Winter 2017 (January-March) by Missouri Academy of Family Physicians

MISSOURI Official Publication of the Missouri Academy of Family Physicians

Family Physician January-March 2017 Volume 36, Issue 1

2017 Advocacy Day Be the voice of your academy page 17

www.mo-afp.org

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 se�ng, dynamic urban loca�on, or somewhere in between, we are commi�ed 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 - Peter Koopman, MD, FAAFP (Columbia) President - Kathleen Eubanks-Meng, DO (Blue Springs) President-Elect - Mark Schabbing, MD (Perryville) Vice President - Sudeep Ross, MD (Kansas City) 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: Caroline Rudnick, MD (St. Louis) Director: Sarah Cole, DO (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: Vacant District 6 Director: Jamie Ulbrich, MD, FAAFP (Marshall) Alternate: David Pulliam, DO, FAAFP (Higginsville) District 7 Director: Vacant Director: Afsheen Patel, 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: Deanne Siemer, MD (Jackson) Alternate: Vicki Roberts, MD (Cape Girardeau) Director At Large Emily Doucette, MD (St. Louis) resident directors Kanika Turner, MD (SLU) Alicia Brooks, MD (Alternate) (SLU) student directors Emily Gray (UMKC) John Heafner, MSPH (Alternate) (SLU) 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, CAE Communications and Education Manager - Sarah Mengwasser Membership and Programs Coordinator - Becki Hughes 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.

MARK YOUR CALENDAR Multi-State Forum February 11-12, 2017 Grand Hyatt DFW, Dallas, TX MAFP Advocacy Day February 28-March 1, 2017 Capitol Plaza Hotel/ Missouri State Capitol Jefferson City, MO AAFP Annual Chapter Leadership Forum/National Conference of Constituency Leaders April 27-29, 2017 Sheraton Kansas City Hotel at Crown Center, Kansas City, MO AAFP Family Medicine Congressional Conference May 22-23, 2017 Washington Court Hotel, Washington, DC MAFP 69th Annual Scientific Assembly (ASA) June 9-11, 2017 The Lodge at Old Kinderhook, Camdenton, MO

MAFP Board of Directors Meeting June 11, 2017 The Lodge at Old Kinderhook, Camdenton, MO AAFP National Conference of Family Medicine Residents & Students (NCFMRS) July 27 â&#x20AC;&#x201C; 29, 2017 Kansas City Convention Center, Kansas City, MO AAFP Congress of Delegates September 11-13, 2017 Grand Hyatt, San Antonio, TX AAFP Family Medicine Experience (FMX) September 12-16, 2017 Grand Hyatt, San Antonio, TX MAFP 25th Annual Fall Conference & KSA Working Group November 10-11, 2017 Big Cedar Lodge, Ridgedale, MO

Are you moving? Changed your name? Or just need to update your email, phone number, or employer information? If so, we want to know. Stay connected with the AAFP and the MAFP no matter where you are. Update your contact information online at www.aafp. org/updatecontactinfo to ensure you receive timely AAFP and MAFP news and updates.

INSIDE THIS ISSUE Pg. 4 5 6 8 9 12 14 16 17 20 22 23

Chair's Report President's Report Resident Grand Rounds Help Desk Answers Capitol Commentary Recap of Annual Fall Conference Nominate the 2017 Family Physician of the Year Precepting Experience Register for Advocacy Day Members in the News Volunteer for the MAFP Chronic Care Management

Advertisements Pg. 2 MHPPS 7 MPM-PPIA 9 Wilshire-Pennington 10 Core Content 11 Stanley's Pharmacy 13 Cox Health 15 NORCAL 16 Missouri Beef Industry Council 19 HCA 22 DPC Clinics 23 Midwest Dairy MO-AFP.ORG 3

CHAIR'S REPORT

Nobody's fault but mine

Peter Koopman, MD, FAAFP

atient satisfaction is important in medicine. I do not deny that fact, but when compared to a group of peers, there is always a bell curve, and 50% of physicians will be in the lower 50% on any measure. This statistically, is also a fact. Being told you are “worse” than your peers can produce physician disappointment that may contribute to physician unhappiness and possibly burnout. Data has been collected and published that improved patient satisfaction scores may actually be associated with worse clinical outcomes1. Although patient satisfaction measures are relevant to a better patient experience I do wonder if informing a group of physicians they are “bad” will universally produce better patient

I do believe we all need to work on continuous improvement, but not everyone can be above average."

outcomes. Given this concern, it is imperative to try to be certain that the measures we should use to determine “good” physicians in terms of patient satisfaction are valid. Is it that the patient was happy when they left the office/hospital? Is it that the patient felt listened to when they were in the physician’s office? Is it that the patient felt the physician spent enough time with them, or is it something else? Recently, I was told that I was fifth out of eight providers at my office on a communication composite score collected by patient surveys. This score is based upon yes/no questions such as, “Did your provider spend enough time?, Did your provider listen?, did your provider explain?, did your provider know your history, etc?” I do believe these are relevant questions and important aspects of care. Of my patients, my provider composite score stated 91% of my patients said yes to these questions. Of the >50 providers in my practice the highest is 98%. The national average of a comparative national sample is 95%. I am below the mean. Yet I am uncertain I am doing poorly. I am doing worse

