Missouri Family Physician October-December 2020

FP FALL 2020

MISSOURI FAMILY PHYSICIAN VOLUME 39, ISSUE 4

Innovations in Teaching, Learning and Practice

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MISSOURI FAMILY PHYSICIAN October - December 2020

FP MISSOURI FAMILY PHYSICIAN

EXECUTIVE COMMISSION BOARD CHAIR Jamie Ulbrich, MD, FAAFP (Marshall) PRESIDENT John Paulson, DO, PhD, FAAFP (Joplin) PRESIDENT-ELECT John Burroughs, MD (Liberty) VICE PRESIDENT Kara Mayes, MD (St. Louis) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

BOARD OF DIRECTORS DISTRICT 1 DIRECTOR Arihant Jain, MD (Cameron)

ALTERNATE Jared Dirks, MD (Kansas City) DISTRICT 2 DIRECTOR Brooks Beal, DO (Kirksville)

ALTERNATE Vacant DISTRICT 3 DIRECTOR Emily Doucette, MD, FAAFP (St. Louis)

DIRECTOR Dawn Davis, MD (St. Louis)

ALTERNATE Lauren Wilfling, MD (St. Louis) DISTRICT 4 DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald)

ALTERNATE Jennifer Allen, MD (Herman) DISTRICT 5 DIRECTOR Natalie Long, MD (Columbia)

ALTERNATE Amanda Shipp, MD (Versailles) DISTRICT 6 DIRECTOR David Pulliam, DO, FAAFP (Higginsville)

ALTERNATE Carrie Peecher, DO (Marshall) DISTRICT 7 DIRECTOR Wael Mourad, MD, FAAFP (Kansas City)

DIRECTOR Afsheen Patel, MD (Kansas City)

ALTERNATE Beth Rosemergey, DO, FAAFP (Kansas City) DISTRICT 8 DIRECTOR Andi Selby, DO (Joplin)

ALTERNATE Kurt Bravata, MD (Buffalo) DISTRICT 9 DIRECTOR Patricia Benoist, MD, FAAFP (Houston)

ALTERNATE Vacant DISTRICT 10 DIRECTOR Vicki Roberts, MD, FAAFP (Cape Girardeau)

ALTERNATE Gordon Jones, MD (Sikeston) DIRECTOR AT LARGE Jacob Shepherd, MD (Lees Summit)

CONTENTS 4 A Letter from the Chair 6 Innovation in Medical School Teaching During COVID-19

10 Mask Use in the Primary Care Setting:

Considerations for the Pediatric Population

13 Multiplying the Data and Dividing Physicians’ Attention

14 Clinical Simulation: A Better Way To Train Rural Doctors

18 What’s New in the ABFM Performance Improvement Activity?

20 2020 Show Me Family Medicine Conference Recap

23 MAFP President Installation 24 Willow Springs Physician Named MAFP Family Physician of the Year

26 Externship Experience Reports 28 MAFP Submits Comments on IRS DPC Rules

RESIDENT DIRECTORS

29 Saint Louis University Recipient of the Family

STUDENT DIRECTORS

30 Celebrating Our Family Physicians

Kelly Dougherty, UMC (Alternate)

32 Members In The News

John Heafner, MD, SLU Morgan Murray, MD, UMKC (Alternate) Noah Brown, UMKC

AAFP DELEGATES Todd Shaffer, MD, MBA, FAAFP, Delegate Keith Ratcliff, MD, FAAFP, Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

MAFP STAFF EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE ASSISTANT EXECUTIVE DIRECTOR Bill Plank MEMBER COMMUNICATIONS AND ENGAGEMENT Brittany Bussey The information contained in Missouri Family Physician is for informational purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed, or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no respsonsibility for the opinion expressed thereon.

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 • p. 573.635.0830 • f. 573.635.0148 Website: mo-afp.org • Email: office@mo-afp.org

Medicine Cares Resident Service Award

35 References

MARK YOUR CALENDAR Oct.

14-18 2020 Nov.

12-14 2020

March

1-2 2021

AAFP Family Medicine Experience (FMX) (Virtual) October 14-18, 2020 MAFP 28th Annual Fall Conference November 12-14, 2020 Big Cedar Lodge - Ridgedale, MO MAFP Advocacy Day March 1-2, 2021 Capitol Plaza Hotel Jefferson City MO-AFP.ORG 3

Innovations Out of Necessity

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Jamie Ulbrich, MD, FAAFP Board Chair

he Greek philosopher Plato has been Lord knows we’ve all learned something we can credited with saying, “Necessity is the share with our colleagues! mother of invention.” If 2020 had a name, I have full faith and confidence that 2021 will it might be Necessity! As the year draws be a better year than 2020. My confidence comes to a close, each of us can look back and reflect on from knowing great physicians like you have been innovations we were forced to make. Some of us able to adjust and create your new environment. are private practice physicians that had to figure out Our profession is uniquely situated to thrive in this ways to keep our doors open while others are employed I am excited to not only learn physicians who had to be topics through CME sessions creative in navigating new roles but also reconnect with each and responsibilities. Still others of you and hope you will share are teachers and students who had their years significantly some of the knowledge you’ve altered by school closures or an gained over this year. abrupt removal of the ability to conduct class in person. Let’s also not forget our members who are matriculating time due to our years of intensive broad-based through their residency and trying to evaluate what educational experience and commitment to lifelong the future holds for them. They are our next wave of learning. I take great comfort in knowing that while innovators and will be faced with many employment we will see difficulties, we all learn from each other’s decisions and opportunities in the next few years as experiences - both good and bad. These lessons will help us maintain our practices, deliver great care to the American healthcare system transforms.

As of the publication of this magazine, the our patients, and support our communities.

My thoughts and prayers go out to each and Academy is working to plan an in-person Annual Fall every member of this Academy that has endured Conference at Big Cedar Lodge in Ridgedale, Missouri the loss of patients and family members affected by – near Branson. Although it will undoubtedly be different, this will be our 28th Annual Fall Conference the pandemic this year. We all embrace our calling and serves as a great reminder that through tough with love, care and compassion to all those we have times, we continue to prevail. I am excited to not been privileged to care for. The Missouri Academy of only learn topics through CME sessions but also Family Physicians are here to support and help you reconnect with each of you and hope you will share through these uncertain times and as always, feel some of the knowledge you’ve gained over this year. free to reach out to us if we can be of any assistance.

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Mission Statement:

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The Missouri Academy of Family Physicians is dedicated to optimizing the health of the patients, families and communities of Missouri by supporting family physicians in providing patient care, advocacy, education and research.

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MISSOURI FAMILY PHYSICIAN October - December 2020

Innovation in Medical School

Teaching During COVID-19

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n these recent few months, the world has changed very rapidly. This swift change is in part due to the novel SARS-CoV2 (COVID-19) pandemic, but also due to the transformation in how technology is utilized in everyday life.

Current practicing physicians have seen a shift in practice because of this; so, it is important to examine how this change has impacted how we educate future physicians. Medical school education has seen changes since its inception. But, unlike the subtle changes that have taken decades to carry out, this new way of life has forced some medical schools to implement quick measures to adapt to these new circumstances. This article will discuss the possible changes some medical schools and clinical clerkships may have taken due to the pandemic. This examination highlights new ways in which existing technology is employed to help educate future physicians that differs from the traditional classroom or clinicalbased education. A particular focus will be given on the use of technology for classroom, pre-clerkship, and clerkship clinical education.

As COVID-19 mitigation efforts were instituted in the United States, most medical schools and clinical rotations quickly halted inperson activity by mid-March, and there was a rush into a remote format (Rose 2020). After this initial blast of remote teaching, medical schools across the country were able to use emerging technology and previously existing methods to repackage their coursework into a meaningful student experience once class resumed for the new academic year (Rose 2020).

One of the methods that is being widely used by some schools is to forgo face-toface, large classroom lectures and instead use synchronous or asynchronous delivery. In synchronous delivery, faculty are able to use

video conferencing platforms to provide live and interactive lectures (Jonas et al., 2019).

This format mimics the traditional large lecture style where students can verbally ask questions in real time during the lecture.

Most of these platforms also have an enabled chat feature with which students can post written questions live for faculty to answer.

This is especially beneficial for the students who were accustomed to attending in-person classes and find the structure of attending classes beneficial. In the asynchronous delivery method, faculty can post prerecorded lectures using voiced over PowerPoint presentations, videos, or another format (Gomez et al., 2020). Faculty can also opt to make online learning modules for students to study at their own pace. This method of asynchronous learning has been implemented in the past by some for flipped classroom use, in which students learn the material on their own by working through selected reading assignments, therefore allowing class time to be used for problem solving.

This can happen in breakout rooms in which the video conferencing platforms can take a large group and organize them into smaller groups for more meaningful discussion (Jonas et al., 2019). This format also allows students more exposure to their classmates. Both the synchronous and asynchronous delivery have been utilized by other fields in the past for online courses, but COVID-19 has given these methods of learning more traction.

The challenge that many medical schools will face is how to provide physical exam/clinical skill education when COVID-19 mitigation requires avoiding large gatherings, social distancing, wearing of personal protective equipment (PPE), at minimum a mask, and sometimes testing. Some schools may opt to

Mariam Akhtar, MD Kansas City University of Medicine and Biosciences, Joplin Campus

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Medical schools across the country were able to use emerging technology and previously existing methods to repackage their coursework into a meaningful student experience once class resumed for the new academic year.

