Missouri Family Physicians April-June 2020

FP SPRING 2020

MISSOURI FAMILY PHYSICIAN VOLUME 39, ISSUE 2

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MISSOURI FAMILY PHYSICIAN April - June 2020

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CONTENTS 4 A Letter from the Chair

MISSOURI FAMILY PHYSICIAN

6 POCUS for Daily Practice

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

ALTERNATE Dawn Davis, MD (St. Louis) DISTRICT 4 DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald)

ALTERNATE Kristin Weidle, MD (Washington) 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)

10 Pediatric Inactivity Triad: A Risky PIT 14 Sports Medicine Dermatology 18 Sudden Cardiac Death in Athletes 22 Youth Participation in Sports 26 White Coats Abound in the Capitol 27 2020 Legislative Update 28 MAFP Priority Legislation 30 Members in the News 32 2020 Multi State Conference 34 References

MARK YOUR CALENDAR June

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RESIDENT DIRECTORS

Misty Todd, MD, UMC John Heafner, MD, SLU (Alternate)

STUDENT DIRECTORS Morgan Dresvyannikov, UMKC Noah Brown, UMKC (Alternate)

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 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

2020

New Date!

Aug.

14-15 2020 Oct.

14-18 2020 Nov.

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2020 Nov.

12-14 2020

March

1-2 2021

MAFP Annual Meeting Saturday, June 13, 2020 — 8:00 AM Virtual Meeting via Zoom Register to Attend MAFP Show Me Family Medicine Conference and Resident/Student Transition Session August 14-15 Margaritaville Lake Resort, Osage Beach AAFP Family Medicine Experience (FMX) October 14-18, 2020 Hyatt Regency, Chicago, IL Rural Health Equity Conference November 7, 2020 Regency Conference Center, O'Fallon, IL MAFP 28th Annual Fall Conference & KSA Working Group 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

A LETTER FROM THE CHAIR

B Sarah Cole, DO, FAAFP Board Chair

ananas. Bonkers. Surreal. These are the and, in the end, we will work to debrief it with you. words my partners and patients alike have been using to describe the past days and Though COVID19 may be permeating our weeks as our state attempts to contain thoughts and actions, it is important to remember and mitigate the COVID19 pandemic. As family that we care for the whole person. Even in the physicians, our job has been to combat midst of a pandemic, patients will present to us misinformation, allay unnecessary panic and deploy our clinical skills wherever they are needed. I Though COVID19 may be permeating salute the bravery, wisdom and compassion of my fellow family our thoughts and actions, it is important physicians as they meet this storm. to remember that we care for the whole The rains may be heavy but we will emerge again into sunshine. person. Even in the midst of a pandemic,

patients will present to us with a myriad MAFP rides this storm with its members. Staff of problems, was proactive in connecting concerned parties in Jefferson with a myriad of problems, including those related City – reaching out to other medical associations and Missouri Division of Health and Senior Services to physical activity. And so, this issue of Missouri Family Physician focuses on sports-related health Director Dr. Randall Williams - early into Missouri’s conditions. I thank the authors for their expert outbreak. MAFP staff members then judiciously guidance on how to keep our patients motivated worked from home to prepare resources for and moving! family doctors combatting COVID19; the MAFP website provides up to date resources in Missouri for COVID19 reporting and treatment. The COVID19 will be an epidemiological and cultural phenomenon that will be studied for years to come

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MISSOURI FAMILY PHYSICIAN April - June 2020

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MISSOURI FAMILY PHYSICIAN April - June 2020

POCUS For Daily Practice I am now using my handheld POCUS device every clinic session POCUS IN FAMILY MEDICINE

I have been using my handheld point of care ultrasound (POCUS) device now daily for several months. As I do more, I find more that I can do with it. I am going to cover in this article how it helps me in daily practice with some cases and encourage you to get trained, get a device and get to scanning.

WHAT CAN WE POCUS TODAY?

I became interested in bedside ultrasound (US) back nearly 30 years ago in my residency.

When I was in residency, we did not have full time sonography in the hospital so we learned how to use US on labor and delivery for things like presentations and position. Some of our patients would present in labor and had no prior US or even good dating. We could do crown rump measurement and at least get an estimate of dating. Once I had a patient with no prenatal care and iffy dates and a heavy smoker with a fundal height of 45 cm that we were able to diagnose twins on her presentation to labor and delivery. We were able to quickly call and mobilize physicians and nurses for the delivery.

The outcome was great for a pair of cute babies that were near term. I quickly realized how powerful US was in my hands and how it could impact the safety and delivery of care for patients at the bedside.

Fast forward through my career as an academic family physician in a safety net hospital for 29 years and I have had many opportunities to hone my skills with US. Several years ago, with the advent of handheld US and the desire to further my skills and our future residents’ skills for rural and missionary medicine, I ventured to the University of South Carolina with two of my 1st year residents to train in a hands-on POCUS

laboratory for several days with simulators. We experienced family physicians doing POCUS and simulated patients of all body types. From this we were able to start our very own POCUS training program in our institution. I had some money left from a previous rural grant and so I used that to purchase an online training program (Osmosis) to have modules for the exams that we wanted to train our residents through online case study and hand held simulation. With the hospital purchasing our first 2 GE Vscan handhelds to add to our other two traditional mobile US machines, the super using residents and myself delved into how POCUS can change the way we practice and deliver family medicine.

I continue to practice full spectrum FM including OB, inpatient, outpatient and lots of procedures both in and out patient. During days in clinic and on the floor, I only found myself limited by not always having an ultrasound handy because we kept them centrally located in our FM clinic and restricted to checking them out. Many days I found myself desiring to do an US in another clinic or part of the building and could not take the time to go get one to check out for my use. This is where I found the biggest limitation to US—not having one in your pocket ready to go when the need arises. I actually created a list in our rounding room that we added to daily entitled: “What could we have POCUSed today?”

The summer of 2019 technology answered with developing a completely different kind of US technology that is portable and replaces several different heads needed for traditional US for different types of exams. It is actually a non medical company in the Silicon Valley of California. They not only developed an amazing device, but the software with it is unprecedented

Todd Darian Shaffer, MD, MBA, FAAFP University of Missouri Kansas City - Professor of Family Medicine

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Ganglion Cyst POCUS Diagnosis for handheld use with constant over the air updates and new functionality released monthly. Not only does this seem too good to be true, but they marketed the handheld at less than $2,000 which is about ¼ the cost of our previous handhelds and as much as 1/10 the cost of the portable rolling US units. I was sold.

So, I bought one and easily hooked it to my iPhone and iPad and started POCUSing and have now eliminated my prior barrier of not having a US when I need it. Now I have it in my pocket and it is always with me no matter what area of FM I am doing for the day.

WHAT KIND OF THINGS DO I USE IT FOR?

I have used it in may different scenarios and my patients have loved the ability to see inside their body. Teaching residents and improving their safety and learning on procedures is one of the most helpful things I have done as an educator in preparing my residents for future rural, mission or any type of practice they desire.

TEACHING

Using a handheld US for paracentesis, thoracentesis, and incising and draining abscesses seem obvious. But how about improving the velocity of learning while doing POCUS prior to a Lumbar tap, a hip injection, or while a resident is placing an IUD? Every one of these scenarios has vastly improved the learner in a safer and effective procedure mastery for their patient under direct visualization.

FAMILY MEDICINE CLINIC

In the residents teaching clinic and in my own personal clinic, I have used the US for diagnosing gallstones, abscesses that really need I and D’d, ganglion cysts (see photos above), lipomas, tendinitis, fluid status in an acute CHF exacerbation, and following pneumonia at the hospital follow-up visit. I have also used it for looking at a known AAA and searching for a DVT in a leg. It has been used on scrotums for hydrocoeles and for estimating a post 8

MISSOURI FAMILY PHYSICIAN April - June 2020

void residual on several patients at follow-up from the hospital with an acute urinary obstruction. These exams and tests are mostly +/- tests looking for whether they have a condition or not. This does not replace traditional US just like my spirometer in my clinic does not replace full PFT’s. It furthers my clinical and physical examinations to have answers immediately at the bedside for prompt and safe care of patients. It allows me to provide more accurate and reliable care for my patients while teaching residents a new skill to add to their hands-on approach for their future patients. This is what we call high tech/high touch all in one.

SAMPLE CASE

One of my residents was at the residency booth at the National AAFP meeting for residents and students and we were ultrasounding visitors’ wrists to look for carpal tunnel tendonitis.

