Summer 2015 (July-September)

MISSOURI Official Publication of the Missouri Academy of Family Physicians

Family Physician Annual Board Reports 2014-15 Year in Review Page 4 Meet Your 2015 Family Physician of the Year Arthur Freeland, MD, FAAFP Page 22 67th Annual Scientific Assembly Highlights from the Conference Page 28

Connect with MAFP on Twitter and Facebook Visit us online at www.mo-afp.org

July-September 2015 Volume 34, Issue 3

PATIENTS ARE

A VIRTUE

WHERE HEALTH IS PRIMARY. Long-term relationships built on trust between patient and doctor are the foundation of good health. That’s why primary care practices treat patients and their families as core members of their health care team.

Family doctors are dedicated to treating the whole person and are seen by their patients as partners. We believe every patient should have access to a health care team that understands and respects them.

Learn more about how you can play an active role in your health care at healthisprimary.org.

Brought to you by America’s Family Physicians

#MakeHealthPrimary

Contents MAFP

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: Carrie Peecher, DO (Unionville) 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: John Paulson, DO, PhD, FAAFP (Webb City)

Alternate: Charlie Rasmussen, DO, FAAFP (Branson) District 9 Director: Patricia Benoist, MD, FAAFP (Houston)

Alternate: Vacant District 10 Director: Vacant

Alternate: Steven Douglas, MD (East Prarie) Director At Large Emily Doucette, MD (St. Louis) resident directors Betsy Wan, MD (SLU) Kevin Gray, MD (Alternate) (UMKC) student directors Sarah Williams (MU) Jenny Eichhorn (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

MARK YOUR CALENDAR AAFP National Conference of Family Medicine Residents & Students (NCFMRS) July 30-August 1, 2015 Kansas City Convention Center Kansas City, MO AAFP Congress of Delegates September 28-October 3, 2015 Hyatt Regency Denver, CO AAFP FMX September 29-October 3, 2015 Hyatt Regency Denver, CO

MAFP 23rd Annual Fall Conference & SAM Working Group Register

by Oct. 5t November 6-8, 2015 h to save $5 0!

Big Cedar Lodge Ridgedale, MO (Board Meeting) MAFP Advocacy Day February 16, 2015 Capitol Plaza Hotel Jefferson City, MO 2016 Annual Scientific Assembly June 3-4, 2016 The Lodge at Old Kinderhook Camdenton, MO

INSIDE THIS ISSUE Pg. 2 Health is Primary 4 Annual Reports 12 Help Desk Answers (FPIN) 14 Resident Grand Rounds 18 Meet Your New President 22 Family Physician of the Year 24 Membership Anniversaries 26 OSA Follow Up Article 28 ASA Recap of Events 32 Safe Sleep Article 34 A Message from MAFP's Legislative Consultant 36 End of Session Report 40 FMCC Recap 41 ACLF/NCCL Recap 42 Members in the News 45 ICD-10 Update 46 Student Externships

Advertisements Pg. 2 Health is Primary 4 Children's Mercy Pediatrics Symposium 12 FPIN 13 FMX 23 NORCAL 25 AAFP Member Interest Groups 29 MPM/PPIA 31 Direct Primary Care, LLC 33 Results Billing Service 35 United States Army 44 SoutheastHEALTH 46 MHPPS 47 SLP, Inc. 48 Children's Mercy

mafp staff Executive Director - Kathy Pabst, MBA Education and Communications 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 Missouri Family Physician July-September 2015

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MAFP Outgoing Officer Report

"

bill fish, md, faafp, outgoing board chair

I

Bill Fish, MD, FAAFP

t has been a busy final year of my ten years on the board for MAFP and things don’t look to be slowing down for those who continue to serve and those who will serve in the future. Continued meaningful use implementation, repeal and retention of parts of the Affordable Care Act, ICD-10, and shift to ‘Pay for Performance’ will represent challenges for our membership and show the need for our organization. Implementation of the new "Assistant Physician" designation will represent a significant change in our state and MAFP has been involved with structuring the best way to integrate this new category of physician into our provider mix.

This year we testified and assisted in passage of legislation related to Direct Primary Care and reinstatement of limits on non-economic damages in medical liability cases. The Tort Reform doesn’t go far enough but it should help stabilize insurance rates. Special thanks to all those who worked diligently in the passage of these bills.

I thank all those who have given time to protect the health of our patients and improve the quality of practice of our members. I encourage each of you to see where you can help in your professional organization’s efforts related to advocacy and education. Try to attend our Advocacy Day in Jefferson City next February and attend meetings of our Education Commission or Advocacy Commission held during our two educational conferences in summer and fall.

The MAFP board is holding a strategic planning meeting in September with the assistance of AAFP staff to evaluate key issues to tackle and continue

4 Missouri Family Physician July-September 2015

I encourage each of you to see where you can help in your professional organization’s efforts related to advocacy and education."

effective representation of our members. Our executive director, Kathy Pabst, will be beginning an outreach program to be sure we are hearing about the various problems our members in different styles of practice face from day to day.

The Academy is in good hands with Dr. Dan Purdom chairing the board, Dr. Peter Koopman as our new president and Dr. Kathleen EubanksMeng as our president-elect. Dr. Jim Stevermer continues as our treasurer and all of these docs have done a terrific job in their service to the board. Take a moment to thank them and thank the director who represents you in your district.

Our directors are listed on our web site: www. mo-afp.org.

Thank you again to all of those who have served MAFP in any way over the past ten years. It was a pleasure working with all of you.

Annual Reports MAFP

peter koopman, md, faafp, president

A

s president elect of the academy this last year, I remain enthusiastic about serving Missouri family physicians.

This last year produced much to be excited about as American family physicians.

Advocacy efforts of your academy carry on regularly in Jefferson City and through events such as our state Advocacy Day and the Family Medicine Congressional Conference (FMCC) in Washington D.C. I attended both events. The state Advocacy Day is a wellattended event which has impact locally.

Based on feedback received from staff and the legislators themselves, our legislators do take notice when so many physicians are at the Capitol. This event, along with the hard work of our Advocacy Commission and its members, supported the passage of Direct Primary Care Legislation. This legislation, authored in part by your academy board, passed unanimously in the Senate and with an overwhelming majority in the House. This bill will allow better definition of Direct Primary Care practices in our state for numerous family physicians who desire to pursue this model of care delivery.

"

At the center of all we do remains the care of our patients, and we are privileged to be able to be family physicians doing this important work."

During this legislative session, Tort Reform also passed with our support, and we made our voice heard regarding the Prescription Drug Monitoring bill that reached our legislators. Although we strongly support a Prescription Drug Monitoring Program (PDMP) in Missouri, the bill that reached our legislators was a bill that failed to achieve any of the goals that are important to the majority of practicing primary care physicians. This bill did not pass. The

passage of a useful PDMP bill remains on our agenda. With these advocacy successes this year, I truly believe the voice of Missouri family physicians is heard in Jefferson City.

My time spent in Washington D.C. at FMCC also leads to a strong belief that primary care and family physicians are an important voice in federal policy discussions. It was a very positive conference this year. We touted the success of the Sustainable Growth Rate Peter Koopman, MD, (SGR) fix. This successful fix of the SGR FAAFP issue was driven by physicians in general; but events like the FMCC and also the work of the AAFP D.C.-based legislative team contributed majorly to allow bicameral and bipartisan support of the bill - eliminating the SGR. With SGR gone, our time with our legislators this year focused on promoting more exclusively the value of family medicine. This year we asked our Senators and Representatives to support examining graduate medical education funding in a transparent fashion, specifically where the funding goes. Once that funding information is available we can begin a conversation about what that large sum of taxpayer money should support. Following this path will lead to better funding and support of primary care and family medicine training.

I have met no one in Washington who does not see the need for an increased primary care workforce. A change in the way graduate medical education is funded will likely be a long process (it took 12 years to eliminate SGR) but we are moving in the right direction. The AAFP Family Medicine for America’s Health campaign intersects and supports this policy discussion smartly.

We, as an academy, will continue to support this discussion and demonstration of family medicine’s importance and relevance to the health of our nation.

I also attended the Annual Chapter Leadership Forum (ACLF) of the AAFP in Kansas City in May with our executive director, Kathy Pabst, and current vice president, Dr. Kathleen Eubanks-Meng.

Sessions attended allowed me to improve my leadership skills. I also had some great barbecue. This experience again emphasized continued on page 6 > Missouri Family Physician July-September 2015

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MAFP Annual Reports kathleen eubanks-meng, do, president-elect

M

President's Report, con't...

y first year on the Executive Commission as vice president has been both enlightening and informative. I am happy to be serving the Missouri Academy of Family Physicians in this way.

As a new Executive Kathleen EubanksCommission member, I Meng, DO want to introduce you to who I am, so that I may better represent you. I have been involved in the AAFP since residency in Kansas City, MO. I served on the Kansas City Academy of Family Physicians board as a resident physician and subsequently served on the board for 12 years and as president of the board for two years. I am currently in a physician owned, multispecialty practice in Lee’s Summit, Missouri.

Previously, I worked for a community-based hospital clinic in Grain Valley, Missouri and in a high volume urgent care clinic. I also serve as a clinical preceptor for the University of Missouri – Kansas City School of Medicine and the Kansas City University of Medicine and Biosciences. I am passionate about being involved and serving in the community I live in. I serve on the Parent Teacher Student Association at both Paul Kinder Middle School and Blue Springs High School as their social media chair. I also serve as an

executive board member for the Child Abuse Prevention Association in Kansas City.

As your vice president this year, I have learned advocacy in the changing role of family medicine and this has helped me become a better leader for the MAFP. These experiences have improved my understanding of family medicine’s future challenges. I attended the AAFP A.C.L.F. with current president elect Dr. Peter Koopman.

Leaders of state chapters from all over the country indicated how other states approach their academy business and showed both similarities and differences in topics important to each state and how this translates at a national level.

I also learned more about not-for-profit board membership policy and procedure. Collaboration is part of the mission and value of the PatientCentered Medical Home as well as the future of value-based reimbursement. The Missouri academy will need to continue to support structures and funding to allow that model to work most effectively and efficiently.

For the fourth straight year, my attendance at the MAFP Advocacy Day allowed me to continue to build relationships with our state and legislators. Advocacy Day allows our voices to be heard and improves our ability to be the most effective advocates with our message. We will also continue this type of advocacy with ongoing training for any members who want to participate.

We may not always get what we want, but we >>

how important our family medicine message is to our state and country. Skills I learned at this conference will help me strive for excellence for our academy. I look forward to pushing our academy to improve its function and ability to serve its members.

The Annual Scientific Assembly this year is well designed and should be excellent- as our educational conferences always are with the MAFP. I am excited to continue to help bring forth new innovations and top notch speakers for our conferences in the future. CME delivery is a dynamic changing environment (as is medical education as a whole). There are many challenges to changing the status quo but I plan to push our conferences to introduce innovations that allow you not just to participate in CME, but also learn new important knowledge. As an

academician at Mizzou, I am challenged daily to figure out how to better educate our medical students and residents and I plan to use these skills to help better educate Missouri family physicians. Education remains a major focus and priority for the academy.

As president in the coming year, I plan to learn and acquire new skills and reflect on how to improve as one of your leaders for the academy. I will consistently promote and support collaboration with our colleagues, advocate for our specialty, research to inform patient care, and the education of our future and current workforce. At the center of all we do remains the care of our patients, and we are privileged to be able to be family physicians doing this important work.

6 Missouri Family Physician July-September 2015

Annual Reports MAFP >> need to continue to advocate for our specialty as one of the primary roles for the academy.

As current co-chair of the Membership Commission, I am proud of our continued success with the MAFP magazine and our new website design in addition to a more consistent presence on social media. I look forward to continued changes and challenges of supporting our members and their needs from the MAFP. As president elect next year, I will continue to develop new skills to improve as one of your leaders for the academy. I look forward to working with and learning from Dr. Koopman during his presidency year. I will continue to promote services to our membership, collaboration, advocacy, and education. I look forward to our future together as family physicians.

jim stevermer, md, msph, faafp, secretary/treasurer

T

he financial stability of the Missouri academy is sound, and we continue to maintain an adequate reserve to ensure the long-term continuity of our organization. Because of the cyclic and intermittent nature of our income and expenses, Jim Stevermer, MD, it is a little harder to evaluate MSPH, FAAFP our actual flows against budget. However, our income is consistent with past years, and our expenses are under budget, primarily due to a staff vacancy. Kathy Pabst and I, along with the Executive Commission, are moving towards implementing a tobacco-free investment policy for the academy and the foundation.

executive director's report

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just completed one year with the MAFP which has been both rewarding and challenging.

I am constantly impressed with the dedication of family physicians to their patients and their profession. I am confident that the MAFP staff will further advance family Kathy Pabst, MBA medicine in Missouri in the coming years.

As I look back on this past year, I have learned that the MAFP is an organization that is moving forward and involved in the future of family medicine. This is evident in the recent announcement from the Family Medicine for America’s Health, Health is Primary campaign.

Missouri and Kansas are co-hosting a city tour in July of next year. We recommended this date as it will be in conjunction with the National Conference of Family Medicine Residents and Students…our future!

Advocacy is critical to the success of MAFP. The passage of the direct primary care legislation during this past session was a reflection of the collaborative efforts among all the stakeholders: MAFP members, board, Advocacy Commission, Pat Strader, MAFP staff, and our excellent relationship with the legislators. Pat Strader, MAFP Governmental Consultant, served as a resource to educate both legislators and members about the bill and the process. We are currently awaiting the governor’s signature on the bill. In addition, the passage of tort reform legislation was also a priority which will have a significant impact on family physicians.

Continuing medical education offerings are an excellent opportunity to stay abreast of key healthcare issues, network with fellow physicians and exhibitors, and to take time to get away and relax. The Annual Scientific Assembly this past year was held at a new venue, The Lodge at Old Kinderhook, and was a success. We hope to see you at the upcoming Annual Fall Conference, November 6-7, at Big Cedar Lodge, in the Branson area. We are working on an excellent lineup of expert speakers who are leaders in family medicine and health care.

AAFP assists state chapters through their many services and programs. The Missouri academy is

continued on page 8 >

Missouri Family Physician July-September 2015

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MAFP Annual Reports Executive Director's Report, con't...

actively involved by participating in conferences such as the Annual Chapter Leadership Forum, National Conference for Constituency Leaders, Chapter Executive Advisory Committee, Chapter Executive Leadership Conference, National Conference of Family Medicine Residents and Students, Family Medicine Congressional Congress, Congress of Delegates, and other topic specific educational opportunities. My participation in these events has allowed me to build relationships with other chapter executives, identify opportunities for collaboration, and to stay abreast of current issues impacting family physicians.

The MAFP has two new staff members who are available to provide member-centered services to the organization: Sarah Mengwasser, Manager of Education and Communications, joined us in September and brings her expertise

in design, writing, editing, public relations and communications.

Lauren Eichelberger, Member Services and Programs Assistant, joins us this month and will focus on recruitment and retention of our members. She will draw on her past experience of customer service, membership services, meeting planning and social media skills. The website was reconstructed last summer a continues to evolve as a resource to members.

Now, as we look to the future, the MAFP is preparing for its next five-year strategic plan, 2016-2021. This process will begin in September with a day-long strategic planning session facilitated by Nancy Laughlin, AAFP Manager of Chapter Relations. Your input is always welcome as we develop the vision of where we want to be in five years and what will it take to get there.

