VOL. LIX • NO. 6/7 • 2019

VOLUME LX • ISSUE NO. 6/7

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August 15-17, 2019

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OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION VOL. LX • NO. 6/7 • JUNE/JULY 2019

SPECIAL ARTICLES

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

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, M4 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 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices.

CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com.

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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

Top 10 Facts You Need to Know about Heat Illnesses Frederick B. Carlton, Jr., MD

200

The Growth of Pediatric Complex Care in Mississippi Sara J. Weisenberger, MD; Andrew R. Hayslett, MD; Sarah M. Jones, MD; Angelle L. Klar, MD; Regina Qadan, FNP-BC; Rebecca Hill, PNP-BC; C. Christian Paine, MD

202

Demographic and Socioeconomic Factors and Trends Associated 206 with Blood Lead Levels among Children Younger than 6 Years Old in Mississippi, 2009-2015 Ninglong Han, MS; Crystal Veazey, BS; Beryl W. Polk, PhD, MS, CPM; Gerri Cannon-Smith, MD, MPH; Lei Zhang, PhD, MBA

Strategies for the Physician Workforce Shortage in Mississippi Khang H. Dang, MD; Vy T. Nguyen, BS; Omair Arain, BS; William A. Pruett, PhD; Ralph Didlake, MD, MA

212

DEPARTMENTS From the Editor – Modern Medicine: Three Kids, Three Jobs Lucius M. Lampton, MD

198

Editorial – Disability is in the Eyes of the Beholder D. Stanley Hartness, MD; Associate Editor

218

Physician Leadership Academy

220

Letter to the Editor

226

New Members

226

MMPAC

227

President's Page – Increasing Access to Health Care in Mississippi: Understanding the Challenges and Possible Solutions Michael Mansour, MD

234

In Memoriam

238

Images in Medicine – Dentistry in Lambert, 1906 Lucius M. Lampton, MD

239

Poetry and Medicine – Hematuria Merrill Moore, MD

240

Summer’s Delight- Ron Cannon, MD, an otolaryngologist in private practice with Head & Neck Surgical Group, photographed these fresh tomatoes. He grows them in the breezeway between his main house and garage apartment where it’s convenient to check on them, water, fertilize, etc. “From my perspective, the main reason to grow tomatoes is for sandwiches, especially a BLT! Generally, I plant ‘Better Boy’ tomatoes from a pot and not seeds as I am not an experienced ‘farmer,’” he said. “However, I do experiment from time to time with different varieties of plants.”

MSMA • Since 1959

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F R O M

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Modern Medicine: Three Kids, Three Jobs W

hat is a day in the life of a modern physician at midcareer? “Three kids, three jobs,” is how a fellow physician described his daily routine. (Mine is two kids, five jobs.) Those four words embody the essential requirement the modern physician faces: the balance of family and work (and how to pay for it!). The modern practice routine has become the ultimate art of repeated multiLucius M. Lampton, MD tasking, not only in our daily work but Editor also in the caring of our families. More doctors these days are having to wear more hats just to make ends meet. Each hat has its own burdens and responsibilities, and the multiple jobs leave the average physician stretched out and stressed out.

Look around and notice fellow physicians being interrupted constantly by texts or phone calls from nurses, staff, clinics, hospitals, patients, nursing homes, hospices, or home health. The overwhelming duties of these different jobs spill into patient rooms, family mealtimes, church, medical meetings, vacation, pretty much wherever

a physician is. The cell-phone tethers the physician as the constant prisoner of modern medicine. In the old days, the pager was turned off when the doc was not on call.

For better, physicians have assumed lately a more prominent role in the lives of their children. Such was long needed, but brings with it additional juggling of responsibilities. These days, physicians often are seen taking their kids to school and picking them up, even attending with faithfulness extracurricular events. The proverbial “three kids” often have different ages, different schools, and different bedtimes.

Surrendering to the marathon of parenthood and its necessity of selfdenial are entwined in modern medical life. Today’s physicians are trying to do it all, even as they struggle with the attending burdens.

The life of a modern physician, you see, is one of inherent stress and responsibility both at work and at home. We juggle the duties of parenthood just as we juggle the duties of our profession. And the work seems unending. Such leaves as imperative a ceaseless endeavor by our profession to make more tolerable the strains of life intrinsic in modern medicine.

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

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

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

ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD CARDIOVASCULAR DISEASE Thad F. Waites, MD

GASTROENTEROLOGY James Q. Sones, MD GENERAL SURGERY Andrew C. Mallette, MD

CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD, MBA, FAPA, CPE

HEMATOLOGY Carter Milner, MD

CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD

INFECTIOUS DISEASE Rathel "Skip" Nolen, III, MD

DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

INTERNAL MEDICINE Daniel P. Edney, MD Daniel W. Jones, MD Brett C. Lampton, MD Kelly J. Wilkinson, MD

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INTERNAL MEDICINE/ EPIDEMIOLOGY Thomas E. Dobbs, MD MEDICAL STUDENT John F. G. Bobo, M4 NEPHROLOGY Harvey A. Gersh, MD Sohail Abdul Salim, MD OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Sheila Bouldin, MD Darden H. North, 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 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

m'ACm®I

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Robert S. Caldwell, MD, Award

recognizing excellence in patient care, documentation, and communication in a senior level resident at the University of Mississippi Medical Center

Congratulations to this year’s award recipient!

Chelsea S. Mockbee, MD Dermatology Past Recipients 1982 Jack Foster, MD – Cardiology

2000 Ford Dye, MD – Otolaryngology

1983 Martha J. Brewer, MD – Ob-Gyn

2001 Chet Shermer, MD – Emergency Medicine

1984 Sam J. Denney, Jr., MD – Pediatrics

2002 Demondes Haynes, MD – Pulmonology

1985 William H. Coltharp, MD – Cardiothoracic Surgery

2003 Kimberly W. Crowder, MD – Ophthalmology

1986 Bobby L. Graham, Jr., MD – Medical Oncology

2004 Kentrell Liddell, MD – Family Medicine

1987 Sam Newell, MD – Neurology

2005 Christopher M. Charles, MD – Pediatrics

1988 Marc Aiken, MD – Orthopaedic Surgery

2006 Matt Runnels, MD – Gastroenterology

1989 W. Richard Rushing, MD – Ob-Gyn

2007 David L. Spencer, Jr., MD – Urology

1990 Charles G. Pigott, MD – General Surgery

2008 Lillian Joy Houston, MD – Psychiatry

1991 R. Glenn Herrington, MD – Ophthalmology

2009 Shane Michael Sims, MD – Ob-Gyn

1992 Mark G. Hausmann, MD – General Surgery

2010 Lee Murray, MD – Neurology

1993 Gary L. Smith, MD – Anesthesiology

2011 Leslie Mason, MD – Ob-Gyn

1994 Michael R. McMullan, MD – Cardiology

2012 Christopher M. Bean, MD – Urology

1995 Damea B. Benton, MD – Pediatrics

2013 Victor Copeland, MD – Ophthalmology

1996 Jeffrey D. Noblin, MD – Orthopedic Surgery

2014 Christina G. Marks, MD – Radiology

1997 Scott E. Harrison, MD – Otolaryngology

2015 James A. Moss, Jr., MD – Orthopaedic Surgery

1998 David Stuart Emerson, MD – Family Medicine

2016 Rishi A. Roy, MD – General Surgery

1999 Timothy B. Murray, MD – General Surgery

2017 Michael T. Cosulich, MD – Dermatology

2018 Madison H. Williams, MD – Hematology/Oncology

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Top 10 Facts You Need to Know about Heat Illnesses FREDERICK B. CARLTON, JR., MD

Introduction A variety of heat-related illnesses are seen in clinical practice.¹ While some are minor and easily treated, the more severe types may be very painful or even lethal.

1

Heat Rash. Heat Rash (also known as prickly heat) may occur at any age, but newborns and infants are most susceptible because of immature sweat ducts. It is especially common in hot, humid weather and occurs when sweat ducts become obstructed and perspiration is trapped under the skin, causing an inflammatory reaction. Symptoms range from clear superficial blisters to red papules to erythematous lesions deeper in the skin. Heat rash may be pruritic.

Infants tend to manifest the rash chiefly on the neck, shoulders, and chest, but it may also be seen in the axillae, antecubital fossae and inguinal areas. The rash typically resolves on its own, but symptoms may be alleviated by cooling the skin and preventing sweating. Loose fitting clothing and/or a cool environment will prevent the development of heat rash.

2

Heat Edema. Heat edema is seen in the legs and hands, usually in the setting of prolonged sitting or standing in a hot environment. The increased warmth causes peripheral vasodilation and predisposes dependent areas of the body to this condition. This malady is more common in individuals who are not acclimated to the heat, is self-limited and is treated by moving to cooler conditions.

3

Heat Syncope. Heat syncope is a mild form of heat illness that occurs more often during physical exertion in a hot environment² and occurs in the setting of significant vasodilation from the body’s attempt to dissipate heat. Peripheral shunting of blood may diminish cerebral perfusion, particularly in the setting of dehydration, to the point that a transient loss of consciousness may occur. Mental status returns to baseline quickly once the patient is in a horizontal position. Prior to the syncopal episode, the patient may experience symptoms such as dizziness, headache, increased pulse rate, restlessness, nausea, and vomiting. Treatment consists of having the patient lie down in a cool environment, if possible, and oral hydration.

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4

Predisposing Factors for Serious Heat-Related Illnesses.

Several factors and conditions predispose an individual to serious heat illnesses including exposure to high ambient temperatures, humidity and physical conditions such as dehydration, cardiovascular and other chronic diseases, obesity, diminished ability to sweat (usually from medications), alcohol use, fatigue and sleep deprivation.3,4 The role of these factors varies with the type of heat illness.

5

Heat Cramps. Heat cramps are involuntary muscle spasms most commonly involving the calves and thighs but may include other muscle groups and can be generalized. They frequently occur in those working in hot and especially humid conditions who fail to maintain adequate hydration. Symptoms resolve with rehydration and, if the patient is having severe discomfort, intravenous hydration may be appropriate and hasten recovery.¹

6

Heat Exhaustion. Heat exhaustion is manifested by symptoms that may include headache, nausea, vomiting, dizziness, irritability, malaise, fatigue, increased thirst, marked sweating, elevated temperature, and decreased urine output. While the core body temperature may be normal, it can be elevated but should be lower than 40° C (104° F). Mental status is not altered in heat exhaustion, helping to differentiate it from heat stroke. Treatment consists of removing the individual from activity, placing him/ her supine in a cool environment, convection measures using cool water on the skin with fans and rehydration. Heat exhaustion may progress to heat stroke if treatment is delayed. ¹,³

7

Classic Heat Stroke. Heat stroke is a multisystem illness characterized by sudden onset of alteration of the central nervous system with multiorgan dysfunction (especially acute kidney injury, liver injury,⁵ disseminated intravascular coagulation and rhabdomyolysis) and high body temperatures, usually in excess of 40° C (104° F).⁶ This form of heat stroke is due to loss of thermoregulatory control during prolonged exposure to a hot environment, such as occurs during a heat wave. Anhidrosis may be noted in classic heat stroke but occurs late and is, thus, not universally found. Individuals most at risk include infants, the elderly and the chronically ill (especially those with reduced cardiovascular reserve or mobility, obesity, neurologic or psychiatric disease or who are on medications including diuretics, betablockers or drugs with anticholinergic properties).

8

Exertional Heat Stroke. Exertional heat stroke occurs when an individual is unable to eliminate heat generated through activity and usually occurs while in high ambient temperatures which contribute to the illness. High humidity is often a significant contributory factor. Other risk factors include dehydration, lack of acclimatization, obesity,⁴ poor physical fitness and sympathomimetic use. As in classic heat stroke, a temperature above 40° C (104° F) is usually noted coupled with sudden alteration in mental status. Renal injury, rhabdomyolysis and disseminated intravascular coagulation are more common than is seen in classic heat stroke.

Treatment of Heat Stroke. The most important action for either classic or exertional heat stroke is rapid cooling. The techniques used depend on what is available and the stability of the patient. The victim should be moved to a cooler environment as quickly as possible. Ice water immersion (of the extremities alone if submersion of the torso is not possible or safe)⁷ or convection with evaporative cooling by keeping the skin wet and using fans to facilitate an endothermic process are the most proven methods for rapidly reducing the core temperature. 8,9

9

Ice packs to the neck, axillae and inguinal areas may be used but are less effective than immersion or evaporation techniques.¹⁰ Invasive procedures such as cool gastric or peritoneal lavage have been suggested, but there is little data to support their use and potential risks such as aspiration or infection should discourage their consideration.

Pharmacotherapy has little to no role as antipyretics have proven ineffective, dantrolene has not been useful¹¹ and benzodiazepines to reduce shivering (and thus heat generation) have not helped lower the core temperature although they may make the treatment more tolerable. Continuous or frequent temperature monitoring is needed to observe response to treatment. Volume resuscitation is important and should be guided by the patient’s volume status, blood pressure and urine output.

10

Prevention. Most forms of heat illness are preventable.

When possible, prolonged exposure to high temperatures should be avoided or frequent rest breaks taken when avoidance is not an option. Maintaining hydration is vital in reducing the frequency and severity of the more significant forms of heat illness.³ The elderly, chronically ill and others at risk for classic heat stroke should be monitored to assure adequate hydration is being maintained and that they are in a safe and climate-controlled environment, especially in times of prolonged elevation of ambient temperatures such as a heat wave.

References 1.

Bross MH, Nash BT Jr, Carlton FB, Jr. Heat emergencies. Am Fam Physician. 1994:50:389–96.

2. Asplund CA, O’Connor FG, Noakes TD. Exercise-associated collapse: an evidence-based review and primer for clinicians. Br J Sports Med. 2011; 45:115762.

3.

Lipman GS, Eifling KP, Ellis MA, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of heat-related illness. Wilderness Environ Med. 2013;24:S55-65.

4. Bedno SA, Li Y, Han W, et al. Exertional heat illness among overweight U.S.

Army recruits in basic training. Aviat Space Environ Med. 2010;81:107-11.

5.

Garcin JM, Bronstein JA, Cremades S, et al. Acute liver failure is frequent during heat stroke. World J Gastroenterol. 2008;14:158-59.

6. al-Mashhadani SA, Gader AG, al Harthi SS, et al. The coagulopathy of heat pilgrimage (Haj) to Makkah. Blood Coagul Fibrinolysis. 1994;5:731-6.

7.

Casa DJ, McDermott BP, Lee EC, et al. Cold water immersion: the gold standard for exertional heat stroke treatment. Exerc Sport Sci Rev. 2007;35:141-49.

8.

Bouchama A, Dehbi M, Chaves-Carballo E. Cooling and hemodynamic management in heatstroke: practical recommendations. Crit Care. 2007; 11:R5464.

9. Smith JE: Cooling methods used in the treatment of exertional heat illness. Br J Sports Med. 2005;39:503-507.

10. Gaudio FG, Grissom CK. Cooling Methods in Heat Stroke. J Emerg Med. 2016; 50:607-615.

11. Bouchama A, Cafege A, Devol EB, et al. Ineffectiveness of dantrolene sodium in the treatment of heatstroke. Crit Care Med. 1991;19:176-80.

Author Information Chair and Program Director, Department of Emergency Medicine, Magnolia Regional Health Center, Corinth. Professor Emeritus, Emergency Medicine, University of Mississippi Medical Center, Jackson (Carlton). Conflicts of Interest: None.

Corresponding Author: Rick Carlton, MD, Department of Emergency Medicine, Magnolia Regional Health Center, 611 Alcorn Drive, Corinth, Mississippi 38834 Ph: (662) 293-7676 (FCarlton@mrhc.org).

Conclusion. Heat illness presents on a spectrum from very mild to potentially lethal. Removing the individual from exposure combined with rehydration and cooling, in most cases, are appropriate therapies.

The aggressiveness of rehydration and cooling techniques depends on the severity of the illness as discussed above. n

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U P - T O - D A T E

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The Growth of Pediatric Complex Care in Mississippi SARA J. WEISENBERGER, MD; ANDREW R. HAYSLETT, MD; SARAH M. JONES, MD; ANGELLE L. KLAR, MD; REGINA QADAN, FNP-BC; REBECCA HILL, PNP-BC; C. CHRISTIAN PAINE, MD Introduction There is a growing population of children in Mississippi as well as nationally with complex medical needs. These patients account for a large proportion of healthcare expenditures, and yet, due to lack of coordination of care and identification of outpatient resources, are frequently underserved. This population, often referred to as children with medical complexity (CMC) or children with complex chronic conditions (CCC), is a special subgroup of children with special healthcare needs (CSHCN) that requires intensive care treatments, lifesustaining technologies and multiple subspecialty care.1 The conditions for these children vary but frequently involve severe neurologic or neuromuscular disability, ventilator dependence, gastrostomy dependence, severe congenital complications involving the heart or lungs, and other life-limiting disease states. There is an increasingly urgent need for a system of healthcare delivery that provides the comprehensive care these children need and deserve. The purpose of this article is to update providers on the growth and challenges facing this special population as well as to discuss the developing ‘Pediatric Complex Care’ models in Mississippi.

Keywords: children with medical complexity (CMC); pediatric complex care, chronic complex care ( CCC).

Background Nationally, many of these children with complax medical needs are covered by Medicaid. One study of Medicaid utilization from 2014 showed that while the CMC population accounted for only 5.8% of Medicaid patients, they also account for 34 % of Medicaid healthcare spending and a staggering 47% of hospital care spending. Perhaps even more noteworthy is that the most severe 5% of the already small but growing CMC population accounted for 50% of the charges for all CMC patients.2 In response, The Lucille Packard Foundation for Children’s Health sponsored a 2015 National Symposium in Washington, D.C., on the increasingly critical challenges of designing systems of care for these children.3 Mississippi, as a state, has also grappled with how to best care for this special group.

An early pioneer in the care of CMC in Mississippi was Dr. Thomas Blake, the first board-certified orthopedic surgeon in the state. He

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helped develop the Mississippi Crippled Children’s Service in 1936 following an epidemic of infantile paralysis. That program was transferred to the State Department of Health in 1974 and subsequently became the Children’s Medical Program (CMP). He continued to attend the clinics until his retirement in 1977. In 1982, the name of the Jackson CMP clinic was changed to the ‘Blake Clinic for Children’ in his honor. The goal of this newly renamed clinic was broadened to provide comprehensive, coordinated, more cost-efficient care to patients requiring complex, multi-specialty care and their families. The Blake Clinic hosted providers from several specialties bringing multiple specialists to the child and family at one appointment.