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continued from page 7

defer physical exam/clinical skill education for a later time in the year or when the schools deem it safe to resume (Rose, 2020). Other schools may plan for protocols to allow students to immediately start skills education. This should be executed by ensuring limited students on campus at a given time, with only essential staff and clinical teaching faculty having campus access. Schools taking this option will need to make sure to quarantine students as they come back to campus, and provide adequate testing for students, essential staff, and faculty before in person classes resume. These schools may also opt to take more precautions by having students don PPE/masks and maintain an adequate social distance with exposure to only a partner and teaching faculty. Those that take this approach will also need to make sure that an appropriate method of contact tracing is available. All students, essential staff and essential faculty will need to be properly trained.

As with any new tool, these new approaches to teaching may have issues to overcome. For remote education, be it synchronous or asynchronous, both students and faculty will need reliable internet access, availability of technology equipment (i.e. laptop, etc.) and some knowledge or training of the platforms being used (Abramson, 2020). Moreover, having lectures that students only watch at home can create a feeling of isolation as they will not have the camaraderie of their classmates. Remote small group, remote tutoring and access to their advisor remotely may help with this. Additionally, students having access to school counselors may be advantageous. Eventually though, the structure that usually comes with on campus classes will be lost as schools implement further remote education. And the boundary between home life and work will also be affected (Rose, 2020). These are some obstacles that students, faculty, and staff will need to o ve rc o m e in order to provide

and receive the best medical education during this transformative period.

For schools that may defer physical exam/clinical skill education, the number of students who are in the same clinical environment at once may increase. This can negatively affect the learning environment due to the volume of students (Rose, 2020). These are also things to consider for medical schools who enter into the unknown that was forced on them by the COVID-19 pandemic.

Telemedicine came to the forefront when COVID-19 first appeared since providers scrambled to treat patients without placing them in unnecessary risk. Telemedicine is not a new concept. It was used as early as the 1930s by the Italians to communicate with ships out in sea or even NASA to early space missions (O’Shea et al., 2015). In the past, it was used for specialty care such as psychiatry for rural areas and as access to technology is more widespread, its use has become safe and cost effective (Waseh et al., 2019). For these reasons, telemedicine has become an answer to giving more clinical experience to students during this COVID-19 pandemic. During the preclinical years, standardized patient encounters are important to help students build rapport with future patients, obtaining an adequate history, and performing a physical exam.

The previous face-to-face standardized patient encounters have been transformed into remote telemedicine encounters in some medical schools. Standardized patients who have access to a laptop, microphone, camera, and good internet connection can be trained to help students go through the entire encounter. Through facial and verbal cues, both student and standardized patient can portray emotions which will help build rapport. Students can perform a complete history and verbally direct the standardized patient through a physical exam (O’Shea et al., 2015). Students in their clinical years who have resumed clerkship are also learning to utilize telemedicine even more. Students in their third and fourth year can obtain history and physical but also formulate assessment and plan all within the guidance of the clinical provider in this remote setting (O’Shea et al., 2015).

Although telemedicine can fill a need, it can come with potential issues. Patients may not have reliable access to technology, which can limit the effective use of telemedicine.

Some patients may not have access to video conference, and some of these encounters may be done over telephone which has the potential to not be ideal for all types of patient complaints. Also, students may not learn how to build an adequate physician-patient relationship during this encounter.

Lastly, students will need to be educated on medico-legal issues that this format of patient care may bring up (O’Shea et al., 2015). Since the pandemic has made telemedicine widespread, eHealth policies are still in the works and not yet fully cemented.

As demonstrated in this article, many new and old methods to deliver remote education are being utilized by medical schools due to the pandemic. These changes are ultimately taken to safeguard students, patient, and faculty. Only time will tell if these are lasting changes and how medical school education will be impacted for years to come.

References found on page 35.

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Mask Use in the Primary Care Setting: Considerations for the Pediatric Population

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Amanda Springer, MS1 Saint Louis University School of Medicine

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n mere weeks, primary care clinics transformed to better serve patients during COVID-19. To name a few changes, the use of telemedicine is crucial, temperature checks and health screenings are performed before visits, hand hygiene is paramount, and virtually everyone attends their visit wearing a mask. In this everchanging situation we quickly adapt. However, one summer morning upon entering a patient’s room I was asked, “Are you smiling or frowning under your mask?” This was both a straightforward and powerful question, it suggested that many others also feel masks have changed communication during the healthcare visit.

In the subsequent appointments it became clear firsthand that patients, especially children, can be confused by primary healthcare providers wearing masks. While research has explored the perceptions, the adult population has of healthcare workers’ mask use,8,12,16 less attention has been given to the pediatric populations’ attitudes, especially when they are visiting their family physician.

MISSOURI FAMILY PHYSICIAN October - December 2020

This article explores how communication between pediatric patients and family medicine healthcare physicians is affected by mask wearing. It examines the impact that the use of personal protective equipment has on patients and provides solutions that can be implemented to alleviate misunderstanding and unnecessary stress during visits. Many studies show that “effectively communicating with patients is the art of medicine.”7,9,12,16 It is therefore important that providers are still able to effectively engage with their patients, despite not being able to rely on non-verbal cues and social distancing.

In fact, positive interactions affect patient compliance and satisfaction.16 Adequately fulfilling both of these aspects of a visit are crucial goals of good medical care. With the idea that mask wearing by both the patient (when ageappropriate for a child) and healthcare provider will be part of the fabric of care for some time, the goal of this piece is to understand what we can do to make children and youths feel more comfortable.

GPA Photo Archive / Libary of Congress St. Louis Red Cross during the Influenza epidemic of 1918.

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Throughout the Influenza Pandemic of 1918 ... St. Louis famously did an excellent job of preventing influenzarelated deaths compared to some other regions, masks were also employed.

COVID-19 has led to an unprecedented time in medical history. For many physicians, residents and allied health professions, this is likely the first pandemic in which they have practiced. As a result, many of the changes taking place in the realm of the clinic can seem strange.

However, it is important to remember that throughout history, as part of standard medical care and in response to epidemics and pandemics, clinicians have made use of personal protective equipment, including masks. In Europe, during the Bubonic Plague of 1348 and the subsequent outbreaks (1630, 56, 65 and 1720), physicians donned gowns, mica goggles and “beak-like masks.”4 Throughout the Influenza Pandemic of 1918 (known to many as the Spanish Flu), in which St. Louis famously did an excellent job of preventing influenza-related deaths compared to some other regions, masks were also employed.4,3,10 These continued to be used. Indeed, operating room masks were a more familiar sight.10 With the advent of all items being made to be disposable in the United States, in the 1960s, face masks were also made to be used once and discarded.10 Many physicians will also remember the Severe Acute Respiratory Syndrome outbreak of 2003 in which personal protective equipment was worn

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in hospitals throughout the country including children’s hospitals.2 Taken together, this short history of masks shows they have largely been affiliated with the hospital and the operating room.

It is clear that the large-scale use of face coverings as part of a primary care practitioners’ tool set is something that is new to most patients. For children there are so many physical and social changes at play during this time. In the last several months, many have felt isolated and have not attended schools or seen friends and family members. In addition, children have become ill with Multisystem Inflammatory Syndrome. 5 There are many more stresses than in ordinary life. In general, The American Academy of Family Physicians has stated that 1 in 6 children in this country has a mental health disorder including anxiety. 15 A lot of young people are facing challenges, and this is especially concerning because they are less likely to speak up and ask for help. Thus, in these difficult times, with simple changes a family physician can actively ensure they do not put more pressure on their pediatric population, unintentionally.

A 2013 randomized controlled trial in a primary care clinic in Hong Kong assigned patients to see doctors with a mask or without one.16 The researchers found that there was a significant reduction in perceived empathy when a physician donned a mask.16 The main reason that this was thought to occur was the lack of expression when a physician has the face covered.16 This shows that obstructing the face does lead to a loss of visual cues that occur in a visit. While perceived empathy diminishes, when implemented correctly children are not afraid of masks. A study in a pediatric hospital found kids do prefer face shields as they can see a provider’s full appearance.6 However, children still feel comfortable with surgical masks.6 MO-AFP.ORG 11

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The literature pertaining to pediatric dentistry is also relevant since protective gear is almost always worn in these practices because of the ubiquitous risk of infection.

These studies suggest children prefer plain masks to those with animations or designs.13 In addition, with a proper explanation, children were even shown to prefer their provider to wear a mask.1 Research shows that with appropriate implementation and sensitivity to a child’s preferences, we can effectively engage the pediatric population while still prioritizing protection. This begs the question what does the proper implementation look like?

To seasoned practitioners this list of proven methods pulled from the literature may be more familiar, however especially to relatively new physicians and trainees perhaps a few things on this list will help you to capture your pediatric patients’ attention while maintaining social distancing.

Children’s perceptions of masks during a family physician checkup is an important and largely unexplored topic.

This article seeks to provide clarification on the history of masks, explores the literature on the pediatric perspective and gives ten concrete tips to implement in daily practice.

While COVID-19 has changed so much of the experience of healthcare, the day-to-day reasons that pediatric patients present to the primary care clinic remain largely the same.

Therefore, while family physicians are busier than ever and constrained for time in visits, these small changes may ensure children and teenagers leave the office feeling understood, happy and adequately supported to comply with their treatment plan!

References found on page 35.

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TIPS FOR MAINTAINING A PEDIATRIC PATIENTS’ ATTENTION

01.