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than a large group of providers on this score. I certainly understand the statistical relevance, but remain uncertain as to the “real world” relevance of this measurement. 91% is pretty good, and I remain uncertain as to what changes to make to bring me to the 95%; or if I should devote my effort to that end. I certainly have a practice pattern that is not as efficient as many peers, and thus, on average, longer wait times. Since I was young, I have struggled with developing a pattern that feels comfortable and correct in order for me to me to improve that aspect of my care, but have not been very successful. Nonetheless, being told I am in the bottom at 91% has made me feel bad and decreased my satisfaction with my clinical time. I do believe we all need to work on continuous improvement, but not everyone can be above average. I do worry however, as these measures get tied to finances and our practice profile; that outside of me feeling bad, this measurement and monitoring could have wider reaching effects. I will get over my feelings and know that I am emotional when it comes to feedback (I am working on it) but still, the larger argument of relevance I feel, remains important. Should I be penalized because 91% of my patients state they are satisfied with my communication skills? Certainly I do not know the right answer, or in any way feel that we should discount patient satisfaction; but I do feel that patient satisfaction in physician service may be different in yet undefined ways from satisfaction with a restaurant or hotel. As more and more of us become employed, and our non-clinical managers collect these measures, I do believe it is imperative for physicians to be informed and aware of these measures, and to demand input into, and discussion of these measures. The AAFP needs to remain vigilant and keep us informed. 1-Fenton JJ, Jerant AF, Bertakis KD, Franks P. The Cost of SatisfactionA National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. 2012;172(5):405-411. doi:10.1001/ archinternmed.2011.1662

PRESIDENT'S REPORT

Family medicine has changed; How do I keep up?

amily medicine is not what it used to be. It is not what I found myself drawn to years ago. It has changed into something I don’t recognize. When I started out, we had breakfast in the doctor’s lounge before rounding on patients. We would interact with the specialists that we collaborate with daily. We would take time to eat lunch with our physician partners with or without a drug representative providing lunch. We live in a world of changing reimbursement rates, patient outcomes data, quality measures, population management and physician report cards. It is easy to feel overwhelmed and disillusioned. I am in a suburban independent practice in Kansas City. We provide patientcentered care in limited space with limited time. It is not easy to check the boxes in the electronic health record (EHR) for the needed information to report on in every visit, and still truly connect and listen to what patients need. I don’t intend to debate the awesomeness or not so awesomeness of EHR, only to say it, at times, is the elephant in the room. When you manage populations instead of partnering with patients to invest in their healthcare, we miss the boat. One of my colleagues, Dr. Matt John, wanted to find a way to connect with our patients and promote health and wellness in our community outside of the chaos of the office. He wanted all of us to reconnect to our “roots” and our patients. He started the Lee’s Summit chapter of Walk with a Doc. Walk with a Doc was founded in 2005 by a cardiologist in Ohio, Dr. David Sabgir, to promote health and wellness, and to connect with his patients outside of the clinical setting. Our clinic providers, nurses, office managers,

As we walked, we talked, not only about health and wellness, but about life. There were no check boxes, no computers, no seven-minute office visit time constraint. The connection to our patients was on a different level."

Kathleen EubanksMeng, DO

staff, and patients met on the coldest Saturday in November at a park in Lee’s Summit, MO. Our staff, administrators, and patients came to walk and learn. Dr. John gave a brief talk about the “why” we met on this cold day and we started walking. Everyone walked at their own pace and their own distance. As we walked, we talked, not only about health and wellness, but about life. There were no check boxes, no computers, no seven-minute office visit time constraint. The connection to our patients was on a different level. A level we needed to be able to reach to enable a partnership with our patients in their healthcare. At the finish of the walk there was warm coffee, healthy snacks, a t-shirt and a pedometer for each participant. Despite the cold winter Missouri promises, we will continue our every other month walks, in the hopes of making them monthly. Medicine is changing, and sometimes it isn’t easy to keep pace. However, stepping out of our comfort zone is often what family doctors do best, and that hasn’t changed. It doesn’t take radical change to make a difference. Take it one step at a time. For more information on Walk with A Doc, visit www.walkwithadoc.org. MO-AFP.ORG 5

RESIDENT GRAND ROUNDS

Capsaicin topical therapy in Osteoarthritis

Sandra MinchowProffitt, MD

Christopher Young, MD

QUESTION Is capsaicin cream safe and effective at reducing knee osteoarthritis pain?

ATTENTION RESIDENTS: NEED TO BE PUBLISHED? Submit your report to be published as a ResidentGrand Rounds article in our quarterly Missouri Family Physician magazine. Contact MAFP: office@mo-afp.org

EVIDENCE-BASED ANSWER Capsaicin cream has small to moderate effect in reducing osteoarthritis (OA) knee pain after at least four weeks of use. Capsaicin cream is safe, but commonly causes application-site burning that rarely leads to stopping treatment (SOR A, systematic review of RCTs and one crossover study). EVIDENCE SUMMARY A 2014 systematic review examined capsaicin cream for knee OA, average age 49-65, in five double blind RCTs and one case-crossover trial.1 Trials assessed treatment efficacy vs placebo over four weeks, two studies reporting data beyond four weeks. Capsaicin concentrations ranged from 0.025-0.075% used topically 3-4 times per day. Visual analog scales (VAS) assessed pain, either from 0-10 or 0-100. The standardized mean difference (SMD) for VAS pain score was 0.44 after four weeks of treatment (95% CI,

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0.25-0.62), a small to moderate reduction in pain compared to placebo. Results were consistent across the trials with no heterogeneity. There was benefit beyond four weeks, however maximum benefit was at four weeks. Mild application site burning was the most common reaction reported in 35-100% of patients, {RR 4.22 (95% CI, 3.35.5)}. A 2012 double-blind RCT compared Civamide 0.075% cream (the cis-isomer of capsaicin with comparable dosing) to Civamide 0.01%, (a less active control cream used to promote blinding) in reducing OA knee pain in 695 patients aged 50 and older over 12 weeks.2 The Western Ontario McMaster University Osteoarthritis Index (WOMAC) was done at baseline and after 12 weeks of treatment evaluating pain. WOMAC scores for pain range from 0-20, with higher numbers representing more pain. A patient with a WOMAC score of >13 is considered to have severe pain. Response was defined as at least 50% improvement in either the WOMAC pain or WOMAC function scores, or at least 20% improvement in both. If baseline WOMAC pain scores were greater than 10, 68% of Civamide

