MISSOURI Official Publication of the Missouri Academy of Family Physicians
Family Physician April-June 2016 Volume 35, Issue 2
Annual Scientific Assembly
See schedule of events and register today Page 12
Key Contact Program
Make a difference for your patients and your academy Page 18
Tar Wars Program速
See how MAFP is utilizing a $4,000 grant from AAFP to educate youth on the dangers of tobacco Page 15 COVER PHOTO COURTESY OF JULIE SMITH/NEWS TRIBUNE
We are dedicated to rural and underserved areas of our great state! MHPPS partners with safety-net providers and health care systems throughout Missouri to help health care professionals, like yourself, find a community that best fits your personal and professional needs. Whether it’s a scenic rural setting, dynamic urban location, or somewhere in between, we are committed to focusing on your interests and careers that count! Find Out More: Contact Us Today! Joni Adamson Manager of Recruitment 573.636.4222 jadamson@mo-pca.org www.3rnet.org/missouri
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executive commission Board Chair - Daniel Purdom, MD, FAAFP (Liberty) President - Peter Koopman, MD, FAAFP (Columbia) President-Elect - Kathleen Eubanks-Meng, DO (Blue Springs) Vice President - Mark Schabbing, MD (Perryville) Secretary/Treasurer - James Stevermer, MD, FAAFP (Fulton) board of directors District 1 Director: John Burroughs, MD (Kansas City) Alternate: Jared Dirks, MD (Kansas City) District 2 Director: Lisa Mayes, DO (Macon) Alternate: Vacant District 3 Director: Sarah Cole, DO, FAAFP (St. Louis) Director: Caroline Rudnick, MD (St. Louis) Alternate: Kara Mayes, MD (St. Louis) District 4 Director: Jennifer Scheer, MD, FAAFP (Gerald) Alternate: Kristin Weidle, MD (Washington) District 5 Director: Lucas Buffaloe, MD (Columbia) Alternate: Afsheen Patel, MD (Jefferson City) District 6 Director: Jamie Ulbrich, MD, FAAFP (Marshall) Alternate: David Pulliam, DO, FAAFP (Higginsville) District 7 Director: Sudeep Ross, MD, MBA (Kansas City) Director: Wael Mourad, MD (Kansas City) Alternate: Ryan Sears, DO (Lee's Summit) District 8 Director: Mark Woods, MD (Ozark) Alternate: Charlie Rasmussen, DO, FAAFP (Branson) District 9 Director: Patricia Benoist, MD, FAAFP (Houston) Alternate: Vacant District 10 Director: Vacant Alternate: Vacant Director At Large Emily Doucette, MD (St. Louis)
MARK YOUR CALENDAR AAFP Family Medicine Congressional Conference April 18-19, 2016 Washington Court Hotel Washington, DC AAFP Annual Chapter Leadership Forum/National Conference of Constituencies Leaders May 5-7, 2016 Sheraton Kansas City Hotel at Crown Center Kansas City, MO MAFP 68th Annual Scientific Assembly (ASA) June 3-4, 2016 The Lodge at Old Kinderhook Camdenton, MO
annual business meeting & legislative luncheon
AAFP National Conference of Family Medicine Residents & Students (NCFMRS) July 28-30, 2016 Kansas City Convention Center Kansas City, MO AAFP Congress of Delegates September 19-21, 2016 Hyatt Regency Orlando, FL AAFP Family Medicine Experience (FMX) September 20-24, 2016 Hyatt Regency Orlando, FL MAFP 24th Annual Fall Conference & SAM Working Group November 4-6, 2016 Big Cedar Lodge Ridgedale, MO
The Missouri Academy of Family Physicians' Annual Business Meeting & Legislative Luncheon will be held at the 68th Annual Scientific Assembly on Saturday, June 4, 2016 at The Lodge at Old Kinderhook in Camdenton, MO from 11:45 am to 1:30 pm.
resident directors Kevin Gray, MD (UMKC) Kanika Turner, MD (Alternate) (SLU) student directors Jenny Eichhorn (UMKC) Emily Gray (Alternate) (UMKC) aafp delegates David Schneider, MD, FAAFP, Delegate Todd Shaffer, MD, MBA, FAAFP, Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Keith Ratcliff, MD, FAAFP, Alternate Delegate mafp staff Executive Director - Kathy Pabst, MBA Communications and Education Manager - Sarah Mengwasser Membership and Programs Assistant - Lauren Eichelberger Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101 p. 573.635.0830 f. 573.635.0148 www.mo-afp.org office@mo-afp.org The information contained in Missouri Family Physician is for information 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 opinion expressed in each article(s) is the opinion of its author(s) and does not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no responsibility for the opinion expressed thereon.
INSIDE THIS ISSUE Pg. 4 President's Report 6 Resident Grand Rounds 8 Help Desk Answers 10 Advocacy Day Recap 12 68th Annual Scientific Assembly Schedule and Registration Form 15 Tar Wars Program速 16 Members In The News 18 Member Input: AAFP Key Contact 20 PDMP Efforts 22 MAFP Key Issues 25 Multi-State Forum/Match Day 27 RLS During Pregnancy 30 Family Physician of the Year Nominees/Family Medicine Cares USA 31 MAFP Strategic Plan 32 Self-Study CME Revenue Sharing
Advertisements Pg. 2 MHPPS 4 Health is Primary 5 NORCAL Mutual 9 Cox Health 14 Children's Mercy - KC 21 DPC Clinics 24 MPM-PPIA 26 SEMO Drug Pharmacy 29 U.S. Army
MO-AFP.ORG 3
PRESIDENT'S REPORT
What is and what should never be
M Peter Koopman MD, FAAFP
4
y father was diagnosed with pancreatic cancer in the summer before I started college. It was 1984. The diagnosis had been difficult and had been a year of weight loss and nausea before an exploratory laparotomy confirmed the diagnosis. He was offered a large surgery called a Whipple procedure which was presented to him as a cure. He went forward to do this procedure and spent six months in the hospital. I vividly remember being called out of a class during my second week of college with my mom on the phone telling me my dad had to go back to surgery and the doctor said there was a high chance he would not survive. She was preparing me and told me to come home. I did. My dad survived that procedure and after about five months, came home. He was weak and skinny but supposedly free from cancer. He was happier than I had ever seen him and made plans to start a new business venture with my mom. For six months he travelled and made plans -- and then the nausea came back. Imaging failed to see a reoccurrence, but a repeat exploratory surgery made it clear cancer was all over and he was terminal. My mother cried all the time. My dad continued to lose weight and home TPN was started by his surgeon. Actually almost all medical decision making involved his “cancer” surgeon. Chemo was initiated and my dad spent weeks vomiting. It was an incredibly difficult time for us as a family. I was in college coming home many week-ends to spend time with dad and watch him suffer. We felt like we were drowning, especially my mom. I relate this personal story to highlight what terminal illness can be like for a family and a caregiver and a patient. I know many others have similar stories and I have heard many as a family physician. Unfortunately, I do not believe this story despite it being 30 years old is remarkably different at times now a days. It is different though. palliative care exists. My dad should have been cared for by a family doctor and a team not just an oncologic surgeon. My dad should have had palliation and comfort discussed and offered. These things are often done today, and from
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my personal experience, remove remarkable amounts of suffering from the course of a person’s life. Should my dad have had the Whipple? I am not sure. He did have six months of good quality of life after; but that may have been achieved in other ways. I certainly feel it should not have been sold to him so much as “curative,” although it is likely the only thing that could have cured. His five months in the hospital was a humongous cost though, and bankrupted my family. Certainly, my mom never recovered
"
Death is not always a failure but the end of a journey. Respect that journey and help pave the way for your patients to walk that journey as independently and in as much comfort as possible."
from this illness to her best quality of life, and the effects of his death linger in myself and many other siblings. I challenge us as family physicians to use our palliative care skills and/or colleagues. Death is not always a failure but the end of a journey. Respect that journey and help pave the way for your patients to walk that journey as independently and in as much comfort as possible. Remember that intervening can often do more damage and cause more suffering than supporting and caring for needs. See the forest and not the trees, and help your patient’s last days be as comfortable as possible. When I see my patients with terminal illness, I often see my father, his last days were all in pain and suffering. He asks me to do better for those I care for and I will continue to try.