In recent years, changes in health care funding have forced the closure of several underfunded clinics in Mississippi. In August 2015 the Blake Clinic, then operating out of the Jackson Medical Mall (JMM), was closed. The leadership at Children’s of Mississippi recognized the ongoing need to provide quality and comprehensive care for the Blake Clinic patients as well as all of the complex patients across the state, thus planting the ‘seed’ for a new Complex Care Clinic at UMMC. In forming a system that works best for CMC patients and families, research has defined three distinct models: primary care centered, comanagement centered, and episode based care.4 Of course, each model has its benefits and challenges. This article will address the needs and management of this growing population, the opportunities and challenges of providing comprehensive care for these patients and their families and what structures of care may work best for providers and patients in Mississippi.

Description of Medical Complexity In response to the need for a more systematic means of identification and management of the CMC population, the American Academy of Pediatrics (AAP) released a clinical report in 2016. This report remarks on the difficulty of defining CMC patients – specifically, that a definition based only on certain medical conditions or on high healthcare resource utilization will likely exclude many relevant patients.5 Another option is to define patients more broadly based on severity of functional limitations, chronic and multisystem health conditions, or dependence on technology for mobility, feeding, or heart and lung function, all sharing a need for supportive and multidisciplinary services.5

Complex medical needs and chronic illness bring with them the necessity for a network of support systems and providers, equipment, multiple medications, and constant care. All of these are directed at preventing complications and carefully managing illness to avoid even more frequent hospital and critical care utilization. One study found that caregivers of CMC spent an average of two hours per week on care coordination and 11 to 20 hours per week on care at home.6 Additionally, over half struggled financially, and in 54 % of cases, a family member had to stop working to care for the child.6 Even with all of this focused effort, still 49 % reported one or more deficiency in healthcare services, and 33 % reported a gap in non-clinical services.6 CMC patients and their families are in need of a care model that can tie together the many settings and types of care they require: primary and subspecialty care (both inpatient and outpatient), critical and emergency care, homenursing, speech therapy, occupational therapy, physical therapy, mental health support, and school-based services.5 The goal of all these efforts would be to improve the quality of care and thus the quality of life for CMC and their families. This will also result in reducing unnecessary emergency visits, admissions, and treatments, thus reducing cost.2 Growth of Complex Care in Mississippi With these goals in mind, it is important to establish a model of care that works for CMC patients across Mississippi. A primary care centered model is often considered ideal due to the proximity to and relationship with the patient and family.4 These factors allow for ongoing support through continuity of care and recognition of needs throughout the illness journey. Another model mentioned as beneficial is the co-managed model, often based in tertiary care centers that actively communicate with the patient’s primary care provider. In this way, patients can connect with multispecialty providers as well as comprehensive resources through a tertiary care hospital clinic while still integrating the care of their local primary physician.7 The last model involves episode-based care and is primarily found in the form of an inpatient ‘Complex Care’ team, thus providing a link and coordination with outpatient and primary care providers during and after inpatient admissions. 4 In all three cases, the necessity of a comprehensive and well-coordinated medical home is emphasized.4, 5, 7 In the ongoing effort to develop a system of care for Mississippi’s CMC patients, the goal has been to maintain and support the primary care medical home of each family’s choosing through collaboration with community providers. There is also progress toward more efficient multispecialty and multidisciplinary models to provide the necessary tertiary care support through Children’s Hospital.

The Complex Care Clinic at JMM is dedicated to care and coordination of resources for CMC patients and families. This clinic functions as a primary care centered model as well as a co-managed model, depending upon an individual patient’s needs. In the clinic, patients see one of three physicians and two nurse practitioners, a nutritionist, and a social worker in addition to other clinic staff. Also, the clinic is a community partner with MSDH’s Office of Health Services, which helps families and providers to identify and utilize community services organized through the public health districts. This includes transitioning to adult

care, adult insurance funding, waivers, and the assistance of public health nurses and social workers. The Complex Care Clinic is supported and staffed by UMMC. As the care of this population requires a substantial investment of non-clinical time in coordination of care, many of the teams caring for these patients are based in larger institutions that can provide financial support beyond revenue generated.

The clinic also helps care for many “medically fragile” patients with technological dependences and frequent admissions who are in definite need of inpatient and outpatient coordination and collaboration as described in the episode-based care model. Part of this effort included the integration of the inpatient Complex Care team with the CMC clinic.

This coordination team is made up of two nurse practitioners, two respiratory therapists, a social worker and nurse coordinator. Patients who are ventilator dependent are also followed by a home vent-team headed by a pediatric pulmonologist. For patients needing symptom relief, discussions of goals of care, and emotional support, Palliative Care physicians partner with the clinic and provide inpatient and outpatient consults. In addition, an inpatient Complex Care admitting service will be established at Children’s of Mississippi to promote continuity of care for CMC patients between inpatient and outpatient encounters.

Referrals are welcomed from all over the state, both by phone at 855984-KIDS (855-984-5437) and through UMMC’s website at www. ummchealth.com/refer/. The ‘care team’ includes all primary care providers (whether out in the community or within the UMMC system), medical specialists, therapists, dental specialists, eye specialists, dietitians, medical supply companies, insurance companies, and others.

Communication and coordination are crucial in the care of medically complex children, and the clinic staff strive to stay in contact via phone, email, and other correspondence with providers around the state regarding referred patients.

Conclusion Although CMC patients represent a relatively small but growing subset of all hospitalized children, they utilize a disproportionately large amount of healthcare resources.8 These patients receive care involving multiple providers, specialties, and settings and often require technological support and skilled care at home.8 Any model of care for CMC must take into account all of these aspects of their care to be successful in providing quality and comprehensive medical care. Further complication is introduced when considering Medicaid rules and reimbursement that are often geared towards the majority of children not in the CMC population.9 Due to the unique challenges of CMC, a unified approach is most likely to produce meaningful improvement of outcomes and cost for this population.10 Particular areas for improvement have been identified as communication and collaboration with CMC patients’ primary care providers, continuity and coordination across care settings, comprehensive care teams with access to necessary resources and specialties, and psychosocial support for families.10

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In Mississippi, as in many other states, access to care is not evenly distributed. Providers must work together to identify the patients and families who need a more unified approach and then collaborate to provide CMC with the resources that they need.

Goals for future consideration will include decreased hospitalizations and emergency room use, decreased re-admissions, increased patient satisfaction, development of a knowledgeable care team for each patient, and improved communication between tertiary care providers and community providers. Costs may also be decreased by reducing the duplication of services and improving home and preventative care for these children. Additionally, as more children live longer with medical complexity and grow into adulthood, concerted efforts from the entire Mississippi healthcare community will be required to continue to care for the most vulnerable of our children and their families.

References 1. Cohen E, Kuo DZ, Agrawal R, et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. 2011;127(3):529-538.

2. Berry JG, Hall M, Neff J, et al. Children with medical complexity and Medicaid: spending and cost savings. Health Aff (Millwood). 2014;33(12):2199-2206.

3. Olson, S. Proceedings for the 2015 Symposium: Designing Systems That Work for Children with Complex Health Care Needs. The Lucile Packard Foundation for Children’s Health. December, 2015: Washington, D.C. 4. Pordes E, Gordon J, Sanders LM, Cohen E. Models of Care Delivery for Children

RightTrack

MEDICAL GROUP

With Medical Complexity. Pediatrics. 2018;141(Suppl 3):S212-S223.

5. Kuo DZ, Houtrow AJ, Council On Children With D. Recognition and Management of Medical Complexity. Pediatrics. 2016;138(6).

6. Kuo DZ, Cohen E, Agrawal R, Berry JG, Casey PH. A national profile of caregiver challenges among more medically complex children with special health care needs.

Arch Pediatr Adolesc Med. 2011;165(11):1020-1026.

7. Cohen E, Lacombe-Duncan A, Spalding K, et al. Integrated complex care coordination for children with medical complexity: a mixed-methods evaluation of tertiary care-community collaboration. BMC Health Serv Res. 2012;12:366.

8. Cohen E, Berry JG, Camacho X, Anderson G, Wodchis W, Guttmann A. Patterns and costs of health care use of children with medical complexity. Pediatrics.

2012;130(6):e1463-1470.

9. Graham L, Ray G. Medical Home Clinics Help Improve Care for Children with Medical Complexities. Children’s Hospitals Today. 2016. https://www. childrenshospitals.org/Newsroom/Childrens-Hospitals-Today/Fall-2016/ Articles/Medical-Home-Clinics-Help-Improve-Care-for-Children-with-MedicalComplexities. Accessed May 16, 2018.

10. Coller RJ, Nelson BB, Sklansky DJ, et al. Preventing hospitalizations in children with medical complexity: a systematic review. Pediatrics. 2014;134(6):e1628-1647.

Author Information University of Mississippi Medical Center, Complex Care Service, (Weisenberger; Hayslett; Jones, Qadan, Hill, Paine) Jackson. Palliative Care Service, (Paine, Hayslett, Klar) Jackson.

Corresponding author: C. Christian Paine, II, MD, University of Mississippi Medical Center, Department of Pediatrics, 2500 N. State St., Jackson, MS 39216 Ph: (601)8158147 (cpaine@umc.edu).

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Demographic and Socioeconomic Factors and Trends Associated with Blood Lead Levels among Children Younger than 6 Years Old in Mississippi, 2009-2015 NINGLONG HAN, MS; CRYSTAL VEAZEY, BS; BERYL W. POLK, PHD, MS, CPM; GERRI CANNON-SMITH, MD, MPH; LEI ZHANG, PHD, MBA

Background Lead exposure can affect nearly every system in the body and is associated with numerous behavioral and learning problems, even for low levels of lead at or below 5 micrograms per deciliter (µg/dL).1-4 Studies show children with high blood lead levels (BLLs) >=70 µg/dL demonstrated severe neurologic problems, including seizures, comas, and even death.5 Children are especially vulnerable to the cognitive, hematological, neurological and behavioral effects of lead toxicity.6-7 In 1991, the Centers for Disease Control and Prevention (CDC) defined venous blood lead levels >=10 µg/dL as the “level of concern” for children under 6 years.8 In 2012, CDC’s Advisory Committee for Childhood Lead Poisoning Prevention (ACCLPP) recommended using a reference level of 5 µg/dL in venous or capillary results to identify children with elevated blood lead levels (EBLLs).9-10 This reference value is based on the 97.5th percentile of the National Health and Nutrition Examination Survey’s (NHANES) blood lead distribution in children.9-10 The CDC will update the reference value every four years using the two most recent NHANES surveys.9-10 In 2017, the Mississippi State Department of Health (MSDH) began using the reference level (blood lead level>=5 µg/dL) to identify children with EBLLs. Previous studies have identified several demographic and socioeconomic factors associated with children with EBLLs, which included children enrolled in Medicaid, AfricanAmerican children, poverty income ratio <1.3, children living in pre 1978 houses, and children at ages 1 and 2.11-12 Our aim is to assess local data on lead risks as the basis for developing policies and activities for child lead prevention and intervention in their areas.

Study Questions There has been a steady decline in the number of children under 6 with confirmed EBLLs>=10 µg/dl from 2009 to 2015 in Mississippi; however, the number and percentage of children with EBLLs>=5 µg/ dl (either in venous or capillary results) was not assessed for those years

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based on the revised criteria (CDC 2012). In 2016, it was reported in the literature that the percentage of children with EBLLs>=5 µg/dl 13 increased from 2009 to 2015 in Mississippi. This study was partially initiated to clarify the equivocal findings and to establish the baseline of number and percentage of children with EBLLs in Mississippi under the CDC recommended reference level (CDC 2012). This study also investigates children younger than 6 years old in accordance with the new reference level of 5 µg/dl in either venous or capillary tests, to identify trends from 2009 to 2015, and to investigate associated demographic and socioeconomic factors including age, gender, race, Medicaid status, and county risk status (place).

Method Data Source The data for the study comes from the Mississippi Lead Poisoning Prevention and Healthy Homes Program (MSLPPHHP) Healthy Housing and Lead Poisoning Surveillance System (HHLPSS).

According to the MSDH’s List of Reportable Diseases and Conditions, all blood lead levels for children younger than 6 years of age in collected laboratories, clinics and hospitals in Mississippi must be reported to the MSLPPHHP.14-15 Using data linkage methods (includes Probabilistic Record Linkage methods), the data were cleaned routinely: cleaning abnormal data, duplicated data, and finding missing data from other sources, such as the Mississippi Division of Medicaid and the MSDH’s Patient Information Management System (PIMS). Verification procedures were conducted to find and delete false links. On average, 44,514 children younger than 6 years of age were tested for lead in Mississippi each year. Using this database, a combined total of 311,601 children under 6 years of age who had a lead test from 2009 to 2015 were included in the study. Data from the Mississippi Division of Medicaid was also used to calculate the test rate in Medicaid children and the rate of Medicaid children with EBLLs. Data from the 2010 Census and results from bridging the

Vintage 2016 postnatal estimates were used to estimate the number of children younger than 6 by age, gender, and race.16 Data from the U.S. Census Bureau’s 2011-2015 American Community Survey 5-Year Estimates were used to determine the proportion of housing constructed before 1978.17 According to the CDC, lead-based paints were banned from use in housing in 1978.18 Statistical Analysis The percentages of children with EBLLs were calculated and placed in three categories: overall, Medicaid, and Non-Medicaid. The Average Annual Percent Changes (AAPC) were calculated for percentages of children with EBLLs during those years. We evaluated the association between the demographic and socioeconomic factors of lead exposure with the likelihood of receiving blood lead testing and having EBLLs. The EBLLs were divided into two categories: 5.0-9.9 µg/dl and >=10.0 µg/dl. Chi-Square testing for trends was used to assess the significance of the changes over the seven years. Chi-Square testing was also used to assess the significance of observed differences between testing rates and demographic and socioeconomic factors, and between EBLLs rates and demographic and socioeconomic factors at a level of significance of α=0.05. Multiple logistic regression models were used to identify demographic and socioeconomic factors associated with EBLLs 5.0-9.9 µg/dl and EBLLs>=10.0 µg/dl. Adjusted odds ratio (aOR) and 95% confidence intervals (CIs) were obtained in each subgroup relative to a referent group while controlling for children’s age, gender, race, Medicaid status, and risk county status. An aOR was considered statistically significant if its 95% CI did not include one (1.0). Statistical Analysis System (SAS) 9.4 was used for the analysis.

Measures of blood lead levels The number and percentage of children who had blood lead tests and the number and percentage of children who had EBLLs were taken from data for 2009 to 2015. Two dichotomous measures of blood lead were used: EBLLs 5-9 µg/dL and EBLLs>=10 µg/dL. According to the section of data and surveillance from the CDC lead poisoning prevention guideline,19 a child may be screened for multiple years or even multiple times within a given year; however, we counted only one screening for each year. If samples were all venous, we took the highest test result during the year. If samples were mixed capillary and venous, we took the highest venous result. If the samples were all capillaries, we took the lowest test result. Unknown sample types were also treated as capillary. A child may have variable Medicaid status during the year. We count the child as a Medicaid beneficiary if the child was ever a Medicaid recipient during the year. Because children may be in families that moved from one place to another during the year, for the category of county risk, we count cases based on where they lived when they had the highest EBLLs. Non-elevations were based on where they lived when they had their first test.

Variable Explanations In analyzing the trends, the dependent variable was the percentage of

children with EBLLs >=5 µg/dl among those tested during the year.

When we calculated the percentage, the numerator represents the number of children with EBLLs >=5 µg/dl, and the denominator represents the number of children tested during the year.

When evaluating the association between the demographic and socioeconomic factors of lead exposure and the likelihood of receiving blood lead testing and having EBLLs, observations were assigned to one of six categories based on age: <1 year, 1 year of age, and 2, 3, 4, and 5 years of age. Observations were divided into two categories based on gender (male and female) and divided into two categories based on race (African-American and Caucasian). Observations were assigned to one of two categories based on children’s Medicaid status: Medicaid or non-Medicaid. Two categories were assigned based on the lead risk in the counties where children live: high-lead risk counties or low-lead risk counties. According to Mississippi State Department of Health’s LPPHHP Screening Plan,20 counties at highrisk meet four criteria: higher number or percentage of children with EBLLs in previous years, higher number or percentage of houses built before 1978, higher percentage of people in poverty, and a lower percentage of children tested for lead. The high-risk counties (23 counties) included Adams, Calhoun, Claiborne, Coahoma, Copiah, Harrison, Hinds, Holmes, Humphreys, Issaquena, Jackson, Jefferson Davis, Jones, Lauderdale, Leflore, Pike, Quitman, Sharkey, Sunflower, Warren, Washington, Webster and Yazoo.

Results Children tested for lead The children tested differed significantly by age (p<0.0001), race (p<0.0001), Medicaid status (p<0.0001), and risk county status (p<0.0001). Children aged 1 and 2-year old were more likely to be tested compared to children in other age categories. The results reflected the MSDH Blood Lead Screening Guidelines, recommending routine lead tests for children at Early and Periodic Screening, Diagnostic and Treatment (EPSDT) visits at 1 and 2-year old.20 The children less than age 1 and age 5 had a lower testing rate (Table 1).

There was no significant difference in the percentage of children tested for lead between male and female (p=0.93). African-American children were more likely to have been tested for lead than Caucasian children (p<0.0001). Non-Medicaid children were more likely to have been tested for lead than Medicaid children (p<0.0001). Children in high-risk counties were more likely to have been tested for lead than children in low-risk counties (p<0.0001) (Table 1).

Children with EBLLs Trends of EBLLs. The percentage of children with EBLLs based on the current standard (EBLLs>=5 µg/dL) in Mississippi significantly decreased from 11.60% in 2009 to 2.55% in 2015 (p<0.0001) by an

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average of 21.80% per year. The percentage of children enrolled in Medicaid with the current standard of EBLLs significantly decreased from 12.31% in 2009 to 2.79% in 2015 (p<0.0001) by an average of 21.33% per year; the percentage of non-Medicaid children with the current standard of EBLLs in Mississippi significantly decreased from 8.25% in 2009 to 2.16% in 2015 (p<0.0001) by an average of 19.33% per year. The disparity measured by percentage difference of EBLLs between children in Medicaid status and children in non-Medicaid status has been reduced from 4.06% in 2009 to 0.63% in 2015 (Figure 1).

Demographic and Socioeconomic Factors with EBLLs. Children with the EBLLs differed significantly by age, gender, race, Medicaid enrollment and high or low-risk county status on both EBLLs levels (EBLLs 5-9.9 µg/dl and EBLLs>=10 µg/dl). Children ages 2 and 3 were more likely to have EBLLs than other ages of children. Males were more likely to have EBLLs than females. African-American children were more likely to have EBLLs than Caucasian children.