RESIDENT GRAND ROUNDS

0.075% users responded compared to 54% of Civamide 0.01% users (P=.002). With baseline WOMAC scores great than 13, 78% of Civamide 0.075% users responded compared to 51% of Civamide 0.01% users (P<.001). Application site burning was the most common adverse reaction, with only 5% of patients stopping the medication due to this. Adverse reactions decreased as the study went forward; 18% of patients in the treatment arm on day 1, 10% by day 14, 6% by day 84. A 2010 double-blind, randomized, placebo-controlled trial of 100 Thai women, age 44-82, with mild to moderate knee OA compared 0.0125% capsaicin cream to placebo gel for treatment of knee OA pain over 4 weeks.3 VAS (range 0-10), and WOMAC scores for pain were done at baseline and after four weeks of treatment. The mean difference in VAS scores was 0.72 after four weeks of treatment (95% CI, 0.171.3). The reduction in mean total WOMAC scores in the capsaicin group was significantly greater than

the control group by 3.4 points (95% CI, 2.34-4.5). Application site burning was the only reported adverse event, occurring in 67% of patients in the capsaicin group. No patients discontinued the medication due to an adverse reaction. This study was limited in that only women farmers were included. REFERENCES 1. Laslett LL, Jones G. Capsaicin for Osteoarthritis Pain. Progress in Drug Research. 2014. 68:277-91 [STEP 1] 2. Schnitzer TJ, Pelletier JP, Haselwood DM, et al. Civamide cream 0.075% in patients with osteoarthritis of the knee: a 12 week randomized controlled clinical trial with a long term extension. J Rheumatology 2012. 39(3): 610-620. [STEP 2] 3. Kosuwon W, Sirichatiwapee W, Wisanuyotin T, et al. Efficacy of Symptomatic Control of Knee Osteoarthritis with 0.0125% Capsaicin Versus Placebo. J Med Assoc Thai 2010; 93(10): 1188-95. [STEP 2]

MO-AFP.ORG 7

HDAs HelpDesk Answers

Are azapirones more effective than placebo in treating panic disorder among adults? EVIDENCE-BASED ANSWER

Azapirones (buspirone) are probably not more effective than placebo in decreasing panic attacks and anxiety symptoms in adults with panic disorder. In addition, azapirones are less well tolerated than placebo (SOR: B, systematic review of low-quality RCTs and single RCT).

EVIDENCE SUMMARY

Benjamin Crenshaw, MD

Jamie Ogden, MD

2014 systematic review analyzed 3 RCTs comparing the oral azapirone, buspirone (mean delivered dose 29.5–61 mg/d) with placebo for the treatment of adults (N=170) with panic disorder.¹ Studies in which participants received other treatments, including psychotherapy, were excluded. The duration of the intervention was 8 weeks. Results were not pooled because of a use of different symptom scales and lack of reporting of standard deviations. One study (n=44) showed no significant difference in the number of panic attacks between buspirone and placebo. A second trial (n=75) evaluated the frequency of panic attacks in the preceding 2 weeks at baseline and then at 2-week intervals. At week 8, the buspirone group showed a mean decrease of 3.8 panic attacks over the preceding 2-week period versus baseline (95% CI, –5.6 to –2.0). The third analyzed trial (n=23) evaluated the frequency of panic attacks per week at baseline and then weekly. At week 8 of therapy, the buspirone group had a median decrease of 1 panic attack per week versus baseline (statistical analysis not reported). Over the study period, the risk for study dropout increased with buspirone (RR 2.1; 95% CI, 1.1–4.1), suggesting that buspirone was less well tolerated than placebo. Secondary efficacy outcomes measuring agoraphobia, anxiety, and depression symptoms on various scales were not statistically different between groups. The included studies had significant limitations, including insufficient reporting of allocation concealment and sequence generation, with high rates of attrition and small sample sizes.¹ Another RCT not included in the systematic review above, due to use of cognitive behavioral therapy (CBT), randomized 77 patients with panic disorder to CBT plus placebo or CBT plus buspirone up to 60 mg daily (mean delivered dose 30 mg daily).² A 2-week trial of placebo occurred prior to randomization, and only placebo nonresponders were subsequently randomized. Of note, 15% of recruited patients had a 50% improvement in symptoms with placebo. Only 41 patients were followed to completion of the study, for

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a 37% dropout rate. The primary outcome was change on the Phobia, Panic, and Generalized Anxiety (PPGA) scale, with 3 subdomains of agoraphobia, generalized anxiety, and number of spontaneous panic attacks, each rated 0 to 8, with higher scores correlating to more symptoms. From baseline to 16 weeks, CBT plus buspirone resulted in a slightly greater reduction in symptoms of generalized anxiety than CBT plus placebo (difference in mean change on PPGA generalized anxiety scale of –1.5; P<.05), but the difference was not sustained at 1 year. The subdomains of agoraphobia and number of panic attacks did not differ between groups. Multiple other secondary outcome measures of general improvement, agoraphobia, anxiety, and depression did not show any between-group differences.² References: 1. Imai H, Tajika A, Chen P, et al. Azapirones versus placebo for panic disorder in adults. Cochrane Database Syst Rev. 2014; (9):CD010828. [STEP 2] 2. Cottraux J, Note ID, Cungi C, et al. A controlled study of cognitive behaviour therapy with buspirone or placebo in panic disorder with agoraphobia. Br J Psychiatry. 1995; 167(5):635–641. [STEP 2]

Interested in more HelpDesk Answers? Get the answers to your clinical questions with a complementary 3 month electronic subscription to