She mentioned her newly acquired friend on the back of her wrist. At first glance it is a ganglion cyst which is common in her age group. (See photos above and on next page). As we let other students scan her wrist, you could see on the faces of many how insightful this is to see the fluid and size of the cyst inside. We made a plan to drain it the next week when we were on the labor and delivery deck. With the confirmation of the fluid sack, the ganglion was drained. I have a great video with audio we can post to our website but for here you can see the progress.

The last photo is in the past week showing her ganglion has not returned in the past 6 months. Now you might say, I would have done the same thing without the US; that is probably true.

However, being able to visualize the fluid gave me the confidence to proceed. I repeated the same scenario last week with a 16yo girl whom I delivered and had probably done an OB US 16 years ago. Now that is continuity and Family Medicine at its core!

This is the same with supposed abscesses that present in clinic. As you all know from experience, we try to determine by examination if it is fluctuating or not. By my experience I am wrong about 1 out of 4 times and do not get pus when I incise

Ganglion Cyst fluid extraction and six-month follow-up

with a scalpel. Now with US I harm 25% fewer patients because if they don’t have a pus pocket by POCUS, I don’t incise. See how it can be safer and create less harm for my patients?

CASE

Labor and delivery patient presents with RUQ pain in the 7th month of pregnancy with severe pain and nausea upon eating.

Using POCUS, we were easily able to identify significant gallstones in her gallbladder. Of course she had an official US too, but immediately we made the diagnosis at the bedside and were able to direct the care she needed as opposed to spending money, time, and potential harm working up some other diagnosis of pregnancy with RUQ pain.

One patient, three exams on my daily POCUSing. I had a new patient that presented for care and I completed 3 POCUS exams on him. First, he had a knot on his upper back that we confirmed as a long-time sebaceous cyst, a non tender mass on his side confirmed as a lipoma and a tendinitis in his Achilles’ tendon that had been bothering him for some time. Now again, I probably could have probably diagnosed all three of these by history and physical exam, but with POCUS, I could actually see each one of them directly and confirm my diagnosis and none of these I would have sent for an actual US in radiology. We scheduled his sebaceous cyst removal in my clinic and we treated him for his Achilles tendinitis all with the help of POCUS diagnosis.

CASE

CASE

CASE

In women’s health clinic, I am often working with residents placing IUD’s. Instead of standing behind them as they place the IUD’s in an Umpire stance peering over their shoulder, I now stand to the patient’s bedside and visualize the uterine and record a short video of the deployment in the fundus of the uterus. Not only is this more safely done while teaching but then they get a direct video of their procedure for feedback and evaluation. By the way, POCUS is also very good when a patient presents with an IUD and she can’t feel her strings and we can’t see them. The IUD is easily visualized in the uterus by POCUS and we can confirm the continuation of her birth control quickly and accurately.

CASE

I often work on our inpatient unit where we also cover the ICU. I use the POCUS for patient in failure and fluid overload. We can easily follow their IVC ratio daily on rounds and see the patient get better at the root of the problem while having less reliability on the X-ray to show improvement with our therapies. This helps the learning process but also confirms our clinical and physical exam findings.

Resident performing a new OB visit in our Family Medicine center at about 11 weeks and could not Doppler heart tones. I was covering labor and delivery that day and the resident texted me and within about 3 minutes of the text I was in the room with the resident visualizing the heart beat and showing the mom and dad the baby’s head, trunk and limbs. High tech/high touch at the bedside? She and her husband were both tearing up with joy to see their new addition to the family and seeing their baby move about in her tummy. Makes you want to cry too doesn’t it?

So, what is holding you back from expanding your scope, improving patient experience and confidence in you, and being safer for your patients? Find a POCUS course today and get started. Find a handheld device that you can store in your pocket and that you will use every day. Family physicians have the perfect set of skills from broad based training to be excellent POCUSers!

For more info on exams and EBM use of POCUS, refer to the article in the March 1, 2020 edition of American Family Physician.

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Pediatric Inactivity Triad: A Risky PIT

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majority of children and adolescents worldwide are not accumulating at least 60 minutes of moderate to vigorous physical activity (MVPA) daily (1). Trends in measures of muscular fitness among youth are on the decline. Too many playgrounds and sports fields are vacant or idle, and physical education is considered an expendable part of the school curriculum.

Consequently, contemporary youth are likely more familiar with controlling a joy stick than they are throwing a ball. This dreary litany is all too familiar.

The ‘‘product’’ of this culture - children who are weaker, slower, and heavier than their peers of yesteryear - is likewise becoming a more familiar site in pediatricians’ offices. Unsurprisingly, a corollary of these contemporary trends is the increasing prevalence of physical, psychosocial, and cognitive health issues in school-age youth (2). The World Health Organization now recognizes physical inactivity as the fourth leading risk factor for mortality from noncommunicable diseases, and the economic costs associated with physical inactivity among children are staggering (3,4).

The lasting effects of physical inactivity during childhood and adolescence can give rise to a lifetime of preventable pathology. The call for action to address this phenomenon has never been more urgent. Yet, we remain stuck in a mindset grounded in guidelines that focus almost solely on the achievement of at least 60 min MVPA each day. For years, the 60-min threshold has been seen as a benchmark (4) ; and over those years, the rising tide of physical inactivity has never ebbed.

It is said that ‘‘The definition of insanity is doing the same thing over and over again, and expecting different results.’’

A change in attitudes and pediatric health care practices is urgently needed because our current strategies are suboptimal. The time has come to expand our conceptual approach so we are better prepared to identify and treat youth who are physically inactive before they proceed too far down the path to chronic disease. In this commentary, we

Avery D. Faigenbaum, EdD, FACSM The College of New Jersey Andrea Stracciolini, MD Childrens Hospital Boston

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propose a tripartite framework of conditions that are collectively driving the pandemic of physical inactivity in youth, and we offer a novel conceptual approach to substantively address this public health crisis.

PEDIATRIC INACTIVITY TRIAD

The pediatric inactivity triad (PIT) we propose is a condition observed in physically inactive youth involving three distinct but interrelated components: 1) exercise deficit disorder, 2) pediatric dynapenia, and 3) physical illiteracy. While each of these components in isolation is an important consideration, we argue they should be viewed collectively to better effect change. Pediatricians and researchers should adapt the practice of leaders in the field of sports injury prevention, who have begun to focus on a complex systems approach to most effectively address that phenomenon (5). Physical inactivity is a multifactorial phenomenon that is influenced by a web of contributing factors. We need to better understand these complex interactions and clarify how these interactions contribute to physical inactivity in children and adolescents. The Figure illustrates our current understanding of the interaction among the components of the PIT. The first component of the PIT relates to the construct called exercise deficit disorder, a term used to describe a condition

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characterized by levels of MVPA that are inconsistent with current public health recommendations (6). Instead of simply labeling a child as inactive, the term ex- ercise deficit disorder should be used to highlight the gravity of this clinical condition, educate parents about the importance of daily MVPA, and prompt intervention on the part of pediatricians and other professionals.

Youth who are not meeting minimal recommendations for MVPA would be identified as having a premorbid condition, and may then be treated with the same energy and resolve as a hypertensive child or a teenage smoker in order to prevent the progression of pathological processes.

Simply asking physically inactive boys and girls to ‘‘walk to school” or “play outside” is not enough. Structured and innovative therapeutic exercise programs are needed to target deficiencies, maintain participation, and promote healthy lifestyle choices for all youth found to have exercise deficit disorder, regardless of body size. Efforts that focus solely on obese youth will miss many at-risk children. The child who is found to have a deficit in MVPA levels but who currently has a body mass index (BMI) within normal limits has a premorbid condition and must be targeted for interventions as well.

Children and adolescents who lack prerequisite levels of muscular fitness and motor skill proficiency are less likely to be competent in sporting tasks (e.g., running, throwing, and so

on) and may be expected to engage in less MVPA throughout the growing years. The second and third components of the PIT highlight the significance of identifying two other interrelated and treatable conditions which both affect and are affected by exercise deficit disorder.

The first phenomenon is pediatric dynapenia, a condition characterized by low levels of muscular strength and power and consequent functional limitations not caused by neurologic or muscular disease (7). A certain amount of muscular strength and power is needed to jump, climb, kick, and throw proficiently.