The journey continues…

resident report Cox Family Medicine Residency, Springfield

Graduating Seniors: Tim Burnett, DO – Hospitalist in Salina, KS Chris Carter, MD – Practice in Bentonville, AR Katie Davenport – Kabonic, DO - OB Fellowship at Cox FMR Michael Kabonic, DO – Faculty at Cox FMR Ryan McDowell, MD – Practice in Monett, MO Ruth Pitts, MD – Locum Tenens Hailey Small, MD – Practice in Dardanelle, AR Jamie Tribo, MD – Still in process of finalizing plans Luke Van Kirk, DO – Opening a DPC clinic in Springfield, MO Betsy Wan, MD Resident Director

News: 1. Chelsea Koehn, DO and Tim Burnett, DO, were married on May 2, 2015.

2. Samantha Potter, DO will be married to Zeb Wallace on June 6, 2015.

3. Steve Zinter, DO (R1) and his wife added a baby girl, Scarlett, to their family in August 2014.

4. Sarah Duda, MD (R2) gave birth to a baby girl, Charlotte (Charley) in October 2014.

5. Angela Conklin, DO (R1) gave birth to a baby boy, Graham, in November 2014.

Mercy Family Medicine

Graduating Seniors: Jennifer Allen, MD – FM practice in Hermann, MO Nick Moore, MD – FM practice in St. Charles, MO Julianna Lippert – Keck, MD - Wound care in southeast MO Dawn Davis, MD – Research at SLU Shahbaz Qalbani, MD – Urgent care in St. Louis, MO Laura Covert, DO – FM practice with Mercy

News: 1. Dr. Jim Lord, one of our faculty, will be retiring in July after 30 years teaching with MFM. 2. Dr. Peter Danis III will be stepping down as chairman and Dr. Grant Hoekzema will be our new chairman beginning in July 2015.

3. Between all of our residents we have had 2 births, 2 marriages, and 2 engagements.

8 Missouri Family Physician July-September 2015

Annual Reports

MAFP

Research Family Medicine Residency, Kansas City, MO

Graduating Residents: 1. Jessica Colanese, MD - Captain in USAF at Scott Air Force Base, IL 2. Jennifer Sturich-Cummins, MD – Shawnee Mission Medical Center Practice, Overland Park, KS 3. Eric Daharsh, DO – Private Practice, Lincoln, NE 4. Regan Dulin, DO – Private Practice, Manhattan, KS 5. Garrett Hooker, MD – Private Practice, Salina, KS 6. Cory Jabara, DO – Private Practice, North Kansas City, MO 7. Tu Anh Luong, MD – Docs Who Care 8. Erin McGonigle, DO – Shawnee Mission Medical Center Practice, Overland Park, KS 9. Maja Stefanovic, MD – Faculty Physician, Research Family Medicine Residency 10. Emily Valenta, DO – Private Practice, Raleigh, NC 11. Eileen Westhues, Do – Docs Who Care

News: 1. Drs. Colanese & Stefanovic are expecting their first baby.

2. Drs. Sturich-Cummins & McGonigle will be practicing together.

3. Maja Stefanovic, MD was selected as the Resident Teacher of the Year and we are so fortunate she will be staying on as a teaching physician.

4. Dr. Sturich-Cummins received the “Natural Medicine Database Recognition Award” for her achievements on the Integrative Medicine Track.

5. Saving the best for last: All of these graduates passed the ABFM Exam – we are SO proud!

Saint Louis University Family Medicine

Graduating Seniors: Gopy Arumugam, MD – Telemedicine and private practice in Toronto, Canada Brandon Luk, MD – Private practice with hospital medicine in Mystic, CT Clarice Nelson, MD – Splitting time between FQHCs in both Kansas and St. Louis, MO Victoria Spencer, MD – Private practice with St. Anthony’s in Fenton, MO

News: 1. Imani Anwisye, PGY-3, and her husband welcomed a baby boy in September 2014.

2. Matthew Witthaus, PGY-2, got engaged at Mizzou’s Homecoming in October 2014.

3. Preethi Schmeidler, PGY-1, and her husband welcomed a baby girl in February 2015.

4. All of our PGY-2 residents attended the MAFP Advocacy Day in February 2015.

5. All of our PGY-3 residents presented posters at the 4th Annual Primary Care Symposium at SLU in May 2015.

6. Kanika Turner, PGY-1, was awarded the SSM St. Mary’s Rising Stars Award and also attended the Congressional Conference in Washington D.C. in May 2015.

7. Thanks to the generosity of the Everest Foundation, we have expanded our residency to 6 residents per class from 4. In addition, we will be sponsoring a two-year research and faculty development fellowship (with option to obtain MPH).

8. Matthew Witthaus and Betsy Wan, PGY-2, are collaborating with several faculty members in a new Opioid Prescribing Protocol to improve patient and provider satisfaction with using narcotics for chronic non-cancer pain.

University of Missouri - Columbia

Graduating Seniors: Kristina Anderson, MD – Southern Illinois Healthcare in St. Louis and Belleville Blake Corcoran, MD – Sports Med Fellowship at University of Utah Seth Freeman, MD – University of Missouri Assistant Professor with clinic at South Providence Medical Park in Columbia, MO Andrew Horine, DO – Private Practice in Carrollton, MO Christopher Howse, MD – OSF St. Joseph Medical Center in Bloomington, IL Allison Kolker, MD – UMKC OB Fellowship Natalie Long, MD – University of Missouri Assistant Professor with private clinic in Columbia, MO Craig Luetkemeyer, MD – Capital Region Medical Center in Jefferson City, MO Jamie Luetkemeyer, MD – Capital Region Medical Center in Jefferson City, MO Mark Mueller, MD – Practicing at an FQHC in Oregon

Missouri Family Physician July-September 2015

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MAFP Annual Reports Morgan Schiermeier, MD – Capital Region Medical Center in Jefferson City, MO Kenneth Tan, MD – Hedrick Family Care in Chillicothe, MO Kate Williams, MD – Rural Health Clinic in Moberly, MO

student report University of Missouri – Kansas City

Sarah Williams, MD Student Director

Graduating Seniors: Jennifer Bihlmaier, DO, MS – Outpatient practice, Parsons, KS Jennifer Ann Blair, DO – Inpatient/outpatient/OB, Trenton, MO Case Calvin Everett, MD – Hospital inpatient/outpatient, Oskaloosa, IA Sara R. Fearn, MD – U of KS Geriatric Medicine, Fellowship, Kansas City, KS Laura E. Kresta, DO, MBA – UMKC Geriatric Medicine, Fellowship, Kansas City, MO Daniel Lalli Hills , MD – Still in process of finalizing plans Shawn Lillig, MD – Outpatient FM/urgent care, Kansas City, KS Mikael J. MacKinney, MD – Hospital owned medical group, Destin, FL Kristen Michael, DO, – UMKC Sports Medicine, Fellowship, Kansas City, MO Stephanie Million, DO, IPC – Hospitalist, Shawnee Mission, KS Barry A. Palizzi, DO – Private practice, Panama City Beach, FL Christopher Paynter, DO, MS – Clinic in Tipton, MO and outpatient hospital, Versailles, MO Benjamin S. Reine, DO – Private practice, Savannah, MO Dylan Thomas Werth, MD – Private/hospital practice, Harrisonville, MO

A.T. Still University – Kirksville

Jenny Eichhorn, Alternate Student Director

Number of FMIG Members: 107 FMIG Contacts: President: Rose Glastetter Vice President: Emma Hall Secretary: Stacy Buscher Treasurer: Evan Symons Family Medicine Match Data: • Number of students matching into FM residency: 35 - two are FM/Neuromuscular Medicine (NMM) • Number of students matching into Missouri FM residency: 6 - one is FM/NMM Meetings/Events: • March – Officer meeting: outgoing and incoming officer planning meeting • March – ACOFP National Convention: Rose Glastetter attended the convention in Las Vegas, Nevada. She participated in several hands-on procedures, learned multiple rapid OTM techniques, and listened to lectures on various topics related to family medicine.

• April – Senior Health Fair: various school organizations helped plan 18 different stations ranging from dermatology screenings and dental care to health history and physical exam. Fifty-two students volunteered at the event and nearly 25 local seniors attended the fair. ACOFP was responsible for planning the health history and vitals station, and ATSU-KCOM’s dean, Dr. Margaret Wilson, provided assistance.

• April – Suturing Workshop: Paula Mackrides, DO and four residents from the Quincy Family Residency lead a suturing workshop for ACOFP members. 41 students attended the workshop. There were four different stations for students to rotate through: suturing, knot tying, injections, and sterile gloving.

• May – Rotations and Residency Panel: Third/fourth year students and residents will speak to first and second year students about what to expect during rotations and residency.

• May – Backpack Drive: ACOFP will be collecting new and gently used backpacks for local elementary school students in need.

10 Missouri Family Physician July-September 2015

Annual Reports

MAFP

Kansas City University of Medicine and Biosciences

Number of FMIG Members: 191 FMIG Contact: President: Mohan Gautum Family Medicine Match Data: • Number of students matching into FM residency: 43 • Number of students matching into Missouri FM residency: 18 Meetings/Events: • EKG Clinic – Dr. Salanski and residents from Research. 75 students attended.

• April – Northeast Kansas City Chalkwalk health tent. Free blood glucose checks and BMI screens from 9am-5pm. Served about 25 community members with 15 volunteers.

Saint Louis University

Number of FMIG Members: 75 FMIG Contacts: Co-Presidents: Kris Pullam and Carly Salter Finances/Membership Chairs: Georgie Philip and Marina Tawfik Service Chairs: Michael Baltes and John Heafner Family Medicine Match Data: • Number of students matching into FM residency: 10 • Number of students matching into Missouri FM residency: 2 Meetings/Events: • February – Our Third Year Essentials meeting was a “speed dating” style event in which second year students preparing for their clinical rotations in May met with current SLU clinical students representing different third year rotations (family medicine, internal medicine, OB/GYN, pediatrics, surgery).

Students were given a chance to have their questions answered about working in the different clerkships, rotating between the different clerkship stations after a designated time. Attendance: 60 • March – FMIG assembled a panel of 4th year SLU students who recently matched into family medicine residency programs to discuss their experiences during the application and interview process. Attendance: 35 • April – FMIG organized a round table dinner discussion with several family medicine residents to discuss their experiences in family medicine and answer questions from students about preparing for and practicing in primary care medicine. Attendance: 20 • April – Coordinating with St. Elizabeth Hospital’s Family Medicine clinic in Belleville, Illinois, FMIG hosted a procedure night open to SLU medical students. Family Medicine residents gave hands on demonstrations of several common procedures in Family

48th Annual Clinical Advances in Pediatrics Symposium September 16-18, 2015 Children’s Mercy | Kansas City, Missouri www.childrensmercy.org/caps

continued on pages 44-45 > Missouri Family Physician July-September 2015

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HDAs HelpDesk Answers

is the combination of medication and psychotherapy better for the long-term treatment and prevention of symptoms in a patient with panic disorder?

EVIDENCE-BASED ANSWER In patients with panic disorder, antidepressant medication combined with psychotherapy is slightly superior to either alone during active treatment. After therapy is discontinued, psychotherapy and combination treatment are equally effective at preventing future symptoms, and superior to antidepressants alone (SOR: A, systematic review of RCTs).

Benzodiazepines do not appear to add benefit to psychotherapy alone (SOR: C, meta-analysis of heterogeneous RCTs).

Jay Brieler, MD Christine Jacobs, MD, FAAFP St. Louis University Family and Community Medicine St. Louis, MO

A

systematic review of 21 RCTs with 1,709 patients with panic disorder compared treatment using antidepressant medication or psychotherapy with the combination of both strategies.1 Selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs) were used in 22 of 23 comparisons and the monoamine oxidase inhibitor phenelzine was used in 1 comparison. Psychotherapy included behavioral therapy or cognitive-behavioral therapy (CBT) in 22 comparisons and psychodynamic therapy in 1 comparison. The primary outcome was significant improvement (“very much or much improved”) from baseline on the Clinical Global Impression Scale (CGIS), 40% or greater improvement in the Panic Disorder Severity Scale (PDSS), or a 50% or greater reduction in panic frequency on the Fear Questionnaire–Agoraphobia subscale.

During the treatment phase (up to 36 weeks), combination therapy had a better response rate than medication alone (11 trials, N=669; RR 1.6; 95% CI, 1.2–2.2) and psychotherapy alone (19 trials, N=1,257;

Interested in more HelpDesk Answers?

Get the answers to your clinical questions with a complementary 3 month electronic subscription to

Evidence-Based Practice!

To sign up for your free 3 month subscription, visit www.fpin.org/comp-ebp.

12 Missouri Family Physician July-September 2015

RR 1.2; 95% CI, 1.0–1.5). After discontinuation of therapy (measured 6–24 months later), patients who underwent combination therapy had fewer symptoms than patients in the antidepressant-alone group (5 trials, N=376; RR 1.6; 95% CI, 1.2–2.1), but no difference in response compared with patients in the psychotherapyalone group (9 trials, N=658; RR 0.96; 95% CI, 0.79–1.2). The review was limited by the lack of validated rating scales for panic disorder at the time of the RCTs, and the lack of control over additional therapies after discontinuation.1 Another systematic review of 3 RCTs involving 243 patients with panic disorder compared the efficacy of benzodiazepines, psychotherapy, or both.2 Alprazolam was used in 2 studies and diazepam in the third.

Psychotherapy consisted of behavioral therapy in 2 trials and CBT in 1 trial. Response was defined as (“much improved” or “very much improved”) on the CGIS or a score of 7 or below on the PDSS. Two trials involving 166 patients showed no difference between combination therapy compared with psychotherapy alone at 8 weeks (RR 0.78; 95% CI, 0.45–1.4) and after treatment had ended up to 7 months later (RR 0.62; 95% CI, 0.36–1.1). In 1 RCT, combination therapy was superior to benzodiazepine at the end of 8 weeks of treatment (N=77, RR 3.4; 95% CI, 1–11).

However, this finding barely met the level of statistical significance (P=.05). After discontinuation of treatment (7–12 months of naturalistic follow-up), no significant difference was found (RR 2.3; 95% CI, 0.79–6.7).

The review authors noted that the small number of studies and patients involved was a significant obstacle to determining the superiority of one treatment over another.2 The American Psychiatric Association recommends SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), TCAs, benzodiazepines, and CBT for panic disorder with no preference given to any specific therapy or combination.3 1. Furukawa TA, et al. Br J Psychiatry. 2006; 188:305–312.

[STEP 1] 2. Watanabe N, et al. Cochrane Database Syst Rev. 2009; (1):CD005335. [STEP 1] 3. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Panic Disorder. 2nd ed. Washington, DC: APA; 2009. http://psychiatryonline.org/pb/ assets/raw/sitewide/ practice_guidelines/guidelines/panicdisorder.pdf. Accessed March 20, 2015. [STEP 5]

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MAFP Resident Grand Rounds

spina bifida: an overview and primary care perspective CLINICAL VIGNETTE A 28 yo G2P2 at 20 weeks gestation presents for anatomical survey. The ultrasonographer notes an abnormality in the lower spine and informs the prenatal provider who reviews the images with a maternal fetal specialist. The specialist informs the patient that the fetus has a myelomeningocele. The parents are upset by the diagnosis and turn to their primary care provider for guidance.

Seth Freeman, MD

INTRODUCTION Spina bifida (SB) means “split” or “divided spine.”