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CAPITOL COMMENTARY

Capitol commentary

he First Regular Session of Missouri’s 99th General Assembly convened at noon on Wednesday, January 4, 2017. Pre-filing of legislation began on December 1, 2016. This year brings new statewide elected office holders (Governor Eric Greitens; Lieutenant Governor Mike Parson; Secretary of State Jay Ashcroft; State Treasurer Eric Schmidt) and numerous legislators elected in the November 2016 General Election. At this point, we are still meeting new legislators and learning of changes in administration, committees, and policies. A challenging state budget Prior to leaving office, Governor Nixon “withheld” significant appropriations dollars, citing a need to do so in order to balance the state’s budget. Governor Greitens will be gearing up for budget discussions to determine if more withholds are necessary. House Budget Chair Rep. Scott Fitzpatrick has already been relaying this message: “I’ve told everybody who has come to talk to me about the budget this year, that they shouldn’t expect anything good to happen. “Play defense,” is kind of what I’ve told anybody whose job relies on a state appropriation because it’s going to be a tough year.” When referring to the Governor, he said, “The biggest challenge that he’s going to be facing is the increase in Medicaid and other mandatory programs, that basically have to be funded in order to pay providers that are providing services to the people that are eligible under state law.”

their patients. Positions are formulated, with the goal of determining “support”, “opposition”, “neutrality” or developing amendments to make a specific bill acceptable to the organization. Positions are based on our research and available data, and by assessing feedback received from members individually and through straw polls. Many measures filed are repeat bills from previous sessions, so our background on those bills is usually more extensive. Friday reports keep you in the loop As MAFP’s legislative consultant, I prepare a “Friday legislative report” to give you the latest updates on major legislation. It will also include any significant events that might have occurred during the week. If a bill you want to know about is not the subject of that week’s report, staff is always available to provide more information.

MAFP Advocacy Day at the Capitol Again this session, we are looking forward to hosting physicians, residents and students at the annual MAFP Advocacy Day scheduled for Wednesday, March 1, with a dinner and preview on Tuesday evening, February 28. I urge you to attend this important and fun event. You can register on the MAFP website. (mo-afp.org)

Legislative alerts – Your chance to make a difference Occasionally, you will receive an “alert” asking you to contact your State Senator or State Representative about a particular bill. We will provide a description, brief talking points, and the contact information. An email or phone call to their office works well. You will need to identify yourself as a “constituent” and provide your address and contact information. Missouri has a large legislature – 34 Senators and 163 State Representatives. This is why it is important for you to become familiar with the people who represent your district at the Capitol. If you have not signed up for MAFP’s key contact program, please consider doing so today. Email Kathy Pabst, MAFP executive director at kpabst@mo-afp.org. Ideally, we would have members matched up with each and every legislator. When members engage and participate in the grassroots process, we can make a big difference in legislative outcomes.

Bill review and process keeps us on track An average of 2,000 bills will be filed this session. As MAFP’s legislative consultant, I thoroughly review all measures, track a large number of bills on MAFP’s behalf, and seek input from members on legislation. The Advocacy Commission reviews legislation to determine how bills will affect physicians and

Testimony needed by physicians No testimony is as convincing as that which comes from a physician or provider. You have practice information to share that puts a face on the issue and represents stories about patients that will be affected by the legislation. While legislators are accustomed to seeing the “lobbyists” sitting across from them at

Pat Strader, MAFP Governmental Consultant

continued on page 11... MO-AFP.ORG 9

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North America’s most widely-recognized program for: • Family Medicine CME • ABFM Board Preparation • Self-Evaluation • Visit www.CoreContent.com • Call 888-343-CORE (2673) • Email mail@CoreContent.com

CAPITOL COMMENTARY Capitol commentary continued from page 9...

hearings almost each and every day, they appreciate the expertise and clinical information that physicians bring to the table. MAFP would like for you to consider “testifying” during the upcoming session. If there is a particular subject or issue that is important to you, let us know so we may add you to our list of available physicians. Also, indicate a day that works best for you. Hearings are held Mondays through Thursdays, with each committee assigned a specific day and time. If you have never testified, MAFP staff will walk you through the process, help with developing testimony, and be at your side to assist. For 2017, here are a few of the issues MAFP will be addressing on behalf of physicians and their patients: • Promote the importance of primary care and the medical care team approach; • Support legislation that addresses affordable health care for all Missourians; • Continue discussions regarding reimbursement, loan repayment for physicians and PRIMO program funding; • Strongly urge adoption of a Prescription Drug Monitoring Program for Missouri (PDMP); • Monitor all scope of practice issues, with a focus on maintaining meaningful collaborative agreements between physicians and advanced practice registered nurses; • Distracted drivers – actively support legislation limiting texting while driving for ALL Missouri drivers – not just those under 21 as in current law. (MoDOT Distracted Drivers Work Group); • Support legislation that promotes healthy behaviors and safety issues such as enacting a primary seat belt law and opposing the repeal of the motor cycle helmet law; • Support legislation that would reduce administrative hassles and paperwork, such as standardized prior authorization forms; • Support legislation that would address medical student suicide prevention; • Monitor legislation relating to medical marijuana; • Highlight and begin to educate legislators regarding the importance of preceptorships

Today

more than 3,500 children will try their first cigarette. Stop kids from starting. Volunteer to be a Tar Wars presenter.

www.tarwars.org

Joe Daugherty R. PH. Owner/Manager 1365 SPUR DRIVE PO BOX 93 MARSHFIELD, MO 65706 Phone: 417-468-2530 or 800-333-6280 Fax: 417-859-7116 www.stanleyspharmacymo.com

Supported in part by a grant from the American Academy of Family Physicians Foundation. MO-AFP.ORG 11 TW hlf vert.10_v2.indd 1

