans Health Administration (VHA): policy recommendations from the VHA clinical pharmacogenetics subcommittee. June 1, 2018. https://www.genomes2people. org/ wpcontent/uploads/2018/07/20180601_G2V_GeneticsInMedicine_ Vassy_PGxTesting.pdf. Accessed November 3, 2018.

Author Information Author Information: Chief Medical Officer, Medical Spark Biologics, LLC, Jackson (Bondurant). Conflicts of Interest: Dr. Bondurant discloses he is the medical director of Medical Spark Biologics, LLC. Corresponding Author: Sidney W. Bondurant, MD, 4400 Old Canton Road, Suite 150, Jackson, MS 39211. sbondurant@medicalspark.com.

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Top 10 Facts You Need to Know about Breast Implants and Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) PAM BROWNLEE, DO; BEN MCINTYRE, MD, FACS Introduction Breast implant safety has once again come into the spotlight with concerns of an association with a rare type of breast malignancy termed breast implantassociated anaplastic large cell lymphoma (BIA-ALCL).1 On July 24, 2019, the US FDA issued a recall on all textured breast implants (Figure) manufactured by the Allergan Corporation. With so many people throughout the world being potentially affected, both doctors and patients should be educated on this disease.

BIA-ALCL is a lymphoma, not breast cancer.

BIA-ALCL is a rare non-Hodgkin’s CD 30 positive lymphoma that affects patients with textured breast implants.2 The running theory of BIA-ALCL causation is that a chronic inflammatory state surrounds a breast implant and begins to cause white blood cells to behave abnormally and mutate into this type of lymphoma. The reason for the chronic inflammatory state would most likely be due to the presence of a bacterial biofilm present since insertion causing subclinical infection and inflammation over a period of many years.3 BIA-ALCL has been linked only to textured breast implants.

There are two primary types of breast implant shells or outer linings: smooth and textured. Texturing is a process by which the shell of a breast implant is ‘roughened’ at a micro- and macroscopic level. The reason for this process is that texturing an implant has been shown to reduce the amount of scar tissue present around an implant which keeps an implant soft and natural feeling. There have been no reported cases of the disease in patients exposed only to smooth breast implants.4,5 BIA-ALCL has been associated with both textured saline and silicone implants.4,6 The overall prevalence of the disease remains low.

As of November 2018, 656 unique cases of BIA-ALCL had been reported worldwide.4,8 Current epidemiologic reports are limited by missed diagnoses, under-reporting, inaccurate and incomplete reporting, small study populations, and the lack of international databases.1,4,5 The estimated risk of BIA-ALCL is broad, ranging from 1:3817-30,000 which accounts for worldwide variabilities in reporting data and populations that appear to be less susceptible to BIA-ALCL.4-6 The most common initial symptom is unilateral breast swelling caused by a delayed (> 1 year after implant placement) seroma.

Late forming seroma is the hallmark feature of BIA-ALCL. Additionally, skin redness and subcutaneous masses surrounding an implant are commonly seen. This can make it difficult for a practitioner to distinguish

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between infection and malignancy. Metastatic disease can occur across the chest wall and axilla, and a thorough physical exam needs to be done in suspected cases.1,4,9 The median time from implantation of a current implant to the diagnosis of the disease is approximately 10 years.4 Suspected cases need to be evaluated by a board-certified plastic surgeon.

The National Comprehensive Cancer Network (NCCN) created guidelines for the diagnosis of BIA-ALCL. Any patient who presents with an enlarged breast more than 1 year after breast implant placement, not explainable by trauma or infection, should undergo breast ultrasound to assess for fluid collections, masses, and lymphadenopathy. If a periprosthetic fluid collection is found, fine needle aspiration should be performed (minimum of 50 mL of fluid required).9 Specimens should be sent for cytology, flow cytometry, CD30 immunohistochemistry, and biomarkers including ALK expression, culture and gram stain.9 Cytologic diagnosis is confirmed by CD30 positive and ALK-negative stains.4,9 All patients meeting pathologic criteria for BIAALCL should be reported through the American Society of Plastic Surgeons’ Patient Registry and Outcomes for Breast Implants and Anaplastic Large Cell Lymphoma Etiology and Epidemiology (PROFILE) Registry.1,9 The keys to treating BIA-ALCL are a timely diagnosis and complete surgical excision.

The mainstay of treatment for BIA-ALCL is surgical with removal

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Figure. Textured Breast Implant. Pictured is a textured breast implant after explantation. Note the "roughened" surface of the implant. Implant texturing has become controversial as more reports of BIA-ALCL are identified.

Figure. Textured breast implant with visual magnification (200x) •

Identifiable patient information has been removed

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of the scar tissue (capsule) surrounding the implant along with the implant en bloc. This does not necessarily mean that a mastectomy is required.

Reports of treatment with standard lymphoma protocols absent surgical resection generally result in metastasis and death.10 Surgeons may consider removal of the contralateral implant and capsule since 2-4.6% of patients develop bilateral disease.9,10 Sentinel lymph node biopsy is not routinely recommended; however, axillary dissection has been performed in the setting of grossly involved lymph nodes.9 Disease confined to the capsule (Stage I) that is completely excised requires no further treatment. Patients with disease beyond the capsule (Stage II+) require systemic therapy with an anthracyclinebased regimen.10 NCCN guidelines also suggest using brentuximab vedotin, a monoclonal antibody directed toward the CD30 protein.9,10 Patients with local residual disease, positive margins, or unresectable disease should undergo local radiation therapy.9,10 Patients with a complete response to treatment require a history and physical exam every 3 to 6 months for 2 years and then as clinically indicated.

There is currently no proven role for radiographic surveillance, but patients can undergo either a chest/ abdomen/ pelvis CT scan with contrast or PET scan every 6 months for 2 years and then as clinically indicated.9 The overall 5-year survival rate for patients with BIA-ALCL is 8991%.7,8 This is significantly higher for patients with Stage I disease that undergo complete surgical excision. The presence of a mass at presentation is a critical prognostic feature for relapse/ refractory disease.11 When chemotherapy is used alone, relapse occurs in 54.5% of patients.10 Recurrence has been seen in 4-11% of patients after complete removal of the disease and implant.10 All relapses after any kind of therapy have occurred within the first 3 years.11 There is no current consensus regarding breast reconstruction following BIA-ALCL treatment.

Successful reports of reconstruction using a variety of techniques have been described.12 Due to the link with textured implants and possibility of a genetic component, only smooth surface implants should be used if implant-based reconstruction is pursued.

Prophylactic removal of textured breast implants is not recommended.

The first thing patients should do is first identify whether or not they have textured breast implants. This should have been provided to them by their plastic surgeon at the time of their surgery, but they may need to contact the plastic surgeon’s office or consult old medical records to find out. Women with textured implants who are asymptomatic should undergo monthly breast self-exams and routine screening mammograms as indicated by their age group.1,13 Fortunately, the majority of breast implants placed in the US are smooth devices and pose no risk. Patients with tear-drop shaped implants are likely to have textured breast implants so these patients may be at a higher risk. Patients with concerns about their breast implants should contact their plastic surgeon immediately.

References

The number of confirmed cases of BIA-ALCL continues to rise throughout the world. This disease can be cured when caught early, but treatment is dependent on a timely diagnosis and plastic surgical referral. n

Corresponding Author: Benjamin C. McIntyre, MD, FACS, Associate Professor of Plastic and Reconstructive Surgery, Program Director, Integrated and Independent Plastic Surgery Residencies, Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216 Ph: (601) 984-5183 (bmcintyre@umc.edu).

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1. Center for Devices and Radiological Health. Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). U.S. Food and Drug Administration. https:// www.fda.gov/medical-devices/safety-communications/fda-takes-action-protectpatients-risk-certain-textured-breast-implants-requests-allergan. Accessed June 3, 2019.

2.

Liu, Delong. Anaplastic Large Cell Lymphoma. eMedicineHealth. https:// emedicine.medscape.com/article/208050-overview. Accessed June 4, 2019.

3. US Food and Drug Administration. Anaplastic Large Cell Lymphoma (ALCL) In Women with Breast Implants: Preliminary FDA Findings and Analyses. http://wayback.archive-it.org/7993/20171115053750/https:/www.fda.gov/ MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/ BreastImplants/ucm239996.htm. Published January 2011. Accessed June 4, 2019.

4. Collett DJ, Rakhorst H, Lennox P, Magnusson M, Cooter R, Deva AK. Current risk estimate of breast implant–associated anaplastic large cell lymphoma in textured breast implants. Plast Reconstr Surg. 2019;143(3S A Review of Breast Implant-Associated Anaplastic Large Cell Lymphoma):30S-40S. doi: 10.1097/ PRS.0000000000005567.