It is a neural tube defect (NTD) usually found in the lumbar or sacral regions. Defects are referred to as “open” (myelocele, myelomeningocele) or “closed” (occulta, lipomyelomeningocele). SB occulta affects 3-5% of the general population and is often, but not always, asymptomatic.1 This discussion will focus on the open forms of SB and their clinical sequelae.

Optimal management of SB involves a multidisciplinary approach and includes: a primary care physician, a team of subspecialists (neurosurgery, orthopedics, urology), therapists (physical, occupational, speech), as well as state and local resources. Subspecialists and therapists are made available through SB clinics at tertiary care centers.

The lifetime cost is estimated to be greater than $635,000.2 Recent data demonstrate a 30-year survival rate of greater than 90%.2 Most patients will live into adulthood and have the opportunity to seek higher education, employment, and engage as productive members of society. Predicting the outlook/prognosis for someone with SB is nearly impossible. Assets such as a determined physical therapist and supportive family can be as vital to the child’s future success as is her specific anatomic defect.1

may reduce incidence by up to 70%;1,2,3 however, a single cause is not known with certainty. A 1989 large prospective trial revealed that NTDs were three times more likely among women not taking vitamins or who took them after the sixth week of pregnancy.5 A protective effect was noted to occur with a daily intake of 100micrograms (mcg) of folic acid.5 Several studies thereafter pointed toward a range of 400-800mcg3 daily as more effective in preventing NTDs. In 1992 the United States Public Health Service issued a recommendation that all women of childbearing age take 400mcg of folic acid daily. In 1991, the United Kingdom Medical Research Council published a trial demonstrating daily use of 4mg prenatally and into early pregnancy proved protective in women with a history of a previously-affected pregnancy.6 The United States Food and Drug Administration mandated that all enriched cereal grain products be fortified with folic acid by 1998. This produced a 31% decline in prevalence between 1996 and 2006, which translates to 1000 fewer affected infants yearly.3 Certain genetic syndromes account for a small percentage of SB including chromosome 5p deletion syndrome, trisomies (8, 13, 21), triploidy and tetraploidy.1

EPIDEMIOLOGY Approximately 1,500 affected children are born in the United States each year.3 Birth prevalence has now decreased to less than 1 in 1000 due to the fortification of enriched cereal grains with folate as well as prenatal diagnosis.3 A 1999 study found that prenatal diagnosis has led to an elective termination rate of approximately 50%,4 however, it is difficult to determine a more accurate figure with the current literature.

EMBRYOLOGY The early embryo is comprised of three germ cell layers. The neuroectoderm – part of the ectoderm that gives rise to the central nervous system– is comprised of two neural folds at around 18 days gestation. Crests form as part of the neural fold and come together near what will be the upper thoracic/ cervical spine. The crests then fuse rostrally and caudally until a closed neural tube is formed, around day 30. SB occurs as a result of errors in this neurulation process.

PATHOGENESIS Folic acid plays a large role in the pathophysiology and following current supplementation guidelines

ANATOMY Open SB is a NTD that is not covered with skin.

The meninges form a fibrous sheath around the

14 Missouri Family Physician July-September 2015

Resident Grand Rounds MAFP spinal cord which is splayed open and exposed (a neural placode) in a myelomeningocele. A myelocele is an open NTD that contains meninges without neural tissue and is generally a small sacral lesion.

Surgical closure of these open defects occurs within 72 hours of birth.1 Postoperatively, infants are placed prone for several days while receiving prophylactic antibiotics.

Myelomeningocele. Note the reddish neural placode with surrounding redundant skin tissue (pink).

The Arnold-Chiari II Malformation affects almost all patients with SB and includes: downward displacement of the cerebellum, elongation and displacement of the fourth ventricle and medulla, a small posterior fossa, and hydrocephalus.

Hydrocephalus may lead to increasing pressure on brain parenchyma. As a result, approximately 90% of children with myelomeningocele require placement of a ventriculoperitoneal (VP) shunt.1,2 Primary Care Pearl #1 Symptoms of shunt malfunction (occurs in 85%): • Irritability • Vomiting • Stridor • Poor feeding • Progressive hydrocephalus The shunt can be a significant source of parental stress. The PCP can provide reassurance if a common childhood illness is evident.

DIAGNOSIS A maternal serum alpha fetal protein (MSAFP) screen between 15-20 weeks gestation and the anatomical survey (morphology scan) between 18-22 weeks gestation are 80-85% and 9095% sensitive for detecting NTDs,2 respectively.

Amniocentesis can also be helpful in establishing a genetic cause for NTD through karyotype and microarray analyses. At diagnosis, refer to a medical geneticist, genetic counselor, maternal fetal medicine and pediatric neurosurgery to discuss potential fetal surgery.

FETAL SURGERY The Management of Myelomeningocele Study (MOMS), a 2011 randomized control trial, compared outcomes of prenatal vs traditional postnatal repair of myelomeningocele.7 It demonstrated a 50% less risk for VP shunt placement at 6 months and patients were twice as likely to walk independently at 30 months. While promising, prenatal surgery has significant risks including prematurity (average of 34.1 vs 37.3 weeks at delivery) and uterine dehiscence (10%).7 Most centers require modified bedrest for the remainder of the pregnancy after surgery is performed between 21-24 weeks.

Primary Care Pearl #2 Even if the family would not consider elective termination, would they benefit from early detection/more information? Referral for prenatal surgery must be made between 21-24 weeks.

The patient is referred to Vanderbilt University for evaluation of possible prenatal surgery. The OB team determines that a small placental abnormality is a contraindication. The infant is delivered by Cesarean section at 40 weeks and undergoes traditional repair of a L4-L5 myelomeningocele as well as placement of a VP shunt at a local center with a Level 3 neonatal intensive care unit.

PRIMARY NEUROLOGIC IMPAIRMENTS SENSORY Sensory nerves do not properly form at the site where the neural tube fails to close – also referred to as the “lesion level.” Sensation is either absent or impaired distal to the lesion level; partial or asymmetric sensory losses are common.

Determining sensation is a difficult but important task in an affected infant as it has implications for mobility and skin care.

MOTOR As with sensory deficits, the lesion level is the main determinant of motor function. Deficits are often asymmetric. The L3-L4 motor functions of knee extension and hip flexion/extension are important for independent walking. The prognosis for independent walking for patients with L3 lesion levels and below is excellent.1 Those with higher lesions may also walk, but may require more extensive bracing or prefer to use a wheelchair when traversing longer distances.

The importance of physical therapy cannot be overstated. The goal of the physical therapist is to

continued on page 16 >

Missouri Family Physician July-September 2015

15

MAFP Resident Grand Rounds AUTONOMIC The autonomic nervous system is important for sensation, coordinated muscle contraction, and sexual function. Sacral and lumbar parasympathetic nerves play a crucial role in bladder, urethral, and rectum sensory and smooth muscle function.

Sympathetic nervous function is important in arousal and orgasm, especially in men.

Resident Grand Rounds, con't...

Pressure sore of the heel after malpositioned orthotic worn overnight.

improve the patient’s functional level beyond the initial limitations of the anatomic level. Common equipment tools include orthotics like ankle-foot (AFO), and knee-ankle-foot (KAFO). Electrical stimulation units have been used successfully in spinal cord injury patients, but have not been studied in SB.8

Knee-ankle-foot orthoses for a toddler with myelomeningocele.

Primary Care Pearl #3 Timely return on therapy prescriptions is important. Equipment often takes weeks to obtain after ordering.

16 Missouri Family Physician July-September 2015

Areas of Strength

Areas of Weakness

Social

Attention

Phonological processing

Abstract reasoning

Long-term memory

Visual perceptual

Expressive language

Hand-eye

Reading

Visual-motor

Spelling

Math

Table 1: Cognitive trends in Spina Bifida, adapted from Living with Spina Bifida6

COGNITIVE In general, the average IQ for children with SB is similar to or slightly lower than the general population. Trends in cognitive strengths and weaknesses have been observed and can be seen in Table 1. It is important to note that future cognitive ability cannot be predicted based solely on the severity/degree of hydrocephalus.

SECONDARY NEUROLOGIC IMPAIRMENTS ORTHOPEDIC Hip dysplasia/subluxation/dislocation is a common concern and is generally a progressive process. It is usually a consequence of functionally strong hip flexors and weak hip extensors. Clinical findings may include leg length discrepancy, extra skin folds, asymmetry, and decreased abduction.

Club foot is the most common orthopedic impairment at birth. Congenital vertical talus, or “rocker-bottom foot,” is also seen. Both of these conditions are corrected surgically, with orthotic shoes and a bracing bar used to maintain proper postoperative alignment.

Scoliosis is a common problem for patients with a lesion in the thoracic spine, and is also a result of muscle imbalance and asymmetry.

Osteopenia affects many individuals and results from an inability to bear weight normally. Fractures may present with erythema/edema only if present in an insensate limb.

Primary Care Pearl #4 If the diagnosis of possible occult fracture is in doubt, obtain an xray.

Resident Grand Rounds MAFP BLADDER DYSFUNCTION Almost all individuals have neurogenic bladder. This leads to an increased risk for urinary tract infection and progressive renal damage. Assessment of the genitourinary tract with ultrasound and urodynamic studies is performed periodically in the first few years of life. Many patients utilize clean intermittent catheterization (CIC) which may lead to chronic bacteruria and make the diagnosis of UTI challenging.

Primary Care Pearl #5 If UTI is suspected, obtain a clean catheterized specimen and assess CIC adherence. Communication with the patient’s urologist is key.

BOWEL DYSFUNCTION Fecal incontinence and constipation often result from abnormal lower gastrointestinal tract innervation. Patients often have colonic motility issues and struggle with sphincter control. Bowel-management programs help promote regular elimination of stool which has significant social implications.

Laxatives, enemas, dietary changes, and timed toileting can all be helpful in achieving continence.

SEXUAL DYSFUNCTION Affected males often deal with altered sensation in the groin as well as erectile dysfunction, but can still be fertile.

Females of child-bearing age should be counseled on contraception options as well as folate supplementation. Girls with hydrocephalus often experience precocious puberty.

Menarche occurs between 10.9 and 11.4 years compared to the Caucasian average of 12.7 years.2 SKIN ISSUES Latex allergy is very common in the SB population. The pathogenesis is thought to be related to early exposure in surgery. Monitor patients for the development of allergic symptoms.

Malpositioning of orthotic devices can lead to pressure sores. Management often involves an orthotic holiday until the sore is healed. Unfortunately, this often means that physical therapy sessions are delayed and may result in regression of strength gains.

Bowel and bladder incontinence may lead to diaper rash and skin breakdown, which is often difficult to control. Recommend barrier creams/ointments along with a cornstarch-based powder.1 Primary Care Pearl #6 Check the child’s skin at each wellness visit and ask parents about allergy concerns.

At 24 months of age, the toddler is able to ambulate with a walker and is working towards independent standing/walking.

Cognitive development is normal. The parents are grateful for the information and support provided by their family physician.

Works Cited: 1. Sandler, A. M. (1997). Living with Spina Bifida: a Guide for Families and Professionals. Chapel Hill (NC): University of North Carolina Press.

2. Burke, R., & Liptak, G. (2011). Providing a Primary Care Medical Home for Children and Youth with Spina Bifida. Pediatrics, e1645-e1657.

3. CDC. (n.d.). Spina Bifida. Retrieved from http://www.cdc.gov/ ncbddd/spinabifida/ 4. Mansfield, C. (1999). Termination rates after prenatal diagnosis of down syndrome, spina bifida, anencephaly, and Turner and Klinefelter syndromes: a systematic literature review. Prenatal Diagnosis, 808-812.

5. Milunsky, A. (1989). Multivitamin/Folic Acid Supplementation in Early Pregnancy Reduces the Prevalence of Neural Tube Defects.

JAMA, Vol262, No.20, p2847-2852.

6. UK Medical Research Council. (1991). Prevention of neural tube defects: Results of the Medical Research Council Vitamin Study. The Lancet, Vol338, No. 8760, p131-137.

7. Adzick, S., Thom, E., & Spong, C. (2011). A Randomized Trial of Prenatal versus Postnatal Repair of Myelomeningocele. New England Journal of Medicine, 364:993-1004.

8. Stein, R. (2002). Electrical Stimulation for Therapy and Mobility After Spinal Cord Injury. Progress in Brain Research, 137:27-34.

attention

residents DO YOU 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 (573) 635-0830 or email office@mo-afp.org for more information

Missouri Family Physician July-September 2015

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MAFP President

meet your new 2015-2016 mafp president, peter koopman, md, faafp

From left: Mike Doerhoff, Susan Horak, Dr. Koopman, Katie Koopman (daughter), Richelle Koopman, MD, MS, FAAFP (wife) Matt Weider, Liz Koopman (daughter), Becky Weider and Betsy Garrett, MD, MSPH.

W

hen I was five, my mom told me that I came home from a school health class and said, “I want to be a doctor." I don’t actually recall that moment but I heard it repeated so many times that it is hard to be sure. Mom certainly reminded me enough about it. No one in the family was involved in health care except for my grandmom who had been a nurse. As the youngest of six kids, with no siblings making similar statements, I think mom saw me as the last hope for a doctor or lawyer in the family. She latched on to that childhood statement with vigor.

My earliest actual recalled memory regarding wanting to be a doctor was around the age of 10 when I chose my confirmation saint.

In Catholicism at confirmation you choose a personal saint. I remember choosing Saint Jerome at least in part because he was called the “doctor” of the Catholic church. Although Saint Jerome actually received that title due to his academic background and contributions to the first translator of the Bible to common language, I chose Jerome in large part due to his association with the term “doctor." Being a “doctor” was my plan by this time. It was very idealistic. I was enthralled by people who devoted their life to the service of others. I wanted to help people - People like Mother Teresa and Martin Luther King Jr. and 18 Missouri Family Physician July-September 2015

closer to home, my family doctor, Dr. Hemmerly, were role models. Doc Hemmerly was my doctor and a family friend. I played with his youngest son Brian. His office was attached to his house and his wife was his business manager. I strongly remember being jealous of Brian whose dad was almost always at home and whose dad worked to make people feel better. My dad was usually away and in service to “business."

My father was a successful businessman, but I had no interest in following that model. As a teenager, making decisions about the direction my life would follow, one of my young teenage rebellious thoughts, “I am not going to grow up like dad; all he cares about is money and the making of it. I want to help people.” Regardless of how inaccurate and unfair to my dad that young belief was, it drove me for a while. I worked hard in high school knowing how important grades were to my now career choice of doctor and got into an excellent college.

During college my dad passed away of pancreatic cancer. During his illness, I was exposed to some of the good and bad of our medical system, including a horrible delivery of his diagnosis from a stressed resident standing in a doorway that I was sure could have been done much, much better. Despite this experience, by the end of my time at the University

President MAFP of Pennsylvania I had experienced some real medical interactions and had a more adult realistic desire to be a “doctor." I was confident I could do better than the resident who told my dad he was dying.

"

I believe that our specialty is what most people still envision as a “real” doctor - A family doctor: A counselor with advanced medical knowledge who has the empathy and skills to listen to them, develop a relationship with who they are as people, and make accurate and appropriate diagnoses."