9/3/10 11:57 AM

ANNUAL FALL CONFERENCE RECAP

Family, fun, food, networking, relaxation and CME

EXHIBITORS Anthem Barnes Jewish Hospital Children’s Mercy Kansas City Citizen’s Memorial Hospital CoxHealth Docs Who Care EMS Fresenius Kidney Care HealthLink HLS Practice Management Home State Health Kowa Pharmaceuticals America Merck & Co. Mercy Clinic Missouri Athletic Trainer’s Assoc. Missouri Care MHPPS MoDocs MPM-PPIA Mylan, Inc. Novo Nordisk Pfizer Sanofi - Cardiovascular Sanofi - Genzyme SoutheastHEALTH Stanley’s Pharmacy St. Louis Children’s Hospital US Army

he 24th Annual Fall Conference was once again a hit with over 180 attendees and 28 exhibitors, all who came in support of family medicine. Sessions consisted of important and timely issues pertaining to healthcare such as MACRA, MIPS and APMs; precepting; and physician burnout. Other topics included electrosurgery, psoriasis, prostate cancer, IBD/IBS, opioid trends and treatment, and knee and back therapy treatments. Friday evening held a beer tasting hosted by Piney River Brewing Company and sponsored by 12

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Missouri Beef Industry Council. All proceeds from the tasting support the Family Health Foundation of Missouri (FHFM), which raised over $3,200, thanks to you, our members. The winner of the 50/50 FHFM Raffle was Solomon Noguera, MD. Thank you to all of our members, exhibitors, and sponsors for your continued support of the Missouri Academy. Thank you also to Midwest Dairy Council, Missouri Beef Industry Council, Direct Primary Care Clinics, Wilshire-Pennington, Peer Review Network, and North Carolina AFP for your sponsorship.

MO-AFP.ORG 13

Do you have an outstanding, caring colleague or physician in your community who deserves the title “Missouri Family Physician of the Year?” The Missouri Academy of Family Physicians (MAFP) supports over 2,400 active members in the work-force - doing extraordinary things every day. You know them, and we would like to acknowledge them. MAFP is now seeking nominations for this prestigious award. Nominate your family physician or a family physician that you know for our next Missouri Family Physician of the Year award.

Deadline for nominations is Monday, January 30, 2017 2017 FAMILY PHYSICIAN OF THE YEAR NOMINATION FORM Nominee: (please print) Physician Name Business Name Street Address City, State, Zip Office Phone E-mail Nominated by: Your Name Street Address City, State, Zip Daytime Phone E-mail Please explain why you feel this person deserves the Family Physician of the Year award:

DO/MD/FAAFP?

Mail this form to: MAFP 722 West High Street Jefferson City, MO 65101 or fax to: 573.635.0148

MAFP staff will verify all information. Nominee must meet all Family Physician of the Year requirements. Please visit www.mo-afp.com to see eligibility requirements.

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PRECEPTING

Precepting: A humbling opportunity

Donald A. Potts, MD, FAAFP

t a recent meeting of the MAFP, there was considerable discussion about the difficulty finding family docs to be preceptors. Several solutions were proposed, one of which was that a procedure for compensating physician preceptors be explored. Many physicians feel they don’t have the time, the patience, or the perceived nuisance of having students with them. I can understand those feelings, even though I never experienced any of them. In the mid-70s, I volunteered as a preceptor for the University of Missouri’s Family Medicine six-week experience. At that time, many of the students lived in the homes of the preceptors. One of my students, Mark, lived with my family and me for those six weeks. He played with my young children, taught them to dance the Hora, and tolerated their short-sheeting his bed.

One evening I heard sirens stop a short distance from my home, and grabbed Mark to see if we could help. A light plane, with an instructor and student pilot on board, had hit a treetop attempting to land at the local airport. We had the opportunity to help at the scene, and then later at the hospital. As with a few other students, Mark and I maintained intermittent contact over the ensuing years. He decided to leave family practice, but enjoyed many years as an emergency physician, utilizing his Family Practice training. A few weeks ago, I received an e-mail from Mark. For those of you who feel that preceptoring is not worth the small amount of trouble involved, take a minute to read this heart-warming letter. Just a small token of the “compensation” I received from the opportunity of having students with me over the years.

“I just began my 38th year in Emergency Medicine! OMG, why do I keep this up? Because of cases like the one I just had yesterday. Because this is a relatively small area, I see people I know all the time. One is Meg, a 71 year old friend of Peg and mine who had been told by her FNP that she needed to see a back specialist because of the pain in her buttocks and thighs. Why not see a back specialist? She had had a lumbar discectomy in 2012 and it seemed reasonable. In fact in the past month, she had lost five pounds, become weaker overall, especially in her proximal upper and lower girdles, her gait was mincing because the hips had to be thoughtfully moved forward, she couldn’t dress herself, her thighs and hips were extremely stiff, especially in the morning. She looked like she’d aged five years and was exhausted due to insomnia which she’d never had in the past. You probably guessed it already…polymyalgia rheumatica. Why am I telling you this? Because you taught me all about this disease. I probably have diagnosed it three times in my career; so few, probably because people usually see their primary physicians, thus never making it to the ER. Each time, I’ve thought of your teaching me about this disease in your office with one of your patients who had it. Her rapid response to low dose prednisone in the next 24 hours, clinched the diagnosis. What a wonderful feeling that was for me. Thanks, Don, for that. Someday I’ll tell her about my wonderful learning experiences with you." -Mark

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Please contact Rachel Gastler at rachel@mobeef.com 16

MISSOURI FAMILY PHYSICIAN

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ADVOCACY DAY

2017 ADVOCACY DAY REGISTRATION FORM Bring a colleague, medical student or resident and join fellow MAFP Members to promote the importance of family medicine and primary care. This is your opportunity to educate your State Representative and State Senator on issues affecting you, your profession, and your patients. Name______________________________________________ Designation(s)_________________________________________ Voting Address_______________________________________