5. Doren EL, Miranda RN, Selber JC, et al. U.S. epidemiology of breast implantassociated anaplastic large cell lymphoma. Plast Reconstr Surg. 2017;139(5):10421050. doi: 10.1097/PRS.0000000000003282.

6. Clemens, M. BI-ACLS by the numbers and what they mean. American Society of Plastic Surgeons Position Statement. July 2019. https://www.plasticsurgery.org/ for-medical-professionals/health-policy/bia-alcl-physician-resources/by-thenumbers. Accessed July 26, 2019.

7 Association of Breast Surgery. BIA-ALCL. https://associationofbreastsurgery.org. uk/clinical/bia-alcl/. Accessed June 7, 2019.

8. de Boer M, van der Sluis WB, de Boer JP, et al. Breast implant-associated anaplastic large-cell lymphoma in a transgender woman. Aesthet Surg J. 2019; 31;39(Supplement_1):S3-S13. doi: 10.1093/asj/sjy331.

9. Clemens MW, Jacobsen ED, Horwitz SM. 2019 NCCN Consensus Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). Aesthet Surg J. 2019; Jan 31 39(Supplement_1):S3-S13. doi: 10.1093/asj/sjy331.

10.

Kaartinen I, Sunela K, Alanko J, Hukkinen K, Karjalainen-lindsberg ML, Svarvar C. Breast implant-associated anaplastic large cell lymphoma - From diagnosis to treatment. Eur J Surg Oncol. 2017;43(8):1385-1392. doi: 10.1016/j. ejso.2017.05.021. Epub 2017 Jun 7.

11.

Thompson PA, Prince HM. Breast implant-associated anaplastic large cell lymphoma: A systematic review of the literature and mini-meta analysis. Curr Hematol Malig Rep. 2013;8(3):196-210. doi: 10.1007/s11899-013-0164-3.

12. Lamaris GA, Butler CE, Deva AK, et al. Breast Reconstruction Following Breast Implant-Associated Anaplastic Large Cell Lymphoma. Plast Reconstr Surg.

2019;143(3S A Review of Breast Implant-Associated Anaplastic Large Cell Lymphoma):51S-58S. doi:10.1097/PRS.0000000000005569.

13. The American Society for Aesthetic Plastic Surgery. BIA-ALCL Advisory Update. https://www.surgery.org/sites/default/files/BIA-7-31-18.pdf. Published July 30, 2018. Accessed June 13, 2019.

Author Information Author Information: Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson (Brownlee, McIntyre).

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quest that started about a year ago for fourth-year medical students at the University of Mississippi Medical Center (UMMC) reached its exhilarating conclusion in a Match Day 2019 ceremony held March 15 at Thalia Mara Hall. About 120 participating residency applicants learned which programs accepted them for training in a medical specialty. According to people who have experienced Match Day before, it is a day of possibility, excitement tinged with stress, and relief as medical students now know the information they need to start planning for the future.

After interviewing with residency programs across the nation, students rank their top-choice programs in order of preference. Training programs, in turn, rank the students who interviewed. The National Resident Matching Program® (NRMP®) then uses a mathematical

algorithm to designate each applicant into a residency program. Each year, thousands of medical school seniors compete for approximately 24,000 residency positions across the United States.

According to the NRMP, the 2019 Main Residency Match is the largest in its history. A record-high 38,376 applicants submitted program choices for 35,185 positions, the most ever offered in the Match. The number of available first-year (PGY-1) positions rose to 32,194, an increase of 1,962 (6.5%) over 2018. The influx of slots is due, in part, to the increased numbers of osteopathic programs that joined the Main Residency Match as a result of the ongoing transition to a single accreditation system for graduate medical education programs.

Full Match Day results of UMMC’s medical school milestone follow:

Alia Abbas Medicine Preliminary LSU School of Medicine-New Orleans New Orleans, Louisiana

Christopher Barnett Pediatrics University of Alabama- Birmingham Birmingham, Alabama

Anna Bryant Medicine-Pediatrics University of Mississippi Medical Center Jackson, Mississippi

Jennifer Abdalla Internal Medicine LSU School of Medicine New Orleans, Louisiana

Hannah Barrett Pediatrics University of Mississippi Medical Center Jackson, Mississippi

William Buchanan Anesthesiology Brigham & Women's Hospital Boston, Massachusetts

Hala Abisamra Internal Medicine University of Mississippi Medical Center Jackson, Mississippi

Laura Lee Beneke Emergency Medicine University of Mississippi Medical Center Jackson, Mississippi

Brandon Bunol Internal Medicine Tulane University School of Medicine New Orleans, Louisiana

Esosa Adah Pediatrics Children's Mercy Hospital-UMKC Kansas City, Missouri

Megumi Boone Family Medicine LSU Health Science Center Shreveport, Louisiana

Hannah Burson Medicine-Pediatrics University of Texas Medical School Houston, Texas

William Allen Emergency Medicine University of Mississippi Medical Center Jackson, Mississippi

Kelsey Bounds Otolaryngology University of Mississippi Medical Center Jackson, Mississippi

Darin Busby Internal Medicine University of Mississippi Medical Center Jackson, Mississippi

Omair Arain Radiology-Diagnostic University of Mississippi Medical Center Jackson, Mississippi

William Briscoe Surgery-General University of Tennessee College of Medicine Chattanooga, Tennessee

Mary Butts Obstetrics-Gynecology University of Tennessee College of Medicine Memphis, Tennessee

Robert Brown Internal Medicine Baptist Memorial Hospital Columbus, Mississippi

Madeline Campbell Internal Medicine University of Tennessee Saint Thomas Hospital Nashville, Tennessee

Amit Bajaj Medicine Preliminary Presbyterian Hospital Dallas, Texas Ophthalmology University of Texas Southwestern Dallas, Texas

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Patricia Campbell Family Medicine St. Lukes Bethlehem, Pennsylvania

Kyle Curtis Surgery-General University of Mississippi Medical Center Jackson, Mississippi

Tameka Carmichael Family Medicine Tuscaloosa College Community Health Tuscaloosa, Alabama

Harrison Davis Medicine-Primary University of Virginia Charlottesville, Virginia

Ronnie Case, II Emergency Medicine University of Mississippi Medical Center Jackson, Mississippi

Johnathan Davis Emergency Medicine University of Mississippi Medical Center Jackson, Mississippi

Pooja Chawla Internal Medicine Virginia Commonwealth University Health Richmond, Virginia

Morgan Davis Otolaryngology UC San Diego Medical Center-CA San Diego, California

Cathy Chen Medicine Preliminary University of Mississippi Medical Center Jackson, Mississippi Radiology-Diagnostic University of Alabama- Birmingham Birmingham, Alabama Bridget Cheng Emergency Medicine University of Mississippi Medical Center Jackson, Mississippi Annie Chu Surgery-General Palmetto Health Richland Columbia, South Carolina Adam Coombs Medicine-Pediatrics University of Mississippi Medical Center Jackson, Mississippi Joseph Creel Internal Medicine University of Tennessee College of Medicine Memphis, Tennessee Rachel Crim Child Neurology University of Virginia Charlottesville, Virginia Tyler Crosswhite Family Medicine North Mississippi Medical Center Tupelo, Mississippi 252 VOL. 60 â&#x20AC;˘ NO. 8 â&#x20AC;˘ 2019

Miles DeBardeleben Internal Medicine University of Mississippi Medical Center Jackson, Mississippi Michael Dedwylder Surgery-General FAU Schmidt College of Medicine Boca Raton, Florida

John Fitzpatrick Surgery-Preliminary Vanderbilt University Hospital Nashville, Tennessee Ophthalmology Vanderbilt University Hospital Nashville, Tennessee William Flowers Medicine Preliminary University of Virginia Charlottesville, Virginia Radiology-Diagnostic University of Virginia Charlottesville, Virginia Joshua Fowler Internal Medicine University of Tennessee College of Medicine Memphis, Tennessee Parker Giroux Pediatrics University of Mississippi Medical Center Jackson, Mississippi

Sean Duke Neurology Case Western Reserve University Cleveland, Ohio

Jonathan Glaze Medicine Preliminary University of Mississippi Medical Center Jackson, Mississippi Ophthalmology University of Mississippi Medical Center Jackson, Mississippi

Kane Edwards Internal Medicine University of Mississippi Medical Center Jackson, Mississippi

Zachery Glenn Emergency Medicine LSU School of Medicine Baton Rouge, Louisiana

Nneamaka Ezekwe Transitional Year University of Texas Rio Grande Valley Edinburg, Texas

Thor Goodfellow Internal Medicine University of Mississippi Medical Center Jackson, Mississippi