I attended the University of Pittsburgh Medical School after graduating with a psychology major, and my plan at this time was to be a psychiatrist. During college the study of the brain and how it worked energized me. By my fourth year of med school, having had a few unfortunate encounters with psychiatry doctors and residents, I was conflicted on my specialty choice. Early in that year I did a family medicine elective rotation at St. Margaret’s Hospital in Pittsburgh. Pitt Med in 1991 did not have family medicine clerkship in the third year so I had not yet seen a family medicine doctor at work. At St. Margaret’s, I met Dr. Jim Ferrante. He immediately reminded me of Doctor Hemmerly but also a little of my dad and he challenged me to reflect on what sort of “doctor” I really wanted to be. This rotation experience was an 'a-ha' moment that I truly wish my medical school had allowed me to experience in the third year. Dr. Ferrante and his colleagues were the first truly patient-centered doctors I had spent concentrated time observing at Pitt. They seemed to enthusiastically care about the patient and who they were.

They treated their patients as people and not just a disease.

They desired to care for people as they were and where they were. Their time spent listening to their patients’ needs with less emphasis on a bottom line resonated strongly with me. They cared about how to deliver bad news which was very important to me. They also seemed to be having fun.

These doctors certainly were smart and thoughtful, but also empathetic. These doctors inspired me like some of my earlier childhood role models. During that four-week rotation, my desire be a “doctor” became a youthful ambition to be like these doctors I was working with. I wanted to be a family physician.

From that point on I have remained resolute in that desire. I have continued to want to be a Family Physician. I tell this tale not just to let you know me better as your incoming president of this academy, but also hopefully to resonate with those in our academy. We choose this specialty for many reasons, the ones I just elucidated are mine; but I have a firm belief that the importance of caring for each patient and not just their disease, and the duty of being empathetic and developing a relationship speaks to each of us in what we do every day. I believe that our specialty is what most people still envision as a “real” doctor - A family doctor: A counselor with advanced medical knowledge who has the empathy and skills to listen to them, develop a relationship with who they are as people, and make accurate and appropriate diagnoses. This doctor provides healing as comprehensively as possible, directs the patient to the right person to heal them if their scope has been breached, and consoles them and provides support when no cure is known. I do this every day and I know you do also. I am a family physician and I am proud to be a family physician.

Dr. Peter Koopman with his presidential oath.

I now start my term as the president of the Missouri Academy of Family Physicians. I am honored to have been chosen to serve in this role. The ability to help influence the specialty of family medicine, which I choose more than 20 years ago and to which I remain committed, is a remarkable privilege. I feel just as proud of this specialty as I did when I committed those many years ago. In my experience with this academy, we remain the humanistic center of the medical profession. We care about the patient in their whole-not just their disease. We work on developing empathy and communication skills and make the relationship a central part of the therapeutic package we deliver. We trumpet >> Missouri Family Physician July-September 2015

19

MAFP President >> patient centeredness and actually transform our practices to attempt to make them more patient centered. The aspects and values of family medicine that inspired me in my fourth year of medical school remain at the heart of what each family medicine doctor does every day. These same values drive this academy. I am inspired by this specialty and my colleagues.

In the last two years on the Executive Commission, and in years before serving on the board and commissions, I have learned and done many things. I have worked with other health care providers and medical school administrators and colleagues to define family medicine and declare its importance. I have worked collaboratively with many groups to work towards how to best serve the needs of the patients in the state. As physicians, I believe it is our duty to support health care to all, both in our practices and in the policies we support. I have become a citizen advocate for policies important to our specialty at the local, state and federal level. I have learned some of the intricacies of how policy is enacted in our government and have been surprised at the unpredictability of change. In our legislative bodies the speed by which change occurs is both at times frightening and frustrating. Our academy has played a role in supporting, creating and opposing legislation at the state and federal level based on the values that Missouri family physicians embrace. I have continued to encourage the scholarship seen in our Missouri Family Physician magazine and the resident and student poster contests. I have become fully aware of the work it takes to put together a medical education conference and the challenges to try to make each conference fresh and meaningful. I have supported the work of inspiring students to pursue family medicine through our statewide family medicine Interest Groups, and supported our residents across the state to attend our educational conferences and be involved in academy business. Interactions with the future of family medicine in these young students and physicians continues to give me faith in that future.

Based on these experiences and my vision for family medicine, I plan to focus on four main topics in the next two years as your president and board chair. In fact, I created a mnemonic in the form of an acronym to make it easier for me to remember; and also because docs love acronyms. Mine is CARE - Collaboration, Advocacy, Research and Education. The acronym spells care, and I believe the care of our patients needs to be at the center of our values and remain our focus.

CARE starts with C - Collaboration - As family physicians we need to continue to collaborate. We all realize that to provide a full range of primary care to patients from all walks of life that is patient centered, we need help. It takes a team. We need to define our teams and debate who is on the team. We need to ask, "Are there other care models that work other than what we are doing now?" We need to be forward thinking and innovative. I do not believe in change for change’s sake, but also there is danger in never exploring what can be done better. The team that each family physician needs to 20 Missouri Family Physician July-September 2015

Dr. Richelle Koopman, Dr. Koopman's wife, swears him in at the Saturday evening installation banquet.

"

CARE - Collaboration, Advocacy, Research and Education."

best serve their patients will vary. We need to respect that individuality, but we also need to accept change and work with it to improve the care we deliver. Collaboration is one of the ways we survive and thrive. As Darwin said, “In the long history of humankind (and animal kind, too) those who learned to collaborate and improvise most effectively have prevailed.”

The academy will continue to support the discussion of these issues and help shape decisions respecting the needs of family medicine.

A - Advocacy - We need to advocate for our specialty and our patients. Our specialty has been shown in situations in the U.S. and across the world to produce better patient outcomes and bend the cost curve. Our legislative bodies now acknowledge this fact when they make policies that impact the health care of our state and nation. I have seen our advocacy events have an impact. We are getting better at advocacy both locally and nationally but we need to continue to show our elected leaders and the country the value of family medicine.

Family medicine has data to support its value but we need a consistent and compelling message. The family medicine for America’s Health campaign is an excellent program and can begin to deliver that message. We need to support this program. Events such as the family medicine Congressional Conference and our local Advocacy Day have impact; but in these settings we have made promises regarding bending the cost curve and pursuing better quality. We need to work hard to fulfill this promise for our patients and for our state and country. We have the potential to deliver on the triple aim of better patient outcomes, lower cost and improved satisfaction; but in order to do so, we as family physicians need to remain committed and informed. This academy will continue to

President MAFP advocate for payment reform, graduate medical education reform and better resources for primary care. Your academy will continue to keep you informed. We, as clinicians, need to stay focused, aware and adaptable.

R - Research - We need to continue to produce data supporting family medicine’s value. We need research into patient centered outcomes that inform our delivery of care.

We need to advocate for funding to support this. The Robert Graham Center has already done great work showing the value of primary care and will continue to do so. We need to spread that information widely and effectively. Our academy magazine and communications can be used as a tool for bringing value of family medicine issues to our membership.

We have included in our magazine clinical inquiries with evidence-based answers to inform our membership. The continued research into how to best deliver care and what is the best care to deliver to our patients needs to be central.

The strongest possibility of delivering on the promise of family medicine depends in large part of having well researched data available to those delivering the care. The academy will continue to work on improved ways to deliver and support this type of research and the dissemination of these results and conclusions.

Lastly E - Education - Educating the current and future workforce of family medicine needs to be a priority. The academy accomplishes this in part through conferences such as the spring and fall conferences. Those events need to continue to improve in delivering relevant and important information in accessible ways. Medical students also need to hear about the value and importance of family medicine.

Residents need support in our state with meaningful education and inspiration. Our academy needs to develop tools and events to work on our workforce. I hope for events at each medical school and residency in the state which better inform and hopefully inspire this future population of potential and young family physicians. Inspiring future family physicians is essential to our continued growth and vitality.

Focusing on graduate medical education funding transparency may allow us to better support family medicine training. Your national academy is beginning this discussion in D.C. If we can continue to demonstrate the value of family medicine and demonstrate that our medical education funding system currently undervalues and has limited commitment to family medicine training; then we hopefully can convince Congress that the billions of dollars spent by taxpayers to support post graduate training of physicians needs to in-part, be tied to producing more family physicians.

Collaboration, Advocacy, Research, Education - this spells CARE. The core of who we are is in the care we take of our patients. We do need to collaborate with our colleagues and others, advocate for our patients and specialty, support research that informs patient care and educate our current and future workforce. Your academy will continue to work on these goals, but we as family physicians need to work on

delivering the best care possible. By taking excellent care of your patients and being a great family physician, you will deliver on the promise of patient centered and relationship driven primary care. Recently, my office on Doctor’s Day, honored its physicians by collecting patient statements about their doctors. I will share a few of the ones collected about myself: “Great manners, friendly and encouraging, Thanks for caring!”; “You make me feel safe and taken care of more than any doctor in the past.”; “Thank you for being such a wonderful and caring doctor.”; “Thanks so much for taking such good care of me. You have saved my life! I appreciate you.” Statements such as these humble me. It is an honor to have a job that allows me to help people and get paid for it.

My youthful dreams have become an adult reality. I do realize this work is incredibly hard some days. I struggle to find the energy and empathy to do it effectively at times and often feel overworked and vexed by systems that do not support what I do; but I would not choose a different path if given the choice. These patient statements resonate with me as to the value of what we do. A patient-centered physician who develops a relationship with you can save your life. Consistent and compelling research data shows that health systems that value primary care produce better outcomes and lower cost.

Incredible value to the people in our state, those in need of health care, and also to the nation’s wellness, exists in what we do every working day. I promise I will CARE for this specialty in the role I have been given. I ask of you to strive to be the best family physician you can be for your patients. I am proud to be a family physician and honored to be the president of the Missouri Academy of Family Physicians. Thank you all so much.

Richelle Koopman, Dr. Koopman's wife, installed him as the 2015-16 President. Peter and Richelle have been partners in family medicine practice for 13 of their 19 years in practice.

"

It's nice to practice together...some days we even get to have lunch together. We went through medical school, residency, and indeed, even college together. Therefore, I feel exceptionally qualified to tell you that you have chosen the right person for the job."

Richelle Koopman, MD, MS, FAAFP

Missouri Family Physician July-September 2015

21

MAFP 2015 Family Physician of the Year

kirksville physician named mafp family physician of the year

"

My family has long thought that his [Dr. Freeland's] work attire should involve some sort of cape." - Patient of Dr. Freeland

L to r: Arthur Freeland, MD, FAAFP, his wife Kelly, and their three children.

D

r. Freeland of Kirksville, Missouri, was chosen as the award recipient by a committee of family physicians from nominations made by patients, community members and fellow physicians.

If you want to get something done, give it to a busy person…this statement is so true about our Family Physician of the Year, Dr. Arthur Freeland. His involvement in medical clinics, community groups, and local organizations shows his commitment to not only his patients and profession, but to medical students and those who live and work in the Kirskville area.

Dr. Freeland was recently featured in the University of Missouri, Department of Family Medicine’s August 2014 newsletter as the featured family medicine preceptor. As a graduate of the MU School of Medicine, and we won’t say what year, he continues his commitment to MU by serving as a preceptor.

MU Students have praised Dr. Freeland as a teacher and a physician. One stated, “Dr. Freeland is a natural teacher. By allowing me to participate in the patient care process and asking my opinion about diagnoses and treatment decisions, he broadened my knowledge on many topics.” As part of another medical student’s rotation cycle, Dr. Freeland opened his home to this student and was able to share the life of a family physician, both in the clinic and outside at the home.

22 Missouri Family Physician July-September 2015

Dr. Freeland’s commitments are for the long term. Whether it is serving the youth in Boy Scouts of America through fundraising and leadership, touching the lives of the many family medicine students he has mentored, or through his volunteer efforts in his community and church. He is vested in the future, the future generation of physicians, the future of his community, and the future of his family.

Dr. Freeland’s mentee mentioned he was on the verge of burnout…yet after seeing the sacrifices Dr. Freeland made for his patients, his dedication to teaching future generations, and his kindheartedness, his mentee's passion for medicine grew. Dr. Freeland inspired him to become a better future doctor.

As one patient stated, “His colleagues seek his advice and the community benefits from his consistent contributions. Arthur has earned the trust we all seek in our leaders and representatives.” Another patient feels that because of the exceptional care that he provides her and her family, 24/7/365, his “work attire should involve some sort of cape.” Yes, Dr. Freeland could be Superman in the Kirksville, Missouri area – just ask his patients.

In Dr. Freeland's closing statements, he concluded, "At least in their [patients] eyes, I am the kind of family doctor I've always wanted to be...and that is what is most important."

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MAFP Membership Anniversaries

Membership ANNIVERSARIES 55 years

Samuel Bonney, MD, FAAFP George Groce, MD

50 years

John Holcomb, MD Claude Smith, MD Porfirio Tiongson, MD, FAAFP

45 years

Bartolome Kairuz, MD, FAAFP Robert Pavlu, MD, FAAFP

40 years

Merlin Brown, MD, FAAFP George Comfort, MD Kenneth Derrington, MD, FAAFP Patrick Harr, MD, FAAFP Richard Kimball, MD, FAAFP Robert Laatsch, MD, FAAFP William Sill, DO, FAAFP Paul Spence, MD

35 years

Carol Berner, MD, FAAFP Larry Carey, MD, FAAFP Babu Dandamudi, MD Carl Davis, MD, FAAFP Arthur Freeland, MD, FAAFP Roy Gillispie, MD, FAAFP R. Griffith, MD, FAAFP Dennis Handley, MD, FAAFP Dale Henselmeier, MD, FAAFP James Hunter, MD, FAAFP Mark Kasten, MD, FAAFP Daniel Lischwe, MD, FAAFP Mark Martin, MD, FAAFP Phillip Monroe, MD Chennaiah Nadindla, MD, FAAFP William Rosen, MD, FAAFP Theodore Schuerman, MD Susan Singer, MD, FAAFP Paul Williams, MD Richard Williams, MD W. Wilson, DO, FAAFP Timothy Wilson, MD, FAAFP 24 Missouri Family Physician July-September 2015

30 years

Donald Allcorn, MD Phillip Asaro, MD Richard Bowles, MD, FAAFP David Cathcart, MD, FAAFP Charles Crist, MD Randall Cross, MD, FAAFP Stanley Crown, MD Peter Danis, MD, FAAFP Patrick Dawson, MD Romeo Eugenio, MD Barbara Froehner, MD, FAAFP Filip Garrett, MD Louis Harris, MD Stephen Hawkins, MD Karen Heath, MD Scott Henderson, MD J. Hernandez, MD, FAAFP James Hilburn, MD Jesse Hoff, MD Charles Judy, MD Kendel Klein, MD Robert Koch, MD Donald Lippert, MD James Lukavsky, MD, FAAFP Gregory Markway, MD Marsha Mertens, MD Nathaniel Murphey, MD Shari Ommen, MD David Ouellette, MD John Owen, MD, FAAFP Robert Power, MD, FAAFP Daniel Purdom, MD, FAAFP Thomas Robbins, MD, FAAFP Bryan Sitzmann, MD, FAAFP Walton Sumner, MD Suzanne Sword, MD, FAAFP Robert Tague, MD, FAAFP Gary Thompson, MD, FAAFP Hope Tinker, MD Kerry Vance, MD, FAAFP Jack Wells, MD, FAAFP Jeffrey Wheeler, MD, FAAFP Philip Wittmer, DO, FAAFP

Congratulations to all of our MAFP members celebrating a milestone anniversary in 2015. The academy thanks you for your continued support of family medicine.