Always introduce yourself to a patient.

Even though you may have met many times in the past, masks can change a person’s appearance entirely2

02.

Have a picture of yourself in the room, on your white coat or make your ID badge clearly visible2

03. Make sure your patient knows you use your mask for everyone (some patients think they are very ill or that you only are using the mask to see them)12 04.

Use the non-verbal cues you still have available: make eye contact, uncross arms, motion with your hands when appropriate, nod your head, use intonation in your voice 2,12,14

05. Project when you speak and limit noise from the hallway, TV, laptops and cellphones11,14 06. State how you feel “I am pleased with X,Y,Z”14 07. Choose a clear mask so the patient can see your lips 08.

Get the patient to tell you what they understood about the visit2

09. Know that class, upbringing, culture and education can play a role in a patient and their parent’s understanding of what a pandemic is and why masks are important12 10.

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MISSOURI FAMILY PHYSICIAN October - December 2020

Be creative: have an office tip sheet2, poster or short video playing on TVs that explains why doctors are wearing a mask during a primary care visit

Multiplying the Data and Dividing Physicians’ Attention

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n 1821, Percy Bysshe Shelley published this observation in his book, Defense of Poetry, “We have more moral, political, and historical wisdom than we know how to reduce into practice; we have more scientific and economical knowledge than can be accommodated to the just distribution of the produce which it multiplies.” ¹ Here we are, 200 years later and family medicine has become the description of this idea in many ways.

Today’s family physician faces unceasing demands for sustaining and increasing financial viability while wrestling with an electronic health record (EHR) that was not designed with clinicians in mind and oceans of data which threaten to drown even the hardiest of attention spans. What tools can help family physicians navigate these uncharted waters?

Artificial intelligence powered by machine learning may provide relief to family practices in the form of a virtual digital assistant (VDA). These tools present a novel approach to administrative complexity and allow you to practice medicine the way you prefer putting more emphasis on the long-term connection with patients to supply solutions that keep them thriving.

Data fuels the engine of clinical knowledge. The correct diagnosis can be lost in the haze of too much fragmented and hard to find data of lab values and diagnostic studies. On the other hand, a diagnosis can be missed with too little data. The goal of a VDA is to take the information that exists and make connections which lead to improved outcomes for the patient and the practice. Increasing administrative simplification and decreasing cognitive burden are two of the highest priorities for these types of tools. The system does not take actions in the encounter. It collects and presents information in a way that makes it easier for physicians to use clinical judgement. There are two examples of VDAs that are intriguing to consider: Suki and Navina.

The American Academy of Family Physicians (AAFP) has created a multi-year effort, the Alliance for eHealth Innovation, that has the goal of finding new and effective solutions for a range of problems facing family medicine. The Innovation Lab’s goal is finding tools, such as VDAs, and assessing whether the class of products are suitable for addition to a physician’s technology portfolio. VDAs are an intriguing development for clinicians. Typically, these are offered as software as a solution (SaaS) which has a monthly per user or per practice charge and

connects to, rather than replacing your EHR. While these can offer an improved user experience, they cannot entirely fix a poorly designed EHR. The clinical workflow may require modifications and as always, your mileage may vary.

Suki is a cloud-based automation tool that helps physicians easily document in the patient record using their voice. Suki can be accessed through an app on your smart phone or an internet browser, and no new hardware is needed. The EHR templates that each user may have developed are the basis for each streamlined encounter. As clinical information is generated by questions you ask the patient, Suki listens to the speech, recognizes, and transcribes the content with a high degree of accuracy. It begins to learn your preferences and the process of documentation becomes more efficient the more you interact with the software. This technology is allowing physicians to step away from the keyboard and gives them several hours back each day through the doctor’s smartphone or a web browser. The Innovation Lab has seen up to a 75% decrease for time needed to document in day-to-day clinical activities.

Navina has a different approach to the complex problem of cognitive burden. Their solution uses artificial intelligence to look at the patient record in its entirety and analyze the existing data to ensure your workflow is complete. Did you follow-up with the patient who had hematuria? Were you able to check that the new medication you prescribed did not have artificial color due to a patient recently developing a sensitivity to Red 40? Navina produces a brief, one to two-page document that supplies information assessed from the EHR in an easy to read format. This will help with pre-visit planning as well as communicating patient status to other clinical team members, while assuring there are fewer, if any, gaps during the treatment encounter.

The VDA powered by artificial intelligence is one tool that family medicine physicians can use to begin addressing the significant information overload and cognitive burden that they face in day-to-day clinical practice. While no single tool can provide total relief, there are several solutions that can help clinicians sort and assess fragmented data, giving them more knowledge and time to make the best decisions for the patient.

If you, or anyone at your practice is interested in learning more about these solutions or other Innovation Lab projects please contact Paul Dow, the eHealth Innovation Strategist at pdow@aafp.org.

J. Paul Dow, MSHI eHealth Innovation Strategist, AAFP

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The goal of a VDA is to take the information that exists and make connections which lead to improved outcomes for the patient and the practice.

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References found on page 35.

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INTRODUCTION

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imulation education is a proven training tool used for decades in many different settings. Aviation, aeronautics, and industry have historically used simulation for training and education. Simulation allows learners to succeed in an artificial environment that approximates reality as closely as possible. It also allows for failure in a safe environment, providing the opportunity to learn from mistakes without the risk of actual harm.

Simulation based medical education began in emergency cardiac care training and has expanded significantly. It has grown to include procedure skills, critical care management, interdisciplinary team training, and clinical patient interaction skills.

Simulation bridges the gap between the classroom and clinical experience. It challenges learners to make decisions, and to evaluate and manage the results of those actions with no possibility of harming patients. Learners use simulation to perform tasks, receive feedback, practice the task incorporating that feedback, and repeat the task after feedback and coaching.

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Simulation training centers are often located in or near medical teaching centers that have the resources and personnel needed to support simulation education.

Located in urban or suburban areas, these simulation centers may not be easily accessible to rural practitioners.

As a result, rural physicians and other rural providers may lack access to training. This can limit opportunities to apply newer diagnostic and therapeutic modalities, and to update training in previously learned skills. This situation can further widen healthcare disparities between rural and non-rural populations.

Rural simulation education can help close the training gap between rural and non-rural providers. Rural simulation education can eliminate the cost of attending training and time away from practice. It can also develop local educators who can then continue to train local providers. Given the adaptability and versatility of simulation, simulation-based education can be a powerful tool for rural healthcare providers.

SIMULATION MODALITIES

Simulation can adapt to numerous educational requirements. It can be a simple model used to practice a specific task, like starting an IV or practicing suture techniques. It can also be a highly sophisticated computerized human patient simulator replicating physiologic states and responses to clinical interventions.

Simulation case scenarios can involve human actors known as standardized patients to simulate a patient or 16

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member of the healthcare team, or use virtual reality to create a completely immersive environment complete with equipment and personnel. All of these modalities can be available in rural settings, either on site, delivered via a mobile simulation vehicle, or accessed online.

EDUCATIONAL BASIS OF SIMULATION

Simulation education uses active learning incorporating the experience and viewpoint of the learner. This is especially applicable to clinicians needing training that is practical, relevant, hands on and immediately applicable.

In simulation, learning is experiential and requires active participation. Simulation allows adult learners to gain new knowledge and integrate it into their database, building on existing knowledge and experience. Each learner has developed his or her own method of problem solving, and everyone’s method may be equally valid.

In simulation-based education, learners bring his or her own experience and their own unique approach to problem solving. They build on their own framework to incorporate new skills. Rather than memorize facts, learners apply them and develop appropriate problemsolving methods.

EFFECTIVENESS OF SIMULATION EDUCATION

The most effective learning is active learning. Learners tend to retain approximately 5% of what they read or hear in a lecture. They tend to retain 75% of what they

learn as an active participant in learning. In addition, if they are required to teach the knowledge, they retain up to 90% of that knowledge. In translating knowledge into practice learners progress in training and experience. Simulation training allows learners to progress from “knowing how” as demonstrated on written test performance, to “showing how” in clinical skills exam or in translating action into performance.

DEBRIEFING

Debriefing is the most important component of simulation education. Most of the learning in simulation education takes place in the debriefing following the event. Debriefing translates actions into knowledge that learners can apply in practice. The most important aspect of debriefing is establishing a safe setting where learners feel free to discuss the session and receive constructive feedback. Facilitators trained in debriefing provide feedback and coaching to improve learner performance. In some settings, learners can then repeat the scenario to incorporate feedback through practice.

a realistic clinical environment for training and debriefing.

The mobile simulation vehicle can also provide onsite training in newer diagnostic and therapeutic modalities like point of care ultrasound. Providers trained in these newer modalities can bring a higher level of care to their patients. Additionally, interested local providers trained as simulation educators can continue training at their locations and mentor new educators who can help train more providers.

Education using virtual reality can also adapt to rural settings.

Requirements vary from a standard computer to practice clinical scenarios and decision-making, to fully immersive virtual reality using a headset adapted to a smartphone. Internetbased training has the flexibility of 24-hour availability at the convenience of the learner, and can be accessed anywhere. It can also link with university training sites to provide high-level training to rural areas.