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RESIDENT GRAND ROUNDS
Assessing medical students' knowledge of fertility awareness-based methods of natural family planning INTRODUCTION What are fertility awareness-based methods (FABMs)? • Natural methods of family planning (NFP) in which a woman monitors biologic markers to identify fertile days which allow a couple to time intercourse to avoid or to achieve pregnancy. • Applications in regard to a woman’s reproductive health. Laura Covert, DO Mercy Family Medicine Residency St. Louis, Missouri
Are these methods effective? • Yes. With the proper instruction, modern methods can be very effective to avoid and to achieve pregnancy. Why should physicians know about these methods? • Three fourths of women seek family planning information from primary care physicians. • Approximately 20% of women would be interested in a FABM to avoid pregnancy. • Approximately 35% of women would be interested in a FABM to achieve pregnancy.
ATTENTION RESIDENTS: NEED TO BE PUBLISHED? Submit your report to be published as a Resident Grand Rounds article in our quarterly Missouri Family Physician magazine. Contact MAFP staff at: office@mo-afp.org
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A 2013 pilot survey of 19 fourth-year medical students assessing their general medical knowledge and confidence in utilizing FABMs in patient care revealed they received an average of less than one hour of teaching about FABMs over all four years of medical school. Nearly half of surveyed students stated they would not feel comfortable providing FABM information to patients and none felt they could confidently use a patient’s NFP chart to assist in diagnosis a gynecologic or reproductive problem. As such, the objective of this curricular project was to assess third year medical students’ knowledge of fertility awareness-based methods in order to improve future education in this area. Two literature searches were completed in October 2013 and February 2015 to determine if there were studies or articles published regarding medical education and NFP/FABMs. Search terms included education, medical, medical students, fertility, menses, NFP, FABM,
MISSOURI FAMILY PHYSICIAN
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contraception (natural), contraception methods (natural, mucus). No relevant articles were found. METHODS Third year medical students were given a ten question assessment at the beginning and end of their six week OB/GYN learning block. • Two lectures reviewed FABM/NFP concepts. • Assessments included eight medical knowledge questions and two student confidence questions After one academic year, data was analyzed from pre and post block assessments. RESULTS All students were assessed with respect to pretest and posttest responses. In most blocks, test results showed a significant improvement in posttest scores. Block 3 was unable to be evaluated due to missing posttest data. Block 7 was not statistically significant and this was thought to be due to low numbers of responses.
Block
Significance
All Blocks 0.000 1 0.008 2 0.010 3 4 0.004 5 0.004 6 0.022 7 0.05* 8 0.001
RESIDENT GRAND ROUNDS A Scree Plot was used to identify clusters or groups of related items (factors). This revealed a gap between material taught and assessed as 37% of the curriculum was not addressed by test questions.
Figure 1: Average Test Scores
DISCUSSION Students showed a significant improvement in their post test scores and confidence levels. • Medical knowledge averages: pretest 38.67% / posttest 53.54%. • Confidence averages: pretest 1.75 / posttest 3.06. Thus, the curriculum at this medical school seems to have been lacking in FABM/NFP education. With additional lectures, the students’ scores improved, but more education may be needed. Limitations of this study included missing data from Block 3 post-tests. Future studies may include improved assessments to better target highlight key broad topics covered in the lectures (domains).
Student confidence levels were evaluated regarding FABM and patient care.
Figure 2: How comfortable would you be providing information regarding methods and efficacy to a patient interested in FABM?
MO-AFP.ORG 7
HDAs HelpDesk Answers
Is isolated anemia a good predictor of gastrointestinal (GI) malignancy? EVIDENCE-BASED ANSWER
Isolated anemia in an adult increases the likelihood of an upper or lower GI malignancy, but it is not a strong predictor. Anemia has a sensitivity of 17%–37% and a specificity of 90%–92% for colorectal cancer, and a sensitivity of 13% and specificity of 95% for upper GI malignancy (SOR: B, meta-analyses of cohort studies).
A Anne Fitzsimmons, MD Carin Reust, MD, MSPH University of Missouri Columbia, Missouri
2011 meta-analysis investigated the diagnostic utility of signs and symptoms for the diagnosis of colorectal cancer in adult primary care patients.1 The analysis of isolated anemia included three prospective cohorts and one retrospective cohort (N=953). After excluding a prospective cohort study (n=280) to minimize heterogeneity among the studies, the prevalence of colorectal cancer ranged from 2.0% to 8.6%, and the pooled positive predictive value (PPV) of anemia was 7% (95% CI, 4.2–11). No other pooled diagnostic statistics were calculated. A 2008 case-control study matched 6,442 patients with colon cancer with 45,066 controls based on age, sex, and practice location.2 Patients were identified from a database of primary care patients in the United Kingdom. The included patients’ ages ranged from 30 to older than 80 years and they were 53% male. Anemia had a sensitivity of 37% and specificity of 92% (positive likelihood ratio [LR+] of 4.6; negative likelihood ratio [LR–] 0.68) for the diagnosis of
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colorectal cancer. Generally, an LR+ of more than five or an LR– of less than 0.2 is considered diagnostically useful.2 A 2008 meta-analysis of five prospective and two retrospective cohort studies (N=4,404) examined the diagnostic utility of presenting symptoms for the identification of colorectal cancer.3 Patients were at least 16 years old and had been referred for lower GI evaluation in a secondary care setting. Pooled prevalence of colorectal cancer was 8% (range 6%–11%). Use of anemia to predict colorectal cancer demonstrated a pooled sensitivity of 17% and specificity of 90% (LR+ 1.4; LR–0.96), with a PPV of 13%. A 2006 meta-analysis of four prospective cohort studies (N=42,327) evaluated the presence of alarm symptoms, including anemia, as a predictor for the presence of an upper GI malignancy in patients undergoing workup for dyspepsia.4 Esophagogastroduodenoscopy served as the diagnostic gold standard. The pooled prevalence of upper GI malignancy was 0.4%. One study (n=1,441) with a sensitivity of 0% was excluded after the calculation of prevalence to allow for further pooling of data. Anemia as a predictor of upper GI malignancy had a sensitivity of 13% and specificity of 95% (LR+ 2.6; LR–0.92), with a PPV of 1%.4 For all studies, neither the type nor degree of anemia was specified. Different gold standards were used to diagnose colorectal cancer (double-contrast barium enema, colonoscopy, CT colonography, or clinical follow-up) and patient demographics, other than age, were usually not described. Heterogeneity between studies resulted from a highly variable prevalence of malignancy.
1. Astin M, et al. Br J Gen Pract. 2011; 61(586):e231– e243. [STEP 2] 2. Hamilton W, et al. Br J Cancer. 2008; 98(2):323–327. [STEP 4] 3. Ford AC, et al. Gut. 2008; 57(11):1545–1553. [STEP 1] 4. Vakil N, et al. Gastroenterology. 2006; 131(2):390– 401. [STEP 1]
PRESIDENT'S REPORT
Missouri Family Physician October-December MO-AFP.ORG 2015 99
ADVOCACY DAY RECAP
A look into our future: Advocacy Day generates impressive turnout of residents and students
A
dvocacy Day was again, a success this year, with 35 members present to speak to their Senators and Representatives on important issues. Advocacy Day kicked off as usual, with a legislative briefing on MAFP priority issues Monday evening by MAFP Legislative Consultant, Pat Strader.
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Some key legislation this year focused on health care coverage and access, telehealth, opposition on APRN independent practice, licensure of physicians, health care workforce analysis, and curbing opioid abuse in Missouri.