25 years

Debra Atkinson, MD Holly Benedict, MD Barbara Bumberry, MD, FAAFP George Carr, MD, FAAFP Kimberly Cater, MD Karen Doerry, MD Neal Erickson, MD Samuel Ferreri, MD, FAAFP Sharon George, MD, FAAFP Donna Harper, DO Laura Holmes, MD, FAAFP Curtis King, MD LaVert Morrow, MD, FAAFP Robin Morse, DO Solomon Noguera, MD, FAAFP Robert Pozzi, DO, FAAFP Caroline Rudnick, MD Kim Smith, MD Kenneth Taylor-Butler, MD, FAAFP Thomas Thomas, MD Gary Upton, DO Susan Vega, DO Jon Welsh, MD

Dan Purdom, MD, FAAFP presents David Cathcart, MD, FAAFP, his anniversary certificate honoring 30 years with the academy.

Other members recognized during the assembly included: Debra Atkinson, MD - 25 years Carolyn Rudnick, MD - 25 years Dan Purdom, MD, FAAFP - 30 years George Comfort, MD - 40 years

Find Your Kind in an AAFP Member Interest Group The AAFP is committed to giving all members a voice within our increasingly diverse organization. Member interest groups (MIGs) have been created as a way to define, recognize, and support AAFP members with shared professional interests. MIGs support members interested in professional and leadership development and provide connections to existing AAFP resources, opportunities to suggest AAFP policy, and networking events with like-minded peers.

Current AAFP MIGs include: • Direct Primary Care • Emergency Medicine/Urgent Care • Global Health • Hospital Medicine • Independent Solo/Small Group Practice • Oral Health • Reproductive Health Care • Rural Health • Single Payer Health Care • Telehealth

Visit aafp.org/mig to learn more, join a MIG, or start your own.

OSA Follow Up Article MAFP

treatment of obstructive sleep apnea

Barry G. Fields, MD IIene M. Rosen, MD, MSCE

I

n the last edition of the Missouri Family Physician, we discussed a 49-year-old-man with GERD, depression, hypertension, and obesity who complained of snoring and excessive daytime sleepiness. Suspicion for obstructive sleep apnea (OSA) was high, and the authors reviewed indicators of and screening for the disorder. This article discusses OSA treatment options.

Case continued: The patient undergoes a home sleep study which shows an apnea-hypopnea index (AHI) of 26 respiratory events per hour.

Before revisiting his sleep specialist, he discusses treatment options with his family physician.

An AHI of 26 events/hr indicates moderate OSA. The decision to treat his sleep disorder depends on many factors, including OSA severity, medical comorbidities, and associated symptoms (e.g. daytime sleepiness). Treatment of severe OSA, with or with symptoms, has been associated with cardiovascular event reduction.1,2 Anyone with OSA and daytime sleepiness (“OSA syndrome”) should be offered treatment.3,4 Our patient’s history of depression and hypertension are also indications for definitive treatment, regardless of OSA severity.

Weight loss counseling is an essential first step; weight management decreases OSA severity and associated symptoms. 5-7 Positive airway pressure (PAP) is first-line therapy for all patients with moderate to severe OSA,

26 Missouri Family Physician July-September 2015

those with mild OSA syndrome, and any patients with significant comorbidities (e.g. depression, diabetes, hypertension).8 PAP works as a pneumatic splint, relieving upper airway obstruction during sleep. A small, quiet device sends pressurized room air through flexible tubing into a facial interface. Available interfaces include “full face” masks delivering air through the nose and mouth, nasal masks and “pillows” providing air intranasally, and rarer “oral masks” delivering air only through the mouth.

Mandibular advancement devices (MADs) offer another effective treatment option for patients with mild to moderate OSA as well as those with severe disease who decline or are intolerant to PAP.9,10 Supplied by dentists, after referral from the physician, these oral appliances increase upper airway caliber by bringing forward the jaw, tongue, and other soft tissues. While viable treatment alternatives, MADs are not as effective as PAP in normalizing AHI11 and are not indicated as first line therapy for severe OSA.12 Many medical insurances, including medicare, provides coverage.

Various surgical options are available, including uvulopalatopharyngoplasty (UPPP) and maxillomandibular advancement (MMA). These procedures can reduce the AHI, but less effectively than PAP. They carry significant risk of side effects

and are reserved for patients intolerant to PAP or MADs, and those with significant cranio-facial abnormalities (e.g. mandibular hypoplasia).13,14 Tracheostomy remains a viable option for PAPintolerant patients with severe OSA; the procedure is nearly 100% effective in eliminating obstructive apneic events, but associated social stigma and lifestyle modifications limit patient acceptance.15 Tonsillectomy/adenoidectomy is considered firstline therapy for pediatric OSA but is less effective in adults.16 An array of other OSA treatments have emerged.

Positional therapy, accomplished by sewing tennis balls into the back of a night shirt, sleeping laterally against a full body pillow, or wearing an anti-supine belt, is available for supinepredominant OSA. It can be effective17 but not to the extent of PAP.18 Patients with mild to moderate OSA can also trial nasal expiratory positive airway pressure (EPAP) generated by a one-way valve adhered to the base of the nostrils. Although early data shows modest benefit19,20, direct comparisons to PAP in treatment-naïve patients are lacking. Emerging methods of hypoglossal nerve stimulation may also improve airway patency through genioglossus muscle contraction.21,22 Case conclusion: The patient and his physician agree that he should begin PAP therapy. His sleep specialist prescribes autotitrating PAP (APAP) at a range of 5-20 cm H20. Over the next several months his excessive daytime sleepiness improves, he no longer snores, and he has more energy to use his fitness center.

Several models of care for ongoing PAP management for patients with OSA exist. Primary care clinicians may consider consultation and collaboration with a sleep specialist as an effective model of care (24 which would now be 23).

Additionally, successful models driven by primary care practitioners have been demonstrated (23 now 24). The decision to start APAP versus fixedsetting, continuous PAP (CPAP) is increasingly common. APAP units adjust PAP based on airflow limitation, apneas, and snoring. They are as effective as CPAP25 and, given reduced need for in-laboratory CPAP titration, can lead to significant cost savings. APAP- or CPAP-intolerant patients and individuals requiring more advanced nocturnal ventilation may use bi-level PAP (BPAP).

Whichever PAP mode is utilized – APAP, BPAP, or CPAP – adherence is essential. A dose-response relationship exists between increasing PAP use and improved sleepiness, blood pressure, and quality

OSA Follow Up Article MAFP

of life.26,27 Although the Centers for Medicare and Medicaid Services (CMS) and many private insurers require ≥4 hours of use on ≥70% of nights to document adherence, PAP use should be encouraged with all sleep. Family physicians can dovetail their efforts with those of sleep specialists to improve PAP adherence by promoting positive initial experiences with PAP, providing anticipatory support for future troubleshooting, and involving bed partners and other family members in OSA treatment.

References 1. Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 2005;365:1046-53.

2. Gottlieb DJ, Yenokyan G, Newman AB, et al.

Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure: the sleep heart health study. Circulation 2010;122:35260.

3. Patel SR, White DP, Malhotra A, Stanchina ML, Ayas NT. Continuous positive airway pressure therapy for treating sleepiness in a diverse population with obstructive sleep apnea: results of a meta-analysis.

Archives of internal medicine 2003;163:565-71.

4. Weaver TE, Mancini C, Maislin G, et al. Continuous positive airway pressure treatment of sleepy patients with milder obstructive sleep apnea: results of the CPAP Apnea Trial North American Program (CATNAP) randomized clinical trial. American journal of respiratory and critical care medicine 2012;186:67783.

5. Johansson K, Neovius M, Lagerros YT, et al. Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: a randomised controlled trial. Bmj 2009;339:b4609.

6. Tuomilehto HP, Seppa JM, Partinen MM, et al.

Lifestyle intervention with weight reduction: first-line treatment in mild obstructive sleep apnea. American journal of respiratory and critical care medicine 2009;179:320-7.

7. Foster GD, Borradaile KE, Sanders MH, et al. A randomized study on the effect of weight loss on obstructive sleep apnea among obese patients with type 2 diabetes: the Sleep AHEAD study. Archives of internal medicine 2009;169:1619-26.

8. Epstein LJ, Kristo D, Strollo PJ, Jr., et al. Clinical guideline for the evaluation, management and longterm care of obstructive sleep apnea in adults. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 2009;5:26376.

9. Phillips CL, Grunstein RR, Darendeliler MA, et al. Health outcomes of continuous positive airway pressure versus oral appliance treatment for

References continued on page >35

Missouri Family Physician July-September 2015

27

MAFP 67th Annual Scientific Assembly

new venue a hit for asa

T

he 67th Annual Scientific Assembly, held June 6-7, at the Lodge at Old Kinderhook, Camdenton, proved to be a relaxing, yet educational, experience for all attendees. Over 65 family physicians and students attended the two-day conference held at this new conference center. Experts provided 13.75 hours of evidence-based CME on topics such as diabetes management, Mohs procedures, updates on new drugs and literature, physician burnout, substance abuse, direct primary care, maternal child health, and osteoporosis. Networking with exhibitors provided members the opportunity to explore current trends and technology in health care.

The MAFP Annual Meeting was also held where your new officers were elected, and installed during the Awards and Installation Dinner: • Chair – Dan 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 – Jim Stevermer, MD, MSPH, FAAFP (Fulton) – 3 Year Term The membership ratified the slate of Missouri delegates and alternates to attend the AAFP Congress of Delegates, but a change was made during the board meeting held the following day due to a vacancy. Your Missouri representatives on the Congress of Delegates are: AAFP Delegates – Todd Shaffer, MD, MBA, FAAFP (Kansas City) and David Schneider, MD, FAAFP (St. Louis) AAFP Alternate Delegates – Kate Lichtenberg, DO, MPH, FAAFP (Kirkwood) and Keith Ratcliff, MD, FAAFP (Washington) The highlight of this conference was the announcement of the Missouri Family Physician of the Year…Dr. Arthur Freeland of Kirksville, MO. (See article on page 22 recognizing Dr. Freeland’s exemplary career.) Also during the Awards and Installation Dinner, MAFP leaders were recognized for their commitment to family medicine.

Dr. Bill Fish, MD, FAAFP received the Soaring Eagle Award recognizing his service during the last year as board chair.

Three Missouri physicians were conferred the AAFP Degree of Fellow: • Matthew Brown, MD, FAAFP (Houston) • Victor Pace, MD, FAAFP (Springfield) • Jennifer Scheer, MD, FAAFP (New Haven) This degree is awarded to those physicians who have distinguished themselves among their colleagues, as well as in their communities, by their service to

28 Missouri Family Physician July-September 2015

2015 Tar Wars Winner, Danielle Hamann, Kansas City, poses with her poster. Danielle was recognized at the Saturday evening Awards and Installation Dinner; accompanied by her parents and younger brother. Danielle and her mother sent thank you cards (see right) thanking MAFP for the wonderful experience.

family medicine, by their advancement of health care to the American people, and by their professional development through medical education and research.

The success of MAFP is attributed to our membership. Members with milestone anniversaries were recognized for their lifelong commitment and dedication to family medicine (see page 24).

With the Tar Wars National Conference cancelled, Missouri recognized our Tar Wars Poster Contest winner at this conference. Danielle Hamann, St. Therese School, Kansas City was presented with a plaque and a $100 check.

Residents and students displayed posters during the Awards and Installation Reception. There were 13 poster entries with 21 participants. The winners were: First Place: Jennifer Blair, DO and Kristen Michael, DO, UMKC TMC Lakewood Topic: The Effect of Barometric Pressure on Rupture of Membranes and Spontaneous Onset of Labor in Preterm and Term Pregnancies Second Place: Olivia Kwan (Student), UMKC Topic: Latent Autoimmune Diabetes in Adults: Is Screening Beneficial?

Third Place: Barry Palizzi, DO, UMKC TMC Lakewood Topic: Diabetic Control After Instituting Post-of-Care Hemoglobin A1C Evaluation Prizes of $300, $200, and $100 were awarded, respectively.

The conference wrapped up on Sunday with commission meetings and the board meeting.

"

67th Annual Scientific Assembly MAFP

As a parent, it was touching to see Danielle's eyes light up when she saw her 1st place ribbon. I am sure Danielle gained a tremendous amount of confidence that will serve her well in the - Julie Hamann future."

(Danielle's mother)

Missouri Family Physician July-September 2015

29

MAFP 67th Annual Scientific Assembly

30 Missouri Family Physician July-September 2015

67th Annual Scientific Assembly MAFP MAFP

THANK YOU TO ALL OF OUR EXHIBITORS FOR YOUR CONTINUED SUPPORT Anthem Direct Primary Care Clinics, LLC Freeman Health System GeneTrait Laboratories Genzyme, A Company of Sanofi HealthLink MPM/PPIA Medtronic Missouri Army National Guard MO Health Professional Placement Services St. Louis University Hospital Sanofi Pasteur U.S. Army Health Care

Thank You to Direct Primary Care Clinics, LLC & Dr. Jenny Powell for sponsoring lanyards at ASA Direct Primary Care empowers people to take charge of their own healthcare, and empowers you to regain control of your practice. Contact Dr. Jenny Powell at (573) 933-0872 or (417) 664-5054 to open your own Direct Primary Care Clinic.

DPCareClinics.com Missouri Family Physician July-September 2015

31

MAFP Safe Sleep

safe sleep turns twenty

E Gail Jones, MAPA, MICT Gail Jones is the manager for the Multi-specialty clinics for PeaceHealth in Ketchikan, Alaska.

Prior to this position, she was the practice management expert for the American Academy of Family Physicians and had the opportunity to author material for the medical home and resources to assist practices across the country. In addition to many years of experience in practice management, she has a B.A. in Management and HR and a M.A. in Organizational Administration.

ach year in the United States, there are about 3,500 Sudden Unexpected Infant Deaths (http://www.cdc.gov/sids/ aboutsuidandsids.htm) (SUID). These deaths occur among infants aged 1-12 months and have no immediately obvious cause.1 According to Eunice Kennedy Shriver National Institute of Child Health and Human Development’s (NICHD)“Safe Sleep” program: •SIDS is the leading cause of death among babies between 1 month and 1 year of age.

•Most SIDS deaths occur when in babies between 1 month and 4 months of age, and the majority (90%) of SIDS deaths occur before a baby reaches 6 months of age. However SIDS deaths can occur anytime during a baby’s first year.

•SIDS is a sudden and silent medical disorder that can happen to an infant who seems healthy.

•SIDS is sometimes called "crib death" or "cot death" because it is associated with the timeframe when the baby is sleeping. Cribs themselves don't cause SIDS, but the baby's sleep environment can influence sleep-related causes of death.2 For the past twenty years, “Safe Sleep” has worked to decrease those numbers. “SIDS rates for the United States have dropped steadily since 1994 in all racial and ethnic groups. Thousands of infant lives have been saved, but some ethnic groups are still at higher risk for SIDS.” However, the rates still remain high among some ethnic groups.

This chart shows sudden unexpected infant death (SUID) rates (which include sudden infant

SOURCE: CDC/NCHS, National Vital Statistics System, Period Linked Birth/Infant Death Data.

death syndrome, unknown cause, and accidental suffocation and strangulation in bed) by race/ ethnicity in the United States from 2008 to 2012.

SUID death rates per 100,000 live births for American Indian/Alaska Native (213.3) and non32 Missouri Family Physician July-September 2015

Hispanic black infants (180.9) were more than twice those of non-Hispanic white infants (88.1).