Megan Fasick Family Medicine Self Regional Healthcare Greenwood, South Carolina

Callie Grey Pediatrics University of Mississippi Medical Center Jackson, Mississippi

Ashli Fitzpatrick Medicine Preliminary Massachusetts General Hospital Boston, Massachusetts Dermatology Vanderbilt University Hospital Nashville, Tennessee

Katherine Hall Obstetrics-Gynecology University of Texas Health Science Center San Antonio, Texas Taylor Harvey Internal Medicine University of Mississippi Medical Center Jackson, Mississippi

Maribeth Hillhouse Family Medicine North Mississippi Medical Center Tupelo, Mississippi

Ashley Kraft Otolaryngology LSU School of Medicine New Orleans, Louisiana

Matthew Martin Radiology-Diagnostic University of Mississippi Medical Center Jackson, Mississippi

Bonnie Hodge Transitional Year Brookwood Baptist Health Birmingham, Alabama Dermatology University of Alabama- Birmingham Birmingham, Alabama

Torey Krause Family Medicine North Mississippi Medical Center Tupelo, Mississippi

Regan Maxwell Family Medicine Mountain Area Health Education Center Asheville, North Carolina

Joshua Lambert Urology Augusta University Augusta, Georgia

Van-Vi Le Family Medicine University of Mississippi Medical Center Jackson, Mississippi

Shelby Liddell Preliminary Surgery University of Mississippi Medical Center Jackson, Mississippi

Joseph Maxwell, IV Psychiatry Mountain Area Health Education Center Asheville, North Carolina

Shaoxin Lu Pediatrics Baylor College of Medicine Houston, Texas

Falan McKnight Family Medicine North Mississippi Medical Center Tupelo, Mississippi

Louis Ma Anesthesiology University of Oklahoma College of Medicine Oklahoma City, Oklahoma

Hunter McLendon Psychiatry University of Mississippi Medical Center Jackson, Mississippi

Gary Hodge, II Family Medicine St. Vincent's East Birmingham, Alabama Nathaniel Hughes Medicine Preliminary University of Mississippi Medical Center Jackson, Mississippi Anesthesiology Rutgers Robert Wood Johnson Medical School New Brunswick, New Jersey Richelle Jefferson Family Medicine University of South Alabama Mobile, Alabama Meghan Johnson Family Medicine Forrest General Hospital Hattiesburg, Mississippi Meredith Jordan Pediatrics University of Virginia Charlottesville, Virginia Ramanjit Kaur Internal Medicine University of Texas Medical School Houston, Texas Muzamil Khawaja Internal Medicine Baylor College of Medicine Houston, Texas Seth Knight Internal Medicine University of Kentucky Medical Center Lexington, Kentucky

Michael Magee, II Emergency Medicine University of Mississippi Medical Center Jackson, Mississippi Vy Mai Internal Medicine Sunrise Health GME Consortium Las Vegas, Nevada Caleb Martin Emergency Medicine University of Virginia Charlottesville, Virginia Laura Martin Internal Medicine University of Virginia Charlottesville, Virginia

Haley McCool Obstetrics-Gynecology University of Mississippi Medical Center Jackson, Mississippi Matthew McGuire Child Neurology University of Mississippi Medical Center Jackson, Mississippi

Samuel Metcalf Medicine-Pediatrics University of Mississippi Medical Center Jackson, Mississippi Hannah Miller Transitional Year Spartanburg Regional Healthcare Spartanburg, South Carolina Ophthalmology University of North Carolina Hospital Chapel Hill, North Carolina Katelyn Mitchell Internal Medicine Baptist Memorial Hospital Columbus, Mississippi Jacob Morris Family Medicine University of Mississippi Medical Center Jackson, Mississippi

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Sorsha Morris Psychiatry Tulane University School of Medicine New Orleans, Louisiana

Denise Powell Pediatrics UC San Francisco San Francisco, California

David Rueff Pediatrics University of Mississippi Medical Center Jackson, Mississippi

Alexander Mullen Medicine Preliminary University of Mississippi Medical Center Jackson, Mississippi Radiology-Diagnostic University of Alabama- Birmingham Birmingham, Alabama

George Puneky Orthopedic Surgery Medical College of Georgia Augusta, Georgia

Mark Rushing Pediatrics University of Tennessee College of Medicine Memphis, Tennessee

Courtney Mullins Internal Medicine University of North Carolina Hospital Chapel Hill, North Carolina Brannon Myrick Oral Maxillofacial Surgery University of Mississippi Medical Center Jackson, Mississippi Ashton Nicholson Transitional Year Naval Medical Center San Diego, California Juliet Nonnemacher Pediatrics Medical Center Macon, Georgia Jasmine Padgett Medicine-Pediatrics University of Mississippi Medical Center Jackson, Mississippi Murti Patel Internal Medicine Virginia Commonwealth University Health Richmond, Virginia Naishal Patel Anesthesiology University of Oklahoma College of Medicine Oklahoma City, Oklahoma

Resham Rahat Internal Medicine Johns Hopkins Hospital Baltimore, Maryland Logan Ramsey Emergency Medicine University of Cincinnati Medical Center Cincinnati, Ohio Christopher Rawls Family Medicine Forrest General Hospital Hattiesburg, Mississippi Jacob Read Internal Medicine Medical University of South Carolina Charleston, South Carolina Alison Redding Medicine-Primary Wake Forest Baptist Medical Center Winston-Salem, North Carolina Jonathan Redding Emergency Medicine Wake Forest Baptist Medical Center Winston-Salem, North Carolina Peyton Reves Internal Medicine University of Mississippi Medical Center Jackson, Mississippi Thomas Ricks, IV Family Medicine Trident Medical Center Charleston, South Carolina

Sean Patterson Psychiatry Yale New Haven Hospital New Haven, Connecticut

James Roberts Medicine Preliminary University of Mississippi Medical Center Jackson, Mississippi

Nykia Porter Emergency Medicine University of Florida College of Medicine Gainesville, Florida

William Ross Family Medicine Tuscaloosa College Community Health Tuscaloosa, Alabama

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William Sanders Internal Medicine University of Cincinnati Medical Center Cincinnati, Ohio David Sandlin Transitional Year Emory University School of Medicine Atlanta, Georgia Neurology Emory University Affiliated Hospitals Atlanta, Georgia Ryan Sessums Internal Medicine University of Virginia Charlottesville, Virginia Tyler Shack Anesthesiology University of Mississippi Medical Center Jackson, Mississippi Rachel Sharp Family Medicine LSU Health Science Center Shreveport, Louisiana Jacob Sivils Internal Medicine Greenville Health System Greenville, South Carolina Richard Smith Anesthesiology University of Mississippi Medical Center Jackson, Mississippi Jacob Smithey Orthopedic Surgery University of Mississippi Medical Center Jackson, Mississippi Melinda Solomon Internal Medicine University of Mississippi Medical Center Jackson, Mississippi

Benjamin Stevens Otolaryngology University of Mississippi Medical Center Jackson, Mississippi

Shelby Walters Obstetrics-Gynecology University of Mississippi Medical Center Jackson, Mississippi

Billy Sullivan, II Orthopedic Surgery University of Mississippi Medical Center Jackson, Mississippi

John Weldy Orthopedic Surgery Tulane University New Orleans, Louisiana

Connor Tierney Medicine Preliminary University of Chicago Medical Center Chicago, Illinois Radiology-Diagnostic University of Chicago Medical Center Chicago, Illinois

Michelle Wheeler Family Medicine Baylor College of Medicine Houston, Texas

Moniqua Tillman Psychiatry University of Alabama- Birmingham Birmingham, Alabama Brent Treadway Emergency Medicine University of Mississippi Medical Center Jackson, Mississippi Helen Turner Medicine-Pediatrics University of Louisville School of Medicine Louisville, Kentucky Hardeep Uppal Neurology University of Texas Southwestern Dallas, Texas Elliot Varney Radiology-Diagnostic University of Mississippi Medical Center Jackson, Mississippi John Waddell Anesthesiology University of Mississippi Medical Center Jackson, Mississippi Marlee Wadsworth Medicine-Pediatrics University of Mississippi Medical Center Jackson, Mississippi

David Wilbanks Internal Medicine University of Tennessee College of Medicine Memphis, Tennessee Hunter Wilkerson Medicine-Pediatrics University of Alabama- Birmingham Birmingham, Alabama Jeremy Wise Orthopedic Surgery Greenville Health System Greenville, South Carolina Robert Wood Preliminary Surgery University of Mississippi Medical Center Jackson, Mississippi Joanna Young Internal Medicine University of Mississippi Medical Center Jackson, Mississippi Perry Young, Jr. Radiology-Diagnostic University of Mississippi Medical Center Jackson, Mississippi Hobart Zhu Internal Medicine University of Illinois College of Medicine Chicago, Illinois

Christina Wallace Medicine-Primary University of Mississippi Medical Center Jackson, Mississippi

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University Medical Alumni Chapter Additions to Hall of Fame GARY PETTUS 2019 DISTINGUISHED ALUMNUS AWARD Dr. John C. Fleming, Jr. 2019 DISTINGUISHED ALUMNA AWARD Dr. Sherry Martin 2019 HALL OF FAME Dr. Thomas M. “Peter” Blake Dr. Julius M. Cruse, Jr. Dr. Martin “Mart” McMullan Dr. Richard C. Miller and Dr. Suzanne T. Miller Dr. James T. “Tate” Thigpen A former four-term congressman and an internationally known diabetes expert were celebrated as distinguished graduates of the School of Medicine during the University of Mississippi Medical Medical Alumni Awards Dinner honorees or their representatives are, from left, Dr. Robert Center Medical Alumni Awards Dinner.