I really appreciated the opportunity to learn more about the process and thought it was fantastic that you were able to offer an educational briefing over the issues the night before - great choice to add that last year. Hope to join you all again in the future!" Rebecca Ringling, student, University of Missouri - Columbia
Back row L-R: Program Director, Todd Shaffer, MD, MBA, FAAFP; PGY II Residents: Nick Miller, DO; Cierra Johnson, MD, MS; Coleen Quinn, MD. Front row L-R: Medical Education Manager, Octavia Jones, MA.Ed/AET; PGY II Residents: Aniesa Slack MD; Rachel Seymour, MD, MSc; Whitney Trusty, MD.
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ADVOCACY DAY RECAP
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2
Advocacy day was a fantastic opportunity for me to experience family medicine in a new and rewarding fashion. This was my first time advocating in Jefferson City and it was an enriching experience. I learned about the legislative process as well about the many bills that will impact my future practice and my future patients' lives." John Heafner, student, St. Louis University
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1. 2016 Advocacy Day attendees. 2. L-R: Kanika Turner, MD, David Schneider, MD, FAAFP, Emily Doucette, MD and John Heafner, student. 3. Rebecca Ringling, student, and Tony Bell, MD, stop for a photo by Harry S. Truman in the Missouri State Capitol during Advocacy Day. 4. Members discussing key legislation. MO-AFP.ORG 11
OU RI
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E
THE MIS S
EMY PRESENT AD ST C A H
annual
th SCIENTIFIC ASSEMBLY
68TH ANNUAL SCIENTIFIC ASSEMBLY
Friday, June 3, 2016 7:00 - 8:00 am 7:00 - 11:00 am 8:00 - 9:00 am
MAKE YOUR HOTEL RESERVATIONS EARLY
Registration and Breakfast Buffet with Exhibitors Exhibit Hall Open (Grand Ballroom A) *All Lectures will be held in Grand Ballroom B The Many Facets of Chronic Pain Management in Primary Care Sponsored by the New Jersey Academy of Family Physicians Kurt Bravata, MD
9:00 - 10:00 am
Bruises: Was This Child Abused? Adrienne Atzemis, MD, FAAP (Fellow of the American Academy of Pediatrics)
10:00 - 10:45 am
Refreshment Break with Exhibitors (Grand Ballroom A)
10:45 - 11:45 am
Eat What You Love, Love What You Eat Keynote Speaker: Michelle May, MD
12:00 - 1:00 pm
Interactive Luncheon with Michelle May, MD Sponsored by the Missouri Beef Industry Council
1:00 - 1:15 pm
Break
1:15 - 2:15 pm
Being Prepared for In-Office Emergencies Sarah Cole, MD, FAAFP
2:15 - 3:15 pm
Managing T2D in Special Populations: Patient-Centered Treatment to Improve Outcomes Sponsored by the New Jersey Academy of Family Physicians Beth Rosemergey, DO, FAAFP
3:15 - 4:15 pm
5 TIWIKLY (5 Things I Wish I Knew Last Year) Louis Kuritzky, MD
5:30 - 7:30 pm
Family Fun Fiesta Join us for an evening of fun-filled activities including Sparkie dá Clown & Merry Mary (Hearth Room and Patio)
Contact The Lodge at Old Kinderhook Toll Free: 1-888-346-4949 for room reservations. The MAFP block of rooms and group rate of $152 per night (plus tax) is valid through May 2, 2016.
Saturday, June 4, 2016 7:00 - 8:00 am Registration and Breakfast Buffet with Exhibitors 7:00 - 11:00 am Exhibit Hall Open (Grand Ballroom A) *All Lectures will be held in Grand Ballroom B 8:00 - 9:00 am
Pediatric Earmarks Paul Berman, MD
9:00 - 10:00 am
ABFM's MC-FP (MOC): The Latest Updates and Tips for Successful Completion Joseph Wade Tollison, MD
10:00 - 10:45 am Refreshment Break with Exhibitors (Grand Ballroom A) 10:45 - 11:45 am "D" is for "Dubious": The Contentious Role of Vitamin D Supplementation Louis Kuritzky, MD
Annual Business Meeting and Legislative Luncheon (Hearth Room)
1:30 - 1:45 pm
Break
1:45 - 2:45 pm
Infertility in Family Medicine Wael Mourad, MD
2:45 - 3:45 pm
Pediatric Dental Talk Sudeep Ross, MD
3:45 - 4:45 pm
The New Frontier: Oral Health and Primary Care Jamey Onnen, DDS
5:15 - 6:15 pm
Reception (Hearth Room)
11:45 am - 1:30 pm
6:15 - 8:15 pm
Awards and Installation Dinner (Hearth Room) • 2016 MAFP Family Physician of the Year Award • Soaring Eagle Award • Installation of MAFP President & Board Members • AAFP Degree of Fellow Convocation • Tar Wars Poster Contest Award
Sunday, June 5, 2016
FEATURING KEYNOTE SPEAKER
9:15 - 11:00 am 11:00 am - 1:30 pm
MICHELLE MAY, MD
Commission Meetings with Continental Breakfast (Advocacy and Member Services - Hearth Room; Education - Cypress Room) Board Meeting with Working Lunch (Hearth Room)
CUT AND MAIL TO MAFP
68th Annual Scientific Assembly June 3-4, 2016 The Lodge at Old Kinderhook Camdenton, Missouri
REGISTRATION FORM Register before the early bird deadline and be entered to win a FREE two-nights' stay at the Lodge at Old Kinderhook.
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□ One complimentary guest will accompany me to the dinner. FOUR WAYS TO REGISTER: Online with credit card at www.mo-afp.org • Fax this form to (573) 635-0148 • Call us at (573) 635-0830 • Mail this form with payment to: MAFP, 722 West High Street, Jefferson City, MO 65101-1526 REGISTRATION CANCELLATIONS must be in writing and received by MAFP no later than May 2, 2016. MAFP policy requires a $50 administrative fee be deducted from each refund processed. Questions? Call (573) 635-0830 or email: office@mo-afp.org.
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CME sessions, meals, breaks, and electronic syllabus are included in the registration fee. All functions in the Exhibit Hall are for registrants only. By registering for this conference, I authorize MAFP to use photographs of me with or without my name for any lawful purpose, including print or online marketing.
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PHOTO COURTESY OF JULIE SMITH/NEWS TRIBUNE
Tar Wars Program expands in Missouri
S
tudents from Lawson Elementary School in Jefferson City move vigorously before having to sit down and breathe through straws; a lesson to mimic breathing after years of smoking. The Missouri Academy and the Family Health Foundation of Missouri are focusing on expanding Tar Wars and have partnered with the Council for Drug Free Youth, which works to serve communities throughout mid-Missouri to empower youth to live healthy drug free lives
through educational programs and community engagement. The American Academy of Family Physicians Foundation offered 10 mini-grants of $4,000 for state chapters wanting to promote the Tar Wars program, with Missouri being one of the winners. After the presentations, students in the 4th and 5th grades are encouraged to participate in a poster contest. Three finalists are chosen, and the winner is recognized at the Missouri Academy's Annual Scientific Assembly in June.
The kids really enjoyed it, and they learned a lot!" Tricia Benoist, MD, FAAFP Tar Wars presenter Dr. Benoist presented Tar Wars to 175 4th and 5th grade students at Houston Elementary School in Houston, Missouri. MO-AFP.ORG 15
MEMBERS the
IN NEWS The Missouri Family Physician magazine welcomes your input. Please submit newsworthy items for review to: office@mo-afp.org
MU School of Medicine alumni recognized for service
Heafner Appointed as AAFP FMIG Regional Coordinator
PHOTO COURTESY OF JUSTIN KELLEY, UNIVERSITY OF MISSOURI
NEWS TO SHARE?
Donald Kuenzi, MD and Debra Howenstine, MD.
The University of Missouri School of Medicine presented its most prestigious awards to graduates and supporters Thursday, March 17, in St. Louis. Nine award recipients were honored during a reception and dinner at the Norwood Hills Country Club in conjunction with the Missouri State Medical Association’s annual conference. Two family medicine physicians were among those honored. Family medicine physicians and MU School of Medicine alumni Debra Howenstine and Donald Kuenzi received Distinguished Service Awards in recognition of their community service.