Youth with low levels of muscular strength and power are more likely to remain inactive, experience functional limitations, and suffer activity-related injuries during free play and sport. These observations underscore the need to identify at-risk youth and target them for interventions designed to enhance muscular fitness. Improvements in strength and power will positively alter physical activity trajectories so inactive youth are able to break through a so-called strength barrier to catch up with their stronger peers. One need only to observe beginners in a gymnastics class or martial arts program to appreciate that prerequisite levels of muscular strength and power are needed to move with style, grace, and precision.

The third component of the PIT relates to the concept of physical illiteracy, which describes the lack of confidence, competence, motivation, and knowledge to move proficiently in a variety of physical activities. The term physical literacy has been broadly used to capture the attributes and characteristics that influence physical activity throughout the life course (8). The term physical illiteracy, we argue, incorporates the interrelated and negative influences of exercise deficit disorder and pediatric dynapenia, as seen in weak, inactive youth.

Without requisite MVPA and muscular strength, children will be less apt to climb a playground structure or kick a ball. The less they engage in such play, the less fit they become and the less likely they are to experience the sheer joy of movement. Since the concept of physical illiteracy encompasses psychomotor, cognitive, and affective domains of learning, interventions need to be reinforced with effective pedagogical, motivational, and social strategies so inactive youth can learn the value of physical activity.

The quantity of prescribed MVPA needs to be balanced with the quality of the movement experience (9).

A PARADIGM SHIFT

Since positive and negative behaviors established during childhood tend to track into adulthood, we need to identify and

treat physically inactive youth early in life to prevent the expected cardiometabolic, musculoskeletal, and psychosocial consequences later in life. Traditional interventions taken by pediatricians are currently triggered only after a child already has an elevated BMI or HgbA1c. We argue that the ‘‘horse is out of the barn’’ already if we wait for these signs to address at-risk youth.

This novel concept also will aid stakeholders in defining specific treatment goals. Traditional interventions tend to overlook the multifactorial, interconnected relationships between exercise deficit disorder, pediatric dynapenia, and physical illiteracy.

Treatment strategies that only address one component of the PIT are less likely to result in desired outcomes. For example, walking programs that attempt to increase MVPA in youth but overlook the critical importance of enhancing neuromuscular fitness and improving physical literacy often have limited long-term benefit.

Conversely, integrative exercise programs that include physical and cognitive training are more likely to improve health outcomes, enhance motor competence, boost fitness performance and reduce activity-related injuries in youth (10).

More than two millennia ago, the ancient Greeks and Romans argued that exercise was good for one’s health and well-being.

However, Hippocrates and Galen did not have to contend with entertainment technology, the contemporary obesogenic physical environment, and a disease-focused health care system. The effects of physical inactivity on a child’s physical, psychosocial, and cognitive development are incontrovertible, but simply telling a child or a parent to embrace physical activity as our ancestors did has achieved next to nothing.

In this commentary, we have argued for the adaption of a new framework for addressing the epidemic of pediatric inactivity: the PIT, with its individual components. We believe that the proposed concept of PIT offers a new model that challenges our current approach and stimulates discussion, debate, and most especially, action on this pervasive public health issue. Concerted efforts from fitness professionals, health care providers, school administrators, public health officials, and others are needed to change social mores and common practice about physical inactivity. It is time that PIT, and its individual elements, enters the lexicon of all those concerned about the health of our children.

The authors thank Devon Mulrine for graphic art assistance with the figure.

The authors declare no conflict of interest and do not have any financial disclosures.

References are found on page 34

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anaging athletes requires focus on both prevention and treatment of skin conditions in Sports Medicine. Athletes are a big part of today’s society and have a variety of unique needs, influenced by personal behavior as well as conditions related to their sport. Recognizing these behavioral patterns helps uncover the underlying disease. A complete skin exam is often not performed as other parts of the physical examination, such as the cardiovascular, pulmonary and neurological systems, which are a priority.

There are many reasons for a proper complete skin exam in the competitive athlete who may be exposed to a variety of sports associated physical & environmental stressors on the skin, hair, nails & mucous membranes.

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Athletic equipment and the sports disciplines are the perfect petri dish without preventative protocols in place.

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Infections are the most common cause for disruption of practices and competitive events. Athletic equipment and the sports disciplines are the perfect petri dish without preventative protocols in place.

Correct diagnosis allows quick return to competition. For example tinea pedis has many mimickers, such as pitted keratolysis, which does not respond to oral or topical antifungal treatment. Pitted keratolysis is caused by several bacterial species, including micrococcus, and resolves with topical antibiotics. Both tinea pedis and pitted keratolysis can be prevented with moisture wicking socks, keeping feet dry and cool. This perfectly illustrates why swift diagnosis and preventative measures are key.

The new names for skin infections include herpes gladiatorum, tinea corporis gladiatorum and impetigo staff folliculitis and furuncles. These names underline the importance of preventative measures in every sports discipline to prevent major epidemics (i.e. the St. Louis Rams having a massive outbreak of MRSA). (1) Thanks to new development of clothing engineered for athletes, keeping them cool and dry, the amount of skin to skin contact can be greatly decreased, thus preventing large outbreaks. Preventing sharing of towels and equipment in the locker room and on the field are equally important.

Being able to distinguish between cutaneous Infection versus contact dermatitis helps keeping athletes in play. Contact dermatitis can stem from two sources, equipment or topical medications athletic trainers and athletes apply to their skin. For example, Neomycin for any skin ailment as well as Benadryl Spray are often used and will over time lead to allergic contact dermatitis.

Swimmers can develop a complete body irritant contact dermatitis to bromine, which is increasingly used by universities and public pools as a sanitizing agent. Green hair in blond haired, fair skinned female swimmers can be treated with copper chelating shampoo. The copper stems from algicides and copper pipes in older pools, which leach copper into the water.

Exercise induced anaphylaxis is rare. It is important to consider this in athletes with several symptoms, including headache, swelling of the lips and hands. Only one third have respiratory and cardio vascular collapse.

Therefore, exercise induced anaphylaxis is not always deadly, and both treatment and instruction for prevention techniques are essential. Avoiding extreme temperatures (both warm and cold) and refraining from eating directly before exercising can greatly impact the frequency and severity of exercise induced anaphylaxis for predisposed athletes. The two main therapies are scheduled antihistamines and having an EpiPen available in the event of anaphylaxis. Some clinicians refer to exercise induced anaphylaxis as exercise induced angioedema to convey that it is not always deadly.

By definition, urticaria is divided into acute (lasting less than six weeks), or chronic (lasting more than six weeks) forms. Additionally, chronic urticaria can be classified as either spontaneous (previously known as idiopathic urticaria), where no specific etiology is identified (however 40-50% of these cases also have an autoimmune etiology); or inducible urticaria (previously known as physical urticaria), where a specific precipitating factor is identified. A third group, known as other inducible urticaria, which includes cholinergic urticaria/ exercise induced urticaria and aquagenic urticaria. (4). Some of the more unique types of urticaria are solar urticaria and cold urticaria. It is important to recognize these in athletes.

Skin cancers at the front of the hair line or where your hair is parted on the scalp and protruding parts, such as ears and nose can be prevented with repeated application of sunscreen (minimum SPF 30) in those areas. Today there are many sunscreens geared towards athletes.

The diagnosis, treatment and management of athletes is crucial to prevention and spread of epidemics in sports. Refer to the National Federation of State High School Sports (NFHS) and the National Collegiate Athletic Association (NCAA) guidelines for Return to Play for detailed recommendations on the prevention and care of skin diseases in athletes. These guidelines are minimum requirements and physicians should continue treatment even after the competitive athlete has returned to play to ensure complete clearance.

Dr. Scott Darling practices at his Total Skin Center clinic in Liberty, MO. References are found on page 34

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Sudden Cardiac Death in Athletes: Epidemiology, Review of Current Screening Guidelines and Role of Family Physicians in Determining Risk Factors

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udden cardiac death (SCD) is the most common cause of sudden death in athletes. Specific estimates in incidence and prevalence are varied; however, a recent estimate of the incidence of SCD ranged from 1:40,000 to 1:80,000 athletes per year. [1] Various studies have indicated that the physical expenditure involved with sports training can double to quadruple the risk of SCD relative to that in non-athletes and even recreational athletes. When estimating SCD incidence, the population of athletes “at risk” is difficult to quantify due to the lack of evidence suggesting risk correlations within specific population groups.