Children enrolled in Medicaid were more likely to have EBLLs than those not in Medicaid, and children who resided in high-risk counties were more likely to have EBLLs (Table 2).

When controlling age, gender, race, Medicaid status, and county lead exposure status, the following was found: For category EBLLs 5-9.9 µg/dl, Using 5-year old children to be referent, 2-year old children had about 61% increased odds to have EBLLs, 3-year old children had about 39% increased odds to have EBLLs, 1-year old children had about 25% increased odds to have EBLLs, 4-year old and under 1-year old children had about 12% increased odds to have EBLLs (p<0.0001).

Males had about a 19% increased odds to have EBLLs than females (p<0.0001). African-American children had about a 7% increased odds to have EBLLs than Caucasian children (p<0.0001). Children enrolled in Medicaid had a 93% increased odds to have EBLLs than non-Medicaid enrolled children (p<0.0001). County status didn’t significantly affect children’s risk for EBLLs (p=0.9597).

For category EBLLs >=10 µg/dl, Using children less than 1-year old to be referent, 1-year old children were about 2.25 times as likely to have EBLLs, 2-year old children were about 3.80 times as likely to have EBLLs, 3-year old children were about 3.42 times as likely to have EBLLs, 4-year old children were about 2.65 times as likely to have EBLLs, and 5-year old children were about 2.67 times as likely to have EBLLs (p<0.0001). Males had Table 1. Blood Lead Testing by Selected Demographic Factors, Children about a 17% increased odds to have EBLLs than females (p=0.0019).

African-American children were not more likely to have EBLLs than Under 6, Mississippi, 2009-2015 . Blood Lead Testing

by Selected Demographic Factors, Children Under 6, Mississippi, Caucasian children (p=0.3298). Children enrolled in Medicaid had 2009-2015 about an 85% increased odds to have EBLLs than Non-Medicaid enrolled children (p<0.0001). Children in high-risk counties were Population Tested Percentage 2.21 times more likely to have EBLLs than children in low-risk P-value Under 6 Children of Tested (%) counties (p<0.0001) (Table 3).

Overall

1,717,164

311,601

18.15

Age (Years)

<0.0001 <1

276,375

22,599

8.18

1

281,162

93,374

33.21

2

287,486

65,277

22.71

3

288,833

48,221

16.70

4

290,814

61,344

21.09

5

292,494

20,786

7.11

Gender

A total of 311,601 children younger than 6 years old were tested for lead by blood sampling between 2009-2015. The trend reveals a gradual decline in rates of elevated blood lead levels during this time period and parallels CDC’s national Surveillance data.21 This study Figure. The Percentage of Children with EBLLs>= 5µg/dl by Year and Insurance Status in Figure 1. 2009-2015 The Percentage of Children with EBLLs>= 5µg/dl by Year and Mississippi

0.9300 Female

841,050

149,283

17.75

Male

876,114

155,465

17.74

Race

Discussion

Insurance Status in Mississippi 2009-2015 14

<0.0001 764,752

191,166

25.00

Caucasian

919,911

98,699

10.73

Medicaid

<0.0001 Enrolled

Not enrolled

1,366,697

241,099

17.64

350,467

70,502

20.10

County Risk of Lead Exposure

<0.0001

High-Risk County

668,822

133,742

20.00

Low-Risk County

1,048,342

177,082

16.89

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12

Percentage(%)

African American

10 8 6 4 2 0

2009

2010

--

Overall

2011

2012

2013

2014

.......Medicaid ....... NonMedicaid

2015

Table 2. Children Under 6 Years Old with EBLLs by Selected Demographic and Socioeconomic Table 2. Children Under 6 Years Old with EBLLs by Selected Demographic and Socioeconomic Factors, Mississippi, 2009-2015 Factors, Mississippi, 2009-2015 Tested Children Overall

Number of EBLLs 5.0-9.9 µg/dl

Rate of EBLLs 5.0-9.9 µg/dl (%)

P-value

Number of EBLLs>=10 µg/dl

Rate of EBLLs>=10 µg/dl (%)

P-value

311,601

Age (Years)

<0.0001

<0.0001

<1

22,599

1,118

4.95

46

0.20

1

93,374

5,237

5.61

417

0.45

2

65,277

4,627

7.09

496

0.76

3

48,221

3,013

6.25

344

0.71

4

61,344

3,098

5.05

337

0.55

5

20,786

943

4.54

118

0.57

786

0.53

950

0.61

Gender

<0.0001 Female

149,283

7,812

5.23

Male

155,465

9,540

6.14

Race

0.0019

<0.0001 African American Caucasian

0.0001

191,166

11,548

6.04

1,185

0.63

98,699

5,516

5.59

499

0.51

Medicaid

<0.0001

<0.0001

Enrolled

241,099

15,633

6.48

1,518

0.63

Not enrolled County Risk of Lead Exposure High-Risk County Low-Risk County

70,502

2,403

3.41

240

0.34

0.0073

<0.0001

133,742

7,578

5.67

1,071

0.80

177,082

10,436

5.89

679

0.38

Table 3. Adjusted Odds Ratios for EBLLs by Selected Demographic and Socioeconomic Factors, Table 3. Adjusted Odds Ratios for EBLLs by Selected Demographic and Socioeconomic Factors, Mississippi, 2009-2015 Mississippi, 2009-2015

EBLLs 5.0-9.9 µg/dl Among Those Tested Odds Ratio Estimate

95% CI*

EBLLs>=10 µg/dl Among Those Tested Odds Ratio Estimate

95% CI

<1 1 2 3

1.12 1.25 1.61 1.39

(1.02-1.23) (1.16-1.35) (1.50-1.74) (1.28-1.50)

1.00 2.25 3.8 3.42

(referent) (1.63 -3.11) (2.76- 5.23) (2.47 -4.75)

4

1.12

(1.04-1.21)

2.65

(1.91- 3.68)

5

1.00

(referent)

2.67

(1.86-3.83)

1.00 1.17

(referent) (1.06 - 1.29)

0.95 1.00

(0.85 - 1.06) (referent)

1.85 1.00

(1.60 - 2.15) (referent)

2.21 1.00

(1.99 - 2.44) (referent)

Age (Years)

P-value <0.0001

Sex Female Male Race/Ethnicity AfricanAmerican Caucasian

<0.0001

<0.0001 1.00 1.19

(referent) (1.15-1.23)

1.07 1.00

(1.04-1.11) (referent)

0.0019

<0.0001

Medicaid Enrolled 1.93 Not enrolled 1.00 County Risk of Lead Exposure High-Risk 1.00 County Low-Risk 1.00 County interval * CI: Confidence

0.3298

<0.0001 (1.84-2.03) (referent)

<0.0001

0.9597 (0.97-1.03) (referent)

P-value

<0.0001

identified several demographic and socioeconomic factors associated with higher lead testing rates in children younger than 6 in Mississippi.

The factors were children aged 1 or 2-years old, African-American race, non-Medicaid enrollment status and residence in high-risk counties for lead exposure and are statistically significant independent factors for lead testing on children. Children aged 1 and 2-year old had a higher testing rate (33.21%, 22.71%) compared to children of other ages. The results are consistent with the expectations of targeted screening and reflect the CDC and MSDH Blood Lead Screening Guidelines,8, 20 requesting routine lead tests for children at Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) visits at 1 and 2-years old.

In contrast to expectations, we found that the percentage of non-Medicaid children screened was higher than that of Medicaid children. This dissimilarity may be attributed to the comparatively small number of non-Medicaid children, a higher rate of screening in the Children’s Health Insurance Program (CHIP) in Mississippi, underscreening or lack of adherence to Medicaid screening guidelines as indicated by recent data matching, or a combination of factors to be further investigated. AfricanAmerican children and children residing in a higher-risk county also tended to have higher rates of lead testing, regardless of insurance coverage.

This study also identified several demographic and socioeconomic factors associated with children with EBLLs. Children aged 2 or 3-year old, male gender, African-American race, Medicaid recipient status and residence in high-risk counties for lead exposure had statistically significant higher rates of EBLLs. Previous national studies have found that EBLLs tend to be highest in the 1

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and 2-year old age group and that more children in this age group have EBLLs,12 leading to current CDC and state guidelines recommending routine lead tests for children at EPSDT visits at 1 and 2-years old.8, 20 We found, however, in this population, that 2 or at 3-year olds have more EBLLs than 1 or 2-year olds, despite a lower testing rate (16.7%) at 3-years old. These findings suggest a need to increase screening for blood lead elevations prior to age 3-years old and strict adherence to follow up in accordance with targeted screening in Mississippi.

Further investigation is warranted for sources of exposure in this age group. Males were more likely to have EBLLs than girls in both groups (5ug/dl -9 µg/dl and > 10 µg/dl). Medicaid children were almost two times more likely to have EBLLs than Non-Medicaid children in both groups. We found that race was a statistically significant and independent predicator of children with EBLLs at both higher and lower groups of elevated levels, but when we controlled for other factors, race was not a predicator for children at EBLLs>=10 µg/dl level.

The findings from the study also revealed the relationship between county residence status and children with EBLLs. The children in higher-risk counties were more likely to have EBLLs at both 5ug/dl -9 µg/dl and > 10 µg/dl. When we controlled for other factors, children in higher-risk counties were 2.21 times as likely to have EBLLs>=10 µg/dl as the children in lower-risk counties; however, the children’s residential status doesn’t differ significantly on children at EBLLs 5-9 µg/dl. This finding suggests that the high-risk county of residence status is a less sensitive indicator of lower blood lead levels. Given the ubiquitous distribution of levels 5ug/dl -9 µg/dl, it is imperative that lead screening standards and reporting are maintained uniformly across the state.

Increased awareness/education is essential regarding environmental lead exposure. For our highest exposure among 2 to 3-year-olds, we found: 83.75% of the environments had lead contaminated dust, 66.25% had lead-based paint, 28.75% had lead in the soil, 30% had ceramic tubs or sinks that tested positive for lead, 16.25% had vinyl mini-blinds that tested positive for lead, 20% of keys tested positive, 8.75% of toys tested positive and 1.25% had drinking water with lead.

Limitations Missing data may limit the generalizability of the study. To moderate the effect, we retrieved some missing data via data linkage with other data sources. In the adjusted regression analysis, 92% of records were included in the analysis. State policies regarding confirmatory testing was not fully implemented until 2017, so the findings may not be comparable to other studies published elsewhere.

Summary In summary, the study shows that overall trend of the percentage of children with EBLLs >=5 µg/dl in Mississippi significantly decreased during 2009-2015, but some children continued to be at great risk for exposure to lead than others. This study identified several demographic and socioeconomic factors associated with EBLLs in children younger than 6 years in Mississippi. They were children at 2 or 3-year old, male gender, African-Americans, Medicaid recipients and living in highrisk counties for lead exposure. Demographic and sociodemographic factors associated with higher rates of lead testing were children aged 1 or 2-years old, African-American race, non-Medicaid enrollment status and residence in high-risk counties. While most of the factors were in alignment with the national data, disparities among children with EBLLs in Mississippi highlighted the need to continue strategies focusing on targeted intervention, prevention education, behavior, policy change, reducing environmental exposures from soil, dust, paint and water, and reassessment of risk.

References 1. CDC. National Center for Environmental Health: CDC’s Childhood Lead Poisoning Prevention Program. CDC. 2017. Website. https://www.cdc.gov/ nceh/information/healthy_homes_lead.htm. Accessed May 3, 2018.

2. Bellinger DC, Stiles KM, Needleman HL. Low-level lead exposure, intelligence and academic achievement: a long-term follow-up study. Pediatrics 1992; 90:8556.

3. Bellinger DC, Needleman HL. Intellectual impairment and blood lead levels.

N Engl J Med 2003; 349:500–502. Website. http://www.nejm.org/doi/ full/10.1056/NEJM200307313490515. Accessed May 3, 2018.

4. Heda Dapul, MD, Danielle Laraque, MD. Lead Poisoning in Children. Advances Ped 2014; 61:313-333.

5.

U.S Department of Health and Human Services. National Toxicology Program Health Effects of Low-Level Lead. U.S. Department of Health and Human Services. Website. https://ntp.niehs.nih.gov/ntp/ohat/lead/final/ monographhealtheffectslowlevellead_newissn_508.pdf. Accessed May 3, 2018.

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Prevention of Childhood Lead Toxicity /Council of on Environmental Health. Pediatrics July 2016. Volume 138/issue 1. Website. http://pediatrics. aappublications.org/content/138/1/e20161493. Accessed May 3, 2018.

7. National Research Council. Measuring lead exposure in infants, children, and other sensitive populations. Washington, DC: National Academy Press, 1993.

8. CDC. Preventing lead poisoning in young children: a statement by the Centers for Disease Control. Atlanta, GA: US Department of Health and Human Services, CDC; 1991. Website. https://wonder.cdc.gov/wonder/prevguid/p0000029/ p0000029.asp. Accessed May 3, 2018.

9. CDC. Low level lead exposure harms children. A renewed call for primary prevention. Report of the Advisory Committee on Childhood Lead Poisoning Prevention of the Centers for Disease Control and Prevention. Atlanta, GA: US Department of Health and Human Services, CDC; 2012 https://www.cdc.gov/ nceh/lead/ACCLPP/Final_Document_030712.pdf. Accessed May 3, 2018.

10. CDC. Lead Standard Surveillance Definitions and Classifications. Website. https://www.cdc.gov/nceh/lead/data/definitions.htm. Page last updated: November 18, 2016. Accessed May 3, 2018.

11. CDC. Blood Lead Levels in Children Age 1-5 Years –United States, 19992010 https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6213a3.htm?s_ cid=mm6213a3_e. Accessed May 3, 2018.

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12. CDC. Screening young children for lead poisoning: guidance for state and local public health officials. Atlanta, GA. US Department of Health and Human Services November 1997.

19. CDC. Screening young children for lead poisoning: guidance for state and local public health officials. Atlanta, GA: US Department of Health and Human Services, CDC; 1997.

13. Leland F. McClure, Justin K. Niles, Harvey W. Kaufman. Blood Lead Levels in Young Children: US, 2009-2015. Website. http://www.jpeds.com/article/ S0022-3476(16)30206-2/pdf. J Pediatrics Vol. 181. Accessed May 3, 2018.

20. Mississippi State Department of Health Lead Poisoning Prevention and Healthy Homes Screening Plan. Section V. website. https://msdh.ms.gov/msdhsite/_ static/resources/3084.pdf. Accessed May 3, 2018.

14.

Mississippi State Department of Health List of Reportable Diseases and Conditions. Revision: March 24, 2017. Authority for the Mississippi State Board of Health to Make and Publish Rules and Regulations. Website. https://msdh.ms.gov/ msdhsite/_static/resources/877.pdf. Accessed May 3, 2018.

21. Morbidity and Mortality Weekly Report (MMWR). Childhood Blood Lead Levels in Children Aged <5 Years — United States, 2009–2014. Surveillance Summaries / January 20, 2017 / 66(3);1–10. Website. https://www.cdc.gov/ mmwr/volumes/66/ss/ss6603a1.htm#T3_down . Accessed May 3, 2018.

15. Mississippi State Department of Health. Rules and Regulations Governing Reportable Disease and Conditions. Section 41-3-17, Mississippi code of 1972 as amended. Website. https://msdh.ms.gov/msdhsite/_static/resources/1719.pdf.

Accessed May 3, 2018.

Author Information

16. National Vital Statistics System. Bridged-Race Population Estimates - Data Files and Documentation. Website. https://www.cdc.gov/nchs/nvss/bridged_race/ data_documentation.htm#vintage2012. Page last updated: June 2017. Accessed May 3, 2018.

17.

US Census Bureau’s 2011-2015 American Community Survey 5-Year Estimates. American Fact Finder. Website. https://factfinder.census.gov/ faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_16_5YR_ DP04&prodType=table. Accessed May 3, 2018.

Research Biostatistician, Office of Health Data & Research (Han). Lead Program Director, Division Director II, Office of Child and Adolescent Health (Veazey).

Director, Office of Child and Adolescent Health (Polk). Pediatric Medical Consultant (Cannon-Smith). Director, Office of Health Data & Research (Zhang). All at the Mississippi State Department of Health, Jackson. Conflicts of Interest: None.

Corresponding author: Lei Zhang, PhD, MBA, Director, Office of Health Data & Research, Mississippi State Department of Health, Post Office Box 1700, Jackson, MS 39215-1700. Ph: (601) 576-8165 (Lei.Zhang@msdh.ms.gov).

18. CDC. Lead Prevention Tips. Website. https://www.cdc.gov/nceh/lead/tips. htm. Page last updated: June 19, 2014. Accessed May 3, 2018.

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S C I E N C E

O F

M E D I C I N E

Strategies for the Physician Workforce Shortage in Mississippi KHANG H. DANG, MD; VY T. NGUYEN, BS; OMAIR ARAIN, BS; WILLIAM A. PRUETT, PHD; RALPH DIDLAKE, MD, MA

Abstract Purpose: Addressing the shortage of physicians in Mississippi is a challenging and difficult endeavor. The purpose of the study is to develop a predictive model on the physician workforce based on the University of Mississippi Medical Center School of Medicine (SOM) and its residency programs enrollments.

Method: Demographic data were obtained for 801 medical students and 328 residents who matriculated from 2003 through 2011 at the University of Mississippi Medical Center (UMMC). Data were applied in a probability model and statistical analysis comparing the impact of program type, state of original residence, gender, age, ethnicity, medical school, residency type, and practice location to predict the state’s future physician workforce.

Results: Our results showed that increases in the graduation rate,

medical school class size, and UMMC residency program enrollment led to a steady increase in the total number of physicians in the state.

Election to practice in Mississippi was correlated positively with primary care residencies (more females), the decision to forgo fellowship training, originating from Mississippi, dedication to primary care, and in-state medical school education. Age did not play a significant role.

Conclusions: Our model showed that an increase in UMMC class and residency size would increase Mississippi’s physician presence.

Recruiting medical students and resident physicians with specific characteristics may also be an effective strategy for increasing Mississippi’s future physician workforce.

Introduction Addressing the national shortage of physicians is a challenging endeavor that has been a subject of ongoing debate. A potential shortage of 85,000

Figure 1. Flow of the Physician Workforce Model

Physician Workforce Model Out of State

Emigration & Immigration

University of Mississippi Medical Center Residency Programs

Deaths

Retirements

This diagram depicts the dynamic of the workforce, which includes many inputs and outputs. Inputs include individuals graduating college and coming from out Figure 1. Flow of the Physician - This diagram depicts the dynamic of the workforce, of state. Outputs include death, retirement,Workforce emigration fromModel Mississippi.

which includes many inputs and outputs. Inputs include individuals graduating college and coming from out of state. Outputs include death, retirement, emigration from Mississippi.