DONALD KUENZI, a graduate of the 1951 MU School of Medicine Class, is a retired family physician in Kansas City who volunteers for Health Teams International, a Christian-based medical and dental mission organization that provides medical and dental services in underserved countries worldwide.
DEBRA HOWENSTINE, a graduate of the 1988 MU School of Medicine class, is an associate professor of clinical family and community medicine at the MU School of Medicine and medical director of the Columbia/Boone County Department of Public Health and Human Services.
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Hahn to complete NIPDD Fellowship Shelby Hahn, MD, associate program director at Cox Family Medicine Residency in Springfield, MO, will complete the National Institute of Program Director Development (NIPDD) Fellowship through the AAFP this spring. The year-long fellowship is a professional development program for program directors in family medicine. NIPDD, a nationally recognized fellowship, is open to a limited number of participants each year. Those accepted for a NIPDD fellowship will engage with and learn from seasoned Shelby Hahn, MD associate program director program directors, family medicine educators, and other family medicine Cox Family Medicine leaders. The NIPDD fellowship uses a one-of-a-kind, adult learning model Residency to enhance knowledge, attitudes, and skills and to groom participants to become effective residency program directors. Dr. Hahn has also been selected to attend Stanford University this spring to complete the Stanford Faculty Development Center’s Clinic Teaching Program. Cox FMR faculty and residents are excited to learn from him when he returns.
St. Louis Academy of Family Physicians installation dinner The St. Louis Academy of Family Physicians hosted their installation dinner on Jan. 9, 2016 at Maggiano's Little Italy. Walt Sumner, MD will return as Washington University's representative in Sharon George's absence. New SLU reps are Jasmine Lau and Bradley Waller. Congratulations to all. Top photo: Dr. Joule Stevenson takes the oath of office as President of St. Louis Academy, administered by MAFP President, Peter Koopman, MD, FAAFP. Bottom photo, seated L-R: Katy Liu, MD; Andrea Baxter, MD; Joule Stevenson, MD; TinaRose Troost, MD. Standing L-R: William Manard, MD; Kara Mayes, MD; Tonya Little, MD; Christine Jacobs, MD; Chris Blanner, MD; Rosa Galvez-Myles, MD; Kevin King, MD; Lauren Wilfling, DO. Also installed as board members but not pictured: Radha Patnana,MD; and Emily Doucette, MD.
Kansas City Academy hosts FMIG event The Kansas City Academy of Family Physicians hosted a social gathering and dinner for FMIG students and family physicians in February at the University of Missouri – Kansas City. Dr. Wael Mourad, MAFP District 7 board member and Kathy Pabst, executive director, represented the Missouri Academy at this event.
FAMILY MEDICNE CARES USA ndation's AAFP Fou rium Humanita Program Signature
A 'MAKING CE N E DIFFER IN MO!' 0 See page
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Ratcliff – AAFP Key Contact
Keith Ratcliff, MD, FAAFP was once again chosen to become to Key Contact via AAFP's Key Contact Program. This program helps the AAFP build and maintain positive contact with representatives and senators through family physicians’ relationships with their legislators. Key contacts work in conjunction with the AAFP’s Government Relations staff to ensure family medicine issues are heard in Washington, DC. Dr. Ratcliff will attend the Family Medicine Congressional Conference in Washington, DC this spring.
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MEMBER INPUT
Consider becoming a legislative Key Contact for the AAFP
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Keith Ratcliff MD, FAAFP
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s I speak with many of our fellow family physicians, they are often astounded at some of the changes in medicine that are being imposed upon our patients and ourselves by the legislative process. Frequently I hear, “who thought of that and why on earth would that change be made in our health care system...Didn’t they know that…?” It is difficult to realize that our legislators are often not nearly as knowledgeable in matters of health care policy as we presume them to be, and unintended consequences frequently accompany legislative decisions that are made. So often I hear from our legislators that they receive no communication from their physician constituents to help guide their vote on a particular issue, but they hear many comments from other interested parties during the legislative process. As physicians, we often choose not to help influence change; yet are surprised when change happens that we did not anticipate and do not approve of. If we, as a specialty, do not effectively reach out and try to impact these decisions before they become law, we can expect results that continue to be harmful to our patients and to our profession. Thankfully AAFP has made it very easy for you to provide information to our legislators on a particular issue by becoming a Key Contact. The Key Contact program has been in place for several years and is now a very mature and
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influential tool. At the core of this program is a physician like you who cares deeply about advocating for our patients and our specialty. The Key Contact is a predetermined family medicine liaison committed to establishing and nurturing relationships with our elected officials, so that when a specific legislative issue which impacts our work is being considered, there is a knowledgeable resource available to efficiently and effectively communicate our views to the Senate and House members. Key Contacts work in conjunction with the AAFP Government Relations staff to insure Family Medicine views are heard in Washington, DC. Expanding and utilizing the Key Contact program will be essential to help return our country to a primary care focus, which has proven throughout the world to be the key to healthier populations. Any member of the AAFP can easily engage as a Key Contact, and this process is designed to be very time efficient for you. The resources are very well designed and easy to navigate through the AAFP website. Simply log in to www.AAFP.org (it is already on your favorites bar isn’t it?) and on the home page along the top index bar, choose “Advocacy,” which is the sixth selection from the left margin. You will feel like Alice jumping down the rabbit hole when you see the Advocacy section for the first time. It is full of links with very short explanations of the issues your academy
MEMBER INPUT has been working on. Within minutes you will be able to distill knowledge that would take hours to assimilate on your own. As Jim Stafford taunts us in his song “Wildwood Weed,” you can “take a trip and never leave the farm." On the Advocacy page click on the link near the top on the right that reads “Grass Roots Advocacy Tool Kit,” and feel the power as you take control of your destiny. The cool thing: this is where it gets really easy. If you dare, click the link “Lend Your Voice," and initially ignore everything on the page except the itty-bitty-empty box on the right under “Find Your Elected Officials." For those who are not cowards, if you put your zip code in the itty-bitty-magic box and hit “go” you will be rewarded more splendidly than Willy Wonka, as photos pop up for everyone from the President down through your specific federal Senator and Representative, and all the way down to your local State Representative and State Senator. Golly gee, even the Governor is there, as well as the State Attorney General. If you happen to be in some sort of trouble that could come in real handy. Good picture of Joe Biden too. But wait, it gets even better! Click on any of the smiling heads and a full bio appears; including clickable links to their website and contact information. This is too cool for school. Within about 40 seconds after entering the AAFP website YOU can be hammering out an email to any of these distinguished individuals who are making decisions impacting your patients and yourself every day. If there is an issue you are passionate about, peck an email to the best looking head on your screen using your most eloquent and convincing style, then copy your thoughts and open the next person you want to influence and paste the message there also. Don’t worry, this is not an EMR and it is okay to copy and paste -- the recipients never talk to each other anyway! But, they do listen carefully to what their constituents have to say. For fun, send something to the VP too because he probably doesn’t get much sent to his in basket. To offer your services as a Key Contact, start on the “Advocacy Tool Kit” page, then open the “Become a Key Contact” section for an explanation of the process. The commitment is really only a few hours a year, but will make a world of difference for your patients and for your academy. The AAFP will contact you when there are issues that will be heard in a committee your officials participate in, or a vote on the floor, so you can send a timely communication and hopefully help educate and clarify when
appropriate. Legislative research has told us that as few as ten contacts from constituents, especially physicians, can change a legislator’s vote. Remember these folks usually do not hear from their voters at all on a specific issue, so every contact makes a difference. It is a good idea to contact the staff of your legislators several times a year, and perhaps meet with them when they are back in district so that you can build a
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The committment is really only a few hours a year, but will make a world of difference for your patients and for your academy."
relationship over time. Consider signing up for the email newsletter on the website of your Senators and your Representative; this way your name will already be familiar to them when you reach out on an issue. Just as you have realized in your medical practice, the best and most effective relationships are built in small increments over time, and every encounter adds to your influence. If you have offered your services as a Key Contact, the AAFP will automatically send you notifications when your officials will be hosting local events such as a Town Hall, and you could even be selected to hand deliver a FamMedPAC check to your Senator or Representative. Being a Key Contact for your elected officials is an easy and very effective means by which even the busiest family physician can contribute to the advancement of our specialty. Keith Ratcliff, MD, FAAFP Renaissance Family Health Care 200 Madison Avenue Suite 200 Washington, Missouri 63090 drr@renaissancefamilyhealthcare.com 636.432.1985 Key Contact AAFP Senator Claire McCaskill and Senator Roy Blunt Representative Blaine Luetkemeyer
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PDMP EFFORTS
Leapfrogging state, St. Louis County becomes first jurisdiction to enact prescription program
PHOTO BY ROBERTO RODRIGUEZ
Reprinted with permission by Jack Suntrup and Steve Giegerich, St. Louis Post Dispatch
St. Louis County Executive Steve Stenger discussed some of his office priorities and also addressed threats he has received since being elected during a press conference before being sworn in, Thursday, Jan. 1, 2015.