WELL, WHAT EXACTLY IS AN ATHLETE?

The definition of an athlete varies. A competitive athlete has been defined as “one who participates in an organized team or individual sport that requires competition against others as a central component, places a high premium on excellence and achievement, and requires some form of systematic (and usually intense) training.” [1] This definition can be best applied to high school athletics and beyond, but it is more difficult to accurately define significantly younger and/or older populations that participate in athletics for recreational purposes. That being

Primary Author Theodros Zemanuel, DO Cox Family Medicine Residency Springfield, MO

said, statistics suggest that the main focus for prevention of SCD should be aimed at collegiate athletics, where incidence rates far eclipses rates within other groups. The population with the highest risk for SCD in collegiate athletics has traditionally been black, male basketball players.

Black, male collegiate football players represent the second highest risk group. These findings are based primarily on retrospective studies following physical manifestations associated with SCD-related pathologies such as Hypertrophic Obstructive Cardiomyopathy (HOCM), Brugada syndrome, Right Ventricle Arrhythmogenic Co-author/Contributor Dysplasia, Prolonged Q-T syndrome, etc. [2] The Trevor Conner, DO cardiac abnormalities contributing to SCD in Cox Family Medicine Residency athletes ≤35 years of age generally fall into three Springfield, MO categories: electrical, acquired, and structural cardiac abnormalities.

PEDIATRIC INACTIVITY TRIAD

The pediatric inactivity triad (PIT) we propose is a condition observed in physically inactive youth involving three distinct but inter-related components: 1) exercise deficit disorder, 2) pediatric dynapenia, and 3) physical illiteracy.

While each of these components in isolation is an important consideration, we argue they should be viewed collectively to better effect change.

Pediatricians and researchers should adapt the practice of leaders in the field of sports injury

Faculty Member Shannon Woods, MD Medical Director Cox Health Sports Medicine

MO-AFP.ORG 19

event. [2] Evaluation of these symptoms and prompt medical attention given by a qualified member of the sports medicine team is an important aspect of the medical care of athletes and SCD prevention. That said, since many of the cardiac conditions that cause SCD in athletes may not present with warning symptoms, there has been considerable discussion about the role of pre-participation screening tests to evaluate for occult cardiovascular disease regardless of symptomatic accounts.

ARE THERE SCREENING GUIDELINES FOR SCD?

prevention, who have begun to focus on a complex systems approach to most effectively address that phenomenon (5). Physical inactivity is a multifactorial phenomenon that is influenced by a web of contributing factors. We need to better understand these complex interactions and clarify how these interactions contribute to physical inactivity in children and adolescents. The Figure illustrates our current understanding of the interaction among the components of the PIT. The first component of the PIT relates to the construct called exercise deficit disorder, a term used to describe a condition characterized by levels of MVPA that are inconsistent with current public health recommendations (6). Instead of simply labeling a child as inactive, the term ex- ercise deficit disorder should be used to highlight the gravity of this clinical condition, educate parents about the impor- tance of daily MVPA, and prompt intervention on the part of Are there prodromal symptoms involved with SCD? Most prodromal symptomatic accounts regarding SCD are not reported proactively and are subject to different biases, thus making actual estimates difficult to ascertain. However, upwards of approximately 30% of athletes with SCD have reported to have symptoms such as chest pain, shortness of breath, performance decline, palpitations, pre-syncope, or syncope leading up to the 20

MISSOURI FAMILY PHYSICIAN April - June 2020

Limited studies suggest that the incidence and causes of SCD vary widely depending on the age, gender, race, country of origin, and sport(s) played.

Therefore, it is unlikely that any single screening program will be effective across all groups AND represent the least level of screening to prevent over-utilization. There is currently no consensus in universal screening for SCD-related pathologies. Instead, there are different associations that have their own recommendations. The American Heart Association (AHA) and American College of Cardiology (ACC) recommend screening that is limited to a targeted medical history and physical exam. The specific 14-element list recommended by the AHA includes questions regarding a personal history of concerning cardiovascular symptoms (i.e., chest pain, syncope, dyspnea) and a family history of premature sudden death or disability from heart disease in addition to a focused physical exam. [2] For those identified as having a moderate to high risk of cardiac disease and still want to participate in vigorous athletic activities, further evaluation with ECG and exercise stress testing is indicated.

The 14-point evaluation has been standard in pre-participation physical exams for a number of years however; a recent study has revealed its inadequacy in predicting risk of SCD and SCD-related pathology compared to ECG. [4] In contrast to the AHA/ACC recommendations, the European Society of Cardiology (ESC) and International Olympic Committee (IOC) advocate for screening that includes a resting 12-lead electrocardiogram (ECG). The role of the baseline ECG in preparticipation screening has garnered considerable debate. Limited studies involving ECG-inclusive screenings have demonstrated an increase in sensitivity of pre-participation screening for identifying cardiovascular disorders that predispose to SCD. [2] There is a need for well-designed prospective randomized studies to evaluate whether or not this translates into improved outcomes.

SO, WHAT CAN WE LOOK FORWARD TO?

Statistically speaking, SCD is rare. However, its occurrence in athletes who are often young and presumably healthy has a significant emotional and social impact on the surrounding community.

Therefore, considerable efforts have been made to provide for improved screening and to better understand the relationship between SCD-related pathologies and certain demographic risk factors.

This, in theory, will lead to optimal strategies for early detection of disease, and ultimately, prevention of SCD. SCD in athletes is a relatively uncommon but devastating event. An understanding of the basic aspects of initial pre-participation evaluation of athletes is essential for family physicians. For now, pre-participation cardiovascular screening of athletes should include, at the very least, an AHA 14-point questionnaire to assess risk. Routine pre-participation ECG remains an area of considerable debate, although limited studies have demonstrated an increase in early detection of some cardiac pathologies associated with SCD. Overall, the current AHA/ACC model for screening appears to make the most clinical sense and prevents over-utilization of resources that is associated with universal ECG screening. However, with the increased sensitivity of ECG criteria for SCD-related pathology and time, more evidence clarifying specific demographic risk groups could lead to modifications of screening protocol and incorporation of ECG screening for these athletic populations.

IRB Approved Study on SCD

Recognizing longitudinal heterogeneity may help with efforts to target preventive strategies for groups with the highest risk. [3] With that in mind, a team of clinical researchers, including head team physician for Drury University and Evangel University, Dr. Shannon Woods, fellow resident physician, Dr. Trevor Conner and myself have established a prospective study. This study, which is sponsored by Cox Health Systems and the Cox Family Medicine Residency Program, is meant to screen for ECG abnormalities defined by the international consensus standards for ECG interpretation in athletes and those identified as potential indicators for SCD-related pathologies and then compare these findings with associated demographic data points.

Nearly 1000 collegiate athletes from two local universities, Drury and Evangel, were included during the previous two years of the study. Those with significant past medical histories for a previous cardiac condition were excluded.

Data collection is ongoing and each consecutive year; new subjects will be added to the study. There is the potential that results could demonstrate a significant correlation between race, gender and/or sports played with specific ECG abnormalities. The ultimate goal is to elucidate optimal athletic populations for pre-participation screening with ECG.

References are found on page 34 MO-AFP.ORG 21

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MISSOURI FAMILY PHYSICIAN April - June 2020

Youth Participation in Sports

Y

outh participation in sport offers numerous benefits to include improved self-esteem, peer socialization, and the opportunity to develop a physically fit child more likely to grow into an active adult.

However, in recent years many have raised concerns over increasing overuse injuries and burnout in young athletes. Early sport specialization and intense training schedules may play a role. The false narrative of the “10,000 hour rule� where repetitive practice is sold as a method for success, and the belief that earlier focus on a single sport will lead to improved athletic performance, has increased pressure to begin high intensity training at young ages. The big business of youth sports also contributes. Coaches, personal trainers, club team organizations, sporting-good manufacturers, and tournament organizers have a financial stake in youth sport participation that may conflict with the well-being of the child. Family Medicine physicians are in a unique position to identify those at risk for sport-related overuse injury or burnout. This paper will focus on risk factors for overuse injuries and burnout in physically active youth as well as methods that can be used to prevent and manage such conditions.

It is estimated that approximately 27 million youth between the ages of 6 and 18 participate in team sports in the US. The National Council of Youth Survey found 60 million children between 6 and 18 years old participated in organized sport, and 44 million participate in more than one sport. Although little data exists on the incidence

and prevalence of overuse injuries in youth, it is estimated that between 45.9% and 54% of all sports injuries are due to overuse. Injury patterns appear to vary by sport, age and gender. Given that most studies define an injury as requiring time away from sport these numbers likely underrepresent the true burden of this issue.