212 VOL. 60 • NO. 6/7 • 2019

Methods Figure 2. Example of Our Model

Study Design Demographic data and practice Power Model location for 801 medical students 0 and 328 residents who matriculated U 1C fnt utno Cius Siu :J 135 from 2003 through 2011 at Y•ar s, Since 2012 0 0 UMMC were obtained. Data were applied in a probability model 5 91 7 and statistical analysis comparing Total PhySICiln Wor fOl(f ,n Mrssrsslppl the impact of program type, state

Entering Class of original residence, gender, age, Years 135 140 145 150 155 160 ethnicity, medical school, residency type, and practice location to 0 5817 5817 5817 5817 5817 5817 predict the state’s future physician 1 5843 5844 5845 5846 5847 5848 workforce. Current medical 2 5870 5872 5874 5876 5878 5880 student, resident, or physician-in3 5896 5899 5902 5905 5908 5911 training were not included in our 4 5923 5927 5931 5935 5938 5942 model. Requirements included that 5 5949 5954 5959 5964 5969 5974 our model be parametric, based on 6 5976 5982 5987 5993 5999 6005 historical trends, sufficiently flexible 7 6002 6009 6016 6023 6030 6036 to allow hypothesis testing related 8 6029 6036 6044 6052 6060 6068 to policy change, and predictive in 9 6055 6064 6073 6081 6090 6099 long term forecasts. Approval of the 10 6081 6091 6101 6111 6121 6130 study protocol was obtained from This tool allows forecasts over time based on changes made to the UMMC entering SOM class size and residency training the Institutional Review Board Figure Example Model This tool allows forecasts timeinbased changes made toin the programs2.and predicts of theOur resulting size –and composition of the physician over workforce a givenon time period. Numbers the (IRB) of our institution.

orange columns represent predicted totalresidency number of physicians Mississippi.and predicts the resulting size and UMMC entering SOMthe class size and training in programs composition of the physician workforce in a given time period. Numbers in the orange columns represent the predicted total number of physicians in Mississippi.

physicians is expected in 2020 with the constant need for physicians due to an increasingly aging population and misdistribution of healthcare resources.1,2 Affected by these challenges, Mississippi also has the lowest percapita primary care physician supply: 8.3 physicians per 10,000 people in 2012.3 With the national average of 12.8 physicians per 10,000 people, Mississippi will need 1,330 more physicians to meet the national average, and this shortage affects all areas of healthcare.3,4 Meeting these healthcare challenges requires intelligent datadriven approaches and effective strategies to improve the general Mississippi physician workforce (Figure 1).

Several strategies have been pursued, but, in particular, predictive modeling of the physician workforce based on statistical analysis has been reported in the literature. Cooper et al.5 used historical trend analysis to make projections on the supply and demand of physicians with an emphasis on understanding the impact of economic growth on healthcare. Examining a 37-year- period, Freed et al.6 used previous historical census and economic data to make accurate projections of the pediatric workforce. Also, Fincher et al.7 developed a classification method based on a ranking system in which individuals’ residency choices were able to be predicted. Ultimately, these studies focus on a national level to make their predictions on the physician workforce; however, each state has its own characteristics and composition of residents. This is important because a combination of factors such as demographics or personal interests influence graduates’ ultimate practice locations.8-11 A statistical model predicting the number of matriculating graduates remaining in-state to practice does not exist for Mississippi, and there has been no formal analysis looking at demographic factors leading to retention in the state. Using the UMMC medical school and residency training programs, we wanted to create a data-driven approach which would examine the size and character of the state’s physician workforce.

The goal of our study is to develop a predictive model of UMMC SOM and residency programs to help address the shortage of physicians. We predicted that the decision to practice in Mississippi was positively correlated with primary care residencies, females, originating from Mississippi, and in-state medical school education.

Statistical Analysis Various demographic, school, and workforce information was analyzed: program type, age, gender, degree, ethnicity, birthplace, program size, graduation rate, retention rate, retirement,mortality,practicelocation, and migration. Graduation rates, mortality rates, emigration rates, and retention rates were obtained and based on an average over our study period.

These ratios and rates were combined to develop a probability model that predict changes to the total physician workforce in Mississippi when altering the class size of the UMMC School of Medicine or residency departments (Figure 2). Looking at UMMC residency programs, ratios of several demographic data that corresponded to an individual staying in-state versus out-of-state after training were calculated.

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graduation rate from 2003 -2011 was calculated as 0.914 (Range: 0.80 to 1.00). During our study period, the average retirement rate for insured physicians was 1.31% (Range: 1.26 to 1.40), and the average death rate in MS was 9.87% (9.70 to 10). Family Medicine, Neurology, Pathology, Psychiatry, and Anesthesiology were excluded due to incomplete data.

Results Demographic data, training specifics, and practice locations of a total of 801 medical students and 328 residents from 2003 through 2011 were used to develop our probability model (Figure 1).

Regarding rates used in our model, the average UMMC SOM Table 1. Demographics of UMMC Medical School

Table 1. Demographics of UMMC Medical School Years 2004 Entering Class Size, n Entering Class Male/Female Ratio, n/n Graduating Class Size, n Graduating Class Male/Female Ratio, n/n Graduating Class In‐ State/ Out of State for Residency Ratio, n/n

2005

2006

2007

2008

2009

2010

2011

100

105

110

110

110

120

135

135

49/51

72/33

54/56

64/46

55/55

77/58

91/44

79/56

90

102

97

97

92

92

114

117

50/40

56/46

58/39

40/57

51/41

43/49

48/66

59/58

51/39

68/34

61/36

56/41

47/45

60/32

55/59

73/44

Table 2. Demographics of UMMC Residency Programs

Table 2. Demographics of UMMC Residency Programs Emergency Diagnostic General Medicine** Radiology Surgery

Internal Medicine

Neuro‐ surgery

Obstetrics‐ Gynecology

167

58

19(11.3) 97 (58.0)

10 29.3 (3.1) 0 (0) 1 (10.0)

141 (84.4)

8 (80.0)

54 (93.1)

Black 3.(3.94) 1 (2.27) 2 (4.76) 12 (7.18) ‐ Hispanic ‐ 1 (2.27) 2 (4.76) ‐ 1 (10) Asian ‐ 1 (2.27) 1 (2.38) ‐ 1 (10) Native American ‐ ‐ ‐ ‐ ‐ Other 4 (5.2) ‐ ‐ 14 (8.3) ‐ Current Residents, n 42 35 34 104 11 Medical School in MS, n (%) 29 (38.1) 19 (43.1) 17 (40.4) 107 (64.0) 1 (10.0) Pursued Fellowship, n (%) N/A** 31 (70.4) 13 (30.9) 112 (67.0) 4 (40.0) Fellowship Location in MS, n (%) N/A** 11 (35.4) 6 (46.1) 67 (59.8) 1 (25.0) Practice Location in MS, n (%) 40 (52.6) 23 (52.2) 20 (47.6) 123 (73.6) 6 (60.0) MS, Mississippi; N/A, Not Applicable *Excluded: Family Medicine, Neurology, Pathology, Psychiatry, and Anesthesiology (Incomplete Data) **Emergency Medicine was missing Fellowship Information

3 (5.1) ‐ 1 (1.7) ‐ ‐ 19 29 (50.0) 4 (6.8) 3 (75.0) 37 (63.7)

Sample Size, n Age, y (mean [SD])

34.1(4.7)

Female, n (%) MS as Residence, n (%) Race, n (%)

19 (25.0) 24 (31.1)

44 42 34.5 32.7 (4.2) (3.1) 8 (18.1) 7 (16.6) 17 (38.6) 16 (38.0)

66 (86.8)

41(93.1)

White

214 VOL. 60 • NO. 6/7 • 2019

76

37 (88.0)

31.4 (3.5)

31.1 (2.5) 33 (56.8) 33 (56.8)

For the UMMC SOM, both entering and graduating class size have been gradually increasing, but the graduating ratio fluctuates through the study period with a range of 0.80 to 1.00. The ratio of the graduating classes favors in-state over out-of-state for residency with an average ratio of 1.48 (Range: 0.93 to 2.00). The ratio of male to females has been approaching 1:1; however, males are typically more representative with an average ratio of 1.06 (Range of 0.70 to 1.48). A review of the demographics of UMMC SOM can be seen in Table 1.

For UMMC residency programs, our analysis suggested that compared to the graduates leaving MS to practice, graduates remaining in-state after training tend to be dedicated to primary care specialties, without fellowship training, original residents of MS, females, and graduates of UMMC SOM. Primary Care Specialties had an increased percentage of their graduates remaining in-state: Internal Medicine (73.6%), Obstetrics-Gynecology (63.7%) and Pediatrics (60.8%). On the other hand, sub-specialties had a lower percentage: Emergency Medicine (52.6), Diagnostic Radiology (52.2), General Surgery (47.6), Neurosurgery (60%), Ophthalmology (55.5), Orthopaedics (41.6), Otolaryngology (30%), and Urology (33.3). A review of the

demographics of specific UMMC residency programs is shown in Table 2. Graduates who reported Mississippi as their state of original residence were more likely to remain in the state to practice (75%). Graduates who reported another state other than Mississippi as their state of original residence were more likely to leave Mississippi to practice (66.5%). Also, the location of medical school training had an impact on the decision to practice in Mississippi. In particular, graduates who were trained at the UMMC SOM were more likely to remain in-state after training (75.7%). Age was similar between in-state and out-of-state groups (36.5 compared to 37.3) while minorities did not have a sufficient number of graduates to calculate a significant ratio. A greater percentage of female graduates (55%) remained in-state after graduation while 55.2% of graduates without fellowship training stayed in Mississippi. A comprehensive review of these ratios from UMMC residency programs is shown in Table 3.

Discussion Currently, the nation faces several healthcare workforce issues: underfunding for medical resources, shortages of physicians, and difficulties with access to care.12-16 Informed data-driven approaches are

Table 2. Demographics of UMMC Residency Programs Continued*

Table 2. Demographics of UMMC Residency Programs continued* Ophthalmology Orthopaedics Otolaryngology Pediatrics Urology Sample Size, n Age, y (mean [SD]) Female, n (%) MS as Residence, n (%) Race, n (%)

27

36

20

97

32.7 (3.4)

33.7 (3.0)

31.9 (1.9)

31.5 (4.7)

6 (22.2) 13 (48.1)

2 (5.5) 17 (47.2)

6 (30.0) 9 (45.0)

64 (65.9) 36 (37.1)

25 (92.5) 36 (100.0) 20 (100.0) 66 (68.0) White ‐ ‐ ‐ 10 (10.3) Black 2 (7.4) ‐ ‐ ‐ Hispanic ‐ ‐ ‐ 6 (6.1) Asian ‐ ‐ ‐ ‐ Native American ‐ ‐ ‐ 15 Other 12 24 16 42 Current Residents, n Medical School in MS, n (%) 13 (48.1) 13 (36.1) 9 (45.0) 75 (77.3) Pursued Fellowship, n (%) 14 (51.8) 33 (91.6) 5 (25.0) 20 (20.6) Fellowship Location in MS, n (%) 0 (0.0) 8 (24.2) 1 (20.0) 7 (35.0) Practice Location in MS, n (%) 15 (55.5) 15 (41.6) 6 (30.0) 59 (60.8) MS, Mississippi; N/A, Not Applicable *Excluded: Family Medicine, Neurology Pathology, Psychiatry, and Anesthesiology (Incomplete Data)

18 33.6 (4.1) 2 (11.1) 7 (38.8) 17 (94.4) 1 (5.5) ‐ ‐ ‐ ‐ 10 8 (44.4) 6 (33.3) 0 (0.0) 6 (33.3)

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necessary to tackle these problems.2,12 In particular, probability modeling of the physician workforce is a tool that can potentially aid in addressing the shortage of providers. With this objective in mind, UMMC SOM and residency programs were used to develop a predictive model of the physician workforce and perform analysis to determine retention factors to practice in Mississippi.

Our results showed that increases in graduation rate, SOM class size, and UMMC residency program enrollment led to a steady increase in the total number of physicians in the state. Also, primary care residencies, such as obstetrics-gynecology, pediatrics, and internal medicine, showed a greater proportion of graduates staying in Mississippi compared to other specialties. For UMMC residency programs, graduates who remained instate were originally residents of the state, primary care specialists, without fellowship training, females, and graduates of the UMMC SOM. Also, age did not play a role in individuals wanting to go out-of-state after graduation.

Results for females who are more likely to go into primary care specialties were more likely to remain in-state after completing their intended programs. Individuals who were original residents of other states tend to go back out-of-state after graduation. Our study did not have a sufficient number of minorities to find a significant effect on the likelihood of their practicing in-state. Additionally, individuals who went to in-state medical schools were more likely to stay in Mississippi after graduating.

Previous predicative models on the physician workforce did not allow this individualized investigation of certain demographic characteristics and had other aims.10,11 Cooper et al.5 used historic and national trend analysis to make projections on the healthcare workforce, but their model was vulnerable to any demographic changes or deviations from historical trend line. Also, Fincher et al.7 used survey responses which could be subjected to bias. Other models had difficulties with calculating attrition rate or accounting the changing national demographics.2,17 Xierali et al.11 reported the need to address the demographic trend towards more ethnic and racial diversity due to recent population changes.

Furthermore, other physician workforce models’ aims included determination of appropriate number of both primary care and subspecialty physicians, consideration of international medical school graduates, and understanding the impact of the growing number of female providers.2,18,19 Current enrollment within UMMC’s medical education and training programs appears to be insufficient to secure the physician presence needed to address Mississippi’s health demands. Regarding this shortage, we wanted to consider that several different specialties comprised the physician workforce, suggesting that these dissimilarities may contribute to their decision to remain in Mississippi to practice.2 Residency programs are ultimately distinct from one another, and their residents’ desires to pursue that particular specialty varies.8-10,20-22 Those who choose primary care, such as Family Medicine and Pediatrics, commonly value longitudinal patient care, ambulatory care and controllable lifestyle.8,9,21 On the other hand, Bennett et al.20 reported sub-specialty residents, such as Orthopaedics and Urology, are influenced more by income,

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Table 3. Ratios of UMMC Residency Programs

Table 3. Ratios of UMMC Residency Programs MS as Original Residence Staying in MS, n (%) MS as Original Residence Leaving MS, n (%)

105 (75%) 35 (25%)

Out of State Residence Staying in MS, n (%) Out of State Residence Leaving MS, n (%) Race Staying in MS White

63 (33.5) 125 (66.5)

Black Hispanic Asian Other Race Leaving MS White Black Hispanic Asian Other Fellowship Trained Staying in MS, n (%) Fellowship Trained Leaving MS, n (%) No Fellowship Staying in MS, n (%) No Fellowship Leaving MS, n (%) Males Staying in MS, n (%) Males Leaving MS, n (%) Females Staying in MS, n (%) Females Leaving MS, n (%) UMMC SOM Trained Staying in MS, n (%) UMMC SOM Trained Leaving MS, n (%) Another SOM Trained Staying in MS, n (%) Another SOM Trained Leaving MS, n (%) Average Age Staying in MS, yr Average Age Leaving MS, yr MS, Missississpi; SOM, School of Medicine

4 (40) 1 (20) 1 (33.3) 1 (16.7)

143 (47.1) 6 (60) 4 (80) 2 (66.7) 5 (83.3) 47 (43.1) 62 (56.9) 121 (55.2) 98 (44.8) 122 (49.8) 123 (50.2) 46 (55.4) 37 (44.6) 103 (75.7) 33 (24.3) 65 (33.8) 127 (66.2) 36.5 (25.8‐ 57.25) 37.3 (29.3 – 53.3)

161 (52.9)

reputation, and ideal future lifestyle. Overall, multiple factors, such as interests, demographics, lifestyle, or financial considerations, affect these residents differently.8-10,20-22 Our study reinforces this notion that certain demographics, such as commitment to primary care, female, and state of original residence, can influence a graduate to remain instate to practice.

Limitations of our study include that our data came from only one academic hospital, the University of Mississippi Medical Center. The data presented in this study demonstrates that certain demographic attributes were more characteristic of individuals remaining in Mississippi after training. However, we do not have any research data to explain the exact reasons for these findings. Thus, future investigations may address specific location-related, individual-related, and system-

related factors contributing to this phenomenon. In addition, our data was retrieved from multiple departments. This is inherently associated with certain limitations, such as variable data entry. Also, since demographic data and practice locations from Family Medicine, Pathology, Psychiatry, and Anesthesiology were incomplete, they were also excluded. Despite these limitations, we were able to develop a predictive model of the physician workforce and determined factors that were predictive of retention in Mississippi.

In conclusion, our model was successful in predicting that increases in graduation rates, medical school class size, and residency programs would positively correlate with election to practice in Mississippi. Recruiting medical students and/or resident physicians with specific characteristics may also be an effective strategy for increasing Mississippi’s future physician workforce. Further development and application of these models could help identify the optimum sizes of medical classes and post graduate training programs in order to achieve specific physician per capita targets as well as guide educators and policy makers in developing physician workforce with specific characteristics such as the number of primary care providers per capita.

References 1. Council on Graduate Medical Education. Physician Workforce Policy Guidelines for the U.S. for 2000 –2020. Rockville, MD: U.S. Department of Health and Human Services, 2005.

supply: 2010–2025. Pub Health Reports. 2011;126:708-16.

18. Grover A, Niecko-Najjum LM. Physician workforce planning in an era of health care reform. Acad Med. 2013;88:1822-6.

19. Salsberg ES, Forte GJ. Trends in the physician workforce, 1980–2000. Health Aff. 2002;21:165-73.

20. Bennett KL, Phillips JP. Finding, recruiting, and sustaining the future primary care physician workforce: a new theoretical model of specialty choice process. Acad Med. 2010;85:S81-8.

21. Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students’ career specialty choices: data from two US medical schools, 1998–2004. Acad Med. 2005;80:809-14.

22. Sanfey HA, Saalwachter-Schulman AR, Nyhof-Young JM, Eidelson B, Mann BD. Influences on medical student career choice: gender or generation? Arch Surg.

2006;141:1086-94.

Acknowledgements The authors wish to acknowledge the coordinators of the University of Medical Medical Center Residency Programs, who were instrumental in the providing the data for this paper. We also acknowledge the staff of the University of Mississippi School of Medicine Medical Student Research Program, who agreed to formally review and support the conceptual model.