CLAYTON, March 1, 2016 • St. Louis County on Tuesday became the first jurisdiction in Missouri to enact a program aimed at monitoring the sale of prescription drugs, specifically the opioids experts call the entry point to heroin abuse. The unanimous County Council vote came hours after the Missouri House gave initial approval to a bill that would establish a statewide database to track the dispensing of some prescription painkillers. The state legislation, which still faces a final House vote, is expected to die in the Senate. Missouri is the only state in the nation without a program to monitor distribution of prescription medicine. 20
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The lack of a statewide monitoring is “terrible for Missouri,” said County Councilman Sam Page, an anesthesiologist and the sponsor of the local legislation. “We’re the drugstore for America, where drug dealers come to get prescriptions filled because we have nothing in place to monitor them,” he said. The sponsor of the House bill, Rep. Holly Rehder, R-Sikeston, said the absence of a database has turned Missouri into a haven for “doctor-shopping” — patients seeking out multiple doctors for the same prescriptions. Leapfrogging the state, St. Louis County plans to have the pharmacies within its boundaries enrolled in its database within 180 days. The
PDMP EFFORTS
county estimates an initial start-up cost of about $100,000. County Executive Steve Stenger will sign the legislation into law at a ceremony Wednesday morning. Page and Stenger said the county may soon expand the program in partnerships with jurisdictions regionally and across the state. The identity of one the partners is expected to be announced Wednesday. “I believe, but I can’t mention specific jurisdictions at this point, but we have received word from some of the larger jurisdictions surrounding us that they are considering passage of their own bill and will either utilize our database or have their own database,” Stenger said. “But there will certainly be linkage with some of our regional partners.” U.S. Sen. Claire McCaskill, D-Mo., announced last week that she is sponsoring an amendment to a Senate drug deterrence bill that could support the county effort with federal grant funds. Denouncing Jefferson City’s inaction on the issue, McCaskill, in a statement, said: “I applaud St. Louis County leaders for working to fill the void, and I’m eager to get them the resources they need to do so.” According to the Centers for Disease Control and Prevention, the use of opioid painkillers such as Vicodin and OxyContin has quadrupled during a 17-year study period that shows a leveling-off of medical conditions causing chronic pain. A 2015 report from the Missouri Hospital Association said that hospital stays due to painkiller misuse have increased 139 percent over the last decade. A National Institute on Drug Abuse analysis found a 2.8-fold increase in deaths attributed to prescription pill abuse from 2001-2014. Heroin overdoses, meanwhile, jumped sixfold over the same time period. Mitch Stenger, 23, became part of the statistical framework when he died of a heroin overdose a month after his uncle was elected St. Louis County executive in 2014. A bottle of OxyContin, Page said, has a street value of between $5,000-$7,000. Opioids secured from family medicine cabinets additionally get in the hands of teens who share them at “pill parties.” Rep. Cloria Brown, R-South St. Louis County, predicted Rehder’s bill would reduce access to drugs for young people. Brown said when her mother fell ill she took on the task of tracking her mother’s prescriptions.
“I was my mother’s database,” Brown said. “I kept track of all her meds. Fortunately I did, because whenever she was in the hospital — and she was there often — when she would leave, they would say these are your meds and I would say, ‘No, she already takes that.’ “Had I not been there, then she might’ve taken multiple drugs, because she was in a lot of pain,” said Brown, an advocate of the legislation. Opponents of the House legislation view a statewide monitoring system as an infringement on personal liberty. Still, Rep. Jay Barnes, R-Jefferson City, said Missourians not suspected of any crime shouldn’t have their medical histories tracked. “I think there are two questions,” said Barnes. “One is: Will it work? And two is: Even if it might work, is this the sort of thing that is consistent with our values as a free society?” Unlike the county ordinance, the state bill would exempt children 16 and younger from the database. A state law, if enacted, would supersede the county legislation. Stenger said he would welcome a statewide program. But he sees little inclination on the part of lawmakers to implement a system that studies show has reduced overdose deaths in Florida (50 percent) and New York (55 percent). “I’m not optimistic,” Stenger said. “But this is a huge step for our county, a huge step for our region and the opportunity for a huge step by our state.”
Consulting packages are available, providing our proven business model to help build a strong DPC clinic providing exceptional and affordable care to all. Contact Dr. Jenny Powell at (573)933-0872 or (417)664-5054.
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PDMP EFFORTS
Prescription drug abuse – A major public health crisis Studies show that
of people who abused prescription opioids eventually transition to heroin -- as pills become too difficult or expensive to obtain.
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n Jan. 19, U.S. Senator Claire McCaskill held a field hearing of the Senate Special Committee on Aging in Jefferson City that highlighted the national epidemic of increased opioid addiction, abuse, and overdose deaths. Kathy Pabst, MAFP executive director, and Pat Strader, MAFP governmental consultant, represented the academy at this important meeting. Paul Tatum, MD, MAFP member served as a panelist and addressed palliative care. Last year, drug overdoses killed more than 40,000 Americans—nearly two thirds of those overdose deaths were related to opioids other than heroin. A press release from Senator McCaskill's office stated: “America is facing a serious and growing epidemic,” McCaskill said. “Prescription drug abuse and heroin use is a major public health crisis that affects every community across this nation, and has unfortunately claimed the lives of many Americans. Although there are a number of prescription drugs being misused and abused, we are concentrating on the growing, and too often, deadly problem of prescription opioid abuse. Studies show that four out of five people who abused prescription opioids eventually transition to heroin -- as pills become too difficult or expensive to obtain. Today’s prescription opioid abuser could easily become tomorrow’s heroin user. And the financial costs associated with the misuse and abuse of prescription drugs are staggering.” State Senator, Holly Rehder of Sikeston, who is leading efforts in the Missouri legislature to pass
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a prescription drug monitoring program, told the personal story of her daughter’s drug addiction, which began with prescription opioids, saying:
“I tell you this story to show that drug addiction is no respecter of persons. It crosses all socioeconomic statuses. When you go into a high school and ask the kids, ‘what do you want to be when you grow up?’ The answers are ‘a doctor,’ ‘a lawyer,’ ‘a business owner.’ None say, ‘I want to be an addict.’ Yet addiction is the growing epidemic of our time."
Opioids are the most commonly prescribed pain medications, which include hydrocodone (e.g. Vicodin), oxycodone (e.g. OxyContin), and Oxymorphone (e.g. Opana). Deaths from drug overdoses are steadily increasing, especially among older adults. Among Midwestern states, Missouri ranked number one in the rate of prescription opioids sold in the region. Addressing Missouri’s lack of a program to monitor prescription drugs, McCaskill continued: “When 49 states have [implemented a prescription drug monitoring database] and Missouri is the only one that hasn’t, my Missouri common sense tells me maybe we’re the problem, not the other way around.”