Overuse injuries occur from repetitive submaximal loading of a structure with inadequate recovery and adaptation. This leads to a weakened, damaged structure. Such injuries may occur at the muscle-tendon unit, bone, physis, articular cartilage, and/or neurovascular structures. Risk factors can be broadly categorized as intrinsic and extrinsic. Intrinsic risk factors are those attributed to biologic diversity and psychosocial traits. Examples include variations in growth and development, anatomical alignment, flexibility, muscle-tendon imbalance, and conditioning. Extrinsic risk factors include those related to the external forces of the activity as well as the sporting environment itself.

Examples include workload, technique, training environment, and equipment.

Amongst the intrinsic factors, age poses unique risks for overuse injuries. Rapidly growing physes, apophyses and articular surfaces of skeletally immature athletes are at higher risk of injury from shear, tensile and compressive forces compared to mature bone or more immature pre-pubescent bone. Several factors may contribute. Changes in metaphyseal perfusion may be responsible for the increase in physeal stress injuries seen during adolescent growth spurts. A decrease in

Christian Verry, MD, CAQSM Faculty, Mercy Family Medicine Residency Adjunct Assistant Professor, SLU School of Medicine, Dept of Family and Community Medicine Team Physician, St Louis Cardinals

MO-AFP.ORG 23

age-adjusted bone mineral density which occurs just before years old (10 hrs per wk in organized sports for a 10 year peak height velocity may increase risk for bony injuries old child). To prevent anxiety and burnout, a focus on skill in adolescence. Increased joint hypermobility that occurs development, rather than competition and winning should before and during adolescence has also been shown to be emphasized. When considering intrinsic risk factors increase risk. Finally, imbalances between growth and it should be noted that outside of joint hypermobility muscle development create potential risks. Longitudinal (a known risk), other biomechanical factors and their growth of extremities leads to changes in stress forces contribution to risk are less clear. Neither anatomical on the bone-tendon and muscle tendon junctions, as alignment nor flexibility have been clearly associated with well as the growth cartilage and ligaments. This occurs injury risk. It is likely that such relationships are complex asynchronous to strength development. These imbalances and depend on both age and sport. As such, the impact in growth and strength, coupled with repetitive loading, of interventions such as flexibility programs, orthotics appear related to increased injury risk. and bracing remain questionable. Instead, clinicians can Extrinsic risk factors include workload, scheduling and advise for pre-season conditioning programs focused on equipment. Higher training volumes have consistently endurance, strength and motor skills which have been been shown to increase shown to decrease injury rates overuse injuries. In one study in youth athletes. of high school aged athletes, An easy rule is no more than 8 To minimize risk of injury there was a linear relationship months per year in a single sport, and unnecessary emotional between sports participation distress, a child’s level of and injury risk. Athletes who and limiting hours per week of growth and development trained more than 16 hours per (motor, sensory, cognitive, week experienced significantly organized sports participation to social/emotional) must greater injury rates than their number of years old match the requirements counterparts. Overscheduling of the sport. Chronological may also pose a risk for injury age should not be used to or burnout. Year-round participation in sports, simultaneous determine readiness for sport since motor, cognitive and involvement on multiple teams in a single sport, and social skills develop at individual rates regardless of age. tournament scheduling that involves multiple games in Premature engagement with a sport may lead to unrealistic a single day or over consecutive days may increase risk expectations causing the individual to feel they are not for injury. In another study on high school aged athletes, making progress. The child may lose self-esteem and those who reported year-round participation in sports eventually withdraw from the sport. They may mistakenly had a 42% increased risk of overuse injuries versus those believe they are not good at sports and purposefully avoid who competed 3 seasons or less. Finally, use of improper future opportunities. In our current epidemic of child and or poorly maintained equipment may pose a risk. Specific adult obesity our focus must be on engaging all children in concerns include improper fitting equipment (bats that are physical activity and minimizing factors that may prevent too large, poorly fit shoes, bikes, or tennis rackets), and the development of an active and healthy adult. poor utilization of resistance devices such as swim paddles Finally, concern exists within the sports medicine or weights. community about premature sport specialization. Some Prevention of youth activity-related injuries and data exists showing youth athletes who engage in a single burnout is multifaceted. When assessing intrinsic and sport, year-round, at the exclusion of other sports may extrinsic risk factors it is important to consider training be at higher risks for overuse injuries and sport burnout. load. Clinicians can screen for this during the Well Child or While not conclusive there is literature to show that sport preparticipation visit, asking about physical activity, training diversification during early and middle adolescence may be and competition schedule. Parents should be encouraged more effective in developing elite-level skills in a primary to allow adequate rest between training and competition, sport, due to skill transfer. Educating our young patients and and to minimize overscheduling. Clinicians can educate their parents about the potential benefits of diverse sports patients and their families on the importance of limiting participation, and possible risk for injuries and burnout with repetitive sport specific movements (utilization of pitch early sport specialization may help to prevent missed time or counts) and having scheduled rest time by limiting weekly self-selected withdrawal from physical activity. and yearly participation time. An easy rule is no more than 8 months per year in a single sport, and limiting hours References are found on page 34 per week of organized sports participation to number of

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MISSOURI FAMILY PHYSICIAN April - June 2020

EMERGENCY AND URGENT CARE COURSES

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Choose your course and register now for the AAFP’s course and another 6 for participating in optional workshops Emergency or the AAFP’s Emergency and Urgent (additional fees apply).

Care Courses live course in St. Louis, MO, July 8-11. AAFP members: $995/Nonmembers: $1,295 Be prepared to take a hands-on approach to care when time is limited and accuracy is critical. Educational sessions meet the requirements of trauma CME and cover what you are likely to see during emergency and urgent care situations.

After the course, you will be able to: • Prepare treatment plans for patients who present to emergency departments and/or urgent care clinics.

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• Incorporate emergency plans into practice.

Optional Workshop Sessions (Additional fees apply) • ECG Interpretation | Basic and Advanced (Earn 3 AAFP Prescribed credits) • POCUS: Focused Lung, Musculoskeletal and Vascular Scans (Earn 3 AAFP Prescribed credits)

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SERVE YOUR PATIENTS WHILE YOU SERVE YOUR COUNTRY.

That’s the Army difference. As a family medicine physician on the U.S. Army Reserve health care team, you’ll serve the needs of Soldiers and family members in your military community. For two days a month and two weeks a year you may use your medical skills and knowledge to support humanitarian missions, train and lead your own medical team at a military field hospital, or work in one of our state-of-the art medical facilities. To learn about the variety of career opportunities in Army medicine, visit www.goarmy.com/amedd.

For more information contact Capt. Raymond Olympio at 210-392-1403 or 314-738-0300 with the U.S. Army St. Louis Medical Recruiting Station.

©2018. Paid for by the United States Army. All rights reserved.

MO-AFP.ORG 25

WHITE COATS ABOUND IN THE CAPITOL

W

e were on a mission…and mission accomplished!

Family physicians gathered in Jefferson City for this year’s MAFP Advocacy Day, February 1718, and drew participation from over 45 family physicians, residents and students eager to meet with their legislators and share the same message…family physicians are the key to reducing health care costs in Missouri. The Missouri Association of Free and Charitable Clinics also joined our group and met with their legislators to encourage their support of Medicaid expansion and to increase access to care.

The MAFP and the Missouri Healthcare Workforce Coalition have joined forces and crafted the preceptor tax credit legislation. Representative Jon Patterson, MD, is the bill sponsor. The week after our Advocacy Day, the bill was heard in the House Ways and Means Committee…you made a difference! But, we still need you to speak out on behalf of this bill. Many organizations supported the bill including the Missouri State Medical Association, Missouri Association of Osteopathic Physicians and Surgeons, Missouri Academy of Physician Assistants, Missouri Hospital Association, and many more. There was NO opposition. Our next step is to have the committee bring it up for a vote, but with the current stay at home order for the state, we may need to save our efforts for 2021. You can still let your elected leaders know you support the concept and bill.