Funding/Support

2. Salsberg E, Grover A. Physician workforce shortages: implications and issues for academic health centers and policymakers. Acad Med. 2006;81:782-7.

The authors have no conflicts of interest to disclose. This study was supported by Dr. Dang’s time (July 2012 to May 2015) as a research fellow for the University of Mississippi School of Medicine.

3. American Medical Association. AMA Physician Masterfile. Chicago: American Medical Association. 2012.

Disclaimer

4. Mississippi Legislature Assembly. House Bill 317. Regular Session. 2012.

5. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff. 2002;21:140-54.

6. Freed GL, Nahra TA, Wheeler JR. Predicting the pediatric workforce: use of trend analysis. J Ped. 2003;143:570-5.

7. Fincher RM, Lewis LA, Rogers LQ. Classification model that predicts medical students’ choices of primary care or non-primary care specialties. Acad Med. 1992;67:324-7.

8. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA. 2003;290:1173-8.

9. Fincher RM, Lewis LA, Jackson TW. Why students choose a primary care or nonprimary care career. Am J Med. 1994;97:410-7.

10. Lambert EM, Holmboe ES. The relationship between specialty choice and gender of US medical students, 1990–2003. Acad Med. 2005;80:797-802.

11. Xierali IM, Castillo-Page L, Zhang K, Gampfer KR, Nivet MA. AM last page: the urgency of physician workforce diversity. Acad Med. 2014;89:1192.

12. Cooper RA. Seeking a balanced physician workforce for the 21st century. JAMA. 1994;272:680-7.

13. Cooper RA. There’s a shortage of specialists: is anyone listening? Acad Med. 2002;77:761-6.

14. Cooper RA. Weighing the evidence for expanding physician supply. Ann Intern Med. 2004;141:705-14.

The opinions expressed in this article are those of the authors alone and do not reflect the views of the University of Mississippi Medical Center, University of Texas Health Science Center at San Antonio, or University of Tennessee Health Science Center at Memphis.

Previous Presentations Preliminary versions of this conceptual model were presented as a poster at the Research Day conference at the University of Mississippi Medical Center in April 2014.

Author Information Resident, Department of Orthopaedics, University of Texas Health Science Center, San Antonio, Texas (Dang). Student, School of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee (Nguyen). Student, School of Medicine, University of Mississippi Medical Center, Jackson (Arain). Instructor, Department of Physiology and Biophysics, Center for Computational Medicine, University of Mississippi Medical Center, Jackson (Pruett). Associate Vice Chancellor, Department of Academic Affairs, University of Mississippi Medical Center, Jackson (Didlake).

Conflicts of Interest: None

15. Freeman J, Ferrer RL, Greiner KA. Developing a physician workforce for America’s disadvantaged. Acad Med. 2007;82:133-8.

Corresponding Author

16. Staiger DO, Auerbach DI, Buerhaus PI. Comparison of physician workforce estimates and supply projections. JAMA. 2009;302:1674-80.

Khang H. Dang, MD, UT Health San Antonio, Department of Orthopaedic Surgery, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX 78229.

Ph: (901)409-6035 (dangk@uthscsa.edu).

17. Hooker RS, Cawley JF, Everett CM. Predictive modeling the physician assistant

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E D I T O R I A L

Disability is in the Eyes of the Beholder

R

etirement continues to afford just enough professional engagement to prevent boredom. Chief among these activities remains performing Social Security Disability examinations, and I’ve often commented that the most difficult part of the job is maintaining a straight face while some claimants recount their cockamamie stories followed by Academy Award-winning performances during their physical examinations. But don’t get me wrong—I’ll go the extra mile for legitimacy.

This brings me to a recent visit with grandson Will at Auburn. The trees at Toomer’s Corner still looked as if climate change in the form of a toilet paper blizzard had struck following the War Eagles’ Final Four success. On a walkabout downtown, we ventured into Auburn Hardware, a hardware store/gift shop hybrid which has been in operation for over 100 years and under the same ownership since 1969.

A fan of unusual soaps, I couldn’t resist Sally Anders’ “Hogwash” made with a blend of “all our soaps and lots of cornmeal for scrubbing.” The fact that it resembled “head cheese” (one of my favorites) made it even more irresistible. As the older gentleman (presumably the owner) rang up my purchase, I noticed that he had only his right thumb and index finger having lost the other digits in an industrial accident (nosy me).

I couldn’t help but reflect on many SSD claimants with complaints ranging from “possible carpal tunnel syndrome” to “prediabetes.”

That evening we were treated to a concert by the Auburn Symphonic Winds Band with grandson Will on clarinet. Each selection was conducted by a music major who was also a member of the band.

Ride with the #1 car insurer in Mississippi.

For their final number, the timelessly elegant Elsa’s Procession to the Cathedral by Wagner, a French horn player stood to assume the podium.

Imagine our surprise when we realized that he was totally blind! This beautiful music along with this young man’s determination to meet a devasting disability head-on made an indelible Dr. Stanley Hartness impression I’ll not soon forget.

So, I’ve been thinking about what differentiates this hardware store proprietor and the young college musician from those who allow disabilities, real or imagined, to define their lives. Surely support from family members and associates who serve as cheerleaders and accountability groups is a major factor. And I can also appreciate the significance of role models who demonstrate determination in the face of overwhelming odds.

But from what I recently learned, having a dream for one’s life outranks them all. They say that the future belongs to those who believe in the beauty of their dreams. Poet Langston Hughes wrote, “Hold fast to dreams For if dreams die Life is a broken-winged bird That cannot fly Hold fast to dreams For when dreams go Life is a barren field Frozen with snow.” I fear that in my encounters with disability claimants I am encountering far too many flightless, frozen creatures. n — D. Stanley Hartness, MD; Associate Editor

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M I S S I S S I P P I

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[_) Physician

Leadership Acadetny

Scholars Take Leadership Skills to the Next Level Physicians, by definition, are leaders. However, they are not formally trained in leadership. The MSMA Physician Leadership Academy prepares MSMA members for future leadership positions. Physicians with leadership skills are uniquely positioned to play a significant role in today's healthcare changes to better the lives of their patients.

This in-depth program enables physicians to enhance their leadership skills through training in core aptitudes.

Upon completion, they are better prepared to excel as future leaders, in their practices, organized medicine and the public policy arena.

Overview Session 1: The Case for Physician Leadership Skills Effective leaders are consistent in demonstrating knowledge, integrity, self-confidence and passion.

Scholars focused on self-assessment, interpersonal skills, group dynamics and leadership with colleagues and stakeholders.

Session 2: Conflict Resolution Effective leaders must master the skills needed for reducing and eventually eliminating disruptive behavior and its negative consequences.

Topics included making decisions in different and difficult situations, resolving conflicts, creating win-win scenarios, and mastering the art of the “crucial’ conversation to be skilled at finding resolve within conversations where emotions run high and opinions differ.

Session 3: Media and Communication Skills for Leaders This session focused on helping the participants assess their unique communication style and skill, learn how to become active listeners, how to promote dialogue and how to enhance non-verbal communication ability. Scholars learned to appreciate and work with different communicators’ styles and maximize contributions from all team members. This session also includes an overview of MSMA and its advocacy efforts to prepare participants for their next session at the Capitol, full of political action.

Session 4: Advocacy Day Each scholar served as “Doctor of the Day” during the legislative session where MSMA staff arranged for scholars to meet their state congressional leaders and advocate for medical causes.

Session 5: The Art of Negotiation Scholars learned a method called “mutual gains negotiation.” The mutual gains framework combines the successful strategies of experienced negotiators with proven theory to help: 1) Prepare for negotiations more effectively; 2) Focus on problems and not on personalities; 3) Avoid typical “win-lose” situation; and 4) Deal better with those who play outside the rules.

Session 6: Collaboration and Influence The final session integrated the lessons learned to date with the knowledge that physicians have as leaders.

They are in a prime position to make significant changes in their local community as well as at a state level.

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Meet the Class of 2018-19

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r. Afifa Adiba did not make her decision about going into medicine in a moment of blinding revelation.

“I decided to become a physician following a myriad of personal experiences and a genuine need to make a difference, not only in my life but also in the lives of others. When I was in middle school, my grandfather was diagnosed with lung cancer. I was with him during Afifa Adiba, MD that time and witnessed the suffering of my grandfather and my family. I also saw how helpless he felt. I witnessed the noble work of the doctors trying to cure him. I wanted to be able to do the same one day.”

Over the last two years, as she performed her psychiatry residency, it became more apparent to her how one’s psychological well-being shapes and affects one’s overall physical well-being. “It challenges

me intellectually, allows the use of my creativity, and allows me to utilize my greatest personality traits. During my residency, I realized that I enjoy addressing the unique psychiatric conditions, social and developmental issues of children.”

“Being a psychiatrist has allowed me to support them at their most vulnerable state.”

“I believe the first part of becoming a great leader is becoming conscious of self by identifying one’s strengths and weaknesses.

Being aware of one’s weaknesses better equips people to ‘challenge themselves to apply new skills and improve themselves through practice (Komives &Wagner).’ By identifying one’s strengths, one can learn how to apply those skills to benefit a group or situation.”

“The courses offered by the leadership program allowed me to identify my strengths and weaknesses. This training led me to develop a deeper understanding of my actions, motives, and values; and how they contribute to successful outcomes or negative consequences.”

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r. Mary Gayle Armstrong grew up in a medical family and wanted to be a doctor from the earliest she can remember.

of medical school and residency.”

“To me, organized medicine is about so many things. It is more than the political aspect. There are many other ways that MSMA is supportive of physicians.”

She was drawn to her specialty because she couldn’t decide what she liked most.

“I decided I could do it all in family medicine, and that also makes it the most challenging. I spent a year at the Mississippi Department of Public Health after my residency and loved it, so I decided to stay.”

“My father, who was a physician, and my brother, who motivated me, they were both my mentors. They were there during the tough times

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r. Jennifer Bryan knew she wanted to pursue a career in medicine before Kindergarten. “I was encouraged by my parents and my physician family members.” She was drawn to family practice so she could take care of all ages, the entire family.

Jennifer Bryan, MD

“My mentors encouraged me to participate in organized medicine and taught me the importance of work-life balance.”

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r. Kristen Crawford: “I decided as a young child that I wanted to go into medicine. I had multiple nurses in the family and great interactions with physicians who were caring for my family or me.

“I was drawn to my specialty because I loved the complexity of the patients in internal medicine. I love primary care specifically because of the ongoing relationship between physicians and patients- this is the most rewarding.”

Mary Gayle Armstrong, MD

Organized medicine is important to Dr. Bryan because it is how she can best effect change and, because it is a part of her life, she finds fulfilling. Dr. Bryan has improved her communication and leadership skills through the Physician Leadership Academy. Her most significant achievement as a doctor was providing disaster relief and medical care immediately after Hurricane Katrina on the Gulf Coast.

“I have seen changes such as the implementation of EHR’s and more employed physicians since the beginning of my career, and I hope to see more physician autonomy and less bureaucracy. I want MSMA members to know that organized medicine and advocating for physicians is a personal joy of mine.”

insurance companies to get her patients the best care.

“Dr. Jimmy Stewart was my mentor in residency. He encouraged me to pursue primary care, and he still is a mentor and close friend.

“This is my calling, my ministry. It is life-giving to me. I truly enjoy being a part of patients’ lives and caring for them.

Kristen Crawford, MD

Dr. Crawford said the most challenging part of her job is dealing with

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“The PLA has been an outstanding learning experience, but the best has been the networking and development of friendships.”

“Through the Physician Leadership Academy skills, I hope to effect long term change in Mississippi medicine. I do not like the way medicine is going, and things need to change if I want to continue to practice longterm.

“I have stepped out of my comfort zone in hopes of effecting long term change. I want all my young physician colleagues to join me.”

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r. W. Jeremy Erwin: “I decided to pursue a career in medicine halfway through college. I was a business major but found I loved biology and was good at science. I spent some time shadowing a couple of local physicians and loved the relationships they were able to have with their members.

the enemy of good is better, which I find to be helpful in clinical practice. I strongly believe the practice of medicine should always take place inside a physician and patient relationship. I feel it is important that physicians have a unifying voice that advocates for the best interests of patients.

“As an Ob/Gyn, the ability to perform surgeries and procedures as well as being W. Jeremy Erwin, MD able to practice primary care is what drew me to the field. It is also nice to be able to follow patients throughout their entire lives.”

“During medical school, I was influenced by our MFM professor, Dr. Lucas, who was great at condensing very complex information into easy to understand topics. During my residency, I was greatly influenced by our chair, Dr. Stringer who, as a Gyn Oncologist, was the best surgeon I ever worked with. He would teach that sometimes

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r. DeGail J. Hadley is a native of Cleveland where he is a member of Lincoln Garden Church of Christ.

“I am involved in several civic and social service organizations. I am the president of the Mississippi Osteopathic Medical Association (MOMA). I am a member of Phi Beta Sigma Fraternity, Incorporated, and I serve as the Director of Social Action for the state of Mississippi. I now am blessed to serve my home town community.

A S S O C I A T I O N

“I hope to learn the ability to connect with colleagues and become a better advocate for our profession through PLA and to become a bridge in between our organization, managed care, and policymakers.

“Being able to safely deliver two of my own children has been my most significant achievement as a doctor. The continued implementation of technology such as wearable devices, AI, and robotics in medicine has been very fun to witness. The increased attention given to population health and social determinates of health has also been good.

“However, the exponential increase in costs of medicine has been very alarming. I am also wary of the rise of entrepreneurial medicine, especially when the products or surgeries have no or little clinical benefit.“

“I was drawn to the field of family medicine by the fact the field is diverse. As a family medicine physician, I can learn and treat a wide variety of illnesses that affect the entire family. I find the most rewarding part of my job is the ability to develop long lasting relationships with patients of all backgrounds.

“Organized medicine is important to me because it allows physicians to have a stronger voice to encourage positive change in the field of medicine. Organized medicine develops and pools resources that aid physicians in becoming better physicians and yields improved clinical outcomes for the patients we serve.

DeGail J. Hadley, DO

“I decided that I wanted to pursue a career in medicine when I was very young. As a child, I went to visit my mother when she was in the hospital, and I was inspired by observing the medical professionals who were involved in her care. I desired to help people in the same way that they helped my mother.

“My most significant achievement as a doctor has been the opportunity to serve the Mississippi Delta, my hometown. It is a blessing for me to be able to make deposits in the community where I grew up. Each time I am able to care for a patient and make a difference in their health, it’s an achievement for me.”

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r. Katherine Pannel: “I decided to be a physician very early in life.

Initially, I wanted to be a policewoman because I wanted to help people. Then I became fascinated with science and human anatomy and knew that I wanted a job that explored that. I also wanted a career that challenged me daily. Medicine satisfied all of those criteria.

“Public speaking has always been a fear of mine. I hoped to get experience and comfort with public speaking and did. I also recently became the Medical Director of Right TracK Medical Group and wanted to improve upon my leadership skills to lead effectively in my clinics.

“I initially did not want anything to Katherine Pannel, DO do with Psychiatry. Mental illness has affected my family throughout my life, and I planned to avoid Psychiatry at all costs. However, it was my very last medical student rotation, and I fell in love with it. I felt I could relate on a different level with both patients and families having been exposed to mental illness so intimately.

“Besides mental health, Advocacy is my other passion. Organized medicine has given me an outlet to pursue this passion and has encouraged me every step of the way.

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r. Sara Robertson grew up in a medical family; her father, grandfather, and three uncles all were OBGYNs. “My grandfather and father especially modeled for me what a doctor is and all that one could accomplish by going into the medical profession. My father would come home every day telling us what happened that day, and it just sounded so exciting. I knew I wanted that feeling every day, knowing that I had helped another person!

“Becoming a member of the Board of Trustees for the MSMA is my most significant achievement as a physician. It has taught me so much over one year, and I have met so many wonderful people. I have reached goals that I never thought possible before becoming elected to the board.

“I would like MSMA members to know that my most favorite and important job is being a mom to my three precious kids. They have taught me more about life in eight short years than all of my schooling.

They are also my biggest encouragement. My two girls have seen first hand that women can be passionate doctors and advocates. When others ask them what their mom does, they reply, ‘She’s trying to make mental healthcare better for her patients.’

“I could not be more proud.”

and expect medicine to stay the same forever. Patient-centered care led by physicians is of the utmost importance, and unless we stand up for those principles, they could be taken away.

“It is so important for physicians to take time for self-reflection, self-awareness, and to learn skills that will help us take better care of our patients. I believe by participating in the Physician Leadership Academy that I have become a better physician by learning about how to be a better leader through conflict management, advocacy, and negotiation.

Sara Martin Robertson, MD

“There is nothing about anesthesiology I don’t like. Everything about the specialty and my subspecialty of pediatrics is challenging and rewarding. I go to work every day, but I truly don’t feel like it is a job. I get to interact with children and their families.

“There is power in numbers, plain and simple. We cannot go it alone

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A S S O C I A T I O N

“I started medical school a little over a decade ago, and there has been a lot of change in medicine during that time. I hope we continue to put the patient first and also continue to educate physician leaders who are well-trained and try to make a difference in our communities.

“I am a native Mississippian, and so is my husband. It was very special for us to come back to the state we love after training to serve our friends and neighbors.”

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r. Geri Lee Weiland: “I had always had an interest in medicine from an early age, but decided when I was 10 that I wanted to be a physician. I had an intussusception requiring surgery when I was 4 1/2 and was properly diagnosed by a female physician.

supported and encouraged my love of pediatric cardiology. The month I spent in pediatric surgery with Dr. Patricia Moynihan taught me a female physician could be a great doctor, wife and mom.

“I initially said I would ‘never’ do pediatrics ... but I realized pediatrics, especially general pediatrics, is tremendously diverse Geri Lee Weiland, MD and mentally challenging. It is rewarding to know I have helped children from birth until they become young adults and even have had the pleasure of treating the children of my patients!

“I feel all of the pediatric faculty were mentors during my Residency... the Pediatric Department was small at that time ... each subspecialist taught me valuable lessons. I do need to spotlight ‘Dr. J’ James Joransen and Dr. David Watson in pediatric cardiology since they

“I hope to continue to improve my leadership skills so that I can be an effective voice for organized medicine. I enjoyed serving as Doctor of the Day as part of the PLA program and also learning to give an interview in front of a camera.

“My most significant achievement as a doctor is being an integral part of the medical community in Vicksburg for over 35 years ... helping babies come in to the world healthy, watching them grow, and serving as the team physician for the football team.