SUID death rates per 100,000 live births were lowest among Hispanic infants (53.8) and Asian/ Pacific Islander infants (36.5).1 To combat this problem in 1994, the NICHD– in partnership with the American Academy of Pediatrics, the Maternal and Child Health Bureau of the Health Resources and Services Administration, the SIDS Alliance (now First Candle), and the Association of SIDS and Infant Mortality Programs – launched the Back to Sleep campaign to educate parents and caregivers about ways to reduce the risk of SIDS. Today, the Safe to Sleep® campaign builds on the successes of Back to Sleep to address SIDS and other sleep-related causes of infant death and to continue spreading safe sleep messages to members of all communities.

Many providers find that there are a variety of obstacles in overcoming language and cultural barriers. Often parents cannot afford to provide a safe place to sleep. To address this problem several different programs have been developed across the country including offering cribs4 and other means of providing unique safe sleep environments.

Over 75 years ago in Finland the government developed the “Baby Box” that is given to each mother. This, and the education that is given to mothers, have drastically reduced infant mortality; and now Finland has one of the lowest rates in the world. (http://www.bbc.com/news/

Safe Sleep MAFP magazine-22751415) From this concept, several infant box programs have been launched in the U.S. One example is from the State of Alaska where there is an average of 11,438 births per year.

Among Native Alaskans the rate of 9.2 deaths per 100 live births remains roughly 50% higher than the national average. In a 2010 state wide study looking at 53 infant deaths, it was discovered that at least 25 of these deaths were preventable and up to 49 were possibly preventable. Often the babies had been placed in the bed with others due to no place safe for them to sleep and then died of suffocation. In remote areas this is an even greater risk. The state observed an 80% increase in the odds of deaths for infants where the mother’s residence was reached by air or boat compared to those reached by a roadway.

Due to the increase in infant deaths, a pilot program was created at PeaceHealth Medical Center in Ketchikan Alaska, called the “Little Alaskan Dream” (http://littlealaskadream.com/) which partnered local healthcare providers at the community hospital and clinics with public health nurses.5 Together they developed a more robust safe sleep program by offering the infant boxes as an incentive to attend “Box Showers” where the attendees receive an infant box based upon the Finland model. The classes include Safe Sleep, Shaken Baby Syndrome prevention, the importance of immunizations, breast feeding and bonding. Often the providers had trouble with attendance at classes, and by offering an infant box they were able to increase their numbers and ensure the attendees were engaged. They set up the program as a 'box shower' since many of the mothers do not have baby showers. The program includes games and door prizes mixed with difficult subject matter.6 While offering patient education material, the providers often faced language and cultural barriers. To help overcome these issues they worked to develop a pre-test for the class and a post-test that was picture based. In one class with 28 attendees they had 12 attendees miss at least one question – and up to four questions. In the post-test questions they did not miss any.

The program has garnered a lot of interest due to the success of attendance of patients that are at high risk of SIDS, and the understanding the parents have gained from the classes. The program used in Ketchikan is a pilot program in Alaska that has already spread to other parts of the state and elsewhere in the country. Many of

the programs in Alaska plan to use an infant box7 while others are using cribs. The focus has been to tie a class into providing a safe place to sleep and patient education.

While SIDS is not always preventable, program organizers agree that one preventable death is one death too many; and they are joining together to “Save Babies One Box (or crib) at a Time.”6 Resources: 1. Centers for Disease Control. Sudden Unexpected Infant Death and Sudden Infant Death Syndrome-Data and Statistics. Downloaded May 5, 2015 from http://www.cdc. gov/sids/data.htm 2. Safe to Sleep Public Education Campaign. “Fast Facts About SIDS”. Downloaded May 5, 2015 from http://www. nichd.nih.gov/sts/about/SIDS/Pages/fastfacts.aspx 3. British Broadcast Company (BBC). “Why Finnish babies Sleep in Cardboard Boxes.” Downloaded May 8, 2015 from http://www.bbc.com/news/magazine-22751415 4. Cribs For Kids. “About Us.” Downloaded May 11,2015 from http://www.cribsforkids.org/about-us/ 5. Demer,L. Alaska Dispatch News: Rash of sleep-related infant deaths troubles health officials. February 14, 2015.

Downloaded May 16, 2015 from http://www.adn.com/ article/20150214/rash-sleep-related-infant-deathstroubles-health-officials 6. Little Alaskan Dreams. “Our Story.” Downloaded May 16,2015 from http://littlealaskandream.com/about 7. Safe and Sound. “What We Do.” Downloaded May 16, 2015 from http://www.safeandsoundinnovations.com/ what-we-do.html

Deaths: Residents of Missouri Number Year Rate

Cause of Death Sudden Infant Death Syndrom (SIDS)

16

2013

Rates are per 100,000 Age adjustment uses 2000 standard population @ Rate is unstable; numerator less than 20.

0.3@

Breakout of Missouri deaths caused by SIDS - according to the State of Missouri Department of Health and Senior Services in 2013. http://health. mo.gov/data/mica/ mica/death.php.

Missouri Family Physician July-September 2015

33

MAFP A Message from MAFP's Legislative Consultant

physicians have an impact on the legislative process at the local level

T Pat Strader MAFP Legislative Consultant

he 2015 legislative session is over and we are well on our way to the next one which begins January 6, 2016.

During the session, MAFP has a daily presence at the Capitol. We review, monitor and track legislation important to patients and physicians.

We research issues to support our positions, testify before committees, and discuss issues with legislators and other state officials. We also strive to keep you well informed through Legislative Updates and are available to answer your questions about legislation. While MAFP continues to need your support during the session by testifying at the Capitol and responding to “alerts” on specific bills, your assistance during the interim is also extremely important to the overall Key Contact Program.

So, how can you as a physician and member of MAFP provide support during the interim to educate legislators and move MAFP’s legislative agenda forward? Summer and fall months are great times to contact your State Representative and State Senator in their home districts. As Tip O’Neill once said “All politics is local.”

What do legislators care about?

• Legislators want to make good decisions based on accurate and timely information.

• Legislators respect constituents’ opinions and want to support positions expressed by them when at all possible. They want to understand the issues and how legislation affects their constituents and the communities they serve.

• Legislators respond to “grassroots” and the physician(s) who serve his or her district and community. They recognize that physicians are knowledgeable about the complex health care system and can answer their questions.

• Legislators are influenced by public opinion.

• Due to term limits, legislators are constantly “running for election or re-election” which takes much of their time and a lot of money.

34 Missouri Family Physician July-September 2015

What can you do now?

• If you are not already a MAFP key contact, staff can assist in matching you with your respective legislators.

• Get to know your legislators by making the initial contact during the interim between legislative sessions.

• Support your local legislators by attending one of their functions. Many host receptions or barbeques in their home districts.

• Invite them for coffee, or if appropriate, to your workplace or office for a visit.

• Support decision makers that support your profession and your patients.

• Be sure they have your contact information so they might ask for your opinions.

• Join MAFP Political Action Committee to combine your voice with other members to strengthen our advocacy efforts to achieve legislative goals and objectives.

• Utilize the links below to find the legislators that represent you at the State Capitol.

FIND LEGISLATORS IN YOUR AREA www.senate.mo.gov/ LegisLookup/default.aspx

MAFP PAC - CONTRIBUTE

TODAY AND HELP SUPPORT FAMILY PHYSICIANS www.mo-afp.org/ advocacy/politicalaction-committee/

References on OSA article, con't. from pg. 27 MAFP Health outcomes of continuous positive airway pressure versus oral appliance titration process on efficacy, adherence, and outcomes. Sleep 2011;34:1083-92. treatment for obstructive sleep apnea: a randomized controlled trial. American 26. Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE. A journal of respiratory and critical care medicine 2013;187:879-87. systematic review of CPAP adherence across age groups: clinical and empiric 10. Gagnadoux F, Fleury B, Vielle B, et al. Titrated mandibular advancement versus insights for developing CPAP adherence interventions. Sleep medicine reviews positive airway pressure for sleep apnoea. The European respiratory journal 2011;15:343-56.

2009;34:914-20.

27. Haentjens P, Van Meerhaeghe A, Moscariello A, et al. The impact of continuous 11. Lim J, Lasserson TJ, Fleetham J, Wright J. Oral appliances for obstructive sleep positive airway pressure on blood pressure in patients with obstructive sleep apnea apnoea. The Cochrane database of systematic reviews 2006:CD004435. syndrome: evidence from a meta-analysis of placebo-controlled randomized trials.

12. Morgenthaler TI, Kapen S, Lee-Chiong T, et al. Practice parameters for the Archives of internal medicine 2007;167:757-64. medical therapy of obstructive sleep apnea. Sleep 2006;29:1031-5.

This article was developed through the National Healthy Sleep Awareness Project, 13. Franklin KA, Anttila H, Axelsson S, et al. Effects and side-effects of surgery for a joint effort of the Centers for Disease Control and Prevention (CDC), American snoring and obstructive sleep apnea--a systematic review. Sleep 2009;32:27-36.

Academy of Sleep Medicine (AASM) and the Sleep Research Society (SRS). Visit 14. Caples SM, Rowley JA, Prinsell JR, et al. Surgical modifications of the upper www.sleepeducation.org for more information. airway for obstructive sleep apnea in adults: a systematic review and meta-analysis.

This article was supported by the cooperative agreement number Sleep 2010;33:1396-407.

1U50DP004930-01 from the Centers for Disease Control and Prevention (CDC).

15. Guilleminault C, Simmons FB, Motta J, et al. Obstructive sleep apnea syndrome Its contents are solely the responsibility of the authors and do not necessarily and tracheostomy. Long-term follow-up experience. Archives of internal medicine represent the official views of the CDC. 1981;141:985-8.

16. Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome.

Sleep 1996;19:156-77.

17. Permut I, Diaz-Abad M, Chatila W, et al.

Comparison of positional therapy to CPAP in patients with positional obstructive sleep apnea. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 2010;6:238-43.

18. Ha SC, Hirai HW, Tsoi KK. Comparison of positional therapy versus continuous positive airway pressure in patients with positional obstructive sleep apnea: a meta-analysis of randomized trials. Sleep medicine reviews 2014;18:19-24.

19. Berry RB, Kryger MH, Massie CA. A novel nasal expiratory positive airway pressure (EPAP) device for the treatment of obstructive sleep apnea: a randomized controlled trial. Sleep 2011;34:479-85.

20. Rosenthal L, Massie CA, Dolan DC, Loomas B, Kram J, Hart RW. A multicenter, prospective study of a novel nasal EPAP device in the treatment of obstructive sleep apnea: efficacy and 30-day adherence. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine 2009;5:532-7.

21. Rodenstein D, Rombaux P, Lengele B, Dury M, Mwenge GB. Residual effect of THN hypoglossal stimulation in obstructive sleep apnea: a diseasemodifying therapy. American journal of respiratory and critical care medicine 2013;187:1276-8.

22. Schwartz AR, Barnes M, Hillman D, et al. Acute upper airway responses to hypoglossal nerve stimulation during sleep in obstructive sleep apnea.

American journal of respiratory and critical care medicine 2012;185:420-6.

23. Chai-Coetzer CL, Antic NA, Rowland LS, et al.

Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life: a randomized trial. Jama 2013;309:997-1004.

24. Parthasarathy S, Subramanian S, Quan SF. A For more information call Sergeant First Class Amanda Nelson multicenter prospective comparative effectiveness toll free at 877-574-7029 or visit us at, http://www.goarmy.com/careers-andSFC Dayton K. Davis study of the effect of physician certification and jobs/amedd-categories/medical-corps-jobs/family-practice-physician.html center accreditation on patient-centered outcomes U.S. Army Shreveport Medical Recruiting in obstructive sleep apnea. Journal of clinical sleep Office: 1-318-861-3751 medicine : JCSM : official publication of the American Academy of Sleep Medicine 2014;10:243-9.

Email: dayton.k.davis.mil@mail.mil 25. Kushida CA, Berry RB, Blau A, et al. Positive airway pressure initiation: a randomized controlled trial to assess the impact of therapy mode and

Family Medicine Physicians Have you considered the Army Reserve?

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Missouri Family Physician July-September 2015

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MAFP End of Session Report

MAFP 2015 end of session report

T

he Missouri Legislative Session ended at 6:00 p.m. on Friday, May 15. Over 2,000 bills and resolutions were introduced. It was a very successful year for MAFP - several priority bills passed early enough to not be involved in the last two weeks of severe legislative turmoil. The good news is that many of the bills we opposed did not pass. During the final week when it became clear the Senate would not be taking up additional bills, the House began to peel off their House Committee Substitutes, taking the bills back to the Senate versions. With the Senate slowdown, the resignation of Speaker John Diehl, and the election of Rep. Todd Richardson as Speaker of the House, it was quite a final week of session. Governor Nixon has until July 14 to sign or veto bills. If action has occurred on a bill as of this publication, it is indicated below. Here are the highlights:

GOVERNOR NIXON SIGNS MAFP PRIORITY LEGISLATION Pat Strader MAFP Legislative Consultant

Tort Reform/Medical Malpractice (SB 239) – Signed by the Governor Non-economic damages are capped at $400,000 for most general medical negligence cases and $700,000 for cases resulting in catastrophic injury or death. The bill also contains an annual 1.7% increase to the caps. There were numerous tries in the previous sessions to reinstate the cap at the $350,000 level, but that proved to be unworkable to get through the Legislature and send something to the Governor that would be signed into law. Rep. Eric Burlison and Senator Dan Brown sponsored the tort reform legislation.

Direct Primary Care Legislation (HCS HB 769) – Signed by the Governor This legislation was passed with overwhelming bi-partisan support by the Legislature (House 134-13; Senate 34-0).

MAFP members really stepped up to the plate on this bill and provided the support and testimony needed to get it to the finish line. The bill is pretty simple in that it defines “direct medical care” in the statutes and provides important clarification that DPC is not insurance. The legislation provides that patients may use health savings accounts (HAS) and flexible savings accounts (FSA) to pay their monthly retainer fee, subject to state and federal law. The bill would also allow employers to pay for pay their employee’s retainer fee directly to the physician. HB 769 outlines what must be included in a transparent retainer agreement which is signed by the physician and the patient. MAFP provided key information to the Governor’s staff regarding direct primary care and the importance of this legislation to MAFP members and patients. Governor Nixon signed HB 769 on July 2.

OTHER BILLS THAT PASSED Fiscal Year 2016 Budget - $26 Billion – Signed by the Governor Included legislative authority for the state to extend managed care statewide for current MO HealthNet population. $4 million increase included for provider reimbursement (HB 11).

Federal Reimbursement Allowance (FRA) (SB 210) – Signed by the Governor This was a “nail biter” as the legislation was left hanging right up to the end of the session. After Senate leadership used the parliamentary procedure known as the “Previous Question” which stopped debate and forced a vote on right to work legislation, Democrat Senators vowed that nothing further would pass. However, they relented on this issue due to its importance. This act extends the sunset from September 30, 2015 to September 30, 2016, for the Ground Ambulance, Nursing Facility, Medicaid Managed Care Organization, Hospital, Pharmacy, and Intermediate Care Facility for the Intellectually Disabled Reimbursement Allowance taxes which allow the state to draw down federal funds.

Without passage, the state would have lost approximately $3.6 billion.

Prescriptive Authority - Schedule II-Hydrocodone (HB 709) – Signed by the Governor This bill allows APRNs, physician assistants and assistant physicians to prescribe Schedule II-hydrocodone, limited to one 5-day supply without refill. This issue popped up because hydrocodone was moved from a Schedule III to a Schedule II controlled substance.