Lewis, accepting for Dr. Julius Cruse Jr.; Dr. Suzanne Miller, accepting for herself and her Another six physicians who entered the ranks of the chapter’s Hall of Fame for their triumphs in medicine and science were also recognized during the August 22 observance in Jackson.

“Make no mistake about it, YOU are the School of Medicine,” said Dr. LouAnn Woodward, vice chancellor for health affairs and dean of the School of Medicine, addressing those commended at the event, held at the Country Club of Jackson.

“Your career achievements make up the biggest part of our reputation for excellence, not just in Mississippi but also across the country,” said Woodward, a 1991 alumna. “It’s a good, hard-earned reputation and I’m proud to represent our school at state and national meetings.”

Making the awards presentations was orthopaedic surgeon Dr. Karen Hand of Gulfport, a 2006 medical school graduate and outgoing president of the Medical Alumni Chapter. She will be succeeded in the fall by president-elect Dr. Randy Richardson, an Oxford ophthalmologist and member of the medical school class of 1985.

The occasion was one of several 2019 Medical Class Reunion activities welcoming back the classes of 1969, 1979, 1989, 1994, 1999 and 2009.

The UMMC Medical Alumni Chapter has named a Distinguished Alumnus since 2010; two years later, the first Hall of Fame recipients were acclaimed. As of this year, around 50 physicians have been inducted into the Hall of Fame or declared a Distinguished Alumnus, or both.

husband Dr. Richard Miller; Dr. Sherry Martin; Dr. John Fleming Jr.; Dr. Tate Thigpen; and Dr. Mart McMullan. Not pictured is Dr. Ralph Vance Sr., who accepted for Dr. Peter Blake.

“The scope of their achievements is absolutely breathtaking,” Woodward said of this year’s guests of honor.

2019 DISTINGUISHED MEDICAL ALUMNUS Dr. John Fleming, Jr. is the 2019 Distinguished Medical Alumnus.

Dr. John C. Fleming, Jr. of Minden, Louisiana, who was sworn in this year as the nation’s Assistant Secretary of Commerce for Economic Development, accepted the 2019 Distinguished Alumnus Award.

“This is the first trophy I’ve won since a participation award in Little League,” said Fleming, a 1976 School of Medicine graduate.

The Meridian native praised his “first-class medical school education” at UMMC. “I decided I wanted to be a doctor at age 11,” he said. “There is no greater honor or calling in life than to be a physician.”

Fleming was introduced by Dr. Melissa Love, a family medicine physician in Louisiana and a 2006 medical school graduate.

For eight years, until 2017, Fleming was the representative of Louisiana’s 4th Congressional District, serving on the U.S. House Armed Services Committee.

Until his current role in helping lead the federal economic development

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agenda, Fleming was deputy assistant secretary at the U.S. Department of Health and Human Services.

A military veteran, Fleming opened his family medicine practice in Minden while also starting several companies employing more than 600 people today.

He was Louisiana’s Family Doctor of the Year in 2007, a year after he published a parents’ guidebook on bringing up drug-free children.

2019 DISTINGUISHED MEDICAL ALUMNA Dr. Sherry Martin receives the 2019 Distinguished Alumna Award.

Dr. Sherry Martin of Tupelo, vice president of diabetes global medical affairs at Eli Lilly and Company, is the recipient of the Distinguished Alumna Award.

In 1988, Blake received the Laureate Award from the Mississippi chapter of the American College of Physicians-American Society of Internal Medicine.

Trained in cardiovascular research at Vanderbilt University, he was the Medical Center’s authority on electrocardiography.

Although he officially retired in 1990, Blake still put in half-days at UMMC to accommodate physicians who turned to him for his EKG expertise.

He was also the Medical Center’s unofficial historian, documenting through photographs the life of the institution he served for decades before his death in 2002.

Dr. Julius M. Cruse Jr., a universally recognized authority on immunology, was the founding editor-in-chief of three international medical/ scientific journals and the author or editor of more than 50 scientific books.

The 1982 medical school alumna was introduced by Dr. Bruce Longest of Bruce, a 1986 alumnus and former chapter president.

An endocrinologist, Martin said that because of her education at the Medical Center, “never has anyone questioned my clinical skill.”

Among his best-known works are the Illustrated Dictionary of Immunology and the Atlas of Immunology.

Working with her patients has been “the joy of my life,” she said.

Martin won the 2018 Lilly Research Labs Progress Through Research Award for her work, which included leading a team studying a new type 2 diabetes treatment – now known as Trulicity. Her contributions to the advancement of diabetes research and education are recognized across the globe.

In her home state, Martin opened the first endocrinology clinic in north Mississippi, based in Tupelo. The North Mississippi Diabetes Treatment Center, which she started in partnership with North Mississippi Medical Center, operates today as a group of centers for diabetes management.

2019 HALL OF FAME Dr. Thomas M. “Peter” Blake came to work for the Medical Center the year it opened, in 1955, when he set up the heart catheterization lab.

Dr. Thomas M. "Peter" Blake

His influence extends to today’s future physicians and to generations who came before them: He organized a course in physical diagnosis that is now the “Introduction to Clinical Medicine” – the final class secondyear medical students complete before beginning their clinical years.

From Blake, medical students “learned to take a history, do a physical, take a review of systems … learned how to practice medicine,” said Dr. Ralph B. Vance, Sr., UMMC professor emeritus and a member of the medical school class of 1971, who spoke on behalf of his late mentor and friend.

At the Medical Center, he served as Guyton Distinguished Professor of Pathology, Medicine and Microbiology and as Distinguished Professor of the History of Medicine. He was the first professor of immunology and the first distinguished professor of the history of medicine at the University of Mississippi in Oxford.

Dr. Julius M. Cruse, Jr.

For his world-renowned abilities, Cruse was accepted as a fellow of the American Academy of Microbiology and of the Royal Society of Health and the Royal Society of Medicine in the United Kingdom.

“In spite of his many awards, he was kind and gracious, genteel and humble,” said Dr. Helen R. Turner, UMMC associate vice chancellor emeritus, a 1979 School of Medicine graduate and a 2018 Hall of Fame inductee.

Dr. Robert Lewis, a retired professor of pathology who earned his PhD in pathology/immunology at UMMC, accepted the Hall of Fame award on behalf of Cruse, who died in August 2018.

Lewis, who worked with Cruse for more than 40 years, described him as a “Renaissance educator,” noting his love of history, science, literature, book-collecting and more.

“He was my teacher, mentor and my friend,” Lewis said. “I learned from this man every single day. I’m a much better person today for having known him.”

Dr. Martin “Mart” McMullan, a thoracic and cardiovascular surgeon, had retired from private practice when he joined the UMMC faculty in 2005 as a professor emeritus of surgery and senior advisor to the vice chancellor for health affairs.

AUGUST • JOURNAL MSMA

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McMullan, a 1966 medical school graduate who completed his surgery residency under Medical Center icon Dr. James Hardy, was a key figure in bolstering the Medical Center’s heart surgery program and cardiovascular services; he was instrumental in re-establishing the Batson Children’s Hospital congenital heart surgery program.

Dr. Martin "Mart" McMullan

“You are a person who went into medicine for all the right reasons,” said Dr. James Keeton, who summarized McMullan’s career.

Keeton, former vice chancellor for health affairs and dean of the School of Medicine, the 2014 Distinguished Medical Alumnus and a 2018 Hall of Fame honoree, has known McMullan since 1962.

At one time, McMullan joined Keeton and Woodward on a tour of the state in an effort to boost the Medical Center’s image as a place of academic excellence, Keeton said.