SUMMARY

Simulation education provides effective clinical training. Rural simulation education gives rural clinicians access to training they would not otherwise have. Mobile simulation facilities and RURAL APPLICATION Rural training is an ideal application for simulation education. online training modalities are readily available. These options Mobile simulation is a viable solution to overcome the barriers bring the training to the learner, rather than requiring the of distance and expense. Using a mobile simulation unit, training learner to travel to the training. They also allow local educators can be adapted to most of the needs of local practitioners. Task to become simulation education “champions” to develop and trainers brought to the location can provide procedure skill deliver local training programs. By taking advantage of the training. Similarly, high fidelity patient simulators brought to a benefits of simulation education, rural clinicians can enhance given location can provide critical care and team training. The their clinical skills and learn new techniques to enhance the care mobile simulation unit itself can serve as a training platform. The they provide. interior of the simulation unit is self-contained and can provide References found on page 35.

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What’s New in the ABFM Performance Improvement Activity?

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Elizabeth Baxley, MD

Ashley Webb, MA

Ann Williamson, RN, CCRC

foundational professionalism commitment for physicians is to continually improve the care they provide through lifelong learning by keeping up-to-date with advances in medicine and to reflectively look at their practice, wherever that may be, to determine if changes in care delivery are needed. One of the most significant series of changes in the American Board of Family Medicine (ABFM) Continuous Certification process over the past two years has been in Performance Improvement (PI) activities. The purpose of the PI activity requirement is to demonstrate that boardcertified family physicians can identify a gap in outcomes or an improvement they wish to make in their care of patients, plan and implement an intervention to address the gap or desired change, and to reassess to see if the intervention resulted in an improvement. Meeting this requirement, which applies to any clinically active physician, is accomplished by completing a minimum of one (1) PI Activity within every three-year stage. Completing any of these activities will meet the PI requirement and provide 20 points towards the overall 50-point certification requirement.

In response to feedback about the limited availability of options relevant to physicians in more focused practice (e.g. emergent/urgent care; hospitalists; hospice/palliative care; sports medicine), the ABFM created 15 new directed activities that focus broader set of topics to enhance the value for the most Diplomates. The ABFM also created the PI locator to assist physicians in choosing the activity that is the best fit for their practice.

ABFM SELF-DIRECTED PI PROJECT: CLINICAL PATHWAY

This new option allows you to submit a customized clinical improvement project based on the quality improvement activities you are already doing in your practice, or to tailor your efforts in a more focused direction based on your own interests or practice setting (e.g. locums; nursing home; etc.). You may complete this activity individually or as a small group (up to 10) of family physicians. There is an easy and efficient application process to complete for the SelfDirected PI activity with quick response time from ABFM regarding your credit.

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EXPANDED PI MODULES

The ABFM-developed PI activities platform presents an opportunity to complete a guided PI activity covering a broad range of topic areas. The physician can select at least one of the four approved measures and utilize resources to develop individual performance improvement interventions. ABFM has significantly expanded the choices to 15 practice areas or conditions to choose from, shown below.

Additionally, the platform has been redesigned to make it easier to do and provide an enhanced user experience.

• • • • • • • • • • • • • • •

Asthma Acute Care Behavioral Health Cardiovascular Chronic Care Diabetes Efficiency and Cost Reduction Emergency Department/Urgent Care Hospice and Palliative Care Hospitalist Hypertension Patient Safety Pediatrics Preventive Care Sports Medicine

PERFORMANCE IMPROVEMENT (PI) LOCATOR TOOL

Over the years, ABFM has received feedback from many Diplomates that felt finding and choosing a relevant and meaningful PI activity to meet certification requirements was quite challenging. It is for this reason that we developed and launched the PI Locator tool in 2019 to simplify this process.

Diplomates can identify the most relevant activities for completing this requirement based on practice type and scope using the PI Locator within the Physician Portfolio. You can enter and save your personal preferences such as type of practice, areas of practice interest, and quality recognition programs in which you are involved. The PI Locator will then select the most relevant activities to your preferences, making it easier to choose an activity that is right for you and your practice.

NEW BROADLY RELEVANT ACTIVITIES:

To support more timely and relevant areas of performance improvement, ABFM added a new activity focused on the COVID-19 pandemic and another one focused on health equity.

• The new COVID-19 Self-Directed Clinical activity provides a mechanism for meeting the PI requirement by telling us about the rapid changes Diplomates had to make in the way they delivered care, as necessitated by the COVID pandemic. This PI can include a variety of changes such as virtualization of office visits, establishing screening protocols for patients, developing new office processes to protect staff health, determining how to re-establish in-person care and balancing continued telehealth, or preparing for dealing with the “twindemic” of influenza and COVID this fall and winter.

• The new Health Equity Self-Directed Clinical activity provides a mechanism for meeting the PI requirement by developing ways to improve how a Diplomate’s practice addresses social determinants of health, reducing disparate outcomes in clinical measures across various groups of patients, assessing for implicit bias or unintentional barriers to care at the practice level, and working with communities to address drivers of inequality outside of the practice. This activity can apply

improvements in care for a variety of sub-populations such as assessing inequities or barriers by race/ethnicity, socioeconomic status, sexual orientation/gender identity, disability, rural, and including common screening activities (cancer, HIV) and/or conditions (quality measures for hypertension, diabetes).

ABFM intends for Performance Improvement to be a meaningful activity that helps guide Diplomates in continuously improving the care they deliver. We strive to continue to offer a wide array of options for activities that are relevant to a variety of practice types, while reducing the burden of work by giving credit for what Diplomates are already doing in practice, using streamlined reporting processes.

Information regarding each of these activities can be found at https://www.theabfm.org/continue-certification/performanceimprovement. To help guide physicians through this process and answer questions, ABFM offers virtual office hours. Our Performance Improvement Manager can assist with questions.

For current dates and call-in information, please visit the ABFM website at https://www.theabfm.org/continue-certification/ performance-improvement or you can contact the ABFM support center (https://www.theabfm.org/support-center, 877.223.7437 or help@theabfm.org) at any time with your questions.

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RECAP Written by MAFP Staff

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AFP held its first ever virtual conference, the 2020 Show Me Family Medicine Conference August 14 – 15, 2020. The conference was created out of necessity due to the COVID-19 pandemic, as discussed in the 2020: The Year of the Pivot. The conference drew approximately 65 family physicians, residents and students from across Missouri to earn 13 hours of CME and celebrate family medicine in this new virtual format.

The conference started with a Transition to Practice session Friday morning for family medicine residents and students. Family physicians joined the rest of the conference which was held from noon to 6:00 p.m. on Friday and 8:00 a.m. until 4:00 p.m. on Saturday. All sessions were held virtually, via Zoom, with links shared with participants to join easily. Rehab Specialty Medical was the presenting sponsor of the conference. A slide show of exhibitors and sponsors, including guided stretches from the American Association of Physical Therapists of Missouri, played between sessions.

Friday’s sessions started off with a Legislative Update with Keith Ratcliff, MD, FAAFP, joining MAFP Governmental Consultants Brian Bernskoetter and Randy Scherr. They discussed family medicine advocacy issues, the reality of operations in the State Capitol during COVID-19, and a projection of the 2021 Session. The 2020 issues discussed included Preceptor Tax Credit, Scope of Practice for

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APRNs, Physician Assistants, Assistant Physicians and Athletic Trainers, Physician Assistants Staffing Ambulances, Opioid Guidelines, Any Willing Provider, Vaccinations, Interstate Medical Licensure Compact, Radiologic Technician Licensure, Physical Therapists Direct Access, Motorcycle Helmets, DPC and Medicaid, Surprise Billing, Contraceptives, PDMP, Non-Compete Agreements, and Punitive Damages / Unlawful Merchandising Practices.

2021 Legislative Priorities identified are Primary Care Investment, Preceptor Tax Credit, PDMP, and Preserving the Scope of Practice of Medicine for Family Physicians. Family Physicians are encouraged to testify on important issues as they arise and join your colleagues at the MAFP Advocacy Day March 1-2 in Jefferson City. Other topics presented on Friday included: Integrating Behavioral Health in Primary Care, Recent Advances in the Management of Hyperkalemia, two sessions on Diagnosing and Treating Common Sleep Disorders in Primary Care, and an update from AAFP Board Chair John S. Cullen, MD, FAAFP on Priority Issues Impacting Missouri Family Physicians.

Saturday’s sessions included Intimate Partner Violence, Health Equity, Cancer Survivorship – The Role of the Primary Care Physician, Management and Prevention of Influenza in High-Risk Patients, Hormone Replacement Therapy in Menopause, Travel Medicine, and a presentation on pandemics including COVID-19.

How did we do?

Our responses from the post-conference evaluations indicate attendees were pleased with the conference but understand we can never replace live in-person conferences. We agree 100% as the MAFP team misses seeing our members! The aggregated response statistics are below:

Overall satisfaction with the Show Me Family Medicine Virtual Conference

95.24%

How would you rate the overall organization of the conference?

96.77%

How would you rate the overall relevancy of the topics?

96.77%

This is a conference that I would attend again

100%

Good or Excellent

Good or Excellent

Good or Excellent

Yes

What type of conference do you prefer?

No Preference: 22.58% In Person: 54.84% Virtual: 22.58% Saturday also included an Awards and Installation Ceremony. This ceremony celebrated the 2020 Family Physician of the Year, Robert Shaw, MD, FAAFP, (Willow Springs); Outstanding Resident of the Year, Misty Todd, MD, (Columbia); and installed your new MAFP President, John Paulson, DO, PhD, FAAFP, (Joplin).