February 28-March 1, 2017 Capital Plaza Hotel and Missouri State Capitol, Jefferson City, MO

Tuesday, February 28, 2017

6:30 – 8:30 pm Legislative Briefing of Key Issues and Buffet Dinner, Capital Plaza Hotel

City_________________________________________________ State________________________________________________ Zip _________________________________________________ State Senator_________________________________________

Wednesday, March 1, 2017 8:00 am – 1:00 pm Legislative Briefing and Breakfast, Capital Plaza Hotel

State Representative___________________________________ Phone________________________________________________ Email________________________________________________ Please indicate the event(s) you plan to attend: ___I will attend the evening briefing on Tuesday, February 28, 2017 ___I will attend Advocacy Day on Wednesday, March 1, 2017 If attending Advocacy Day on Tuesday, please indicate the event(s) you plan to attend: ___Breakfast ___Lunch ___Board Meeting Special dietary needs of physical accommodations required: ___________________________________________________ ___________________________________________________

Visit Legislators’ Offices (appointments to be scheduled for you by MAFP staff) Lunch buffet at hotel 1:30 – 5:00 pm Board of Directors Meeting *There are a limited number of complimentary sleeping rooms available through the MAFP. Contact Kathy Pabst at kpabst@mo-afp.org for more information and availability. MAIL REGISTRATION FORM TO: MAFP 722 W. HIGH STREET JEFFERSON CITY, MO 65101 *OR REGISTER ONLINE AT WWW.MO-AFP.ORG MO-AFP.ORG 17

PRECEPTING

Giving effective feedback to medical students

D Kimberly Zoberi, MD St. Louis University School of Medicine

o you dread filling out the student assessment at the end of a clerkship rotation? Do you feel like your comments are too generic, or are you at a loss for what to write altogether? Knowing how the various elements are used may make the preceptor more confident in filling in the “comments” section of the student evaluation. Formative comments give the preceptor an opportunity to shape the student’s ongoing education by discussing areas of strength, weakness and suggestions for improvement. At St. Louis University, we have chosen to include three unique fields in our evaluation: fields which ask the preceptor to comment on areas in which the student meets expectations, exceeds expectations, and should strive to improve upon. These were included specifically to facilitate this kind of formation, as preceptors are often hesitant to discuss any areas for improvement. Preceptors should understand that formative comments are for the student’s benefit and are in no way used to influence the final grade. Summary comments are an assessment of the student’s overall performance relative to his/ her peers at the same level of training. Summary

All comments should be specific to the student, quantifiable, and include examples."

comments should discuss both the hard skills” (history taking, physical examination, note writing, presentations, procedures) as well as the “soft skills” (professionalism, compassion, empathy, enthusiasm for learning, cost effectiveness, ability to work well with others including staff.) Do not undervalue the importance of commenting about “soft skills,” as these skills are uniquely important for producing the kind of physician who thrives in family medicine and can avoid burnout in this emotionally demanding field. What makes a useful feedback comment? All comments should be specific to the student, quantifiable, and include examples. For example, “Student A took detailed histories in a relatively short amount of time,” versus “Student A was a great student.” When possible, it is very helpful to put comments in quantifiable terms, especially if this student’s skill level can be compared to other students at the same level. “Student A had an

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impressive fund of knowledge and was particularly good at pharmacology. She was probably in the top 10% of students I have ever precepted,” versus “Student A is a bright young man with a promising future.” Examples of some of the best FORMATIVE preceptor comments are below. These comments are not included in the MSPE (Dean’s Letter.) My commentary on why these are great comments are included in italics after the quotes. • “Primary care database is still weak and needs further improvement.” Specific and fair. • “We would expect more from a student halfway through his third year, although he has not had medicine yet. He needs to read, read, read. He was able to pull more information from his memory towards the end of the rotation, but in general I felt his knowledge base to be lacking at this point.” Could be more specific, but it is quantified, in referencing the student to her peers at the same level of training. • “Your detail and fund of knowledge are already above average. Now work on paring out the extraneous details to make notes shorter. Also, frustrating as it is, patient visits will have to be shorter.” Specific, quantified, and even gives a pathway for improvement. • “Student A had a consistent problem with being punctual in the mornings, although that did improve by the end of the rotation. His motivation was okay, but most previous students have been more ambitious.” Professionalism counts! Examples of some of the best SUMMATIVE comments are below. These comments are usually included verbatim in the Dean’s Letter. • “A very mature, hard working and motivated junior physician with an exemplary work ethos. She worked hard and accepted and welcomed constructive criticism in order to develop and hone her emerging clinical skills. She was well received by patients and staff, being viewed as an effective team player and compassionate physician…I would consider hiring her if she completed a family medicine residency.” The preceptor has conveyed very well that this sounds like an idea residency candidate: smart, affable and malleable. • “Student A was one of the best students we ever had at this site. He was professional, knowledgeable, compassionate and had an excellent work ethic. He strives to give all tasks, even the seeming routine, his very best effort. He was especially effective in patient education and single-handedly convinced one of my patients to stop smoking.” Similar to above, and includes an example.