As in past years, we began Monday evening with a detailed review of priority legislation that impacts family physicians and patients. We had a virtual component added to this year’s session for members who were unable to attend in person. Members could participate via live webinar format to learn about our issues, how a bill becomes a law, and strategies when communicating with your legislators. The following morning, white coats were seen in the halls of the capitol as members met with over 16 Senators and 26 Representatives. Many of our attendees met with their legislators on the chamber floor and were introduced to the Senate and/or House of Representatives. Some held a brief “side bar” meeting to educate our elected leaders about our priority bills. A summary document that described our priority bills and issues, including, but not limited to: preceptor tax credit, assistant physician pathway to licensure, scope of practice expansion, patient safety, and again, a prescription drug monitoring program was provided to the legislators for future reference. This document is included in this issue of the

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magazine on page 28-29. It is unlikely that we will be able to report the passage of the preceptor tax credit legislation this session, but we have introduced the concept and will continue our efforts next year.

Advocacy Day also had an added feature of a “Speak Out” component for members unable to attend, but could still participate and share our message to their Senators and Representatives. Prepared messages were sent on the preceptor tax credit, assistant physician, and Medicaid expansion.

Advocacy Day is one day out of the session that an organized event is held for family physicians. But, it’s not the only day you can come to Jefferson City. The legislative week begins on Mondays around noon, and ends on Thursdays at noon. The MAFP staff and governmental consultants are ready to help you meet with your legislators at your convenience. We will arrange your appointments and attend your appointment with you, if you choose. You are the expert and your message may be what it takes to help them better understand why family physicians are the key to better health outcomes in Missouri.

2020 LEGISLATIVE UPDATE

T

his legislative session is filled with many of the bills that have been on the MAFP’s priority legislation list for many years. We continue to advocate on your behalf in Jefferson City. Listed below are just a few bills that the MAFP has been working on this legislative session. Since the status of bills changes daily, this summary of top bills is included in this issue of the magazine. COVID-19 has impacted the schedule and activities at the Capitol. Updates will be provided in the weekly legislative reports that are emailed to all members.

Preceptor Tax Credit Legislation

Leading up to this legislative session the MAFP has been working in conjunction with the Missouri Healthcare Workforce Coalition to develop strategies and policies to support the primary care workforce.

To that end, the MAFP had Representative Jon Patterson, a physician and Republican member of the Missouri House of Representatives, introduce House Bill 2036 which creates a preceptor tax credit program for physicians and physicians’ assistants in primary care specialties and other related specialties.

As most residency programs and teaching hospitals will attest, getting physicians and physician assistants to precept a student is difficult because it often has to be done on a volunteer basis. Our goal with this program is to provide some additional incentive to get more preceptorships available to medical and physician assistant students.

The tax credit will be self-assessed by the physicians and physicians’ assistants by adding a small additional charge to their new and renewal licensing fees. For physicians, it will be an additional $7.00 per year and for physicians’ assistants it will be an additional $3 per year. At those rates, the program should generate approximately $200,000 annually. Each preceptor that precepts a student for 120 hours will be eligible for a $1,000 tax credit. The legislation stipulates that only those who aren’t already being paid for precepting students will be eligible for the tax credit.

The bill was heard in the House Ways and Means Committee and it went very well. The bill received the full support of other interest groups representing physicians and the Missouri Hospital Association.

If you haven’t already contacted your legislator to urge them to support House Bill 2036, the preceptor tax credit bill, please do so TODAY!

to create an alternative pathway to licensure for assistant physicians. His bill, House Bill 1977, establishes a quasiapprentice model within the confines of a collaborative practice arrangement.

The MAFP has continued our strong opposition to any legislation regarding assistant physicians and, especially so, the creation of an alternative pathway to licensure in lieu of a residency program.

The MAFP members provided expert in-person and written testimony against this legislation. We anticipate this legislation will be offered to other healthcare related bills later on in the session.

Collaborative Practice Arrangements

Missouri currently has a mileage restriction for physicians to collaborate with APRNs and PAs of 75 miles. There is legislation, House Bill 1816, that would do away with the mileage restriction for all counties except first class counties. This is an attempt by the sponsor to deal with some issues she’s having in her district in which has proven difficult to find collaborating physicians to work with the APRNs that take care of a largely Mennonite population.

The MAFP has been working with other physician groups to fight this legislation. This measure is likely to pass the House but generally has been held up in the Senate.

TAKE ACTION

Most importantly, for every piece of legislation that we track, we need you! Other professions actively engage in contacting legislators on their priority bills. Legislators listen to their constituents-you take care of them, their family, friends, and neighbors.

They want to hear from you…it can be as simple as you sending an email to support or oppose a bill, or including a justification for your position. You are a resource to them!

Assistant Physician Legislation

Representative Lynn Morris has once again filed legislation MO-AFP.ORG 27

MAFP PRIORITY LEGISLATION MAFP SUPPORTS PRECEPTOR TAX CREDIT PROGRAM SUPPORT HB 2036 (Patterson) • Preceptors are a critical component in the learning process for medical and physician assistant students. They provide invaluable experience for students to develop clinical skills and competencies, gain practical experience working with patients, and understand the diversity within the patient population and treatment settings.

• Evidence shows that early and consistent primary care preceptor mentorships for medical students increases the likelihood of students choosing family medicine as a career.

• MAFP supports this self-imposed license fee increase to fund this preceptor tax credit because of the significant need to incentive preceptors to provide this critical learning opportunity, particularly in rural and healthcare shortage areas.

• Primary Care Physicians and Physician Assistants will be able to take advantage of this tax credit program which will be eligible for up to 200 preceptor rotations a year.

• Most preceptors at public schools of medicine are not paid for providing this service.

• This tax credit could improve exposure of medical students and physician assistants to rural medicine.

MAFP SUPPORTS COLLABORATIVE PRACTICE WITH OUR APRN COLLEAGUES OPPOSE HB 1441 (Schroer), HB 1617 (Kelly), HB 1816 (Kelly), HB 2226 (Stephens), SB 714 (Burlison), SB 965 (O’Laughlin) • MAFP believes the physician-led team approach delivers the best and most cost-effective care to Missourians and that APRNs are dedicated, skilled members of the health care team.

• While APRNs have an important role on the health care team, they have not completed training that affords them the same experience and skill as those who have completed a medical education. A Doctorate in Nursing Practice completes approximately 5,350 hours compared to 20,000 hours for a physician.

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• Alternatives to an expanded scope of practice for APRNs are loan repayment/forgiveness/scholarships for primary care physicians; less administrative burden, such as prior authorizations; increased reimbursement for primary care services; and expand primary care residency slots.

• Evidence shows (AMA, 2017) that most physicians are reducing the number of opioid prescriptions written. Exceptions are nurse practitioners, physician assistants, and pain management physicians who have increased their number of opioid prescriptions.

EXPANSION OF ASSISTANT PHYSICIAN OPPOSE HB 1977 and HB 2104 (Morris) • This bill creates a pathway to bypass the three-year residency and become a licensed physician by passing Step 3 of the USMLE within three attempts; five years of collaborative practice. This bill removes the requirement to practice in a rural area of the state.

• MAFP supports efforts to increase physicians in rural, underserved areas through increased Missouri primary care residency slots and loan repayment/forgiveness programs.

• The primary assumption that any care is better than no care, and anyone can provide primary care is false. This must be weighed against the principle that our underserved Missourians deserve safe, quality healthcare, preferably by a fully-trained family physician.

• Medical school trains students to become residents, not physicians. Residency provides graduated responsibility and progressive duties to many different patients (chronic and complex conditions), pathologies, practice settings, and undifferentiated signs and symptoms which require critical thinking and differential diagnosis.

PROTECT OUR PATIENTS • OPPOSE SB 590 (Burlison) – MAFP supports the requirement to use headgear for motorcycle/motortricycle use, even when the operator has additional insurance coverage

• SUPPORT HB 1290 (Evans), HB 1633 (Porter), HB 1674 (Bland-Manlove) – Prohibits the use of hand-held wireless communication devices and texting while driving.

PATIENTS DESERVE ACCESS TO QUALITY HEALTH CARE • The MAFP believes that all Missourians should have access to essential health care services, regardless of social, economic or political status, race, religion, gender, or sexual orientation.

We support measures that increase Medicaid coverage to Missourians who lack affordable health care.

• Medicaid Expansion – MAFP support the expansion of Medicaid to cover the working Missourians who fall in the gap between Medicaid eligibility and ACA Marketplace vouchers.