He was the longtime director of the Cystic Fibrosis Center, and was awarded an honorary Doctor of Science from Millsaps College in 2011.

In 2017, the Richard C. Miller, M.D. Pediatric Surgery Chair was established at UMMC, the year before he died, in August 2018.

In 1973, when the Medical Center became a designated Cystic Fibrosis Center, Suzanne Miller was named its director.

After working alongside her husband for years, she retired in 1999, but returned to care for cystic fibrosis patients in UMMC’s Adult Pulmonology Department three years later.

In 2008, she joined the Pediatric Cystic Fibrosis Center until her retirement from both departments in 2012.

“Both of us enjoyed our patient care so much,” Suzanne Miller said. “I loved my CF patients and enjoy seeing some of them today … with a baby in their arms.”

Dr. James T. “Tate” Thigpen, professor emeritus of medicine at UMMC since 2017, has made a lasting impact on the treatment of cancer in Mississippi.

McMullan’s son-in-law, Kelley Williams Jr. of Jackson, spoke on his behalf, noting how several other family members had pursued a medical education at the Medical Center.

“As much as Mart has meant to UMMC, UMMC has meant more to Mart and the family,” Williams said.

Dr. Richard C. Miller and Dr. Suzanne Miller, a pioneering husband-and-wife team who furthered health care for Mississippi’s children, were introduced by Dr. Mary Taylor, Suzan B. Thames Chair of Pediatrics and professor and chair of the Department of Pediatrics at UMMC.

Drs. Richard and Suzanne Miller

For most of Richard Miller’s career, he was the only pediatric surgeon in the state, said Taylor, a member of the 1991 School of Medicine class.

Suzanne Miller, recruited to Batson Children’s Hospital in 1969, was the first pediatric pulmonologist to serve Mississippi.

“We’re deeply indebted to the Millers for the legacy they’ve left,” Taylor said.

It was at Case Western Reserve University in Cleveland that Richard Miller, then a surgery resident, and Suzanne Thorne, a fellow house officer, met.

After a few years of marriage, they moved to Mississippi to begin work at University Hospital. For 43 years, Richard Miller held many administrative positions while also treating children and training physicians. He was interim chair of the Department of Anesthesiology and the Department of Surgery; associate dean for clinical affairs; and medical director of the University Hospital.

258 VOL. 60 • NO. 8 • 2019

Dr. James T. "Tate" Thigpen

The Picayune native helped expand UMMC’s cancer program and began, at age 32, deciding which research studies would be funded as head of the Protocol Committee in the Gynecologic Oncology Group.

A 1969 graduate of the School of Medicine, he served on the Department of Medicine faculty since 1973 and directed the Division of Oncology for 35 years before leading the Division of Hematology and Oncology. He has made enduring contributions to gynecologic cancer research.

For his success in advancing cancer patient care, he received in 2017 the Distinguished Leadership Award from the Society of Gynecologic Oncology.

“He is the reason I’m doing what I do today,” said one of his five sons, Dr. Samuel Calvin Thigpen, who introduced his father.

“He loves to play games. He has taught us not only how to compete, but also how to compete in the right way,” said Calvin Thigpen, assistant professor of medicine in the Division of General Internal Medicine, and a 2005 School of Medicine graduate.

For his part, Tate Thigpen said “the greatest thing that happened to me” was being introduced to his future wife, Louisa Kessler. They also have nine grandchildren.

Throughout his remarks, Thigpen stuck to the accomplishments of his colleagues and others he worked with, concluding with: “I hope you can see, from what I’ve said, it’s not me; it’s a whole group of people working together to make something happen.” n

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Hepatitis A Outbreak, Mississippi 2019: What Physicians Need to Know Mississippi is in the midst of a person-to-person hepatitis A outbreak with sustained increases in cases dating back to first part of April 2019.

As of August 12, 2019, there have been 25 outbreak cases in the state (Figure 1), primarily affecting drug users (injection and non-injection), homeless persons and individuals who were recently incarcerated (see www.healthyms.com for updated case counts). Many other states have been experiencing similar hepatitis A outbreaks among the same high-risk groups, leading to almost 24,000 cases and over 230 deaths across the US since 2016 (see https://www.cdc.gov/hepatitis/ outbreaks/2017March-HepatitisA.htm).

likelihood that cases will also occur in persons without known risk factors due to widespread person-to-person transmission.

Use of Hepatitis A Vaccine Vaccination efforts targeting those at higher risk for infection in this outbreak is the key to reducing the number of susceptible individuals and interrupting transmission. A single dose of hepatitis A vaccine is considered to provide up to 95% protection for up to 11 years and has been shown to be effective at controlling transmission during hepatitis A outbreaks (see outbreak specific vaccine guidance from CDC https:// www.cdc.gov/hepatitis/outbreaks/InterimOutbreakGuidance-HAVVaccineAdmin.htm). Providing a second dose of hepatitis A vaccine to high risk groups is not the main priority during an outbreak.

Hepatitis A Outbreak, Mississippi 2019: What Physicians Need to Know Mississippi Epidemiology

The median age for the outbreak-related cases in Mississippi is 36 years with the majorityis(88%) occurring in males. the hospitalization Mississippi in the midst of a While person to person hepatitis A outbreak with sustained increases in rate (60%) is similar to outbreaks in other states, there have been no Mississippi State Department of Health Response cases dating back to first part of April 2019. As of August 12, 2019 there have been 25 outbreak hepatitis A related deaths reported in Mississippi. Drug use is by far Vaccination: In order to facilitate vaccination of high-risk individuals, cases in common the state 1), primarily affecting users (injection and ofnon-injection), the Mississippi State Department Health (MSDH) is partnering the most risk (Figure factor identified at 60%; however, cases have drug with county jails in areas where cases are identified and is workingfor with also been identified in persons who are homeless, thosewere with recent homeless persons and individuals who recently incarcerated (see www.healthyms.com facilities that provide services to the homeless and drug users to further incarceration and counts). among menMany who haveother sex with men. Cases updated case states havehave been experiencing similar hepatitis A outbreaks been reported from all parts of the state with the most recent occurring expand hepatitis A vaccine coverage. among same high-risk groups, leading toacute almost 24,000 cases and over 230 deaths across the in Souththe and Southwest Mississippi (Figure 2). More cases of Investigation: In addition to vaccination efforts, timely identification US sinceA are 2016 (seeamong https://www.cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm). hepatitis expected those in high risk groups with the and reporting of acute infections is vital. MSDH investigates every Figure 1. Hepatitis A , acute, Cases by Year and Outbreak Status, Mississippi, 2010- 2019 Figure 1. . Hepatitis A , acute, Cases by Year and Outbreak Status, Mississippi, 2010- 2019 Hepatitis A, acute, Cases by Year and Outbreak Status, Mississippi, 2010 - 2019* 30

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AUGUST • JOURNAL MSMA

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BY PHONE specific vaccine guidance from CDC to MSDH within 24 hours of first knowledge or suspicion.

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• Report cases of hepatitis A to MSDH within 24 hours of first knowledge or suspicion

by Department telephone to (601) 576-7725 during Mississippi State of Health Response routine business hours (or (601) 576-7400 after hours, weekends, and holidays); Vaccination: order of high-risk individuals, the Mississippi State •Vaccinate persons atInhigher risktoforfacilitate hepatitis Avaccination infection Health (MSDH) is partnering with county jails in areas where cases are identified Department • People whoofuse drugs (injection or non-injection) and• People experiencing or unstable is working with homelessness facilities that providehousing; services to the homeless and drug users to further expand • Menhepatitis who have sex with men; A vaccine coverage.

• People who are or have recently been incarcerated; Investigation: • People with chronic liver disease, including cirrhosis, In addition to vaccination efforts, timely identification and reporting of acute hepatitis B, or hepatitis C. infections is vital.

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601-540-2864 jonm9564@gmail.com

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262 VOL. 60 • NO. 8 • 2019

A M A

Jackson Physician Dr. Sharon Douglas Elected to the AMA Council on Medical Education

S

haron P. Douglas, MD, was elected to the American Medical Association’s (AMA) Council on Medical Education in mid-June. Dr. Douglas practices pulmonary medicine at the GV Sonny Montgomery VA Medical Center and is Professor of Medicine and Associate Dean for VA Education at the University of Mississippi School of Medicine (UMMC).

Founded in 1904, the Council on Medical Education recommends educational policies to the AMA House of Delegates. The council also recommends to the AMA Board of Trustees the appointments of representatives to medical education organizations, accrediting bodies, and certification boards.

The council collaborates with other key organizations in medical education, supports the accreditation of medical education programs, and gathers and disseminates medical education data and products/ services.