PRECEPTING • “She did what was needed to be done without being asked… She showed compassion and care which was far over and above what was warranted.” • “Student A not only revealed a deep fund of clinical knowledge from the start of his clerkship, he also maintained a rigorous learning plan throughout.” • “Many people commented that they hoped he’d consider family medicine for a specialty as he seemed to fit in and responded well to patients of all ages.” Patient recommendations carry a unique weight. • “Her understanding of the core content of family medicine, principles of preventive care, and her ability to put patients at ease during the exam were beyond what was expected at her level of training.” Specific, examples given, and quantified! Here are examples of the least helpful comments, formative or summative: • “Student A deserves a grade of honors.” Grading is based on multiple factors, please do not “promise” the student any specific grade. • “Just keep up the good work!” This was the entire comment. How can the student know what she did so well? • “Focus on working with the team. Continue to work on presentation skills.” What is wrong? Does the student have a problem with professionalism? Are the presentation skills too lengthy or too brief? This might have been an extremely valuable comment, but no specifics were given. • “You did well in your Family Medicine rotation.” Does this mean that student is average or above average? In what areas

did she do especially well? • “Student A was an excellent student who performed well above his current training level.” With no further examples, I have no idea if this is an accurate assessment or an exaggeration. • "Student A’s performance was good. I have no constructive criticism to offer." A lukewarm comment such as “good” is actually an indicator that the student may be in the bottom half of the class. Is this what the preceptor meant? How well does the preceptor really know this student? • “Will do well in residency. Pleasure to work with.” This comment needs to be “fleshed out” in order to carry weight. It is a “near-miss” for a truly positive evaluation. What can you write about a student who is “merely” average, but has worked hard and should be proud of her accomplishments? A preceptor may wish to praise and encourage her without exaggerating her skill level. The following verbiage may be helpful: • "Student A is right on track for her level of training." • "Student A worked hard during this rotation and made steady progress. Her history taking skills were not well developed in the beginning, but she responded well to suggestion and improved greatly by the end of the rotation." • "Student A is a good student with a solid knowledge base." Hopefully the above discussion will help preceptors to evaluate students in a fair, accurate and useful way. Preceptors are the backbone of family medicine education. Thank you to all our preceptors for your hard work and commitment.

MO-AFP.ORG 19

MEMBERS the

IN NEWS NEWS TO SHARE?

The Missouri Family Physician magazine welcomes your input. Please submit newsworthy items for review to: office@mo-afp.org

Tatum wins Distinguished Physician Award

Paul Tatum, MD

The Cunniff-Dixon Foundation recently awarded Paul Tatum, MD, MSPH, associate professor of family and community medicine at the University of Missouri School of Medicine, with the 2016 Hastings Center Cunniff-Dixon Physician Award for Outstanding Care of Patients Near the End of Life. The Hastings Center seeks to support palliative care skills and virtues by awarding financial prizes to physicians who deliver excellent patient-centered palliative care. The Cunniff-Dixon Physician Award is given in categories of senior, mid-career and early-career, with Tatum winning the $25,000 mid-career award.

Ratcliff, physician champion for Million Hearts Program On October 12th, in Springfield, Dr. Keith Ratcliff gave a presentation at the Missouri Million Hearts Conference on the program "TargetBP" (www.targetbp.org), which is a joint effort by the American Heart Association (AHA) and the American Medical Association (AMA) to increase awareness and treatment of high blood pressure in our nation. The premise is that by focusing on the control of blood pressure in our individual patient populations within our practices, we can make a meaningful impact on the health of our population. Ratcliff Dr. Ratcliff has been a physician champion for the Million Hearts Program of the American Heart Association since the program's inception in 2012 (www.millionhearts.hhs.gov). The Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services co-lead the initiative on behalf of the U.S. Department of Health and Human Services. The conference was generously co-sponsored by the Greene County Medical Society and Dr. Jim Blaine of Springfield was the moderator.

Schultz leads efforts to implement POCUS Dr. Jon Schultz, Associate Residency Program Director Sports Medicine, Department of Community and Family Medicine at Truman Medical Center Lakewood in Kansas City, MO, recently led efforts to have faculty and residents trained simultaneously on Point of Care Ultrasound (POCUS). Emphasis on recruiting and training a faculty and resident "super user" was paramount to the success of establishing a POCUS curriculum. After purchasing a Sonosite Edge ultrasound unit, Sonosite educators taught two free mini-POCUS courses for interested faculty to jump start their skills. Josh Booth, MD, first year resident super user was identified via a rigorous application process to attend an all-expenses paid two-day POCUS course, in exchange for assistance in developing a resident-led POCUS curriculum. As a result, POCUS is currently being used on a more regular basis to deliver low cost, efficient healthcare to our patients in Jackson County. 20

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Schultz

Booth

Dr. Peter Danis serving his 17th year of medical missions Dr. Peter Danis, faculty physician at Mercy Family Medicine Residency, St. Louis, participated in a 10-day medical mission trip to El Salvador. Hosted by Helping Hands Medical Missions (HHMM). HHMM has served more than 212,000 patients and hosted 134 medical missions in; Mexico, El Salvador, Venezuela, Brazil, Dominican Republic, Guatemala, Philippines, and Ghana. Each mission is 9-12 days and 10 missions are scheduled annually. This is Dr. Danisâ&#x20AC;&#x2122; 17th consecutive year joining the group for an annual mission. If you are interested in joining Dr. Danis on future trips, more information can be found at www.hhmm.org.

University of MO-Columbia resident retreat

Heafner elected to serve on AAFP Commission John Heafner, MPH, was appointed to serve on the AAFP's Commission on Health of the Public and Science. Heafner will serve to provide information and strategies for improving the health of the nation.

University of Missouri Family Medicine residents pose for a picture after their 2016 resident retreat. The residents explored innovative ways to help residents thrive during the training.

Heafner

Rues appointed to AAFP delegation Lawrence Rues, MD, FAAFP, was appointed to the AAFP Delegation to the AMA during the Dec. 6-11, 2016 Board of Directors' meeting. Rues will serve as a key source of information on activities, programs and policies of the AMA.

Shaffer appointed additional year on AAFP Commission

Shaffer

Todd Shaffer, MD, MBA, FAAFP, was appointed an additional year on AAFP's Commission on Continuing Professional Development during the Dec. 6-11, 2016 Board of Directors' meeting. Dr. Shaffer began serving on this commission in 2015.