KEY MAFP ISSUES
s e u s Is P F A M y e K f A Breakdown o Strategies to Curb Opioid Abuse
• Missouri remains the only state without a Prescription Drug Monitoring Program (PDMP). State-run programs play a critical role in helping to prevent drug misuse and abuse by providing prescribers timely data to best guide the treatment of patients with highly addictive pain medicines known as opioids. • In 2014, there were more drug overdose deaths in the US than deaths from motor vehicle crashes. A PDMP has been shown to reduce abuse, save lives, and protect our communities. • MAFP supports the development of a robust PDMP. (SUPPORT HB 1892-Rehder) • MAFP supports provision of naloxone to any individual to administer, in good faith, to another individual suffering from an opiateinduced drug overdose. (SUPPORT HB 1568-Lynch and SB 813-Brown)
Health Care Workforce Analysis
• Currently, Missouri does not have an accurate assessment of the practice characteristics or the location of its health care professionals. • Appropriate planning for health care services in our state is dependent upon the availability of accurate, timely and reliable data. • This legislation would allow various boards to collaborate with state departments to collect data through the professional licensing process and analyze this data to assess the availability of qualified health care professions. (SUPPORT HB 1850-Franklin)
Collaborative Practice with APRNs, PAs and APs
• 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. • The current collaborative agreement process has served Missouri patients well and MAFP believes it should be maintained in its present form. • Allowing APRNs independent practice
and allowing APRNs, PAs and APs prescriptive authority to prescribe all Schedule II controlled substances will worsen the epidemic of opioid availability in a state without prescription drug monitoring. (OPPOSE HB 1866-Hubrecht, OPPOSE HB 1775-Redmon, OPPOSE HB 1697-Rowland and OPPOSE SB 826-Wallingford) • The one-month requirement of the APRN practicing with their collaborating physician, which assures cooperative collaboration and patient safety, is at risk of being eliminated. (OPPOSE HB 1465-Burlison) • Physician chart review of their collaborators’ clinical documentation ensures patients are receiving the appropriate care; eliminating this requirement is dangerous. (OPPOSE HB 1465-Burlison) • By removing the geographic proximity requirement and increasing the number of collaborative agreements a physician may enter into with an APRN from 3 to 5, the teambased approach to medicine is drastically weakened. (OPPOSE HB 1697-Rowland)
Licensure of Physicians
• Physicians receive over 20,000 hours of education and training, in addition to ongoing continuing medical education, which provides for a highly qualified physician workforce. • The Missouri Board of Healing Arts should not require maintenance of specialty certification as a condition for a physician to be licensed to practice in Missouri. (SUPPORT SB 772-Onder and HB 1816-Koenig and HB 2304-Frederick) • MAFP supports this legislation that would prohibit state licensure to be conditioned on participation in any public or private health insurance. (SUPPORT HB 1682-Frederick)
Telehealth
• Telemedicine can be an important tool for family physicians and their patients. • Missouri should develop clear definitions for telehealth services, such as for originating sites and parity that reimburses providers as they would for an in-person visit. • A reasonable standard of care should be preserved in telehealth encounters. continued on pg. 24 MO-AFP.ORG 23
KEY MAFP ISSUES continued from pg. 23
• MAFP supports the concept that all physicians providing telehealth in Missouri should be licensed in Missouri. • Telehealth consultations and asynchronous “store-and-forward" technology are important tools for serving patients in rural areas where specialists may not be available. • MAFP is closely monitoring these legislative measures. (SUPPORT SB 621-Romine, HB 1923-Barnes, and HB 2350-Burlison)
Health Care Access and Coverage
• The MAFP believes that all Missourians, regardless of social, economic or political status, race, religion, gender, or sexual orientation should have access to essential health care services and supports measures that increase Medicaid coverage to Missourians who lack affordable health care. • Hundreds of thousands of low income, working Missourians are still without access to primary care. Most are working adults who do not qualify for Medicaid and are unable to afford plans offered on the health insurance exchange. • Increased eligibility and transformation of Medicaid services is the most immediate way to provide access to primary care and preventive
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services, particularly to vulnerable populations. MAFP supports bills that make health care coverage available to all Missourians.
Other Legislation SUPPORTED by MAFP
• Show-Me Compassionate Medical Education Act to study medical student suicide. (HB 1658-Frederick) • Eliminate physician “covenants not to compete” for private, nonprofit health care entities or governmental health care entities. (HB 1660-Frederick) • Development of a Prior Authorization standardized form. (HB 1552-Neely) • Step Therapy/Requires Override Exception Request be Expeditiously Granted. (HB 2029-Hoskins) • MO HealthNet Reimbursement for Behavioral Health. (HB 1659-Frederick) • Perinatal Regionalization to improve neonatal mortality. (HB 1875-Haefner) • Development of a Palliative Care & Quality of Life Interdisciplinary Council. (HB 1994-Cornejo and SB 635-Hegeman) • Streamline the process by which licensees can report required changes to their specific boards. (SB 831-Wasson)
MULTI STATE CONFERENCE / MATCH
Multi-State: Sharing insight on issues
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The ability to meet with our national and multiple state leaders in family medicine was invigorating. We are not alone in the challenges we face in the future. Conversations and communication that Multi- State allowed will bring future solutions for Missouri and our country. Our participation and seats at the table continue to be important for success in the future of the MAFP and family medicine."
Mark Schabbing, MD, Kathleen Eubanks-Meng, DO and Kathy Pabst, MAFP executive director.
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eaders from thirteen Midwestern state chapters congregated in Dallas for a two-day meeting where they shared best practices in their states. The ongoing discussion at many chapter meetings is physician payment with MACRA. Shawn Martin, senior vice president of advocacy, practice advancement, and policy with AAFP has his finger on the
As a first-time attendee, this meeting was a great opportunity to meet and work with other chapter leaders to discuss important topics that impact family medicine." Mark Schabbing, MD
Kathleen Eubanks-Meng, DO pulse of this issue and explained the implementation timeline, the two payment pathways, and identified resources available to physicians. Other important issues discussed addressed telemedicine, PCMH, and Texas GME funding. Each chapter provided an update on state legislative issues (see pages 23-24) and best practices.
Match Day: A new family; A new beginning
T
he 2016 Match was again a success for family medicine with a total of 3,105 medical students and graduates matching to family medicine residency programs. Of those matches, 1,481 were filled with U.S. seniors. Family medicine offered 3,260 positions (44 more than in 2015). This is the seventh straight year that the family medicine match rate has climbed steadily.
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1. University of Missouri medical students, Kaitlin Bruegenhemke, Brady Fleshman, and Kristen Killen, will be joining the University of Missouri FMR this summer. 2. Stephanie Lersch, who also matched at Mizzou FMR, stops for a picture with her brother who is a medical student at UMKC. 3. Jenny Eichhorn points to Springfield after finding out she matched to Cox FMR.
WANT TO SEE MORE ON THE MATCH? Visit: http://www.aafp.org/medical-schoolresidency/program-directors/nrmp.html
PRESIDENT'S REPORT
Diagnosis and treatment of Restless Legs Syndrome (RLS) during pregnancy Jonathan P. Hintze, MD Shalini Paruthi, MD
Case: A 31-year-old healthy female, 28 weeks into her third pregnancy sees her doctor to discuss her sleep. She complains of difficulty falling asleep and waking up multiple times throughout the night. She says she “just can’t get comfortable” and is tossing and turning all night because her legs “won’t sit still.” Upon further questioning she confirms that her legs feel worse particularly at night, and feel better when she gets up and walks around. Her pregnancy is otherwise uncomplicated and her only daily medication is a prenatal vitamin, though she has started trying over the counter benadryl at night without improvement in her sleep. She never had this problem with her other pregnancies. Her physical exam, including a detailed exam of her lower extremities, is unremarkable.