“It is a great honor to have been selected by the AMA House of Delegates to serve on the Council on Medical Education,” said Dr. Douglas. “In this role, I will be able to help shape the AMA’s positions on medical education across the continuum of medical education from medical school to postgraduate education and also to changes in continuing education for practicing physicians. It is an honor to follow Dr. Carl Evers as the second Mississippi physician to hold this post for the AMA. I am so thankful to the UMMC medical students, Jill Gordon from MSMA, and Dr. Edward Hill for their support and assistance with my campaign.

I also want to thank the Mississippi Physicians Care Network for their monetary campaign support.”

The council focuses on issues and initiatives related to four areas: undergraduate medical education; graduate medical education; continuing medical education; and continuing professional development.

Dr. Douglas is Associate Dean for VA Education for the UMMC School of Medicine and Professor of Medicine in the UMMC Department of Medicine. Academic honors and leadership positions at the UMMC School of Medicine include: Evers Society Teaching Hall of Fame; Alpha Omega Alpha Teacher of the Year (2010); Faculty Advisor M3/ M4 Humanism in Medicine Book Club; Faculty Advisor, UMMC Department of Medicine’s Clinical Quality Improvement Conference, and she is an Advanced Cardiovascular Life Support (ACLS) Instructor.

She also received a Secretary’s Hero Award from the VA Central Office for her work post-Hurricane Katrina.

Dr. Douglas has been active in local, statewide, and national medical associations. Dr. Douglas is currently on the Mississippi delegation to the AMA House of Delegates, having served as vice-chair and also chair of the MSMA delegation to the AMA. She is a member and delegate of the Central Medical Society. She serves on the MSMA’s Council on Ethical and Judicial Affairs and the Journal of Mississippi State Medical Association’s Editorial Advisory Board.

Other AMA positions she has held include a former member of the AMA’s Council on Ethical and Judicial Affairs (2005-2012); AMABOT choice to be a member. She served on the Liaison Committee for Medical Education Council (2012 to 2016); Executive Committee of Southeastern Delegation (2013 to 2016); Resolutions Committee of the Southeastern Delegation to AMA; as well as a Governing Council member of the AMA’s Academic Physicians Section of the AMA. Dr. Douglas is also a Fellow in the American College of Chest Physicians, where she has served on the Palliative and End of Life Care Network.

She has also served on a USMLE Question Writing Committee for Step 1 (2004-2008). n

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AUGUST • JOURNAL MSMA

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P R E S I D E N T ’ S

P A G E

A Better Job It is easy to work when the soul is at play

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—Emily Dickinson

hen our oldest child was six years old, my wife and I were going through our nightly routine of putting our four children to bed. I received a page from the answering service and announced that I would have to return to the hospital. As I was telling all of them goodnight, our 6-year-old told me that I needed to get a better job. She explained, “You have to go to work every day, you never get off on the weekends, and when you come home at night they call you, and you have to go back to work.” I suppose this is not uncommon for physicians, especially those who work in under-served areas. While this has been an age-old problem for many physicians, we find ourselves today dealing not only with the demands of patient care but also with the demands of a changing healthcare system. For some of us, when we are working our soul is at play, but for a growing number of others, the increasing demands external to patient care itself are creating a health crisis of burnout. Some of us are experiencing illness related to these demands while others are simply choosing to look for a better job.

Herbert Freudenberger, a psychologist working in a free clinic in 1974, coined the term “burnout” as it applies to the experience of caring for marginalized patients. In the context of that experience he recognized the difficulty caring for patients knowing their socioeconomic circumstances are actively causing harm beyond the scope of medical care.1,2 This is particularly pertinent to current efforts to address the social determinants of health that contribute to the epidemic burden of noncommunicable disease and premature death.

We have sought during the past year to educate and partner with our members, our policymakers, civic and business organizations to raise awareness and collaborate in ongoing efforts to address the underlying contributors to non-communicable disease as a way both to improve health and to decrease the cost of healthcare. We published the August 2018 issue of the Journal of The Mississippi State Medical Association dedicated entirely to Population Health, its rationale and efforts across Mississippi and around the world. We have met with the Governor, the Lieutenant Governor, the Speaker of the House of Representatives, the Mississippi Hospital Association, the Mississippi Medicaid Commission, the Department of Medicaid, the Mississippi State Department of Health, leaders of the YMCA, insurance companies, and the School of Population Health at the University

of Mississippi Medical Center to promote these ideas of population health and prevention.

We have encouraged a great deal of ongoing work and facilitated the exchange of ideas as a way to promote the health and well being of Mississippi and its health care professionals. We also submitted public comments to the Centers for Medicare and Medicaid and the United States Senate Health, Education, Labor, and Pensions Committee promoting population health, preventive health and improved access to healthcare as the best means to control the cost of healthcare.

We promoted the use of a tobacco users fee as an effective means of encouraging smokers to quit and encouraging young people to avoid smoking altogether while raising state tax revenue to potentially be used to expand access to healthcare.

Physicians have chosen a life of service, and many don’t necessarily think of insufficient reward as an essential factor in career satisfaction.

But for physicians who work with populations in unfortunate socioeconomic circumstances, the inability to do anything about the root cause of their patients’ medical issues leads to a sense of burnout due to the futility of adequately addressing health concerns given the limitations of patients’ socioeconomic environments.3 Today the concept of burnout goes far beyond the initial perspective of addressing the social determinants of health, and confronting issues related to burnout continues to be particularly relevant today.4 Burnout remains a syndrome characterized by a high degree of emotional exhaustion and cynicism and a low sense of personal accomplishment from work. The high prevalence of burnout among healthcare providers is cause for concern because it appears to be affecting quality, safety, and healthcare system performance.5 Short visits, complicated patients, lack of control, electronic health records stress, and poor work-home balance may lead to physicians leaving practices they once loved, poor patient outcomes, and shortages especially in primary care physicians.6 The American Medical Association is addressing issues causing and fueling burnout, including time constraints, technology, and excessive regulations.3 In 2013, a study commissioned by the American Medical Association highlighted some of the factors associated with higher professional satisfaction. Perceptions of higher quality of care, autonomy, leadership, collegiality, fairness, and respect were critical.

The report also highlighted persistent problems with the usability of electronic health records.7 In the coming years, the medical community will have to rethink the human computer interface.

Perhaps virtual scribes and artificial intelligence will eventually reduce our documentation burden.

AUGUST • JOURNAL MSMA

265

Technology alone cannot restore our professional satisfaction. Our profession will have to rebuild a sense of teamwork, community, and the ties that bind us together as healers and as human beings. We can start by recalling the original purpose of physicians' work to aid others suffering and provide comfort and care. That remains a privilege at the heart of the medical profession.7 Many organizations have initiated steps to address the aspects of burnout, but many important challenges remain. The American Medical Association's STEPS Forward is an open-access platform to empower practices to implement transformative changes designed to increase operational efficiencies, elevate clinical team management, and improve patient care. Its goal is to improve the work-lives and well being of healthcare professionals.5 Because physician burnout may jeopardize patient care, a reversal of this trend has to be viewed as a fundamental goal of healthcare policy across the globe. Healthcare organizations must invest in efforts to improve physician wellness, particularly for early career physicians.8 Approximately $4.6 billion in costs related to physician turnover and reduced clinical hours is attributable to burnout each year in the United States.9 Studies suggest that improvement is possible, investment is justified, and return on investment measurable.10 Hospital management should take initiatives toward understanding the challenges to overcome clinician burnout and provide an improved sense of well being by proposing more evidence-based solutions and monitoring their effectiveness promptly.11 For Medicine to fulfill its mission for patients and public health, all stakeholders and healthcare delivery organizations must work together to develop and implement effective remedies for physician burnout.12 Through collective action and targeted investment, we cannot only reduce burnout and promote physician wellbeing but also help physicians carry out the sacred mission that drew us to the healing professions: providing the very best care to patients.13 We are working with the University of Mississippi Medical School to improve access and cost-effectiveness of continuing education by making Grand Rounds available online. We believe this will help to reduce the demands of fulfilling continuing education requirements and help to keep our physicians on the cutting edge of medical knowledge and practice.

There is no better job for those who have the privilege to heal the sick, promote the wellness and enhance the lives of all people, especially those burdened by chronic disease and challenged socioeconomic circumstances. But we must also recognize that in caring for and comforting the sick that we can ourselves become a victim of preventable illness.

For our colleagues that require medical care for burnout, depression, and anxiety, we must encourage them to seek the appropriate medical care. We have been able to encourage the Mississippi State Board of Medical Licensure to remove the query regarding medical treatment for these issues to help encourage physicians to seek the proper care

266 VOL. 60 • NO. 8 • 2019

without concern that it could affect their medical license renewal.