Rues

MO-AFP.ORG 21

VOLUNTEER

Volunteers are the heart of MAFP

olunteers are at the heart of MAFP‘s work. Because of the contributions of volunteers’ time, talent, and expertise, MAFP is able to provide the essential information on issues and exceptional experiences important to family physicians.

VOLUNTEERING WILL ALLOW YOU TO: • Give back to the family medicine community by assisting in shaping sessions related to MAFP Conferences (Annual Scientific Assembly and Annual Fall Conference). • Share your voice in upcoming issues by taking an active role in identifying future family medicine trends and issues. • Make valuable business and personal connections by working alongside other family physicians. This will help broaden your network and build lasting friendships with other thought leaders. • Enhance your leadership skills by expanding on skills through your participation. WHAT CAN I VOLUNTEER FOR? There are many opportunities within MAFP for you to volunteer, below are just a few: • Board Member • Commission Member (remember, you do not have to be a board member to serve on a commission) • Tar Wars Presenter • Conference Speaker • Legislative Witness (testify) • Representative at the National Conference of Constituency Leaders (NCCL) • Represent the Missouri Academy on external advisory boards/committees We are seeking to build an energetic, inclusive, and innovative group of volunteer leaders. Together, we can accomplish incredible things and move family medicine forward. If this is an opportunity that interests you, we hope you’ll apply to volunteer for your organization, the Missouri Academy of Family Physicians. Email us at office@mo-afp.org or call 573.635.0830 today.

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.

DPCareClinics.com 22

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Chronic Care Management – A Critical Component of Primary Care NETWORK TMF QUALITY INNOVATION

Medicare Has Initiated a Non-Visit-Based Payment Code for Chronic Care Management

Introducing the Chronic Care Management Learning and Action Network

Care management is one of the critical components of primary care that contributes to better health for individuals and reduced health care expenditures. In recognition of this fact, the Centers for Medicare & Medicaid Services (CMS) introduced a non-visit-based payment code for chronic care management (CCM) services on Jan. 1, 2015. CCM is a technique that clinicians can use to effectively manage their Medicare fee-for-service (FFS) patients who have two or more chronic conditions. The CCM payment method allows eligible clinicians to be reimbursed for offering Medicare beneficiaries, with two or more chronic conditions that are expected to last at least 12 months or until death, with 20 minutes of non-face-to-face care coordination services a month.

A Collaborative Approach According to CMS, 35 million Medicare beneficiaries are eligible to receive CCM services, yet only 100,000 are receiving these valuable care coordination services, based on billing records as of October 2015. When the care of patients with two or more chronic conditions is not coordinated, there are increases in the use of hospital care, use of the emergency department, medication errors, polypharmacy and use of specialty care. To help increase the number of practitioners effectively implementing and providing CCM services to their patients, the TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) will leverage existing relationships with physicians, nurse practitioners and physician assistants in Arkansas, Missouri, Oklahoma and Texas. We will provide them with the technical assistance and expertise needed to implement CCM services. As a What is chronic care management? result, practitioners will also be better prepared for the implementation of Care management is one of the critical components of Act primary care that the Medicare Access and CHIP Reauthorization of 2015 (MACRA). contributes to better health for individuals and reduced health care expenditures. This will allow practitioners to participate in one of two payment options:The Centers for Medicare & Medicaid Services introduced a non-visit-based payment code the Merit-based Incentive Payment System or the Advanced Alternative for chronic care management Payment Models. (CCM) services on Jan. 1, 2015. CCM enables clinicians

to be reimbursed for providing 20 minutes a month of care coordination services to Our Goals their Medicare fee-for-service patients who have two or more chronic conditions.

Why Chronic Care Management? 67% of Medicare patients have 2+ chronic conditions

chronic conditions

93%

of Medicare spending is on beneficiaries with 2+ chronic conditions

Providing chronic care management (CCM) to eligible Medicare patients with 2+ chronic conditions means: Using 1 billing code for 20 minutes per month of CCM services Receiving monthly payments for your efforts

Through the Chronic Care Management project, patients will learn more

about their diseases How does this benefit me? and how to appropriately self-manage and participate

the practitioner’s office team. This will result in improved quality of care Medicare’swith payment structure for eligible clinicians providing CCM services can reduceisoverall medical costs to Medicare. to Medicare and beneficiaries approximately $42 per month (Current Procedural payment structurenon-face-to-face for eligible clinicians CCM Terminology Medicare’s Code 99490) for providing care providing and care coordination servicespatients. to Medicare beneficiaries approximately $42 per month Case for services to eligible Read the ChronicisCare Management Business Terminology Code 99490) for providing Participation(Current (PDF) toProcedural learn more about the benefits of offering CCM services and non-face-to-face care and care coordination services to patients with joining the CCM network. (tmfqin.org) two or more chronic conditions.

The TMF QIN-QIO will assist a minimum Join the chronic care management networkof 100 clinicians with identifying

Helping patients better manage their health

Join the Chronic Care Management Network Visit www.TMFQIN.org to join the Chronic Care Management network for free training and support.

eligibleInnovation patients and will help with processes such Organization as billing, documentation The TMF Quality Network Quality Improvement (QIN-QIO) is and service tracking tools as well ask providing educational T e x a s • A r a n s a s • M with i s stools oprocesses u rand i • such Oklahoma • Puerto Rico assisting clinicians with identifying eligible patients and will help Source: Centers for Medicare & Medicaid Services opportunities. as billing, documentation and service tracking tools as well as providing educational Continued tools, resources and events.

MO-AFP.ORG 23

ANNUAL SCIENTIFIC ASSEMBLY

2017

DATE in

THE

E EARN CM NETWORK RELAX

SAVE

2017

JUNE 9-10

THE LODGE AT OLD KINDERHOOK

ANNUAL FALL CONFERENCE

NOVEMBER 10-11

BIG CEDAR LODGE

2017

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