The Soaring Eagle Award was presented to 2018-2019 President Sarah Cole, DO, FAAFP. New officers were installed, and Degree of Fellow was conferred to Tess Garcia, MD, FAAFP.

Where do we go from here?

Despite a successful virtual conference, we understand our members crave personal interaction that is impossible to replicate virtually.

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continued from page 21

2020: The Year of the Pivot

The 2020 Show Me Family Medicine Conference was shaping up to be a great one. It was scheduled to be held June 12 and 13 at Margaritaville Lake Resort. We had nationally recognized speakers coming in from Kansas, Tennessee, Texas, Pennsylvania, Massachusetts, Maryland, South Dakota, and Alaska along with every corner of Missouri.

Then COVID hit. The global pandemic incited travel hesitation, travel bans, corporate budget slashing, and significant concerns about bringing geographically diverse presenters and attendees together. We made the difficult decision in mid-May to postpone our conference to August 14 and 15, 2020 after Margaritaville affirmed they would be able to accommodate us. We immediately made plans and started working with vendors to pivot to a hybrid model where our conference would be held both in-person and livestreamed to attendees regardless of their location. Following the 4th of July weekend, MAFP received notice from almost every presenter that they were unwilling or unable to travel to Lake of the Ozarks – largely due to the area’s well-publicized lack of effort to control the spread of the virus.

On July 14th, the decision was made to pivot to a 100% virtual conference. MAFP staff knew a virtual conference would never measure up to a live conference, but we also knew it was our mission to deliver top quality CME to our members. With so many CME options available, our charge was to create a high-quality conference of relevant topics and presentations for family physicians. We were also sensitive to connecting our attendees to exhibitors and began working on methods to create meaningful interactions.

We immediately reached out to our presenters to ensure they were able to present virtually. We were pleased to hear all speakers

agreed and were eager to present in this new conference format.

After consulting with other professional meeting planners, attending several webinars and meetings on best practices to consider when pivoting to virtual, and learning from virtual conferences that we attended, we put many lessons learned to use. The most impactful lesson learned was to prerecord our sessions. Prerecording allowed us to mitigate presenter connection issues and delays, as well as create a scenario where the presenter was able to answer questions through a live Q&A function while their prerecorded session was playing. This gave MAFP staff time to edit videos as needed.

Creating a networking environment among members and exhibitors is a challenge with virtual meetings. Regarding the exhibitors, we wanted to ensure our sessions were compliant with the requirement that CME sessions be free of commercial influence. This allowed our exhibitor and sponsor information to be incorporated before each CME session. That meant we were able to create an automated slide show of our sponsor and exhibitor information to play during session intermissions. As we too have experienced, sitting for long periods of time is not healthy so we included guided stretches to provide attendees with some activities to refresh the mind and body.

Moving forward, we will continue to do all we can to deliver live, in-person conferences in a safe environment, but stand ready to pivot however we need to deliver the high-quality CME that you have come to expect from MAFP. We have learned about your expectations for CME, whether in person or virtual, and we hope that future conferences will continue to exceed those expectations. We would like to express our appreciation to the speakers for their flexibility, the Education Commission for their guidance, and the MAFP Board for their support through this transition. YOU make MAFP a leader in primary care!

Thank you to all our attendees, exhibitors, and sponsors who made this conference a success!

Alexion Metabolics Division | CoxHealth Physician Recruiting | Crossroads Hospice Charitable Foundation | Missouri Health Professional Placement Services | Missouri Telehealth Network and Show-Me ECHO | OnPoint Allergy Services | Rehab Specialty Medical, Inc. | US Army Medical Recruiting 22

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MAFP President Installation

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his year has been an exceptional year with flexibility due to the COVID-19 virus. We have all learned to adapt in these challenging times. John Paulson, DO, PhD, FAAFP, was elected as the MAFP President during the June 13 Virtual Annual Meeting. At the time, we hoped to hold an in-person meeting in August for the installation of our new president.

However, that was not the case and Dr. Paulson was installed during the virtual Annual Awards and Installation Ceremony on August 14. Congratulation Dr. Paulson!

John Paulson, DO, PhD, FAAFP Acceptance Speech Back in 2007, while I was a resident at Cox Family Medicine Residency in Springfield, I was asked to serve as the Alternate Resident Director on the MAFP board.

That is where I started and I now have been involved with the MAFP ever since. I appreciate the people I have met, places we have gathered, and things I have learned while part of the organization.

It is an honor to represent the 2,500+ MAFP members, especially in these trying times when Family Physicians are on the front lines of this pandemic. I am proud that we are doing

a better job of representing our members by taking “no stance” on topics and policies where our members do not agree. I am confident that if we focus more on topics that our members agree on and less on the ones we don’t, significant progress can be made for our patients and members.

We have been very intentional with the reorganization of the MAFP staff recently and I want to recognize Kathy, Bill, and Brittany as they are and will continue to be the workhorses behind the organization. We are investing in them because we know they can help us achieve our strategic goals.

Recently, I heard someone say “Change is certain, Progress is not.” Our job as an executive committee and board the next year is not to mistake change for progress. We are going to continue to focus in these uncertain times to work creatively toward meeting our strategic goals, specifically developing our FM pipeline, increasing public awareness, and continued advocacy for our patients and all family physicians.

I thank the Lord every day for my wife, Crissy, and daughter, Ella. If you know Crissy, you will certainly recognize that I married up and out of my league. But in closing, I want to thank each of our MAFP members, board members, and staff for all of their hard work. I lead a highly talented and efficient team in my day job and we are like family. I attribute our success as a team to their potential, not mine. I am asking each and every one of our members to get involved and share your talents and expertise with our organization so that we can see progress out of this crisis and not regression like many others are likely to see.

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Willow Springs Physician Named MAFP Family Physician of the Year

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he Missouri Academy of Family Physicians (MAFP) presented Robert Shaw, Jr., MD, FAAFP, of Willow Springs, Missouri, with the 2020 Family Physician of the Year Award at the Academy’s 72nd Annual Show Me Family Medicine Conference held August 1415, 2020 via Zoom. Dr. Shaw was chosen as the award recipient by a committee of family physicians from nominations made by patients, community members, and fellow physicians.

Dr. Shaw has been active in the Academy throughout his career as a family physician. He became board certified during residency and continues his certification today. He has served over 20 years as an alternate or

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director on the Missouri Academy of Family Physicians board of directors. During his time as a family physician, he delivered approximately 1,000 babies before retiring from obstetrics in 2009. He has served in a variety of positions on local and state societies and committees.

He has practiced full scope family medicine throughout his career as a family physician, an emergency room physician, director of a rural health clinic, and medical director of nursing homes. Putting “family” in family practice, Dr. Shaw is involved in local programs, schools, Boy Scouts, his church, rural health clinics, and mission trips. His hobbies include kayaking, rappelling, camping, bicycling, and downhill skiing. He’s not afraid of anything!

Dr. Robert Shaw, Jr., MD, FAAFP, completed medical school at University of Missouri Columbia, and residency at Family Practice Residency, St. John’s Mercy Medical Center, St. Louis.

He is married to Janet and they have two children and four grandchildren.

Robert Shaw, MD FAAFP Acceptance Speech

I would like to begin by thanking the many people who made this award possible. First and foremost, my wife, Janet, and my children, Kim and Tom who through the last 41 years have had to endure interrupted dinners, parties, ball games and other activities due to phone calls, emergencies, deliveries, and medical meetings. Also, my “second family”, that is my office staff. From the front desk to the scheduling clerks, lab personnel, office manager, and most of all, my nurses, especially my current nurse, Kelly, who has put up with me the longest. As many of you know, our patients are more often looking forward to seeing our nursing staff than they are to see us. Without their help, we could not function. And I would like to thank the numerous people who not only nominated me for this award but took the time and effort to write letters and gather information regarding my work as a family physician.

I am especially honored knowing that in Missouri there are many qualified family physicians for this award.

I would also like to thank all the patients who trust their health care and advice for medical concerns to all of us as family physicians. For most patients, we are the first step in addressing a medical issue, often the person they turn to for interpreting a specialist opinion, and in many cases, the physician they want advice from before proceeding with a surgery or treatment option.

To fulfill this role as family physicians, we must be up to date on the latest medical information from TAVR indications to COVID developments. We also need to maintain relationships and good lines of communications with our specialist colleagues.

This last requirement has been made more difficult with the disappearance of the family physician from hospital medicine.

What used to be an easy chat in the hallway now becomes a phone call during a busy day’s schedule to discuss a patient.

Yet to maintain the best care for our patients, this effort needs to be made.

Perhaps most importantly, however, is the need to work together for the future of family medicine. This begins with the training of medical students, extends into the daily practice of medicine, and unfortunately involves political involvement.

None of us went into medicine because we love politics. Yet if we ignore politics, many of the issues that affect us every day will have no input from us, either individually or as a group.

Every year there are many old and new issues that affect

our profession. These include a wide and important variety of subjects including reimbursement, malpractice, scope of practice, even who can call themselves “doctor” and with what training. How we practice the “art” of medicine can be dictated by insurance companies or the government unless we stand together. Most of these issues will be addressed through a political decision usually at the state level. Every year these and other matters that affect our practice come to Jefferson City for debate and vote. For us to have a seat at the table, a voice that can be heard, we must work together.