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estless legs syndrome (RLS) is a common sleep disorder that increases in prevalence during pregnancy. It is estimated to affect approximately 25% of all pregnancies with a peak in the third trimester.1,2,3,4 It is the third most common reason for insomnia during pregnancy5, and as seen in our patient, the risk of developing RLS increases with each pregnancy and may not have been present in prior pregnancies.6,7 It is a clinical diagnosis which is made if the following criteria
are met: (1) An urge to move the legs, usually associated with an unpleasant sensation in the legs, (2) this urge is worse with rest or inactivity (i.e. lying down), (3) it is relieved at least partially with movement (e.g. walking or stretching), (4) and is worse in the evenings or at night. Additionally, symptoms cannot be explained by another condition (leg cramps or venous stasis, for example) and the symptoms must cause sleep disturbance, distress, or some impairment of function, whether mental, physical, social, or others.8 This patient clearly meets criteria for the diagnosis of RLS. As she describes, the sleep disturbance commonly observed in RLS is at sleep onset and may impact sleep maintenance as well.2,3,9-12 Although the pathophysiology of RLS in pregnancy is still under investigation, in the general population there is evidence that genetics, the central dopamine system, and iron all play roles.13-17 The role of iron is of particular interest during pregnancy, as many women develop iron deficiency during pregnancy.18 Specifically, iron is a known co-factor for the enzyme tyrosine hydroxylase, which is a ratelimiting reaction of dopamine production and has been hypothesized as a connection between low iron status and RLS.15 Therefore, it is not surprising the same population who is at a
The National Healthy Sleep Project involves a partnership between the American Academy of Sleep Medicine (AASM), the Center for Disease Control (CDC) and Sleep Research Society (SRS). The long-term goal of the project is to promote improved sleep health in the U.S. The project will increase public awareness of the importance of healthy sleep. It also will promote the treatment and prevention of sleep disorders.
continued on pg. 28 MO-AFP.ORG 27
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higher risk of iron deficiency is at a higher risk of developing RLS. Recently, the International RLS Study Group (IRLSSG) published clinical guidelines for the diagnosis and treatment of RLS during pregnancy.19 The first step is to accurately diagnose RLS with the above criteria, and assess severity and possible comorbid depression.20 Next, assessing iron status should be done by checking a serum ferritin, and this may also include a hemoglobin, iron, TIBC, and percent transferrin saturation as deemed appropriate. It is notable that ferritin is an acute phase reactant and may be elevated if there is a concurrent illness or chronic inflammation, making additional iron studies more useful. Ferritin levels below 75 mcg/L should be treated with oral iron supplementation of 65 mg elemental iron 1-2 times daily21, and advising patients to take vitamin C together with iron can improve absorption.22 Repeat ferritin levels should be checked after 6-12 weeks to monitor a response. If there is a failure of response to oral iron and ferritin remains below 30 mcg/L, intravenous iron can be considered23,24 though is rarely needed. Patients with RLS that is refractory to iron supplementation, or patients with an initial ferritin over 75 mcg/L may be considered for dopamine therapy specifically with carbidopa/levodopa. Low-dose clonazepam in the evening may also be considered.19 As with any medication considered during pregnancy, side effects, and the benefit to potential harm ratio must be discussed openly with each patient. However, even in patients with refractory RLS, reassurance can be given that most cases of pregnancy-related RLS will improve or resolve within one month after delivery.1-3 Non-pharmacologic treatment considerations which have been proven to improve RLS include moderate-intensity exercise, yoga, massage, and pneumatic compression devices.25-27 Anecdotally, many patients describe relief with compression stockings during the day, warm bath/shower before bedtime, or wearing socks to sleep. Lastly, care should be taken to avoid common RLS exacerbating factors, such as sedating antihistamines like our patient has tried. Case conclusion: The patient and her physician decide to check her hemoglobin and ferritin. They find that her ferritin is only 8mcg/L and begin an additional iron supplement in addition to her prenatal vitamin. Within three weeks she has significant improvement in her leg restlessness and is now able to fall asleep more quickly and sleep through the night.
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REFERENCES 1. M. Manconi, V. Govoni, A. De Vito, N.T. Economou, E. Cesnik, I. Casetta, et al. Restless legs syndrome and pregnancy. Neurology, 63 (2004), pp. 1065–1069. 2. A. Hubner, A. Krafft, S. Gadient, E. Werth, R. Zimmermann, C.L. Bassetti. Characteristics and determinants of restless legs syndrome in pregnancy: a prospective study. Neurology, 80 (2013), pp. 738–742. 3. J.P. Neau, A. Porcheron, S. Mathis, A. Julian, J.C. Meurice, J. Paquereau, et al. Restless legs syndrome and pregnancy: a questionnaire study in the Poitiers District, France. Eur Neurol, 64 (2010), pp. 268–274. 4. Ismailogullari, S., Ozturk, A., Mazicioglu, M.M., Serin, S., Gultekin, M., and Aksu, M. Restless legs syndrome and pregnancy in Kayseri, Turkey: a hospital based survey. Sleep Biol Rhythms. 2010; 8: 137–143. 5. Kızılırmak, A., Timur, S., and Kartal, B. Insomnia in pregnancy and factors related to insomnia. Sci World J. 2012; 2012: 1–8. 6. Berger, K., Luedemann, J., Trenkwalder, C., John, U., and Kessler, C. Sex and the risk of restless legs syndrome in the general population. Arch Intern Med. 2004; 164: 196–202. 7. Pantaleo, N.P., Hening, W.A., Allen, R.P., and Earley, C.J. Pregnancy accounts for most of the gender difference in prevalence of familial RLS. Sleep Med. 2010; 11: 310–313. 8. American Academy of Sleep Medicine. International classification of sleep disorders, 3rd ed. Darien, IL: American Academy of Sleep Medicine, 2014. 9. Vahdat, M., Sariri, E., Miri, S., Rohani, M., Kashanian, M., Sabet, A. et al. Prevalence and associated features of restless legs syndrome in a population of Iranian women during pregnancy. Int J Gynecol Obstetrics. 2013; 123: 46–49. 10. de Castro, C.H., Martinez, F.G., Angulo, A.M., and Alejo, M.A. Restless legs syndrome in pregnancy. Aten Primaria. 2007; 39: 625–626. 11. Chen, P.-H., Liou, K.-C., Chen, C.-P., and Cheng, S.-J. Risk factors and prevalence rate of restless legs syndrome among pregnant women in Taiwan. Sleep Med. 2012; 13: 1153–1157. 12. Minar, M., Habanova, H., Rusnak, I., Planck, K., and Valkovic, P. Prevalence and impact of restless legs syndrome in pregnancy. Neuro Endocrinol Lett. 2013; 34: 366–371. 13. Trenkwalder, C., Hogl, B., and Winkelmann, J. Recent advances in the diagnosis, genetics and treatment of restless legs syndrome. J Neurol. 2009; 256: 539–553. 14. Picchietti, M.A. and Picchietti, D.L. Advances in pediatric restless legs syndrome: iron, genetics,
diagnosis and treatment. Sleep Med. 2010; 11: 643–651. 25. M.M. Aukerman, D. Aukerman, M. Bayard, F. Tudiver, 15. Allen, R. Dopamine and iron in the pathophysiology of L. Thorp, B. Bailey. Exercise and restless legs syndrome: a restless legs syndrome (RLS). Sleep Med. 2004; 5: 385–391. randomized controlled trial. J Am Board Fam Med, 19 (2006), 16. Clemens, S., Rye, D., and Hochman, S. Restless legs pp. 487–493. syndrome: revisiting the dopamine hypothesis from the spinal 26. M. Russell. Massage therapy and restless legs syndrome. cord perspective. Neurology. 2006; 67: 125–130. J Bodyw Mov Ther, 11 (2007), pp. 146–150. 17. Dauvilliers, Y. and Winkelmann, J. Restless legs syndrome: 27. C.J. Lettieri, A.H. Eliasson. Pneumatic compression update on pathogenesis. Curr Opin Pulm Med. 2013; 19: devices are an effective therapy for restless legs syndrome: a 594–600. prospective, randomized, double-blinded, sham-controlled trial. 18. DeMayer EM, Tegman A. Prevalence of anaemia in the Chest, 135 (2009), pp. 74–80. World. World Health Organ Qlty 1998; 38: 302-16. 19. Picchietti DL, et al. Consensus clinical practice guidelines for the diagnosis and treatment of restless legs syndrome/Willis-Ekbom disease during pregnancy and lactation, Sleep Medicine Reviews (2014), http://dx.doi.org/10.1016/j. smrv.2014.10.009. 20. J. Wesstrom, A. Skalkidou, M. Manconi, S. Fulda, I. Sundstrom-Poromaa. Pre-pregnancy restless legs *$75,000 Cash Bonus syndrome (Willis-Ekbom disease) is associated with *Up to $250,000 Loan Perinatal depression. J Clin Repayment Sleep Med, 10 (2014), pp. 527–533. •One weekend per month and 21. R.N. Aurora, D.A. Kristo, S.R. Bista, J.A. Rowley, R.S. Zak, two weeks per year K.R. Casey, et al. The treatment •Low Cost Health Insurance of restless legs syndrome and periodic limb movement •VA Benefits disorder in Adults—An update for 2012: practice parameters with •Paid CMEs an evidence-based systematic review and meta-analyses. •Retirement Opportunities Sleep, 35 (2012), pp. 1039– •Savings Plan TSP (similar to 1062. 22. Cook JD and Reddy MB. 401K) Effect of ascorbic acid intake on nonheme-iron absorption from •Experience unlike any a complete diet. Am J Clin Nutr. •Service for American Heroes 2001;73:93–8. 23. D. Vadasz, V. Ries, W.H. and their families Oertel. Intravenous iron sucrose for restless legs syndrome in For more information call Sergeant First Class Amanda Nelson pregnant women with low serum toll free at 877-574-7029 or visit us at, http://www.goarmy.com/careers-andSFC Dayton K. Davis ferritin. Sleep Med, 14 (2013), jobs/amedd-categories/medical-corps-jobs/family-practice-physician.html U.S. Army Shreveport Medical Recruiting pp. 1214–1216. 24. J. Schneider, A. Krafft, A. Office: 1-318-861-3751 Bloch, A. Huebner, M. Raimondi, Email: dayton.k.davis.mil@mail.mil C. Baumann, et al. Iron infusion in restless legs syndrome in pregnancy. J Neurol, 258 (2011), p. 55.