“The changes I have seen since I started my medical career some 40 years ago are wondrous and too numerous to list. Physicians have gotten better at almost everything, but I am concerned that the importance of a physician-led medical team is underappreciated.”

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Inez Kelleher, MD – Physician, Health Advocate and Legislative Candidate Dear Journal Editor, “I had always dreamed of becoming a doctor,” Dr. Inez Kelleher told me, “though I never imagined that my medical career would evolve in this way.”

An orthopedic surgeon on the Mississippi Gulf Coast since 1996, Dr. Kelleher has had a diverse life. Born in the small Illinois River town of Geneva, she was raised in a working-class family – beginning work herself as a young teenager by babysitting, teaching piano, and working as a department store clerk. Learning the lesson that achievement requires determination and a lot of hard work, she financed her way through college on an academic and track & field scholarship. While in college she met her first husband, Kevin Kelleher, a fellow track team member.

Following college, her husband joined the U.S. Air Force, and while he attended Office Training School, she worked as a janitor and a warehouse stocker. They had their first child during this time, and their second at Ellsworth AFB. “Money was tight,” she said. “I did whatever was necessary to help support my family.”

Inez’s family was transferred to Germany where Inez taught biology at the University of Maryland, Heidelberg Division, and moved back to Laughlin AFB in Texas when her husband began pilot training. Inez took her MCAT but, instead of medical school, decided to focus on her family with plans to obtain a Ph.D. later. All of these plans came to a sudden and tragic end when her husband died in an aircraft training accident in 1985, leaving Inez with three young boys, ages 1, 4, and 6.

With this event, Inez realized that God had different plans for her, and “after much prayer and reflection,” she decided to attend medical school. “I truly felt called to the profession,” she said. And she never looked back. “During prayer, I promised to step through the open doors, but if they closed, I would pursue another direction.”

But the doors kept opening. She matriculated to Georgetown Medical School on a military scholarship, graduating in 1990 in the top 20% of her class – all while raising her three boys. During her medical school rotations, she fell in love with orthopedics, and despite only 4% of orthopedic surgeons being women and acceptance for both men and women in this highly technical specialty being highly competitive, she won a spot in the famous Orthopedic Surgery Resident Program at Mayo Clinic, Rochester, MN. Following completion of her residency, Dr. Kelleher earned a fellowship in Pediatric Orthopedic Surgery at Children’s Hospital of Philadelphia. She began her USAF active duty Orthopedic Surgery practice at Keesler AFB, Biloxi.

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2001 was a memorable year for Dr. Kelleher. Following the terrorist attacks of September 11, she married her fiancée, Peter Hoar, and was soon deployed twice, to Diego Garcia and to Bagram AFB in Afghanistan, for Operation Enduring Freedom. In response to Hurricane Katrina, she volunteered at Memorial Hospital Gulfport and continued as an employed Orthopedic Surgeon at MGH beginning in October of that year.

Inez’s interest in running resurfaced in 2012 when she began training for the National Senior Games. In 2015 she represented Mississippi at the NSG and won silver medals in the 100m and the 200m. Currently she cross-trains for Track and Field in biking, track, weight training, and swimming.

This year Dr. Kelleher has undertaken a new goal. With her vast experience in observing the difficulties her patients have in obtaining adequate health care in Mississippi, she has entered the race for state legislature for district 117 (Biloxi and part of Gulfport). Her health campaign platform focuses on three areas: (1) the need to expand health care coverage, including mental health for all Mississippians, and to assure affordable quality care by physician-led teams, (2)the need to promote education, especially fully funding primary as well as developing education programs for postgraduates, and (3) the need to address the infrastructure needs of our community. “I firmly believe that it is a representative’s duty to represent the best interests of all her constituents, regardless of their differences.”

“I’ve always relied on divine providence to open doors,” she said, “and when God has opened those doors, I entered.”

Philip L. Levin, MD; Gulfport

Welcoming Our Newest Members HAMPTON, JACQUELINE, Clarksdale, Internal Medicine LOVE, SAMUEL, Jackson, Internal Medicine PREECE, PEYTON, Corinth, Hospitalist RUSSELL, HORACE, Canton, Internal Medicine UDLER, ILIYA, Jackson, Internal Medicine

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JOE AUSTIN, MD CLAUDE D. BRUNSON, MD RICKEY CHANCE, DO AMBER COLVILLE, MD RANDY EASTERLING, MD DANIEL P. EDNEY, MD HUGH GAMBLE, MD LEE NICOLS, MD

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* Names included in insert are as of listing date, June 25, 2019.

For more information about MMPAC, call David Roberts at 601-853-6733 or join or donate today at MMPAConline.com

Mississippi Medical Political Action Committee

2019 I.V. LEAGUE PLATINUM THOMAS E. DOBBS, MD F. HENRY FLAUTT, JR., MD RODERICK GIVENS, MD WILLIAM M. GRANTHAM, MD SCOTT L. HAMBLETON, MD

J. CLAY HAYS, JR., MD JON COREY JACKSON, MD THOMAS E. JOINER, MD DEREK E. MARSHALL, MD LORI H. MARSHALL, MD

GERALD MCKINNEY, MD SHAWN A. MCKINNEY, MD NEIL SLOAN, MD

GOLD ANONYMOUS JOEL BRUNT, MD JOEL BERMAN BURWELL, DO SCOTT A. CARLTON, MD

THOMAS J. COBB, MD W. MARK HORNE, MD MICHAEL G. KANOSKY, MD KATHERINE T. PATTERSON, MD

WAYNE A. SLOCUM, MD MEREDITH M. TRAVELSTEAD, MD

SILVER CHARLES D. BORUM, MD JENNIFER J. BRYAN, MD JOHN CLAY, MD RENIA RUSH DOTSON, MD BRADFORD J. DYE, III, MD R. LEE GIFFIN, MD JESSICA EILEEN GORDON, DO FASEEH HADIDI, MD J. EDWARD HILL, MD LUCIUS M. LAMPTON, MD

CARLOS A. LATORRE, MD PHILIP LEVIN, MD ERIC E. LINDSTROM, MD MICHAEL MANSOUR, MD WILLIAM A. MARTIN, DO JUSTIN ANTHONY MAY, DO W. DAVID MCCLENDON, JR., MD JEFFREY A. MORRIS, MD MERRELL ROGERS FIDEL FABIAN SENDRA, MD

MONA M. CASTLE, MD KRISTEN CRAWFORD, MD JOHN CROSS, MD CHRISTOPHER CUMMINS, MD EDWARD F. DALY, III, MD AMANDA DAHO-HABEEB, DO KENNETH SLOAN DRANE, MD J. MURRAY ESTESS, JR., MD HENRY P. EWING JR., MD JEAN HILL CHIP D. HOLBROOK, MD WILLIAM P. HOWARD, MD TERICA JACKSON, MD

MOHAMED JAH, MD BYRON THOMAS JEFFCOAT, MD AZAD KABIR, MD CANDACE E. KELLER, MD THOMAS KING, III, MD SON G. LAM, MD HAL T. LIDDELL, MD C. KENNETH LIPPINCOTT, MD WILLIAM L. MARCY, MD TOBE MOMAH, MD JOHN F. PAPPAS, MD SHARON M. PENNINGTON, MD JEREMY T. RAINEY, DO

ABHASH C. THAKUR, MD KENNETH THOMAS, MD CHASITY L. TORRENCE, MD BRIAN K. TSANG, MD J. MARTIN TUCKER, MD J. LEE VALENTINE, DO W. MARK VALVERDE, MD THAD F. WAITES, MD CHRISTOPHER H. WYATT, MD JULIE WYATT, MD

BRONZE DAVID L. REEVES, MD HEATHER RIFKIN JAMES RISH, MD RANDOLPH J. ROSS, MD GEORGE V. SMITH, MD ROBERT SMITH, MD HELEN R. TURNER, MD JOHN P.F.H. VANDERLOO, MD GERI LEE WEILAND, MD JEREMY B. WELLS, MD DONNA E WITTY MACK D. WOO, MD THOMAS D. WOOLDRIDGE, MD LAFARRA D. YOUNG, MD

JOIN TODAY AT WWW.MMPACONLINE.COM 228 VOL. 60 • NO. 2 • 2019

Thank you, too To the 2019 members of the Mississippi Medical Political Action Committee AUDIE M. ADAMS, MD SIGNE ADAMS JONATHAN R. ADKINS, MD TODD N. ADKINS, MD JOHN H. AGNONE, MD CAROL FRANKS AKIN, MD KATHERINE PIGOTT ALEXIS, MD RUSSELL ELBEY ALLMAN, JR., MD NABIH AL-SHEIKH, MD STEPHEN T. AMANN, MD ADELO E. AQUINO, MD TIMOTHY L. ARNOLD, DO MICHAEL ARTIGUES, MD WILLIAM C. ASHFORD, MD JOSEPH D. AUSTIN, MD STEPHANIE AUSTIN PETE T. AVARA, III, MD JOHN B. AVERETTE, MD DEBORAH T. AZAR, MD GEORGE J. AZAR, III, MD JOHN D. BAILEY, MD D. KYLE BALL, MD DAVID A. BALL, MD ERICA R. BALTHROP, MD TERRY LEE BANG, MD VIVEK BARCLAY, MD BROOKS BARHAM, MD JEAN MARIE BARKER, MD J. RUSSELL BARNES, MD SARAH E. BAROWKA, MD HARRY A. BARTEE, SR., MD JOHN MICHAEL BATEN, MD VICTOR T. BAZZONE, MD JAMES R. BECKHAM, MD CANON JADE BEISSEL, MD KRISTEN S. BELL, MD WM. SCOT BELL, MD BOYD P. BENEFIELD, MD DONALD W. BENEFIELD, MD SONIA BENN, MD ALLISON DERRICK BENNETT, MD KRISTOPHER BENNETT J. MONTGOMERY BERRY, MD BARRY D. BERTOLET, MD BRENT D. BEVARD, DO LENORA BIGLER STEVEN A. BIGLER, MD WM. A. BILLUPS, III, MD ARTHUR DEWAYNE BLACK, MD DON J. BLACKWOOD, MD EARL J. BLANCHARD, JR., MD CHRISTOPHER BLOMBERG, MD BENJAMIN D. BLOSSOM, MD

MICHAEL T. BOLER, MD KEVIN H. BOND, MD MICHAEL J. BORNE, MD CHARLES D. BORUM, MD DANIEL L. BOYD, MD STEWART A. BOYD, MD DAVID S. BRADEN, MD KAREN BRADEN SCOTT T. BRADLEY, MD K. PAGE BRANAM, MD SHELBY K. BRANTLEY, JR., MD KARA L. BRANTLEY-ROSAMOND, MD

WILLIAM C. BRAWNER, MD MARSHALL ADAMS BRISCOE, JR., MD

LINDA BRODELL ROBERT T. BRODELL, MD DAVID J. BROOKS, MD CHARLENE B. BROOME, MD BRETT O. BROWN, MD JAMES JAY BROWN, MD JULIAN ARTHUR BROWN, MD GREG BROWNING, MD CLAUDE D. BRUNSON, MD JOEL BRYNT, MD JENNIFER J. BRYAN, MD STEPHEN E. BUCKLEY, MD JUSTIN P. BUFORD, MD J. DAVID BULLOCK, MD JOHN D. BURK, MD DUDLEY S. BURWELL, JR., MD JOEL BERMAN BURWELL, DO WILLIAM G. BUSH, MD LISA CLARK BUSHARDT, MD JOEL ALAN BUTLER, MD L. SUSAN BUTTROSS, MD ADAM C. BYRD, MD GEORGE L. CAIN, JR., MD BRYAN S. CALCOTE, MD WILLIAM B. CALHOUN, MD JOE H. CAMPBELL, JR., MD ASHLEY M. CANIZARO, MD ROB M. CANNON, MD SUSAN STRONG CANNON, MD TROY R. CAPPLEMAN, MD SCOTT A. CARLTON, MD W. LARKIN CARTER, III, MD AMANDA CASSELL MATTHEW W. CASSELL, MD MONA M. CASTLE, MD ANN CASTLEBERRY G. M. CASTLEBERRY, MD WILL L. CAUTHEN, MD RICKEY L. CHANCE, DO J. KEVIN CHANDLER, MD

J. PATRICK CHANEY, MD JOSEPH J. CHAPPELL, JR., MD CHRISTINE K. CHARD, MD CHRISTOPHER M. CHARLES, MD GREGORY W. CHILDREY, MD MICHAEL J. CHRISTIE, MD GARY A. CIRILLI, MD ROGER C. CLAPP, JR., MD CHERYL G. CLARK, MD ROBERT E. CLARK, MD BRYAN M. CLAY, MD JOHN C. CLAY, MD THOMAS J. COBB, MD TIMOTHY L. COLE, MD AMY B. COLEMAN, MD JAMES P. COLEMAN, II, MD LEE WALKER COLEMAN, MD MICHAEL W. COLEMAN, MD R. VAN COLEMAN, MD AMBER DAWN COLVILLE, MD NATHAN LYLE COMPTON, MD CASSIE N. CONFAIT, MD JEFFREY N. COOK, MD LARRY DARNELL COOPER, MD FRED A. CORDER, MD, AGAF ROBERT STEPHEN CORKERN, MD MARY ANN COWART, MD E. HOWELL CRAWFORD, JR., MD KRISTEN CRAWFORD, MD VIRGINIA M. CRAWFORD, MD JOHN CROSS, MD BEVERLY CROSSEN KARL J. CROSSEN, MD E. THOMAS CULLOM, III, MD CHRISTOPHER CUMMINS, MD JERRY M. CUNNINGHAM, MD MICHAEL CUNNINGHAM, MD STEVEN G. CUNNINGHAM, MD ROBERT L. CURRY, IV, MD AMANDA DAHO-HABEEB, DO EDWARD F. DALY, III, MD KUSHNA K. DAMALLIE, MD C. RALPH DANIEL, III, MD MELISSA DANIEL ZAINEB DAUD, MD ALTON H. DAUTERIVE, MD GARY M. DAVIS, MD JOHN D. DAVIS, IV, MD CHRISTOPHER HALE DECKER, MD LAWRENCE E. DEESE, MD STEVE DEMETROPOULOS, MD DANIEL DRU DENISON, MD JAYANT DEY, MD

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******** ******** ******** ******** ******** ******** ******** ******** ******** ******** ******** ******** ******** ******** ******** ******** MICHAEL J. DIAZ, MD GREGG A. DICKERSON, MD ELIZABETH DIMITRI, DO SHANNON DOBBS, DO THOMAS E. DOBBS, MD CATHERINE A. DONALD, MD RENIA RUSH DOTSON, MD SHARON P. DOUGLAS, MD KENNETH SLOAN DRANE, MD J. JOEL DRUMMOND, MD T. JASON DUNN, DO BRADFORD J. DYE, III, MD JANIE EASTERLING S. RANDY EASTERLING, MD DANIEL P. EDNEY, MD LEIGH B. EDWARDS, MD MAROUN ELIE EL-HAYEK, MD NADINE EL-HAYEK CHARLES M. ELLIOTT, MD LESLIE E. ENGLAND, MD CALVIN S. ENNIS, MD J. MURRAY ESTESS, JR., MD OLGA ESTESS JACK C. EVANS, MD HENRY P. EWING, JR., MD WILLIAM M. FARMER, DO JACKSON MOTT FARROW, MD NICHOLAS FAYARD, MD F. HENRY FLAUTT, JR., MD DAVID THOMAS FLEMMING, MD JONATHAN G. FLOWERS, DO HERBERT B. FLOYD, MD TERESA FLOYD JOEL R. FLYNT, MD BEN P. FOLK, III, MD AMANDA H. FOWLER, MD ERVIN R FOX, MD HENRY CREED FOX, MD SARAH ELIZABETH FRENCH, MD SHAWN KEITH FRENCH, DO

RODNEY E. FROTHINGHAM, JR., MD

STEPHANIE FUSSELL, MD KRISTEN T. FYKE, MD ROB FYKE IRA E. GADDY, III, MD HUGH A. GAMBLE, II, MD CYNTHIA GANDY DAVID J. GANDY, MD RACHEL C. GARNER, MD THOMAS C. GARROTT, MD SAMIR C. GAUTAM, MD HARVEY A. GERSH, MD DEE DEE GIFFIN R. LEE GIFFIN, MD HILTON L. GILLESPIE, JR., MD J. BARRY GILLESPIE, MD WM. M. GILLESPIE, III, MD JAMES GILMORE, MD WALTER E. GIPSON, IV, MD WESLEY G. GIROD, MD RODERICK C. GIVENS, MD CHERYL L. GLADNEY, MD E. CHAD GNAM, III, MD RICHARD A. GOLDBERG, DO BARBARA B. GOODMAN, MD JESSICA EILEEN GORDON, DO KYLE F. GORDON, MD S. CARLTON GORTON, II, MD W. MACK GORTON, MD MICHAEL C. GRAEBER, MD JOSEPH GRAHAM, DO

WILLIAM M. GRANTHAM, MD L. LANGSTON GRAY, MD LAURA A. GRAY, MD BRADLEY N. GREENHAW, MD D. FRANK GUEDON, MD SHY GUEDON DARYL P. GUEST, MD WILLIAM E. GUSA, JR., MD YOLANDA GUTIERREZ, MD FASEEH HADIDI, MD KENNETH A. HAHN, MD WILLIAM C. HAIRE, JR., DO BETHANY R. HAIRSTON, MD JOHN C. HALBROOK, III, MD J. MACK HALTOM, III, MD JAMES R. HALTOM, MD SCOTT L. HAMBLETON, MD BURNETT HANSON, MD LILLIE HANSON R. HOUSTON H. HARDIN, JR., MD CHERYL HARDY, PHD JULIE G. HARPER, MD WILLIAM B. HARPER, DO ELLEN HARRIS JOE TANNER HARRIS, MD SCOTT E. HARRISON, MD D. STANLEY HARTNESS, MD BETH HARTNESS AAMIR HASHMAT, MD JOHN F. HASSELL, MD ARLIN HATFIELD, MD J. CLAY HAYS, JR., MD DAVID M. HEADLEY, MD STEPHEN E. HELMS, MD CHARLES A. HENDERSON, MD CHARLES D. HERNANDEZ, DO JOEL H. HERRING, MD OLIVIA HIGHTOWER, MD DOUGLAS L. HILL, MD J. EDWARD HILL, MD JEAN HILL JULIAN B. HILL, JR., MD RYAN CARL HILL, MD BRENDA P. HINES, MD KENNETH L. HINES, MD RANDALL S. HINES, MD ROB HINES PADAM HIRACHAN, MD HOAT MINH HOANG, MD CHIP D. HOLBROOK, MD JOHN G. HOLLAND, MD JOHN J. HOLLISTER, MD EDWARD H. HOLMES, MD DELPHIA E. HORD, MD W. MARK HORNE, MD JASON HOSEY, MD JEFFREY C. HOUIN, JR., MD JAMES R. HOUSE, III, MD WILLIAM P. HOWARD, MD ANTOINETTE M. HUBBLE, MD CLAY B. HUDSON, MD JEFFREY L. HUDSON, MD ROGER LEE HUEY, MD KAREN A. HUGHES, MD