Now trying to get a group of physicians to agree on any subject is like herding cats. But there are many more issues that we agree on than we disagree on. To have a seat at the political table and represent the family physician’s viewpoint, we must continue to support our representative groups such as the Missouri Academy of Family Physicians even when we do not agree on everything. In fact, the best way to change opinions is to get involved with phone calls or letters to the MAFP board members expressing your opinion. Or better yet, express your interest and dedicate the time to serve as a board member.

Finally, we should not count on other family physicians to give us a free ride by their involvement regarding these issues and then grumbling when our point of view is not represented.

This is like complaining that your patient is getting their advice for lifestyle modification from the internet when you have not ever given them any advice on the subject. Get involved, write letters, support the MAFP political action committee, be part of the fight for the future of family medicine.

For over 20 years one of my hobbies was whitewater kayaking. My group paddled not just in the United States but multiple other countries, everything from small eastern creeks to large rivers like the Colorado through the Grand Canyon.

One of our sayings was the river does not distinguish you from debris. If you as a family physician do not wish to be swept along as debris in the politics of medical decisions, you need to stick out a paddle and help change your course. Keep this in mind when an article crosses your desk where your autonomy, authority, or decision-making is being challenged by another political decision.

I hope that all of you in this room will continue to strongly support the profession and specialty that you have chosen.

While being a family physician requires years dedicated to obtaining the knowledge, degrees, board certifications, and keeping up with the constant flow of new information, and at times political involvement, in the end it is a reward well worth the cost.

I again thank the Missouri Academy of Family Physicians as well as the many people who made it possible for me to receive this prestigious honor.

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Externship Experience Reports

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he Family Health Foundation of Missouri and the American Academy of Family Physician Foundation sponsored four medical students to participate in the MAFP summer externship program. Because of your financial support, we are able to continue this program for medical students interested in family medicine. Here are stories about their experience this summer.

NOAH BROWN, MS3

University of Missouri Kansas City Externship Site: University of Missouri-Kansas City Family Medicine Residency This externship was truly an amazing experience. From the first day to the last day, I enjoyed every second of my time at Truman Medical

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Center – Lakewood with the UMKC Family Medicine Residency Program. I was able to learn so much about the residency program, about medicine in general, and about how truly wonderful the field of family medicine is through this incredible opportunity. I have always had family medicine at the top of my list for specialties, and this experience further sealed that.

One of the things I really enjoyed about this experience was getting to learn about the UMKC Family Medicine Residency Program. This program at TMC-Lakewood has the unique opportunity to truly train for a full-scope practice, as family medicine physicians are an integral part throughout the hospital. From inpatient medicine, to OB/ GYN, to clinic, to procedures, and everything in between, residents at UMKC’s program get training in every aspect of family medicine, and really every aspect of medicine in general. It is because of this that graduates from this residency can truly shape their practice to whatever they desire, whether it be more clinic, more inpatient, more OB, or just a little bit of everything.

Whenever I asked a resident about their experience in this program, they said that this variety in their training was one of the greatest aspects of this program. This was definitely one of the greatest aspects of my experience, as well. To be able to get exposure in so many areas, I really learned so much. To add to this, the residents and faculty that I worked with were incredible in their willingness and ability to teach. They were happy to answer each and

every question that I had, and if they did not know the exact answer, they would do their absolute best to find the answer, whether that be from another resident, faculty, or research articles. Additionally, the residents would ask me questions in regard to the patients we would see. This was one of my favorite parts because I was able to have a meaningful discussion with the resident about what I thought would be appropriate for the patient, and I was able to learn so much from these interactions.

These things made it easier to learn, as they not only made me feel comfortable to ask questions, but they challenged me in order to practice my own clinical skills.

Another important aspect of this program that I observed throughout my experience was the camaraderie among the residents and faculty. You could tell that they were one big family who truly care about each other and their patients. I remember what one resident said to me, “It’s the people that make the program.” And this is why the residency program at UMKC is truly one-of-a-kind: the community. It was a lot of fun to be able to be a part of this community during my externship.

The residents and faculty are truly one big family, and they do their best to ensure that students and others feel just as much a part of that family as they are. This was definitely a breath of fresh air and it gives me something to look forward to in the future.

Overall, I am very happy to have participated in this wonderful experience. These four weeks went by so fast, but it’s as they say, “time flies when you’re having fun”. Through this externship, I was able to learn so much, refine my own clinical skills, and meet some truly incredible residents and faculty at TMC-Lakewood.

MONISA SARAVANAN, MS1

Kansas City University of Medicine and Biosciences Externship Site: Research Medical Center Family Medicine Residency I had the honor of being selected for the summer externship program through the American Academy of Family Physicians and the Family Health Foundation of Missouri. I am so thankful for having spent my summer learning from incredible faculty, residents, and staff at Research Medical Center. My supervisor, Dr. Jennifer Tieman, was so gracious for letting me make my experience exactly how I wanted it. Before even starting my externship, Dr. Tieman took the time to figure out what I wanted from the program and specifically tailored my externship to my interests. Having had limited exposure to all that family medicine could entail, I asked to be given the chance to explore the field in its entirety. This resulted in a four-week excursion through outpatient clinic, inpatient rounds, labor and delivery and a visit to newborns in the nursery.

Throughout my first year and especially after the burnout experienced during our Neuroendocrine block, I felt that I maybe had lost sight of the ultimate goal and got a little too

caught up in my scores and academic performance. Being able to work alongside physicians like Dr. Tieman, her colleagues, and her residents, I was reminded of why I wanted to pursue medicine and specifically family medicine in the first place.

This externship was like a breath of fresh air. I was reminded of how important the patient-provider relationship is and how the quality of that relationship is a direct result of the quality of care experienced by patients and the enthusiasm shown by their physicians. Additionally, after having spent most of our time in the classroom, it was refreshing to see how the things I learned were applied in a clinical setting.

During my clinical experience, I had the opportunity to interview patients, conduct physical exams, and observe procedures. I also participated in grand grounds, attended lectures and performed a Mini-Mental State exam. All of these experiences allowed me to practice and build on the skills that I had been taught over the past year. As someone who has been grappling with which specific subset of primary care to pursue, this externship has defined family medicine as the career choice for my future endeavors. This field has the unique capacity to tailor your career to include a specific skill set (i.e. OB surgery) while also taking on the responsibilities of the profession.

Additionally, family medicine has the beauty of being able to work with the greatest breadth of individuals while also enabling close patient-provider relationships - as evidenced by patients’ reactions when the 3rd year residents informed them of their move to other locations.

Each encounter I had with the physicians, residents, patients, and staff was a learning experience and has contributed to my growth as a student doctor. I look forward to taking the skills and new insight I have developed through my journey to becoming a future physician. In my role as the current chapter president of ACOFP at Kansas City University, I aim to recommend this program to other interested medical students so 2they too can experience what I have had the privilege to.

LILLIAN SCANLON, MS1

Saint Louis University Externship Site: University of MissouriColumbia Family Medicine Residency This summer, I was selected for the Family Health Foundation of Missouri’s externship program, which allowed me to spend four weeks at the Family Health Center in Columbia, MO. At the FHC, I was immersed in the day to day life of a family medicine physician.

I worked with several different residents and attendings throughout my experience. It didn’t take long to notice the enthusiasm, dedication, and passion that all of these physicians had for their work. This only bolstered my interest in pursuing family medicine as a career.

One of the best parts of this experience was having the opportunity to interview patients on my own. During my first year of medical school, most of my practice with taking a patient’s history was with standardized patients in a classroom

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setting. Having this independence was an excellent learning opportunity. I was encouraged by how open and trusting patients were, even moments after meeting me. As I honed my interviewing skills and learned how to ask the right questions, I grew excited for my future career as a physician.

The FHC is a federally qualified health center that cares for uninsured and underinsured families. Throughout my time there, I was able to see a racially, ethnically, and socioeconomically diverse patient population. I saw various patients- everything from prenatal visits, geriatric, sports medicine, and pediatrics.

Throughout these visits, the physicians I worked with were willing to explain their thought process to me as they performed the exam and arrived at a diagnosis. This provided a lot of insight into how the mind of a physician works.

I was also able to observe grand rounds, weekly resident didactics, and the student-run clinic: MedZou, which allowed me to dive deeper into the field of family medicine. During my externship, the third-year residents were wrapping up their residency experience. As I watched them say goodbye to patients that they had been caring for during the past three years, I realized how unique the physician-patient relationship is in the field of family medicine. Physicians focus on caring for the whole patient, and in turn, are able to build lasting and trusting relationships. Throughout the summer, I learned an incredible amount about medicine and gained skills that I can take with me when I care for my future patients.

AMANDA SPRINGER, MS1

Saint Louis University Externship Site: Mercy Hospital Family Medicine Residency I am extremely grateful for the opportunity I had as the MAFP Summer Extern at Mercy Family Medicine.

This was a truly exceptional experience where I was exposed to both outpatient and inpatient care. In addition, I attended didactic lectures and workshops about ultrasound, suturing, joint injections and osteopathic skills. The final component of my placement helped to foster my understanding of advocacy work. This included completing Family Medicine Advocacy Modules, a community needs assessment and presenting a capstone project!

COVID-19 has changed so much about our life and it was humbling to hear patients’ stories about what they are going through during these difficult times. I will keep these experiences with me at school this year and remember how family medicine practitioners are the backbone of the healthcare system.