The physicians who pose a risk to patient safety are those with active, untreated medical conditions who don’t seek help out of fear or shame. Physicians who are actively engaged in a treatment program are the safest, thanks to their own self-care plans and support and accountability programs. We know that physicians suffering from these illnesses receiving the proper medical care are better suited to care for themselves and their patients.14 Working together, we can lead the transformation of healthcare to be more cost-effective and efficient without allowing outside interests to jeopardize physician health and the quality of health care our patients deserve. n

Michael Mansour, MD President, Mississippi State Medical Association References 1. Freudenberger HJ. Staff burn-out. J Soc Issues. 1974;30:159-65.

2. Hood CM, Gennuso KP, Swain GR, et al. County health rankings: Relationships between determinant factors and health outcomes. Am J Prev Med 2016;129-35.

3. Fred HL, Scheid MS. Physician Burnout: Causes, Consequences, and (?) Cures.

Texas Heart J. 2018;45(4):198-202.

4. Eisenstein L. To Fight Burnout, Organize. N Engl J Med. 2018;379(6):509-511.

5.

Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high quality care. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. https://nam.edu/burnout-among-health-care- professionals-a-call-toexplore-and-address-this-underrecognized-threat-to- safe-high-quality-care.

6. Agency for Healthcare Research and Quality. Physician Burnout. 2017; AHRQ Pub.No.17-Mo18-1-EF. www.ahrg.gov.

7. Rosenthal DI, Verghese A. Meaning and the Nature of Physicians’ Work. N Engl J Med. 2016;375(19):1813-1815.

8. Panagioti M, Geraghty K, Johnson J, et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction: A systematic review and meta-analysis. JAMA Intern Med. 2018;178(10):1317-1330.

9. Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;170(11):784-790.

10. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well- being. JAMA Intern Med. 2017;177(12):1826-1832.

11. Patel RS, Bachu R, Adikey A, et al. Factors related to physician burnout and its consequences: A review. Behav Sci. 2018;8(98):1-7.

12. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors and solutions. J Intern Med. 2018;283:516-529.

13. Dzau VJ, Kirch DG, Nasca TJ. To care is human—collectively confirming the clinician-burnout crisis. N Engl J Med. 2018;378(4):312-314.

14. Hill, AB. Breaking the stigma—A physician’s perspective on self-care and recovery.

N Engl J Med. 2017;376(12):1103-1105.

I M A G E S

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M I S S I S S I P P I

M E D I C I N E

TOUGALOO COLLEGE HOSPITAL, 1909 – This photographic image, dated January 11, 1909, at Tougaloo, Mississippi, is of one of the earliest hospitals in the state for African-American patients utilizing African-American physicians: Tougaloo College Hospital. The two-story frame structure served as the college hospital (similar to the Alcorn College Hospital at Lorman at the same time) for the students and staff at this historically black liberal arts college. Tougaloo College was established in 1869 by the American Missionary Society of New York. Sitting on 500 acres of land, remnants of the larger Boddie Plantation, the college is located on West County Line Road on the northern edge of Jackson. The plantation included a mansion built in 1860 and other buildings, although other buildings were soon erected with monies from the Freedman’s Bureau. Today, much of the campus is on the National Register of Historic Places. The Mississippi State Legislature granted the institution a charter under the name of “Tougaloo University” in 1871 and for two decades provided state funding for the education of African-American teachers in the state. In its early period, the large acreage was farmed by students to cover their tuition. Over the years, Tougaloo developed a reputation for academic excellence and social activism. The institution developed close relationships with many institutions, sending its students to Brown and Tufts for their medical education. According to its website, the institution has “historically produced over 40% of the African-American physicians and dentists practicing in the state of Mississippi.” The name Tougaloo (TOO-guh-loo) derives from the Choctaw “atukla” or “tuklo” which signifies “second” or “two” originally referring to streams and was associated with the possible translations “second creek,” “two streams” or their confluence “where the creeks meet.” (There is another, less credible, theory associating the name with one of the nine villages of the Natchez listed by Iberville in 1699.) If you have more information on this image or have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. n — Lucius M. “Luke” Lampton, MD JMSMA Editor

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Edited by Lucius Lampton, MD; JMSMA Editor [This month, I continue a multi-issue focus on the poetry of the late physician-poet Merrill Moore, MD (1903-1957), a noted American psychiatrist and neurologist who also achieved fame as a poet and sonneteer. “LES SAVANTS NE SONT PAS CURIEUX” pierces me as a physician. It speaks to the earliest aphorism of Hippocrates: “Ars Longa, Vitae Brevis.”

The art is indeed long to learn, and life is short. Our intimate knowledge of life and death imparts no protection against the arithmetic of disease and our own mortality. “Doctors must die, too; all their knowledge… matters little if death raps again.”

The title is also noteworthy, referring to the famous caveat of French novelist Anatole France (1844-1924): “Les savants ne sont pas curieux,” roughly translated “those who know are not curious.” Moore, a widely-read psychiatrist, was referencing founding psychoanalyst Sigmund Freud’s use of France’s aphorism to chastise physician critics of his landmark 1899 book “The Interpretation of Dreams” (which introduced his theory of the unconscious), lamenting the medical status quo’s resistance to new ideas. I find effective Moore’s use of the terms henbane and digitalis, ancient medicinal herbs, to impart the clinging to old traditions over new. The poem is from “M: One Thousand Autobiographical Sonnets” published in 1938 (see page 899).

The tome includes a memorable frontispiece engraving by Rockwell Kent. Moore picked the poem to introduce section IX of the book, “Preoccupations on the theme of death.” Any physician is invited to submit poems for publication in the Journal either by email at lukelampton@cableone.net or regular mail to the Journal, attention: Dr. Lampton.] — Ed.

Les Savants Ne Sont Pas Curieux Doctors must die, too; all their knowledge of Digitalis, adrenalin, henbane, Matters little if death raps again--Once he may be forestalled, but their great love Or little love of life is merely human: Doctors must die like other men and women.

Ah, yes, they know the coronary well, The lenticulo-striate artery, like a bell In the village church; and when those strike their knell, What may have been well is no longer well.

Knowledge of nature gives exemption to No one, his father, and to no one’s son; No one is probably the only one Who lives any longer than other mortals do.

— Merrill Moore, MD (1903-1957)

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[In this issue, we have a long-awaited memoir from perhaps Mount Olive, Mississippi’s most famous citizen, Dr. Joe Johnston.

I had badgered him for some time now to write something for the JOURNAL MSMA after looking back to bound copies encompassing the decade he served as Associate Editor from 1983-1993. His editorials were totally honest and from the heart, insightful and refreshing , and always filled with humor and pathos that we can’t often get away with anymore in this regrettably ‘Politically Correct’ journalistic era. There were times when he would stir a bit of controversy, but such is a healthy thing. Particularly, I remember one editorial on obesity poked more than a little fun at fat women. I thought to myself that Dr. Joe had “stopped preaching and started meddling.” For several years in the early 1980s, Dr. Joe published “The Magnolia State Family Physician” magazine. Dr. Johnston was in active practice for 57 years, retiring in 2015.

It seems that Dr. Joe Johnston has been a permanent part of my life in medical practice. Although I have regrettably never set foot in Mount Olive, I feel connected to the area by knowing Dr. Joe and also his son and partner, Dr. Word Johnston. I think we first met on one of those deep sea fishing rodeos that MSMA always sponsored when meetings were on the Mississippi Gulf Coast.

He never let me live down getting sea-sick at every outing. I was privileged to serve with him on the Mississippi State Board of Medical Licensure for several years and genuinely respected his candor and the level-headed determinations and comments he would make. His judgments were always informed by many decades of experience in full-service, full-bore small town “womb to the tomb” medical practice. Another joy that he brings me personally comes from his almost daily e-mailing of some of the funniest and wackiest SPAM imaginable. It was so good to see my handsome smiling Dr. Joe and his sweet wife Mary in Destin recently at Mississippi Academy of Family Physicians 70th Annual Convocation. I know you will enjoy reading this submission. Thank God, my friend Dr. Johnston is and will always be a dear and glorious physician. — Dwalia S. South, MD]

Birthing Babies: From New York Lying-In Hospital to Mount Olive, Mississippi JOE JOHNSTON, MD The Women’s Hospital Division of the New York Hospital known as the “Lying-In Hospital” (where I trained as a medical student in 1953) was at one time one of the most prestigious centers for obstetrics and gynecology in the nation. Dr. R.Gordon Douglas, Sr., who was chairman of that division, was world-renowned and when I was there, his textbook was used in almost every medical school across the country. Dr. Joseph Nathanson, Cornell Medical School Professor, was my tutor in OB-GYN. Dr. Joe was a small rotund Jewish man in his 50’s who was very helpful to me. He had a private Park Avenue OB-GYN practice and delivered many of the “elite” in New York City at that time. I was “impressed" because he charged $1500 to $2000 per delivery, which was a fortune at that time. In today’s money that would probably equate to ten times that amount! His endearing qualities included his sympathy, kindness, and his radiation of confidence and knowledge.