Family Medicine Physicians Have you considered the Army Reserve?
MO-AFP.ORG 29
FAMILY PHYSICIAN OF THE YEAR NOMINEES / FAMILY MEDICINE CARES USA
Meet your Family Physician of the Year nominees The Missouri Academy of Family Physicians would like to congratulate our 2016 Family Physician of the Year nominees. Thank you to everyone who submitted nominations. Family Physician of the Year is a very prestigious honor, and is awarded to physicians who provide his/her patients with compassionate, comprehensive and caring family medicine on a continuing basis. The winner will be selected in April by a committee of family physicians from nominations made by patients, community members and fellow physicians.
Kelly Bain, MD
's ation d n u Fo m AAFP anitariu Hum ature Sign am r Prog
FAMILY MEDICNE CARES USA
American Academy of Family Physicians Foundation
Scott Griswold, MD
Timothy Long, MD
James Miller, DO, FAAFP
Jennifer Powell, MD, FAAFP
FMC USA - Making a difference in MO
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ince the program’s inception in 2011, Family Medicine Cares USA (FMC USA), the AAFP Foundation’s Humanitarian Signature Program, has awarded $271,089 to 22 free medical clinics. These awards across the United States provided an estimated 17 million dollars in services as a result of approximately 80,000 patient visits. The FMC USA program gives up to $25,000 for the start-up efforts of new free health clinics and up to $10,000 for existing health clinics that provide services at no charge to patients nationwide.
Recently, FMC USA was pleased to award $21,986 to Still Caring Health Connection in Affiliation with VIM. The clinic began providing free health care to patients in April 2015 and serves uninsured residents of Adair County and surrounding areas in rural Northeast Missouri. All counties within the service area have been designated Health Professional Shortage Areas by the U.S. Department of Health and Human Services. 30
Gene McFadden, MD, FAAFP
MISSOURI FAMILY PHYSICIAN
APRIL-JUNE 2016
The clinic plans to use the vast majority of FMC USA funds to purchase portable exam tables, stools, exam lights, stethoscopes, portable otoscopes, a HbA1c and lipid panel machine, laptops and a portable dental X-ray machine. Still Living has started with offering 20 hours per month of direct patient care and plans to expand as they grow. The clinic gained support from A.T. Still University, which has both a medical and dental school, in Kirksville, Missouri. This collaboration allowed for the start-up of a student organization within the medical school. In its charter year, the student organization has become the largest on campus and currently has over 200 students. This provides a pool of volunteers for the clinic as well as renewable financial support for the clinic in the form of members’ dues and university fundraisers. In addition to providing the grant the FMC USA program also offers opportunities for family physicians, residents, and medical students to volunteer at the free clinics in their area. Still Living utilizes over 60 volunteers per month. To learn more about the FMC USA program, please contact Sharon Hunt at shunt@aafp.org or visit their website at http://www.aafpfoundation. org/fmcusa.
MAFP STRATEGIC PLAN
STRATEGIC PLAN 2016-2018
Last fall, MAFP leaders traveled to Columbia, MO to attend the academy’s strategic planning session. Nancy Laughlin, AAFP chapter relations manager, facilitated the lively discussion among board members, AAFP delegates and alternate delegates, commission chairs and the MAFP staff. The commitment of these leaders allowed a thorough review of the academy’s mission and vision statement, assess performance of the previous strategic plan, and ultimately, look to the future.
OUR VISION
The Missouri Academy of Family Physicians will be recognized as the leading medical specialty organization for our patients and our members.
OUR MISSION
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. The Board of Directors, at its November meeting, selected a new mission statement that reflects the true intent of the membership. Although members differ on a variety of health care policies and issues, we are united with family medicine. This new mission statement will be our compass for the next three years. The Board of Directors set four broad goals spanning three years. The plan will be reviewed for progress annually and used by the president-elect to set the work plan. Committee efforts should support the plan’s goals and strategies.
STRATEGIES TO ADVANCE THE GOALS I. Advocacy Advocate for the specialty of family medicine. A. Identify legislative priorities B. Engage members in advocacy efforts C. Partner with organizations around policy II. Practice Enhancement Provide assistance to family physicians with the business of medicine. A. Provide resources to physicians in all practice settings B. Explore feasibility of providing resources for patients III. Membership Ensure members are satisfied and engaged. A. Explore opportunities for member networking B. Increase engagement of past leaders C. Conduct member satisfaction survey D. Develop family medicine community preceptor program IV. Education Provide quality education for physicians, residents and students. A. Expand live CME events to include updates on policy and state activities and increased opportunities for networking. B. Survey members regarding CME meeting format V. Operations Maintain a strong, sustainable Academy. A. Create leadership development plan B. Develop communication plan C. Adopt social media policies MO-AFP.ORG 31
Self-Study CME Revenue Share EARN CME. SUPPORT YOUR CHAPTER.
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mprove patient care and bridge your knowledge gaps with AAFP self-study CME—when and where it’s convenient for you—and help your chapter earn additional revenue through the AAFP Self-Study CME Revenue Share program. Visit AAFP.org/cme. Clinical Packages Use AAFP self-study packages to enhance your expertise and expand your knowledge on common family medicine topics. Featuring recorded audio and video presentations from current AAFP live clinical courses, these interactive self-study packages take approximately 20-45 hours to complete and include: • 18-43 lectures between 30 and 60 minutes in length • Opportunities to report CME and evaluate after each lecture • Interactive interface with QuestionPause™ to briefly halt the presentations • Post-test (online)
Choose the package format that’s right for you: *BEST VALUE: A one-year online subscription and USB Flash Drive. Smartphone/tablet compatible. Includes a print and PDF color syllabus.
Online Access: Study when and where you want with a one-year online subscription. Smartphone/tablet compatible. Includes a PDF color syllabus. USB Flash Drive: Convenient, portable access to all of your self-study materials. Includes a USB Flash Drive, audio CDs with select packages, and a print and PDF color syllabus. Online access valid one year from purchase date of online-inclusive package. How to Benefit Your Chapter through the AAFP Revenue Share Program: Visit aafp.org/chapter-selfstudy. At checkout, add 4MYCHAPTER in the source code box (see below) and a portion of your purchase revenue will be shared back with your chapter.
4MYCHAPTER