Missouri’s rural and underserved populations have the most to gain by expanding Medicaid. And, Medicaid expansion will support our rural hospitals from closure and maintain access to care.

• WATCH HB 1416 (Helms) – Although we support direct primary care (DPC) practices, we want to ensure that this measure includes an appropriate monthly fee based on current practices and does not require additional reporting for reimbursement which is one of the basic tenants of a DPC practice.

• OPPOSE SB 303 (Riddle) – Patient Safety and Radiologic Imaging Act would create an access to care issue in rural areas if clinic staff are not allowed to offer in-clinic x-rays.

• OPPOSE HB 1869 (Gregory) – Physical therapists should work with a referring physician to ensure proper diagnosis and treatment of the patient.

MAFP CONTINUES TO SUPPORT EFFECTIVE OPIOID PRESCRIBING SUPPORT HB 1693 (Rehder), SB 677 (Luetkemeyer) • In 2018, there were 1,132 opioid overdose deaths in Missouri.

(Bureau of Vital Statistics, MDHSS)

• The MAFP supports a PDMP that monitors the prescribing and dispensing of controlled substances, requires dispensers to electronically submit specified information within 24 hours of dispensation, and does not require a pharmacist or prescriber to obtain information from the database.

• OPPOSE HB 1472 (Applebaum) and HB 1580 (Ingle) – MAFP opposes codifying the CDC guidelines into regulations because it undermines the physician and patient shared decision making. It would also disrupt the care of patients who are currently receiving long-term chronic pain treatment. Missouri’s current treatment infrastructure does not have the capacity to absorb a large number of patients newly cut off from opioid treatment.

LAWSUIT REFORM • SUPPORT SB 591 (White) – This bill addresses the low standard for awarding punitive damages against a provider by increasing the threshold for levying the damages to clear and convincing evidence in medical negligence cases.

• SUPPORT SB 845 (Burlison) – Current law allows a defendant that is found to bear 51% or more of fault can be held joint and severally liable for the judgement amount. This bill allocates the liability of the judgement to the proportion that each defendant is found to be at fault.

OTHER IMP ORTANT LEGISLATION • OPPOSE SB 670 (Hough) – This bill is an expansion of the athletic trainer scope of practice to allow them to treat illnesses, provide clinical evaluation and assessment, for all active individuals (not just athletes).

• SUPPORT HB 1697 (Henderson) – This bill prohibits insurers from reducing a provider’s payment for services to a patient when another provider was overpaid for the same patient.

• SUPPORT HB 1974 (Morris) – establishes “Any Willing Provider” for healthcare providers MO-AFP.ORG 29

MEMBERS IN THE NEWS

DO YOU HAVE NEWS TO SHARE?

Email it to office@mo-afp.org for review.

We love to hear from our members!

The UMKC Family Medicine Residency program was well represented at the Annual MSACOFP Winter Family Medicine update!

For dedication to Osteopathic Family Medicine in Missouri, Dr. Chris Koehn, D.O. Chief Resident of the Family and Community Medicine program at Truman Medical CenterLakewood was the recipient of the 2020 Family Medicine Resident Scholarship. The Missouri Society of the American College of Osteopathic Family Physicians established the Resident Scholarship Program to help identify and develop future leaders for the MSACOFP and Osteopathic Family Medicine in Missouri. The Scholarships are awarded annually to residents in Missouri family medicine residency programs who have demonstrated leadership skills and have committed to practice in Missouri following residency.

In addition, current faculty member Chelsie Cain, DO served on the Convention and education Committee, and former Assistant Program Director, Laura Hempstead, DO, FACOFP was the recipient of the 2020 James A. DiRenna, Sr., DO Appreciation and Recognition Award. This award is given to an individual or company who has shown continued support for the Winter Family Medicine Update or has given years of dedication to Osteopathic Family Medicine and the Osteopathic Profession.

Pictured with Dr. Koehn (right) is Dr. Christopher Paynter, DO, MS President of the MSACOFP and a 2015 alumnus of the UMKC Family Medicine Residency Program.

Dr. Karissa Merritt featured in 417 Magazine

Congratulations to KCUMB Congratulations to the Kansas City University of Medicine and Biosciences, Joplin Campus, on receiving a Student Organization Core Grant from the AAFP. This grant will support the KCUMB-Joplin Campus’ FMIG activities and programs. Way to go!

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Dr. Karissa Merritt, resident physician at CoxHealth Family Medical Care Center, was the subject of a recent article in the February 2020 edition of 417 Magazine.

The article discussed her efforts with partners from Springfield-based nonprofit Crosslines and Springfield Community Gardens to address food insecurity in her local community.

The article states, “By cross-referencing data within the CoxHealth system, Merritt is documenting the effect of food insecurity on overall health. So far, the data indicates notably higher occurrences of illnesses like depression, cardiovascular disease, hypertension, kidney disease and diabetes in people who screen positive for food insecurity. Her next steps are to publish these findings and, hopefully, export this program to other clinics. She’s also exploring grant funding options to help maintain and expand it. “I’m humbled by this project,” she says. “It’s more than I ever expected.”

The full article can be viewed at https://www.417mag.com/lifestyle/health/ fighting-food-insecurity/.

MISSOURI AND ILLINOIS CHAPTERS AWARDED GRANT The Missouri and Illinois Academy of Family Physicians joined teams and were awarded a grant from the AAFP to offer a Rural Health Equity Conference this year. Planning has begun and we are bringing together experts to focus on rural health as it relates to maternal mortality and OB deserts, workforce footprints, obesity and diabetes, immunizations, COPD/asthma, mental health, and access to care. Mark your calendar for Saturday, November 7, 2020, Regency Conference Center, O’Fallon, IL. Look for more information later this year.

MAFP MEETS WITH RESIDENTS AT UNIVERSITY OF MISSOURI COLUMBIA

MedZou Clinic Directors and Advisors from left to right : Chase Seiller, Brenda Gois, Dr. Natalie Long (Faculty Advisor), Clara Oh, and Jimmy Dorroh

MedZou Clinic at SSRFC Conference 2020 Medzou Community Clinic is the student-run free clinic at University of Missouri – Columbia Medical School. The free clinic at Mizzou Med is run primary by first-year students, which gives them time to search and implement opportunities for growth. Four Student Directors represented the Clinic at the Society of Student-Run Free Clinics Conference held in Orlando, Florida from March 7-8, 2020, attended by more than 400 students nationwide. From poster sessions to creative oral presentations, there were many opportunities to hear ideas from various clinic models used by other medical schools. Topics ranged from managing pharmacies, emergency preparedness, providing vaccines and screenings, and more.

The MedZou Directors had a wonderful time at conference networking with and learning from various student-led clinics around the country. Applying what they have learned at clinic, the Directors are excited to implement quality improvement projects throughout this year. MedZou Clinic leaders would like to thank the Missouri Academy of Family Physicians for their assistance in traveling to the SSFRC Conference.

As part of the MAFP’s outreach efforts, Sarah Cole, DO, FAAFP, Board Chair, joined Kathy Pabst and Bill Plank at the University of Missouri Columbia Family Medicine Residency to discuss the benefits of being a member of the Missouri Academy of Family Physicians, as well as encouraging our future family physicians to be involved in advocacy efforts.

Dr. Cole shared a synopsis of her journey across the state as president which included anecdotal statements from family physicians in rural and urban communities. A discussion on this year’s assistant physician legislation was interesting and several questions were entertained by Dr. Cole and Kathy Pabst. The residents were reassured that MAFP will continue to represent family physicians in opposition to this new mid-level provider and any efforts to create a new pathway to licensure as a Missouri physician. Kathy also provided information on the collaborative efforts of the MAFP and our position on various issues in the legislature and regulatory agencies.

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2020 MULTI STATE CONFERENCE Missouri Academy of Family Physicians was one of 16 chapters represented at this year’s Multi State Conference. This conference brings together chapter leaders and executives to learn from each other about legislative and regulatory issues, and best practices. The conference kicked off with Gary LeRoy, MD, FAAFP, AAFP President, sharing his updates on the many programs and services provided by AAFP. Shawn Martin, AAFP’s Senior Vice President for Advocacy, Practice Management, and Policy, and the incoming EVP, shared key takeaways about our advocacy efforts in Washington, DC, and the challenges we are all facing in our daily visits with patients. As you would expect, reducing administrative complexity is near the top of the list, after supporting and sustaining comprehensive family medicine practices.