I want to thank my incredible mentor Dr. Sarah Cole for her invaluable lessons each day and always encouraging me to learn more! I also want to thank the amazing residents I shadowed at the clinic, Dr. Chelsea Drissell and Dr. Vanessa Murillo, your wisdom will stay with me! This is an experience I will always remember and will definitely recommend to anyone who is interested in family medicine!

MAFP Submits Comments on IRS DPC Rules The Internal Revenue Services (IRS) called for comments on proposed rules related to direct primary care (DPC) membership payments to be eligible for payment through a health savings account (HSA). MAFP Board Chair, Jamie Ulbrich, MD, FAAFP submitted written comments to the agency in August that we oppose any regulation that would define direct primary care as a health plan or health insurance.

Missouri’s law, RSMo 376.1800, clarifies that direct primary care is not insurance and would allow patients to use health savings accounts (HSA) and flexible savings accounts (FSA) to pay their monthly membership fee, subject to state and federal law.

The Missouri law allows employers to pay for their employees’ membership fee through the HSA, FSA or directly to the physician.

The monthly membership fee is for comprehensive primary and preventive care service that includes acute and urgent care, regular checkups, preventive care, chronic disease management, and care coordination.

Ulbrich stated that “The federal government should embrace this emerging practice model for primary care. Direct primary care benefits patients by providing a greater degree of access to—and

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“

The federal government should embrace this emerging practice model for primary care. Direct primary care benefits patients by providing a greater degree of access to—and time with—their physician.

Jamie Ulbrich, MD, FAAFP

”

time with—their physician.” Nationally, statistics are showing positive outcomes of increased visit time, improved patient experience of care, and improved clinical outcomes as patients become more engaged in managing their own health care.

MAFP has been instrumental in crafting and maintaining the Missouri direct primary care practice model legislation. For more information or to obtain a copy of the comments submitted, contact MAFP Executive Director, Kathy Pabst, at kpabst@mo-afp.org.

Saint Louis University Recipient of the Family Medicine Cares Resident Service Award

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he complexities revolving around addiction are well known to PGY-3 Family Medicine residents at Saint Louis University, Rebecca Rada, DO and Mindy Guo, MD. Whether on their hospital service providing inpatient detoxification from opiates, benzodiazepines, or alcohol; seeing patients in the outpatient setting for Medication for Addiction Treatment (MAT) induction; or having continued conversations about smoking cessation; the struggles revolving around addiction are ongoing.

The opioid epidemic has reached all communities, and we as primary care physicians are at the forefront of treatment. Two million Americans have opioid use disorder (OUD), and only about one fifth of people with OUD are accessing treatment.

While overdoses from heroin have been an under-reported issue for decades for black people specifically, the profound impact opiate use has had on communities is devastating. At their urban, underserved resident clinic in St. Louis, Missouri, Dr. Rada and Dr. Guo started volunteering with the local needle exchange program, called MoNetwork, to learn more about the impact of opiate use on their local community. MoNetwork provides education, outreach, treatment resources, and support to those who have issues with addiction. They provide clean needles to the greater St. Louis metropolitan area, providing an important and essential means for harm reduction in an already vulnerable population.

While volunteering with MoNetwork, Dr. Rada and Dr. Guo were shocked to find that two of the needle exchange locations were less than a block away from their clinic. When talking with one of the coordinators that evening, they shared that the majority of the people they provide clean needles to reside around that specific area. They were also shocked to find out people who were seeking treatment were having to travel to recovery clinics miles away- many who don’t have adequate or reliable transportation. They soon after put their heads together and started to look into opiate use statistics and demographics in the area surrounding their clinic. What they found was that there were significantly higher overdoses in the zip codes around their clinic, increased rates of 911 calls due to overdoses, and deaths from overdoses. The zip code of their clinic, 63111, received 500 or more calls to paramedics for overdose calls as of 2018 and 2019, which was the highest number of calls in the region.

They ultimately came up with an idea to expand access for MAT at their resident clinic, specifically to target those individuals who are seeking treatment in the surrounding vicinity of the clinic. They applied for a grant from the American Academy of Family Physicians (AAFP) called the Resident Cares Award. In May, they were shocked and ecstatic to learn they were awarded the $16,500 grant to implement their project! Their project, titled “Patient Centered Addiction Treatment: Leveraging Accessibility and Inclusion to Improve Medication for Addiction Treatment” is geared towards improving access to care, breaking down barriers in the areas surrounding their resident clinic, and trying to decrease the stigma and disparities revolving around addiction.

What started out as a required quality improvement project to graduate residency eventually culminated into their grant, a new partnership with MoNework and their resident clinic, and a project that will hopefully have an impact for years to come. Some of the main issues revolving around patients who seek out treatment for addiction include issues with transportation, unstable housing, financial instability, inability to access care, stigma revolving around addiction, and lack of support. Their plans for grant funds include covering costs of MAT medications, co-pay’s for clinic visits, transportation, and lab fees until patients can get onto Gateway to Better Health.

Gateway to Better Health is a temporary health insurance program provided to uninsured adults as a bridge until they are able to enroll in health insurance coverage through the Affordable Care Act. The first few months of treatment with MAT is an incredibly vulnerable and stressful time for patients, so they wanted to ensure the financial burden of starting treatment would not hinder their remission.

The overall goals of their project include increasing access to care for opiate use disorder and MAT at their clinic, decreasing the amount of overdoses/deaths in the surrounding zip codes due to opiate use, and continuing the partnership with MoNetwork to allow for those who live in the surrounding areas to have improved access to care. They also plan on doing a quality improvement study to look at barriers to care, specifically to determine the most important barriers for patients who seek treatment and how to overcome those barriers. Their project will be implemented into their resident clinic from Fall 2020 through June 2021. They will present their quality improvement study findings at the 2021 National Conference of Family Medicine Residents and Medical Students. In the future, both Dr. Rada and Dr. Guo plan on continuing to provide care for patients with opiate use disorder. They are both passionate about underserved care, health disparities revolving around vulnerable and discriminated populations, and ensuring everyone receives quality health care regardless of their ability to pay.

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RESIDENT STIPEND AWARD

This award is to help Missouri family medicine residents understand the complex negotiation process as they transition to a full-time Missouri family physician. The recipient should exhibit exemplary patient care, demonstrate leadership, display a commitment to the community, contribute to scholarly activity and is dedicated to the specialty of family medicine. This financial award (up to $500) will be presented to one resident per Missouri family medicine residency program per year to have their Missouri employment contract reviewed by an attorney of their choosing and/ or financial planning consultation. The recipient is selected by the Missouri family medicine residency program during the resident’s 2nd or 3rd year of residency. In addition, the recipient will receive one free MAFP conference registration for the Show Me Family Medicine Conference, valued at $275 (early bird rate), within the first three years after completing residency. The deadline for nominations is March 31.

EXEMPLARY TEACHING AWARD

Celebrating Our Family Physicians Now Accepting Nominations for Member Recognition and Awards

W

e all have exemplary family physicians whom work hard for their patients and profession.

The Missouri Academy of Family Physicians recognizes the Missouri Family Physician of the Year at our annual meeting. We want to do more to recognize your efforts for improving Missouri health care and we have added four new awards to recognize family physicians who are in the forefront of this effort.

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Acknowledges MAFP members who deserve recognition of exemplary teaching skills, as well as individuals who have implemented outstanding educational programs and/or developed innovative teaching models. The recipient must be in active practice, spend at least 50 percent of his/her time in the academic setting, be a MAFP member in good standing, be board certified in family medicine and/or an AAFP Fellow, and be in academics at least ten years since completing residency training.

The deadline for nominations is February 3.

OUTSTANDING RESIDENT OF THE YEAR AWARD

Presented to a graduating Missouri resident who exhibits exemplary patient care, demonstrates leadership, displays a commitment to the community, contributes to scholarly activity and is dedicated to the specialty of family medicine.

The nominee for this award must be a current resident member of MAFP and be graduating from a family medicine

residency program in Missouri. MAFP members, family medicine residency faculty, or other members of a family medicine residency administrative staff may submit nominations for the award. The deadline for nominations is February 3.

DISTINGUISHED SERVICE AWARD

Recognizes members, nonmembers, and entities for longtime dedication to advancing, contributing, and supporting the MAFP and the specialty of family medicine - rather than through a single, significant contribution and effective leadership in furthering the development of family medicine. This award is not limited to members only. Nominations must include a letter of recommendation and should include a brief summary of the entity or person’s accomplishments and why the award is deserved for distinguished and dedicated efforts furthering the specialty of family medicine. Nominations may be received from members or MAFP staff. The deadline for nominations is February 3.

FAMILY PHYSICIAN OF THE YEAR AWARD

This award continues the tradition of recognizing a member who provides his/her patients with compassionate, comprehensive

and caring family medicine on a continuing basis; is directly and effectively involved in community affairs and activities that enhance the quality of his/her community; provides a credible role model, both professionally and personally, to his/her community, to other health professionals, and to residents and medical students; effectively represents MAFP and the specialty of family medicine by presenting a good public image; and exemplifies the family physician’s leadership role in improving the health of our state.

The recipient must be in active practice, spend at least 50% of his/ her time in direct patient care of Missouri residents, be an MAFP member in good standing, be board certified in family medicine and/or an AAFP Fellow, and be in practice in Missouri at least 10 years since completing residency training. Nominations may be received from the public, members, or MAFP staff. The deadline for nominations is February 3.

All nominations must be submitted online from the MAFP website at www.mo-afp.org/members/member-recognition/ *MAFP reserves the right to use discretion whether or not to award a nominee annually.