On that rotation, at the same time I was taught by another famous physician Dr. Georgios Papanikolaou (aka George Papanicolaou), a Greek cytopathology pioneer that we all know primarily for his development of the cervical cancer screen known as the “Pap Smear.”

Delivering babies was the most exciting time of my training for me. We had to stay in the student quarters and were on call 24-hours a day during that time on the Obstetrical service. At our hospital, there were 6-8,000 deliveries per year. I was fortunate to deliver eight babies while on that service---but I felt like I knew it all by then!

In the delivery suite, there were always at least seven people in the room: the attending physician, the resident, the scrub nurse, the circulating nurse, the anesthesiologist, his assistant, and then the lowly medical student.

You will soon see what a difference there was when I began delivering babies in rural Covington County in the township of Mount Olive, Mississippi, following my post-graduate work at the University of Texas.

When I first arrived in Mount Olive, the older doctors (Dr. Calhoun and Dr. Stroud) were still doing home deliveries. Dr. Calhoun was beginning to use the Magee General Hospital, so I made up my mind not to do “home deliveries.” I also soon found it necessary to use hospitals that were twenty miles apart, Magee ten miles north of me and Collins Hospital ten miles south of me. This became interesting because invariably if I had a labor case going in one hospital and one in the other hospital at the same time, it became a tossup as to which way to run. Fortunately, I was present for ‘almost’ all of my deliveries, although to this day I have ladies who come up to me and say, “Dr. Johnston, do you remember when you got there too late to deliver me, and the nurse had to do it?”

Back in the day, I was starting out at age 27 with some good basic information but little real experience. Consequently, as there was no “Specialist” close by to refer problem cases to, you had to take care of them yourself! So, I soon learned to do C-sections, complicated deliveries, and take care of the sometimes severe life-threatening problems that go along with an obstetrical practice. Earlier I pointed out the seven people always AUGUST • JOURNAL MSMA

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4 Martin Luther, and L.M.) Although Dr. Calhoun had delivered all of her other babies, he

in attendance at New York’s Lying-In Hospital…in Magee or Collins, what hadintranspired, fornight, her not to let boys come outcalled into me the had had wife a heart attack the middleand of the so he wasthe unavailable.

She there was usually just the nurse, a nurse anesthetist, and me. Many times carport until I got everything cleaned up. down to their house below town when she was in hard labor. in the wee hours, it was just me and one nurse or aide in the heat of battle!

Another time, I was called about ten miles out into the country and When I first started, Chloroform was used for anesthesia. We soon wound up delivering twins by the light of an oil lamp, wrapped each in a changed to “open-drop ether,” which was much safer and easier to use. piece of a blanket, put each in a shoebox, and placed them by an open fire.

Patients were never intubated, and IVs were not necessarily started. Amazingly, I treated those twins ever since I birthed them, at least up until Sometimes it was just me on the business end of things and “whoever” was my retirement in 2015. available on the floor at the patient’s head. As conditions required, I would make aduring pulloffice quote The say, “The blood’s a little dark down here. You better let up on the ether,You ” or might Saturday afternoon hours,here.

I once saw a girlparagraph running down the if the patient began squirming around on the table too much, I wouldgoes say, hallway to the bathroom.

I didn’t know what was going on andcan sent my with above about Lovie Mae. See if you “Give her a little more ether!” nurse to check. The door was locked, and she wouldn’t open it. We finally Photoshop the images to look well enough to forced ourone way inofand found the desperate mother trying to flush her Despite all the complications that came along, practically all my patients newborn baby down the commode.

That “baby” is now a grown woman print. did well and had happy outcomes. Delivering babies 50 years ago was and still around Mount Olive! undoubtedly different from now, and you never knew what was going to crop up at the next delivery!

I simply have to tell you the story of Lovie May. She was our babysitter when my three boys were small. She had five boys herself (Luther, Luther This is going to sound strange but true. In those days, the going price was Martin, Lutheree, Martin Luther, and L.M.) Although Dr. Calhoun had $25.00 for delivering black babies and $35.00 for delivering white babies. delivered all of her other babies, he had had a heart attack in the middle of I am really not sure why this was the case, but these were the days before thetime night,i was so hedriving was unavailable.

She called me downItto their houseside below At that a 1959 MGA convertible. had plastic Medicaid or Medical insurance, and I do recall I was only reimbursed for town when she was in hard labor. panels for windows. I wrestled Lovie Mae into the passenger seat and four of my first sixteen deliveries when I went into practice. Office calls away we flew to the Magee General Hospital ten miles away. The louder were $2.00, and house calls were $3.00 at that time.

At that time I was driving a 1959 MGA convertible. It had plastic side panels she moaned, the faster I drove. There was no way she could have that for windows. I wrestled Lovie Mae into the passenger seat and away we baby flew in that little car, General so the faster i went the away. moreThe those windows My primary competition was not Dr. Calhoun (who was in his 70’s when to the Magee Hospital ten miles louder she moaned, would flap.

But, we made it to the hospital and she had one onlittle the I came to Mount Olive). Instead, it was Mary Lockhart, the steadfast local the faster I drove. There was no way she could have that babypain in that delivery table and there was the baby!

—Joe Johnston, MD black midwife. In those days, Mary would actually move in with the “labor car, so the faster I went the more those windows would flap. But we made cases” and stay until well after the baby came. She became a great friend it to the hospital and she had one pain on the delivery table and there was to me, and I always continued to treat many of her relatives and enjoyed the baby! —Joe Johnston, MD reminiscing with them about Mary.

Although I had spread the word that “I only delivered babies in the hospital,” I got tricked pretty often! “Doctor, come quick! My wife is having terrible stomach pains,” became a frequent ploy. I would get miles out in the country just in time to deliver the baby.

I recall one particular incident on a cold wintry night about 3:00 AM when I heard this “gosh-awful” noise outside my bedroom window and a frantic knocking on the front door. “Doctor, come quick, you have got to save my wife!” This man had arrived in my yard on his tractor with a wide array of spraying rigs on the back of it. I hurriedly dressed, got my medical bag, and followed him to a shotgun shack on the other end of town. I stumbled up the unlit front steps and into the house to find his wife about to deliver! I asked him to turn on the lights.

“Well, no, sir, we ain’t got any ‘lectricity.’”

I said, “Well, then, get me a lamp or a lantern,” and he allowed as to how he didn’t have either of those things either. So by firelight and my tiny otoscope, a healthy baby was delivered into the world. All this occurred while their two other small children slept soundly at the head of the bed.

For many years, after seeing forty-plus patients a day in the office, making a few house calls, and hospital rounds, I would return home only to find cars (patients) lined up in my driveway. The usual comment was, “So sorry, Doc, but we had to work all day so couldn’t make it in to your office.”

On one of these occasions, a young lady came into my carport groaning and holding her stomach. I pushed a chair up for her to sit down in, but instead, she squatted down beside the chair. I said, “Girl, get up in this chair, so I can see what is the matter with you.”

With this, to my surprise, a baby dropped onto my carport floor. At any rate, I tied the cord and did all the necessary things and sent her back home with a healthy baby. I stuck my head in the door to my home and told my 270 VOL. 60 • NO. 8 • 2019

There are hundreds of more episodes I could regale you with after decades of birthing babies in Covington County. All told, I delivered about 2500 babies during my career, and each one of them was special and with a great background story to tell. We will save them for another day.

It was disconcerting to be forced to delete the obstetrical part of my practice back in the mid-1980s. This was not because of my age, lack of experience/ training, or even a personal choice. Instead, it was the “Malpractice Insurance Crisis” that forced family physicians’ insurance premiums to a level that was merely non-sustainable in a small-town Mississippi practice where we were the ones now delivering primarily Medicaid and uninsured patients. Incredibly, our malpractice insurance premiums became the same as full-time obstetricians regardless of our experience or education. This indeed was the sad end of an era for many of us and left a void in Family Medicine that will never again be filled.

I will leave you with this final anecdote. I was once invited to give a class in “Sex Education and Marriage” several years back at our local high school.

Perhaps I put too much emphasis on sex and not quite enough emphasis on marriage because three out of the twelve young ladies who attended my lecture were pregnant by the end of the school year. Oh, well…Thank God I am a physician! n

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