These topics have remained the top member priorities over the past three years. Artificial intelligence will play a roll in primary care and could help with administrative burden, cognitive burden, expanding capacity, expanding capabilities, and predicting disease and outcomes.

And lest we forget, the 2020 election is fast approaching, aside from the presidential election, the control of the House will be closely monitored.

Stay tuned for updates via Facebook, Twitter, and emails from the AAFP. Other topics included an update from the ABFM on certification changes including the FMCLA, KSA changes, PI activities, outreach and engagement, chapter partnerships, and the ABFM strategic plan. Social determinants of health and the role it plays in ensuring delivery of accessible, high quality care across a community.

Kathy Pabst participated in a panel discussion on the primary care investment legislation with representatives from Colorado and Nebraska. Kathy shared Missouri’s experience in a legislative environment that did not support new state coalitions or task forces, and the impact of the state level analysis of the Patient Center Primary Care Collaborative Report that was released in July, 2019.

MAFP SHOW ME FAMILY MEDICINE CONFERENCE POSTPONED After close consultation with partners in both the association industry and medical community, we’ve made the difficult decision to postpone the Show Me Family Medicine Conference, originally scheduled for June 11-14, 2020 due to the SARS-CoV-2 outbreak around the world, the United States, and Missouri.

Having spent months preparing for the conference with the MAFP board, speakers, exhibitors, and event partners, we're disappointed not to be able to host the event at this time.

encouragement. This news has reaffirmed that great things happen when our family medicine community comes together and connects. For this reason, we fully intend to host the best SMFM to date - just later in the summer. We are working with our partners to confirm the details and will share more information as it becomes available.

The Show Me Medicine Conference will now take place on August 14-15, 2020.

Mark your calendars and join us August 14-15 at Margaritaville Lake Resort, Osage Beach. See you at the lake.

Our conference will have the same amount of CME, and the same format you’ve come to expect. We want to thank our members and partners for their support, open discussions and

The MAFP Annual Meeting will be held on June 13, 2020, 8:00 a.m. via Zoom. To register, go to https:// www.mo-afp.org/cme-events/

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BILL PLANK JOINS MISSOURI ACADEMY OF FAMILY PHYSICIANS The Missouri Academy of Family Physicians announced the addition of Bill Plank as Assistant Executive Director. Plank will oversee education initiatives, content development and publication, public relations, and assist with advocacy for the Academy’s nearly 2,500 members throughout the state.

Plank brings over fifteen years of experience in leading professional and non-profit teams. His combination of experience in private industry and involvement in non-profits will be valuable to the Academy as they increase services for their members. In roles prior to joining the Academy, Plank helped grow companies in the financial and human services sector through innovation and thoughtful execution. In addition to his professional roles, Bill has held several volunteer leadership positions in non-profit organizations that provide a valued perspective on organizational dynamics. Executive Director Kathy Pabst said, “Our state’s Family Physicians have nearly 214 million office visits every year and work hard to provide the very best care for their patients. They deserve professionals working for them and we’re very excited to have Bill on board. His breadth of experience, knowledge and management capabilities will be extremely valuable as we execute a strategic plan that will improve the lives of Missourians.”

AAFP ANNOUNCES NEW EVP

MAFP CO-SPONSORS SCREENING OF “DO NO HARM” In partnership with the Missouri Society of the American College of Osteopathic Family Physicians, the MAFP co-sponsored the screening of the film, “Do No Harm,” at their annual meeting in January. This film feature documentary exposes the epidemic of physician suicide and burnout. The synopsis from the Do No Harm Film website summarizes reality of the film: “Jumping off hospital rooftops, hanging themselves in janitorial closets, overdosing on drugs—they’re A students and their suicides are often like wellplanned school projects. Doctors are our healers, yet they have the highest rate of suicide among any profession. Medical students and families of physicians touched by suicide come out of the shadows to expose this silent epidemic and the truth about a sick healthcare system that not only drives our brilliant young doctors to take their own lives but puts patients’ lives at risk too.”

Thank you MSACOFP for the opportunity to share this message with osteopathic family physicians!

The AAFP Board of Directors announced that Shawn Martin, AAFP’s Senior Vice President, Advocacy, Practice Advancement and Policy, has been chosen to be the next Executive Vice President/CEO of the AAFP. As the son of a family physician, Shawn knows first-hand the important role family physicians play in the lives of their patients and local communities. Shawn is passionate about promoting the specialty of family medicine, reducing administrative burden for physicians and ensuring everyone has equal access to affordable health care coverage based in foundational family medicine and primary care.

Those of you who have worked with Shawn may think of him as a serious and tough advocate for family medicine.

But what you may not know is that Shawn is a caring and compassionate leader who is committed to helping people and supporting our staff and chapters in serving our mission.

His experience has prepared him for this role, and he is ready for it!

Shawn will continue in his current role until June 1. At that time, he will become CEO Designee, and will work closely with Doug Henley, MD, FAAFP, AAFP EVP, to ensure a smooth transition upon his August 1 retirement.

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2. Poitras VJ, Gray CE, Borghese MM, et al. Systematic review of the relation- ships between objectively measured physical activity and health indicators in school-aged children and youth. Appl. Physiol. Nutr. Metabol. 2016; 41: S197Y239.

3. Lee BY, Adam A, Zenkov E, et al. Modeling the economic and health impact of increasing children’s physical activity in the United States. Health Aff. (Millwood). 2017; 36:902Y8.

4. World Health Organization. Global Recommendations on Physical Activity for Health. Geneva: WHO Press, 2010.

5. Bittencourt NF, Meeuwisse WH, Mendonc¸ a LD, et al.

Complex systems approach for sports injuries: moving from risk factor identification to injury pattern recognitionnarrative review and new concept. Br. J. Sports Med. 2016; 50:1309Y14.

6. Faigenbaum A, Best T, MacDonald J, et al. Top 10 research questions related to exercise deficit disorder (EDD) in youth.

Res. Q. Exerc. Sport. 2014; 85: 297Y307.

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London, UK: Routledge, Taylor & Francis Group, 2010.

9. Pesce C, Faigenbaum A, Goudas M, Tomporowski P. Coupling our plough of thoughtful moving to the star of children’s right to play. In: Meeusen R, Schaefer S, Tomporowski P, et al, editors. Physical Acitivty and Education Achievement. Oxon, UK: Routledge; 2018. p. 247Y74.

10. Myer G, Faigenbaum A, Edwards E, et al. Sixty minutes of what? A devel- oping brain perspective for activating children with an integrative exercise approach. Brit. J. Sports Med. 2015; 49:1510Y6.

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British Journal of Sports Medicine 48, 284-285.

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3. Houston SD, Knox JM. Skin problems related to sports and recreational activities. Cutis.1977;19:487491.

4. Zuberbier T, Aberer W, Asero R et. al. The EACCI/GA(2)LEN/ EDF/WAO guidelines for the definition, classification and management of urticaria.Allergy.2018;73(7):1393-1414.

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1. Wasfy MM, Hutter AM, Weiner RB. Sudden Cardiac Death in Athletes. Methodist Debakey Cardiovasc J. 2016;12(2):76–80. doi:10.14797/mdcj-12-2-76 2. Kuriachan VP, Sumner GL, Mitchell LB. Sudden cardiac death.

Curr Probl Cardiol. 2015;40(4):133–200. doi:10.1016/j. cpcardiol.2015.01.002 3. Jazayeri MA, Emert MP. Sudden Cardiac Death: Who Is at Risk? Med Clin North Am. 2019;103(5):913–930. doi:10.1016/j.mcna.2019.04.006 4. Williams EA. Performance of the American Heart Association (AHA) 14-Point Evaluation versus Electrocardiography for the Cardiovascular Screening of High School Athletes: A Prospective Study. Journal of The American Heart Association 2019 Jul 16; Vol. 8 (14), pp. e012235

Pages 22-24

1. DiFiori J, Benjamin H, Brenner J, et al. Overuse Injuries and Burnout in Youth Sports: A Position Statement from the American Medical Society for Sports Medicine. Clin J Sport Med 2014;24:3–20.

2. Post E, Biese K, Schaefer D, et al. Sport-Specific Associations of Specialization and Sex With Overuse Injury in Youth Athletes. Sports Health. 2020 Jan/Feb;12(1):36-42.

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3. Brenner JS;Council on Sports Medicine and Fitness. Sports specialization and intensive training in young athletes.

Pediatrics. 2016;138:154-157

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