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MEMBERS IN THE NEWS

Serving on the ACGME Review Committee for Family Medicine – Grant Hoekzema, MD, FAAFP Graduate medical education, including internship, residency and fellowships is a unique system of formal “on-the-job training” which ultimately leads to board certification and independent practice.

This enterprise is funded largely by us as taxpayers but overseen by members of each specialty. The ACGME is a nongovernmental body that has been granted the authority to oversee and accredit this training. The mission of the ACGME is “to improve health care and population health by assessing and advancing the quality of resident physicians’ education through accreditation.” Physicians must remain involved in order to maintain oversight of our profession and its training standards.

To that end, Grant Hoekzema, MD, FAAFP, has served on the Review Committee for Family Medicine (RC-FM) at the ACGME since 2016. This July, Dr. Hoekzema assumed the role of Chair of the RC-FM and will continue for a three-year term.

The Chair of the RC-FM is responsible for the oversight of the committee and its work. The Chair is the face of the committee and represents the specialty at the ACGME and represents the committee at national meetings. The chair leads the committee when it recommends and implements 32

MISSOURI FAMILY PHYSICIAN October - December 2020

updates to the Specialty Program Requirements, from minor tweaks to major revisions. This summer began a kickoff for the next series of major revisions, which will shape Family Medicine residency training for the next 20 plus years. The chair represents Family Medicine amongst ACGME initiatives that impact all programs and gives the input of the specialty. The chair also works collaboratively with Family Medicine organizations to make sure their voices are heard in the deliberations of the committee. Although not a policy making body, nor the guardian of primary care, nor workforce planning entity, the decisions and directions determined by the RC-FM have a profound impact on all of these endeavors; and, the chair must represent or defend the committee in its decisions.

The committee’s members come from four appointing organizations (AAFP, ABFM, AMA, AOA) but an RC member is not there to “lobby” for their nominating organization. RC members are all physician volunteers, who help interpret program requirements to protect the integrity of the ACGME process to assure fairness and avoid conflicts of interest while accrediting programs. Objective program reviews are critical to maintaining that integrity. The

RC must hold the 700+ Family Medicine residency programs to the same standards, regardless of resources, mission, size or community. This is so a Family Medicine resident from Missouri has the same core equivalent educational expectations, work environment and training as a resident from Alaska, Florida, or anywhere in between.

The RC-FM meets three times a year as a full committee. The RC-FM has accredited over 220 new programs in the last 4 years. Of those, 125 came from the Single Accreditation System (SAS) pathway – merging osteopathic and allopathic programs.

Grant Hoekzema, MD, FAAFP, is a graduate of Calvin College and Washington University School of Medicine, St. Louis.

He stayed in St. Louis for residency at St. John’s Mercy Medical Center, now Mercy Hospital, St. Louis.

Dr. Hoekzema joined the Mercy Family Medicine faculty in 1995 after completing residency. He completed a NIPDD fellowship in 1997-98, and served as the Program Director for the Mercy Family Medicine Residency in St. Louis from 1999 to 2017. He was named Chair of the Department of Family Medicine at Mercy Hospital, St. Louis in July 2016 and continues to serve in that role.

He has been actively involved at a national level with Family Medicine Residency training as a board member of the Association of Family Medicine Residency Directors from 2009-2011, then serving as President-elect, President and past-President of the AFMRD in 2011-14.

He also served as Chair of the Council of Academic Family Medicine in 2013-2014 and was the AFMRD representative for the steering committee of Family Medicine for America’s Health. He sits on the In-Training Examination Review Committee for the American Board of Family Medicine and was selected to join the ACGME Review Committee for Family Medicine in July 2016. He was elected Chair of the RC-FM in July 2020, and will serve in that role for three years.

DO YOU HAVE NEWS TO SHARE? Email it to office@mo-afp.org for review.

We love to hear from our members!

respiratory infections, anxiety, depression, low back pain, and other musculoskeletal conditions. Due to costs associated with maintaining a building for the clinic, the VIMCC is delivering health care to those in Christian County at various clinic locations, including the Christian County Health Department, Least of These, and Harmony House in Ozark, Missouri.

All VIMCC board members and staff are volunteers who support the mission to provide free medical care to those in need.

Volunteers are needed to help support the clinic and its mission.

HEALTH RESOURCE CENTER (HRC) is Saint Louis University School

of Medicine’s student-run free clinic which provides a myriad of health and social services to socioeconomically disadvantaged or uninsured patients from St. Louis City and St. Louis County. Through an interdisciplinary team of medical students, volunteering physicians, and Missouri Free Clinics Receive Grants allied health and social work students, the Health Resource Center offers services including primary care Family Medicine Cares (FMC) USA is an AAFP Foundation award visits, women’s health and vision screenings, and initiatives to program where existing free clinics can apply for up to $10,000 improve patient insurance coverage and food security. for durable medical equipment and instruments for the diagnosis This $25,000 grant will help the HRC improve its clinics/facilities and treatment of primary care. This past spring, the Foundation and increase patient access to primary care services. From a new received a generous donation from The Humana Foundation vaccine refrigerator to additional exam tables, funding from the to support COVID-19 emergency relief efforts. Because of this AAFP will allow patients at the HRC to have a more efficient and donation, additional funds became available to free clinics that quality healthcare experience.

In addition, as the clinic continues were in areas of high need (Community Needs Index of a 4.5 and to provide care throughout the COVID-19 pandemic, a portion of higher). Two Missouri free clinics received this grant: the funding will be used to maintain additional safety precautions VOLUNTEERS IN MEDICINE CHRISTIAN COUNTY for both patients and volunteers. As the Health Resource Center CLINIC (VIMCC) was awarded $25,000 to serve the healthcare seeks to expand its outreach and capacity, the support of the AAFP needs of individuals who do not have access to adequate care will accelerate its growth in primary care for the community and and are at or below the 150% Federal Poverty Level (FPL)—which interest in pursuing careers in family medicine for these student is $19,140 for an individual in 2020. VIMCC provides free, non- volunteers. emergency primary care to uninsured individuals, ages 18-64 years, who live in Christian County and who do not have access to Medicare, Medicaid, or private insurance. Poverty affects access to medical care, healthy food, and other necessities that promote wellness. Over 10% of Christian County residents live in households with an income below the FPL. Access to health care, medications and appropriate nutrition are important to optimize health. Some of the conditions frequently managed include diabetes, hypertension, asthma, acute

THE FUNDING FOR THESE GRANTS WAS PROVIDED BY THE AAFP FOUNDATION FROM THE DONATIONS OF OUR MEMBERS. Volunteers

in Medicine America (VMA) is a partner of the AAFP Foundation.

This organization develops potential new free clinics based on a tested model for developing sustainable, locally supported free clinics. VMA provides expertise and guidance throughout the clinic development process.

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MEMBERS IN THE NEWS SLAFP Chooses District Representation Lauren Wilfling, MD, St. Louis, has been selected to fill the vacant St. Louis District position on the MAFP Board of Directors. Kara Mayes, MD, was elected to serve as the MAFP Vice President, which left a vacancy in the St. Louis District. Dawn Davis, MD, will fill the remainder of Dr. Mayes’ term as Director, Emily Doucette, MD, will continue her term as Director, and Dr. Wilfling will begin a new term as Alternate Director. Congratulations all!

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DO YOU HAVE NEWS TO SHARE? Email it to office@mo-afp.org for review.

We love to hear from our members!

Ulbrich Participates in COVID-19 Vaccine Team MAFP Board Chair, Jamie Ulbrich, MD, FAAFP, is representing Missouri family physicians on the COVID Team for distribution of a COVID-19 vaccine.

This team is a collaboration between governmental agencies, military, private sector stakeholders, and key organizations with a vested interest in the efficient distribution of a COVID-19 vaccine. The state of Missouri is proactively moving toward a quick and smooth implementation of a vaccination plan for when a vaccine is available for distribution. Dr. Ulbrich’s insight into clinic management and current vaccine protocols and processes will provide guidance in the development of this plan.

You should have received an email from the MAFP which included a survey to assess the current status of clinics, availability, and resources in place to administer the COVID-19 vaccine. For more information or assistance, contact the MAFP office.

References: INNOVATION IN MEDICAL SCHOOL TEACHING DURING COVID-19 Pages 6-8

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MASK USE IN THE PRIMARY CARE SETTING: CONSIDERATIONS FOR THE PEDIATRIC POPULATION pages 10-12

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MULTIPLYING THE DATA AND DIVIDING PHYSICIANS’ ATTENTION Page 13

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Dreifuerst, K.T. (2009). The Essentials of Debriefing in Simulation Learning: A Concept Analysis. Nursing Education Perspectives, 10(2), 109-114 Parul, Parul & Nair, Rathish. (2013). A study to evaluate the effectiveness of teaching learning strategies on “management of alcoholism” based on identified preferred learning styles in terms of knowledge among nursing students at selected colleges of nursing, Haryana. 10.13140/RG.2.1.2692.9126.https://www. researchgate.net/publication/281684977 McGaghie, W.C., Issenberg, S. B., Petrusa, E.R., & Scalese, R.J. (2010). A Critical Review of Simulation-Based Medical Education Research: 2003-2009. Medical Education, 44, 50-63. doi:10.111/ j.1365-2923.2009.03547.x Squire, K. (2006). From content to context: Videogames as designed experience. Educational Researcher, 35(8), 19-29.

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Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101