VERNON THOMAS HUGHES, JR., DO

NOEL K. HUNT, MD BRANDON D. INGRAM, MD FRED H. INGRAM, MD DEDRI M. IVORY, MD JON COREY JACKSON, MD PAUL D. JACKSON, MD

TERICA JACKSON, MD MOHAMED B. JAH, MD ARJUN JAYARAJ, MD BYRON THOMAS JEFFCOAT, MD JOYCE R. JEFFCOAT JOSEPH W. JOHNSEY, MD HOLLYE R. JOHNSON, MD JEFF N. JOHNSON, MD JOHN JEFFREY JOHNSON, MD KURT D. JOHNSON, MD THOMAS E. JOINER, MD CLARENCE ALLEN JUSTICE, MD AZAD KABIR, MD MICHAEL G. KANOSKY, MD JULIUS KATO, DO INEZ M. KELLEHER, MD CANDACE E. KELLER, MD ANDREW H. KELLUM, MD MARK J. KELLUM, MD RICHARD A. KELLY, MD ANN M. KEMP, MD CHARLES A. KERGOSIEN, MD PAVEL L. KHIMENKO, MD KIRK L. KINARD, DO MARY ANN KING, DO THOMAS KING, III, MD KENT A. KIRCHNER, MD SHAHIN JOHN KORANGY, MD KEVIN A. KOSEK, MD MARK G. KOSKO, MD ROD GEOFFREY KRENTEL, MD PAMELA R. LACY, MD ANGELA LADNER MARK E. LADNER, MD SON G. LAM, MD PAMELA A LAMBERT STEPHEN C. LAMBERT, MD LUCIUS M. LAMPTON, MD CARLOS A. LATORRE, MD JOHN F. LAURENZO, MD ERIC D. LAWSON, MD A. KEITH LAY, JR., MD CLIFTON T. LEATHERBURY, MD CHRISTOPHER J. LEBRUN, MD BOO LEE JOHNATHAN YUN HOW LEE, MD HENRY T. LEIS, MD PHILIP LEVIN, MD SARAH LEWIS HAL T. LIDDELL, MD ERIC E. LINDSTROM, MD C. KENNETH LIPPINCOTT, MD NELSON K. LITTLE, MD STEVEN B. LIVERMAN, MD

DONALD CARLISLE LIVINGSTON, MD

ERIN N. LIVINGSTON, MD WILLIAM R. LOCKE, MD ANDREA F. LOGAN, MD T. BRUCE LONGEST, JR., MD R. H. LOPEZ-SANTINI, MD PHILIP R. LORIA, JR., MD CHESTER C. LOTT, MD FRANK A. LOVELL, MD KURRE T. LUBER, MD ERIC D. LUCAS, MD DIANE P MADDUX ROBERT F. MADDUX, JR., MD DAVID A. MAKEY, MD KAREN MALTBY, MD J. MICHAEL MANNING, MD MICHAEL MANSOUR, MD

******* ******** ******* ******** ******* ******** ******* ******** ******* ******** ******* ******** ******* ******** ******* ******** DANETT MAPLES, MD DON E. MARASCALCO, MD JING JING MARCY WILLIAM L. MARCY, MD LAURA L. MARION, MD TYLER G. MARKS, MD DUSTIN WAYNE MARMALICH, MD DEREK E. MARSHALL, MD LORI H. MARSHALL, MD ANDREW A. MARTIN, MD MURPHY S. MARTIN, MD WILLIAM A. MARTIN, DO J. LAWRENCE MASON, JR., MD ROBERT C. MASTERSON, DO PAUL G. MATHERNE, MD TAYLOR MATHIS, MD ARTHUR M. MATTHEWS, JR., MD WANDA MATTHEWS JUSTIN ANTHONY MAY, DO JAMES R. MCAULEY, MD ANDREA MARQUIS MCCANN, MD RICHARD F. MCCARTHY, MD MARVIN B. MCCAY, MD W. DAVID MCCLENDON, JR., MD CHARLES R. MCCOLLUM, III, MD FRED J. MCDONNELL, MD CHRISTY H MCHENRY DAVID G. MCHENRY, MD EVERETT C. MCKIBBEN, MD GERALD MCKINNEY, MD SHAWN A. MCKINNEY, MD CARROLL M. MCLEOD, MD JOHN R. MCPHERSON, MD JOHN H. MCVEY, SR., MD MAHESH P. MEHTA, MD CARY N. METTETAL, DO KAY E. MIDLER, DO SHELI MILAM, MD JOHNNY F. MILES, JR., MD AMY CHANDA MILLER, MD MATTHEW A. MILLER, MD REGINA C. MILLS, MD STEPHEN J. MILLS, MD MELANIE MILNER PAUL B. MILNER, MD BLANE A. MIRE, MD DON Q. MITCHELL, MD ELIZABETH W. MITCHELL, MD LARKIN H. MITCHELL, MD DONALD ODHIAMBO MITEMA, MD HANNA M. MITIAS, MD EMAD HASHIM MOHAMED, MD W. MARK MOLPUS, MD TOBE MOMAH, MD CARLA G. MONICO, MD JAMES M. MONROE, DO CHARLES W. MONTGOMERY, MD DAVID L. MOODY, MD ALAN R. MOORE, MD CHARLES K. MOORE, MD CHARLES R. MOORE, MD JAMES L. MOORE, JR., MD ANDREA D. MORGAN, MD JEFFREY A. MORRIS, MD C. TROY MORRISSETTE, MD J. SHEA MOSES, MD PAUL E. MULLEN, II, MD JONATHAN BARRY MULLINS, MD MARK GARRY MURRAY, MD CHARLES L. NAUSE, JR., DO HUNTER BEN NELSON, JR., MD

KURT L. NELSON, MD RENEE NELSON VIRGINIA C. NELSON, DO HEATHER NEWLON, MD LEE NICOLS, MD JEFFREY DEAN NOBLIN, MD W. THOMAS OAKES, JR., MD W. GARRETT OGG, MD Y. GRACE OH, MD TUNDE OLUSINA OLUTADE, MD MANUEL L. ONG, JR., MD MATT L. OSWALT, MD STEPHEN K. OTEY, MD GREGORY R. OWENS, MD BENJAMIN ROBERT PACE, MD LEENA PANDE, MD PURUSHOTTAM V. PANDE, MD KATHERINE G. PANNEL, DO RICHARD STEPHEN PANNEL, DO JOHN F. PAPPAS, MD KAMLESH H. PAREKH, MD BILLY D. PARSONS, MD CHANDANBALA PATEL PRAVINCHANDRA P. PATEL, MD GREGORY A. PATINO, MD KATHERINE T. PATTERSON, MD MICHAEL F. PAYMENT, MD JASON A. PAYNE, MD ERIC J. PEARSON, MD SHARON M. PENNINGTON, MD TERRY RAY PERRINE, MD HUONG PHAM, MD DENISE E. PHILLIPS, MD DOUGLAS C. PHILLIPS, MD EDWARD K. PHILLIPS, MD JOHN O. PHILLIPS, MD JOSEPH P. PHILLIPS, MD JOSHUA F. PHILLIPS, MD SONDRA PINSON TERRY W. PINSON, MD TRACY BLAIR PITTMAN, MD TERRY C. PITTS, DO KAREN W. PLUNKETT, MD MICHAEL E. PORTNER, MD RADHA PRASAD CHARLES K. PRINGLE, JR., MD JOE S. PULLIAM, MD SANDRA H. PUPA, MD JAMES PURVIS JANI L. PURVIS, MD ADAM E. QUINN, MD TIMOTHY M. QUINN, MD MILTON R. RAINES, MD JEREMY T. RAINEY, DO RICHARD DOUGLAS RAINEY, MD SESHADRI RAJU, MD ARUN R. RAO, MD J. ANN REA, MD W. RAY REED, JR., MD DAVID L. REEVES, MD R. KIRK REID, MD D BRIAN REMLEY, MD WILLIAM L. RENO, III, MD RICHARD E. RHODEN, MD

CHARLES DAVID RICHARDSON, MD

HARRY LEE RICHARDSON, JR., MD REBECCA RICHARDSON HEATHER RIFKIN EDWARD E. RIGDON, MD ANGELA MARIE RILEY, MD JAMES A. RISH, MD

ANTOINE B. RIZK, MD TANIA RIZK ROWLAND M. ROBERSON, MD JESS CLIFTON ROBERTS, MD RAY J. RODRIGUEZ, MD MERRELL ROGERS CLAIRE B. ROSENBLATT, MD RANDOLPH J. ROSS, MD JOHN MATHEW RUNNELS, MD R. SCOTT RUNNELS, JR., MD RUDOLPH S. RUNNELS, SR., MD E LANE RUSHING, MD WILLIAM RICHARD RUSHING, MD RICHARD L. RUSSELL, MD TAIMUR SALEEM, MD BRADLEY C. SAMS, MD H. JAY SANDERS, IV, MD PHILLIP ANTHONY SANDIFER, MD BEN F. SANFORD, JR., MD PAT H. SCANLON, JR., MD A. CHRIS SCHWARTZ, MD ROBIN H. SCHWARTZ, MD JEFFREY K. SEALE, MD MICHAEL A. SEICSHNAYDRE, MD FIDEL FABIAN SENDRA, MD J. KIM SESSUMS, MD MANOJKUMAR P. SHAH, MD NATHAN P. SHAPPLEY, III, MD PAUL E. SHEFFIELD, MD CHESTER DUANE SHERMER, MD RODERICK A. SHIELDS, MD KELLY N. SHOEMAKE, MD W. FLETCHER SHROCK, JR., MD KATHRYN LAURA SIGURNJAK, MD RYAN C. SIMMONS, MD SHANE M. SIMS, MD JAMIE D. SISK, MD B. TODD SITZMAN, MD ROBERT L. SKINNER, DO NEIL B. SLOAN, MD WAYNE A. SLOCUM, MD DENNIS EARL SMITH, JR., DO GEORGE V. SMITH, MD JASON V. SMITH, MD P. BRENT SMITH, MD ROBERT SMITH, MD ROBERT B. SMITH, MD SCOTT F. SMITH, MD TAYLOR F. SMITH, MD ADAM SMITHERMAN, MD LIZ SMITHERMAN DENISE H. SOJOURNER, MD DEBBIE SONES JAMES Q. SONES, II, MD C. DALLAS SORRELL, MD JOHN RYAN SPEIGHTS, MD HUGH W. STANCILL, III, MD JAMES W. STEPHENS, MD JOHN STEPHENS MELISSA R. STEPHENS, MD CARL W. STEVENS, II, MD DANIEL STEVENS, DO MATTHEW SCOTT STEVENS, MD BETH STONE JAMES E. STONE, JR., MD W. ROSS STONE, MD CLIFTON W. STORY, MD MARK H. STRONG, MD WILLIAM B. STRONG, JR., MD KENNETH W. STUBBS, MD PAIGE SUARES

R. NEAL SUARES, JR., MD ITALO SUBBARAO, DO SABRA SULLIVAN, MD WM DAVID SULLIVAN, MD JEFFREY T. SUMMERS, MD STEPHEN R. SUMRALL, MD AREMMIA D. TANIOUS, MD J. DEAN TANNER, MD STEPHEN W. TARTT, MD VERONICA R. TASSIN, DO CRYSTAL L. TATE, MD JEREMY TAYLOR, MD PAMI JO TAYLOR, MD JOSEPH R. TERRACINA, MD COOPER L. TERRY, MD WILLIAM G. THAGGARD, MD ABHASH C. THAKUR, MD GREGORY THALKEN, MD CHRISITIE H. THERIOT, MD HAROLD R. THOMAS, JR., MD KENNETH R. THOMAS, MD ALLEN HALE THOMPSON, MD WILL P. THOMPSON, MD GEORGE M. THURBER, MD C. RANDOLPH TILLMAN, MD CATHERINE TIMBERLAKE GREGORY A. TIMBERLAKE, MD ANCEL C. TIPTON, JR., MD RAYMOND E. TIPTON, JR., MD BRETT B. TISDALE, MD CHASITY L. TORRENCE, MD MEREDITH M. TRAVELSTEAD, MD ELIZABETH A. TREST, DO BRIAN K. TSANG, MD J. MARTIN TUCKER, MD PAMELA J. TULI, MD HANS HUNT TULIP, MD DIANE TURBA JOHN TURBA, MD D. MICHAEL TURNER, JR., MD HELEN R. TURNER, MD JAMES TURNER, DO JO ANNE TURNER, MD

TIMOTHY G. USEY, MD J. LEE VALENTINE, DO RICHARD C. VALLETTE, MD W. MARK VALVERDE, MD GEORGE KARL VAN OSTEN, III, MD GREGORY A. VANCE, MD JOHN P.F.H. VANDERLOO, MD MATTHEW A. VANLANDINGHAM, MD

DANIEL L. VENARSKE, MD KARTHIK VENKATESH PRASAD, MD SATISH C. VERMA, MD DIMITRIOS VIRVILIS, MD RAHUL VOHRA, MD CHRISTIE VOULTERS LEE VOULTERS, MD DAVID I. WADDELL, MD STANLEY A. WADE, JR., MD TERRY WADE THAD F. WAITES, MD DEXTER WINN WALCOTT, MD LEE HERREN WALKER, MD ALLISON P. WALL, MD MARK BURNETTE WALL, MD RICHARD E. WALLER, MD WILLIAM L. WALLER, MD GEORGE L. H. WARD, MD KEVIN M. WARD, MD PAUL D. WARE, MD JAMES E. WARRINGTON, MD JOHN A. WATSON, DO D. ERIC WEBB, MD MARK C. WEBB, MD GERI LEE WEILAND, MD ROGER D. WEINER, MD JOHN S. WELDON, MD THOMAS E. WELDON, MD DEVIN ANDREW WELLS, MD FORREST S. WELLS, MD JEREMY B. WELLS, MD PEGGY J. WELLS, MD WILLIE LEE WELLS, MD THOMAS W. WESSON, JR., MD RAUN WETZEL, MD

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232 VOL. 60 • NO. 6/7 • 2019

BENTON M. WHEELER, MD A. RANDLE WHITE, MD JAMES L. WHITE, MD RAYMOND Y. WHITEHEAD, MD ALEXANDER C. WHITTINGTON, MD

CHRIS E. WIGGINS, MD W. PAUL WILCOX, MD ANNA ALLRED WILE, MD CHELLE P. WILHELM, MD BRIAN L. WILKINSON, MD J. BARTON WILLIAMS, MD JANE-CLAIRE WILLIAMS, MD ROGER A. WILLIAMS, MD TODD DAVID WILLIAMSON, DO JAMES P. WILSON, MD JOSEPH L. WILSON, MD B. PEARSON WINDHAM, MD ANGELA B. WINGFIELD, MD MICHAEL H. WINKELMANN, MD JAMES K. WINSTEAD, JR., DO JOHN E. WITCHER, MD DANIEL A. WITTERSHEIM, MD DONNA E WITTY MACK D. WOO, MD E. GREG WOOD, III, MD JAMES S. WOODARD, MD ANNA WOODSON, MD BENJAMIN WOODSON, MD THOMAS D. WOOLDRIDGE, MD DARWIN BESHAN WOOTEN, MD TONY LASONYA WRIGHT, MD CHRISTOPHER H. WYATT, MD JULIE P. WYATT, MD ROBERT H. YARBER, MD BEN W. YARBROUGH, MD RYAN A. YATES, MD THOMAS L. YEARWOOD, MD JAMES A. YORK, MD LAFARRA D. YOUNG, MD RONALD A. YOUNG, MD RONALD S. YOUNG, MD LEE YOUNGBLOOD, MD

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Increasing Access to Health Care in Mississippi – Understanding the Challenges and Possible Solutions

M

ississippi has the lowest life expectancy of all the states.

There are many factors that contribute to this statistic.

The overall rate of death in Mississippians improved significantly in the past 20 years but remains lower than all of the other states that have shown more progress. Mississippi leads the U.S. with the highest incidence per capita of non-communicable diseases. The social determinants of health play a significant role in the relatively low life expectancy. Twenty-three percent of the population smoke cigarettes, contributing to the high incidence of heart attacks, strokes, lung disease, and cancer. The Mississippi Legislature has been unable to pass a tobacco tax of $1.50/pack known to deter smoking. Many people are uninsured and do not qualify for Medicaid, lack adequate transportation to seek care outside their home community, and lack sufficient access to proper nutrition and areas for physical activity. Mississippi has been unable to find a way to expand health care coverage to the working poor generally considered to be those people making just above 138% of the Federal Poverty Level. This lack of expansion of access to healthcare has created many challenges for Mississippi. Many people continue to work to develop ways to improve healthcare coverage and outcomes for the most disadvantaged.

Medicaid has generally been a low-cost means of providing health care coverage. Risk-adjusted expenditures for adult and Medicaid beneficiaries are approximately 22% lower than expenditures for adults covered by private insurance.

The Affordable Care Act (ACA) ended Disproportionate Share Payments to rural hospitals intending for this difference in government subsidy to hospitals caring for the poorest patients to be replaced by greater reimbursements with the expansion of health insurance through Medicaid.

Rural hospitals are facing a confluence of pressures. Rural hospitals see a higher percentage of self-pay patients. These hospitals and physicians have the same cost of electronic medical records, supplies and staff.

Many rural patients with insurance have high deductibles that they are unable to pay, resulting in an increase in bad debt for rural hospitals and physicians.

Uncompensated care exceeds hundreds of millions of dollars annually in Mississippi. Mississippi is among the states with the highest medical debt in the country due to extensive need for healthcare services in a population without the ability to meet these financial obligations.1 Thirty-one of Mississippi’s 64 rural hospitals or 48% are at financial

234 VOL. 60 • NO. 6/7 • 2019

risk. There are 430 rural hospitals nationwide at high financial risk. Many of these rural hospitals are essential to their communities. Considering factors like the level of trauma care they can provide, geographic isolation, and hospital employee to county population, Mississippi has 19 of the 64 rural hospitals that are either moderately essential or critically essential to their areas.2 Michael Mansour, MD

Flexibility that facilitates payment approaches designed to slow overall spending and improve outcomes may be an opportunity for bipartisan efforts that could benefit patients and taxpayers.