Board Opinions (SB 107) This act provides that the Board of Healing Arts and certain other professional boards and commissions which license professions may issue oral or written opinions addressing topics relating to the qualifications, functions, or duties of any profession licensed by such board or commission. The opinions are for educational purposes, are not binding on the licensee, and cannot be used as the basis for discipline against a licensee. A board or commission shall not address topics relating to the qualifications, functions, or duties of any profession licensed by a different board or commission.

(Applies to Chapters 330, 331, 332, 334, 335, 336, 337, 338, 340 and 345).

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End of Session Report MAFP Notification of MO HealthNet Audit Changes (SB 210) – Signed by the Governor Under this provision, if the Missouri Medicaid Audit and Compliance Unit (MMAC) changes any interpretation or application of the requirements for reimbursement for MO HealthNet services from the interpretation or application previously applied in an audit of a MO HealthNet provider, the MMAC shall notify MO HealthNet providers of such change at least five days before the changes take effect. If the MMAC fails to notify a provider of such changes, then the provider shall be entitled to receive and retain reimbursement until proper notification is provided and shall not be liable for recoupment or other loss of any payment previously made prior to the five day notice period.

Death Certificates/Disposition of Human Remains (HB 618) Allows APRNs, physician assistants, and assistant physicians, in collaborative arrangements, or the person who performed the autopsy to sign a death certificate. Unfortunately, the new and improved language was included in other bills, but did not make it on this one.

That language said: “provided he or she participated in the patient’s care in consultation with the attending physician for the illness which resulted in the patient’s death." Dr. Frederick and Dr. Neely both pointed out the need for this language when the bill was being debated on the last day and said the language should be amended next session.

We will put that on our “to do” list. Also, by August 30, 2015, the Division of Community and Public Health within DHSS must establish a working group to evaluate the electronic vital records system, develop recommendations to improve the efficiency and usability of the system, and report the findings and recommendations to the General Assembly

by January 2, 2016.

Governor Jeremiah "Jay" Nixon signs SB 239, Tort Reform/Medical Malpractice legislation on May 7.

The bill also contains changes designed to remedy situations when family members or others cannot agree on final disposition of a body or when next of kin cannot be located.

Notice of Non-Immunization/Daycare (SB 341) This act requires all public, private, and parochial day care centers, preschools, and nursery schools to notify parents or guardians, upon request, of whether there are children currently enrolled in or attending the facility for whom an immunization exemption has been filed.

Eating Disorders (SB 145) – Signed by the Governor This act requires health benefit plans delivered, issued for delivery, continued or renewed on or after January 1, 2017, in accordance with current law requirements for coverage of mental health disorders, to provide coverage for the diagnosis and treatment of eating disorders. The act further requires that the provided coverage include a broad array of specialist services as proscribed as necessary by the patient's treatment team. Coverage under this act is limited to medically necessary treatment and the treatment plan must include all elements necessary for a health benefit plan to pay claims. Under the act medical necessity determinations and care management for the treatment of eating disorders shall consider the overall medical and mental health needs of the individual with the eating disorder and shall not be based solely on weight. Coverage may be subject to other general exclusions and limitations of the contract or benefit plan not in conflict with the act.

Disabled Placards and License Plates (SB 254) This act adds physical therapists and assistant physicians to the list of authorized health care practitioners who may issue a prescription for his or her patient to receive a disabled placard or license plate.

Safe Sleep Practices/Recommendations (SB 341) This measure requires all licensed child care facilities that provide care for children under one year of age to implement and maintain a written safe sleep policy in accordance with the recommendations approved by DHSS (from recommendations of the American Academy of Pediatrics).

All employees and volunteers must complete the approved training every three years. If the infant’s licensed health care provider deems the infant requires alternative or special sleeping arrangements different from the recommendations of the Department and AAP, the provider must provide written and signed instructions detailing the alternative and the facility must follow those instructions.

Child Abuse and Neglect Hotline (SB 341) This act requires all public and charter schools to post, in a clearly visible location in a public area of the school, a sign in English and Spanish containing the toll-free child abuse and neglect hotline number established by the Children’s Division. The number must also be posted in all student restrooms. The Children’s Division shall develop an acronym to help children remember the hotline number. continued on page 38 > Missouri Family Physician July-September 2015

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MAFP End of Session Report End of Session Report, con't...

Welfare Benefits (SB 24) – Governor Vetoed; Legislature voted to Override Veto SB 24 reduces the time low-income individuals can receive cash benefits under the Temporary Assistance for Needy Families (TANF) program from five years to three years and nine months.

Money Follows the Person Demonstration Program (HB 343) – Signed by the Governor HB 343 establishes a committee to assess the continuation of the Money Follows the Person Demonstration Program in order to help disabled or aging individuals transition from nursing facilities to community settings.

Amino Acid-Based Elemental Formulas (SB 354) This act requires the Department of Health and Senior Services to provide coverage, through state and federal appropriations, for the full cost of amino acid-based elemental formulas for children under 19 years with a medical diagnosis of specified allergies, syndromes, or disorders.

Liquid Nicotine Containers (HB 531) This legislation requires that nicotine liquid containers sold at retail satisfy federal child-resistant effectiveness standards.

Legislation designating specific dates for medical awareness – All Signed by the Governor: • Designates July 3rd of each year as “Organ Donor Recognition Day” (HB 88); • Designates the month of November each year as “Epilepsy Awareness Month” (HB 400); • Designates the 22nd week of each year as “22 Awareness Week” (increase awareness of individuals with a chromosome 22q11.2 deletion) (HB 778); • Designates the first full week of March each year as “Multiple Sclerosis Awareness Week” (HB 861); • Designates May 7th of each year as “ROHHAD Awareness Day” (Rapid-onset obesity with hypothalamic dysfunction, hypoventilation and autonomic dysregulation presenting in childhood) (HB 1116).

BILLS THAT FAILED TO PASS Prescription Drug Monitoring Program (PDMP) – The Senate and House were too far apart on versions of this legislation for it to make it through the process this session.

Licensure of Physicians – Would have removed the examination restrictions for licensure of physicians which limit the number of times the examination can be taken to three and the time for passage of the examination to seven years but was later amended to leave these requirements in the law but added a provision allowing that “an applicant can petition the board for an exception based upon unusual or extenuating circumstances that the board may deem reasonable."

Maintenance of Certification – Would have prohibited the state from requiring any form of maintenance of licensure as a condition of physician licensure and specified that the state must not require any form of specialty medical board certification or any maintenance of certification to practice medicine in the state. Further, the state board or any other state agency could not discriminate against physicians who do not maintain specialty board certification including recertification.

Primary Care Medicaid Reimbursement – Would have set a reimbursement rate for primary care physicians under Medicaid at the same rate for those providing Medicare services and require MO HealthNet to contract with a third party for eligibility verification.

Collaborative Practice Statutes – Would have removed the current provision requiring the collaborating physician and the APRN to practice for one month before practicing in a setting where the collaborating physician is not continuously present if the collaborating physician is new to a patient population to which the APRN, physician assistant, or assistant physician is already familiar. It would have also removed in the requirement for chart review in that the collaborating physician need not be present at the health care practitioner’s site.

Health Care Workforce Analysis – Would have allowed certain Boards to collect information and provided for an entity to analyze the data. This would have given Missouri much needed data that it needs to determine types, numbers, and areas where specific professions practice.

Perinatal Regionalization Centers – Would have established the Perinatal Advisory Council and established criteria for levels of birthing center care and based its levels of care designations upon evidence and best practices as identified by the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists.

Pain Management Clinics – Would have defined pain management clinics and tightened regulations regarding those services.

Medicaid Expansion/Reform – Various Proposals Managed Care Co-Pays – Would have allowed health maintenance organizations to require cost sharing of its enrollees as a condition of the receipt of health care services, including co-payments, coinsurance, and deductibles.

Medical School Student Screening for Depression/Suicide Prevention – Would have prohibited medical schools from prohibiting, discouraging, or otherwise restricting a medical student organization or medical organization from undertaking or conducting a study of the prevalence of depression 38 Missouri Family Physician July-September 2015

End of Session Report MAFP or other mental health issues among medical students. The bill would also have permitted medical schools to conduct an ongoing multicenter study or studies, which, if conducted, would be known as the “Show-Me Compassionate Medical Education Research Project,” in order to facilitate the collection of data and implement practices and protocols to minimize stress and reduce the risk for depression for medical students in Missouri.

Telehealth – Numerous measures were filed which specified eligible health care providers and originating sites for the provision of telehealth services. Language that would have established the criteria for the use of asynchronous store-and-forward technology in the practice of telehealth was also amended to all moving telehealth bills.

Motorcycle Helmets – Would have repealed this requirement for 21 years of age or older, with appropriate health insurance coverage.

Texting While Driving – Numerous bills filed.

Medication Synchronization – Would have prohibited health carriers or health benefit plans from denying coverage for dispensing drugs prescribed for the treatment of chronic illnesses to synchronize the refilling of prescriptions for a patient. The health carrier or managed care plan could not charge an amount in excess of the otherwise applicable co-payment amount under the health benefit plan and would have to provide a full dispensing fee to the pharmacy that dispenses the prescription drug so long as the terms of the medication synchronization services were met.

Dispensing An Emergency Supply of Medication – Would have provided that only licensed pharmacists can make the determination to dispense an emergency supply of medication without the authorization from the prescriber.

CRNAs/Spinal Injections – This legislation would have removed the sunset clause on legislation that now governs what procedures cannot be performed by CRNAs. Newborn Screening/SCID – Would have added to the list of required newborn screenings SCID (severe combined immunodeficiency – often referred to as Bubble Boy syndrome).

Palliative Care – Would have created the Missouri Palliative Care and Quality of Life Interdisciplinary Council and the Palliative Care Consumer and Professional Information and Educational Program.

Hospital Status – Would have required hospitals to provide written notice of a patient’s hospital status.

Infection Reporting – Would have updated hospital and surgical center infection reporting guidelines.

MO HealthNet Reimbursement for Behavioral Assessment and Intervention – Would have required MO HealthNet reimbursement for certain services based on the new behavior assessment and intervention codes under the Current Procedural Terminology (CPT) coding system.

Naloxone Prescriptions – Would have allowed physicians to prescribe naloxone to any individual to administer, in good faith, to another individual suffering from an opiate-induced drug overdose.

EPI – Would have established requirements for authorized entities to stock epinephrine (EPI) auto-injectors for use in emergencies.

Youth Athletes/Concussions – Would have required that an objective test or measure be used to determine whether a youth athlete is suspected of sustaining a brain injury or concussion during a game or practice.

Midwives Insurance – Would have required midwives to notify clients and carry liability insurance.

Licensing of Midwives – Would have set up licensing of midwives under the Department of Health and Senior Services.

Prescription Drug Repository Program – Would have modified provisions of the program, including transferring the program from DHSS to the Board of Pharmacy.

Expert Witness – Would have brought Missouri into line with the federal judicial system by replacing the Fry standard with the Daubert Standard to admit testimony of expert witnesses.

Chiropractors – Would have provided for MO HealthNet reimbursement.

Family Therapists – Would have provided for MO HealthNet reimbursement.

Occupational Therapists/Handicapped Placards – Like the physical therapists, occupational therapists wanted to be included in the list of providers that are allowed to prescribe disabled and temporary disabled placards to patients.

Deceased Patients Medical Records – Would have provided a statutory method of obtaining medical or payment records of deceased payments, under certain conditions.

Marijuana – A number of bills were introduced relating to marijuana: medical use of marijuana; constitutional amendment legalizing marijuana; imposition of an excise tax on marijuana; and bills relating to convictions for marijuana offenses.

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MAFP FMCC

missouri well represented at nation's capitol

From left: Peter Koopman, MD, FAAFP, Emily Doucette, MD, Jim Stevermer, MD, MSPH, FAAFP, Kathy Pabst, MBA, Executive Director, Senator Roy Blunt, Catherine Moore, DO, Kanika Turner, MD and Keith Ratcliff, MD, FAAFP.

T

he Family Medicine Congressional Conference, held May 12-13, had a significant change this year…SGR was not on the list of priority issues to discuss with our congressional leaders. However, there were plenty of other important family medicine issues (provided by AAFP) that your Missouri delegation discussed with our U.S. Senators and Representatives, including: • Value of Primary Care – Limit the provisions of laws designed to assist primary care to those physicians and other providers who actually offer primary care – which is not equivalent to office visits; eliminate patient co-pays for services provided with the new chronic care management code.

• Data for GME Transparency – Congress should direct the Government Accountability Office (GAO) to conduct a study on current and future data needs of graduate medical education (GME). Payments should be data driven and aligned with the nation’s public health workforce needs to achieve specific outcomes.

This can be accomplished through transparency and accountability of GME programs.

• Family Caregivers and Primary Care – Join the Assisting Caregivers Today (ACT) Congressional Caucus, a bipartisan group that will help bring greater attention to family caregiving, educating Congress on these issues and engage legislators to find solutions.

• Family Medicine’s FY 2016 Appropriations Request– Provide at least $71 million for Title VII Section 747, Primary Care Training and Enhancement (PCTE) administered by the Health Resources and

40 Missouri Family Physician July-September 2015

Services Administration (HRSA); include $375 million for the Agency for Healthcare Research and Quality (AHRQ); and, appropriate $287 million for the National Health Service Corps (NHSC) which offers scholarships and loan repayments for students who become primary care physicians and provide health care to underserved Americans.

Walking through the halls of the Senate and House Office Buildings, Missouri delegates included residents, Catherine Moore, DO (Mercy), and Kanika Turner, MD (Saint Louis University); Keith Ratcliff, MD, FAAFP, (AAFP Key Contact and MAFP Advocacy Commission Co-chair); MAFP officers, Peter Koopman, MD, FAAFP, (now MAFP President) and Jim Stevermer, MD, MSPH, FAAFP, (MAFP Secretary/Treasurer), and your Executive Director, Kathy Pabst, MBA. We met with the staff from the offices of Senator Roy Blunt, Senator Claire McCaskill, Representative Blaine Luetkemeyer, Representative William Lacy Clay, Representative From left: Kanika Turner, MD, Vicky Hartzler, and Catherine Moore, DO and Emily Representative Ann Doucette, MD. Wagner.

ACLF/NCCL MAFP

leaders among leaders

T

he Annual Chapter Leadership Forum (formerly ALF) was held in April/May in Kansas City and was an excellent opportunity for MAFP leaders and staff to reconnect with colleagues across the country.

MAFP President, Peter Koopman, MD, FAAFP; President-Elect Kathleen Eubanks-Meng, DO, and Kathy Pabst, MBA, Executive Director, attended sessions addressing association management including topics on board governance, risk management, From left: Sudeep Ross, MD, MBA, Emily Doucette, MD, Kathy financial responsibilities, and Pabst, MBA, Executive Director, Peter Koopman, MD, FAAFP, Marla legislative communications. Many Tobin, MD, FAAFP, Wael Mourad, MD, and Afsheen Patel, MD, in concurrent sessions were available for Kansas City. staff, board members and physicians.

“The conference was a wonderful opportunity This conference is always informative and an to represent women and discuss the future of excellent opportunity to meet and network with medicine and the impact it has to our practice other chapter staff. Sarah Mengwasser attended and patients” stated Afsheen Patel, MD. She the sessions on communications and shared continued, “I have never attended a conference MAFP publications with other chapters. She with so much energy and enthusiasm. It was a also attended a one-half day session for new wonderful experience; one that I learned a great employees presented by AAFP staff on meetings, deal from and reminded me why I love medicine.” marketing, communications, public relations, Dr. Patel appreciated Dr. Bob Wergin relating a social media, and students/residents. wonderful experience with a medical student.