Discussions about Medicaid have generally overlooked the role of chronic disease management, preventive health and the role of longterm services. Almost half of Medicaid spending has misaligned with care and spending goals tending to favor nursing facilities and institutional-based care over home and community-based services.

Integrated care models which allow patients to receive primary care and treatment for behavioral health conditions have improved patient outcomes especially important for Medicaid populations who have a higher prevalence of mental health and substance abuse conditions than the general population. The greatest benefits to public health and the largest returns on the taxpayer dollar will come from an honest acknowledgment of the program’s successes and weaknesses and the pursuit of policies tailored to the realities of Medicaid and the populations it covers.

Medicaid spending on prescription drugs increased by 24% in 2014.

The Medicaid Drug Rebate Program designed to guarantee Medicaid a “best price” for prescription drugs has left states vulnerable to the high cost of brand-name drugs with little competition. The Rebate Program limits states’ flexibility to exclude low-value drugs from formularies and provides no mechanism for states to negotiate lower prices.3 Medicaid expansion is a cornerstone of the Affordable Care Act (ACA). Arkansas enacted legislation to adopt a model whereby Medicaid funds could be used to buy private health plans sold through the new health insurance exchanges made possible by the ACA. Since 1965 Medicaid has authorized the Secretary of Health and Human Services to use federal funds to pay insurance premiums in states that elect such an approach. Most states have developed Medicaid

managed care systems that now cover 75% of beneficiaries. 4 Thirtyseven states and the District of Columbia expanded Medicaid under the Affordable Care Act. Indiana was one of eight states that used Section 1115 waivers to modify the terms of expansion. The Social Security Act Section 1115 waivers allow providers to experiment with approaches that do not adhere to Federal Medicaid guidelines.

Indiana won approval from CMMS for its Healthy Indiana Plan (HIP 2.0) which expanded Medicaid eligibility to non-elderly non-disabled adults but with State specific variations. 5 As of February 2017, 16 states led by Republican governors had expanded Medicaid. Then Governor of Indiana Mike Pence took his own approach to Medicaid expansion using private insurance, health savings accounts and increased cost-sharing among other policies.

The Healthy Indiana Plan (HIP) allows access to substance-abuse treatment and additional incentives for members to quit smoking, use chronic disease management programs and take part in voluntary job referral and training programs. Beneficiaries pay premiums as low as one dollar per month, get health savings accounts, and can lose their benefits if they miss payments. Seema Verma, the current Administrator of the Centers for Medicare and Medicaid Services, was the architect of the Indiana plan.

Medicaid expansion in Indiana is estimated to cost $1.5 billion but bring $8.6 billion in federal funding from 2018 to 2020.

If Indiana had not expanded coverage at all, the state would have missed out on $17.3 billion in federal funding in a decade from 2013 to 2022.6 Enrollees in the HIP 2.0 Plan can pay premiums to receive more generous benefits called HIP plus. The premiums are as low as one dollar per month for people with incomes in the 0% to 5% of the federal poverty level range or in the form of contributions to a ”Personal Wellness and Responsibility” (POWER) health savings account.

Those who don’t pay premiums receive lesser benefit packages.

For enrollees with incomes between 101% and 138% of the federal poverty level, premiums are required in order to enroll in HIP 2.0.

These premiums are capped at 2% of income. For enrollees at or below the poverty level, HIP Basic offers an alternative that doesn’t require premiums. 5 The HIP can include vision and dental coverage if members make monthly contributions of $1 to $28 to Personal Wellness and Responsibility or (POWER) accounts. This money is used for the first $2500 of medical expenses each year. Indiana pays the bulk of that $2500.

Anthem is one of three private insurers providing coverage under the Healthy Indiana Plan. Nearly 75% of Anthem’s Healthy Indiana members visited a dentist, and 65% sought vision care in the first three months of coverage.

Recipients who make their contributions face no other healthcare costs. They can also lower their future contributions by getting recommended preventive care such as cancer screenings and checkups. State figures showed a 42% drop in emergency room use in 2015 among people who changed from traditional Medicaid to the HIP. Eighty percent of HIP members have used primary care at least once. 7 Starting in 2020, states are responsible for covering 10% of the cost associated with Medicaid expansion. A drafting mistake in the ACA allows people between 100% and 138% of the federal poverty level to receive subsidies to purchase private health insurance on insurance exchanges if they are ineligible for Medicaid. For these people, the Federal government pays the entire cost of subsidizing private coverage. As a result, states save money for every beneficiary whom they can move from Medicaid into their expansion and subsidized health plans. 8 Nearly 75,000,000 U.S. residents have health insurance through Medicaid. Benefits and programs vary by state in part due to Section 1115 waiver projects that are likely to assist in promoting the objectives of the Medicaid statute.

States wishing to implement experimental policies in their Medicaid programs must apply to the Centers for Medicare and Medicaid Services (CMMS) for a Section 1115 waiver which lifts certain federal regulations for five years. Thirty-seven states had active Section 1115 waivers as of October 2018.

Foremost among these policies are community engagement requirements which mandate that non-disabled, non-pregnant adults meet monthly quotas for the time engaged in work, volunteer activities, or school to maintain Medicaid coverage.

Other proposed waiver terms include beneficiary premiums with coverage lockouts for people who do not pay premium surcharges for tobacco use, drug screening and asset testing for beneficiaries, expansion of substance use treatment, elimination of non-emergency medical transportation services, and incentives or benefits tied to engagement in healthy behaviors.

Many new Section 1115 waiver policies are controversial, but waiver policies are diffusing rapidly as states exchange ideas which should establish a knowledge base for Medicaid policy choices.9 Primary care companies around the country have demonstrated the ability to cut costs by managing chronic disease with team-based care with a focus on keeping chronically ill patients out of emergency rooms and hospitals. By having more frequent visits with these patients who average five chronic conditions one primary care company has seen 50% fewer hospital admissions compared with standard primary care practice, 28% lower per member cost and significantly higher use of evidence-based medicine.10 Another model of providing and expanding health to disadvantaged patients has been through Community Health Centers (CHCs).

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These CHCs have traditionally provided care to many Medicaid recipients. In 2011, a model healthcare delivery system was proposed to help gain control over growth and cost and help to preserve access to care for Medicaid recipients in view of many cash strapped states at that time contemplating deep Medicaid cuts.

To sustain CHCs and thereby preserve access to care for Medicaid beneficiaries and other low-income patients while gaining control over cost, CHCs and Academic Medical Partnerships were proposed.

The Community Health Center Academic Medical Partnerships or CHAMPS combines the subspecialists’ expertise, medical technology, and inpatient care of local Academic Medical Centers with the primary care expertise of CHCs.11 A more recent innovation is being led by the Mississippi Hospital Association. Mississippi Cares is a public-private partnership between the State of Mississippi, Mississippi hospitals, and insurance provider Mississippi True and its plan members to reform Medicaid payment and delivery models. Premiums for Mississippi True, a hospital-owned health plan, would be funded by plan members at $20 per member per month and by hospital investments. No state general funds would be needed to fund the premiums. Mississippi Cares proposes to cover almost 300,000 adults who are not currently eligible for Medicaid.

Under a special Medicaid waiver request, Mississippi hospitals would make an additional investment in the premiums needed to fund the insurance coverage through a hospital-owned provider-sponsored health plan, Mississippi True. Due to hospital and participant investment funding the needed 10% state share to match the 90% federal share, this plan will not cost the state any additional dollars.

Healthcare in Mississippi is at a crossroads. Mississippi is the only state with statewide networks providing rapid and life-saving treatments for patients suffering trauma, heart attacks, or strokes. Many patients will be unable to rapidly access these services if Mississippi is unable to maintain its rural hospital network. Hospitals, physicians and the entire healthcare community are facing many challenges in the evolution of healthcare delivery. Shouldering the burden of caring for the uninsured and the underinsured is a responsibility that must be shared by Mississippi as a whole.

Many opportunities exist for Mississippi to do a better job of improving health care delivery and for improving the cost of health care while also improving the health of Mississippians. The greatest benefit for patients and taxpayers will come from honest discussions of the problems Mississippi healthcare faces and the opportunities available to adequately address these problems. Those who put Mississippi’s interest first will address these healthcare issues with the highest sense of urgency. n Michael Mansour, MD President, Mississippi State Medical Association References 1. Press release: Mississippi Hospitals Offer Proposal, Mississippi Cares, to Reform Medicaid in State. Available at https://mycarematters811958087.files.wordpress. com/2019/05/ms-cares-press-release.docx. Accessed June 4, 2019.

2. Larrison C. Half of Mississippi’s rural hospitals at risk of closing, report says, Mississippi Today, February 27, 2019. Available at: https://mississippitoday. org/2019/02/half-of-mississippians-rural-hospitals-at-risk-of-closing-report-says Accessed June 4, 2019.

Other leaders continue to propose innovative ways to increase access to health care. Congressman Michael Guest is sponsoring the physician pro bono care act of 2019. HR 856 would encourage physicians to provide pro bono healthcare to Medicaid and CHIPeligible individuals as well as allow physicians to take a single charitable tax deduction (32%) in place of administratively costly and complex Medicaid and CHIP reimbursement processes. The deduction would be based upon the value of the services based on Medicare rates or usual and customary fees in the state. The bill additionally provides liability coverage.

3. Controlling the Cost of Medicaid. McConnell KJ, Chernew ME. N Engl J Med. 2017;377(3):201-203.

A Deloitte Survey 2018 of US Healthcare Consumers shows that most adult Medicaid beneficiaries own mobile technologies, use them for a variety of health purposes and are interested in trying new digital health applications. One in five people in the United States are enrolled in Medicaid, and many mobile apps on the market are designed to meet diverse needs such as prescription refills, measure fitness and health improvement goals, monitor glucose or mood or receive reminders to take prescriptions. Fourteen percent of Medicaid patients lack digital technology, however, and it emphasizes the importance of maintaining non-digital tools and resources that keep the physicianpatient relationship at the center of healthcare delivery.12

9. Fulfilling States Duty to Evaluate Medicaid Waivers. Underhill K, Venkataramani A, Volpp KG. N Engl J Med. 2018;379:1985-1988.

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4. Using Medicaid to Buy Private Health Insurance – The Great New Experiment?

Rosenbaum S, Somers BD. N Engl J Med. 2013;369(1):7-9.

5. Indiana and the ACA’s Medicaid Expansion. Norris, L. Available at https://www. healthinsurance.org/indiana-medicaid/. Accessed June 4, 2019.

6. Red-State Medicaid Expansion – Achilles’ Heel of ACA Repeal? Sommers BD, Epstein AM. N Engl J Med. 2017;376(6):e7(1)-e7(3).

7. Indiana’s Medicaid Expansion Makes Poorest Pay. Galewitz, P. WebMD News from Kaiser Health News.

8. Small Change, Big Consequences – Partial Medicaid Expansions under the ACA. McIntyre A, Joseph AM, Bagley N. N Engl J Med. 2017;377:1004-1006.

10.

The American Journal of Managed Care (AJMC) website, News-Press Releases https://www.ajmc.com/press-release/increasing-patient-contact-with-doctorscut-medicare-advantage-costs-28-percent-iajmcisupreqsup-s. Accessed June 4, 2019.

11. Community Health Centers: Opportunities and Challenges of Health Reform – issue brief. Menlo Park, CA: Kaiser Family Foundation, August 2010. Hackbarth G, Boccuti C. Transforming Graduate Medical to Improve Health Care Value. N Engl J Med. 2011;364:693-5.

12. Medicaid and Digital Health: Findings from the Deloitte 2018 Survey of U.S. Health Care Consumers. Mayerol M, Carroll W. Available at www.deloitte.com/ centerforhealthsolutions. Accessed June 4, 2019.

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Dr. Carl Joseph Moran died on February 11, 2019, in Diamondhead, Mississippi, at the age of 76.

Dr. Moran graduated from the University of Mississippi School of Medicine.

After practicing family medicine in Raymond, Mississippi, for 20 years, he became board certified in Emergency Medicine and began a new chapter in his career as an emergency medicine physician at Memorial Hospital in Gulfport, Mississippi. He practiced at Memorial Hospital until his retirement.

Dr. Carl Joseph Moran

Dr. Moran is survived by his wife of 52 years, Jacqueline Gwen, two daughters, Melissa Manderson (Chris) and Marianna Flowers (Carl), grandsons Jordan Curry and Tanner Leggett, and one granddaughter Ava Manderson. He is also survived by siblings Helen Teachout (Bill), Lowell Moran (Sue), Warren Moran (Alyce), Frances Gordy, Barbara Westerfield (Woody), Philip Moran (Sheila), and many nieces and nephews. He was preceded in death by his parents Carl and Geneva Moran and his sister Edna Moran Lutz.

Dr. Carl Bernet died on May 19, 2018, in Greenwood, Mississippi, at the age of 91.

Dr. Bernet graduated from the University of Cincinnati Medical School and practiced pediatrics. He completed his pediatric training in New Orleans, Louisiana, and worked in several small towns for Charity Hospital of New Orleans before being recruited to work for the Centers for Disease Control (CDC) in Atlanta, Georgia.

During his time with the CDC, Dr. Bernet was one of the first investigators to study germ warfare after World War II, working both in Atlanta and in Denver, Colorado. For a time, he performed research alongside Dr. Jonas Salk, the inventor of the polio vaccine.

In 1955, he moved to Greenwood and opened his pediatric practice. Dr. Bernet served the Greenwood area for over 50 years, retiring in 2010. After seeing the impact a scholarship made on his granddaughter’s education, he was inspired to bequeath part of his estate to the University of Mississippi School of Engineering. The $100,000 gift will provide academic awards to engineering students from Leflore and Tate counties.

The widower of Janet Wright Bernet, Dr. Bernet is preceded in death by two grandchildren, Christopher Alban Bernet, and Lance Bush. Survivors include two sons, Christopher K. Bernet of Oxford, Mississippi; Carl P. Bernet, III (Vicki) of Magnolia, Texas; two daughters, Beth Hays of Madison, Mississippi; Nan Bush (Daryl) of

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Dr. Carl Bernet and nurse Thelma Hester Greenwood, Mississippi; seven grandchildren, Callie Moser (Joe) of Oxford, Mississippi; Taylor Rivers Bush of Greenwood, Mississippi; Heather Hays of Covington, Louisiana; Kati Coates (Cody) of Calgary, Canada; Becca Huffine (Dale) of Katy, Texas; Carl P. Bernet, IV (Christiana) of Denver, Colorado; and Maggie Bernet of Durango, Colorado; four great-grandchildren; and very special friends, Cathy and Eddie Barnes and Thelma Hester.

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DENTISTRY IN LAMBERT, 1906 – These two images reveal the early practice of the medical art of dentistry in Mississippi, specifically in the newly incorporated Delta community of Lambert. The procedure being performed in the larger image is an apparent tooth extraction. The images reveal a typical dental office of that period with medicine bottles on the shelf behind the white-coated dentist. The dentist in the back, holding the patient’s head (and in his white coat in the inset photo), is Speedy Walker, perhaps so named for his quick performance of dental procedures. The patient restraints are particularly rudimentary: a rope lassoed about the legs and arms. No sterile field (or attempt at one) is appreciated. Lambert is located in Quitman County in the northern part of the Mississippi Delta, four miles south of the county seat of Marks. Its early prominence was due to its location at the junction of the Swan Lake Cut-Off and the Lake Cormorant Branches of the Yazoo and Mississippi Valley (Y. & M. V.) Railroad. The O’Neal Brothers Sawmill was in operation there in 1902, and the area was first called the O’Neal Switch. The Quitman County Development Company, whose president was Dr. P. J. Darby (a Darby Avenue remains there), purchased the holdings of the O’Neal brothers and plotted out the town in 1903, naming it “Lambert” in honor of Dr. Darby’s wife, whose maiden name was Lambert. By 1905, the town was incorporated, and by 1910, the town’s population was 573. By 1937, the bustling city possessed a railroad depot (with the only water tank and refueling station for the railroad in the county), a hotel, a café, six filling stations, two schools, and three churches. Today, the population is approximately 1440. The nearby Marks Hospital, established by Dr. James Edward Furr in 1919, was said to be the first in north Mississippi to possess an “oxygen tent.” The Mississippi State Dental Association was founded in Vicksburg on April 21, 1875. The state’s first Dental Law passed through the Legislature in 1882, creating a Board of Dental Examiners. In 1926, the Legislature provided for a dentist to be appointed as a member of the State Board of Health. The most significant development in state dentistry was the establishment of the University of Mississippi School of Dentistry in 1975 which graduated its first class in 1979. If you have an old or even somewhat recent photograph or image which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal.

— 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 (19031957), a noted American psychiatrist and neurologist who also achieved fame as a poet and sonneteer. Born and educated in Tennessee, he received his MD from Vanderbilt School of Medicine in 1928. While always a prolific poet, he specialized in psychiatry and neurology, conducting a large psychiatric practice while teaching at Harvard Medical School and publishing research on alcoholism, addiction, suicide, and the psychoneurosis of war. “HEMATURIA” is one of my favorites among Moore’s sonnets. It tells a story not unknown to any practicing physician, of ignored bleeding (hematuria, hemoptysis, or hematochezia), which frequently is a presentation of cancer. (“Blood from any orifice is cancer until proven otherwise…” I preach to my medical students!) The poem is from “M: One Thousand Autobiographical Sonnets” published in 1938, on page 917, in a section entitled “Preoccupations on the Theme of Death.” I strongly recommend the book as one of Moore’s most substantial one-volume collections, containing many medical case histories. Moore noted in the book’s introduction that the sonnets in the volume fall into two natural divisions, those presenting the outer experience which he called “the autobiography of the flesh,” and those reflecting the inner events, which he called “the autobiography of the spirit.”

This sonnet seems to contain both flesh and spirit, both blood loss and mortality’s anguish. Expect more Moore sonnets in coming months. 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.

HEMATURIA Andrew knew enough to know that when The yellow stream, the stream that always ran Clear or amber, suddenly ran red, Something should be done; for it was blood.

He took himself to ancient Dr. Smith Who said, “Pooh— pooh,” and gave him pills to take To check the malady. It stopped forthwith, And Andrew forgot the matter, until he woke One morning ten months later then to find The stream completely stopped. “How I was blind To danger!” he reproached himself by saying After the genito-urologist Cystoscoped him, looked and saw the gist Of the trouble was bladder-cancer. Better start praying...

— Merrill Moore, MD (1903-1957) Native of Columbia, TN Long a resident of Boston, MA

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