“A student whose patient had no shoes and was MAFP delegates selected to attend the diabetic - He gave his shoes to help this patient National Conference of Constituency Leaders understand the importance of foot care. This (formerly NCSC) conference were: is the beauty of family medicine. The ability to • Women – Afsheen Patel, MD help and make a difference in every way we can.

• Minority – Wael Mourad, MD These are our tools. Our compassion.”

• New Physician – Emily Doucette, MD Wael Mourad, MD, participated as the delegate • IMG – Sudeep Ross, MBA, MD representing minority members. He experienced • LGBT – Volunteer to represent this the NCCL as a unique opportunity to garner constituency! as many ideas and as much talent from its constituent family physicians. This conference, Dr. Doucette, a new physician less than a year attended by major AAFP officers and board out of residency, stated, “The most valuable members should, “signal to each and every one part of the conference was learning AAFP's of us that our voice matters - that our ideas procedural processes for decision making as can make a difference. We are fortunate to be an academy. Learning this process, as well a part of such a large, inclusive, and visionary as gaining more familiarity with the structure organization that, true to its name, moves forward of the organization, was extremely valuable as a family, together." for a young physician interested in continued The MAFP is always looking for future leaders to involvement in my academy in the future.” She represent Missouri at this conference. If you are sums up her perspective also as a new female interested in any of these constituencies, contact physician, “learning that my academy values the the MAFP office today at (573) 635-0830 or email views of all constituents and has a conference office@mo-afp.org. dedicated to developing the skills of its minority members made me proud of my specialty and my academy.”

"

Learning that my academy values the views of all constituents and has a conference dedicated to developing the skills of its minority members made me proud of my specialty and my academy.”

Emily Doucette, MD

Missouri Family Physician July-September 2015

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MAFP

MEMBERS IN THE NEWS top graduating medical students entering family medicine These new residents each received a $500 scholarship from the Family Health Foundation of Missouri.

James Tucker, DO, AT Still Jordan Carlock, DO, KCUMB Christopher Murphy, MD, SLU

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

Krystal Foster, MD, UMC Katie Davis, MD, UMKC Alvin Caldwell Powell, MD, Wash U

Dr. Joseph Novinger, Chair Family Medicine, Preventive Medicine & Community Health, AT Still, (left) presents James Tucker, DO, his FHFM scholarship.

atsu rotations and residencies panel In May, third/fourth year ATSU students and residents spoke to first and second year students about what to expect during rotations and residency.

From left: Katie Willcox, DO; Kipp VanMeter, DO; Ben Crary, OMS-IV, Sean Kane, OMS-IV.

Tar Wars is a tobacco-free education program for fourth and fifth-grade students

university of missouri-columbia takes third in tar wars challenge for fmig's Amanda Allmon, MD and her medical students won third place and a $200 check by taking place in the 2015 American Academy of Family Physicians Tar Wars Challenge for Family Medicine Interest Groups with impressive tobacco-free presentations and efforts within the community. The students will be recognized at National Conference on July 31.

42 Missouri Family Physician July-September 2015

Members In The NewsMAFP MAFP umkc annual event - a hit in 2015 The University of Missouri Kansas City's Family Medicine Interest Group held their annual Reviving Baseball in Inner Cities free sports physical event on April 11th, in partnership with the Boys and Girls Club of Greater Kansas City. UMKC FMIG's hold this event annually, yet this year, served almost four times the children compared to past years, providing almost 200 free sports physicals in one morning. These physicals allow children to continue to play sports and remain active throughout the year. They also added a nutrition and exercise area this year and educated children and parents about healthy snacks and foods.

This event is always a great way to give back to the community that we, as students, are a part of during our medical school career. It is great to be able to use our skills to give back generously to our community with these physicals. Both the children and parents are grateful for us spending our Saturday morning with them and the smiles on the kid's faces are priceless because they know that after this morning is over, they can go play baseball all summer with the Boys and Girls Club's baseball teams.

"

It is great to be able to use our skills to give back generously to our community with these physicals."

Jenny Eichorn, MD

mafp members serving on congress of delegates

Schneider

Shaffer

Lichtenberg

Ratcliff

David Schneider, MD, FAAFP, Todd Shaffer, MD, MBA, FAAFP, Kate Lichtenberg, DO, MPH, FAAFP and Keith Ratcliff, MD, FAAFP, have been selected to represent Missouri at the 2015 AAFP Congress of Delegates, September 30-October 2, 2015 in Denver, Colorado. The Congress of Delegates is the AAFP’s policy-making body. Its membership consists of two delegates from each constituent chapter. The Congress elects new AAFP officers and three members to serve on the Board of Directors for the following 12 months. AAFP members are welcome to participate in hearings of the five reference committees: Advocacy, Education, Health of the Public and Science, Organization and Finance, and Practice Enhancement. During the two and one-half day meeting (held prior to the Family Medicine Experience), the Congress agenda includes addresses from AAFP officers, resolutions from chapters, and reports from the Board of Directors.

family medicine to the rescue: another successful nafc clinic For the first time ever, The National Association of Free and Charitable Clinics (NAFC) had to close the registration for physician volunteers for the morning shift of the free clinic event held in Kansas City, MO. "That’s never happened before and speaks legions to how strong your support has been," stated Ed Weisbart, MD, CPE, FAAFP. "This clearly would not have happened without your support, and I just want to thank you for that. Events like this are not the solution to the American health care crisis, but they sure do help," he said. "Once again, family medicine to the rescue."

A room full of volunteers at the NAFC free clinic event in Kansas City, MO.

MAFP member, Anne Sly, MD, Kanas City (right) with a group of volunteers.

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MAFP Annual Reports >> Medicine, including: suturing, colonoscopy, vaginal delivery, skin biopsy, and using an ultrasound. Attendance: 32 Upcoming Goals: • Summer planning will primarily focus on organizing our Residency Fair event for Fall, wherein we invite residency programs to come discuss their programs to students interested in family medicine. We will also be coordinating with the pediatrics and internal medicine student groups to prepare events for National Primary Care Week next fall.

44 Missouri Family Physician July-September 2015

Pat Patterson Photography

University of Missouri – Columbia

Number of FMIG Members: 112 FMIG Contacts: Co-Chairs: Kaitlin Bruegenhemke, Misty Todd, Kristen Allcorn Secretary: Kayla Matzek Treasurer: Maddy Novoa Family Medicine Match Data: • Number of students matching into FM residency: 9 • Number of students matching into Missouri FM residency: 6 Meetings/Events: • February – Harbor House Health screenings and health presentations at a local homeless shelter. 4 Student Volunteers, 30 patients.

• February – Ronald McDonald House dinners for families with children in the MU children's hospital. 4 Student Volunteers, 25-30 family members attended.

• February – OB Perinatal Laceration lab. Skills lab event for students led by FM residents. 11 students, 2 residents attended.

• March – FMIG Night at the Movies SoutheastHEALTH serves Southeast Hospital in Cape Girardeau featuring "Patch Adams" was a hit. The a population of 650,000 – » TJC-accredited flagship of SoutheastHEALTH with 96% RNs event allowed time to network with a FM and nearly 300 beds the largest medical market resident and attending and a platform to » Situated on Mississippi River, city is region’s hub for commerce, between St. Louis and discuss patient centered care. Attendance: entertainment, the arts, higher education and healthcare Memphis.

8. » Population of 40,000 with average commute of 20 minutes More than a single location, • April – Residency Fair: 6 residencies SoutheastHEALTH is from the Midwest came to Mizzou to share Southeast Health Center of Stoddard County in Dexter a regional system of about their programs. The registration » Expanding medical facility with nearly 50 beds, ED, ICU, care with facilities and fee was also used as a fundraiser for the telemetry unit and new MOB opportunities for BC/BE FMIG. Approx student attendance: 40. » County population of nearly 30,000: 70% rural physicians across the Raised $900. » 7 wildlife conservation areas, including Mingo Wildlife Refuge, for hunting, fishing, nature watching, hiking and camping region, including...

• April – Elected new officers. National Conference program with approx 10 students in attendance.

Southeast Health Center of Ripley County in Doniphan Opportunities • April – FMIG Dinner Forum. Dr. Zweig, » 30-bed facility in Ozark Foothills just north of Arkansas border for BC/BE physicians: the chair of the FM department, spoke » Heart of Current River with large tourism draw > Minimum salary of 185,000 about the Health is Primary movement. » County population of 14,000+: All rural > Signing bonus up to $50,000 Faculty, residents, and medical students > wRVU-based productivity incentives were invited. 6 were in attendance. It > Student loan repayment up to $200,000 > Relocation assistance, paid CME and much more also allowed students the opportunity to interact with FM faculty.

• Monthly – FMIG leadership meetings For confidential inquiry, with approximately 10-15 in attendance. contact Mandie at 573-331-6374 or mpresser@SEhealth.org

Annual Reports

MAFP

Upcoming Goals: • June – Social event at Shakespheare's pizza co-hosted with Students Interested in Global Health for Tomorrow (SIGHT) to raise funds for an upcoming exchange program between Nicaraguan medical students and Mizzou students. This event will allow new M3s the opportunity to gain information and insight in the third year clerkships.

• July – Activities Fair with FMIG booth and representatives to provide info to new M1s about the FMIG group and AAFP membership.

• August – Back to school BBQ networking and planning event where students, residents, and faculty meet to discuss FM, FMIG, and plans for the year.

University of Missouri – Kansas City

Number of FMIG Members: 40 FMIG Contacts: President: Emily Gray Vice President: Mitchell Elting and Seenu Abraham Secretary: Nymisha Rao Treasurer: Banoo Amighi and Ravali Gummi Family Medicine Match Data: • Number of students matching into FM residency: 8 • Number of students matching into Missouri FM residency: 4 Meetings/Events: • March – EKG Workshop. Led by Dr. Salanski and Research Family Medicine Residents. 15 participants.

• March – Strolling Through the Match panel discussion. Different primary care fields represented. 20 attended.

• April – Free sports physicals. Provided for the Boys and Girls Club of Greater KC. Implemented a booth to encourage healthy eating and exercise. 20 volunteers and served almost 200 children with sports physicals.

• April – Free ice cream snack to our third year class after a Pathology test. About 100 students in the class.

• April – Officer Elections and promoting National Conference. 15 students attended.

• May – Officer Planning meeting.

Upcoming Goals: • Several officers plan on attending the National Conference this summer.

Washington University

Number of FMIG Members: 15 FMIG Contacts: Co-Presidents: Gabe Tissian, Jennifer Farley Family Medicine Match Data: • Number of students matching into FM residency: 3 • Number of students matching into Missouri FM residency: 0 Meetings/Events: • April – Panel of our three 4th years who matched into FM along with director of SLU's FM program, Dr. Christine Jacobs.

Upcoming Goals: • We have no further plans for this year aside from looking into funding for the national conference.

family physicians applaud flexibility in transition to icd-10

I

n a statement released on July 6, The American Academy of Family Physicians (AAFP) applauded CMS on its actions to ease the transition to ICD-10. “The AAFP has advocated for several of these changes, including a one year grace period on coding specificity within families of ICD-10 codes, which will enable family physician offices to keep with up the ICD-10 transition without threatening their financial viability," stated Robert Wergin, MD, President of the AAFP. “We have called for additional appeals and agency monitoring for reporting systems that determine appropriate payment for medical services based on quality measures and meaningful use of electronic health records." The AAFP urged CMS to expand advanced payment options for physicians, to ensure an adequate revenue flow in order to maintain financial stability during the ICD-10 transition.

Missouri Family Physician July-September 2015

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MAFP Student Externships

student externship: julie duncan The AAFP Foundation and FHFM have partnered to offer four-week summer externships to Missouri medical students interested in pursuing a career in family medicine. Congratulations to Julie Duncan who recently completed her student externship on June 16 at the Family Health Center in Columbia, MO.

externships in process John Haefner, SLU Externship Site: SLU Stephanie Lersch, UMKC Externship Site: UMC Rene Romig, UMC Externship Site: UMKC

"WHAT DID THIS EXPERIENCE MEAN TO YOU?" "The externship at the Family Health Center in Columbia, MO provided me with hands-on clinical experience working with an underserved population. I saw a wide variety of patients, and in my short month of working there, got the see the same patients multiple times and develop rapport. The idea on continuity of care in why I was initially interested in a career in family medicine, and my externship highlighted why I feel that is so important. I also learned a lot about the challenges of caring for the underserved, from patients with unstable living situations to pregnant mother who only qualified for two months of Medicaid. The care provided at the Federal Qualified Health Center involved a much higher degree of problem solving than I often see in higher resource areas. It not only provided an incredible learning experience, but further encouraged me to pursue a career in primary care working with underserved populations."

We are dedicated to rural and underserved areas of our great state! We partner 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: Joni Adamson, Manager of Recruitment 573.636.4222 jadamson@mo-pca.org www.3rnet.org/locations/missouri

Proud Partners Of:

Family Medicine Opportunities - Loan Repayment Options - Competitive Salary & Comprehensive Benefits - Team Based Care Models / Care Coordination - Little or No Call / Moving Allowance / Signing Bonus

MHPPS is non-profit and located within the MO Primary Care Association

46 Missouri Family Physician July-September 2015

MAFP

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Snoring because of sleep apnea

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Missouri Family Physician July-September 2015

Contact us at (888) 757-7367 or info@apneastrip.com

47

MAFP

Request a copy of our 6th annual Pediatric Genomic Medicine Conference t a copy of ourwhitepaper, ual“Genome PediatricSequencing in Newborns: Where ic Medicine are We Headed?” at

enceChildrensMercy.org/ whitepaper, e Sequencing newborngenomics borns: Where Headed?” at nsMercy.org/ rngenomics

A FASTER, MORE PRECISE PATH TO DIAGNOSIS AND TREATMENT.

A FASTER, MORE PRECISE PATH TO DIAGNOSIS AND TREATMENT.

As many as one in three newborns admitted to a NICU suffers from a genetic disease. The difference between life and death is often a quick diagnosis that expedites treatment. At Children’s Mercy Kansas City, our Center for Pediatric Genomic Medicine is developing genetic testing that’s helping transform the As many in three newborns livesasofone patients around the world. admitted to a NICU suffers from a genetic

disease. The difference between life and death is often a quick diagnosis that We’ve developed the world’s fastest genome sequencing test, so that you expedites treatment. At Children’s Mercy Kansas City, our Center for Pediatric can diagnose patients in as few as 50 hours. We’ve also developed a single Genomic is developing genetic that’sof helping transform the test Medicine to detect more than 750 diseases that testing are the result a single mutation. the NICU, we’re with pediatric subspecialists throughout lives ofBeyond patients around thecollaborating world.

Children’s Mercy in many of our clinics, including Nephrology, Endocrinology,

We’ve Gastroenterology developed the world’s fastest genome test, sothe that you and Oncology.

This allows ussequencing to better understand genetic causes ofpatients diseases in and unnecessary testing while delivering faster can diagnose asminimizes few as 50 hours. We’ve also developed a single and more accurate diagnoses—improving outcomes for children everywhere. test to detect more than 750 diseases that are the result of a single mutation.

Beyond the NICU, we’re collaborating with pediatric subspecialists throughout Children’s Mercy in many of our clinics, including Nephrology, Endocrinology, Gastroenterology and Oncology. This allows us to better understand the genetic causes of diseases and minimizes unnecessary testing while delivering faster and more accurate diagnoses—improving outcomes for children everywhere.

48 Missouri Family Physician July-September 2015